Ultrasound Obstet Gynecol 2021; 57: 366–377

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.23108

Definition, prevalence, clinical relevance and treatment of

T-shaped uterus: systematic review
M. A. COELHO NETO1,2 , A. LUDWIN3,4 , F. PETRAGLIA5 and W. P. MARTINS2
1
Department of Obstetrics and Gynecology, Faculty of Medicine of Ribeirão Preto, University of São Paulo (DGO-FRMP-USP), Ribeirão
Preto, Brazil; 2 SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil; 3 Department of Gynecology and Oncology,
Jagiellonian University, Krakow, Poland; 4 Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland; 5 Department of
Clinical and Experimental Biomedical Sciences, University of Florence, Florence, Italy

K E Y W O R D S: congenital uterine anomaly; diethylstilbestrol; dysmorphic uterus agreement; lateral indentation; Müllerian
ducts; T-shaped uterus

CONTRIBUTION and including at least 10 women were considered eligi-

What are the novel findings of this work?
The prevalence, etiology and clinical relevance of
T-shaped uterus remain unclear. As most studies on
T-shaped uterus use different definitions, it is probable
that women with a normal uterus are being subjected to
metroplasty. The evidence supporting surgical treatment
for T-shaped uterus is of very low quality, based largely
on studies lacking a control group.
What are the clinical implications of this work?
Surgical treatment for T-shaped uterus is not supported
by robust evidence. Expectant management should be
considered the most appropriate choice for women with
a T-shaped uterus based on current research.
ABSTRACT
Objectives To summarize in a systematic review the cur-
rent evidence regarding definitions, diagnosis, prevalence,
etiology, clinical relevance and impact of surgical treat-
ment for T-shaped uterus not related to diethylstilbestrol
(DES) exposure, and to highlight areas on which future
research should focus.
Methods A search of PubMed, Scopus and EMBASE
was performed on 9 April 2020 using the search terms
‘t-shaped OR t-shape OR infantile OR (lateral indenta-
tion) OR (diethylstilbestrol OR DES) AND (uterus OR
uterine OR uteri) AND (anomaly OR anomalies OR
malformation OR malformations)’. Additionally, the ref-
erence lists of the included studies were searched manually
for other relevant publications. All studies presenting data
on T-shaped uterus not associated with DES exposure
ble. Studies regarding DES-related T-shaped uterus were
excluded because DES has not been used since 1971.
There were no restrictions on language, date of publica-
tion or status of publication.
Results Of 2504 records identified by the electronic
search, 20 studies were included in the systematic
review. The majority of studies were of poor quality.
In 11 of 16 studies reporting on the diagnosis of
T-shaped uterus, the diagnostic method used was
three-dimensional ultrasound. There is no consensus on
the definition of T-shaped uterus, but the most cited
criteria (4/16 studies) were of the European Society of
Human Reproduction and Embryology and the European
Society for Gynaecological Endoscopy (ESHRE/ESGE;
2013). The prevalence of T-shaped uterus varied from
0.2% to 10% in the four included studies reporting
such data. With respect to etiology (except for DES),
T-shaped uterus was considered a primary condition in
three studies and secondary to adhesions in five and
adenomyosis in one. T-shaped uterus was related to
worse reproductive outcome based on subfertility (nine
studies), miscarriage (seven studies), preterm delivery
(two studies), ectopic pregnancy (one study) and repeat
implantation failure (seven studies). Of the 12 studies
that reported on the effects of surgical treatment of
T-shaped uterus by hysteroscopic metroplasty, some
mentioned an improvement in pregnancy rate (rates
ranging from 49.6% to 88%; eight studies), live-birth
rate (rates ranging from 35.1% to 76%; seven studies)
and term-delivery rate (four studies) and a reduction
in miscarriage (rates ranging from 7% to 49.6%; five
studies) and ectopic pregnancy (one study). However,
the evidence is of very low quality with serious/critical

Correspondence to: Dr M. A. Coelho Neto, University of São Paulo, Department of Obstetrics and Gynecology, Medical School of Ribeirão
Preto, av. bandeirantes 3900 monte legre, Ribeirão Preto, São Paulo 14049-900, Brazil (e-mail: marcelalencar@hotmail.com)
Accepted: 16 August 2020

© 2020 International Society of Ultrasound in Obstetrics and Gynecology. SYSTEMATIC REVIEW


