EDITOR’S CORNER

Congenital malformations of the female genital tract:

the need for a new classification system
Grigoris F. Grimbizis, M.D., Ph.D.,a and Rudi Campo, M.D.b
a
First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece;
and b European Academy of Gynecological Surgery and European Society of Gynecological Endoscopy, Leuven, Belgium

Current proposals for classifying female genital anomalies seem to be associated with limitations in effective
categorization, creating the need for a new classification system that is as simple as possible, clear and accurate
in its definitions, comprehensive, and correlated with patients’ clinical presentation, prognosis, and treatment on
an evidence-based foundation. Although creating a new classification system is not an easy task, it is feasible
when taking into account the experience gained from applying the existing classification systems, mainly that
of the American Fertility Society. (Fertil Steril 2010;94:401–7. 2010 by American Society for Reproductive
Medicine.)
Key Words: Congenital malformations, classification, female genital anomalies

Congenital malformations of the female genital tract consist of
a group of miscellaneous deviations from normal anatomy. They re-
sult from embryologic maldevelopment of the M€ullerian or parame-
sonephric ducts during fetal life: failure of one or more M€ ullerian
ducts to either develop (e.g., aplasia in parts of the system, unicorn-
uate uterus without rudimentary horn) or canalize (e.g., unicornuate
uterus with rudimentary horn but without proper cavity), abnormal
fusion of the ducts or a lack of duct fusion (e.g., didelphys uterus,
bicornuate uterus), and failure to absorb the septum, either totally
or partially (e.g., septate uterus, arcuate uterus, obstructing or non-
obstructing cervical or vaginal septum) (1–7).
Although certain types of congenital malformations are the result
of a clear disturbance in one stage of embryologic development,
others are the result of disturbances in more than one stage of normal
formation (3). This multistage involvement seems to be the reason
for the extremely wide anatomical variations and the large number
of combinations observed in congenital malformations of the female
genital tract. Importantly, uterine malformations are only a part,
although the greater part, of female genital malformations.
Congenital anomalies are very common, but their true prevalence
in the general population is not absolutely known mainly owing to
methodological bias (6–8). However, the current availability of
a wide range of noninvasive diagnostic procedures provides the
opportunity to detect anatomical variations in an accurate way. In
an older pooled analysis of all studies, the mean prevalence of
female congenital malformation in the general population was
4% (6); in a more recent systematic review that included studies
using more accurate diagnostic methods, the mean prevalence in
the general population was up to 7% (7).
Received August 8, 2009; revised February 4, 2010; accepted February
15, 2010; published online March 31, 2010.
G.F.G. has nothing to disclose. R.C. has nothing to disclose.
Reprint requests: Assistant Professor Grigoris F. Grimbizis, First Depart-
ment of Obstetrics and Gynecology, Aristotle University of Thessaloniki,
Tsimiski 51 Street, 54623, Thessaloniki, Greece (FAX: 30-2310-991510;
E-mail: grimbi@med.auth.gr).
Therefore, congenital anomalies represent a more frequent
clinical entity than previously expected. The effective appraisal of
the anomalies requires a representative classification system.
THE CHARACTERISTICS OF A CLASSIFICATION SYSTEM
Classification systems are extremely useful and necessary for
organizing any kind of knowledge, especially medical knowledge.
In medicine, categorization enables a better understanding of
disease processes as well as more effective diagnosis and treatment.
Classification systems are based on the systematic categorization of
the patients into groups with similar characteristics. The basic char-
acteristics selected for patient grouping and how they are used in
a system are important and create the differences between the
systems proposed for a group of diseases. The acceptance of a system
indicates its ability to effectively correspond to the needs of the
clinicians in understanding, diagnosing, and treating patients.
The ideal classification system should have the following charac-
teristics: [1] clear enough and accurate for diagnosis and differential
diagnosis; [2] comprehensive, incorporating all possible anatomical
variations; [3] correlated with the clinical presentation and progno-
sis of the patients; [4] correlated with the treatment of the patients;
and [5] as simple as possible.
CURRENT PROPOSALS FOR THE CLASSIFICATION OF
CONGENITAL MALFORMATIONS
In 1979, Buttram and Gibbons (9) did the first serious work on the
classification of congenital malformations, which was the basis for
the American Fertility Society (AFS) classification system, which
was published in 1988 (4). The AFS classification system has
been widely accepted and is currently the most widely used system.
Two other proposals have also been published; in 2004, Acien et al.
(2) proposed a new system based on the embryological origin of the
anomalies, and 1 year later, Oppelt et al. (10) proposed the vagina,
cervix, uterus, adnexae, and associated malformations (VCUAM)

0015-0282/$36.00 Fertility and Sterility Vol. 94, No. 2, July 2010 401
doi:10.1016/j.fertnstert.2010.02.030 Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc.
system. Although it is too early for permanent conclusions, these
systems have not been widely accepted.
AFS Classification
The basis for the AFS classification system is the anatomy of the
female genital tract, especially the uterine anatomy (Table 1). This
system is simple, user-friendly, and clear enough. It has been
successfully adopted as the main classification system for almost
two decades. The fact that the vast majority of the female congenital
malformations are uterine, which is the basic characteristic for pa-
tient grouping, explains the wide acceptability. Also, the classifica-
tion of congenital malformations according to the degree of uterine
deformity seems to correlate well with patient prognoses, mainly the
impact on pregnancy outcome, which is another notable parameter
for explaining the system’s acceptance.
However, as time passes, many problems seem to be associated
with the use of the AFS system:
1. Many clinicians are faced with congenital anomalies that are not
included in the main categories or subcategories of the AFS
classification system, such as bicervical septate uterus with or
without vaginal septum, didelphys with obstructing vaginal sep-
tum, and bicornuate with cervical/vaginal aplasia (2, 3, 11–35).
2. There has been extensive discussion as to whether arcuate uterus
needs to be a separate class in the classification system or should
be included with septate uterus (6, 36).
3. Class I includes cases with hypoplasia and/or dysgenesis of the va-
gina, cervix, uterus, and/or adnexae; the grouping of these patients
into one category is very general and not functional, and it seems to
be an effort to avoid a problem rather than to solve it. Although
these types of anomalies represent an extremely low percentage
of the total number of malformations (37), they incorporate severe
(in terms of deviation from the normal) and complex (more than
one organ) types of congenital anomalies; they are associated
with very serious clinical manifestations, and they usually need
complex surgical treatments (18, 38–40). A clear and accurate
classification is a prerequisite for their treatment. Furthermore,
the two proposals for a different classification system (2, 10), as
well as some subdivisions proposed for certain categories of
genital malformations (40, 32), are derived from the inability of
the AFS classification system to effectively classify ‘‘complex’’
anomalies.
4. ‘‘Obstructive’’ anomalies, which are the result of cervical and/or
vaginal aplasias and/or dysplasias, in the presence of either a nor-
mal or deformed but functional uterus are not represented in the
AFS classification system (40, 32). These anomalies are either
placed together in the first class or are not clearly distinguished
in the other classes (2, 10).
