Arcuate Uterus Research Articles

Intraoperative three-dimensional sonohysterography: a new technique to monitor hysteroscopic metroplasty

OBJECTIVE: To illustrate the utility of a new technique, intraoperative tridimensional (3D) sonohisterography, to monitor non invasively the surgical correction of uterine anomalies. DESIGN: Prospective evaluation of infertility patients undergoing hysteroscopic correction of uterine anomalies in a single private infertility clinic between October 2009 and April 2010. MATERIALS AND METHODS: Twenty infertility patients with septate, subsebtate or arcuate uteri underwent operative hysteroscopy with a Wolf 5 mm compact hysteroscope using cold scissors. Intraoperatively, a voluson i was used to guide the surgery transabdominally with a 3D RAB 4-8 probe. Moreover, a 3D transvaginal RIC 5-9 probe was used to acquire an uterine volume with the hysteroscope in place and monitor the progress of the operation. The result is an intraoperative sonohisterography, which allows precise evaluation of the uterine cavity (mirrowing the histeroscopic view) as well as the external contour of the uterus. RESULTS: In all cases the volumes acquired intraoperatively, which are identical to those obtained when performing 3D sonohisterography, illustrate perfectly the progress of the operation indicating when the surgical procedure is complete and thus minimizing the risk of uterine perforation. CONCLUSION: Three-dimensional ultrasound, both transabdominal and transvaginal, can be used successfully to monitor the progress of hysteroscopic metroplasty, obviating the use of the more invasive, traditionally used laparoscopy. Transvaginal intraoperative 3D sonohisterography is a quick and extremely precise technique.

Septate, subseptate and arcuate uterus decrease pregnancy and live birth rates in IVF/ICSI

A retrospective matched-control study to evaluate the effect of uterine anomalies on pregnancy rates after 2481 embryo transfers in conventionally stimulated IVF/intracytoplasmic sperm injection (ICSI) cycles. The study group of 289 embryo transfers before and 538 embryo transfers following hysteroscopic resection of a uterine septum was compared with two consecutive embryo transfers in the control group. Groups were matched for age, body mass index, ovarian stimulation, embryo quality, IVF or ICSI and infertility aetiologies. Number of embryos transferred, embryo quality and absence of uterine anomalies significantly predicted the pregnancy rates in the study group: odds ratios (OR) 1.7, 2.6 and 2.5, respectively (P<0.001). Pregnancy rates after embryo transfer before hysteroscopic metroplasty were significantly lower, both in women with subseptate and septate uterus and in women with arcuate uterus compared with controls. If two or three embryos with at least one best-quality embryo were transferred, the differences were 9.6% versus 43.6%, OR 7.3 (P<0.001) and 20.9% versus 35.5%, OR 2.1 (P<0.03), respectively. Differences in terms of live birth rates were even more evident: 1.9% versus 38.6%, OR 32 (P<0.001) and 3.0% versus 30.4%, OR 14 (P<0.001). After surgery, the differences disappeared. This retrospective matched control study evaluated the influence of septate, subseptate and arcuate uterus on pregnancy and live birth rates after 2481 in conventionally stimulated IVF/intracytoplasmic sperm injection (ICSI) cycles. The study group included 827 embryo transfers (289 embryo transfers before and 538 embryo transfers following hysteroscopic resection of uterine septum ans was compared with two consecutive mebryo transfers in the control group. Both groups were matched by age, body mass index, stimulation protocol, quality of embryos, use of IVF or ICSI, and infertility aetiologies. Multivariate logistic regression analysis of the study group showed that the number of embryos, embryo quality and the absence of uterine anomalies significantly predicted the pregnancy rates: odds ratios (OR) 1.7, 2.6, and 2.5, respectively (P<0.001). The pregnancy and live birth rates before surgery were lower compared with controls, both in women with subseptate or septate uterus and in women with arcuate uterus. If two or three embryos with at least one best quality embryo were transferred, the differences in terms of pregnancy rates were 9.6% versus 43.6%, OR=7.3 (P<0.001) and 20.9% versus 35.5%, OR=2.1 (P<0.03), respectively. The differences in terms of live birth rates were even more evident: 1.9% versus 38.6%, OR=32 (P<0.001) and 3.0% versus 30.4%, OR=14 (P<0.001). After surgery, the differences disappeared. Negative impact of uterine anomalies on pregnancy and on live birth rates are two important arguments for treating uterine anomalies in infertile women.