T-shaped uterus
risk of bias toward overestimating the intervention effect.
Some authors reported no complications related to the
procedure, while others mentioned persistence of the
dysmorphism (rates ranging from 1.4% to 11%; three
studies), bleeding (1.3%; one study), infection (2.6%; one
study) and adhesions (11.1% and 16.8%; two studies).
Conclusions The prevalence, etiology and clinical rele-
vance, with respect to reproductive outcome, of T-shaped
uterus remain unclear and there is no consensus on
the definition and diagnostic method for this condition.
Expectant management should be considered the most
appropriate choice for everyday practice until randomized
controlled trials show a benefit of intervention. © 2020
International Society of Ultrasound in Obstetrics and
Gynecology.
INTRODUCTION
T-shaped uterus is considered a congenital uterine malfor-
mation resulting from the failure of later embryological
development of the uterus1 . Until the 1980s, T-shaped
uterus was commonly related to diethylstilbestrol (DES)
exposure in utero; however, decades after the withdrawal
of DES from use during pregnancy, women are still pre-
senting with T-shaped uterus and its cause remains poorly
understood2 . A T-shaped uterus typically exhibits a nar-
rowed uterine cavity with lateral indentations3 , with the
shape of the endometrial cavity resembling the letter
T instead of a triangle2 . Three-dimensional ultrasound
(3D-US) allows detailed visualization of the uterine cav-
ity, uterine walls and external contours of the uterus
in the mid-coronal plane4 , thus facilitating non-invasive
assessment of T-shaped uterus. Hysteroscopy, a minimally
invasive method, enables visualization of the inside of the
cervical canal and endometrial cavity besides allowing
treatment of T-shaped uterus.
The T-shaped uterus was first described by Kaufman
et al.5 in 1977 as a DES-related defect, then in 1979 by
Buttram and Gibbons6 as a class-VI Müllerian anomaly
secondary to DES exposure in utero and later in the
American Fertility Society (AFS) classification, in 1988,
as a type-VII DES-related Müllerian duct defect7 . In
2013, the European Society of Human Reproduction and
Embryology and the European Society for Gynaecological
Endoscopy (ESHRE/ESGE) proposed a definition for
T-shaped uterus as a narrow uterine cavity due to
thickened lateral walls, with proportions of 2/3 uterine
corpus and 1/3 cervix3 .
The prevalence of T-shaped uterus8 and its impact on
reproductive outcome remain unknown9 . The presence
of uterine anomalies is not evaluated in patients from
the general population who are asymptomatic. Therefore,
the available studies on T-shaped uterus are largely on
patients with a history of impaired reproductive outcome.
In these patients, hysteroscopic metroplasty has been
considered as a treatment option2 , but there is no robust
evidence regarding its efficacy or safety.
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367
This study aims to summarize in a systematic
review all available information regarding the definition
(criteria), diagnosis (diagnostic tools, accuracy, reliability/
agreement), prevalence, etiology and clinical relevance
and effectiveness of interventions for T-shaped uterus not
related to DES exposure, and to highlight areas on which
future research should focus.
METHODS
The protocol of this systematic review was registered with
PROSPERO (registration number: CRD42019115131;
http://www.crd.york.ac.uk/prospero/).
Eligibility criteria
All studies related to T-shaped uterus not associated with
DES exposure in utero were included in this systematic
review, irrespective of their design. Cases series were
considered if they included at least 10 women. We
included studies regardless of their objectives, since our
aim was to evaluate criteria for definition, diagnostic
method, prevalence, reproductive outcome and effective-
ness of intervention. We decided to exclude studies on
DES-related T-shaped uterus because this drug has not
been used since 1971 and, therefore, women included in
such studies encompass a different population from that
in which we were interested, as women currently at repro-
ductive age have not been exposed to DES. However, we
still included the term ‘diethylstilbestrol OR DES’ in our
search because some authors might continue to use the
term DES-related anomaly to refer to T-shaped uterus.
Search strategy and selection of studies
We searched PubMed, Scopus and EMBASE using the
following search terms: ‘t-shaped OR t-shape OR infantile
OR (lateral indentation) OR (diethylstilbestrol OR DES)
AND (uterus OR uterine OR uteri) AND (anomaly OR
anomalies OR malformation OR malformations)’.
The last electronic search was performed on 9 April
2020. Titles and abstracts were reviewed independently
by two authors (W.P.M. and M.A.C.N.), who checked for
duplicates and used pre-established criteria for inclusion
(T-shaped uterus not related to DES exposure). There
were no restrictions on language, date of publication or
status of publication. The reference lists of the included
studies and related reviews were searched manually for
potentially relevant articles not identified by the electronic
search. Some references which the authors knew to be
relevant were added manually if they had not already
been identified by the earlier searches.
Three authors (M.A.C.N., W.P.M. and A.L.) retrieved
the full-text manuscripts of the references considered to be
potentially eligible after screening the abstract. This step
was particularly difficult since some of the publications
were very old, mainly regarding DES exposure, or not in
English. One author (A.L.) also asked the librarians of his
institution to help retrieve some full-text manuscripts.
Ultrasound Obstet Gynecol 2021; 57: 366–377.

