Open Journal of Obstetrics and Gynecology, 2011, 1, 238-241
doi:10.4236/ojog.2011.14047 Published Online December 2011 ( OJOG
Published Online December 2011 in SciRes.
The role of 3-dimensional ultrasound for the diagnosis of
congenital uterine anomalies
Efraim Zohav1,2*, Yaakov Melcer1,2, Ilan Tur -Kaspa3, Jacob Rabinson1,2, Eyal Y. An teby1,2, Raoul Orvieto1,2
1Department of Obstetrics and Gynecology, Barzilai M edical Center, Ashkelon, Is rael;
2Ben-Gurion University of the Negev, Beer Sheva, Israel;
3Institute for Human Reproduction (IHR), Department of Obstetrics and Gynecology, The University of Chicago, Chicago, USA.
Email: *
Received 17 July 2011; revised 30 August 2011; accepted 18 September 2011.
Objectives: To demonstrate the value of 3-dimensional
(3-D) ultrasound (US) in the diagnosis of congenital
uterine anomalies. Methods: Fifty one infertile pa-
tients referred to our US unit during 12 years period,
with suspected diagnosis of congenital uterine ano-
malies by previous HSG or 2D US examinations, were
evaluated by transvaginal 3-D US. The 3-D US diag-
noses were compared to the initial HSG diagnosis,
and to hysteroscopic evaluation when performed. Re-
sults: 3-D scan confirmed the initial HSG diagnosis in
27 out of 51 (52.9%) women. The concordancy rates
between the initial diagnosis by HSG and 3-D US re-
sults were 30.4% for bicornuate uterus; 75% for ar-
cuate uterus; 83% for septate uterus; and 80% for
unicornuate uterus. Of the 13 cases with normal HSG
and suspicious 2-D US, 30.8% were found to be nor-
mal by 3D sonography. In cases where hysteroscopy
was done, the results were 100% in concordance with
the 3-D US evaluations. Conclusions: 3-D US is an
accurate test for the assessment of uterine congenital
anomalies. Its ability to concomitantly visualized, the
external uterine contour with the uterine cavity on
the same coronal plan, makes this noninvasive, easy
to perform test the procedure of choice for the diag-
nosis of uterine anomalies.
Keywords: Mullerian Anomalies; 3-Dimensional (3-D)
Ultrasonography; Hysterosalpingo g rap hy ; Hy st eroscopy
Congenital Mullerian duct anomaly is a common cause
of infertility, first trimester abortion, preterm labor, and
fetal malpresentations [1]. Its estimated prevalence va-
ries between 0.1% - 3% [2-4] in the general population
and between 3% to 38% in patients with repeated spon-
taneous miscarriages or with infertility [5-10]. This dis-
crepancy results from the heterogeneous population sa-
mples, the clinical diversity of Mullerian anomalies and
the different diagnostic techniques used.
Several techniques are available for the evaluation of
Mullerian duct anomaly, among which the traditional
hysterosalpingography (HSG) is the most world-widely
used, with its inherent limitation resulting from its in-
ability to detect the ex ternal fund al contour of the uterus.
Therefore, an invasive method which combines hystero-
scopy and laparoscopy has been suggested as the gold
standard for achieving a final diagnosis.
Recently, noninvasive tools such as three-dimensional
(3-D) ultrasound and magnetic resonance imaging (MRI)
have been added to our armamentariu m, with their abili-
ty to demonstrate uterine contours, and therefore to im-
prove the detection and differentiation between septate
and bicornuate uteri.
The use of 3-D sonography with image reconstruction
in the diagnosis of congenital uterine anomalies has al-
ready been described [11-14], enabling the assessment
and accurate demonstration of both the internal and ex-
ternal contour of the uterin e fundus which may easily be
missed by the conventional 2-dimensional (2-D) US [15].
In the present study we aim to further evaluate the 3-D
US imaging in the diagnosis of Mullerian duct anomaly,
and its concordance with other imaging methods, such as
2-D US, HSG and hyst er oscopy.
The medical files of all women who underwent 3-D US
during a 12 year period (1998-20 10). Fo r the purp oses of
this study, patients who were referred with the diagnosis
of suspected Mullerian anomaly by previous HSG or
2-D US examinations were included in this study.
