Recurrent Implantation Failure—Is It the Egg or the Chicken?

Recurrent implantation failure (RIF) is an undefined, quite often, clinical phenomenon that can result from the repeated failure of embryo transfers to obtain a viable pregnancy. Careful clinical evaluation prior to assisted reproduction can uncover various treatable causes, including endocrine dysfunction, fibroid(s), polyp(s), adhesions, uterine malformations. Despite the fact that it is often encountered and has a critical role in Assisted Reproductive Technique (ART) and human reproduction, RIF’s do not yet have an agreed-on definition, and its etiologic factors have not been entirely determined. ART is a complex treatment with a variable percentage of success among patients and care providers. ART depends on several factors that are not always known and probably not always the same. When confronted with repeated ART failure, medical care providers should try to determine whether the cause is an embryo or endometrium related. One of the most common causes of pregnancy failure is aneuploidy. Therefore, it is likely that this represents a common cause of RIF. Other RIF potential causes include immune and endometrial factors; however, with a very poorly defined role. Recent data indicate that the possible endometrial causes of RIF are very rare, thereby throwing into doubt all endometrial receptivity assays. All recent reports indicate that the true origin of RIF is probably due to the “egg”.

The incidence of uterine abnormalities

Background: Congenital uterine abnormalities result from abnormal formation, fusion or resorption of the Mullerian ducts during fetal life. These abnormalities have been associated with an increased rate of miscarriage, preterm birth, and other fetal adverse outcomes. Material and methods: Was performed a clinical observational retrospective study of uterine malformations, diagnosed in the Republic of Moldova. Pelvic MRI (1.5-3 tesla) with contrast and without were examined, from 01.01.2016 to 20.11.2016. During this time, 190 MRIs were performed according to the program, 167 MRIs were included in the study, 23 MRIs were excluded, having total or partial hysterectomy performed. The age of the examined persons is between 81 years and 6 months. Results: 15 uterine malformations were detected, which represent 11.13%. Among the uterine abnormalities were detected 6 cases of bicorn uterus, 3 cases of didelph uterus, 2 cases of uterine agenesis and septate uterus and one case of arcuate uterus, and unicorn. Conclusions: In this study it was determined that the prevalence of uterine malformations in an unselected population in the Republic of Moldova is 11.13%, and that of the septate uterus is 1.2%, data that are similar and correspond to the international literature.

A very rare case report of bilateral maldescended ovaries and müllerian duct anomaly associated with inflammatory myositis, myasthenia gravis and thymic pathology

Background Maldescended ovaries are a rare condition. Despite its different embryologic development with the uterus, maldescended ovary is usually accompanied by uterine malformations and is found during the course of infertility. In other cases, it may be incidentally diagnosed in examinations due to abdominal pain or in a survey of finding paraneoplastic origin. Probable immune-related developmental conditions are associated with this abnormality; sometimes cross-reaction with other immune-related diseases is possible. Case presentation Here, the probable paraneoplastic origin is surveyed for a patient with coexisting inflammatory myositis and myasthenia gravis. According to this survey non recognized Mullerian duct and ovarian anomalies were found. Conclusions Knowledge about this anatomical abnormality is helpful for clinicians to prevent misdiagnosis and improper management. Moreover, understanding the probability of accompanying other conditions such as immune-related and neuromuscular junction disorders with Mullerian duct anomalies can offer a comprehensive insight.

O-006 Diagnosis debate – USG vs endoscopy

text MULLERIAN ANOMAIES – DEBATE USG OR ENDOSCOPY Mullerian duct anomalies are a complex spectrum of congenital anomalies resulting from defective fusion or canalization leading to different uterine anomalies. Early detection and proper diagnosis of uterine anomalies are paramount for proper management. Outflow obstruction defects like transvers septal defects or non canalised functional horn present early with complaint of pain while rest of patients present with amenorrhoea , infertility, repeated first-trimester abortion, fetal intrauterine growth restriction, and obstetric complications.The prevalence of uterine malformations is variable depending on the population studied , 0.4% , 4 % respectively in the general population and in infertile women while a high prevalence between 3 and 38% is reported in patients with repeated spontaneous miscarriages. Imaging plays an important role in diagnosis and treatment planning in mullerian duct anomalies. There are different imaging and endoscopic modalities that can be used for the diagnosis and confirmation of uterine malformations. All modalities are having limitations and one need to select and combine various modalities depending on the clinical presentation of patient and pelvic examination. In younger patients or acute cases, trans abdominal ultrasonography (US) is the preferred method because it is readily available, inexpensive, and rapid and does not use ionizing radiation. However it may not give the complete picture because of poor demarcation especially in fatty patient and owing to complex nature of defects , Field-of-view restrictions with US, patient body habitus, and artefact from bowel gas. Pelvic magnetic resonance imaging (MRI) is an excellent tool in the diagnosis of Mullerian duct anomalies due to high soft tissue resolution. But it is more expensive and less available. 3D ultrasound may be a valid alternative to pelvic MRI as It is less expensive and better tolerated by patients however in doubtful cases of complex nature , hysteroscopy combined with laparoscopy may be considered to confirm the diagnosis. Another advantage of endoscopy is the opportunity to correct the defect in the same sitting in most of the cases. Hysterosalpingography (HSG) and hysteroscopy are considered good modalities to assess the uterine cavity. Hysteroscopy provide the direct visualisation of the defect and considered as gold standard for cavity evaluation in doubtful cases of septate and bicornuate uterus and for simultaneous correction. However outer contour cannot be visualised so one need to use laparoscopy for complete evaluation which is a major drawback. Three-dimensional transvaginal sonography provides image quality like those provided by MRI and is being extensively used for diagnosis of all sorts of mullerian defects. it has got the advantage of realtime imaging which is helpful in distorted pelvic anatomy , visualisation of outer contour is possible ,which is considered very important to differentiate between bicornuate and septate uterus and unicornuate uterus with rudimentary horn. however it may not be possible in all cases to get a definitive diagnosis inspite of using a high end 3D machine specially in presence of artefacts , distorted contour and retroverted uterus. In such cases both modalities including MRI and endoscopy may be required to reach to a definitive diagnosis. It can be concluded that primary imaging tool is still 2d ultrasound but 3D TVS should be included in all suspected anomalies along with complete careful pelvic examination to corroborate the findings of USG. In doubt ful or complex cases, MRI should be performed particularly for cervical and vaginal atresia and septum. endoscopy should be reserved for all doubtful cases for confirmation and for acute cases where a corrective surgery can also be planned to relieve the distress.

