Subseptate Uterus Research Articles

60: Hysteroscopy is the gold standard for determining the prevalence of subseptate uterus and arcuate uterine anomaly

The prevalence of septate/subseptate and arcuate uterine anomaly in infertile patients varies in the literature due to different modes of diagnoses and methodological bias. Our group previously reported that mid fundal length on transvaginal 3D US (TV 3D US) with or without saline infusion sonohysterography (SIH) tends to be underestimated in patients with subtle incomplete septum and arcuate uterine anomaly (Abuzeid O. et al. Fertil Steril 2015). The aim of this study is to determine the prevalence of significant subseptate and arcuate uterine anomaly on hysteroscopy and TV 3D US in infertile patients with reproductive failure. All patients who presented to our unit with a history of infertility (2008 – 2016) were studied. Optimal testing for the diagnosis of arcuate and septate/subseptate uterus (ASRM Class Vb and VI) was used. The criterion for optimal testing was TV 3D US with or without SIH, and hysteroscopy with or without laparoscopy. Five hundred fifty six patients who fulfilled inclusion criteria were included in this study. Inclusion criteria included the diagnosis of subseptate or arcuate uterus on hysteroscopy and TV 3D US with or without SIH with measurement of mid fundal protrusion length. For this study we used strict criteria for the diagnoses of the above-mentioned anomalies on hysteroscopy. Such criteria would be a mid fundal protrusion length of ≥15 mm. Such measurement was done at time of diagnostic hysteroscopy using straight resectoscope loop. The TV 3D US definition of such anomalies was a mid fundal protrusion length ≥10 mm. Mean age (years) was 32.6 ± 5.2, mean duration of infertility (years) was 2.9 ± 2.5, mean BMI (kg/m2) was 27.3 ± 6.8, mean FSH level (mIU/ml) was 7.1 ± 2.9 and primary infertility was present in 68.7%. Of the 556 patients included in this analysis, 83 patients had significant subseptate uterus and 161 patients had significant arcuate uterine anomaly on hysteroscopy. Fourteen patients had subseptate uterus and 12 patients had arcuate uterine anomaly on TV 3D US. The prevalence of significant subseptate uterus (14.9%) and arcuate uterine anomaly (29.0%) on hysteroscopy was significantly higher than the prevalence subseptate uterus (2.5%) and arcuate uterine anomaly (2.2%) on TV 3D US (p = 0.000). Our data suggest that TV 3D US tends to underestimate the prevalence of significant subseptate uterus and arcuate uterine anomaly compared to hysteroscopy. Prevalence of such anomalies in infertility patients is much higher than what is reported in the literature. Diagnostic hysteroscopy is the gold standard for diagnosis of such anomalies.

Outcome of assisted reproduction in women with congenital uterine anomalies: a prospective observational study.

To assess the prevalence of congenital uterine anomalies, including arcuate uterus, and their effect on reproductive outcome in subfertile women undergoing assisted reproduction. Consecutive women referred for subfertility between May 2009 and November 2015 who underwent assisted reproduction were included in the study. As part of the initial assessment, each woman underwent three-dimensional transvaginal sonography. Uterine morphology was classified using the modified American Fertility Society (AFS) classification of congenital uterine anomalies proposed by Salim et al. If the external contour of the uterus was uniformly convex or had an indentation of < 10 mm, but there was a cavity indentation, it was defined as arcuate or septate. Arcuate uterus was further defined as the presence of a concave fundal indentation with a central point of indentation at an obtuse angle. Subseptate uterus was defined as the presence of a septum, not extending to the cervix, with the central point of the septum at an acute angle; if the septum extended to the internal cervical os, the uterus was defined as septate. Reproductive outcomes, including live birth, clinical pregnancy and preterm birth, were compared between women with a normal uterus and those with a congenital uterine anomaly. Subgroup analysis by type of uterine morphology and logistic regression analysis adjusted for age, body mass index, levels of anti-Müllerian hormone, antral follicle count and number and day of embryo transfer were performed. A total of 2375 women were included in the study, of whom 1943 (81.8%) had a normal uterus and 432 (18.2%) had a congenital uterine anomaly. The most common anomalies were arcuate (n = 387 (16.3%)) and subseptate (n = 16 (0.7%)) uterus. The rate of live birth was similar between women with a uterine anomaly and those with a normal uterus (35% vs 37%; P = 0.47). The rates of clinical pregnancy, mode of delivery and sex of the newborn were also similar between the two groups. Preterm birth before 37 weeks' gestation was more common in women with uterine anomalies than in controls (22% vs 14%, respectively; P = 0.03). Subgroup analysis by type of anomaly showed no difference in the incidence of live birth and clinical pregnancy for women with an arcuate uterus, but indicated worse pregnancy outcome in women with other major anomalies (P = 0.042 and 0.048, respectively). Congenital uterine anomalies as a whole, when defined using the modified AFS classification, do not affect clinical pregnancy or live-birth rates in women following assisted reproduction, but do increase the incidence of preterm birth. The presence of uterine abnormalities more severe than arcuate uterus significantly worsens all pregnancy outcomes. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Prevalence of Uterine Anomalies in Relation with Radiological Anatomy among Patients Attending Tertiary Care Centre

