Facts Views Vis Obgyn, 2024, 16 (1): 9-22 Systematic review

Impact of congenital uterine anomalies on obstetric and

perinatal outcomes: systematic review and meta-analysis

M. Caballero Campo1,2, F. Pérez Milán1,2,3, M. Carrera Roig4, E. Moratalla Bartolomé5, J. A.

Domínguez Arroyo6,7, J. L. Alcázar Zambrano8,9, L. Alonso Pacheco10, J. Carugno11
On behalf of Spanish Fertility Society Special Interest Group on Reproductive Organic Disorders
1
Reproductive Medicine Unit, Obstetrics & Gynecology Department, Hospital General Universitario Gregorio Marañón,
Madrid, Spain; 2Gregorio Marañón Institute for Health Research, Madrid, Spain; 3Universidad Complutense, Madrid,
Spain; 4Reproductive Medicine Unit, Obstetrics & Gynecology Department, Hospital Universitario Doce de Octubre,
Madrid, Spain; 5Gynecological Surgery and Endoscopy Unit, Hospital Universitario Ramón y Cajal, Madrid, Spain;
6
Centro Extremeño de Reproducción Asistida, Badajoz, Spain; 7Universidad de Extremadura, Badajoz, Spain; 8Clínica
Universidad de Navarra, Pamplona, Spain; 9Universidad de Navarra, Pamplona Spain; 10Gynecological Endoscopy Unit,
Gutenberg Center, Xanit International Hospital, Málaga, Spain; 11Miller School of Medicine, Department of Obstetrics
and Gynecology, University of Miami, Miami, FL, USA.
Correspondence at: Miguel Caballero Campo, Unidad de Medicina Reproductiva. Servicio de Obstetricia y
Ginecología,Hospital General Universitario Gregorio Marañón (Centro Materno-Infantil), Despacho 4-E-06. C/O’Donnell,
48 28009 Madrid, Spain. E-mail: miguel.caballero@salud.madrid.org

Abstract

Background: Congenital uterine anomalies (CUA) can be associated with impairments of early and late
pregnancy events.
Objective: To assess the impact of CUA on reproductive outcomes in pregnancies conceived spontaneously or
after assisted reproduction.
Material and Methods: Systematic review and meta-analysis of cohort studies comparing patients with CUA
versus women with normal uterus. A structured literature search was performed in leading scientific databases
to identify prospective and retrospective studies. The Newcastle-Ottawa scale, adapted to AHRQ standards,
was used to assess the risk of bias. Pooled odds ratios (OR) were calculated. Publication bias and statistical
heterogeneity were assessed, and meta-regression was used to analyse the heterogeneity.
Main outcome measures: Miscarriage, ectopic pregnancy, placental abruption, term, and premature rupture
of membranes (PROM), malpresentation at delivery, preterm delivery prior to 37, 34 and 32 weeks, caesarean
delivery, intrauterine growth restriction/small for gestational age, foetal mortality and perinatal mortality.
Results: 32 studies were included. CUAs increased significantly the risk of first/second trimester miscarriage
(OR:1.54;95%CI:1.14-2.07), placental abruption (OR:5.04;3.60-7.04), PROM (OR:1.71;1.34-2.18), foetal
malpresentation at delivery (OR:21.04;10.95-40.44), preterm birth (adjusted OR:4.34;3.59-5.21), a caesarean
delivery (adjusted OR:7.69;4.17-14.29), intrauterine growth restriction/small for gestational age (adjusted
OR:50;6.11-424), foetal mortality (OR:2.07;1.56-2.73) and perinatal mortality (OR:3.28;2.01-5.36).
Conclusions: CUA increases the risk of complications during pregnancy, delivery, and postpartum. Complications
most frequent in CUA patients were preterm delivery, foetal malpresentation, and caesarean delivery.
What is new? Bicornuate uterus was associated with the highest number of adverse outcomes, followed by
didelphys, subseptate and septate uterus.
Keywords: Congenital uterine anomalies, Müllerian anomalies, pregnancy outcome, obstetric complications,
labour complications, neonatal outcome.