It seems, therefore, that the AFS classification system ‘‘could
function as a framework for the description of anomalies rather
than an exhaustive list of all possible anomaly types.’’
Clinical and Embryological Classification
The basis for the clinical and embryological classification system (2)
is the embryological origin of the different elements of the genitouri-
nary tract (Table 2). This system could lead to a better understanding
of the pathogenesis of female genital tract anomalies, which seems
to be the main purpose of its inventors. Also, the system may be
more effective at classifying the complex anomalies because it is
based on their pathogenesis, a hypothesis that needs to be tested.
However, this system has an inherent limitation that dramatically
402 Grimbizis and Campo Classification of female genital anomalies
reduces its chances of acceptance; there is a radical change on the
basis of the classification system from anatomy, which is the basis
of the widely accepted AFS classification system, to embryogenesis.
Because congenital malformations of the female genital tract are
defined as miscellaneous deviations from normal anatomy, it seems
more logical to choose anatomy per se as the basis for their classifi-
cation. It should also be noted that current theory about female gen-
ital tract embryogenesis, which seems to be reliable, could undergo
some changes in the future as new evidence comes to light. This shift
could cause changes in the basis of the classification system and
the selected and proposed categories.
Furthermore, patients’ clinical manifestations, prognoses, and
treatments seem to be the most important parameters in choosing
the basis for a classification system. Because most therapeutic inter-
ventions tend to restore normal anatomy, and the clinical problems
seem to be associated with anatomical deviations from the norm,
anatomy per se seems to be the more functional basis for the classi-
fication system. Of course, it is useful to explain and understand the
pathogenesis of any genital malformation before undertaking
the best corrective or therapeutic approach. Finally, this system is
not very simple or friendly to use.
VCUAM Classification
The basis of the VCUAM system is the anatomy of the female genital
tract (Table 3). Each organ is classified separately, similar to the tu-
mor, node, and metastasis classification system for breast tumors
(10). This approach provides the opportunity to have a precise, de-
tailed, and extremely representative manner of classification; each
type of anomaly could be described using this system, and the clini-
cian could have an accurate idea of each individual’s genital tract
anatomy.
The main disadvantage of this system is that it is not simple or
user-friendly. Patients are classified only with the help of the classi-
fication system’s tables. ‘‘Translating’’ what a ‘‘V5b, C2b, U4b, A0,
MR’’ patient has (a woman with Mayer-Rokitansky-Kuster-Hauser
syndrome) is not easily done without the use of the appropriate
tables. This system is not practical for everyday use and explains
the low acceptance of this idea.
From the design of the VCUAM classification system, the anom-
alies of each separate organ of the female genital tract have the same
independent importance in the classification of each patient, which
does not allow their frequency to be taken into account in the
patient’s classification. Thus, extremely frequent congenital
anomalies, such as uterine septum, have the same importance in
the classification as the extremely rare anomalies, such as cervical
aplasia. This overestimation of the anatomy seems to not be very
functional because frequency is another important parameter in
the design of the classification systems.
Another misleading problem of the VCUAM system is that there
is a need to discuss the groups for each separate organ from the be-
ginning; according to this system, uterine anomalies are classified
into 0, normal; 1a, arcuate; 1b, septate <50%; 1c, septate >50%;
2, bicornuate; 3, hypoplastic; 4a, unilaterally rudimentary or
aplastic; 4b, bilaterally rudimentary or aplastic; þ, other; and #,
unknown (Table 3). As easily, one could understand there is
a need to discuss from the beginning the adequacy of the proposed
classification to cover all kinds of uterine anomalies (e.g., there is
a need for a distinct class of uterus didelphys and unicornuate
uterus), the necessity of each separate class, and the definitions of
each distinct category.
Vol. 94, No. 2, July 2010
 TABLE 1
AFS classification of patients based on the anatomy of the
female genital system, especially uterine anatomy.
Class I Hypoplasia and (a) Vaginal, (b) cervical,
agenesis (c) fundal, (d) tubal
Class II Unicornuate (a) Communicating,
(b) noncommunicating,
(c) no cavity, (d) no horn
Class III Didelphys
Class IV Bicornuate (a) Partial, (b) complete
Class V Septate (a) Partial, (b) complete
Class VI Arcuate
Class VII DES drug-related
Grimbizis. Classification of female genital anomalies. Fertil Steril 2010.
Thus, although the VCUAM classification system may serve as
an exhaustive list of all possible anomalies, it could not easily serve
as a functional framework for describing the anomalies.
THE NEED FOR A NEW CLASSIFICATION SYSTEM
The need for a new classification system for congenital anomalies of
the female genital tract seems obvious. The new system should seri-
ously and critically take into account all of the experience gained
from the application of the current classification systems, incorporat-
ing their advantages and avoiding their disadvantages and fulfilling, as
much as possible, all the criteria for an ideal classification system. This
is not an easy task, but it is a necessary task for patient management.
Clear and Accurate Definitions
Hysterosalpingography does not really help diagnose a large number
of congenital malformations (e.g., all cases of aplasia or cases with
obstructing vaginal septum that do not allow approximation of the
cervix) or offer an effective differential diagnosis between others
(e.g., between septate and bicornuate uterus), but it was the main
noninvasive diagnostic procedure during the 1980s (7, 8, 41–47).
However, two-dimensional ultrasound using the transabdominal
and/or transvaginal route, as well as sonohysterography later, were
major noninvasive steps forward in the diagnosis of congenital mal-
formations, and a real improvement was made with the introduction
of three-dimensional ultrasound, enabling the physician to estimate
both the endometrial cavity and the outer shape of the uterus in
a more accurate and patient-friendly way (7, 42, 43–58). More
recent advances in the field of computer science and ultrasound
offer the opportunity for the three-dimensional computerized ultra-
sound reconstruction of the uterine cavity, a diagnostic approach that
could be undertaken as virtual hysteroscopy (59).
Magnetic resonance imaging began a new era in the noninvasive
diagnosis of the uterus. Females of reproductive age show three dis-
tinct layers in the myometrium on T2-weighted images: hyperin-
tense inner endometrium, surrounded by the hypointense
junctional zone (JZ), and the intermediate hypointense outer myo-
metrium (60–69). The JZ is functionally important in reproduction
and ontogenetically related to the endometrium (61, 63, 65).
Although its diagnostic accuracy in the management of congenital
anomalies is not yet fully elucidated, it seems to be an extremely
useful tool, especially in cases of obstructive or nonobstructive
vaginal and/or cervical aplasia or dysplasia (8, 11, 24, 25, 70–77).
All these improvements, together with advances in the field of
endoscopy (e.g., office hysteroscopy, hydrolaparoscopy, better
Fertility and Sterility
TABLE 2
Clinical and embryological classification of patients based
on the embryological origin of the different elements of the
genitourinary tract.
1. Agenesis or hypoplasia of a urogenital ridge; unicornuate
uterus with uterine, tubal, ovarian, and renal agenesis on
the contralateral side.