368
Data collection and extraction
Data extraction was performed in a standardized way
by two authors (W.P.M. and M.A.C.N.). Disagreements
were solved by consultation with a third author (A.L.).
Eligibility was assessed against the inclusion/exclusion
criteria, and studies were included or excluded, as
appropriate. The studies were characterized according
to their design.
The following data were extracted from the eligible
studies: criteria and method of diagnosis, prevalence,
etiology and clinical relevance of T-shaped uterus
with respect to reproductive outcome (subfertility,
previous miscarriage, recurrent miscarriage, miscarriage
per pregnancy, preterm birth, repeat implantation failure
(RIF), ectopic pregnancy). For the studies that proposed
surgical intervention for the treatment of T-shaped uterus,
the type of intervention and description of the method
were extracted together with the reported reproductive
outcome. The primary outcomes of interest were live
birth, clinical pregnancy and miscarriage. The authors of
the original studies were contacted to obtain additional
data whenever necessary.
Quality assessment of studies
For retrospective observational studies, the Newcastle–
Ottawa quality assessment form for cohort studies was
used to assess the risk of bias (http://www.ohri.ca/
programs/clinical_epidemiology/oxford.asp). Reliability/
agreement studies were judged according to the
quality appraisal of diagnostic reliability (QAREL)
tool10 . Diagnostic accuracy studies were judged
according to QUADAS-2 (https://www.bristol.ac.uk/
population-health-sciences/projects/quadas/quadas-2/)11 .
Risk of bias was assessed independently by two
researchers (M.A.C.N. and W.P.M.), and disagreements
were solved by consultation with a third author (A.L.).
Overall quality of evidence
The quality of the body of evidence was classified accord-
ing to the Grading of Recommendations Assessment,
Development and Evaluation (GRADE) criteria, which
take into account risk of bias, consistency of the effect,
imprecision, indirectness and publication bias12 . The qual-
ity of evidence was evaluated independently by two
reviewers (M.A.C.N. and W.P.M.) and disagreements
were solved by discussion with a third author (A.L.).
The quality of evidence was interpreted as follows12 .
High quality: we are very confident that the true effect lies
close to that observed in this review; moderate quality:
we are moderately confident in the effect estimate, the
true effect is likely to be close to that observed in this
review, but there is a possibility that it is substantially
different; low quality: our confidence in the effect estimate
is limited, the true effect may be substantially different
from that observed in this review; or very low quality:
we have very little confidence in the effect estimate, the
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Coelho Neto et al.
true effect is likely to be substantially different from that
observed in this review.
Synthesis of results
Data are presented in descriptive tables separately for
diagnostic criteria, prevalence, clinical relevance with
respect to reproductive outcome and effect of surgical
treatment. As there were no studies considered to be
sufficiently similar, the results of the individual studies
could not be combined in a meta-analysis and they were
synthesized in tables.
RESULTS
Study selection and characteristics
A total of 2504 records (PubMed, n = 505, Scopus,
n = 750 and EMBASE, n = 1249) were identified by the
electronic search and 31 additional studies by manual
search. Of these, 729 were duplicates and 1674 were
excluded after reading the title and abstract as they
were not related to T-shaped uterus (Figure 1). We eval-
uated 132 potentially eligible records in full text, of
which 112 were excluded because T-shaped uterus was
related to DES exposure (n = 64)5,13–75 ; the article was
not related to T-shaped uterus (n = 26)76–101 ; the study
included fewer than 10 women with a T-shaped uterus
(n = 15)4,102–115 ; no detailed results for T-shaped uterus
were reported (n = 4)116–119 ; and the article was a descrip-
tive review (n = 3)120–122 . Therefore, 20 studies were
eventually included in this systematic review2,9,123–140
(Figure 1).
Diagnosis of T-shaped uterus
Sixteen studies mentioned the diagnostic methods and/
or criteria for T-shaped uterus (Table S1)2,9,123–129,132,133,
135–138,140
. The most commonly cited diagnostic method
was 3D-US (11 studies), while other methods mentioned
were magnetic resonance imaging (MRI), hysteroscopy,
hysterosalpingography and two-dimensional ultrasound.
Considering 3D-US and MRI as adequate methods for
diagnosing uterine malformations because they allow
visualization of the coronal view of the uterus, 12 studies
mentioned at least one adequate method for diagnosing
T-shaped uterus.
In four126,128,135,140 of the 16 studies, the diagnosis
of T-shaped uterus was performed in a subjective way.
Four studies123,125,133,138 used the criteria proposed by
ESHRE/ESGE3 , according to which a T-shaped uterus
presents with a narrow uterine cavity due to thickened
lateral walls without specifying a definition and cut-off
for thickened lateral walls and narrow uterine cavity.
Eight studies proposed their own criteria for diagnosing
T-shaped uterus2,9,124,127,129,132,136,137 (Table S1). In the
studies of Neal et al.124 and Ludwin et al.9 , the diagnosis of
T-shaped uterus was made subjectively by experts as a first
step, before the authors proposed their own diagnostic
Ultrasound Obstet Gynecol 2021; 57: 366–377.