Introduction: Uterine anomalies arise due to malformation in the Mullerian duct development. These anomalies were often asymptomatic and unrecognized, also increases the risk of adverse pregnancy outcome like infertility, recurrent pregnancy loss, preterm delivery, amenorrhea, pain and fetal malpresentation. Many of these malformations were detected by radiologic or sonographic studies. Materials and Methods: Observational study includes 150 women between 18-35 years with gynecological problem in a tertiary care hospital in Kancheepuram district over a period of 1 year from January 2017 to January 2018. Pelvic imaging of study subjects with transabdominal and transvaginal ultrasound was performed as per the standard procedure. Results: Among 150 patients 75 had the complaint of primary infertility, 71 had primary amenorrhea and 4 came with frequent miscarriage. Out of 150 study subjects who underwent 2D ultrasonography, 69 showed uterine anomalies. Overall prevalence of anomalies was 46%, of which frequency of septate form of anomalies was maximum (45%), followed by bicornuate uterus (17%), arcuate uterus (16%), didelphic uterus (13%), unicornuate uterus (4.3%), and subseptate uterus (4.3%). Conclusion: Actual prevalence with correct assessment of anomalies using radiological anatomy will help to differentiate uterine anomalies and thereby suggests a right therapeutic option.

321 - Ultrasound-Guided Hysteroscopy- and Laparoscopy-Based Treatment of Different Mullerian Anomalies

This case series reports the evaluation and ultrasound-guided management of different Mullerian abnormalities by hysteroscopy and concomitant laparoscopy. 6 patients with septate uteri diagnosed by 2D/3D ultrasound and MRI showed 2 subseptate uteri, 1 arcuate uterus, 1 complete uterine septum, 2 complete uterine septum each with oblique vaginal septum and longitudinal vaginal septum. The procedure was transcervical resection of uterine septum with concomitant laparoscopy under ultrasound control. Incision with complete resection of the oblique and longitudinal vaginal septa was done using monopolar electrode. With concomitant laparoscopy, the pelvis was evaluated for pelvic masses, adhesions, fluid spillage into the pelvic cavity for tubal patency assessment, external fundal contour and the uterine cavity on transillumination. The advantages of post procedural evaluation of the uterine cavity by transrectal ultrasound guidance during hysteroscopic septoplasty are easy estimation of fundal thickness and depth of remaining septum.

Unilateral renal agenesis with subseptate uterus and sacrococcygeal teratoma: A unique triad.

Unilateral renal agenesis (URA) is a rare condition with a reported incidence of 0.93–1.8 per 1000 autopsies. It is commonly diagnosed as an incidental finding on imaging. URA is frequently associated with other genitourinary anomalies. Different associations have been described in both males and females, however, to our knowledge, it has not been reported with subseptate uterus (SSU) and sacrococcygeal teratoma (SCT) in the same individual. Here, we present a unique case of URA with SSU and SCT.

P047 Management of patients using intrauterine contraception device- how a 3d scan can help to make a diagnosis?

Introduction3D scanning can enhance the ability of a clinician to make an accurate diagnosis. The aim of this study was to evaluate the usage of 3D scanning in making a...