2. Mesonephric anomalies with an absence of the Wolffian
duct opening to the urogenital sinus and ureteral bud
sprouting (and, therefore, renal agenesis). The ‘‘inductor’’
function of the Wolffian duct on the Mullerian duct also fails,
and there is usually uterovaginal duplicity plus blind
hemivagina ipsilateral with renal agenesis, clinically
presented as
(a) Large unilateral hematocolpos
(b) Gardner’s pseudocyst on the anterolateral wall of the
vagina
(c) Partial reabsorption of the intervaginal septum, seen as
a ‘‘buttonhole’’ on the anterolateral wall of the normal
vagina, which allows access to the genital organs on
the renal agenesis side
(d) Vaginal or complete cervicovaginal unilateral agenesis,
ipsilateral with renal agenesis, and with [1] no
communication or [2] communication between both
hemiuteri (communicating uteri).
€ llerian anomalies affecting
3. Isolated Mu
(a) Mu€ llerian ducts: the common uterine malformations as
unicornuate (generally with uterine rudimentary horn),
bicornuate, septate, and didelphys uterus
(b) Mu€llerian tubercle: cervicovaginal atresia and
segmentary anomalies, such as transverse vaginal
septum
(c) Both Mu €llerian tubercle and ducts: (uni- or bilateral)
Mayer-Rokitansky-Kuster-Hauser syndrome
4. Anomalies of the urogenital sinus: cloacal anomalies and
others
5. Malformation combinations: Wolffian, Mu €llerian, and
cloacal anomalies
Grimbizis. Classification of female genital anomalies. Fertil Steril 2010.
imaging in laparoscopy), greatly increase our efficacy for an
accurate, clear, and detailed estimation of the anatomy of the
female genital system (78–81).
Ideally, the classification system should be very clear in the de-
scription of its classes, as well as its possible subclasses, to enable
the clinician to efficiently recognize anatomical variations and clas-
sify them easily and exactly. Clarity will enable the clinician to de-
velop a diagnostic strategy. The anatomy of the female genital tract
should be defined as objectively as possible, and for this reason the
examination protocol should be supplemented as needed by any im-
aging modality that contributes to this goal. Clear definitions of each
type may help avoid subjectivity in the criteria used to recognize and
classify each anomaly and avoid ‘‘transitional’’ cases (3, 6, 7, 82).
A clear and accurate classification of the congenital malforma-
tions allows for the correct assessment of their prevalence and the
prevalence of the different types. In addition, the need for standard-
ization is exemplified by the lack of an internationally accepted
orientation system for the display of uterine images. In view of
the worldwide popularity of ultrasound, an internationally accepted
403
 uterus with obstructing vaginal septum, cervical aplasia/dysplasia
TABLE 3 with functioning uterine corpus, and so on (2, 3, 11–35, 83).
VCUAM classification of patients based on the anatomy of These described new variations are probably the result of our
the female genital system, more specifically, the increasing ability to more efficiently detect anomalies and identify
independent estimation of each organ’s anatomy. anatomy in detail using the new diagnostic modalities. The
classification system must be able to incorporate the new entities
Vagina (V) 0 Normal and be open to new possible combinations.
1 (a) Partial hymenal atresia,
(b) complete hymenal atresia
2 (a) Incomplete septate vagina <50%, Correlation with Clinical Presentation and Prognosis
(b) complete septate vagina Ongoing evidence supports the initial perception that uterine anoma-
3 Stenosis of the introitus lies are associated with poor pregnancy outcome (6, 84–90). The
4 Hypoplasia pregnancy-related consequences of each type of anomaly may be dif-
5 (a) Unilateral atresia,
ferent (6, 87, 89–92) or not between different groups (e.g., arcuate and
(b) complete atresia
S [1] Sinus urogenitalis (deep septate uterus) or subgroups of the same group (e.g., partial, complete,
confluence), [2] sinus urogenitalis and bicervical septate uterus) (36, 93, 94). Some of the consequences
(middle confluence), [3] sinus are related to obstetrical complications that are dangerous to
urogenitalis (high confluence) a woman’s life, such as pregnancy in a noncommunicating uterine
C Cloacae horn of a unicornuate uterus (91, 95–99).
þ Other Women with obstructive congenital anomalies (normal functioning
# Unknown uterus with cervical and/or vaginal aplasia or dysplasia) are usually
Cervix (C) 0 Normal associated with severe health problems, such as cyclic pain resulting
1 Duplex cervix from ‘‘trapped menses’’ and coexisting endometriosis, an inability to
2 (a) Unilateral atresia/aplasia,
establish a sexual life, and reproductive problems achieving
(b) unilateral atresia/aplasia
þ Other
a pregnancy, even with assisted reproductive techniques (18, 32, 39,
# Unknown 40, 82, 100–105). The treatment of these patients is urgent in nature,
Uterus (U) 0 Normal and an inability to restore the continuity of the female genital tract is
1 (a) Arcuate, (b) septate <50% uterine substituted only by total hysterectomy (18, 82, 83, 100–102, 104,
cavity, (c) septate >50% uterine 106–108). This group of women has a completely different clinical
cavity presentation and therapeutic requirements than the group of patients
2 Bicornuate with vaginal aplasia/dysplasia and an absent functioning uterus. This
3 Hypoplastic anomaly is associated with a lasting negative psychological impact
4 (a) Unilaterally rudimentary or aplastic, on women. However, the main problems are the inability to
(b) bilaterally rudimentary or aplastic
establish a sexual life and reproductive problems, which could wait
þ Other
# Unknown
until beginning sexual activity (38, 109–113).
Adnexa (A) 0 Normal Thus, it is extremely important for the evidence-based prognosis of
1 (a) Unilateral tubal malformation, female genital anomalies to have a new classification system with clear
ovaries normal, (b) bilateral tubal definitions of each group and subgroup. Ideally, the system should in-
malformation, ovaries normal corporate the different categories of congenital malformations in
2 (a) Unilateral hypoplasia/gonadal a very distinct way; uterine malformations are usually associated
streak, (b) bilateral hypoplasia/ with a different prognosis than that of the cervix and vagina.
gonadal streak
3 (a) Unilateral aplasia,
(b) bilateral aplasia Correlation with Treatment
þ Other Laparoscopy and hysteroscopy markedly increase our therapeutic
# Unknown options (6, 77, 78, 98, 114–121). Furthermore, many new
Associated 0 None therapeutic options have been proposed for the restoration of
malformations R Renal vaginal and/or cervical aplasia/dysplasia in the presence or not of
(M) S Skeleton
a functional uterus (18, 26, 32, 82, 100–104, 106, 113, 122–131).