T-shaped uterus
criteria. The study of Ludwin et al.9 also compared
the diagnostic accuracy of the subjective opinion of
individual experts to that of measurements performed
by 3D-US. The definition for T-shaped uterus proposed
by the Congenital Uterine Malformation by Experts
(CUME) group, using strict measurable criteria and
based on the diagnosis made most often by independent
experts, includes lateral indentation angle ≤ 130◦ , lateral
indentation depth ≥ 7 mm and T-angle ≤ 40◦ , with
good diagnostic accuracy and moderate interobserver
reproducibility9 . This classification was published recently
and is yet to be used by other authors.
Prevalence of T-shaped uterus
Four studies included information about the prevalence
of T-shaped uterus124,131,133,134 . The studies involved
different populations; specifically, women undergoing
hysteroscopy due to infertility133 , infertile women
undergoing in-vitro fertilization (IVF)124 , patients with
singleton pregnancy with uterine anomaly diagnosed
during pregnancy134 and women with adenomyosis131 ,
and, therefore, the prevalence of T-shaped uterus varied
widely from 0.2 to 10% (Table 1). None of the studies
that provided data to infer prevalence mentioned objective
measurements and respective cut-offs for the diagnosis of
T-shaped uterus131,133,134 .
Records identified through Records identified through
electronic search manual search
(n = 2504)
Total records
(n = 2535)
Title/abstract screened
(n = 1806)
Full-text articles assessed
for eligibility
(n = 132)
Included in systematic review
(n = 20)
Figure 1 Flowchart summarizing selection of studies on T-shaped uterus for inclusion in systematic review. DES, diethylstilbestrol.
© 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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369
Etiology of T-shaped uterus
Seven studies mentioned the etiology of T-shaped
uterus2,124,126,129,131,133,137 , however, we found no
research focusing on the cause of T-shaped uterus. Şükür
et al.137 reported that the etiology of this condition is
unknown but is likely to be secondary to adhesions.
Three studies124,129,133 reported that T-shaped uterus is a
primary condition and five2,124,126,133,137 that it presents
secondary to adhesions. One study linked T-shaped
uterus to adenomyosis131 .
Reproductive outcome
T-shaped uterus is generally reported to be associated with
worse reproductive outcome (Table 2). Nine studies high-
lighted a relationship between subfertility and T-shaped
uterus123–128,135,137,140 . Most of these studies included
only patients with subfertility123,124,126,128,135,140 . More-
over, two of these studies included women with unex-
plained subfertility127,128 , while three others included
women with other cause of subfertility123,126,137 . Only
two studies provided a control group for comparison
(subfertile patients with normal uterus)123,124 . In the
three studies that did not include solely women with
subfertility125,127,137 , the prevalence of subfertility in
women with a T-shaped uterus ranged from 45% to
74.2%, which was considered to be significantly higher
than the 15% found in the general population141 .
(n = 31)
Duplicates removed (n = 729)
Eligibility criteria not met (n = 1674)
Excluded (n = 112):
• DES-related T-shaped uterus (n = 64)
• Not related to T-shaped uterus (n = 26)
• Fewer than 10 women with T-shaped uterus (n = 15)
• No results for T-shaped uterus (n = 4)
• Descriptive review (n = 3)
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370
Table 1 Prevalence of T-shaped uterus reported in included studies
Study Prevalence Population
Di Spiezio 12/324 (3.7) Women undergoing hysteroscopy
Sardo (2015)133 due to infertility
Fox (2014)134 10/4473 (0.2) Women with singleton pregnancy
> 22 weeks, diagnosed with
uterine anomaly during pregnancy
Neal (2019)124 10/648 (1.5) Infertile patients undergoing in-vitro
fertilization
Puente (2016)131 25/248 (10.1) Women with adenomyosis
Only first author of each study is given. Data are given as n/N (%).
The presence of subfertility in patients presenting with
T-shaped uterus in the included studies does not allow
us to conclude that subfertility is consequent to T-shaped
uterus as this may be only a reflection of the inclusion
criteria used by the studies.
Seven studies included patients with T-shaped uterus
and a history of previous miscarriage123–127,136,139 ,
with the prevalence varying between 22% and 50%.
One study included only patients with a history of
miscarriage136 . Only two studies123,124 had a control
group of patients with a normal uterus for comparison,
one of which showed that the history of miscarriage was
five times more common in patients with a T-shaped
uterus compared to those with a normal uterus124 and
the other that it was similar between the two groups123 .
Five studies reported on the incidence of recurrent
miscarriage in women with a T-shaped uterus123–127 .
Two of these studies compared the prevalence of recurrent
miscarriage between women with a T-shaped and those
with a normal uterus, showing a higher prevalence in
patients with T-shaped uterus (20% vs 10.2% in Neal
et al.124 and 17.6% vs 10.8% in Uyar et al.123 , though
the difference did not reach statistical significance in the
latter study). For the other studies, it is possible to infer
the higher prevalence of recurrent miscarriage in patients
with T-shaped uterus, which was 17.9–33.3%125–127 vs
approximately 5% in the general population142 . One
study did not clarify what was defined as repeat pregnancy
loss124 . The definition used in most studies was two
or more spontaneous early pregnancy losses123,125–127
and two studies added a negative work-up including
karyotype analysis and antiphospholipid syndrome126,127 .
Two studies128,137 reported a very high rate (> 80%) of
miscarriage per clinical pregnancy. One study134 reported
a high rate (20%) of preterm delivery related to T-shaped
uterus, while in another study128 , no patient with a
T-shaped uterus had preterm delivery.
Seven studies reported on the prevalence of
RIF in patients presenting with a T-shaped
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Coelho Neto et al.
Observations
Prevalence of T-shaped uterus in excluded women is
unknown. Diagnosis was made by hysteroscopy
and 3D ultrasound. Authors report they used
ESHRE/ESGE definition3 in their prospective study
performed between June 2011 and March 2012;
however, ESHRE/ESGE definition of T-shaped
uterus was unknown during study period
Diagnosis made based on 1998 American Fertility
Society classification
Study mentions measurements and comparison of
T-shaped with normal and intermediate uterus, but
is not clear regarding criteria to diagnose T-shaped
uterus
Study uses term ‘pseudo T-shaped’ uterus, which has
similar appearance to T-shaped uterus, but does
not include objective diagnostic criteria
uterus123,124,126–128,139,140 . This varied between 3.7%
and 35.1% in the studies that did not include solely
women with RIF. The definition of RIF was not uniform
between the studies, including two or more failed IVF
cycles despite good quality embryos126,127 , absence of
pregnancy after transfer of ≥ 5 embryos140 and three
or more failed IVF cycles123 , while one study described
the number of RIF per patient128 . One study, which did
not provide a definition for RIF124 , included a control
group and showed an incidence of 10% in women with
T-shaped uterus vs 7% in women with normal uterus.
The most accepted definition of RIF in the literature is
three consecutive failed IVF attempts with transfer of
one to two embryos of high-grade quality, and based
on this definition, the expected prevalence of RIF is
approximately 10%143 . Considering this 10% expected
prevalence of three consecutive negative pregnancy tests
following embryo transfer (the studies on T-shaped uterus
did not mention the quality of the embryos transferred
and therefore the expected prevalence would be higher),
we found that one study showed a much higher incidence
(35.1%)123 of RIF in women with T-shaped uterus,
one reported a similar proportion (14.3%)126 and one
reported a lower proportion (3.7%)128 of RIF in women
with T-shaped uterus.
One study128 reported a 15.5% prevalence of ectopic
pregnancy in women with T-shaped uterus, much higher
than the 1–2% expected in the general population144 .
Effect of surgical treatment
Since there are concerns that T-shaped uterus may be asso-
ciated with poor reproductive outcome, some authors are
proposing hysteroscopic metroplasty as potential treat-
ment for T-shaped uterus in patients with a history
of impaired reproductive outcome. Recently, a cascade
of surgical reports on metroplasty of T-shaped uterus
has been published2,123,125–130,135–137,139 (Table S2). All
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T-shaped uterus 371

