Reproductive Implications and Management of Congenital Uterine Anomalies

Abstract

Plain language summary Congenital uterine anomalies (CUAs) are malformations of the womb that develop during fetal life. When a baby girl is in her mother’s womb, her womb develops as two separate halves from two tubular structures called ‘müllerian ducts’, which fuse together before she is born. Abnormalities that occur during the baby’s development can be variable from complete absence of a womb through to more subtle anomalies, which are classified into specific categories. While conventional ultrasound is good in screening for CUAs, 3D ultrasound is used to confirm a diagnosis. If a complex womb abnormality is suspected, MRI scanning may also be used, with a combination of laparoscopy in which a camera is inserted into the cavity of the abdomen, and hysteroscopy, when the camera is placed in the womb cavity. As there can be a link between CUAs and abnormalities of the kidney and bladder, scans of these organs are also usually requested. Although CUAs are present at birth, adult women typically do not have any symptoms, although some may experience painful periods. Most cases of CUA do not cause a woman to have difficulty in becoming pregnant and the outcome of pregnancy is good. However, these womb anomalies are often discovered during investigations for infertility or miscarriage. Moreover, depending upon the type and severity of CUA, there may be increased risk of first and second trimester miscarriages, preterm birth, poor growth of the baby in the mother’s womb (fetal growth restriction), pre‐eclampsia and difficult positioning of the baby for birth (fetal malpresentation). Surgical treatment is only recommended to a woman who has had recurrent miscarriages and has a septate uterus, i.e., the womb cavity is divided by a partition. In this case, surgery may improve her chances for a successful pregnancy, although the risks of surgery, especially scarring of the womb should be considered. However, further evidence from randomised controlled trials are required to provide conclusive evidence‐based recommendations for surgical treatment for septate uterus. Surgical treatment for other types of CUAs is not usually recommended as the risks outweigh potential benefits, and evidence for any benefits is lacking. Women with CUAs may be at an increased risk of preterm birth even after surgical treatment for a septate uterus. These women, if suspected to be at an increased risk of preterm birth based on the severity of CUA, should be followed up using an appropriate protocol for preterm birth as outlined in UK Preterm Birth Clinical Network Guidance.1>

Reproductive Performance Following Hysteroscopic Surgery for Uterine Septum: Results from a Single Surgeon Data

“…High quality evidence through randomized controlled prospective trials is still lacking on the efficacy of surgical treatment on improving the reproductive outcomes so as to generate evidencebased recommendations. However, based on retrospective observational studies assessing the pre-and post-operative reproductive outcome of women with septa and on nonrandomized comparative studies between septum resection and expectant management, hysteroscopic septum treatment by experienced specialists in symptomatic women has been adopted as having a beneficial effect on reproductive outcome [7,8,10,11,13,14]. Similarly, the American Society for Reproductive Medicine (ASRM) and the National Institute for Health and Care Excellence (NICE), recommended hysteroscopic treatment of septate uterus in patients with infertility and unfavorable pregnancy outcomes [5,25].…”

“…This may be complete or partial failure of resorption, leading to either a complete septum or subseptate uterus [3]. There is no universally accepted classification system of congenital uterine anomalies including septa, however the most commonly used are the European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy (ESHRE/ESGE) classification system, the American Society of Reproductive Medicine (ASRM) system, and the Congenital Uterine Malformation by Experts (CUME) criteria, which allow objective classifications based on 3D ultrasound [4][5][6][7]. Women with septate uterus have an increased risk of subfertility and pregnancy complications including pregnancy loss, preterm delivery, fetal mal-presentation and intrauterine growth retardation, resulting in poor outcomes including higher perinatal morbidity and mortality [2,8].…”

“…Hysteroscopic septum incision guided by preoperative three-dimensional ultrasound imaging is considered a solution and has been standard treatment for those patients with impaired reproductive outcomes. Although high quality evidence through randomized controlled prospective trials is still lacking on the efficacy of surgical treatment, the current evidence from retrospective observational studies and non-randomized comparative studies shows that septum surgery is beneficial in symptomatic women [7,8,[10][11][12][13][14]. There has been a recent controversy on the need for surgery for septum [15].…”

Kinderwunsch bei Müller-Gang-Fehlbildungen – Diagnostik und Therapie

“…Es gibt aber viele Arbeiten, die den Wert der Metroplastik infrage stellen. In einem aktuellen Review-Artikel wurde sowohl von der laparoskopischen als auch von der abdominalen Metroplastik aufgrund der intraund postoperativen Komplikationen und der fehlenden Evidenz in Bezug auf das reproduktive Outcome abgeraten [8].…”

Successful vaginal delivery in a woman with longitudinal vaginal septum: a case report

“…2 The ESHRE/ESGE classification includes descriptions for all female genital tract malformations including vagina (uterine U0-U6, cervical C0-C4 and vaginal V0-V4). 3 A longitudinal vaginal septum is a rare congenital anomaly that can cause dyspareunia, difficulty with tampon insertion, infertility and dysmenorrhea. 4 It is commonly associated with uterine didelphys, bicornuate uterus or complete septate uterus.…”