Automatic Segmentation and Alignment of Uterine Shapes from 3D Ultrasound Data.

BACKGROUND: The uterus is the most important organ in the female reproductive system. Its shape plays a critical role in fertility and pregnancy outcomes. Advances in medical imaging, such as 3D ultrasound, have significantly improved the exploration of the female genital tract, thereby enhancing gynecological healthcare. Despite well-documented data for organs like the liver and heart, large-scale studies on the uterus are lacking. Existing classifications, such as VCUAM and ESHRE/ESGE, provide different definitions for normal uterine shapes but are not based on real-world measurements. Moreover, the lack of comprehensive datasets significantly hinders research in this area. Our research, part of the larger NURSE study, aims to fill this gap by establishing the shape of a normal uterus using real-world 3D vaginal ultrasound scans. This will facilitate research into uterine shape abnormalities associated with infertility and recurrent miscarriages. METHODS: We developed an automated system for the segmentation and alignment of uterine shapes from 3D ultrasound data, which consists of two steps: automatic segmentation of the uteri in 3D ultrasound scans using deep learning techniques, and alignment of the resulting shapes with standard geometrical approaches, enabling the extraction of the normal shape for future analysis. The system was trained and validated on a comprehensive dataset of 3D ultrasound images from multiple medical centers. Its performance was evaluated by comparing the automated results with manual annotations provided by expert clinicians. RESULTS: The presented approach demonstrated high accuracy in segmenting and aligning uterine shapes from 3D ultrasound data. The segmentation achieved an average Dice similarity coefficient (DSC) of 0.90. Our method for aligning uterine shapes showed minimal translation and rotation errors compared to traditional methods, with the preliminary average shape exhibiting characteristics consistent with expert findings of a normal uterus. CONCLUSION: We have presented an approach to automatically segment and align uterine shapes from 3D ultrasound data. We trained a deep learning nnU-Net model that achieved high accuracy and proposed an alignment method using a combination of standard geometrical techniques. Additionally, we have created a publicly available dataset of 3D transvaginal ultrasound volumes with manual annotations of uterine cavities to support further research and development in this field. The dataset and the trained models are available at https://github.com/UL-FRI-LGM/UterUS.

The Future of Adhesion Prophylaxis Trials in Abdominal Surgery: An Expert Global Consensus.

Postoperative adhesions represent a frequent complication of abdominal surgery. Adhesions can result from infection, ischemia, and foreign body reaction, but commonly develop after any surgical procedure. The morbidity caused by adhesions affects quality of life and, therefore, it is paramount to continue to raise awareness and scientific recognition of the burden of adhesions in healthcare and clinical research. This 2021 Global Expert Consensus Group worked together to produce consented statements to guide future clinical research trials and advise regulatory authorities. It is critical to harmonize the expectations of research, to both develop and bring to market improved anti-adhesion therapies, with the ultimate, shared goal of improved patient outcomes.

Hysteroscopy in recurrent in-vitro fertilisation failure (TROPHY): a multicentre, randomised controlled trial.

BACKGROUND: The success rate of in-vitro fertilisation (IVF) remains low and many women undergo multiple treatment cycles. A previous meta-analysis suggested hysteroscopy could improve outcomes in women who have had recurrent implantation failure; however, studies were of poor quality and a definitive randomised trial was needed. In the TROPHY trial we aimed to assess whether hysteroscopy improves the livebirth rate following IVF treatment in women with recurrent failure of implantation. METHODS: We did a multicentre, randomised controlled trial in eight hospitals in the UK, Belgium, Italy, and the Czech Republic. We recruited women younger than 38 years who had normal ultrasound of the uterine cavity and history of two to four unsuccessful IVF cycles. We used an independent web-based trial management system to randomly assign (1:1) women to receive outpatient hysteroscopy (hysteroscopy group) or no hysteroscopy (control group) in the month before starting a treatment cycle of IVF (with or without intracytoplasmic sperm injection). A computer-based algorithm minimised for key prognostic variables: age, body-mass index, basal follicle-stimulating hormone concentration, and the number of previous failed IVF cycles. The order of group assignment was masked to the researchers at the time of recruitment and randomisation. Embryologists involved in the embryo transfer were masked to group allocation, but physicians doing the procedure knew of group assignment and had hysteroscopy findings accessible. Participants were not masked to their group assignment. The primary outcome was the livebirth rate (proportion of women who had a live baby beyond 24 weeks of gestation) in the intention-to-treat population. The trial was registered with the ISRCTN Registry, ISRCTN35859078. FINDINGS: Between Jan 1, 2010, and Dec 31, 2013, we randomly assigned 350 women to the hysteroscopy group and 352 women to the control group. 102 (29%) of women in the hysteroscopy group had a livebirth after IVF compared with 102 (29%) women in the control group (risk ratio 1·0, 95% CI 0·79-1·25; p=0·96). No hysteroscopy-related adverse events were reported. INTERPRETATION: Outpatient hysteroscopy before IVF in women with a normal ultrasound of the uterine cavity and a history of unsuccessful IVF treatment cycles does not improve the livebirth rate. Further research into the effectiveness of surgical correction of specific uterine cavity abnormalities before IVF is warranted. FUNDING: European Society of Human Reproduction and Embryology, European Society for Gynaecological Endoscopy.