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Introduction
Congenital uterine anomalies (CUA) are
uncommon entities caused by abnormal
development, fusion, or resorption of Müllerian
ducts during organogenesis, which results in
defects in canalisation, unification, or conformation
of Müllerian-derived structures. Their prevalence
is difficult to assess, due to the lack of a universally
accepted classification and differences in diagnostic
methods or the population profiles reported in the
available studies. A systematic review published
by Chan et al. (2011b) estimated that CUA are
present in 5.5% of infertile patients, in 13.3% of
women with previous miscarriage and in 24.5% of
women affected by both conditions.
CUA comprises a broad spectrum of congenital
defects, characterised by different degrees of
distortion of the uterine anatomy, which could
generate different levels of perinatal risk. The
association with reproductive outcomes has been
extensively analysed. Until now, four systematic
reviews on the association between CUA and
obstetrical and perinatal risks have been published
(Chan et al., 2011a; Grimbizis et al., 2001; Kim
et al., 2021; Venetis et al., 2014). However, they
include observational studies which are affected
considerably by the risk of bias. Recently, several
studies looking at the correlation between CUA and
adverse pregnancy outcomes have been published.
The objective of this systematic review with
meta-analysis is to evaluate the association between
CUA with adverse pregnancy outcomes. Eligibility
of studies will follow the actual criteria for risk
of bias assessment of observational studies that
complement score-based scales with domain-based
evaluation, particularly concerning comparability
between exposed and non-exposed patients.
Materials and methods
Protocol registration
The systematic review and meta-analysis protocol
were defined according to MOOSE guidelines and
registered at PROSPERO (CRD42023380794).
Study selection
For eligibility, the following inclusion criteria were
applied: a) Prospective and retrospective cohort
studies analysing the effects of CUA on obstetrical
and perinatal outcomes in spontaneous or ART
pregnancies in patients affected by infertility,
recurrent pregnancy loss, or general population;
b) Fair or high quality studies with an adequate
level of comparability between exposed and
non-exposed patients; c) Peer-reviewed articles
10 Facts Views Vis Obgyn
published in English, French, German or Spanish
between January 1980 and April 2022.
As exclusion criteria we considered case-control
design, insufficient information on the population
considered or on diagnostic techniques used, lack
of adjustment for potential confounders, studies
considering comparisons other than those of
interest, and non-comparative studies.
Information sources and searches
A systematic review of primary studies was carried
out by investigators in well-recognised scientific
databases (MEDLINE, EMBASE, Current
Contents, Web of Science, and Cochrane Database
Register for Clinical Trials, ClinicalTrials.gov
and Google Scholar). Search terms and limits
are provided in Appendix 1 and were adapted to
specific syntax in the different databases. Cross
references were hand-searched.
Studies selection and individual risk of bias
assessment
Identified studies were initially classified according
to title and abstract by two different authors. Studies
concordantly selected were full text evaluated, and
discrepancies were solved by consensus with a
third evaluator.
Eligibility criteria were applied to the studies
selected for full-text evaluation. Risk of bias was
assessed using Newcastle-Ottawa Scale (NOS)
for cohort studies, and qualified according to the
standards of United States Agency for Healthcare
Research and Quality (AHRQ) (Wells et al., 2021).
Only studies qualified as good or fair quality
(granted with 1 or 2 stars in the comparability
domain), were included, considering age and
parity as main potential confounders for all
outcomes analysis. Reasons for exclusion were
discussed and summarised. The studies selection
process was in accordance with MOOSE Statement
recommendations for systematic reviews (Stroup
et al., 2000).
Data collection, outcomes, and summary
measures
Data extraction from selected studies was
performed by one of the authors and verified by a
co-author, using a pre-designed form. Definitions
and classification categories for CUA used by
authors were specifically checked.
We considered as outcomes first and second
trimester miscarriage, ectopic pregnancy, placental
abruption, term, and preterm premature rupture of
membranes (PROM/PPROM) foetal malposition
or abnormal presentation at delivery, preterm
delivery, preterm delivery prior to 34 and prior to
32 weeks, caesarean delivery, intrauterine growth
restriction or small for gestational age (IUGR/
SGA), foetal mortality and perinatal mortality.
Odds ratios of these outcomes were considered as
summary measures.
Statistical analysis
Articles favourable for quantitative synthesis were
meta-analysed applying a random-effects model
(DerSimonian and Kacker, 2007). Pooled odds
ratios (OR) and its 95% confidence interval were
used as pooled effect measures.
Statistic heterogeneity was estimated by
Cochran’s Q and I2 statistics. Q statistics with
p values <0.05 was considered statistically
significant. I2 values were evaluated considering
critical thresholds previously defined (Borenstein
et al., 2021; Higgins and Thompson, 2002).
Publication bias was assessed through funnel
plots for each outcome. In case of obtaining non-
conclusive plots, we applied Begg’s and Egger’s
tests. Meta-regression based on random-effects
models (Borenstein et al., 2021) was applied to
adjust the effect on overall estimates affected by high
statistical heterogeneity (I2 >50%), considering as
covariates the type of cohort-study design (classical
