To estimate the differences in frequency of diagnosis of septate uterus using three different definitions and determine whether these differences are significant in clinical practice, and to examine the association between diagnosis of septate uterus, using each of the three definitions, and infertility and/or previous miscarriage as well as the cost of allocation to surgery.This was a secondary analysis of data from a prospective study of 261 consecutive women of reproductive age attending a private clinic focused on the diagnosis and treatment of congenital uterine malformations. Reanalysis of the datasets was performed according to three different means of defining septate uterus: following the recommendations of the American Society for Reproductive Medicine (ASRM), a 2016 update of those of the American Fertility Society from 1988 (ASRM-2016: internal fundal indentation depth ≥ 1.5 cm, angle of internal indentation < 90° and external indentation depth < 1 cm); following the recommendations of the European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy (ESHRE/ESGE), published in 2013 and reaffirmed in 2016 (ESHRE/ESGE-2016: internal fundal/uterine indentation depth > 50% of uterine-wall thickness and external indentation depth < 50% of uterine-wall thickness, with uterine-wall thickness measured above interostial/intercornual line); and using a definition published last year which was based on the decision made most often by a group of experts (Congenital Uterine Malformation by Experts; CUME) (CUME-2018: internal fundal indentation depth ≥ 1 cm and external fundal indentation depth < 1 cm). We compared the rate of diagnosis of septate uterus using each of these three definitions and, for each, we estimated the association between the diagnosis and infertility and/or previous miscarriage, and anticipated the costs associated with their implementation using a guesstimation method.Although 32.6% (85/261) of the subjects met the criteria for one of the three definitions of septate uterus, only 2.7% (7/261) of them were defined as having septate uterus according to all three definitions. We diagnosed significantly more cases of septate uterus using ESHRE/ESGE-2016 than using ASRM-2016 (31% vs 5%, relative risk (RR) = 6.7, P < 0.0001) or CUME-2018 (31% vs 12%, RR = 2.6, P < 0.0001) criteria. We also observed frequent cases that could not be classified definitively by ASRM-2016 (gray zone: neither normal/arcuate nor septate; 6.5%). There were no significant differences (P > 0.05) in the prevalence of septate uterus in women with vs those without infertility according to ASRM-2016 (5% vs 4%), ESHRE/ESGE-2016 (35% vs 28%) or CUME-2018 (11% vs 12%). Septate uterus was diagnosed significantly more frequently in women with vs those without previous miscarriage according to ASRM-2016 (11% vs 3%; P = 0.04) and CUME-2018 (22 vs 10%; P = 0.04), but not according to ESHRE/ESGE-2016 (42% vs 28%; P = 0.8) criteria. Our calculations showed that global costs to the healthcare system would be highly dependent on the criteria used in the clinical setting to define septate uterus, with the costs associated with the ESHRE/ESGE-2016 definition potentially being an extra US$ 100-200 billion over 5 years in comparison to ASRM-2016 and CUME-2018 definitions.The prevalence of septate uterus according to ESHRE/ESGE-2016, ASRM-2016 and CUME-2018 definitions differs considerably. An important limitation of the ASRM classification, which needs to be addressed, is the high proportion of unclassifiable cases originally named, by us, the 'gray zone'. The high rate of overdiagnosis of septate uterus according to ESHRE/ESGE-2016 may lead to unnecessary surgery and therefore unnecessary risk in these women and may impose a considerable financial burden on healthcare systems. Efforts to define clinically meaningful and universally applicable criteria for the diagnosis of septate uterus should be encouraged. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Congenital uterine anomalies are common but their effect on reproductive outcome is unclear. We conducted a systematic review to evaluate the association between different types of congenital uterine anomaly and various reproductive outcomes.Searches were performed using MEDLINE, EMBASE, the Cochrane Library and Web of Science. The Newcastle-Ottawa Quality Assessment Scale was used for quality assessment. Uterine defects were grouped into arcuate uteri, canalization defects (septate and subseptate uteri) and unification defects (unicornuate, bicornuate and didelphys uteri). Pooled risk ratios (RR) with 95% confidence intervals (CI) were computed using random effects models.We identified nine studies comprising 3805 women. Meta-analysis showed that arcuate uteri were associated with increased rates of second-trimester miscarriage (RR, 2.39; 95% CI, 1.33-4.27, P = 0.003) and fetal malpresentation at delivery (RR, 2.53; 95% CI, 1.54-4.18; P < 0.001). Canalization defects were associated with reduced clinical pregnancy rates (RR, 0.86; 95% CI, 0.77-0.96; P = 0.009) and increased rates of first-trimester miscarriage (RR, 2.89; 95% CI; 2.02-4.14; P < 0.001), preterm birth (RR, 2.14; 95% CI, 1.48-3.11; P < 0.001) and fetal malpresentation (RR, 6.24; 95% CI, 4.05-9.62; P < 0.001). Unification defects were associated with increased rates of preterm birth (RR, 2.97; 95% CI, 2.08-4.23; P < 0.001) and fetal malpresentation (RR, 3.87; 95% CI, 2.42-6.18; P < 0.001).Canalization defects reduce fertility and increase rates of miscarriage and preterm delivery. None of the unification defects reduces fertility but some are associated with miscarriage and preterm delivery. Arcuate uteri are specifically associated with second-trimester miscarriage. All uterine anomalies increase the chance of fetal malpresentation at delivery.Copyright © 2011 ISUOG. Published by John Wiley & Sons, Ltd.