不全中隔子宮に対する子宮鏡下子宮腔形成術後の妊娠成績に関する検討

Objective: To examine the efficacy of transcervical resection (TCR) for subseptate uterus in patients with infertility or recurrent miscarriage.

Twin pregnancy in the congenital malformed uterus

The frequency and outcome of twin pregnancies in women with uterine malformation were studied. The cohort comprised 13 (4.9%) women with twin pregnancy found among 263 women. They had 483 deliveries, 13 of them twins (2.7%; 95% CI 1.6–4.6%). Among 38 patients with unicornuate uterus 5 (6.8%) out of 74 deliveries were twins, 39 women with didelphic uterus 2 (3.2%) out of 62 deliveries and 147 women with septate or subseptate uterus 6 (2.3%) out of 264 deliveries were twins. The mean duration of gestation was 249 days (range 190–268 days), 5 (38%) out of 13 deliveries were premature, 25 out of 26 newborns were alive. Mean durations of gestation and mean weights of newborns did not differ when 7 cases with unicornuate or didelphic uterus were compared to 6 cases with complete or partial uterine septum. A congenital malformed uterus can bear twin pregnancy without severe complications apart from prematurity.

Novel heterozygous deletion in the HNF1β gene - adolescent with antibody negative diabetes, longstanding hyperglycaemia without ketosis, cataracts, small echogenic kidneys with a cortical cyst, pancreatic atrophy, exocrine pancreatic insufficiency and a uterine anomaly

A 13 year old pubertal Caucasian female presented with longstanding polyuria/polydipsia and weight loss of 12kg over 4 months (BMI decreased from 23 to 17.5kg/m2 despite a 5cm height gain). There was no personal / family autoimmunity history. A paternal grandparent was thought to have type 2 diabetes. She was haemodynamically stable and mildly dehydrated without clinical signs of insulin resistance. She had bilateral stellate posterior subcapsular cataracts. Plasma glucose was 57mmol/L with normal blood ketones and venous pH. HbA1c was 18.2% (175mmol/mol). Mildly elevated urea and creatinine corrected after rehydration. Liver function tests, serum magnesium and urate were normal. Islet autoantibodies were negative. Renal ultrasound (US) identified bilaterally small kidneys (<5th centile), with echogenic parenchyma, reduced corticomedullary differentiation, normal cortical thickness and a 5mm left cortical cyst. Urinary albumin/creatinine and calcium/creatinine were normal. Further imaging (US and MRI) demonstrated severe pancreatic atrophy and a mullerian duct anomaly (arcuate / subseptate uterus). Faecal elastase 1 in a soft stool sample was low (range of severe exocrine pancreatic insufficiency). However the patient has gained weight with insulin treatment and had normal measures of fat-soluble vitamins.

2092307 Clinical Relevance Of Uterine Subseptations: Does The Differentiation Between Arcuate And Septate Uterus Still Matter?

Uterine cavity subseptations are correlated with adverse pregnancy outcomes and the length of the uterine cavity subseptum artificially differentiates between arcuate (<10 mm) and septate (≥10 mm) uterus. Existing recommendations warrant correction of septate uteri, only. Based on the decrease in cavity width after surgical correction of arcuate and septate uteri, we evaluated whether a different subseptation length is clinically indicated to correct. This was a prospective cohort study. Patients diagnosed with arcuate or subseptate uteri were evaluated with 3-D ultrasound before and after undergoing surgical resection of the anomalies by hysteroscopic separation of the anterior from the posterior wall. Measurements of the subseptum’s length (measured from the base to the tip of the septum) and width (measured at the septum’s base as it comes off the fundus), and cavity width (measured between the tubal ostia, at the fundus), were obtained on a frozen coronal view of the uterus. We used t-test, Pearson correlations, and we created an ROC curve using a cut off of 5 mm difference in cavity width in pre-, and post-operative measurements. A p<0.05 defined significance. Seventy patients were included in the study. Fourty-five had a subseptum <10 mm and 25 had a subseptum ≥10 mm. Subseptum width was 18.5±7.2 mm in the arcuate and 23.7±8.6 mm in the septate uterus groups, respectively. The post-operative cavity width (28±10 mm) was correlated to the pre-operative subseptum length (R=0.42; p=0.016) and width (R=0.54; p=0.001). The ROC curve identified 5.4 mm (sensitivity=50%, specificity=73%) as a threshold subseptum length which portrays a post-operative cavity remodeling similar to a 10 mm length. The clinical relevance of the arcuate uterus is currently undetermined and underrated. Our data indicate a new subseptation cut-off length with clinical relevance similar to a septate uterus. We propose a revision of the recommendations for surgical correction to include subseptation lengths greater than 5.4 mm.