versus matched controls cohort studies), studied
population (general population, infertile patients
and previous pregnancy loss history) and type of
pregnancy (singleton or multiple).
Review Manager 5.4.1 was used to calculate
pooled estimated effects and heterogeneity and
Figure 1: PRISMA flowchart diagram.
REPRODUCTIVE IMPACT OF MÜLLERIAN ANOMALIES – CABALLERO CAMPO et al.
Stata software 17 was used for publication-bias and
meta-regression analysis.
Results
Systematic review
The structured searches identified 12794 reports.
From these, 6461 were screened by title and 328
by title and abstract. A final subset of 78 studies
were full-text evaluated (Figure 1), of which 32
(Ban-Frangez et al., 2009; Ben-Rafael et al., 1991;
Cahen-Peretz et al., 2017; Cai et al., 2021; Cooney
et al., 1998; Crane et al., 2012; Chen et al., 2018;
Chen et al., 2019; Erez et al., 2007; Hiersch et
al., 2016; Hua et al., 2011; Jayaprakasan et al.,
2011; Kong et al., 2021; Leible et al., 1998; Li et
al., 2017; Lu et al., 2021; Marianna et al., 2022;
Mastrolia et al., 2017; Mastrolia et al., 2018;
Ouyang et al., 2020; Ozgur et al., 2017; Pleş et al.,
2018; Prior et al., 2018; Qiu et al., 2022; Saravelos
et al., 2010; Sugiura-Ogasawara et al., 2010;
Surrey et al., 2018; Takami et al., 2014; Tomaževič
et al., 2010; Zambrotta et al., 2021; Zlopasa et al.,
2007) fulfilled inclusion criteria (Table SI). Scores
granted by Newcastle-Ottawa Score and quality
assessment using AHRQ standards are presented in
Appendix 2. Reasons for exclusion of non-included
studies (Acién, 1993; Acién et al., 2014; Airoldi
et al., 2005; Akar et al., 2005; Alonso Pacheco et
al., 2019; Ben-Rafael et al., 1990; Colacurci et al.,
1996; Chen et al., 2013; Elsokkary et al., 2018;
Fedele and Bianchi, 1995; Fox et al., 2019; Fox
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et al., 2014; Gabbai et al., 2018; Ghi et al., 2012;
Grimbizis et al., 2001; Hynes et al., 2021; Jaslow
and Kutteh, 2013; Lavergne et al., 1996; Liang and
Hu, 2010; Ludwin, 2018; Maneschi et al., 1995;
Neal et al., 2019; Portuondo et al., 1986; Raga et
al., 1997; Ravasia et al., 1999; Ridout et al., 2019;
Rogers and Needham, 1985; Salim et al., 2003;
Sendag et al., 2010; Shuiqing et al., 2002; Sorensen
and Trauelsen, 1987; Sugiura-Ogasawara et al.,
2015; Tofoski and Antovska, 2014; Tomazevic et
al., 2007; Tonguc et al., 2011; Woelfer et al., 2001;
Zhang et al., 2010; Zupi et al., 1996) are described
in Table SII.
Meta-analysis
Miscarriage
CUA increased the risk of first trimester miscarriage
(OR:1.62, 95%CI:1.06-2.47; 7 studies; I2:76%)
(Table SIII; Figure 2. This risk was only detectable
for bicornuate uterus (OR:1.56; 95%CI:1.04-2.34,
4 studies; I2:0%), and resulted not significant
for arcuate, septate, subseptate, didelphys and
unicornuate uterus (Table SIII; Figure 3).
The presence of any CUA increased risk of
second trimester miscarriage (OR:1.8; 95%CI:1.19-
2.73; 6 studies; I2:0%) (Table SIII; Figure 2). This
risk was only present with septate uteri (OR:6.65;
95%CI:2.66-16.16; 2 studies; I2:55%). The
estimated effect of the subseptate uterus on this
outcome derived from a single study (OR:4.53;
95%CI:1.37-15.0) (Zlopasa et al., 2007). The rest
of the evaluated anomalies (arcuate, didelphys,
bicornuate and unicornuate uterus) showed no
association with risk of second trimester miscarriage
(Table SIII; Figure 4).
The risk of miscarriage in any trimester increases
in the presence of any CUA (OR:1.54; 95%CI:1.14-
2.07; 17 studies; I2: 75%) (Table SIII; ). The specific
anomalies that have increased risk of miscarriage in
the first or second trimester were subseptate uterus
(OR:6.19; 95%CI:2.3-16.66; 3 studies; I2:41%),
septate (OR:2.93; 95%CI:1.72-4.99; 7 studies;
I2:49%), bicornuate (OR:2.09; 95%CI:1.47-2.97;
6 studies; I2:16%) and T-shaped uterus (OR:5.22;
95%CI:1.89-14.42). On the contrary, arcuate,
didelphys and unicornuate uterus did not increase
the risk of miscarriage (Table SIII; Figure 5).
Ectopic pregnancy
Ectopic pregnancy is not increased in patients
with CUA (OR:1.30; 95%CI:0.82-2.05; 6 studies;
I2:0%) (Table SIII; Figure S1). When analysed by
type of anomaly, only septate uteri had a significant
increased risk of ectopic pregnancy (OR:2.04;
95%CI:2.03-4.04, 2 studies; I2:49%) (Qiu et al.,
2022; Saravelos et al., 2010). Effects of arcuate,
12 Facts Views Vis Obgyn
and T-shaped uterus were estimated each one from
a single study (Marianna et al., 2022; Saravelos et
al., 2010), whereas effects of didelphys, bicornuate
and unicornuate uterus derived from the data of
two (Qiu et al., 2022; Saravelos et al., 2010), three
(Kong et al., 2021; Qiu et al., 2022; Saravelos et al.,
2010) and four studies (Chen X. et al., 2018; Li et
al., 2017; Qiu et al., 2022; Saravelos et al., 2010)
respectively (Table SIII; Figure S2).
Placental abruption
Presence of any CUA increased risk of placental
abruption (OR:5.04; 95%CI:3.66-7.04; 6 studies;
I2:40%) (Table SIII; Figure S3). This event is more
frequent in patients with subseptate (OR:17.45;
95%CI:5.05-60.22; 1 study) and bicornuate uterus
(OR:12.11; 95%CI:3.14-46.74; 2 studies; I2:81%).
No effects of septate, didelphys and unicornuate
uterus were found analysing data from a single
study (Takami et al., 2014) (Table SIII; Figure S4).
PROM/PPROM
Combined PROM-PPROM risk was increased in
patients with CUA (OR:1.71; 95%CI:1.34-2.18; 9
studies; I2:65%) (Table SIII; Figure S5), specifically
with bicornuate uterus (OR:1.79; 95%CI: 1.37-
2.33; 2 studies; I2: 0%). No effect was detected for
unicornuate uterus (OR:0.46; 95%CI:0.18-1.21, 1
study) (Lu et al., 2021) (Table SIII; Figure S6).
Fetal Malpresentation at delivery
Fetal malpresentation at the time of delivery
was consistently increased in women with CUA
(OR:21.04; 95%CI:10.95-40.44; 7 studies; I2:97%)
(Table SIII; Figure S7). Arcuate uterus (OR:11.38;
95%CI:1.49-87.07; 2 studies; I2:41%), subseptate