Patients underwent transvaginal 3-D US examinations
using Voluson 530 and Voluson 730 expert (GE medical
System) with transvaginal probes (3-D V-DW5-8B and
RIC 5-9H respectively). All examinations were perfor-
E. Zohav et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 238-241 239
med by the same experienced sonographer (EZ) who was
blinded to the clinical history and HSG/2D US eval uations.
Patients underwent 3-D US during the late follicular
phase of the menstrual cycle [16], because of the in-
creased thickness and echogenicity of the endometrium
compared with the surrounding myometrium, which ena-
bles an easy and accurate interpretation.
Initial 3-D static volume acquisition with high resolu-
tion and sweep angle of 90 degree was done on 2-D ul-
trasound in mid-sagittal view of the uterus. All 3 per-
pendicular planes (sagittal, transverse and coronal sec-
tions) were displayed immediately after volume acquisi-
tion. The plans could be rotated simultaneously for the
complete review of the anatomy. Reconstructed 3-D i-
mages in the coronal plan were further studied to differ-
rentiate major uterine anomalies.
The diagnosis of Mullerian anomaly was made when
good quality imag e showing bo th uterine cavity and fun-
dus in coronal rendered plane was displayed. Mullerian
anomalies were classified according to the American Fe-
rtility Society classification system [1]:
To distinguish bicornate from septate uteri we used c-
riteria based on the presence or absence of fundal inden-
tation of 1 cm or greater above the line connecting the
two tips of the endometrial horns and divergent uterine
horns with an intercornual distance exceeding 4 cm [17,18].
The crite r ia for th e d iag no s is of an arcuate uterus were
a rounded endometrial indentation of the fundus and nor-
mal fundal contour.
Patients’ 3-D US diagnoses were compared to their
HSG and/or 2-D US imaging evaluations. Moreover, if a
patient had undergone a further hysteroscopic evaluation,
the result was also included in our analysis.
Data on patient age and infertility work-up evaluation
were collected from their medical files. The results are
expressed as means and standard deviations.
The study was approved by the institutional Clinical
Research Committee.
Fifty one patients met the inclusion criteria. Mean pa-
tients’ age at diagnosis was 32 ± 6.9 years. Mean patients’
gravidity and parity were 0.88 ± 1.38 and 0.29 ± 0.57,
respectively. Among the 51 women, 35 had a diagnosis
of infertility with a mean duration of 4 ± 2.7 years and
16 suffered from repeated miscarriages.
The results of the initial 2-D US and HSG evaluation s
and the subsequent 3-D US and hysteroscopic examina-
tions of the study group are shown in Figure 1.
3-D US confirmed the initial HSG diagnosis in 27 out
of 51 (52.9%) women. Among the 23 cases that were
initially diagnosed by HSG as bicornuate uterus, the 3-D
sonography confirmed the diagnosis in 7 (30.4% con-
cordance), while in the remaining 16 patients, 7 were
diagnosed as having arcuate and 9 with septate uterus.
Hysteroscopy confirmed the 3-D US diagnosis in 1 case
of bicornuate uterus and 4 cases of septate uterus.
Figure 1. Two di mensional-US and HSG evaluatio ns and the subsequent 3D-US and hy steroscopic
examinations of the study group.
opyright © 2011 SciRes. OJOG
E. Zohav et al. / Open Journal of Obstetrics and Gynecology 1 (2011 ) 238-241
Four patients were initially diagnosed by HSG as ha-
ving an arcuate uterus. The 3-D sonography confirmed
the diagnosis in 3 (75% concordance) out of 4, and the
fourth case was diagnosed as having septate uterus. Hy-
steroscopy confirmed the 3-D US diagnosis in the case
of septate uterus. Moreov er, in 6 cases that were initially
diagnosed by HSG as suffering from septate uterus, the
diagnosis was also confirmed by 3-D sonography in 5
cases (83% concordance) and hysteroscopy (done in 4
Unicornuate uterus was initially diag nosed by HSG in
5 cases. While the 3-D sonography confirmed the diag-
nosis in 4 (80% concordance), in the fifth case the diag-
nosis was a bicornuate uterus. Hysteroscopy confirmed
the 3-D US diagnosis in 2 cases of unicornuate uterus.
