Fundus Thickness Assessment by 3D Transvaginal Ultrasound Allows Metrics-Based Diagnosis and Treatment of Congenital Uterine Anomalies

Abstract

Purpose The development of a metric fundus assessment and definition of the uterine fundus thickness (FTH) for supporting objective diagnosis and treatment of congenital uterine anomalies (CUAs).

Materials and Methods A) In a prospective cohort study, FTH was systematically assessed by 3 D transvaginal ultrasound (TVS) in patients, who presented a normal uterus. B) The mean normal FTH recorded was applied to uteri with fundal protrusions and septations, and compared to two CUA classification systems (ASF and ESHRE/ESGE). C) FTH was studied for preoperative metric planning and evaluation of the postoperative outcome.

Results A) From August 2013 to January 2014, FTH was assessed in 100 normal uteri. An FTH of 12.02 +/- 2.03 mm (mean +/- SD) was recorded. B) Evaluating the 8 detected abnormal uteri, excellent correlation with the new ESHRE/ESGE classification system was observed, taking an FTH of 12 mm as the overall normal FTH equivalent to the individual normal wall thickness (WTH) stipulated in the classification and an FTH of 18 mm as the WTH + 50 %, serving as a cut-off value of (abnormal) septation. C) Metric fundus assessment was initially applied before and after septum resection and the following pregnancy could be monitored.

Conclusion An FTH measurement in 3 D TVS paves the way for metric fundus diagnostics. This objectively distinguishes normal from abnormal fundi. It also has the potential to support accurate septum resection planning and objective postoperative evaluation. The value of the fundus assessment and metrics proposed in this study is not known. It should be investigated in prospective randomized controlled trials.

Zusammenfassung

Ziel Entwicklung einer metrischen Beurteilung des uterinen Fundus mit Messung der uterinen Fundusdicke (FTH) zur Unterstützung einer objektiven Diagnostik und Therapie angeborener Uterusfehlbildungen (CUAs).

Material und Methoden A) In dieser prospektiven Kohortenstudie wurde bei Frauen mit normalem Uterus die FTH in der 3D-Transvaginalsonografie (TVS) standardisiert gemessen. B) Der erarbeitete FTH-Mittelwert wurde auf Uteri mit fundalen Protrusionen oder Septen angewendet und mit zwei CUA-Klassifikationen verglichen. C) Die FTH wurde als metrisches Instrument in der präoperativen Planung und Beurteilung des postoperativen Ergebnisses erstmalig untersucht.

Ergebnisse A) Von August 2013 bis Januar 2014 konnte die FTH an 100 normalen Uteri bestimmt werden. Sie maß 12,02 +/- 2,03 mm (mean +/- SD). B) In der Beurteilung der 8 entdeckten abnormalen Uteri wurde eine ausgezeichnete Übereinstimmung mit der ESHRE/ESGE Klassifikation gefunden, wenn 18 mm FTH (12 mm + 50 %) der ESHRE/ESGE-Regel individuelle Wanddicke (WTH) + 50 % gleich gesetzt und als Grenzwert zur Diagnose eines Septums angenommen wurde. C) In einem ersten Fall konnte die FTH-Messung vor und nach Septumresektion eingesetzt und die folgende Schwangerschaft begleitet werden.

Schlussfolgerung Die 3D-TVS-Messung der FTH eröffnet die metrische Fundusdiagnostik. Diese ermöglicht eine einfache und objektive Unterscheidung zwischen normalen und abnormalen Fundi. Sie besitzt zudem das Potential, eine exakte präoperative Planung einer Septumresektion durchzuführen und das operative Ergebnis objektiv zu beurteilen. Der Stellenwert der vorgestellten Messmethode wie auch der vorgeschlagenen Messgrößen ist nicht bekannt. Diese sollten in prospektiv randomisierten kontrollierten Studien überprüft werden.