the studies mentioned improvement of reproductive out-
come in patients with T-shaped uterus after metro-
plasty: eight studies reported an increase in preg-
nancy rate123,125–128,135,137,139 , seven studies reported
increase in live-birth rate2,123,125,127,129,130,135 , five studies
reported reduction in miscarriage rate2,127–129,137 , four
studies reported increased term-delivery rate128,135–137
and one study reported reduction in ectopic-pregnancy
rate128 (Table 3). After metroplasty, pregnancy rate
varied between 49.6% and 88%123,126,128,135,137,139 ,
clinical pregnancy rate was between 43.2% and
83.3%123,125,127 , miscarriage rate between 7% and
49.6%123,125,127,128,137 and live-birth rate varied between
35.1% and 76%2,123,125,127,129,130,135 .
Complications related to the procedure varied between
the studies, from no complications126–128,136 to per-
sistence of the dysmorphism requiring complementary
hysteroscopic approach (1.4%125 ; 3.8%137 ; 11%139 );
bleeding (1.3%137 ); infection (2.6%137 ) and adhesions
(16.8%125 ; 11.1%139 ).
One study did not ask for approval of the institu-
tional review board125 . The surgical technique used for

Table 2 Association of T-shaped uterus with reproductive outcome

Prevalence Prevalence
in women in women
with T-shaped with normal/
Study uterus arcuate uterus Conclusion