uterus (OR:25.62; 95%CI:10.69-60.85; 2 studies;
I2:25%), septate uterus (OR:45.48; 95%CI:16.97-
121.89; 2 studies; I2:0%), uterus didelphys
(OR:19.15; 95%CI:15.16-24.18; 3 studies; I2:0%),
unicornuate (OR:32.74; 95%CI:6.21-172.67; 3
studies; I2:53%) and bicornuate uterus (OR:17.96;
95%CI:12.19-26.47; 3 studies; I2:27%) (Table SIII;
Figure S8).
Preterm delivery
The risk of preterm delivery is higher in patients
with CUA, both in the global analysis (adjusted
OR:4.34; 95%CI:3.59-5.21; 19 studies; I2:56%)
and for most anomalies. Estimated OR of preterm
birth were 8.91 (95%CI:3.1-25.63) for arcuate
uterus (2 studies; I2: 0%), 5.24 (95%CI:1.87-
14.67) for subseptate uterus (2 studies; I2:58%),
4.62 (95%CI:2.43-8.8) for didelphys uterus (7
studies; I2:74%) and 4.45 (95%CI:1.29-15.5) for
T-shaped uterus (1 study). Significant Adjusted OR
were found for bicornuate (OR:4.9; 95%CI:3.93-
6.11; 7 studies; I2:8%) and unicornuate uterus
(OR:3.85; 95%CI:1.84- 8.16; 8 studies; I2:0%).
After adjustment, the effect of septate on the risk of
preterm delivery became not significant (adjusted
OR:1.04 (95%CI: 0.51-2.01; 5 studies; I2:0%)
(Table SIII; Figure S9 and Figure S10).
Preterm birth before 34 weeks of gestational
age was also more frequent in patients with CUA
(OR:5.36; 95%CI:4.29-6.7; 6 studies; I2:12%). The
risk of prematurity prior to 34 weeks was increased
in presence of didelphys uterus (OR:53.78;
95%CI:5.43-532.94; 1 study) and bicornuate uterus
(OR:11.34; 95%CI:1.14-112.75, 1 study) (Crane
et al., 2012). No significant effect of septate and
unicornuate uterus were detected, and no estimates
were available for arcuate, subseptate and T-shaped
uterus (Table SIII; Figure S9 and Figure S11).
The rate of preterm delivery before 32 weeks
was not affected by CUA (adjusted OR:1.64;
95%CI:0.91-2.97; 6 studies; I2:0%). Septate,
didelphys, bicornuate and unicornuate and uterus
did not show association with this outcome (Table
SIII; Figure S9 and Figure S12). Data to estimate
effects of arcuate, subseptate and T-shaped uterus
were not available.
Caesarean delivery
Compared to women with normal uterus, the
caesarean delivery rate was higher in patients with
any type of CUA (adjusted OR:7.69; 95%CI:4.17-
14.29; 16 studies; I2:96%) (Table SIII; Figure S13).
Caesarean rate was also increased in patients with
subseptate uterus (OR:11.27; 95%CI:3.01-42.23;
2 studies; I2:58%), uterus didelphys (adjusted
OR:29.9; 95%CI:8.24-126.4; 6 studies; I2:75%),
bicornuate (adjusted OR:23.8; 95%CI:10.17-55.7;
6 studies; I2: 46%) and unicornuate uterus (adjusted
OR:12.1; 95%CI:5.64-26.5; 6 studies; I2: 0%).
Arcuate and septate uterus showed no association
with caesarean delivery rate (Table SIII; Figure
S14). No estimations for T-shaped effect were
available.
IUGR/SGA
The risk of IUGR or SGA, considered as a combined
outcome, was higher in patients affected by CUA
(adjusted OR:50.0; 95%CI:6.11-424; 9 studies;
I2:83%) (Table SIII; Figure S15). The rates of IUGR/
SGA were increased in pregnancies of women with
subseptate (OR:2.54; 95%CI:1.10-5.89; 2 studies;
I2:0%), didelphys (OR:3.82; 95%CI:1.93-7.56; 3
studies; I2:36%), and bicornuate uteri (OR:2.75;
CI95%: 1.96-3.86; 4 studies; I2:0%). Arcuate,
septate and unicornuate uteri were not associated
with this outcome (Table SIII; Figure S16).
REPRODUCTIVE IMPACT OF MÜLLERIAN ANOMALIES – CABALLERO CAMPO et al.
Foetal and perinatal mortality
Risk of foetal mortality was increased in patients
with CUA (OR:2.07; 95%CI:1.56-2.73; 9 studies;
I2:10%) (Table SIII; Figure S17). Foetal demise
was also more frequent in the presence of uterus
didelphys (OR:2.67; 95%CI:1.29-5.51; 3 studies;
I2:0%), bicornuate (OR:3.46; 95%CI:2.0-5.99;
3 studies; I2:0%) and unicornuate (OR:2.36;
95%CI:1.23-4.54; 3 studies; I2:0%). Arcuate,
subseptate and septate uteri were not associated
with increased risk of foetal demise (Table SIII;
Figure S18).
Perinatal mortality was higher in women
diagnosed with any CUA (OR:3.28; 95%CI:2.01-
5.36; 6 studies; I2:56%) (Table SIII; Figure S19).
Specifically, the didelphys (OR:6.69; 95%CI:1.59-
28.15; 2 studies; I2:25%), bicornuate (OR:4.25;
95%CI:1.56-11.6; 2 studies; I2:0%) and unicornuate
uterus (OR:3.05; 95%CI:1.75-5.31; 3 studies;
I2:0%). No association was found between arcuate,
septate, subseptate uterus and increased perinatal
mortality (Table SIII; Figure S20).
Analyses of funnel-plot and results of Begg’s
and Egger’s tests, performed, when necessary, did
not reveal relevant risk of reporting bias.
Discussion
Summary of main results
This meta-analytic review supports the association
between CUA and adverse obstetrical and perinatal
outcomes. Considering the different types of
CUA individually, most frequent defects can
be classified as U1 (T-shaped), U2 (septate or
subseptate), U3 (bicorporate) and U4 (categories
of ESGE classification were associated to relevant
adverse outcomes. Both septate and subseptate
uterus, as well as bicornuate and didelphys uterus,
increased risks of miscarriage, preterm birth,
foetal malpresentation at delivery, IUGR and
need for caesarean delivery. By contrast, arcuate
and unicornuate uterus were associated with a
significantly lower number of adverse outcomes.
Comparison with previous studies
Our meta-analysis included 32 studies, which is
more than those selected by Chan et al. (2011a)
and Venetis et al. (2014), although less than those
included in the 2021 Kim’s meta-analysis. Twelve
of the studies selected by Kim et al. (2021) were not
included in our meta-analysis: one was published
out of time limits (Forde et al., 1978) while the
other eleven did not achieve the minimum score
on the AHRQ-adapted NOS scale (Acién, 1993;
Fox et al., 2014; Liang and Hu, 2010; Maneschi
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et al., 1995; Neal et al., 2019; Ravasia et al., 1999;
Shuiqing et al., 2002; Sorensen and Trauelsen,