A Unique Case of Twin Gestation in Subseptate Uterus after Spontaneous Conception

ABSTRACT Abnormal fusion of the müllerian ducts or failure of absorption of the septum during embryological life results in a variety of congenital uterine malformations. These congenital abnormalities are associated with abortions, premature labor, premature rupture of the membranes and malpresentation. We are reporting the rare occurrence of spontaneous twin gestation in a woman with subseptate uterus. How to cite this article Vijay N, Kawthalkar A, Kumare B. A Unique Case of Twin Gestation in Subseptate Uterus after Spontaneous Conception. J South Asian Feder Obst Gynae 2015;7(3):216-217.

Poor obstetrics outcome in an undiagnosed sub-septate uterus

This is a case of a 22-year-old woman who has had a second-trimester abortion and two preterm deliveries incidentally diagnosed of sub-septate uterus on hysterosalpingography (HSG). The case is presented to emphasize on the value of HSG in the management of recurrent pregnancy loss due to suspected Mullerian duct anomaly (MDA). The degree of intercornual angle distinguishes between the types of MDAs and angles of <75° that have a high diagnostic accuracy for the septate uterus variety.

Magnetic resonance imaging of uterovaginal lesions associated with female infertility

Abstract Objective To study the mandatory indications and accuracy of magnetic resonance (MR) imaging for the diagnosis of uterovaginal lesions associated with female infertility. Design Prospective cross sectional study. Main outcome measures Indications and accuracy of MR imaging for the diagnosis of uterovaginal lesions. Materials and methods 423 infertile women were investigated by hysterosalpingography (HSG) and transvaginal ultrasonography (TVUS). In 54 women having uterovaginal lesions and 76 women with tubo-ovarian lesions, the diagnosis was not conclusive by HSG and TVUS and consequently they were examined by MR imaging. The present study was devoted for infertile women suffering from uterovaginal lesions. Results MR imaging confirmed the diagnosis of agenesis of the uterus and the vagina (1 case), unicornuate uterus (2 cases, functioning rudimentary horn connected to the dominant horn in 1 case), uterus didelphys (1 case), bicornuate uterus (5 cases), septate and subseptate uteri (10 cases). Eighteen patients had multiple corporeal leiomyomas, 8 subserous and 10 intramural, diffuse adenomyosis, 14 cases and localized adenomyoma, 3 cases. Intramural leiomyomas showed enhancement on T2-weighted imaging suggesting a good response to uterine artery embolization (UAE). The size, number and location of myomas were precisely demonstrated on MR imaging, information necessary for myomectomy and UAE. The findings of MR imaging were compared with the final diagnosis after laparoscopy or surgical intervention and histopathological study. The accuracy, sensitivity, specificity, and positive and negative predictive values of MR imaging for diagnosing uterovaginal lesions associated with infertility were 100%. Conclusion The present study proved that MR imaging was the method of choice for precise diagnosis of uterovaginal lesions associated with infertility, when the diagnosis was not conclusive on HSG and TVUS. MR imaging was mandatory for conclusive diagnosis of mullerian duct anomalies, adenomyosis uteri and multiple uterine leiomyomas destined to myomectomy or uterine artery embolization. The accuracy, sensitivity, specificity and positive and negative predictive values of MR imaging for diagnosis of these lesions were 100%.