Three‐dimensional ultrasound in the diagnosis of Müllerian duct anomalies and concordance with magnetic resonance imaging

To demonstrate the value of three-dimensional (3D) ultrasound in the diagnosis of uterine malformations and its concordance with magnetic resonance imaging (MRI). This study included 286 women diagnosed with uterine malformation by 3D ultrasound, having been referred to our clinics on suspicion of uterine malformation following clinical and/or conventional two-dimensional ultrasound examination. With the exception of three with intact hymen, patients underwent both bimanual examination and speculoscopy before and/or after sonography. MRI was performed in 65 cases. We analyzed the diagnostic concordance between the techniques in the study of uterine malformations. Using 3D ultrasound we diagnosed: one case with uterine agenesis; 10 with unicornuate uterus, four of which also underwent MRI; six with didelphic uterus, one of which had MRI; 45 with bicornuate uterus, 12 of which had MRI; 125 with septate uterus (18 with two cervices), 42 of which had MRI (six with two cervices); 96 with arcuate uterus, three of which had MRI; and three with diethylstilbestrol (DES) iatrogenic uterine malformations, all of which had MRI. Among the 65 which underwent MRI, the diagnosis was: four cases with unicornuate uterus, 10 with bicornuate uterus (two with two cervices), 45 with septate uterus (five with two cervices), three with arcuate uterus and three with DES-related uterine malformations. The concordance between 3D ultrasound and MRI was very good (kappa index, 0.880 (95% CI, 0.769-0.993)). Discrepancies in diagnosis between the two techniques occurred in four cases. There was very good concordance in the diagnosis of associated findings (kappa index, 0.878 (95% CI, 0.775-0.980)), this analysis identifying differences in two cases. There is a high degree of concordance between 3D ultrasound and MRI in the diagnosis of uterine malformations, the relationship between cavity and fundus being visualized equally well with both techniques. 3D ultrasound should be complemented by careful gynecological exploration in order to identify any alterations in the cervix.