1987; Woelfer et al., 2001; Zhang et al., 2010; Zupi
et al., 1996). Our meta-analysis includes seven
studies not considered by Kim et al. (2021) (Cai et
al., 2021; Crane et al., 2012; Chen et al., 2018; Lu
et al., 2021; Marianna et al., 2022; Qiu et al., 2022;
Surrey et al., 2018).
We have detected a significantly increased risk
in all the outcomes analysed, with the exception
of ectopic pregnancy. We have identified a higher
rate of caesarean delivery and intrauterine foetal
death, which is consistent with Kim et al. (2021).
Our results also support an increased risk of IUGR/
SGA, in line with Kim et al. (2021) but in contrast
to Venetis et al. (2014). In our analysis, the pooled
effects for several outcomes affected by high
levels of statistical heterogeneity, which were not
reduced by meta-regression, and that are similar to
those estimated in Kim’s in his meta-analysis (Kim
et al., 2021).
Canalisation anomalies has been consistently
associated with increased risk of miscarriage,
as concluded in our meta-analysis and those by
Chan et al. (2011a), Venetis et al. (2014), and Kim
et al. (2021). According to our results, septate
uterus was associated with second trimester but
not with first trimester miscarriage, in contrast
with the estimation of previous meta-analysis.
Our estimation on association of septate uterus on
first trimester miscarriage risk is based in pooled
results of three good quality studies, which totalled
612 events and 1335 patients. On the contrary,
previous meta-analysis included studies performed
on small samples and/or excluded from our criteria
by low quality scoring. For subseptate uterus, we
identified only an increased risk of second trimester
miscarriage, contrary to Kim et al. (2021).
Bicornuate uterus is the unification defect most
commonly associated with risk of miscarriage, as
our study and those of Chan et al. (2011a), Kim
et al. (2021), and Venetis et al. (2014) reported.
With regard to the pathogenic implication of
each type of defect in gestational loss, it should
be recalled that bicornuate uterus and the septate/
subseptate uterus share to some extent certain
similar characteristics that may explain their
causal association with pregnancy loss, such as
reduced volume and distensibility of the uterine
cavity or abnormal vascularization (Venetis et al.,
2014). None of the meta-analyses have found a
correlation between uterus didelphys and the risk
of miscarriage. Unicornuate uterus seems related to
miscarriage according to Venetis et al. (2014), and
with first trimester miscarriage as described Chan et
al. (2011a).
14 Facts Views Vis Obgyn
We found no association between arcuate uterus and
risks of miscarriage, which differs from what was
previously reported by Chan et al. (2011a), Kim et
al. (2021), Venetis et al. (2014). However, this result
could be biased by the difficulty in discriminating
arcuate uterus from normal or subseptate uterus, due
to changes in diagnostic criteria and to differences
in clinical imaging accuracy. Therefore, it must be
assumed that a proportion of uterus classified as
arcuate in the included studies would be considered
normal according to current diagnostic criteria.
Finally, in our analysis T-shaped uterus markedly
increased the risk of first or second trimester
miscarriage.
Ectopic pregnancy was more frequent in patients
with septate uterus (derived from a single study),
which is different from Kim et al. (2021) review,
which includes 11 studies on this item (10 of them
excluded from our meta-analysis).
Kim et al. (2021) identified an increased risk of
placental abruption for all types of CUA, and Venetis
et al. (2014) only for arcuate and septate uterus. We
found an increased risk of placental abruption only
for subseptate and bicornuate uterus. However, as
it was obtained from a single study (Takami et al.,
2014), it should be considered with caution.
Risk for combined outcome PROM/PPROM
from our data revealed a significant association with
bicornuate uterus. This result is comparable with
that obtained by Venetis et al. (2014), who found
increased risk of PROM for arcuate and septate
uterus, and by Kim et al. (2021), in whose analysis
PPROM rate was increased for all types of CUA.
We found that the preterm delivery rate is
increased in most CUA. Previous meta-analyses
identified an increased risk of prematurity for
subseptate, unicornuate, bicornuate and didelphys
uterus (Chan et al., 2011a; Kim et al., 2021; Venetis
et al., 2014). Arcuate uterus was not associated with
preterm delivery risk according to Chan, Venetis
and Kim studies (Kim et al., 2021; Venetis et al.,
2014; Chan et al.,2011a), but showed a strong
association in our study (OR:8.91; 95%CI:3.10-
25.63). The estimate of Kim et al. (2021) is based
on ten studies, eight of which were not included in
our synthesis. Septate uterus increases the risk of
preterm delivery according to the three previous
meta-analyses. This risk was not significant when
adjusted by meta-regression, as it depended on
the design of the selected studies. Risk of preterm
delivery <34 weeks was significantly associated
with unification defects (bicornuate and didelphys
uterus). Only Venetis et al. (2014) has estimated
this correlation, and found an association with most
CUA, but not with arcuate uterus. Although never
analysed in the past, we did not find correlation
 Miscarriage (all CUA)
A) First trimester miscarriage
Exposed Controls Odds Ratio Odds Ratio
Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI Year M-H, Random, 95% CI
Jayaprasan 2011 8 43 20 158 10.7% 1.58 [0.64, 3.88]
Chen 2018a 13 302 25 368 13.4% 0.62 [0.31, 1.23]
Zlopasa 2007 62 246 62 379 17.5% 1.72 [1.16, 2.56] 2007
Saravelos 2010 183 251 431 630 18.4% 1.24 [0.90, 1.72] 2010
Li 2017 43 238 86 818 17.4% 1.88 [1.26, 2.80] 2017
Cai 2021 12 65 32 195 12.8% 1.15 [0.55, 2.40] 2021
Kong 2021 6 41 18 1139 9.8% 10.68 [3.99, 28.54] 2021