Thirteen patients were referred to 3-D sonography be-
cause of suspicious Mullerian anomalies by 2-D sono-
graphy despite a normal HSG. 3-D US undertaken in
these patients resulted in 4 normal cases (30.8% concor-
dance), 1 case of unicornuate uterus and 8 cases of ar-
cuate uteri. Hysteroscopy confirmed the 3-D US diagno-
sis in 1 case of normal uterus and 1 case of arcuate uterus.
In the present study, 3-D US study of patients with sus-
pected uterine mullerian anomalies by 2-D US and HSG
confirmed the initial diagnosis in 52.9% of women.
Clear visualization and satisfactory images of the uterine
cavity were obtained in all patients without exclusion.
The best concordance between 3-D US results and the
initial 2-D US and HSG diagnosis was with regard to
septate uterus (83% concordancy), while in unicornuate,
arcuate and bicornuate uteri the concordancy rates were
80%, 75% and 30.4%, respectively. Of patients with
normal HSG and suspicious 2-D US, 3-D US revealed
uterine mullerian anomalies in 69.2%. In the 14 patients
undergoing hysteroscopic evaluation, all results were in
agreement with the 3D US studies (100% concordancy).
Our results support other studies demonstrating that
3-D US should become an important method for the as-
sessment and the diagnosis of congenital uterine anoma-
lies. In 1995 Jurkovic et al. [13] compared 2-D and 3-D
ultrasound and HSG, finding both ultrasound modalities
to have high predictive value for larger anomalies, espe-
cially in the differentiation of bicornuate and partially
septate uteri. Raga et al. [14] found 3-D US to have a
91.6% accuracy in the study of the fundus and 100% in
that of the cavity, compared to laparoscopy and HSG,
respectively. Wu et al. [19], while comparing the 3-D US
with laparoscopy and/or hysteroscopy, found 3-D ultra-
sound to have a 92% accuracy in the diagnosis of septate
uterus and 100% for bicornuate uterus. Further studies
comparing 3-D US to endoscopy revealed sensitivity of
97% - 100%, specifity of 96% - 100%, positive predic-
tive value of 92% and negative predictive value of 99%
in the diagnosis of Mullerian anomalies [20,21] with a
96% concordance between ultrasound and endoscopy
with respect to the type of anomaly diagnosed [21].
Compared to 3-D US, the 2-D US, while being a sen-
sitive method for detection of uterine anomalies [15,18],
it provides only a limited view of the uterine fundus and
therefore cannot reliably differentiate between arcuate,
bicornuate, and septate uteri [17,22]. HSG provides in-
formation on uterine cavity contour and tubal patency,
however, its limitations results from its inability to clas-
sify the different subtypes of congenital uterine anoma-
lies and to patients’ exposure to ionizing radiation [23].
Hysteroscopy, on the other hand, is the gold standard
diagnostic technique for endometrial cavity abnormali-
ties, which can help revealing fundal septa suspected or
unrecognized on HS G or ul trasound examinations [24] .
3-D US overcomes th e limitation of 2-D US and HSG
by providing a coronal view of the uterus, which can
rarely be seen by conventional 2-D US [13]. Recently
[25], the value of 3D ultrasound in detecting congenital
mullerian anomalies was found as accurate as MRI.
The coronal view enables th e visualization of both th e
endometrial cavity and uterine fundus, thus providing all
information necessary for a complete assessment of the
nature and extent of the congenital anomaly and also
facilitating the differential diagnosis between various
fusion defects. The examination is performed in a stan-
dardized plane using corneal-interstitial portions of the
fallopian tubes as the reference point, which enables
quantitative description of uterine morphology. In addi-
tion, 3-D volumes can be stored on disk and re-examined
later, which facilitates audit and independent v erification
of the diagnosis [13,14,19 ].
In conclusion, 3-D US is an excellent, noninvasive, and
accurate technology, which can serve as the gold standard
in the assessment of congenital uteri ne anomalies.
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