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Images in Women's Health

September 2004

Infertility Due to Uterine Anomaly

Elizabeth Puscheck, MD, MS

CASE HISTORY

A 29-year-old woman, gravida 1, para 0, presented with infertility of 2 years' duration. Her menstrual cycles were regular, and ovulation had been confirmed by ovulation prediction kits and midluteal pro-gesterone levels. The patient had undergone an uncomplicated first-trimester abortion several years earlier. She had no personal or family history of miscarriage, and her medical and surgical histories were likewise negative. Her husband was 30 years of age and healthy, and had never fathered any children. His semen analyses are notable for mild oligospermia (15 to 18 million/mL); other parameters were within normal limits.

A brief ultrasound was performed during her physical examination and it appeared normal. A hysterosalpingogram was ordered and the image is present below.

Click to enlarge

Figure. Hysterosalpingography was performed, revealing the image presented here.

DIAGNOSIS

This image is most consistent with a congenital T-shaped uterus.

Without calculation of uterine volume, ultrasonography did not suggest a T-shaped uterus. However, hysterosalpingography (HSG) is the preferred modality for making this diagnosis.¹ The family history was reviewed again, but there was no indication that the patient's mother received diethylstilbestrol (DES), and she denied using DES during her pregnancy with this patient or at any other time. Overall, her mother's pregnancies were uncomplicated except for mild hyperemesis gravidarum, which was well controlled and did not require hospitalization.

DISCUSSION

Typically, the occurrence of a T-shaped uterus is associated with DES exposure in utero. Indeed, on review of the literature, no cases were found reporting a T-shaped uterus without DES exposure. However, it makes biologic sense that a T-shaped uterus may occur naturally or with exposures other than DES.

This patient was initially treated with clomiphene citrate (CC) and intrauterine inseminations. Each cycle had excellent follicular growth with two to four mature follicles, but the endometrial thickness remained at less than 4 mm. Supplemental estrogen was administered orally and then vaginally, with minimal response. There was concern about the possibility of intrauterine adhesions, as the lining of a T-shaped uterus would be expected to respond to estrogen.²

In this patient, HSG showed no evidence of adhesions. Hysteroscopy was considered to evaluate and treat any adhesions, or possibly to correct the T-shaped uterus as described in a limited case series report,³ but this procedure was deferred. After several unsuccessful CC cycles, gonadotropin-releasing hormone therapy was initiated with insemination. The follicular response was excellent, and the endometrial lining attained a depth of more than 5 mm. The patient conceived a singleton pregnancy, and fetal heart motion was detected at 6.5 weeks' gestation. Her cervix remained long and closed, and no cerclage was required.⁴ There were no episodes of preterm labor, and the patient delivered a healthy infant at 38 weeks' gestation.

Elizabeth Puscheck, MD, MS, is assistant professor, Department of Obstetrics and Gynecology, Wayne State University Medical School, Detroit, Mich.

References

1. Kipersztok S, Javitt M, Hill MC, Stillman RJ. Comparison of magnetic resonance imaging and transvaginal ultrasonography with hysterosalpingography in the evaluation of women exposed to diethylstilbestrol. J Reprod Med. 1996; 41(5):347-351.
2. Noyes N, Liu HC, Sultan K, Rosenwaks Z. Endometrial pattern in diethylstilboestrol-exposed women undergoing in-vitro fertilization may be the most significant predictor of pregnancy outcome. Hum Reprod. 1996;11(12):2719-2723.
3. Katz Z, Ben-Arie A, Lurie S, Manor M, Insler V. Beneficial effect of hysteroscopic metroplasty on the reproductive outcome in a ‘T-shaped' uterus. Gynecol Obstet Invest. 1996; 41(1):41-43.
4. Golan A, Langer R, Neuman M, Wexler S, Segev E, David MP. Obstetric outcome in women with congenital uterine malformations. J Reprod Med. 1992;37(3):233-236.

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