Subfertility
Alonso Pacheco (2019)127 27/60 (45.0) NR No comparison made in study; high risk vs general population
Boza (2019)126 56/56 (100) NR No comparison made in study; high risk vs general population
Di Spiezio Sardo (2020)125 92/124 (74.2) NR No comparison made in study; high risk vs general population
Ferro (2018)140 190/190 (100) NR No comparison made in study; high risk vs general population
Haydardedeoglu (2018)128 272/272 (100) NR No comparison made in study; high risk vs general population
Mounir (2012)135 88/88 (100) NR No comparison made in study; high risk vs general population
Neal (2019)124 10/10 (100) 472/472 (100) No conclusion
Şükür (2018)137 43/78 (55.1) NR No comparison made in study; high risk vs general population
Uyar (2019)123 74/74 (100) 148/148 (100) No conclusion
Previous miscarriage
Alonso Pacheco (2019)127 20/60 (33.3) NR No comparison made in study; high risk vs general population
Boza (2019)126 22/56 (39.3) NR No comparison made in study; high risk vs general population
Di Spiezio Sardo (2020)125 32/124 (25.8) NR No conclusion
Ferro (2009)139 4/18 (22.2) NR No conclusion
Giacomucci (2011)136 17/17 (100) NR No conclusion
Neal (2019)124 5/10 (50.0) 48/472 (10.2) T-shaped uterus is higher risk
Uyar (2019)123 19/74 (25.7) 25/148 (16.9) Similar risk
Recurrent miscarriage
Alonso Pacheco (2019)127 20/60 (33.3) NR No comparison made in study; high risk vs general population
Boza (2019)126 10/56 (17.9) NR No comparison made in study; high risk vs general population
Di Spiezio Sardo (2020)125 32/124 (25.8) NR No comparison made in study; high risk vs general population
Neal (2019)124 2/10 (20.0) 48/472 (10.2) T-shaped uterus is higher risk
Uyar (2019)123 13/74 (17.6) 16/148 (10.8) Similar risk
Miscarriage per pregnancy
Haydardedeoglu (2018)128 93/110 (84.5) NR No comparison made in study; high risk vs general population
Şükür (2018)137 63/75 (84.0) NR No comparison made in study; high risk vs general population
Preterm delivery
Fox (2014)134 2/10 (20) NR No conclusion
Haydardedeoglu (2018)128 0/110 (0) NR No conclusion
Repeat implantation failure
Alonso Pacheco (2019)127 16/60 (26.7) NR No comparison made in study; high risk vs general population
Boza (2019)126 8/56 (14.3) NR No comparison made in study; high risk vs general population
Ferro (2009)139 5/18 (27.8) NR No conclusion
Ferro (2018)140 190/190 (100) NR No comparison made in study; high risk vs general population
Haydardedeoglu (2018)128 10/272 (3.7) NR No comparison made in study; high risk vs general population
Neal (2019)124 1/10 (10.0) 31/472 (6.6) T-shaped uterus is higher risk
Uyar (2019)123 26/74 (35.1) 26/148 (17.6) T-shaped uterus is higher risk
Ectopic pregnancy
Haydardedeoglu (2018)128 17/110 (15.5) NR T-shaped uterus is higher risk

Only first author of each study is given. Data are given as n/N (%). In general population: prevalence of subfertility is about 15%141 ;
prevalence of previous miscarriage is near 15%159 ; prevalence of recurrent miscarriage (two or more losses < 24 weeks of gestation) is
5%142 ; prevalence of repeat implantation failure (after three consecutive in-vitro fertilization attempts, in which one or two high-grade
quality embryos were transferred in each cycle) is 10%143 ; preterm-delivery rate is 5–10% in singletons and 40–60% in multiples160 ;
ectopic-pregnancy prevalence is 1–2%144 . NR, not reported.

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372 Coelho Neto et al.

Table 3 Summary of conclusions of studies assessing hysteroscopic metroplasty for improvement of reproductive outcome in women with
T-shaped uterus

Study Pregnancy rate Live-birth rate Miscarriage rate Term-delivery rate Ectopic-pregnancy rate

Alonso Pacheco (2019)127 Improved Improved Reduced NR NR

Boza (2019)126 Improved NR NR NR NR
Di Spiezio Sardo (2020)125 Improved Improved Not clear NR NR
Ducellier-Azzola (2018)129 NR Improved Reduced NR NR
Fernandez (2011)2 NR Improved Reduced NR NR
Ferro (2009)139 Improved NR NR NR NR
Giacomucci (2011)136 NR NR NR Improved NR
Haydardedeoglu (2018)128 Improved NR Reduced Improved Reduced
Mounir (2012)135 Improved Improved NR Improved NR
Soekoer (2016)130 NR Improved NR NR NR
Şükür (2018)137 Improved NR Reduced Improved NR
Uyar (2019)123 Improved Improved Not clear NR NR

Only first author of each study is given. NR, not reported.