Total (95% CI) 1186 3687 100.0% 1.62 [1.06, 2.47]

Total events 327 674
Heterogeneity: Tau² = 0.23; Chi² = 25.42, df = 6 (P = 0.0003); I² = 76%
0.01 0.1 1 10 100
Test for overall effect: Z = 2.21 (P = 0.03)
Favours exposed Favours controls

B) Second trimester miscarriage

Exposed Controls Odds Ratio Odds Ratio
Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI Year M-H, Random, 95% CI
Chen 2018a 7 302 5 368 12.7% 1.72 [0.54, 5.48]
Zlopasa 2007 21 246 12 379 32.1% 2.85 [1.38, 5.91] 2007
Saravelos 2010 20 251 21 360 42.2% 1.40 [0.74, 2.64] 2010
Li 2017 2 238 3 818 5.3% 2.30 [0.38, 13.86] 2017
Cai 2021 2 65 4 195 5.7% 1.52 [0.27, 8.47] 2021
Kong 2021 0 41 5 139 2.0% 0.29 [0.02, 5.44] 2021

Total (95% CI) 1143 2259 100.0% 1.80 [1.19, 2.73]

Total events 52 50
Heterogeneity: Tau² = 0.00; Chi² = 3.76, df = 5 (P = 0.58); I² = 0%
0.01 0.1 1 10 100
Test for overall effect: Z = 2.80 (P = 0.005)
Favours exposed Favours controls

C) First or second trimester miscarriage

Exposed Controls Odds Ratio Odds Ratio
Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI Year M-H, Random, 95% CI
Jayaprasan 2011 8 43 20 158 5.1% 1.58 [0.64, 3.88]
Chen 2018a 20 302 30 368 6.9% 0.80 [0.44, 1.44]
Chen 2018b 36 178 104 605 7.9% 1.22 [0.80, 1.86]
Ben-Rafael 1991 99 245 139 413 8.4% 1.34 [0.96, 1.85] 1991
Cooney 1998 5 22 4 66 3.0% 4.56 [1.10, 18.86] 1998
Erez 2007 25 31 13 62 4.2% 15.71 [5.33, 46.28] 2007
Zlopasa 2007 83 246 74 379 8.2% 2.10 [1.45, 3.03] 2007
Sugiura-Ogasawara 2010 17 42 432 1528 6.6% 1.73 [0.92, 3.23] 2010
Saravelos 2010 203 251 452 630 8.2% 1.67 [1.16, 2.39] 2010
Li 2017 45 238 89 818 8.0% 1.91 [1.29, 2.83] 2017
Ozgur 2017 6 50 53 100 4.9% 0.12 [0.05, 0.31] 2017
Surrey 2018 4 61 16 276 4.0% 1.14 [0.37, 3.54] 2018
Ples 2018 7 29 4 59 3.3% 4.38 [1.16, 16.45] 2018
Cai 2021 14 65 36 195 6.2% 1.21 [0.61, 2.43] 2021
Kong 2021 6 41 23 139 4.7% 0.86 [0.33, 2.29] 2021
Marianna 2022 2 22 7 266 2.5% 3.70 [0.72, 19.00] 2022
Qiu 2022 35 154 200 1331 8.0% 1.66 [1.11, 2.50] 2022

Total (95% CI) 2020 7393 100.0% 1.54 [1.14, 2.07]

Total events 615 1696
Heterogeneity: Tau² = 0.25; Chi² = 64.94, df = 16 (P < 0.00001); I² = 75%
0.01 0.1 1 10 100
Test for overall effect: Z = 2.81 (P = 0.005)
Favours exposed Favours controls

Figure 2: Forest plots of individual and pooled effects of CUA (combined) on first (A), second trimester (B) and any trimester (C)
Figure 2: Forest plots of individual and pooled effects of CUA
miscarriage risk.(combined) on first (A), second trimester (B) and any
trimester (C) miscarriage risk.

REPRODUCTIVE IMPACT OF MÜLLERIAN ANOMALIES – CABALLERO CAMPO et al. 15

 Miscarriage by type of CUA
First trimester miscarriage

Exposed Controls Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI Year M-H, Random, 95% CI
2.1.1 Arcuate uterus
Jayaprasan 2011 5 36 20 158 15.4% 1.11 [0.39, 3.19]
Zlopasa 2007 2 13 62 379 7.3% 0.93 [0.20, 4.30] 2007
Saravelos 2010 74 101 431 630 77.2% 1.27 [0.79, 2.03] 2010
Subtotal (95% CI) 150 1167 100.0% 1.21 [0.80, 1.84]
Total events 81 513
Heterogeneity: Tau² = 0.00; Chi² = 0.17, df = 2 (P = 0.92); I² = 0%
Test for overall effect: Z = 0.91 (P = 0.36)

2.1.2 Subseptate uterus

Jayaprasan 2011 2 3 20 158 26.9% 13.80 [1.20, 159.25]
Zlopasa 2007 10 31 62 379 73.1% 2.43 [1.09, 5.42] 2007
Subtotal (95% CI) 34 537 100.0% 3.88 [0.86, 17.54]
Total events 12 82
Heterogeneity: Tau² = 0.64; Chi² = 1.75, df = 1 (P = 0.19); I² = 43%
Test for overall effect: Z = 1.76 (P = 0.08)

2.1.3 Septate uterus

Jayaprasan 2011 1 2 20 158 6.4% 6.90 [0.41, 114.75]
Zlopasa 2007 21 60 62 379 44.0% 2.75 [1.52, 5.00] 2007
Saravelos 2010 77 106 431 630 49.6% 1.23 [0.77, 1.94] 2010
Subtotal (95% CI) 168 1167 100.0% 1.95 [0.92, 4.15]
Total events 99 513
Heterogeneity: Tau² = 0.24; Chi² = 5.46, df = 2 (P = 0.07); I² = 63%
Test for overall effect: Z = 1.75 (P = 0.08)

2.1.4 Bicornuate uterus

Jayaprasan 2011 0 1 20 58 1.6% 0.63 [0.02, 16.07]
Zlopasa 2007 25 91 62 379 57.9% 1.94 [1.13, 3.31] 2007
Saravelos 2010 21 29 431 630 23.9% 1.21 [0.53, 2.78] 2010
Kong 2021 6 41 18 139 16.6% 1.15 [0.42, 3.12] 2021
Subtotal (95% CI) 162 1206 100.0% 1.56 [1.04, 2.34]
Total events 52 531
Heterogeneity: Tau² = 0.00; Chi² = 1.65, df = 3 (P = 0.65); I² = 0%
Test for overall effect: Z = 2.14 (P = 0.03)

2.1.5 Didelphys uterus

Zlopasa 2007 2 8 62 379 12.2% 1.70 [0.34, 8.64] 2007
Saravelos 2010 8 10 421 630 13.3% 1.99 [0.42, 9.43] 2010
Cai 2021 15 83 38 249 74.5% 1.22 [0.63, 2.36] 2021
Subtotal (95% CI) 101 1258 100.0% 1.36 [0.77, 2.40]
Total events 25 521
Heterogeneity: Tau² = 0.00; Chi² = 0.40, df = 2 (P = 0.82); I² = 0%
Test for overall effect: Z = 1.06 (P = 0.29)

