Congenital uterine anomalies (Müllerian duct anomalies)

A 33-year-old sits across the desk from you with three first-trimester losses and a 3D ultrasound report describing "a fundal indentation." The number that decides whether she has surgery is not the size of the indentation — it is which definition of septate you adopt, and the same uterus can be septate, arcuate or unclassifiable depending on the rule you read. Congenital uterine anomalies reward the candidate who knows the classifications, the imaging tier, and the limits of the evidence; they punish the one who resects first and asks later.^[7][8]

Overview and definition

Congenital uterine anomalies — also called Müllerian duct anomalies — are structural deviations of the uterus, cervix and/or upper vagina arising from abnormal development of the paired paramesonephric (Müllerian) ducts. They range from clinically silent to profoundly disruptive, and their reproductive burden falls on miscarriage, preterm birth and subfertility rather than on mortality.^[2][5]

Three ideas anchor the whole topic. First, classification is contested: three systems coexist (the 1988 American Fertility Society classification, the 2013 ESHRE/ESGE CONUTA classification, and the 2021 ASRM Müllerian Anomalies Classification), and they do not agree on what counts as an anomaly. Second, the septate uterus dominates the clinical conversation because it is the commonest clinically significant anomaly and the only one routinely operated on. Third, imaging shows the cavity and the contour, and the external fundal contour is the feature that separates a septum (operable hysteroscopically) from a bicornuate uterus (not).^[3][7][15]

References16ShowHide

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2. [2]Grimbizis GF, Gordts S, Di Spiezio Sardo A, Brucker S, De Angelis C, Gergolet M, Li TC, Tanos V, Brölmann H, Gianaroli L, Campo R The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies Human reproduction (Oxford, England), 2013.PMID 23771171
3. [3]Pfeifer SM, Attaran M, Goldstein J, Lindheim SR, Petrozza JC, Rackow BW, Siegelman E, Troiano R, Winter T, Zuckerman A, Ramaiah SD ASRM müllerian anomalies classification 2021 Fertility and sterility, 2021.PMID 34756327
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8. [8]Carriles I, Brotons I, Errasti T, Ruiz-Zambrana A, Ludwin A, Alcazar JL Prevalence of Septate Uterus in a Large Population of Women of Reproductive Age: Comparison of ASRM 2016 and 2021, ESHRE/ESGE, and CUME Diagnostic Criteria: A Prospective Study Diagnostics (Basel), 2024.PMID 39335698
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11. [11]Joosse MI, Kostova EB, Rikken JF, Mol BWJ, Goddijn M, van Wely M Septum resection for women of reproductive age with a septate uterus The Cochrane database of systematic reviews, 2025.PMID 41268817
12. [12]Wu X, Zhang M, Sun P, Jiang JJ, Yan L Pregnancy and Adverse Obstetric Outcomes After Hysteroscopic Resection: A Systematic Review and Meta-Analysis Frontiers in surgery, 2022.PMID 35832500
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15. [15]Dixit R, Duggireddy CS, Pradhan GS Mullerian anomalies: revisiting imaging and classification Insights into imaging, 2025.PMID 39962011
16. [16]Ludwin A, Ludwin I, Kudla M, et al. Diagnostic accuracy of three-dimensional sonohysterography compared with office hysteroscopy and its interrater/intrarater agreement in uterine cavity assessment after hysteroscopic metroplasty Fertility and sterility, 2014.PMID 24581576