Key words

congenital uterine anomalies - fundus thickness - 3 D ultrasound - hysteroscopy - uterine septum resection

• References

• 1 Chan YY. Jayaprakasan K. Zamora J. et al. The prevalence of congenital uterine anomalies in unselected and high-risk populations: a systematic review. Human Reproduction Update 2011; 17: 761-771
• 2 Saravelos SH. Cocksedge KA. Li TC. Prevalence and diagnosis of congenital uterine anomalies in women with reproductive failure: a critical appraisal. Hum Reprod Update 2008; 14: 415-429
• 3 Woelfer B. Salim R. Banerjee S. et al. Reproductive outcomes in women with congenital uterine anomalies detected by three-dimensional ultrasound screening. Obstet Gynecol 2001; 98: 1099-1103
• 4 Ghi T. Casadio P. Kuleva M. et al. Accuracy of three-dimensional ultrasound in diagnosis and classification of congenital uterine anomalies. Fertil Steril 2009; 92: 808-813
• 5 Gubbini G. Di Spiezio Sardo A. Nascetti D. et al. New outpatient subclassification system for American Fertility Society Classes V and VI uterine anomalies. J Minim Invasive Gynecol 2009; 16: 554-561
• 6 Ghi T. De Musso F. Maroni E. et al. The pregnancy outcome in women with incidental diagnosis of septate uterus at first trimester scan. Hum Reprod 2012; 27: 2671-2675
• 7 Bermejo C. Martinez Ten P. Cantarero R. et al. Three-dimensional ultrasound in the diagnosis of Müllerian duct anomalies and concordance with magnetic resonance imaging. Ultrasound Obstet Gynecol 2010; 35: 593-601
• 8 The American Fertility Society classifications of adnexal adhesions, distal tubal obstruction, tubal occlusion secondary to tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine adhesions. Fertil Steril 1988; 49: 944-955
• 9 Acien P. Acien M. Sanchez-Ferrer M. Complex malformations of the female genital tract. New Types and revision of classification. Hum Reprod 2004; 19: 2377-2384
• 10 Acien P. Acien M. Sanchez-Ferrer ML. Mullerian anomalies ‘‘without a classification’’: from the didelphys-unicollis uterus to the bicervical uterus with or without septate vagina. Fertil Steril 2009; 91: 2369-2375
• 11 Oppelt P. Renner SP. Brucker S. et al. The VCUAM (Vagina Cervix Uterus Adnex-associated Malformation) classification: a new classification for genital malformations. Fertil Steril 2005; 84: 1493-1497
• 12 Grimbizis GF. Gordts S. Di Spiezio Sardo A. et al. The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies. Hum Reprod 2013; 28: 2032-2044
• 13 Pabuçcu R. Gomel V. Reproductive outcome after hysteroscopic metroplasty in women with septate uterus and otherwise unexplained infertility. Fertil Steril 2004; 81: 1675-1678
• 14 Molle A. De Franciscis P. Colacurci N. et al. Hysteroscopic resection of the septum improves the pregnancy rate of women with unexplained infertility: a prospective controlled trial. Fertil Steril 2009; 91: 2628-2631
• 15 Grimbizis GF. Camus M. Tarlatzis BC. et al. Clinical implications of uterine malformations and hysteroscopic treatment results. Hum Reprod Update 2001; 7: 161-174
• 16 Raga F. Bonilla-Musoles F. Blanes J. et al. Congenital Müllerian anomalies: diagnostic accuracy of three-dimensional ultrasound. Fertil Steril 1996; 65: 523-528
• 17 Wu MH. Hsu CC. Huang KE. Detection of congenital Müllerian duct anomalies using three-dimensional ultrasound. J Clin Ultrasound 1997; 25: 487-492
• 18 Letterie GS. Structural abnormalities and reproductive failure: Effective techniques of diagnosis and management. New York: Blackwell Science; 1998
• 19 Bermejo C. Martinez Ten P. Recio M. et al. Three-dimensional ultrasound and magnetic resonance imaging assessment of cervix and vagina in women with uterine malformations. Ultrasound Obstet Gynecol 2014; 43: 336-345
• 20 Imboden S. Müller M. Raio L. et al. Clinical significance of 3D ultrasound compared to MRI in uterine malformations. Ultraschall in Med 2014; 35: 440-444
• 21 Jayaprakasan K. Chan YY. Sur S. et al. Prevalence of uterine anomalies and their impact on early pregnancy in women conceiving after assisted reproduction treatment. Ultrasound Obstet Gynecol 2011; 37: 727-732
• 22 Verguts J. Ameye L. Bourne T. et al. Normative data for uterine size according to age and gravidity and possible role of the classical golden ratio. Ultrasound Obstet Gynecol 2013; 42: 713-717
• 23 Troiano R. McCarthy S. Mullerian duct anomalies: imaging and clinical issues. Radiology 2004; 233: 19-34