C Cardiac
N Neurologic
More importantly, the results of their treatment could be evaluated
þ Other in clinical series or in reviews of case reports or case series
# Unknown (18, 32, 82, 100–103, 106, 113, 122, 125, 128, 129, 132–135).
When planning a clear therapeutic strategy for female genital
Grimbizis. Classification of female genital anomalies. Fertil Steril 2010. malformations the following questions should be asked for every
category: [1] Is treatment needed? For example, restoring the conti-
nuity of the female genital tract is a necessity in cases of obstructing
standard orientation would assist clinicians in their interpretation
anomalies. [2] Is there a treatment? For example, hysteroscopic sep-
of the literature.
tum resection can restore normal uterine anatomy in cases of septate
uterus, but restoration of the uterine anatomy is not feasible for
Comprehensive Incorporation of All Potential Variations unicornuate uterus. And [3] will treatment restore the functional
An ongoing number of publications have reported a number of new problems related to the anomaly?
variations of undescribed anomalies with unclear classification: sep- In planning our therapeutic strategy, there is an obvious need for
tate bicervical uterus with or without vaginal septum, didelphys an evidence-based patient classification according to the patient’s

404 Grimbizis and Campo Classification of female genital anomalies Vol. 94, No. 2, July 2010
therapeutic needs. The classification system should, therefore, in-
corporate treatment-related options in its design. This approach
will make it feasible to evaluate the safety, efficacy, and effective-
ness of the procedure to restore normal anatomy and function.
Simple and User-friendly
The system should, ideally, be simple, user-friendly, and functional.
To be user-friendly and functional, there should be a direct and ob-
vious association with the anatomy of the female genital system
without using complicated tables. As the AFS committee for the
classification of congenital anomalies pointed out, the scheme of
the classification system should be given in one page. The system
has to be both complete and simple; it is not necessary to be analyt-
ical and extremely detailed. The frequency of the congenital
anomalies should also be taken into account.
CONCLUSION
Congenital malformations of the female genital system seem to rep-
resent a common clinical entity, especially in patients with infertility
problems. The most commonly used classification system is that of
the AFS, but its appropriateness today has been challenged. There is
an urgent need to have a more exact, clear, and accurate definition of
the different malformations to facilitate researchers and clinicians in
providing correct answers for the prognosis and treatment of the
different malformations.
The European Academy of Gynecological Surgery, in collabora-
tion with the European Society of Gynecological Endoscopy, recog-
nizes the scientific and clinical significance of an evidence-based
updated classification of female congenital malformations and has
established a working group specifically for this issue. To achieve
a most broad consensus, all scientific societies working in a field
related to this subject will be invited to participate in this project.
Using the Delphi procedure, a cost-efficient oversight communica-
tion is guaranteed.
The task definition is obvious but not easy; a new classification sys-
tem should have the practicality of the AFS classification system, but
definitions should avoid subjectivity in the criteria used for patient
grouping and take into account the modern diagnostic and therapeutic
modalities. Anatomy should preferably be the basis of an updated
classification system taking into account, if possible, embryogenesis.
The different types of anomalies should be categorized in a strict
manner. Scientific interest has been focused on uterine anomalies
rather than on the genital tract in general, and, therefore, this might
be taken into account in an updated classification. Completeness,
flexibility, simplicity, and friendliness of use should be discussed.
It is planned to use the Delphi procedure (136) to find a consensus
among the experts in the field. The Delphi procedure is an affordable
and user-friendly communication model, characterized by anonym-
ity, to avoid dominance; and where processes occur in rounds, it al-
lows individuals to change their opinion. Through controlled
feedback and statistical group response, the expert group comes to
a form of consensus. This review article provides a necessary over-
view of the existing problem and will be used as the starting point for
the working group containing a minimum of 20 practicing clini-
cians, surgeons, radiologists, ultrasound specialists, geneticists,
and researchers interested in uterine embryology.
This process is only an intermediate step in the problem solution
because the existence of a consensus does not mean that the answer
has been found. Each answer needs to be matched to observable
events and needs its clinical approval in the field.

REFERENCES
1. Acien P. Embryological observations on the
female genital tract. Hum Reprod 1992;7:
437–45.
2. Acien P, Acien M, Sanchez-Ferrer M. Complex mal-
formations of the female genital tract. New Types
and revision of classification. Hum Reprod
2004;19:2377–84.
3. Acien P, Acien M, Sanchez-Ferrer ML. Mullerian
anomalies ‘‘without a classification’’: from the
didelphys-unicollis uterus to the bicervical uterus
with or without septate vagina. Fertil Steril
2009;91:2369–75.
4. American Fertility Society. The AFS classification
of adnexal aghesions, distal tubal occlusion, tubal
occlusion secondary to tubal ligation, tubal pregnan-
cies, Mullerian anomalies and intrauterine adhe-
sions. Fertil Steril 1988;49:944–55.
5. Ashton D, Amin HK, Richard RM, Neuwirth RS.
The incidence of asymptomatic uterine anomalies
in women undergoing transcervical tubal steriliza-
tion. Obstet Gynecol 1988;72:28–30.
6. Grimbizis GF, Camus M, Tarlatzis BC, Bontis JN,
Devroey P. Clinical implications of uterine malfor-
mations and hysteroscopic treatment results. Hum
Reprod Update 2001;7:161–4.
7. Saravelos SH, Cocksedge KA, Li T-C. Prevalence
and diagnosis of congenital uterine anomalies in
womwn with reproductive failure: a critical ap-
praisal. Hum Reprod Update 2008;14:415–29.
8. Troiano RN, McCarthy SM. M€ullerian duct anoma-
lies: imaging and clinical issues. Radiology
2004;233:19–34.
9. Buttram VC, Gibbons WE. Mullerian anomalies:
a proposed classification (an analysis of 144 cases).
Fertil Steril 1979;32:40–6.
10. Oppelt P, Renner SP, Brucker S, Strissel PL,
Strick R, Oppelt PG, et al. The VCUAM (Vagina
Cervix Uterus Adnex Associated Malformation)
Classification: a new classification for genital mal-
formations. Fertil Steril 2005;84:1493–7.
11. Ballesio L, Andreoli C, De Cicco ML, Angeli ML,
Manganaro L. Hematocolpos in double vagina asso-
ciated with uterus didelphys: US and MRI findings.
Eur J Radiol 2003;45:150–3.
12. Burgis J. Obstuctive Mullerian anomalies: case
report, diagnosis and management. Am J Obstet
Gynecol 2001;185:338–44.
13. Chang AS, Siegel CL, Moley KH, Ratts VS,
Odem RR. Septate uterus with cervical duplication
and longitudinal vaginal septum: a report of five
new cases. Fertil Steril 2004;81:1133–6.
14. Coskun A, Okur N, Ozdemir O, Kiran G,
Arykan DC. Uterus didelphys with an obstructed
unilateral vagina by a transverse vaginal septum as-
sociated with ipsilateral renal agenesis, duplication
of inferior vena cava, high-riding aortic bifurcation
and intestinal malrotation a case report. Fertil Steril
2006;2008:90.e9–11.
15. Duffy DA, Nulsen J, Maier D, Schmidt D,
Benadiva C. Septate uterus with cervical duplica-
tion: a full-term delivery after resection of a vaginal
septum. Fertil Steril 2004;81:1125–6.
