Uterine Factors

Congenital Uterine Anomalies - Womb Wonders & Woes

• ASRM classification (Class I-VII) guides diagnosis. Prevalence: ~5.5% general, up to 24% in RPL.
• Common Types: Septate (most frequent, poorest prognosis), Bicornuate (partial/complete fusion failure), Arcuate (mildest).
• Impact: ↑ Implantation failure, RPL, preterm labor, malpresentation.
• Diagnosis:
  • Screening: HSG (cavity), 3D USG (cavity + fundus).
  • Confirmation: MRI (non-invasive), Hysteroscopy + Laparoscopy (gold standard).
• Management: Hysteroscopic metroplasty for symptomatic septate uterus significantly improves live birth rates.

⭐ Septate uterus has the worst obstetric outcome among Mullerian anomalies and benefits most from surgical correction (hysteroscopic metroplasty).

Uterine Fibroids & Polyps - Pesky Pelvic Growths

Uterine Fibroids (Leiomyomas): Benign myometrial tumors.

• FIGO Classification (Impacting Cavity):
  • Type 0: Pedunculated intracavitary.
  • Type 1: Submucosal <50% intramural.
  • Type 2: Submucosal ≥50% intramural.
  • Type 3: Intramural, contacts endometrium.
• Impact on Fertility: Submucosal (FIGO 0, 1, 2) & large intramural (if distorting cavity) can ↓ implantation & ↑ miscarriage via cavity distortion, inflammation, altered contractility.
• Diagnosis: USG, Saline Infusion Sonography (SIS), Hysteroscopy, MRI.
• Management (Fertility): Myomectomy (hysteroscopic for submucosal; laparoscopic/abdominal for others). UAE generally avoided.

Endometrial Polyps: Benign endometrial overgrowths.

• Impact on Fertility: May cause inflammation or mechanical interference with implantation.
• Diagnosis: USG, SIS, Hysteroscopy.
• Management (Fertility): Hysteroscopic polypectomy usually recommended.

⭐ Submucosal fibroids (FIGO type 0, 1, 2) have the most significant negative impact on fertility and ART outcomes, and their removal is generally recommended.

Management Algorithm for Fibroids in Infertility:

Intrauterine Adhesions & Endometritis - Sticky Situations & Infections

• Intrauterine Adhesions (IUA) / Asherman's Syndrome: Fibrous bands within uterine cavity.
  • Etiology: Post-curettage (esp. post-partum/abortal), endometritis (e.g., genital TB).
  • Clinical: Amenorrhea/hypomenorrhea, infertility, Recurrent Pregnancy Loss (RPL).
  • Diagnosis: HSG/SIS (filling defects); Hysteroscopy (gold standard for diagnosis & adhesiolysis). AFS/ESGE classification.
  • Management: Hysteroscopic adhesiolysis; strategies to prevent recurrence (IUD, estrogen therapy, anti-adhesion barriers).

  ⭐ Hysteroscopy is the gold standard for both diagnosis and treatment (adhesiolysis) of Asherman's syndrome.

![Hysteroscopic view of Asherman's syndrome adhesions](https://ylbwdadhbcjolwylidja.supabase.co/storage/v1/object/public/notes/L1/Obstetrics_and_Gynecology_Fertility_and_Infertility_Uterine_Factors/b1439840-f6b7-45a0-8c82-19d96089615c.jpg)

• Chronic Endometritis (CE): Persistent endometrial inflammation.
  • Etiology: Bacterial (often polymicrobial).
  • Diagnosis: Hysteroscopy with endometrial biopsy (key: plasma cells CD138+).
  • Treatment: Antibiotics (e.g., Doxycycline 100mg BD x 14 days).

Adenomyosis & Endometrial Receptivity - Implantation Impediments

• Adenomyosis: Ectopic endometrial glands/stroma within myometrium.
  • Fertility Impact: Impaired implantation, altered uterine contractility, inflammation, hostile environment.
  • Diagnosis:
    • TVUS: Heterogeneous myometrium, cystic anechoic spaces, '?' mark sign.
    • MRI: Thickened Junctional Zone (JZ) >12mm.
  • Management: GnRH agonists pre-IVF; surgery has limited fertility utility.
• Endometrial Receptivity:
  • Key Factors:
    • Endometrial thickness >7-8mm.
    • Trilaminar pattern (USG).
    • Molecular markers (e.g., ERA test - investigational).
  • Thin Endometrium (<7mm):
    • Causes: e.g., Asherman's syndrome, clomiphene use.
    • Treatments (variable evidence): Estrogen, aspirin, sildenafil, G-CSF, PRP.

⭐ A junctional zone (JZ) thickness of ≥12 mm on MRI is a key diagnostic criterion for adenomyosis.

High‑Yield Points - ⚡ Biggest Takeaways

• Asherman's syndrome (intrauterine adhesions), often post-D&C, severely impacts fertility.
• Congenital uterine anomalies, especially septate uterus (most common, surgically correctable), cause recurrent pregnancy loss.
• Submucosal and cavity-distorting intramural leiomyomas (fibroids) are key culprits for infertility.
• Endometrial polyps can interfere with embryo implantation.
• Hysterosalpingography (HSG) and hysteroscopy are primary diagnostic tools for uterine cavity evaluation.
• Chronic endometritis can impair endometrial receptivity and implantation success.