Effective Treatment for Recurrent Pregnancy Loss

Understanding the etiology of recurrent pregnancy loss (RPL) has been increasing in importance in reproductive medicine, especially in societies with low birth rates. Since the cause of human miscarriage is often complicated and multifactorial, effective treatment for the successful maintenance of pregnancy requires the comprehensive clinical management of recurrent wastages. Immunology for the maintenance of pregnancy is a very attractive field; however, the role of immunology during human gestation cannot be confirmed in couples with a history of recurrent pregnancy loss unless other clinical causes of miscarriage are especially ruled out.Balanced chromosomal rearrangements have been found at an increased frequency in couples with recurrent pregnancy loss compared with the general population. The major anomalies are Robertosonian or reciprocal translocations, while most minor variants include pericentric inversion of chromosome 9. Both major and minor anomalies result in a spontaneous abortion rate of approximately 80-90%. Though the incidences of these chromosomal abnormalities vary in reported studies, a survey indicated an incidence of 9.8% (3.9% in male partners and 5.9% in female partners) among 1,639 couples with a history of recurrent pregnancy loss.Congenital uterine anomaly resulting in a suboptimal uterine environment may influence ovum implantation and early fetal development and may be a candidate in the etiology of reproductive wastage.A review on the relation between congenital uterine anomalies and the spontaneous abortion rate concluded that a precise diagnosis of uterine cavity deformity, especially arcuate uterus, is a key issue for determining the clinical prognosis during human gestation. After establishing diagnostic criteria for uterine cavity anomaly, 278 congenital uterine anomalies were detected in a series of 2,061 hysterosalpingographies (13.5%) performed in women with a history of recurrent pregnancy loss. Among these abnormalities, the incidences of spontaneous abortion were equally high among patients with arcuate uterus and those with partial septate uterus. A few studies on abortion mechanism in patients with congenital uterine anomalies have been reported. Histological findings using CD34- positive staining indicate the lack of a blood capillary system in both the uterine septum and the fundus muscle layer. The results of metroplastic surgery on congenital uterine anomaly are also controversial. Based on our fundamental findings of the maldistribution of uterine capillaries, we performed ideal metroplastic surgery in 173 women and significantly reduced the spontaneous abortion rate from a pre-operative values of 93.2% to a post-operative value of 12.5%.Anti-cardiolipin antibody was first described by Huge et al. as a pathogenic auto-antibody capable of causing recurrent pregnancy loss. Since then several other candidates for zwitterionic antiphospholipid antibodies to anionic phospholipids that are capable of inducing miscarriage such as phosphatidylethanolamine (aPE) and phosphatidylserine (aPS). In a multicenter study on antiphospholipid antibodies conducted at 15 insitutes and hospitals between 2000 and 2002, significant levels of IgG and IgM for aPE were detected among women with a history of recurrent pregnancy loss. By establishing an enzyme-linked immunosorbent assay system, we determined that the IgG and IgM levels for aPE were significantly higher than those for other phospholipids antibodies during the first trimester recurrent spontaneous abortions. Coagulation factor XII, prekallikrein and the high molecular weight molecule kininogen have been reported as plasma contact proteins in the intrinsic pathway of the blood coagulation system. Deficiencies of these proteins are not associated with clinical obstetrical intrauterine bleeding, suggesting that these proteins possess anticoagulant and profibrinolytic activities.(View PDF for the rest of the abstract.)

Three-dimensional Ultrasonography in the Diagnosis of Müllerian Duct Anomalies

Abstract Aims We studied the effectiveness of three-dimensional (3D) ultrasonography in the diagnosis of uterine malformations. Methods 175 patients with clinical or ultrasonographic suspicion of uterine malformation were studied between November 2004 and June 2008. In all women we measured uterine volume for processing and later reconstruction of 3D images. Cases in which no anomaly was detected with the 3D technique were excluded from study. A thorough physical genital examination with speculum was done before or after ultrasonography, except in three women with an imperforate hymen. Uterine malformations were recorded in detail, and the findings were catalogued according to the American Fertility Society (AFS) classification. In 32 women magnetic resonance (MR) imaging was also used, and agreement between the two techniques was calculated with the kappa index. Results The 175 müllerian anomalies we analyzed were diagnosed as agenesis (1 case), unicornuate uterus (1 genuine, 1 communicating), didelphys uterus (4), bicornuate uterus (22), septate uterus (80, 8 with two cervices) and arcuate uterus (68). For 1 unicornuate, 3 bicornuate, 25 septate (4 with two cervices) and 3 arcuate uteri we performed MR imaging. Diagnostic correlation between 3D ultrasonography and MR imaging was obtained in all cases according to the AFS classification (kappa = 100%); concordance was also seen for descriptions of associated uterine malformations except for two cases: 1 bicornuate uterus with the additional presence of a cervical septum as detected by MR imaging, which was not found on hysteroscopy for resection, and 1 septate uterus that appeared to have two cervices on 3D ultrasonography in a patient in whom physical examination was not possible, and in whom MR imaging showed a complete septum with hypointense signals (kappa = 93.45%; 95% confidence interval 80.75- 100%). Discussion Owing to its ability to clearly render contours of anatomical structures, 3D ultrasonography provides detailed images of uterine malformations and yields very similar results to those obtained with MR imaging. For an accurate comparison of the two techniques, ultrasonography should be accompanied by gynecologic physical exploration, since the two methods yield equivalent results for the relation between the uterine cavity and the fundus. MR imaging is especially useful to evaluate the cervix and vagina.