Clinical Significance of 3D Ultrasound Compared to MRI in Uterine Malformations

Congenital uterine anomalies often remain asymptomatic until they cause problems, for example during pregnancy. We studied the diagnostic aspects of two- and three-dimensional ultrasound and MRI. 63 women referred for suspected uterine anomalies were studied: In the first group (until July 2008) with 2 D-US and MRI, in the second group (from August 2008) additionally with 3 D-US; these women also had diagnostic or therapeutic operative confirmation. In the third group, only 3D-US was used. In all women 3D-US was possible and successful. The most common anomaly was a subseptate uterus, while a septate uterus was less frequent, and uterus bicornis (unicollis) and uterus didelphys (bicornis bicollis) were rare. The women in the first two groups all underwent at least diagnostic hysteroscopy, and some (subseptate or septate uterus) underwent operative hysteroscopy. After preoperative volume imaging, laparoscopies were required less often. 3D-US diagnoses as judged by intraoperative findings were correct in 100 % of cases, while the MRI diagnoses in the same group were correct in only 7/13 cases. Since the introduction of volume imaging (MRI, later 3 D-US), laparoscopy during hysteroscopic septum resection was not necessary in the majority of cases. 3D-US brings the diagnostics of uterine anomalies back into the hands of the gynecologist and can provide the gynecological surgeon with a higher subjective degree of certainty during operative hysteroscopy.

Third-Trimester Uterine Rupture Following Hysteroscopic Septoplasty: The Need for Standardization of Indications

Abstract Background: Hysteroscopic septal resection has become the treatment of choice for women with septate or subseptate uteri because of this procedure's increased safety and efficacy. The indications/benefits for septal resection should be balanced against the risks. This article presents a case that illustrates the potential catastrophe that can result from an intervention performed on a patient with a “soft” indication for this procedure. Case: A second gravida female, whose previous pregnancy was complicated by preeclampsia and fetal death, had a history of hysteroscopic septal resection. At 34 weeks' gestation, she presented with abruptio placenta and subsequently had a uterine rupture after two doses of prostaglandin E2 gel. She was given a laparotomy to remove the deceased fetus and the ruptured tissues were repaired. Her uterus was conserved. Results: This patient recovered well and was discharged on the ninth postoperative day. She was advised to use contraception for at least 1 year and to m...

Patient Diagnosed of Budd-Chiari Willing to Get Pregnant: Presentation of a New Case of Full-Term Pregnancy

Budd-Chiari syndrome is an infrequent pathology characterized by the obstruction of the suprahepatic venous outflow. It can manifest in several ways and may become very severe. So far, there is great controversy on the issue of whether these patients should become pregnant, because of the complications this implies in this disease. Nowadays, there are very few cases of full-term pregnancy with good outcome reported. We present a case of a 36-year-old patient with subseptate uterus diagnosed of Budd-Chiari with Polycythemia Vera (jack2 gene mutation and heterozygosity for factor V Leiden). After being treated and the disease controlled, the patient got pregnant. This is one of the few cases that exist with good outcome. Strict follow-up of the patient was carried out at our hospital and no complications occurred throughout pregnancy and postpartum. The patient was treated prior to pregnancy with low molecular weight heparin and antiplatelet drugs until 24 hours prior to labor. Delivery occurred by cesarean section (CS) at 37 weeks without complications. The healthy newborn was discharged with the mother after one week of hospitalization . The proper control of this disease prior to pregnancy , together with strict monitoring conducted during it seems one of the keys to make possible pregnancy in young patients willing to get pregnant. In conclusion, this case could not support the contraindication of pregnancy in certain cases of this pathology. Moreover, the patient should be always informed of all the existing risks and complications. doi: http://dx.doi.org/10.4021/jcgo148w

Ultrasound assessment of uterine cavity remodeling after surgical correction of subseptations

Arcuate and subseptate uteri taken together account for 53% of all Mullerian anomalies. Their incidence is even higher in patients with infertility and recurrent pregnancy loss and restoration of normal fertility/pregnancy outcomes are achieved with surgical correction. We sought to evaluate uterine cavity measurements in patients with arcuate or subseptate uteri in the pre- and post-resection periods.

