Uterine Abnormalities

Uterine Abnormalities are associated with infertility, recurrent miscarriages, fetal intrauterine growth restriction, preterm labor, and retained placenta.

When uterine abnormalities occur from birth, they are known as Mullerian defects. Two Mullerian ducts grow and later fuse together to develop a single uterus, cervix, and vagina. If this development is disrupted, Mullerian defects occur. Mullerian defects include a unicornuate uterus, a septate uterus, a bicornuate uterus, uterine didelphys, Mullerian agenesis, and a T-shaped uterus.

With a unicornuate uterus, the uterine cavity is only half the size that it should be and the patient only has one functioning fallopian tube. Though pregnancy may be possible, the risks for late 2nd and 3rd trimester pregnancy losses, as well as ectopic pregnancy, increase.  Currently, no surgical repair exists to correct a unicornuate uterus.

A septate uterus occurs when the Mullerian ducts fuse together to form one uterus but all tissue is not reabsorbed, leaving a wall of connective tissue between each uterus. This wall of connective tissue has extremely poor blood supply and may make implantation of an embryo very difficult. If implantation does occur, miscarriage is much more likely because the embryo does not receive the blood flow and nutrients it requires during development. Your doctor can perform surgery to remove the uterine septum and allow the uterine cavity to essentially function in a normal capacity.  The surgery is typically done by hysteroscopy and is an outpatient procedure.

If the Mullerian ducts fuse together at the bottom only, a large uterine septum is formed and a bicornuate uterus occurs. On each side of the uterine septum, a normal endometrium develops and two small uteri are formed.  These two uteri each have a fallopian tube and share a cervix.  When a woman has a bicornuate uterus, pregnancy is possible in because the uterine lining provides enough blood flow for the embryo to grow and develop. The risks of premature labor increase with a bicornuate uterus because of the smaller uterine cavity, with the pregnancy literally running out of room to grow and develop.

Uterine didelphys occurs when there are two uteri that each develop with their own fallopian tube and cervix. Your doctor may diagnose uterine didelphys during a physical examination when duplicate vaginas and or cervices are found. Pregnancy rates are decreased with this condition, but surgical repair does not seem to improve the pregnancy outcomes.

Mullerian agenesis is a condition in which the fallopian tubes, uterus and the upper part of the vagina do not develop as they normally would. Usually, a physician will make this diagnosis when a young woman has normal development of sexual characteristics, but does not ever begin her period. Usually, a gestational carrier is best option for achieving pregnancy in this particular case.

A T-Shaped uterus can develop because from maternal exposure to DES during pregnancy.  DES, a synthetic estrogen, was prescribed from 1938 to 1971 to help women with a history of repeated miscarriage.  At the time, doctors thought these women had low levels of estrogen, which increased the risk for miscarriage.  Now, research has proven that DES did not improve the miscarriage rate in these women.  In fact, children exposed to DES in utero are at a higher risk of having infertility issues.

Often, DES alters the shape of the uterus and makes the uterus a lot smaller than normal. The uterus resembles the letter “T,” limiting the size of the uterus and making implantation of a pregnancy difficult.  No surgical procedure can correct a T-shaped uterus, and a woman who continues to have difficulty conceiving may consider a gestational carrier.

Fibroids
Non-cancerous growths, uterine fibroids develop from the smooth muscle of the uterus and can occur inside or outside of the uterus. Depending on the location, fibroids can affect both infertility as well as pregnancy outcomes. 

Often, women with fibroids are asymptomatic, but common signs of fibroids include heavy, lengthy periods, pelvic pain and pressure, difficulty with urination, constipation, and painful intercourse. The location of the fibroid can greatly influence the symptoms associated with the condition and the degree to which the fibroid impacts fertility and pregnancy. Submucosal fibroids grow into the inside of the uterine cavity. Subserosal fibroids press against the outside of the uterus. These fibroids can sometimes press against your bladder and your rectum, producing increased urinary symptoms; sometimes, the fibroid can press against the rectum causing constipation.

Surgical intervention may be required to remove a fibroid depending on the location. Your physician can surgically remove a fibroid by either laparotomy or laparoscopy based on the on the location and size of the fibroids in the uterus. Typically, a laparotomy is performed when several large fibroids are present or if the fibroids are inside of the uterine wall and are more difficult to access. Fibroids can also be removed by laparoscopy when the fibroids are smaller and are not located deep within the uterus.

Polyps
A growth of tissue that forms in the uterine cavity is called a uterine polyp. Most of the time polyps stay within the uterus, but they can also form in the vagina and cervix as well. Uterine polyps can grow in the inner wall of the uterus, are typically attached to the uterus by a stalk, and can vary greatly in size. Polyps are estrogen sensitive and increasing with higher amounts of estrogen.

Many women do not experience any symptoms with a uterine polyp, but it is not uncommon to experience irregular menstrual cycles, bleeding in between menstrual cycles, heavy menstrual cycles, and infertility.

Uterine polyps can contribute to infertility and recurrent miscarriage. When a patient has a uterine polyp that may prevent an embryo from implanting or restrict growth of a pregnancy, surgical removal is recommended.  Usually, your physician can remove the polyp vaginally through a hysteroscopy, an outpatient surgical procedure. After surgery, uterine polyps can develop again, so you need to notify your physician immediately if you begin experiencing any of the previously mentioned symptoms.

Asherman’s Syndrome
When the uterus adheres to itself in response to uterine inflammation, the condition is called Asherman’s Syndrome.  Inflammation in the uterus can occur following uterine surgeries to remove polyps, fibroids, a uterine septum, and after a D & C.  Asherman’s can also develop after a uterine infection from a cesarean section or IUD placement.

Symptoms of Asherman’s Syndrome include absence of menstruation, infertility, and recurrent miscarriage.  Although these symptoms can are common to other problems, your physician may suspect Asherman’s Syndrome if the symptoms occur immediately following a surgical procedure such as a D & C, surgery to repair a septate uterus, or removal of polyps and fibroids.