Laparoscopic Strassman’s metroplasty for bicornuate uterus

The authors report the case of a 28-year-old nulliparous woman with a bicornuate uterus and one previous second trimester pregnancy loss, in whom investigations for other probable causes of abortion like genetic, infective, hormonal, and immunological were negative. A laparoscopic metroplasty was performed by Strassman’s method. Second-look hysteroscopy and laparoscopy, which was performed 7 months later, revealed a single uniform cavity with a median muscular ridge, which resembled an arcuate uterus. Pelvic adhesions were noted between the small bowel, omentum, and posterior wall of the uterus, along with pelvic endometriosis and a chocolate cyst of the left ovary. Adhesiolysis, cyst excision, and fulgration of endometriotic deposits were carried out, which were followed by the application of an adhesion barrier.

The outcome of singleton pregnancies after IVF/ICSI in women before and after hysteroscopic resection of a uterine septum compared to normal controls

Objective(s) To evaluate the effect of hysteroscopic resection of a large uterine septum (Class V according to the American Fertility Society (AFS) classification) and of a small partial uterine septum (Class VI according to AFS classification or arcuate uterus) on the abortion rate in pregnancies after IVF and ICSI. Study design The retrospective matched control study included 31 women who conceived following IVF or ICSI before hysteroscopic resection of a large (12 women) or small partial (19 women) uterine septum and 106 women who conceived following IVF or ICSI after hysteroscopic resection of a large (49 women) or small partial (57 women) uterine septum. For each pregnancy in the study group, we found two consecutive pregnant control women from the IVF/ICSI registry who had a normal uterus and were matched for age, BMI, stimulation protocol and the use of IVF or ICSI and for various infertility causes. The abortion/pregnancy rate was the main outcome measure. Data on the septum length were obtained during hysteroscopic resection by comparing the length of the 1.4 cm long yellow tip of the electric knife to the length of the resected septum. Results The abortion rate before hysteroscopic metroplasty was significantly higher, both in women with a small partial septum (78.9% before resection vs. 23.7% in the normal controls, OR 12.08) and a large septum (83.3% before resection vs. 16.7% in normal controls, OR 25.00) compared to women with a normal uterus. After the surgery, the abortion rate was comparable to the abortion rate in women with normal uterus: in both women with a small partial and women with a larger septum. Conclusion(s) Similar to a large uterine septum, a small partial uterine septum is an important and hysteroscopically preventable risk factor for spontaneous abortion in pregnancies after IVF and ICSI.

Prevalence and diagnosis of congenital uterine anomalies in women with reproductive failure: a critical appraisal

The prevalence of congenital uterine anomalies in women with reproductive failure remains unclear, largely due to methodological bias. The aim of this review is to assess the diagnostic accuracy of different methodologies and estimate the prevalence of congenital uterine anomalies in women with infertility and recurrent miscarriage (RM). Studies from 1950 to 2007 were identified through a MEDLINE search; all relevant references were further reviewed. The most accurate diagnostic procedures are combined hysteroscopy and laparoscopy, sonohysterography (SHG) and possibly three-dimensional ultrasound (3D US). Two-dimensional ultrasound (2D US) and hysterosalpingography (HSG) are less accurate and are thus inadequate for diagnostic purposes. Preliminary studies (n = 24) suggest magnetic resonance imaging (MRI) is a relatively sensitive tool. A critical analysis of studies suggests that the prevalence of congenital uterine anomalies is approximately 6.7% [95% confidence interval (CI), 6.0-7.4] in the general population, approximately 7.3% (95% CI, 6.7-7.9) in the infertile population and approximately 16.7% (95% CI, 14.8-18.6) in the RM population. The arcuate uterus is the commonest anomaly in the general and RM population. In contrast, the septate uterus is the commonest anomaly in the infertile population, suggesting a possible association. Women with RM have a high prevalence of congenital uterine anomalies and should be thoroughly investigated. HSG and/or 2D US can be used as an initial screening tool. Combined hysteroscopy and laparoscopy, SHG and 3D US can be used for a definitive diagnosis. The accuracy and practicality of MRI remains unclear.

