Reproductive Outcomes in Women With Uterine Anomalies

Paul C. Lin, M.D.

In This Article


Hypoplasia or agenesis may involve any part of the reproductive tract, including the cervix, fallopian tube, and vagina. Because of its infrequency, the literature on cervical agenesis is limited to case reports concerning the possibility of pregnancy. This is embryologically attributed to segmental local atrophy and failure of canalization to the lower fused portion of the müllerian ducts. Management usually involves hysterectomy following a painful hematometra soon after menarche. Several case reports have discussed successful pregnancy delivered by cesarean section, with retention of the uterus and formation of a fistulous tract with a retained catheter. Pregnancy was reported recently in 10 of 18 subjects treated over a 30-year span.[26] Attempts to retain the uterus for future fertility are discouraged. Successful surgical recanalization depends on the amount of normal cervix remaining.

Tubal agenesis has not been reported beyond several case reports. In-vitro fertilization (IVF) would be the logical therapy, but commonly associated uterine anomalies may have an undetermined impact on IVF outcome.

Embryologically, vaginal agenesis results from a failure of descending müllerian ducts to contact the sinovaginal bulbs. Vaginal agenesis is commonly associated with urological abnormalities, and patients have normal ovaries and rarely have a nonatretic uterus and cervix. Several case reports have described pregnancy and term delivery by cesarean section in patients with vaginal agenesis after a fistulous tract was created and gamete intrafallopian transfer was performed.[27,28] In patients desiring pregnancy, MRI is essential to determine the presence of a uterus and fallopian tubes. Consideration for a tubal embryo transfer can then be discussed with a specialist in reproductive endocrinology and infertility.

A cohort study of 12 subjects with vaginal agenesis evaluated optimal methods of oocyte retrieval and characterized the response to ovulation induction with gonadotropins and pregnancy rates. Pregnancy outcome was comparable between these vaginal agenesis subjects and a control group: subjects using gestational carriers for surgically absent uterus or severe uterine abnormalities.[29] In a total of 34 IVF cycles, 8 of 12 women with vaginal agenesis achieved pregnancy. With normal spontaneous cyclic pituitary gonadotropin concentrations, normal ovarian endocrine function, normal 46XX chromosomal complement, and normal secondary sexual characteristics, ovarian stimulation resulted in a similar number of oocytes retrieved and fertilization rates. Hence, ovarian function in women with vaginal agenesis appears to be normal. Transvaginal retrieval was noted to be more difficult because of more scar tissue with surgically created neovaginas than with neovaginas created with dilators.

The reproductive impact of hypoplastic uteri suffers from an inconsistent definition of a small uterus in the literature. Therefore, the impact of the congenital hypoplastic uterus on reproduction is unknown.


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