16. Fedele L, Bianchi S, Frontino G, Ciappina N,
Fontana E, Borruto F. Laparoscopic findings and pel-
vic anatomy in Mayer-Rokitansky-Kuster-Hauser
syndrome. Obstet Gynecol 2007;109:1111–5.
17. Goluda M, MSt Gabrys, Ujec M, Jedryka M,
Goluda C. Bicornuate rudimentary uterine horns
with functioning endometrium and complete
cervical-vaginal agenesis coexisting with ovarian
endometriosis: a case report. Fertil Steril 2006;86:
462.e9–11.
18. Grimbizis G, Tsalikis T, Mikos T, Papadopoulos N,
Tarlatzis BC, Bontis JN. Successful end-to-end cer-
vico-cervical anastomosis in a patient with congen-
ital cervical fragmentation: case report. Hum
Reprod 2004;19:1204–10.
19. Growdon WB, Laufer MR. Uterine didelphys with
duplicated upper vagina and bilateral lower vaginal
agenesis: a novel M€ullerian anomaly with options
for surgical management. Fertil Steril 2008;89:693–8.
20. Grunfeld L, Klein J, Steren C. The management of
uterus septus. Fertil Steril 2004;83:766–7.
21. Hur J-Y, Shin J-H, Lee J-K, Oh M-J, Saw H-S,
Park Y-K, et al. Septate uterus with double cervices,
unilaterally obstructed vaginal septum and ipsilat-
eral renal agenesis: a rare combination of Mullerian
and Wolffian anomalies complicated by severe en-
dometriosis in an adolescent. J Min Invas Gynecol
2007;14:128–31.
22. Kumar S, Singh SK, Mavuduru R, Naveen A,
Agarwal MM, Vanita J, et al. Bicornuate uterine
horns with complete cervico-vaginal agenesis and
congenital vesicouterine fistula. Int Urogynecol J
2008;19:739–41.
23. Madureira AJ, Mariz CM, Bernardes JC, Ramos IM.
Uterus didelphys with obstructing hemivaginal sep-
tum and ipsilateral renal agenesis. Radiology
2006;239:602–6.
24. Mirkovic L, Ljubic A, Mirkovic D. Magnetic reso-
nance imaging in the evaluation of uterus didelphys
with obstructed hemivagina and renal agenesis:
a case report. Arch Gynecol Obstet 2006;274:246–7.
25. Orazi C, Lucchetti C, Schingo PMS, Marchetti P,
Ferro F. Herlyn-Werner-Wunderlich syndrome:

Fertility and Sterility 405

 uterus didelphys, blind hemivagina and ipsilateral
renal agenesis. Sonographic and MRI findings in
11 cases. Pediatr Radiol 2007;37:657–65.
26. Patterson D, Mueller C, Strubel N, Rivera R,
Ginsburg HB, Nadler EP. Laparoscopic neo-os crea-
tion in an adolescent with uterus didelphys and ob-
structed hemivagina. J Pediatr Surg 2006;41:E19–22.
27. Patton PE, Novy MJ, Lee DM, Hickok LR. The di-
agnosis and reproductive outcome after surgical
treatment of the complete septate uterus, duplicated
cervix and vaginal septum. Am J Obstet Gynecol
2004;190:1669–78.
28. Parsanezhad ME, Alborzi S, Zarei A, Dehbashi S,
Shirazi LG, Rajaeefard A, et al. Hysteroscopic met-
roplasty of the complete uterine septum, duplicate
cervix and vaginal septum. Fertil Steril 2006;85:
1473–7.
29. Pavone ME, King JA, Vlahos N. Septate uterus with
cervical duplication and a longitudinal vaginal sep-
tum: a Mullerian anomaly without a classification.
Fertil Steril 2006;85:494.e9–10.
30. Sadik S, Taskin O, Sehirali S, Mendilcioglu I,
Onoglu AS, Kursun S, et al. Complex Mullerian
malformations: report of a case with hypoplastic
non-cavitated uterus and two rudimentary horns.
Hum Reprod 2002;17:1343–4.
31. Spitzer RF, Caccia N, Kives S, Allen LM. Hystero-
scopic unification of a complete obstructing uterine
septum: case report and review of the literature.
Fertil Steril 2008;90:2016.e17–20.
32. Strawbrigde LC, Crough NS, Cutner AS,
Creighton SM. Obstructive Mullerian anomalies
and modern laparoscopic management. J Pediatr
Adolesc Gynecol 2007;20:195–200.
33. Tsai C-H, Chen C-P, Chang MD-T, Chang S-J,
Chien S-C. Hematometrocolpos secondary to didel-
phys uterus and unilateral imperforated double va-
gina as an unusual cause of acute abdomen.
Taiwan J Obstet Gynecol 2007;46:448–52.
34. Vercellini P, Daguati R, Somigliana E, Vigano P,
Lanzani A, Fedele L. Asymmetric lateral distribu-
tion of obstructed hemivagina and renal agenesis
in women with uterus didelphys: institutional case
series and a systematic literature review. Fertil Steril
2007;87:719–24.
35. Zurawin RK, Dietrich JE, Heard MJ, Edwards CL.
Didelphic uterus and obstructed hemivagina with re-
nal agenesis: case report and review of the literature.
J Pediatr Adolesc Gynecol 2004;17:137–41.
36. Tomazevic T, Ban-Frangez H, Ribic-Pucelj M, Pre-
mru-Srsen T, Verderik I. Small uterine septum is an
important risk variable for preterm birth. Eur J Ob-
stet Gynecol Reprod Biol 2007;135:154–7.
37. Aittomaki K, Eroila H, Kajanoja P. A population-
based study of the incidence of M€ullerian aplasia
in Finland. Fertil Steril 2001;76:624–5.
38. Guerrier D, Mouchel T, Pasquier L, Pellerin I. The
Mayer-Rokitansky-Kuster-Hauser syndrome (con-
genital absence of uterus and vagina)—phenotypic
manifestations and genetic approaches. J Nedat
Results Biomed 2006;5:1–8.
39. Joki-Erkkil€a MM, Heinonen PK. Presenting and
long-term clinical implications and fecundity in
females with obstructing vaginal malformations.
J Pediatr Adolesc Gynecol 2003;16:307–12.
40. Rock JA, Carpenter SE, Wheeless CR, Jones HWJ.
The clinical management of maldevelopment of the
uterine cervix. J Pelv Surg 1995;1:129–33.
41. Braun P, Grau FV, Pons RM, Enguix DP. Is hystero-
salpingography able to diagnose all uterine malfor-
mations correctly? A retrospective study. Eur J
Radiol 2005;53:274–9.
42. Kupesic S. Clinical implications of sonographic de-
tection of uterine anomalies for reproductive out-
come. Ultrasound Obstet Gynecol 2001;18:387–400.
406 Grimbizis and Campo Classification of female genital anomalies
43. Lindheim SR, Adsuar N, Kushner DM, Pritts EA,
Olive DL. Sonohysterography: a valuable tool in
evaluating the female pelvis. Obstet Gynecol Survey
2003;58:770–84.