Should Diagnostic Hysteroscopy be a Routine Procedure During Diagnostic Laparoscopy in Infertile Women?

The aim of this study was to clarify the role of simultaneous combined diagnostic approach using laparoscopy and hysteroscopy in the evaluation of female infertility. In a retrospective study, 360 infertile women underwent complete fertility evaluation. All the patients were examined by simultaneous combined laparoscopy and hysteroscopy as a part of the routine infertility evaluation. Laparoscopy and hysteroscopy were successful in 360 patients. Bilateral tubes were blocked in 18 (5%) and unilateral tubal occlusion were in 30 (8,33%) of patients. Pelvic adhesions were revealed in 40 (11,11%), and myomas in 42 (11,65%) out of that 31 (8,6%) were revealed by laparoscopy and 11 (3,05%) by hysteroscopy. Endometrial polyps were revealed in 26 (7,22%) and Syndrome Asherman in 3(0,83%) of patients. Uterine anomaly was found in 19 (5,27%) of cases and out of that septate uterus in 7 (37,15%), bicornuate uterus in 5 (26,31%), arcuate uterus in 4 (21,26%) and uterus unicornu cum cornu rudimentario in 3 (15,27%) of uterine anomalies. Endometriosis was found in 51 (14,16%), dermoid cysts in 8 (2,22%) and in 16 (4,44%) functional cysts of patients. Also, Fitz-Hugh-Curtis syndrome was revealed in 23 (6,11%) of our patients. Laparoscopy and hysteroscopy play very important role as diagnostic tools in the infertility women. Combined diagnostic simultaneous laparoscopy and hysteroscopy should be performed in all infertile patients before the treatment.

Hystero-salpingography: An obituary or a new beginning.?

Hystero-salpingography: An obituary or a new beginning.?

Benefits of preventive transhisteroscopic metroplasty (THM) in septate uterus

Benefits of preventive transhisteroscopic metroplasty (THM) in septate uterus

Uterine anomalies and pregnancy outcome following resectoscope metroplasty

Objective To compare reproductive outcome in women with uterine anomalies and women with a normal uterus, and evaluate the effect of resectoscope metroplasty. Methods The pregnancy outcomes, past and present, of 105 women with congenital uterine anomalies were compared with those of 182 women with a normally shaped uterus. The outcomes of 25 women with septate and bicornuate uteri before and after resectoscope metroplasty were also analyzed. The χ 2 and Mann–Whitney U test were used for statistical analysis, with P < 0.05 considered statistically significant. Results Uterine anomalies were associated with higher rates of spontaneous abortion, preterm delivery, intrauterine growth retardation, breech presentation, and cesarean delivery ( P < 0.001). The highest incidence of early spontaneous abortion was noted among women with septate uteri, and the highest incidence of preterm labor was noted among women with arcuate or bicornuate uteri. Among women with arcuate uteri, significantly lower gestational age and birth-weight were observed compared with any other type of adverse outcome. Compared with their previous pregnancies, the abortion rates were lower and delivery rates were higher in women who conceived following hysteroscopic metroplasty ( P < 0.001). Conclusion Resesctoscope metroplasty significantly improved pregnancy outcome in women with uterine anomalies.