T-shaped uterus varied greatly across the identified studies DISCUSSION

(Table S2). Importantly, we did not find any randomized
controlled trial (RCT) evaluating the value of hystero-
scopic metroplasty on treatment of T-shaped uterus, only
observational studies, none of which had a control group
of untreated women for comparison. Four studies recog-
nized the controversy of indicating metroplasty for women
with T-shaped uterus125,126,129,140 . Nine studies recog-
nized the need of prospective controlled trials to delin-
eate a recommendation for hysteroscopic metroplasty for
patients with T-shaped uterus2,123,125–128,133,136,140 .
Quality of studies
All of the retrospective observational studies included
in the systematic review were considered to be of poor
quality2,123–130,133,135–140 , except for the study of Fox
et al.134 , which was rated as moderate quality (it was use-
ful for the study of prevalence and clinical relevance of
T-shaped uterus) (Table S3). The only identified diagnos-
tic accuracy study9 was judged to have low risk of bias
according to QUADAS-2 (Table S4). The same study9 was
the only one assessing reliability/agreement in the diag-
nosis of T-shaped uterus and was considered to be of
moderate quality according to QAREL (Table S5). All the
studies assessing interventions were of poor quality (obser-
vational and quasiexperimental with before–after design).
The prevalence of T-shaped uterus ranged between 0.2%
and 10% in the studies included in this systematic review.
The etiology of T-shaped uterus is still unknown, being
considered to be of primary origin or secondary to adhe-
sions or adenomyosis in different studies. Moreover, there
is no universal definition for T-shaped uterus and its diag-
nosis is performed by different methods, mainly by 3D-US
(Figures 2 and 3). Studies on T-shaped uterus were largely
performed in women with impaired reproductive out-
come and the benefits of surgical treatment for T-shaped
uterus seem to be largely exaggerated. This systematic
review revealed that the available evidence regarding the
diagnosis, prevalence, clinical relevance and particularly
interventions for T-shaped uterus is of very low quality.
There is no consensus on the diagnostic criteria for
T-shaped uterus. Four studies used the ESHRE/ESGE
definition3 for T-shaped uterus, however, this definition
is unclear and likely to be misinterpreted as it is based
on the subjective assessment of the observer rather than
objective criteria. No measurable cut-offs were provided

Quality of evidence

The quality of the evidence was judged to be very

low according to GRADE. The quality of evidence was
downgraded two levels because only observational studies
were included. Further downgrade was performed because
of important limitations of the included studies, such as
lack of a control group and high risk of bias. Moreover, Figure 2 Hysterosalpingography of uterus with two patent tubes.
the quality of the evidence was also downgraded Shape of uterine cavity can be considered to resemble a T instead of
a triangle. However, diagnosis is dependent on subjective judgment
because of serious imprecision (studies with small sample
and it may not be reproducible between observers. Moreover,
size; median, 47 (interquartile range, 19.5–80.5)) and observer cannot be sure whether uterine cavity is assessed in
inconsistency of the results observed across the studies. coronal or oblique view.

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T-shaped uterus 373

for the definition of narrow uterine cavity and thickened
lateral walls. Using the ESHRE/ESGE classification, 70%
of women have a uterine malformation106 . Reports
of surgical treatment for uterine malformations were
uncommon before this classification was proposed106,145 ,
which is associated with overestimation of uterine
anomalies and potential surgical treatment of patients
with a normal uterus146,147 . CUME was the first study
to provide objective criteria for T-shaped uterus using
as reference standard the decision made most often by
expert clinicians, surgeons and sonologists9 (Figure 4).
The effectiveness of surgical treatment for T-shaped
uterus was assessed based on only observational studies
lacking a control group of untreated patients undergoing
expectant management. However, only well-designed
RCTs would be able to assess the effectiveness and

Figure 3 Coronal view of uterus obtained using three-dimensional (3D) ultrasound (a,b), 3D sonohysterography with HDlive render
mode (c), 3D sonohysterography with volume contrast imaging (d) and 3D sonohysterography with automatic volume calculation software
(SonoAVC; SonoHysteroAVC technique) (e). Performing measurements with high reliability is challenging considering that subtle uterine
contractions and peristalsis can influence endometrial cavity and that quality of imaging is not perfect. One can consider saline 3D-sonohystero-
graphy to improve quality of imaging and delineation of uterine cavity contour. With additional use of automatic volume calculation
software161 , it is possible to assess uterine cavity volume, another interesting parameter for further research, and better understand diversity
of uterine morphology and its impact on reproductive outcome.

≤ 40° ≥ 7 mm ≤ 130°

Figure 4 Coronal view of uterus obtained with curved render modes of three-dimensional transvaginal sonography. Top row: HDlive mode;
bottom row: volume contrast imaging. Uterine cavity shape can be suspected to be T-shaped based on subjective impression (bottom row),
however, without measurements, reliability of diagnosis is only moderate among representative experts. According to Congenital Uterine
Malformation by Experts (CUME) group, three sonographic criteria should be present (lateral indentation depth ≥ 7 mm, lateral indentation
angle ≤ 130◦ and T-angle ≤ 40◦ ) for reliable and accurate diagnosis of T-shaped uterus9 . CUME definition of T-shaped uterus reflects
diagnosis made most often by several representative experts. When CUME definition and criteria are used, doctors and patients can be
confident that diagnosis of T-shaped uterus has high probability of being correct.