44. Mazouni C, Girard G, Deter R, Haumonte J-B,
Blanc B, Bretelle F. Diagnosis of Mullerian anoma-
lies in adults: evaluation of practice. Fertil Steril
2008;89:219–22.
45. Renbaum L, Ufberg D, Sammel M, Zhou L,
Jabara S, Barnhart K. Reliability of clinicians versus
radiologists for detecting abnormalities on hystero-
salpingogram films. Fertil Steril 2002;78:614–8.
46. Roma Dalfo A, Ubeda B, Ubeda A, Monzoni M,
Rotger R, Ramos R, et al. Diagnostic value of hys-
terosalpingography in the detection of intrauterine
abnormalities: a comparison with hysteroscopy.
2004; Am J Radiol 183:1405–9.
47. Swart P, Mol BW, van der Veen F, van Beurden M,
Redekop WK, Bossuyt PM, et al. The accuracy of
hysterosalpingography in the diagnosis of tubal pa-
thology: a meta-analysis. Fertil Steril 1995;64:
486–91.
48. Alborzi S, Dehbashi S, Parsanezhad ME. Differen-
tial diagnosis of septate and bicornuate uterus by so-
nohysterography eliminates the need for
laparoscopy. Fertil Steril 2002;78:176–8.
49. Cepni I, Ocal P, Erkan S, Saricalli FS, Akbas H,
Demirkiran F, et al. Comparison of transvaginal so-
nography, saline infusion sonography and hystero-
scopy in the evaluation of uterine cavity pathologies.
Aust N Z J Obstet Gynaecol 2005;45:30–5.
50. Ghi T, Casadio P, Kuleva M, Perrone AM,
Savelli L, Giunchi S, et al. Accuracy of three-
dimensional ultrasound in diagnosis and classifica-
tion of congenital uterine anomalies. Fertil Steril
2009;92:808–13.
51. Guimar~aes Filho HA, Mattar R, Pires CR, Araujo
Junior E, Moron AF, et al. Comparison of hystero-
salpingography, hysterosonography and hystero-
scopy in evaluation of the uterine cavty in patients
with recurrent pregnancy losses. Arch Gynecol
Obstet 2006;274:284–8.
52. Guven MA, Bese T, Demirkiran F, Idil M, Mgoyi L.
Hydrosonography in screening for intracavitary pa-
thology in infertile women. Int J Gynecol Obstet
2004;86:377–83.
53. Jurkovic D. Three-dimensional ultrasound in gyne-
cology: a critical evaluation. Ultrasound Obstet
Gynecol 2002;9:109–17.
54. Raine-Fenning N, Fleischer A. Clarifying the role of
three-dimensional transvaginal sonography in re-
productive medicine: an evidence-based appraisal.
J Exper Clin Ass Reprod 2005;2:10.
55. Salim R, Woelfer B, Backos M, Regan L,
Jurkovic D. Reproducibility of three-dimensional
ultrasound diagnosis of congenital uterine anoma-
lies. Ultrasound Obstet Gynecol 2003;21:578–82.
56. Shokeir S, Abdelshaheed M. Sonohysterography as
a first-line evaluation for uterine abnormalities in
women with recurrent failed in vitro fertilization-
embryo transfer. Fertil Steril 2009;91:1321–2.
57. Tur-Kaspa I, Gal M, Hartman M, Hartman J,
Hartman A. A prospective evaluation of uterine ab-
normalities by saline infusion sonohysterography in
1009 women with infertility or abnormal uterine
bleeding. Fertil Steril 2006;86:1731–5.
58. Valenzano MM, Mistrangelo E, Lijoi D,
Fortunato T, Lantieri PB, Risso D, et al. Transvagi-
nal sonohysterographic evaluation of uterine mal-
formations. Eur J Obstet Gynecol Reprod Biol
2006;124:246–9.
59. Ayoubi J-M, Fanchin R, Ferretti G, Pons J-C,
Bricault I. Three-dimensional ultrasonographic re-
construction of the uterine cavity: toward virtual
hysteroscopy? Eur Radiol 2002;12:2030–3.
60. Woodward PJ, Wagner BJ, Farley Te. MR Imaging
in the evaluation of female infertility. Radiographics
1993;13:293–310.
61. Brosens JJ, Barker FG, deSouza NM. Myometrial
zonal differentiation and uterine junctional zone hy-
perplasia in the non-pregnant uterus. Hum Reprod
Update 1998;4:496–502.
62. Hricak H, Alpers C, Crooks LE, Sheldon PE. Mag-
netic resonance imaging of the female pelvis: initial
experience. Am J Radiol 1983;141:1119–28.
63. Brosens JJ, de Souza NM, Barker FG. Uterine junc-
tional zone: function and disease. Lancet 1995;346:
558–60.
64. Brosens J, Campo R, Gordts S, Brosens I. Submu-
cous and outer myometrium fibroid are two distinct
clinical entities. Fertil Steril 2003;79:1452–4.
65. Fusi L, Cloke B, Brosens JJ. The uterine junctional
zone. Best Pract Res Clin Obstetr Gynaecol
2006;20:479–91.
66. Gianaroli L, Gordts S, D’Angelo A, Magli MC,
Brosens I, Cetera C, et al. Effect of inner myome-
trium fibroid on reproductive outcome after IVF.
Reprod Biomed Online 2005;10:473–7.
67. Gordts S, Brosens JJ, Fusi L, Benagiano G,
Brosens I. Uterine adenomyosis: a need for uniform
terminology and consensus classification. Reprod
Biomed Online 2008;17:244–8.
68. Scoutt LM, Flynn SD, Luthringer DF, McCauley TR,
McCarthy SM. Junctional zone of the uterus: corre-
lation of MRI and histologic examination of hyster-
ectomy specimen. Radiology 1991;179:403–7.
69. Tetlow RL, Richmond I, Manton DJ, Greenman J,
Turnbull LW, Killick SR. Histological analysis of the
uterine junctional zone as seen by transvaginal ultra-
sound. Untrasound Obstet Gynecol 1999;14:188–93.
70. Imai A, Takagi H, Matsunami K. Double uterus asso-
ciated with renal aplasia; magnetic resonance appear-
ance and three-dimensional computed tomographic
urogram. Int J Gynecol Obstet 2004;87:169–71.
71. Levsky MJ, Mondshine RT. Hematometrocolpos
due to imperforate hymen in a patient with bicornu-
ate uterus. Am J Radiol 2006;186:1469–70.
72. Marten K, Vosshenrich R, Funke M, Obenauer S,
Baum F, Grabbe E. MRI in the evaluation of M€ullerian
duct anomalies. J Clin Imaging 2003;27:346–50.
73. Minto CL, Hollings N, Hall-Craggs M, Creighton S.
Magnetic resonance imaging in the assessment of
complex Mullerian anomalies. Br J Obstet Gynecol
2001;108:791–7.
74. Pui MH. Imaging diagnosis of congenital uterine
malformation. Comput Med Imag Graph 2004;28:
425–33.
75. Scarsbrook AF, Moore NR. MRI appearances of
Mullerian duct abnormalities. Clin Radiol
2003;58:747–54.