Small uterine septum is an important risk variable for preterm birth

Objective(s) To evaluate whether a uterus with a small septum (arcuate uterus or class VI according to the American Fertility Society (AFS) classification) behaves similarly to a uterus with a larger septum (septate or subseptate uterus or AFS class V). Study design Observational study included 826 singleton deliveries to 730 women with a history of hysteroscopic resection of the uterine septum. Data on deliveries were obtained from the National Perinatal Registry of Slovenia (NPIS). Multiple gestations were excluded. We analysed and compared perinatal outcomes before and after hysteroscopic resection in two groups of women: in women with a small uterine septum (Group A) and in those with a larger uterine septum (Group B). Data on the septum length were obtained during hysteroscopic resection by comparing the length of the 1.4-cm long yellow tip of the electric knife to the length of the resected septum. A small uterine septum was defined as having a length of 1.3–1.5 cm. Results The preterm birth rate in Group A ( n = 420) was 33.9% before and 7.2% after hysteroscopic resection ( P < 0.001); the preterm birth rate in Group B ( n = 406) was 36.5% before and 8.0% after hysteroscopic resection ( P < 0.001). The very preterm birth rate in Group A was 12.5% before and 3.1% after hysteroscopic resection ( P < 0.001); the very preterm birth rate in Group B was 15.0% before and 2.9% after hysteroscopic resection ( P < 0.001). After surgery, we registered a decreased need for neonatal intensive care, as well as a significant decrease in stillbirth and neonatal death rates in both groups of patients. Conclusion(s) Similarly to a large uterine septum, a small uterine septum or arcuate uterus is an important hysteroscopically preventable risk variable for preterm birth.

A prospective evaluation of uterine abnormalities by saline infusion sonohysterography in 1,009 women with infertility or abnormal uterine bleeding

To evaluate the role of saline infusion sonohysterography (SIS) in the investigation of uterine abnormalities and malformations in patients referred for infertility work-up compared with women with abnormal uterine bleeding (AUB). Prospective cohort study. Academically oriented private practice. One thousand nine consecutive women examined by SIS for infertility work-up (n = 600, infertility group) or AUB investigation (n = 409, AUB group). SIS. Intracavitary abnormalities and uterine anomalies. Among the women in the infertility group, 16.2% (n = 97) were found to have intracavitary abnormalities, including polyps (13.0%), submucous fibroids (2.8%), and adhesions (0.3%). Significantly, more patients in the AUB group (39.6%, n = 162) revealed intracavitary abnormalities, including polyps (29.8%), submucous fibroids (9.0%), and adhesions (0.7%). In contrast, significantly more uterine anomalies were found in the infertility group (20%, n = 120) compared with the AUB group (9.5%, n = 39). Arcuate uterus was the most common finding (15% vs. 6.4% of patients, respectively). An SIS procedure for infertility work-up revealed a substantial percentage of infertile patients with intracavitary abnormalities and uterine anomalies. Because the technique is safe, well tolerated, and feasible in an outpatient setting, SIS should be considered routinely in the early stage of infertility and AUB investigation.

OP13.03: Assessment of palpable nodules of the abdominal wall with postpartum onset

unicornuate uterus. We compare the pregnancy outcomes with each anomaly. Results: We found 106 cases of congenital uterine anomaly within a given period of time. There are 63 cases of bicornuate uterus, 19 cases of didelphys, 16 cases of septate uterus, 5 cases of arcuate uterus, and 3 cases of unicornuate uterus. The overall preterm delivery rate is 22.6% (24/106), and Cesarean section rate is 74.5% (79/106). A high Cesarean section rate is due to metroplasty, abnormal fetal presentation, and uterine anomaly itself. The preterm delivery rate and Cesarean section rate of each uterine anomaly do not differ statistically from one another. Five fetuses were stillborn, and one fetus died after birth because of a placenta abruption. The overall take-home baby rate is 94.3% (100/106). There is no maternal mortality and only one case was suffered from postpartum bleeding. Conclusions: Our results suggest that the most of women with uterine anomaly exceeding 20 weeks of gestation may take their baby home.