2.1.6 Unicornuate uterus

Chen 2018a 13 125 25 160 32.4% 0.63 [0.31, 1.28]
Zlopasa 2007 2 8 62 379 14.0% 1.70 [0.34, 8.64] 2007
Saravelos 2010 3 5 421 630 12.1% 0.74 [0.12, 4.49] 2010
Li 2017 43 238 86 818 41.5% 1.88 [1.26, 2.80] 2017
Subtotal (95% CI) 376 1987 100.0% 1.16 [0.56, 2.39]
Total events 61 594
Heterogeneity: Tau² = 0.29; Chi² = 7.48, df = 3 (P = 0.06); I² = 60%
Test for overall effect: Z = 0.40 (P = 0.69)

0.01 0.1 1 10 100

Favours exposed Favours controls

Figure 3: Forest plots of individual and pooled effects on first trimester miscarriage by type of CUA.
Figure 3: Forest plots of individual and pooled effects on first trimester miscarriage by type of CUA

16 Facts Views Vis Obgyn

Second trimester miscarriage

Exposed Controls Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI Year M-H, Random, 95% CI
2.2.1 Arcuate uterus
Zlopasa 2007 1 13 12 379 49.0% 2.55 [0.31, 21.22] 2007
Saravelos 2010 1 101 21 630 51.0% 0.29 [0.04, 2.18] 2010
Subtotal (95% CI) 114 1009 100.0% 0.84 [0.09, 8.13]
Total events 2 33
Heterogeneity: Tau² = 1.57; Chi² = 2.41, df = 1 (P = 0.12); I² = 58%
Test for overall effect: Z = 0.15 (P = 0.88)

2.2.2 Subseptate uterus

Zlopasa 2007 4 31 12 379 100.0% 4.53 [1.37, 15.00] 2007
Subtotal (95% CI) 31 379 100.0% 4.53 [1.37, 15.00]
Total events 4 12
Heterogeneity: Not applicable
Test for overall effect: Z = 2.47 (P = 0.01)

2.2.3 Septate uterus

Zlopasa 2007 8 30 12 379 42.8% 11.12 [4.12, 30.01] 2007
Saravelos 2010 14 106 21 630 57.2% 4.41 [2.17, 8.98] 2010
Subtotal (95% CI) 136 1009 100.0% 6.55 [2.66, 16.16]
Total events 22 33
Heterogeneity: Tau² = 0.24; Chi² = 2.23, df = 1 (P = 0.14); I² = 55%
Test for overall effect: Z = 4.08 (P < 0.0001)

2.2.4 Bicornuate uterus

Zlopasa 2007 0 13 12 379 25.0% 1.09 [0.06, 19.37] 2007
Saravelos 2010 4 29 21 630 50.4% 4.64 [1.48, 14.53] 2010
Kong 2021 0 41 5 139 24.6% 0.29 [0.02, 5.44] 2021
Subtotal (95% CI) 83 1148 100.0% 1.64 [0.25, 10.54]
Total events 4 38
Heterogeneity: Tau² = 1.45; Chi² = 4.19, df = 2 (P = 0.12); I² = 52%
Test for overall effect: Z = 0.52 (P = 0.60)

2.2.5 Didelphys uterus

Zlopasa 2007 0 3 12 379 12.0% 4.20 [0.21, 85.75] 2007
Saravelos 2010 1 10 21 630 24.6% 3.22 [0.39, 26.61] 2010
Cai 2021 3 83 10 249 63.4% 0.90 [0.24, 3.34] 2021
Subtotal (95% CI) 96 1258 100.0% 1.48 [0.52, 4.21]
Total events 4 43
Heterogeneity: Tau² = 0.00; Chi² = 1.62, df = 2 (P = 0.45); I² = 0%
Test for overall effect: Z = 0.73 (P = 0.46)

2.2.6 Unicornuate uterus

Chen 2018a 7 125 5 160 57.4% 1.84 [0.57, 5.94]
Zlopasa 2007 0 8 12 379 9.3% 1.73 [0.09, 31.66] 2007
Saravelos 2010 0 3 21 630 8.8% 4.05 [0.20, 80.88] 2010
Li 2017 2 238 3 818 24.5% 2.30 [0.38, 13.86] 2017
Subtotal (95% CI) 374 1987 100.0% 2.07 [0.85, 5.03]
Total events 9 41
Heterogeneity: Tau² = 0.00; Chi² = 0.26, df = 3 (P = 0.97); I² = 0%
Test for overall effect: Z = 1.61 (P = 0.11)

0.01 0.1 1 10 100

Favours exposed Favours controls

Figure 4: Forest plots of individual and pooled effects on second trimester miscarriage by type of CUA.

Figure 4: Forest plots of individual and pooled effects on second trimester miscarriage by type of CUA

REPRODUCTIVE IMPACT OF MÜLLERIAN ANOMALIES – CABALLERO CAMPO et al. 17

 First or second trimester miscarriage
Exposed Controls Odds Ratio Odds Ratio
Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI Year M-H, Random, 95% CI
2.3.1 Arcuate uterus
Jayaprasan 2011 5 36 20 158 13.5% 1.11 [0.39, 3.19]
Zlopasa 2007 3 13 74 379 8.7% 1.24 [0.33, 4.61] 2007
Saravelos 2010 75 101 452 630 65.8% 1.14 [0.70, 1.83] 2010
Surrey 2018 4 83 16 378 12.0% 1.15 [0.37, 3.52] 2018
Subtotal (95% CI) 233 1545 100.0% 1.14 [0.77, 1.68]
Total events 87 562
Heterogeneity: Tau² = 0.00; Chi² = 0.02, df = 3 (P = 1.00); I² = 0%
Test for overall effect: Z = 0.67 (P = 0.50)