A rare case of successful twin pregnancy in bicorporeal septate uterus with co-existent septate cervix

Pregnancy occurring in patients with uterine malformations need to be managed with care as they are at risk of developing adverse outcomes. Multiple pregnancies in patients with uterine abnormalities further increase the risk of complications. Due to the rarity of this problem, there are no recommendations to guide and plan the management of these patients. Delivery planning is also tricky and needs to be individualised as either mode of delivery can be associated with complications. We discuss the management of a twin pregnancy in a primigravida (conceived after ovulation induction) with Mullerian abnormality- Septate uterus with co-existent septate cervix; ESHRE type U-2B C-1.

ABNORMAL UTERUS A CAUSE FOR MISCARRIAGE

Some women have a congenital uterine abnormality, which is a womb/uterus that is formed in an unusual way before birth. Uterine malformations occur due to a birth defect. In the womb, female infants develop two separate halves of their uterus that merge together before birth. If the two halves fail to merge completely, the woman may be born with a malformed uterus. Uterine malformations make up a diverse group of congenital anomalies that can result from various alterations in the normal development of the Mullerian ducts. It has been found that the prevalence of uterine abnormality is estimated to be 6.7% among general population. About 18% of women who have recurrent miscarriages have some type of uterine abnormality. Uterine conditions don't always show signs or symptoms until one tries to conceive. When a baby girl is developing in the womb, two small tubes call Mullerian ducts come together to form her uterus. For some baby girls, the Mullerian ducts don't come together completely. Symptoms range from amenorrhea, infertility, recurrent pregnancy loss, and pain, to normal functioning depending on the nature of the defect. A uterine malformation that does not usually cause symptoms does not usually require treatment. However, if the malformation if causing problems, then surgery will be considered. Surgical intervention aims to x the malformation and can often be performed laparoscopically with a hysteroscope.

Sonographic and Hysteroscopic Assessment of Uterine Congenital Malformations: A Retrospective Study

Aim: Congenital uterine malformations are often diagnosed via Transvaginal Sonography (TVS) and/or office hysteroscopy. Few studies address the diagnostic accuracy of both techniques in detecting these abnormalities. The aim of this study is to evaluate sonographic and hysteroscopic findings in women with uterine congenital malformations. Methods and Materials: A nested retrospective study on 137 medical records of women with congenital malformations undergoing vaginoscopic office hysteroscopic and transvaginal sonographic assessment in the Endoscopic Unit, Department of Gynaecology, University Hospital of Ioannina, Greece was conducted. All women were examined initially via Transvaginal Sonography (TVS) and the sonographic findings were correlated with the hysteroscopic findings. Women with septate or bicornuate uteri confirmed their pathology through laparoscopy, a proposed gold standard technique. Result: Hysteroscopy was able to detect 136 out of 137 cases of congenital malformations with a false positive bicornuate uterus. Transvaginal sonography (TVS) showed moderate diagnostic accuracy accompanied by positive predictive value (PPV) at 79.79%, negative predictive value (NPV) at 99.17%, sensitivity at 79.79%, and finally specificity at 99.17%. Endometrial thickness assessed by TVS was found to be higher in cases of complete septate and bicornuate uteri. The incidence of congenital malformation within the total population was estimated at 4.56%. Conclusion: Diagnostic hysteroscopy is a reliable tool in detection uterine congenital malformations compared to two-dimensional sonography. Office hysteroscopy demonstrates high diagnostic accuracy and should replace traditional sonographic assessment in determining congenital uterine malformations. Clinical significance: Hysteroscopy is superior than TVS in detecting uterine congenital malformations.