Improvement of uterine artery Doppler velocimetry indices after metroplasty in arcuate uteri

ObjectiveOur study aimed to evaluate the effect of metroplasty performed in arcuate uteri on uterine artery Doppler velocimetry. Study designWe performed uterine artery Doppler velocimetry transvaginally before and after metroplasty in 36 women with arcuate uteri. Pulsatility indexes (PI) of uterine arteries were calculated and the presence or absence of a protodiastolic notch was evaluated. ResultsComparing Doppler indexes before and after metroplasty, we found that uterine artery impedance improves as assessed by lower mean PI. We observed that PI after intervention was significantly lower compared with indexes before for mean Doppler index evaluations (mean uterine PI pre: 2.07±0.61 and post: 1.49±0.24 [p<0.03]). No differences were observed as regards bilateral protodiastolic notch absence or presence. A protodiastolic notch was present in 22 out of 36 women before metroplasty (61%), and a notch was observed in 19 out of 36 (52%) after metroplasty. ConclusionsOur results suggest that, metroplasty, as well as making the uterine cavity wider, leads to better uterine perfusion.

79: Arcuate or Minimally Septate Uterus: Diagnosis and Treatment

To evaluate the diagnosis and efficacy of treatment in arcuate uteri. Evaluation of patients with two or more abortions and fundal curvature >5<15mm, diagnosed by transvaginal ultrasound, 3D ultrasound and diagnostic Hysteroscopy, before and after hysteroscopic metroplasty. Obstetric and gynecologic dept of University Hospital in Rome Italy. Twenty-three patients with two or more spontaneous abortions without term pregnancies and uterine fundal curvature depth between 5 and 15 mm. Resectosope transection of uterine fundal curvature. No perforation or other major complication occurred. Eighteen patients became pregnant till now and 13 (72%) had a term pregnancy, while 4 (22%) aborted and 1 (5.5%) had a preterm delivery at 30 week. Arcuate uterus is a separate class in AFS classification of uterine malformations, but the limits and differences with partial septum and normal uterus are not well defined. For these reasons the reproductive impairment of arcuate uteri is till controversial. In our work we selected and treated patients with reproductive failure and fundal curvature between 5 and 15 mm, obtaining 72 % of term pregnancies. Our preliminary results show that TVUS with 3D and diagnostic hysteroscopy can select patients with a history of repeated abortions and uterine fundal curvature that can increase their reproductive outcome with hysteroscopic metroplasty.

Three-Dimensional Inversion Rendering

The purpose of this presentation is to describe the use of the 3-dimensional (3D) sonographic inversion rendering mode in displaying fluid-filled structures using dedicated hardware and software in gynecology. The 3D software used inverts anechoic into echogenic voxels, which, against the black background of the monitor screen, display the fluid-filled structure as a "cast" of it. The technique of the rendering process is described. Three-dimensional sonographic volumes of the adnexal area in 3 patients thought to have adnexal or ovarian masses were stored and rendered with the use of the laptop version of the inversion software. The same process was used in an additional 12 women for various indications: 7 with suspected uterine malformations and 5 with uterine bleeding. Of these 12 women, 11 underwent saline infusion sonohysterography. Rendering the inverted fluid-filled adnexal structures revealed that, in all 3 cases, they were tubal, not ovarian, in origin (chronic hydrosalpinges). Of the 7 uterine cavities suspected of malformation, 3 were normal and 4 had uterine malformations: 2 arcuate uteri and 2 incomplete septate uteri. Of the 4 woman with dysfunctional uterine bleeding, 3 had endometrial cavities with polyps and 1 had an irregular surface of the cast. One woman with postmenopausal spotting had an enlarged but otherwise normal cavity. After a relatively short learning curve to master the inversion rendering technique, it is possible to use it in a selected number of gynecologic cases with fluid-filled structures. In resolving the correct diagnosis of the adnexal masses, the inversion images performed better than the 2-dimensional (2D) and 3D orthogonal planes. For diagnosis of uterine disease, the inversion pictures presented marginal value over the 2D and 3D images. The 3D inversion rendering technique may have added value in selected gynecologic cases, establishing a more accurate diagnosis somewhat faster than only 2D sonography or even the 3D orthogonal planes.