76. Takagi H, Matsunami K, Noda K, Furui T, Imai A.
Magnetic resonance imaging in the evaluation dou-
ble uterus and associated urinary tract anomalies:
a report of five cases. J Obstet Gynaecol 2003;23:
525–7.
77. Takeuchi H, Sato Y, Shimanuki H, Kikuchi J,
Kitase M, Kinoshita K. Accurate preoperative diag-
nosis and laparoscopic removal of the cavitated non-
communicated uterine horn for obstructive Muller-
ian anomalies. J Obstet Gynecol Res 2006;32:74–9.
78. Bettocchi S, Ceci O, Nappi L, Pontrelli G, Pinto L,
Vicino M. Office hysteroscopic motroplasty: three
"diagnostic criteria" to differentiate between septate
and bicornuate uteri. J Min Invas Gynecol 2007;14:
324–8.
79. Campo R, Van Belle Y, Rombauts L, Brosens I,
Gordts S. Office mini-hysteroscopy. Hum Reprod
Update 1999;5:73–81.
80. Gordts S, Campo R, Puttemans P, Verhoven H,
Gianaroli L, Brosens J, et al. Investigation of
Vol. 94, No. 2, July 2010
 the infertile couple: a one stop outpatient endoscopy-
based approach. Hum Reprod 2002;17:1684–7.
81. Philbois O, Guye E, Richard O, Tardieu D, Seffert P,
Chavrier Y, et al. Role of laparoscopy in vaginal
malformation. An experience in 22 children. Surg
Endosc 2004;18:87–91.
82. Acien P, Acien MI, Quereda F, Santoyo T. Cervico-
vaginal agenesis: spontaneous gestation at term after
previous reimplantation of the uterine corpus in
a neovagina: case report. Hum Reprod 2008;23:
548–53.
83. Acien P, Sanchez-Ferrer M, Mayol-Belda M-J. Uni-
lateral cervico-vaginal atresia with ipsilateral renal
agenesis. Eur J Obstet Gynecol Reprod Biol
2004;117:249–51.
84. Acien P. Reproductive performance of women with
uterine malformations. Hum Reprod 1993;8:122–6.
85. Garcia-Enguidanos A, Calle ME, Valero J, Luna S,
Dominguez-Rojas V. Risk factors in miscarriage:
a review. Eur J Obstet Gynecol Reprod Biol
2002;102:111–9.
86. Heinonen PK, Saarikoski S, Pystynen P. Reproduc-
tive performance of women with uterine anomalies.
An evaluation of 182 cases. Acta Obstet Gynecol
Scand 1982;61:157–62.
87. Lin PC, Bhatnagar KP, Nettleton GS, Nakajima ST.
Female genital anomalies affecting reproduction.
Fertil Steril 2002;78:899–915.
88. Rackow BW, Arici A. Reproductive performance of
women with Mullerian anomalies. Curr Opin Obstet
Gynecol 2007;19:229–37.
89. Raga F, Bauset C, Remohi J, Bonilla-Musoles F,
Simon C, Pellicer A. Reproductive impact of con-
genital Mullerian anomalies. Hum Reprod
1997;12:2277–81.
90. Zlopasa G, Skrablin S, Kalafatic D, Banovic V,
Lesin J. Uterine anomalies and pregnancy outcome
following rsectoscope metroplasty. Int J Gynecol
Obstet 2007;98:129–33.
91. Akar ME, Bayar D, Yildiz S, Ozel M, Gilmaz Z. Re-
productive outcome of women with unicornuate
uterus. Aust N Z J Obstet Gynecol 2005;54:148–50.
92. Heinonen PK. Unicornuate uterus and rudimentary
horn. Fertil Steril 1997;68:224–30.
93. Heinonen PK. Complete septate uterus with longitu-
dinal vaginal septum. Fertil Steril 2006;85:700–5.
94. Woelfer B, Salim R, Banerjee S, Elson J, Regan L,
Jurkovic D. Reproductive outcomes in women
with congenital uterine anomalies detected by
three-dimensional ultrasound screening. Obstet
Gynecol 2001;98:1099–103.
95. Arshad Z, Mohan S. Pregnancy in a non-
communicating uterine horn. Acta Obstet Gynecol
Scand 2005;84:1023.
96. Cutner A, Saridogan E, Hart R, Pandya P,
Creighton S. Laparoscopic management of pregnan-
cies occurring in non-communicating accessory
uterine horns. Eur J Obstet Gynecol Reprod Biol
2004;113:106–9.
97. Khanapure A, Aravind S, Lawley R, Verwood G.
Rupture of a pregnancy in the rudimentary commu-
nicating horn of the uterus. J Obstet Gynecol
2005;25:310–1.
98. Sonmezer M, Taskin S, Atabekoglou C, Gungor M,
Unlu C. Laparoscopic management of rudimentary
uterine horn pregnancy: case report and literature re-
view. J Soc Laparoendosc Surg 2006;10:396–9.
99. Tang R, Sheng Y, Chen ZJ. Rupture of pregnancy in
a communicating rudimentary uterine horn after in
vitro fertilization and embryo transfer. Int J Gynecol
Obstet 2004;86:394–5.
100. Bedner R, Rzepka-Gorska I, Blogowska A,
Malecha J, Kosmider M. Effects of a surgical treat-
ment of congenital cervicovaginal agenesia. J Pe-
diatr Adolesc Gynecol 2004;17:327–30.
Fertility and Sterility
101. Deffarges JV, Haddad B, Musset R, Paniel BJ.
Utero-vaginal anastomosis in women with uterine
cervix atresia: long-term follow-up and reproductive
performance. A study of 18 cases. Hum Reprod
2001;16:1722–5.
102. Fujimoto VY, Miller JH, Klein NA, Soules MR.
Congenital cervical atresia: report of seven cases
and review of the literature. Am J Obstet Gynecol
1997;177:1419–25.
103. Selvaggi G, Monstrey S, Depypere H, Blondeel P,
Van Landuyt K, Hamdi M, et al. Creation of a neova-
gina with the use of a pudendal thigh fasciocutane-
ous flap and restoration of uterovaginal continuity.
Fertil Steril 2003;80:607–11.
104. Sparac V, Stilinovic K, Ilijas M, Barcot Z,
Kupesic S, Prka M, et al. Vaginal aplasia associated
with anatomically and functionally normal uterus.
Eur J Obstet Gynecol Reprod Biol 2004;115:110–2.
105. Ziebarth A, Eyster K, Hansen K. Delayed diagnosis
of partially obstructed longitudinal vaginal septa.
Fertil Steril 2007;87:697.e17–20.
106. Bugmann P, Amaudruz M, Hanquinet S, La Scala G,
Birraux J, Le Coultre C. Uterocervicoplasty with
a bladder mucosa layer for the treatment of complete
cervical agenesis. Fertil Steril 2002;77:831–5.
107. Connolly G, Devaney D, McKenna P. A case of
cervical dysgenesis. J Obstet Gynecol 2004;24:
322–33.
