Reproductive potential of the anomalous uterus

Congenital anomalies of the uterine cervix and fundus arise from errors during embryogenesis and have been recognized as etiologic factors in recurrent pregnancy loss (RPL) since Ruge performed the first septum resection in 1884 and Paul Strassman described his metroplastic procedure a quarter of a century later. Habitual first- and second-trimester abortion, premature birth, intrauterine growth retardation (IUGR), and fetal malpresentations are the major obstetric difficulties seen in association with the anomalous uterus. Acquired uterine defects secondary to diethylstilbestrol (DES) exposure, traumatic cervical incompetence, Asherman's syndrome, and growth of leiomyomata have also been recognized as contributory or etiologic factors in RPL. The spectrum of reproductive difficulties seen with acquired uterine defects is similar to that seen with congenital defects. Habitual abortion has been the most common indication for surgical intervention for the anomalous uterus. However, Jones and Wheeless correctly pointed out that a double uterus 'may be quite consistent with satisfactory reproductive performance', and therefore in those patients with reproductive failures, a complete evaluation of other causes of abortion should be carried out. Despite the fact that metroplasty is one of the oldest gynecologic operations there is still controversy regarding the incidence and classification of uterine anomalies, the extent of reproductive failure associated with them, and their optimal management. Choosing the best surgical approach is sometimes difficult owing to the heterogeneous nature of these disorders. The purpose of this article is to assist the clinician in the management of RPL secondary to a uterine defect. The reproductive performance of patients with various uterine anomalies is reviewed and the available therapeutic options are discussed.