The Thessaloniki ESHRE/ESGE consensus on diagnosis of female genital anomalies.

What is the recommended diagnostic work-up of female genital anomalies according to the European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) system? The ESHRE/ESGE consensus for the diagnosis of female genital anomalies is presented. Accurate diagnosis of congenital anomalies still remains a clinical challenge due to the drawbacks of the previous classification systems and the non-systematic use of diagnostic methods with varying accuracy, with some of them quite inaccurate. Currently, a wide range of non-invasive diagnostic procedures are available, enriching the opportunity to accurately detect the anatomical status of the female genital tract, as well as a new objective and comprehensive classification system with well-described classes and sub-classes. The ESHRE/ESGE Congenital Uterine Anomalies (CONUTA) Working Group established an initiative with the goal of developing a consensus for the diagnosis of female genital anomalies. The CONUTA working group and imaging experts in the field have been appointed to run the project. The consensus is developed based on (1) evaluation of the currently available diagnostic methods and, more specifically, of their characteristics with the use of the experts panel consensus method and of their diagnostic accuracy performing a systematic review of evidence and (2) consensus for (a) the definition of where and how to measure uterine wall thickness and (b) the recommendations for the diagnostic work-up of female genital anomalies, based on the results of the previous evaluation procedure, with the use of the experts panel consensus method. Uterine wall thickness is defined as the distance between interostial line and external uterine profile at the midcoronal plane of the uterus; alternatively, if a coronal plane is not available, the mean anterior and posterior uterine wall thickness at the longitudinal plane could be used. Gynaecological examination and two-dimensional ultrasound (2D US) are recommended for the evaluation of asymptomatic women. Three-dimensional ultrasound (3D US) is recommended for the diagnosis of female genital anomalies in "symptomatic" patients belonging to high-risk groups for the presence of a female genital anomaly and in any asymptomatic woman suspected to have an anomaly from routine avaluation. Magnetic resonance imaging (MRI) and endoscopic evaluation are recommended for the sub-group of patients with suspected complex anomalies or in diagnostic dilemmas. Adolescents with symptoms suggestive for the presence of a female genital anomaly should be thoroughly evaluated with 2D US, 3D US, MRI and endoscopy. The various diagnostic methods should be used in a proper way and evaluated by experts to avoid mis-, over- and underdiagnosis. The role of a combined ultrasound examination and outpatient hysteroscopy should be prospectively evaluated. It is a challenge for further research, based on diagnosis, to objectively evaluate the clinical consequences related to various degrees of uterine deformity.

Does hysteroscopic metroplasty for septate uterus represent a risk factor for adverse outcome during pregnancy and labor?

The aim of the study was to evaluate whether hysteroscopic metroplasty for septate uterus represents a risk factor of adverse outcome in pregnancy, during labor, and after delivery. This is a retrospective comparative study of obstetric complications of 99 patients who underwent hysteroscopic metroplasty in a 5-year period (study group) and 4155 women, who gave birth in the same hospital in the same period (control group). No difference in obstetric outcome (preterm labor, hemorrhage before and after delivery, mean weeks of gestation at delivery, mean birth weight, breech presentation, and cesarean section rate) between the two groups has been found. The results of this study suggest that patients who underwent hysteroscopic metroplasty for septate uterus are at no higher risk of adverse obstetric outcome at term and during labor, comparing to the general population. Though vaginal delivery seems to be safe, rare but serious complication, reported by several studies, like uterine rupture during pregnancy or labor, should always be taken into consideration.