Role of diagnostic hystero-laparoscopy in the evaluation of infertility: A retrospective study of 300 patients

OBJECTIVE:To determine the role of diagnostic hysterolaparoscopy in the evaluation of infertility in tertiary care centres.MATERIALS AND METHODS:This retrospective study was conducted at two tertiary care centres (the infertility clinics of Sriram Chandra Bhanj Medical College and Prachi hospital at Cuttack, Odisha) throughout the year in 2008. Women aged 20-40 years with normal hormone profile without male factor infertility were included.RESULTS:Out of 300 cases, 206 (69%) patients had primary infertility. While laparoscopy detected abnormalities in 34% of the cases, significant hysteroscopy findings were noted in 18% of cases. Together, diagnostic hysterolaparoscopy detected abnormalities in 26% of the infertile patients in both groups. While the most common laparoscopic abnormality was endometriosis (14%) and adnexal adhesion (12%) in primary and secondary infertile patients, respectively, hysteroscopy found intrauterine septum as the most common abnormality in both groups.CONCLUSIONS:Hysterolaparoscopy is an effective diagnostic tool for evaluation of certain significant and correctable tubo-peritoneal and intrauterine pathologies like peritoneal endometriosis, adnexal adhesions, and subseptate uterus, which are usually missed by other imaging modalities.

Successful outcome from empirical use of heparin and aspirin in unexplained pregnancy loss

Abstract Success in pregnancy of a 42-years old woman with a history of unexplained recurrent miscarriages is described. She had a sub-septate uterus with free spillage bilaterally, based on hysterosalpingogram, and it was corrected by hysteroscopy in October 2009, which was followed by transcervical septal resection (TCRS). Clomiphene citrate was given ovulation. She was treated with folic acid supplementation, aspirin 75 mg, micronized progesterone 400 mg/d, and low molecular heparin 2500 IU/d, from the diagnosis of pregnancy at 5 weeks, until the delivery. However, at 28 weeks glucose tolerance test with 100 g glucose revealed mild derangement in first (159 mg/dL) and second (164 mg/dL) hour values; metformin was given for the control of sugar. Heparin injections were given to the patient continuously during the antenatal period. No major bleeding episode was noted during pregnancy or delivery. A male child weighing 3.2 kg with a good APGAR score was delivered at the end of the term. Both anatomical abnormality and advanced maternal age had determinative role in pregnancy loss, but TCRS and antithrombotic heparin and aspirin treatment had the blithesome effect.

No clinical relevance of the height of fundal indentation in subseptate or arcuate uterus: a prospective study

The American Fertility Society has classified the arcuate uterus as a minor malformation with a benign clinical behaviour. The aim of this prospective study was to verify whether there is any scientific basis for this differentiation. Patients with at least one early miscarriage and a subseptate or arcuate uterus were admitted for hysteroscopic metroplasty. Patients were allocated to a subseptate uterus group, with an indentation of 1.5cm or more, or an arcuate uterus group, with a smaller indentation. The miscarriage rates after metroplasty were similar between the two groups (14.0% in the subseptate uterus group versus 11.1% in the arcuate uterus group). Before metroplasty, the miscarriage rates were significantly higher in subseptate uterus group, as well as in the arcuate uterus group (both P<0.001). According to these results, there is no evidence to support that the arcuate uterus has a different effect on the reproductive outcome in comparison to the subseptate uterus, neither before nor after surgical correction of the anomaly. Since there is no scientific basis for a separate classification of the arcuate uterus, a review of the classifications of uterine congenital anomalies should be considered as necessary.Congenital uterine malformations have been classified by the American Fertility Society (AFS) since 1988. Although the AFS classification received wide acceptance and is still the most broadly used system, it is associated with various limitations in effective categorization of the anomalies. It is interesting that, until now, none of the other available options have been able to effectively replace the AFS system. Numerous papers indicate septate or subseptate (partial septate) uterus (AFS class V) is a possible cause of an unfavourable pregnancy outcome. Arcuate uterus (AFS class VI), a slight malformation similar to septate uterus, should differ from septate or subseptate uterus, because this ‘minor’ malformation should behave benignly with respect to the septate uterus. The aim of this study was to scientifically validate the difference between the arcuate and subseptate uterus in their effect on reproductive outcome through the results of a metroplasty in both groups of patients. A group of 96 patients, who underwent metroplasty after at least one early miscarriage, was divided into two groups according to the severity of the congenital uterine malformation. Our results indicate that there are no differences in pregnancy outcome after metroplasty either in patients with septate or arcuate utera. The poor pregnancy outcome in women with septate uterus seems not to be correlated to the dimension of the septum itself. There are no scientific bases for a separate classification of the arcuate uterus and it is proposed that a review of the classification of uterine congenital anomalies is necessary.