Uterine Malformation: Diagnosis and Results After Hysteroscopic Metroplasty

Abstract

Uterine anomalies result from a defect in the development or fusion of the paired Mullerian ducts during embryogenesis and are the most common types of malformations of the female reproductive system. The septate uterus is the most common structural uterine anomaly and results from failure of the partition between the two fused Mullerian ducts to resorb (Taylor and Gomel 2008). Congenital malformations may be associated with recurrent pregnancy loss, preterm labor, abnormal fetal presentation, and infertility (Heinonen et al. 1982). The overall frequency of uterine malformations was 4.0 % (Raga et al. 1997). Infertile patients (6.3 %) had a significantly (P < .05) higher incidence of Mullerian anomalies, in comparison with fertile patients (3.8 %). Septate (33.6 %) and arcuate (32.8 %) uteri were the most common malformations observed (Raga et al. 1997). The septate uterus is associated with the highest incidence of reproductive failure among the Mullerian anomalies (Fedele et al. 1993). Thirty-eight percent to 79 % of pregnancies in women with septate uteri ended in miscarriage (Raga et al. 1997; Homer et al. 2000). Such outcomes are thought to be a result of poor blood supply, rendering the septum inhospitable to the implanting embryo (Fedele et al. 1996). Diagnosis is established with hysterosalpingography, magnetic resonance imaging, and ultrasound. The diagnostic accuracy of hysterosalpingography in patients with septate uteri has been reported to be between 20 and 60 % (Braun et al. 2005; Pellerito et al. 1992). Transvaginal ultrasonography is more accurate, with a sensitivity of 100 % and a specificity of 80 % in the diagnosis of the septate uterus (Pellerito et al. 1992). Three-dimensional sonography (3DULS) is associated with an even higher diagnostic accuracy of 92 % (Wu et al. 1997) and hysterosonography, with a 100 % diagnostic accuracy in the largest series published to date (Alborzi et al. 2002). The benefit of 3DULS is the view of the uterus in the coronal plane, which allows the operator to distinguish between arcuate, septate, and bicornuate uteri, thereby eliminating the need for simultaneous laparoscopy (Figs. 3.1 and 3.2). In this review we describe the diversity of clinical presentations, management strategies, and report the obstetric outcomes observed in our series of 114 women with uterine septa.