The Thessaloniki ESHRE/ESGE consensus on diagnosis of female genital anomalies.

STUDY QUESTION: What is the recommended diagnostic work-up of female genital anomalies according to the European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) system? SUMMARY ANSWER: The ESHRE/ESGE consensus for the diagnosis of female genital anomalies is presented. WHAT IS KNOWN ALREADY: Accurate diagnosis of congenital anomalies still remains a clinical challenge because of the drawbacks of the previous classification systems and the non-systematic use of diagnostic methods with varying accuracy, some of them quite inaccurate. Currently, a wide range of non-invasive diagnostic procedures are available enriching the opportunity to accurately detect the anatomical status of the female genital tract, as well as a new objective and comprehensive classification system with well-described classes and sub-classes. STUDY DESIGN, SIZE, DURATION: The ESHRE/ESGE CONgenital UTerine Anomalies (CONUTA) Working Group established an initiative with the goal of developing a consensus for the diagnosis of female genital anomalies. The CONUTA working group and imaging experts in the field have been appointed to run the project. PARTICIPANTS/MATERIALS, SETTING, METHODS: The consensus is developed based on: (i) evaluation of the currently available diagnostic methods and, more specifically, of their characteristics with the use of the experts panel consensus method and of their diagnostic accuracy by performing a systematic review of evidence and (ii) consensus for the definition of where and how to measure uterine wall thickness and the recommendations for the diagnostic work-up of female genital anomalies, based on the results of the previous evaluation procedure, with the use of the experts panel consensus method. MAIN RESULTS AND THE ROLE OF CHANCE: Uterine wall thickness is defined as the distance between the interostial line and external uterine profile at the midcoronal plane of the uterus; alternatively, if a coronal plane is not available, the mean anterior and posterior uterine wall thickness at the longitudinal plane could be used. Gynecological examination and two-dimensional ultrasound (2D US) are recommended for the evaluation of asymptomatic women. Three-dimensional (3D) US is recommended for the diagnosis of female genital anomalies in 'symptomatic' patients belonging to high risk groups for the presence of a female genital anomaly and in any asymptomatic woman suspected to have an anomaly from routine evaluation. Magnetic resonance imaging (MRI) and endoscopic evaluation are recommended for the subgroup of patients with suspected complex anomalies or in diagnostic dilemmas. Adolescents with symptoms suggestive for the presence of a female genital anomaly should be thoroughly evaluated with 2D US, 3D US, MRI and endoscopically. LIMITATIONS, REASONS FOR CAUTION: The various diagnostic methods should always be used in the proper way and evaluated by experts to avoid mis-, over- and underdiagnosis. WIDER IMPLICATIONS OF THE FINDINGS: The role of a combined US examination and outpatient hysteroscopy should be prospectively evaluated. It is a challenge for further research, based on diagnosis, to objectively evaluate the clinical consequences related to various degrees of uterine deformity. STUDY FUNDING/COMPETING INTERESTS: None.

A case of avoidable heterotopic pregnancy after single embryo transfer.

A rare case of a heterotopic pregnancy after single embryo and blastocyst transfer is presented. A couple suffered from idiopathic infertility and underwent assisted reproduction techniques in a university hospital. Intercourse on the day of HCG administration was the probable cause for an in vivo fertilization of an oocyte that was not collected during the oocyte retrieval. The patient accessed a regional hospital with a massive haemoperitoneum in the 11th week of pregnancy with the confusing information that only one embryo had been transferred during the assisted reproduction treatment. After tubal pregnancy removal, the in-utero pregnancy proceeded normally but, at the time of the second trimester scan, a caudal regression syndrome was diagnosed and the patient decided to terminate the pregnancy.

The ESHRE-ESGE consensus on the classification of female genital tract congenital anomalies.