108. Fedele L, Bianchi S, Berlanda N, Fontana E,
Raffaelli R, Bulfoni A, et al. Neovaginal mucosa af-
ter Vecchietti’s laparoscopic operation for Rokitan-
sky sundrome: structural and ultrastructural study.
Am J Obstet Gynecol 2006;195:56–61.
109. Heller-Boersma JG, Schmidt UH, Edmonds DK. A
randomized controlled trial of a cognitive-
behavioural group intervention versus waiting-list
control for women with uterovaginal agenesis
(Mayer-Rokitansky-Kuster-Hauser syndrome:
MRKH). Hum Reprod 2007;22:2296–301.
110. Morgan EM, Quint EH. Assessment of sexual func-
tioning, mental health and life goals in women with
vaginal agenesis. Arch Sex Behav 2006;35:607–18.
111. Oppelt P, Renner SP, Kellermann A, Brucker S,
Hauser GA, Ludwig KS, et al. Clinical aspects of
Mayer-Rokitansky-Kuester-Hauser syndrome: rec-
ommendations for clinical diagnosis and staging.
Hum Reprod 2006;21:792–7.
112. Seccia A, Salgarello M, Sturla M, Latorre S,
Farallo E. Neovaginal reconstruction with the mod-
ified McIndoe technique: a review of 32 cases. Ann
Plast Surg 2002;49:379–84.
113. O’Connor JL, DeMarco RT, Pope JC, Adams MC,
Brock JW. Bowel vaginoplasty in children: a retro-
spective review. J Pediatr Surg 2004;39:1205–8.
114. Colacursi N, De Franciscis P, Mollo A, Litta P,
Perino A, Cobellis L, et al. Small-diameter hystero-
scopy with Versapoint versus resectoscopy with uni-
polar knife for the treatment of septate uterus:
a prospective randomized study. J Min Invas Gyne-
col 2007;14:622–7.
115. Fedele L, Bianchi S, Zanconato G, Berlanda N,
Bergamini V. Laparoscopic removal of the cavitated
noncommunicating rudimentary uterine horn: surgi-
cal aspects in 10 cases. Fertil Steril 2005;83:432–6.
116. Grimbizis G, Camus M, Clasen K, De Munck L,
Devroey P. Hysteroscopic septum resection in pa-
tients with recurrent abortions or infertility. Hum
Reprod 1998;13:1188–93.
117. Theodoridis TD, Saravelos H, Chatzigeorgiou KN,
Zepiridis L, Grimbizis GF, Vavilis D, et al. Laparo-
scopic management of unicornuate uterus with non-
communicating rudimentary horn (three cases).
Reprod Biomed Online 2006;12:126–8.
118. Litta P, Spiller E, Saccardi C, Ambrosini G,
Caserta D, Cosmi E. Resectoscope or Versapoint
for hysteroscopic metroplasty. Int J Gynecol Obstet
2008;101:39–42.
119. Nawroth F, Schmidt T, Freise C, Foth D, Romer T. Is
it possible to recommend an ‘‘optimal’’ postopera-
tive management after hysteroscopic metroplasty?
A retrospective study with 52 infertile patients
showing a septate uterus. Acta Obstet Gynecol
Scand 2002;81:55–7.
120. Pabuccu R, Gomel V. Reproductive outcome after
hysteroscopic metroplasty in women with septate
uterus and otherwise unexplained infertility. Fertil
Steril 2004;81:1675–8.
121. Sinha R, Mahajan C, Hegde A, Shukla A. Laparo-
scopic metroplasty for bicornuate uterus. J Min In-
vas Gynecol 2006;13:70–3.
122. Alborzi S, Momtahan M, Parsanezhad ME,
Yazdani M. Successful treatment of cervical aplasia
using a peritoneal graft. Int J Gynecol Obstet
2008;88:299–302.
123. Cai B, Zhang JR, Xi XW, Yan Q, Wan XP. Laparos-
copically assisted sigmoid colon vaginoplasty in
women with Mayer-Rokitansky-Kuster-Hauser syn-
drome: feasibility and short-term results. Br J Obstet
Gynaecol 2007;114:1486–92.
124. Creighton SM, Davies MC, Cutner A. Laparoscopic
management of cervical agenesis. Fertil Steril
2006;85:1510.e13–15.
125. Darwish AM. A simplified novel laparoscopic for-
mation of neovagina for cases of Mayer-
Rokitansky-Kuster-Hauser syndrome. Fertil Steril
2007;88:1427–30.
126. Ding D-C, Hsu S, Liu J-Y. Vaginal agenesis in a girl
with normal uterus and cervix reconstructed with
vulvar skin graft. Eur J Obstet Gynecol Reprod
Biol 2005;123:257–8.
127. Fedele L, Bianchi S, Berlanda N, Bulfoni A,
Fontana E. Laparoscopic creation of a neovagina
and recovery of menstrual function in a patient
with Rokitansky syndrome: a case report. Hum
Reprod 2006;21:3287–9.
128. Fedele L, Bianchi S, Frontino G, Berlanda N,
Montefusco S, Borruto F. Laparoscopically assisted
uterovesticular anastomosis in patients with uterine
cervix atresia and vaginal aplasia. Fertil Steril
2008;89:212–6.
129. Jasonni VM, La Marca A, Matonti G. Utero-vaginal
anastomosis in the treatment of cervical atresia. Acta
Obstet Gynecol Scand 2007;86:1517–8.
130. Kresowik J, Ryan GL, Austin C, Van Voorhis BJ. Ul-
trasound-assisted repair of a unique case of distal
vaginal agenesis. Fertil Steril 2007;87:976.e9–12.
131. Miller RJ, Breech LL. Surgical correction of vaginal
anomalies. Clin Obstet Gynecol 2008;51:223–6.
132. Brun J-L, Belleannee G, Grafeille N, Aslan A-F,
Brun GH. Long-term results after neovagina crea-
tion in Mayer-Rokitansky-Kuster-Hauser syndrome
by Vecchietti’s operation. Eur J Obstet Gynecol Re-
prod Biol 2002;103:168–72.
133. Communal P-H, Chevret-Measson M, Golfier F,
Raudrant D. Sexuality after sigmoid colpopoiesis
in patients with Mayer-Rokitansky-Kuster-Hauser
syndrome. Fertil Steril 2003;80:600–6.
134. Darai E, Toullalan O, Besse O, Potiron L, Delga P.
Anatomic and functional results of laparoscopic-
perineal neovagina construction by sigmoid colpo-
plasty in women with Rokitansky’s syndrome.
Hum Reprod 2003;11:2454–9.
135. Giannesi A, Marchiole P, Benchaib M, Chevret-
Measson M, Mathevet P, Dargent D. Sexuality after
laparoscopic Davydov in patients affected by congen-
ital complete vaginal agenesis associated with uterine
agenesis or hypoplasia. Hum Reprod 2005;10:2954–7.
136. Jones J, Hunter D. Consensus methods for medical
and health services research. Br Med J 1995;311:
376–80.
407