Abnormalities of the uterus can have a significant impact on the ability of a woman to conceive and to carry a pregnancy successfully. Some women have an abnormally developed uterus from birth (congenital) while others may develop a uterine problem due to infection or surgery (acquired).
Fertility problems involving the uterus include:
A variety of uterine factors can play a significant role in reproductive failure. These factors may contribute to infertility and also to recurrent miscarriage. Even when uterine factors are diagnosed, all other potential factors which might contribute to infertility should be aggressively evaluated and treated. Only when the entire picture is clearly understood and alternatives, risks, and benefits have been thoroughly discussed should a surgical approach be considered.
The diagnosis of congenital uterine anomalies is made on the basis of clinical suspicion and a hysterosalpingogram (HSG, or uterine x-ray). The diagnosis is often suspected at the time of an office ultrasound, particularly when a fluid contrast ultrasound (sonohysterogram) is performed. This is done by injecting a small amount of sterile water or saline (usually several tablespoons) and looking at the uterus by transvaginal ultrasound. It is performed in the office and is not usually very uncomfortable. These ultrasound techniques will often allow the physician to see two separate uterine cavities and may also allow discrimination between the septate and bicornuate uterus. Even if the diagnosis is strongly suspected at the time of the sonohysterogram, hysterosalpingogram (HSG or uterine x-ray) is usually recommended in order to confirm the size of the septum and the caliber of the individual uterine horns. Magnetic resonance imaging (MRI) has also been used to aid in the diagnosis and clarification of these anomalies, but does not commonly add very much to the combination of ultrasound and HSG.
If a woman with repeated miscarriages has a double uterus as described above it is often assumed that the congenital uterine anomaly is the cause of the problem. However, it is important to exclude any other factor contributing to miscarriage before initiating treatment. Surgical repair should only be considered after a thorough evaluation and an extensive discussion between patient and physician.
Surgical correction of the uterus (metroplasty) is the recommended approach for treatment of the septate or bicornuate uterus. One important study confirmed that very intense obstetrical observation and management did not improve the obstetrical outcome for patients with these anomalies, reinforcing the role of surgery in their treatment. At the time of metroplasty, the distinction between bicornuate and septate uterus must be clear. If the surgeon is not absolutely confident of the diagnosis prior to surgery, then laparoscopy should be performed as the first step. If the diagnosis of septate uterus is made by finding a normal external uterine configuration, the septum can usually be removed by hysteroscopy while the patient is still under anesthesia. However, if the external configuration is "rabbit-eared" suggesting a bicornuate uterus, surgical correction is performed by laparotomy (open abdominal surgery) at which time the abnormal uterine cavity is surgically united. In the first case, pregnancy can be attempted relatively soon after surgery, and the prognosis for a successful pregnancy is excellent. In general, the woman is allowed to have a normal labor and vaginal delivery. However, after surgery for a bicornuate uterus, it is generally recommended that patients wait at least three months before conceiving, and that cesarean section be performed for delivery. This recommendation is based on an increased risk of uterine rupture during labor for women who have had surgical correction of a bicornuate uterus. No surgical procedure has been shown to be effective in the treatment of either unicornuate uterus or uterus didelphys.