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374
safety of the intervention148 . The challenges regarding
T-shaped uterus are similar to those for septate uterus:
hysteroscopic septum resection for septate uterus has been
performed worldwide for more than 30 years without
high-quality supporting evidence148–150 . The largest
multicenter cohort study on septum resection in women
with a septate uterus included 257 patients diagnosed with
a septate uterus over a period of 37 years151 ; the diagnostic
methods and criteria varied in such a long interval, as did
the management of the patients149 . In this cohort, 80 of
151 (53%) women who underwent metroplasty had at
least one live birth, compared to 76 out of 106 (71.7%)
who had expectant management, and the study concluded
that metroplasty does not improve live-birth rate or
decrease miscarriage or preterm birth when compared
to expectant management151 . Another important issue of
performing hysteroscopic metroplasty in patients with a
septate uterus, despite the lack of good-quality evidence
about its effectiveness and safety, is the difficulty to
recruit participants in clinical trials when the patients
think that the intervention is effective, as a patient may
not want to be randomized in a trial in which there is
a possibility that they will not receive any treatment.
The only concluded RCT on the topic took 10 years to
randomize 80 women152 , a very long time to provide some
light on the topic. Recently announced results confirm that
septum resection related to ESHRE/ESGE classification
does not improve reproductive outcome153 .
The studies reporting on reproductive outcome of
women with a T-shaped uterus, included in this systematic
review, used different inclusion criteria for women with
history of impaired reproductive outcome in addition to
different diagnostic methods and criteria for T-shaped
uterus. The surgical technique proposed for treating the
condition varied between the studies. Therefore, it was
not possible to combine data in a meta-analysis due to
the design and heterogeneity of the studies. The observed
improvement in reproductive outcome related to surgical
treatment is most likely the result of very high risk of
bias toward overestimation of the treatment effect, as the
before–after design of the studies with the same group of
women serving as test and control always favors the tested
intervention, particularly when all included participants
have not achieved success before the intervention148 .
A recently published review, focusing on reproductive
outcome following hysteroscopic metroplasty of patients
with a T-shaped uterus and history of poor reproductive
outcome154 , concluded that hysteroscopic metroplasty
is a simple procedure which can potentially improve
reproductive outcome, but the data are not robust. Of
the 15 studies included in that review, seven were also
included in the present review2,129,130,133,135,136,138 , and
of the rest, seven were not eligible (two due to DES
exposure155,156 , two due to inclusion of fewer than 10
women with T-shaped uterus113,114 , two not reporting
the outcomes for T-shaped uterus separately118,119 and
one that did not mention T-shaped uterus157 ) and one
could not be identified because it was missing from
the list of references. Another review on hysteroscopic
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Coelho Neto et al.
metroplasty for dysmorphic uterus in patients with
a previous miscarriage158 (class U1 includes T-shaped
uterus, uterus infantilis and other minor deformities3 )
included six studies, all of which were also included in
the present review2,125,126,129,133,137 , and concluded on
the benefit of metroplasty based on a live-birth rate of
50%, clinical pregnancy rate of 73% and miscarriage
rate of 23%. Quality assessment of the studies, using the
Newcastle–Ottawa Scale, showed an overall good score
regarding the selection and comparability of the study
groups, as well as for ascertainment of the outcomes of
interest158 , however, none of the studies had a control
group.
For future studies, there is a need for reliable and widely
accepted criteria for diagnosing T-shaped uterus. We need
to assess initially whether women with reliable diagnosis
of T-shaped uterus have worse reproductive outcome
when compared to women with normal/arcuate uterus. If
evidence of impaired reproductive outcome is found, an
RCT evaluating the effectiveness and safety of metroplasty
is necessary before incorporating this intervention into
clinical practice.
Conclusions
The true prevalence, causes and clinical relevance of
T-shaped uterus are still unclear as the available
studies use different definitions and diagnostic criteria for
this condition. Additionally, robust evidence is lacking
regarding the effect of proposed interventions for
T-shaped uterus, such as hysteroscopic metroplasty, as
there is currently no RCT on this topic and the available
observational studies use inconsistent diagnostic methods
and definitions and do not have a control group for
comparison. We would discourage performing more
uncontrolled before–after studies on T-shaped uterus,
which are likely to add nothing to what is already
known. Until RCTs prove the benefit and safety of
surgical treatment for T-shaped uterus, women should
not be exposed to the risk and financial burden of this
intervention, which is also associated with a financial
burden to healthcare systems and societies. Expectant
management should be considered the most appropriate
choice in daily practice for women with a T-shaped uterus.
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SUPPORTING INFORMATION ON THE INTERNET
The following supporting information may be found in the online version of this article:
Table S1 Diagnostic methods and criteria for T-shaped uterus used by included studies
Table S2 Studies assessing effect of interventions for T-shaped uterus
Table S3 Quality of included observational studies according to Newcastle–Ottawa Scale
Table S4 Judgement of diagnostic accuracy studies according to QUADAS-2
Table S5 Judgement of reliability/agreement studies according to quality appraisal of diagnostic reliability tool
A video abstract of this article is available online.
© 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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