Double or bicornuate uterus [Hysteroscopy for IVF]

Introduction

Today we are going to present a very interesting case. It was a patient who had a cervix and then two hemi uteri, so it is about seeing how we can help her get pregnant safely, based on a correct diagnosis.

About the patient and the diagnosis.

When these cases of double uteri occur, each one of the two hemi cavities of the two hemi uteri usually has a single tube, then this tube may be permeable or not, and from there start with the possibility of pregnancy or not, in In the hysterosalpingography that we performed, we observed that the drawing of the hemi uteri was visible, but the trajectory of the tubes was not observed, that is, that both tubes are obstructed. This has nothing to do with the malformation of the uterus, but it is the reason why she never got pregnant in all the previous years, so, in principle, we already have a diagnosis of tubal obstruction that justifies the time of infertility, but It turns out that now we also have to consider that she is a 41-year-old patient.

Combining tubal obstruction with age, because really the best alternative or the best opportunity that she has is in the area of In Vitro Fertilization, already focused on this as a strategy to get her pregnant, so now we are going to evaluate how her uterine cavity is, because we have We have to decide what to do to give you the best reproductive prognosis once the embryo transfer is done, and that’s how we arrange for a hysteroscopy. On another occasion, Dr. Valdés had presented them with a hysteroscopy in which the resection of a uterine septum was performed, that is, the uterine cavity was divided.

On this occasion, as the two cavities were clearly visible in the uterus, and they seemed quite large, we decided to approach the diagnostic part first with another imaging strategy to define whether it was worth making a cut, like the one made on that occasion.

Diagnostic and surgical hysteroscopies

When we enter, we pass through the cervix, in principle we see how the entrance to both cavities is observed. A right cavity that was long, tubular, but small and with the tubal orifice at the bottom clearly obstructed. We withdraw from the hysteroscope and enter the second quality. The left cavity, also with its tubal ostium in the background, is seen to be much larger, with much more space to carry out the reproductive function. So, already having a first diagnosis on which cavity had the best opportunity, we organized a surgical work.

With scissors we entered that cavity that was larger, we cut a little at the bottom a tissue that looked clearly fibrous and indeed it was, we cut all the fibrosis that was at the bottom, part of the lateral wall that separated it from the other hemi uterus and in this way we were able to generate a much wider uterine cavity, which in the hysteroscopic image looked or looks like a single cavity of normal size. So, in this way, the hysteroscopy allowed us: First, to conclude the diagnosis of which of the two uterine cavities had the best prognosis, but we were also able to improve the conditions of that cavity.

The next step now will be to bring you the in vitro fertilization procedure and supported by ultrasound, direct the transfer cannula towards that cavity that we have worked on, once the embryos are placed, generate that opportunity that you have been looking for for so long.

Conclusions.

Müllerian malformations in general, since it is estimated that they occur in 1% to 5% of women, but the percentage can be much higher, around 10% to 15% of women who have some type of reproductive disorders or fertility problems. So, you have to evaluate them in a general context; take into account age, the masculine factor, all the elements that can intervene in fertility.

If you have a diagnosis of some type of alteration or Müllerian malformation, like this one, or one of the others that exist, you must make a comprehensive evaluation to decide which is the best way to help you get pregnant, it would not necessarily have to be an in vitro , perhaps we can approach low complexity techniques, but for this we have to start with a good diagnosis and in this sense, not only imaging studies, but also hysteroscopy are very important tools to set the tone.