The new ESHRE/ESGE classification system of female genital anomalies is presented, aiming to provide a more suitable classification system for the accurate, clear, correlated with clinical management and simple categorization of female genital anomalies. Congenital malformations of the female genital tract are common miscellaneous deviations from normal anatomy with health and reproductive consequences. Until now, three systems have been proposed for their categorization, but all of them are associated with serious limitations. The European Society of Human Reproduction and Embryology (ESHRE) and the European Society for Gynaecological Endoscopy (ESGE) have established a common Working Group, under the name CONUTA (CONgenital UTerine Anomalies), with the goal of developing a new updated classification system. A scientific committee has been appointed to run the project, looking also for consensus within the scientists working in the field. The new system is designed and developed based on: (1) scientific research through critical review of current proposals and preparation of an initial proposal for discussion between the experts, (2) consensus measurement among the experts through the use of the DELPHI procedure and (3) consensus development by the scientific committee, taking into account the results of the DELPHI procedure and the comments of the experts. Almost 90 participants took part in the process of development of the ESHRE/ESGE classification system, contributing with their structured answers and comments. The ESHRE/ESGE classification system is based on anatomy. Anomalies are classified into the following main classes, expressing uterine anatomical deviations deriving from the same embryological origin: U0, normal uterus; U1, dysmorphic uterus; U2, septate uterus; U3, bicorporeal uterus; U4, hemi-uterus; U5, aplastic uterus; U6, for still unclassified cases. Main classes have been divided into sub-classes expressing anatomical varieties with clinical significance. Cervical and vaginal anomalies are classified independently into sub-classes having clinical significance. The ESHRE/ESGE classification of female genital anomalies seems to fulfil the expectations and the needs of the experts in the field, but its clinical value needs to be proved in everyday practice. The ESHRE/ESGE classification system of female genital anomalies could be used as a starting point for the development of guidelines for their diagnosis and treatment.

The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies.

STUDY QUESTION: What classification system is more suitable for the accurate, clear, simple and related to the clinical management categorization of female genital anomalies? SUMMARY ANSWER: The new ESHRE/ESGE classification system of female genital anomalies is presented. WHAT IS KNOWN ALREADY: Congenital malformations of the female genital tract are common miscellaneous deviations from normal anatomy with health and reproductive consequences. Until now, three systems have been proposed for their categorization but all of them are associated with serious limitations. STUDY DESIGN, SIZE AND DURATION: The European Society of Human Reproduction and Embryology (ESHRE) and the European Society for Gynaecological Endoscopy (ESGE) have established a common Working Group, under the name CONUTA (CONgenital UTerine Anomalies), with the goal of developing a new updated classification system. A scientific committee (SC) has been appointed to run the project, looking also for consensus within the scientists working in the field. PARTICIPANTS/MATERIALS, SETTING, METHODS: The new system is designed and developed based on (i) scientific research through critical review of current proposals and preparation of an initial proposal for discussion between the experts, (ii) consensus measurement among the experts through the use of the DELPHI procedure and (iii) consensus development by the SC, taking into account the results of the DELPHI procedure and the comments of the experts. Almost 90 participants took part in the process of development of the ESHRE/ESGE classification system, contributing with their structured answers and comments. MAIN RESULTS AND THE ROLE OF CHANCE: The ESHRE/ESGE classification system is based on anatomy. Anomalies are classified into the following main classes, expressing uterine anatomical deviations deriving from the same embryological origin: U0, normal uterus; U1, dysmorphic uterus; U2, septate uterus; U3, bicorporeal uterus; U4, hemi-uterus; U5, aplastic uterus; U6, for still unclassified cases. Main classes have been divided into sub-classes expressing anatomical varieties with clinical significance. Cervical and vaginal anomalies are classified independently into sub-classes having clinical significance. LIMITATIONS, REASONS FOR CAUTION: The ESHRE/ESGE classification of female genital anomalies seems to fulfill the expectations and the needs of the experts in the field, but its clinical value needs to be proved in everyday practice. WIDER IMPLICATIONS OF THE FINDINGS: The ESHRE/ESGE classification system of female genital anomalies could be used as a starting point for the development of guidelines for their diagnosis and treatment. STUDY FUNDING/COMPETING INTEREST(S): None.

No clinical relevance of the height of fundal indentation in subseptate or arcuate uterus: a prospective study.

