Anatomic Factors in Recurrent Pregnancy Loss

Anne S. Devi Wold, MD; Norma Pham, MD; Aydin Arici, MD


Semin Reprod Med. 2006;24(1):25-32. 

In This Article


Anatomic causes of RPL are typically diagnosed using ultrasonography, hysterosalpingography (HSG) or sonohysterography. Hysteroscopy, laparoscopy, or magnetic resonance imaging can also be performed as needed. Recently, transvaginal three-dimensional ultrasonography has been introduced and has allowed an accurate and noninvasive diagnosis of congenital uterine anomalies.

Transvaginal ultrasound is useful for the diagnosis of uterine fibroids and endometrial polyps, and assessment of fetal viability. Hysterosalpingography is used to evaluate tubal patency and can also detect submucous myomas, most uterine malformations, and intrauterine adhesions. It cannot reliably differentiate between a septate and bicornuate uterus, unless a laparoscopy to view the uterine fundus is performed.

Saline infusion sonohysterography involves transcervical instillation of fluid into the uterus during transvaginal ultrasound examination. The technique delineates the internal contours of the uterine cavity and provides concomitant visualization of the outer surface of the wall of the uterus. It provides more information about uterine abnormalities than HSG or ultrasound alone (Fig. 2). Like HSG, it is performed early in the follicular phase of the menstrual cycle after cessation of menses.

Figure 2.

Sonohysterogram of a patient with intrauterine polyp.

Hysteroscopy allows the diagnosis and simultaneous treatment of many intrauterine abnormalities (Figs. 3 and 4). Simultaneous laparoscopy is often necessary to visualize the uterine fundus and reliably differentiate between a septate and bicornuate uterus. Magnetic resonance imaging can also be used for this purpose and is less invasive than laparoscopy.

Figure 3.

Hysteroscopy of a patient with submucosal leiomyoma.

Figure 4.

Hysteroscopy of a patient with thick intrauterine adhesions.

Three-dimensional ultrasound has the advantage of being noninvasive and allows a complete assessment of uterine morphology. The technique involves the collection of a large series of sequential ultrasound images that are then collated into an ultrasound volume. These three-dimensional volumes can be stored on disk and re-examined later in an infinite number of planes. Thus, it is possible with three-dimensional ultrasound to visualize the uterus in the coronal plane with the external and internal contours of the fundus visible on one image. It is also possible to measure uterine dimensions and the extent of the morphological defect, and thus evaluate the likely success of any surgical intervention.[52] Three-dimensional ultrasound has been compared with hysterosalpingography and laparoscopy in several studies and has shown a high level of agreement in the diagnosis of congenital uterine anomalies.[53,54]


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