Congenital uterine abnormalities are a heterogeneous group of uterine configurations that may adversely affect reproductive potential. Although subtle variations can occur, the more common abnormalities fall into two broad categories of unilateral development or failure of midline fusion. These abnormalities have been well described for over a century although the mechanisms of their unfavourable impact on fertility and clinical management have not been systematically studied until recently. The quality of the literature on this topic has traditionally fallen below the level on which solid evidence-based decisions can be made. Nonetheless, considerable progress has been made in recent times. The understanding of the aetiology of these abnormalities and how they impact reproduction has matured and evolved and this evolution and the growing body of recent studies better define clinical scenarios in which intervention will clearly and positively impact outcome. This article will review four common congenital abnormalities, their impact on reproduction, options for management and the role of assisted reproduction treatment in maximizing reproductive potential. Recommendations are made with consideration of the quality of the literature in an outcome-driven environment.Copyright © 2011 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

Twenty-nine cases of cervical incompetence were found among 98 women diagnosed as having a congenital uterine anomaly on hysterosalpingography, a high incidence of 30%. The highest incidence was found in the bicornuate uterus group--38%. The incidence of premature delivery and late abortion was higher in this group than in the rest of the patients with uterine anomalies (55% and 68%, vs. 45% and 32%). An obvious improvement in obstetrical performance was noted after cerclage. In the cervical incompetence group, term deliveries increased from 26% to 63%. Premature deliveries and late abortions dropped from 74% to 37%. Even in the patients with anomalous uterus without proven diagnosis of cervical incompetence, term deliveries increased from 64% to 96%, and pregnancies terminating prematurely dropped from 35.6% to 4%, following cerclage. No doubt exists as to the need for cerclage in cases of cervical incompetence. We also believe it should be performed prophylactically in cases of bicornuate uterus. The concept of routine prophylactic cerclage in all cases of uterine anomalies should be considered.

Fifteen women with diminished fertility as a result of congenital uterine anomalies were treated by cervical suture (cerclage) in the 11th-12th week of pregnancy without surgical correction of the uterine anomaly. None of these women had either clinical or radiological evidence of cervical incompetence. As a result of the treatment, 13 of the women delivered live full-term mature infants. None of the women aborted, only two women delivered prematurely, and both infants were alive and well. Comparison of these good results to the very poor outcome of previous pregnancies in these women points to a distinct advantage to be gained by cervical suture. As a result of this experience, we recommend cervical suture in cases of diminished fertility as a result of congenital uterine anomaly. We recommend that the suture be performed before considering surgical repair of the anomaly and irrespective of lack of evidence of cervical incompetence. Only in cases where cervical suture is unsuccessful, would we recommend surgical correction according to the accepted techniques.

Cervical incompetence is basically a cervix that is too weak to stay closed during a pregnancy. It is generally categorized as premature opening of the cervix without labor or contractions.To estimate the incidence of incompetence of the uterine cervix at patients with congenital uterine malformations.Our study was a retrospective and prospective one between 2002 and 2009. We evaluate the length of the cervix by transvaginal ultrasonography during the second trimester of pregnancy.We had 316 cases with congenital uterine malformations. From these we found 49 (15.3%) women with incompetence of the cervix: 8 (2.5%) with unicornuate uterus, 11 (3.4%) with bicornuate uterus and 30 (9.5%) cases uterus with septum. For all these wad made cerclage when we found funneling of the cervix or the cervix was open less than 4 cm. The use of ultrasonography has been very helpful with the diagnosis, and is made when the cervical os (opening) is greater than 2.5 cm, or the length has shortened to less than 20 mm. All patients had preterm delivery.When we have cases with congenital uterine malformations we must think that incompetence of the cervix could be associated, so we must assess the status of the cervix for these patients by serial ultrasound examinations starting between 16 and 20 weeks of gestation. Our patients had preterm delivery caused not only the incompetent cervix, but the malformation of the uterus is implicated also.