3D ultrasound vs Sonohysterography for the diagnosis of uterine anomalies: A prospective blinded study of 1000 consecutive women

Sonohysterography (SHG) is widely used for the diagnosis of intrauterine pathology. We investigated, as a prospective blinded study, the accuracy of SHG, compared to three-dimensional ultrasound (3D US), in detecting uterine anomalies. A prospective blinded study. 1000 consecutive women who were referred for SHG because of infertility (n=591), or for the investigation of irregular uterine bleeding or abnormal endometrial appearance (control, n=409), also underwent 3D US for the diagnosis of uterine anomalies. 3D ultrasounds and SHGs were performed by experienced reproductive sonographers. 3D ultrasounds were preformed using General Electric (GE) Voluson 730 Experts, and the SHGs by GE Logiq 400 Pros. Uterine anomalies were defined by the American Society of Reproductive Medicine criteria. Sensitivity, specificity, positive and negative predictive powers of SHG compared to 3D US were measured. Cohen’s Kappa was used to analyze the extent to which the two tests agree, correcting for chance agreement. 23.9% of women (n=239) were diagnosed by 3D US to have uterine anomalies. Arcuate uterus was the most frequent anomaly (n=186) and the others were partial (n= 25), or complete (n= 20), septated uterus, bicornuate (n= 2), didelphys (n= 1), hypoplastic (n= 1), unicornuate (n= 1), and borderline septate/arcuate (n= 3). The prevalence of anomalies was significantly higher in the infertile group (29.8%) compared to the non-infertile group (15.4 %; p < 0.0001). Using the 3D US as the gold standard, the SHG had sensitivity, specificity, positive and negative predictive powers of 61.9%, 97.8%, 92.4%, and 85.8% for the infertile women (Kappa = 0.618; p < 0.001), and 57.1%, 99.1%, 92.3%, and 92.7% for the non-infertile group (Kappa = 0.655; p < 0.001), respectively. SHG diagnoses most uterine anomalies. When a uterine anomaly is suspected, 3D US should be recommended first. 3D US allows precise recognition of uterine anomalies by visualizing both the uterine cavity and the fundal uterine contour in the coronal plane. 3D US should become the gold standard for diagnosing uterine anomalies, instead of laparoscopy with hysteroscopy, or with a hysterosalpingogram. 3D US may become routine for the investigation of the infertile women.

Is hysterosalpingography able to diagnose all uterine malformations correctly?: A retrospective study

Background: Müllerian duct anomalies are an uncommon but often a treatable cause of infertility. Material and methods: From January 2002 until November 2003, a total of 705 hysterosalpingographies were realised of which 658 were analysed retrospectively in order to determine the importance of uterine malformations in infertile and sterile patients. In ten cases, the results of hysterosalpingography were compared with hysteroscopy and laparoscopy. Results: The frequency of uterine malformations in infertile and sterile women was 10%. In this population, arcuate uterus (57.6%) was the most common malformation, followed by subseptate uterus (18.2%), uterus bicornis unicollis (10.6%), uterus bicornis bicollis (3.0%), septate uterus (6.1%), unicornuate uterus (3.0%) and unicornuate uterus with double vagina (1.5%). Discussion: Our bibliographic research confirmed that arcuate uterus is the most frequent congenital malformation, but in gestations it does not show a significantly reduced live birth rate. Nevertheless, the septate uterus presents an important decrease of live birth rate that can be improved significantly by doing hysteroscopic metroplasty. As this is a completely different surgical intervention compared to bicornuate uterus, a correct diagnosis is very important. Differentiation of these two malformations is quite difficult by hysterosalpingographic exploration, wherefore an additional exploration by means of endovaginal or three-dimensional ultrasound is recommended.