The American Fertility Society has classified the arcuate uterus as a minor malformation with a benign clinical behaviour. The aim of this prospective study was to verify whether there is any scientific basis for this differentiation. Patients with at least one early miscarriage and a subseptate or arcuate uterus were admitted for hysteroscopic metroplasty. Patients were allocated to a subseptate uterus group, with an indentation of 1.5 cm or more, or an arcuate uterus group, with a smaller indentation. The miscarriage rates after metroplasty were similar between the two groups (14.0% in the subseptate uterus group versus 11.1% in the arcuate uterus group). Before metroplasty, the miscarriage rates were significantly higher in subseptate uterus group, as well as in the arcuate uterus group (both P<0.001). According to these results, there is no evidence to support that the arcuate uterus has a different effect on the reproductive outcome in comparison to the subseptate uterus, neither before nor after surgical correction of the anomaly. Since there is no scientific basis for a separate classification of the arcuate uterus, a review of the classifications of uterine congenital anomalies should be considered as necessary. Congenital uterine malformations have been classified by the American Fertility Society (AFS) since 1988. Although the AFS classification received wide acceptance and is still the most broadly used system, it is associated with various limitations in effective categorization of the anomalies. It is interesting that, until now, none of the other available options have been able to effectively replace the AFS system. Numerous papers indicate septate or subseptate (partial septate) uterus (AFS class V) is a possible cause of an unfavourable pregnancy outcome. Arcuate uterus (AFS class VI), a slight malformation similar to septate uterus, should differ from septate or subseptate uterus, because this 'minor' malformation should behave benignly with respect to the septate uterus. The aim of this study was to scientifically validate the difference between the arcuate and subseptate uterus in their effect on reproductive outcome through the results of a metroplasty in both groups of patients. A group of 96 patients, who underwent metroplasty after at least one early miscarriage, was divided into two groups according to the severity of the congenital uterine malformation. Our results indicate that there are no differences in pregnancy outcome after metroplasty either in patients with septate or arcuate utera. The poor pregnancy outcome in women with septate uterus seems not to be correlated to the dimension of the septum itself. There are no scientific bases for a separate classification of the arcuate uterus and it is proposed that a review of the classification of uterine congenital anomalies is necessary.

Management of endometrioma prior to IVF: compliance with ESHRE guidelines.

Management of endometrioma before IVF remains controversial. As well as some measurable benefits from surgical treatment, there are also potential risks that should be discussed with the patients to help them make an informed decision. When surgery is compared with expectant management, there appear to be no statistically significant differences in pregnancy rate and ovarian response to exogenous stimulation. The objectives of this European Society of Human Reproduction and Embryology (ESHRE)-sponsored survey were to acquire knowledge of current strategies for the management of endometrioma (>3 cm) prior to IVF and to explore adherence to ESHRE guidelines. A validated, peer-reviewed online questionnaire made of 14 questions was sent to 396 members of the ESHRE Special Interest Groups (Reproductive Surgery and Endometriosis/Endometrium), with a response rate of 27%. Surgical management is the most common treatment (82.2%), with drainage and excision of the cyst wall being the preferred surgical approach (78.5%). Monthly depot gonadotrophin-releasing hormone analogues are the preferred choice of medical treatment of endometriomas before IVF, with an average duration of treatment of 3 months. The findings demonstrate that surgery remains the commonest treatment offered for women with endometrioma before IVF. This is in line with the recommendations of the ESHRE guidelines.

Possible role of endometriosis in the aetiology of spontaneous miscarriage in patients with septate uterus.

A recent study found a significant correlation between endometriosis and non-obstructive forms of Müllerian anomalies. Other studies described an increased miscarriage rate in patients with endometriosis. This study assessed the effect of endometriosis on pregnancy outcome in a group of patients with endometriosis and septate uterus. Spontaneously achieved pregnancies were taken into consideration. The outcome of 179 infertile women who underwent surgery for septate uterus was analysed in a retrospective study. Stage I or II endometriosis was found by laparoscopy in 36 patients. The pregnancy outcomes, before and after metroplasty, of the group of 36 patients with septum and endometriosis were compared with the pregnancy outcomes of 143 patients with septate uterus with no endometriosis. Before metroplasty the incidence of pregnancy loss was 67% in patients without endometriosis and 75% in patients with endometriosis and the difference was not significant. After metroplasty, no significant differences have been found between the two groups, suggesting that endometriosis could be an occasional finding not influencing pregnancy outcome.