2.3.2 Subseptate uterus

Jayaprasan 2011 2 3 20 158 13.5% 13.80 [1.20, 159.25]
Erez 2007 15 19 9 38 32.4% 12.08 [3.19, 45.81] 2007
Zlopasa 2007 14 31 74 379 54.1% 3.39 [1.60, 7.20] 2007
Subtotal (95% CI) 53 575 100.0% 6.19 [2.30, 16.66]
Total events 31 103
Heterogeneity: Tau² = 0.32; Chi² = 3.38, df = 2 (P = 0.18); I² = 41%
Test for overall effect: Z = 3.61 (P = 0.0003)

2.3.3 Septate uterus

Jayaprasan 2011 1 2 20 128 3.3% 5.40 [0.32, 89.92]
Erez 2007 10 12 4 24 6.7% 25.00 [3.89, 160.49] 2007
Zlopasa 2007 29 60 74 379 26.0% 3.86 [2.19, 6.79] 2007
Saravelos 2010 91 106 452 630 25.8% 2.39 [1.35, 4.24] 2010
Sugiura-Ogasawara 2010 1 7 541 1803 5.4% 0.39 [0.05, 3.24] 2010
Ples 2018 2 9 4 59 6.6% 3.93 [0.61, 25.51] 2018
Qiu 2022 19 81 97 746 26.2% 2.05 [1.18, 3.58] 2022
Subtotal (95% CI) 277 3769 100.0% 2.93 [1.72, 4.99]
Total events 153 1192
Heterogeneity: Tau² = 0.20; Chi² = 11.73, df = 6 (P = 0.07); I² = 49%
Test for overall effect: Z = 3.96 (P < 0.0001)

2.3.4 Bicornuate uterus

Jayaprasan 2011 0 1 20 128 1.2% 1.76 [0.07, 44.83]
Zlopasa 2007 39 91 74 379 35.1% 3.09 [1.90, 5.03] 2007
Saravelos 2010 25 29 452 630 9.9% 2.46 [0.84, 7.17] 2010
Sugiura-Ogasawara 2010 20 45 541 1803 26.3% 1.87 [1.03, 3.39] 2010
Kong 2021 6 41 23 139 11.7% 0.86 [0.33, 2.29] 2021
Qiu 2022 9 31 71 392 15.9% 1.85 [0.82, 4.19] 2022
Subtotal (95% CI) 238 3471 100.0% 2.09 [1.47, 2.97]
Total events 99 1181
Heterogeneity: Tau² = 0.03; Chi² = 5.92, df = 5 (P = 0.31); I² = 16%
Test for overall effect: Z = 4.08 (P < 0.0001)

2.3.5 Didelphys uterus

Zlopasa 2007 2 8 74 379 8.8% 1.37 [0.27, 6.94] 2007
Saravelos 2010 9 10 452 630 5.4% 3.54 [0.45, 28.18] 2010
Cai 2021 18 83 44 249 61.3% 1.29 [0.70, 2.39] 2021
Qiu 2022 6 24 49 307 24.5% 1.76 [0.66, 4.64] 2022
Subtotal (95% CI) 125 1565 100.0% 1.48 [0.91, 2.39]
Total events 35 619
Heterogeneity: Tau² = 0.00; Chi² = 1.01, df = 3 (P = 0.80); I² = 0%
Test for overall effect: Z = 1.59 (P = 0.11)

2.3.6 Unicornuate uterus

Chen 2018b 36 178 104 605 18.9% 1.22 [0.80, 1.86]
Chen 2018a 20 125 30 160 17.1% 0.83 [0.44, 1.54]
Zlopasa 2007 2 8 74 379 8.7% 1.37 [0.27, 6.94] 2007
Saravelos 2010 3 5 452 630 7.6% 0.59 [0.10, 3.56] 2010
Ozgur 2017 6 50 53 100 14.1% 0.12 [0.05, 0.31] 2017
Li 2017 45 238 89 818 19.1% 1.91 [1.29, 2.83] 2017
Qiu 2022 7 42 32 193 14.5% 1.01 [0.41, 2.46] 2022
Subtotal (95% CI) 646 2885 100.0% 0.83 [0.45, 1.56]
Total events 119 834
Heterogeneity: Tau² = 0.50; Chi² = 30.90, df = 6 (P < 0.0001); I² = 81%
Test for overall effect: Z = 0.57 (P = 0.57)

2.3.7 Dysmorphic uterus

Ples 2018 3 14 4 59 38.9% 3.75 [0.73, 19.16] 2018
Marianna 2022 4 27 7 266 61.1% 6.43 [1.75, 23.62] 2022
Subtotal (95% CI) 41 325 100.0% 5.22 [1.89, 14.42]
Total events 7 11
Heterogeneity: Tau² = 0.00; Chi² = 0.26, df = 1 (P = 0.61); I² = 0%
Test for overall effect: Z = 3.18 (P = 0.001)

0.01 0.1 1 10 100

Favours exposed Favours controls

Figure 5: Forest plots of individual and pooled effects on any trimester miscarriage by type of CUA.
Figure 5: Forest plots of individual and pooled effects on any trimester miscarriage by type of CUA
5

18 Facts Views Vis Obgyn

between CUA and prematurity <32 weeks with
septate uterus or unification defects.
Regarding IUGR/SGA, the three previous meta-
analyses (Chan et al., 2011a; Kim et al., 2021;
Venetis et al., 2014) found an association with
unification defects, especially with didelphys and
bicornuate uteri, which is consistent with our results.
Canalization defects are less consistently associated
with this outcome. Subseptate uterus increases the
risk of IUGR/SGA both according to Kim’s study
and ours, although Venetis estimated an increased
risk of IUGR only for septate uterus (Venetis et al.,
2014).
Concerning delivery and postnatal events,
malpresentation at delivery is the most frequently
reported adverse outcomes for all types of CUA.
Caesarean delivery is more frequent in patients
carrying canalization defects, as concluded meta-
analysis from Kim et al. (2021) and our study.
Unification defects also increase the risk of
caesarean section, as also by Kim et al. (2021).
Chan et al. (2011a) and Venetis et al. (2014) did not
consider this outcome. Finally, our results support
an increase of risk of foetal mortality in patients with
CUA due to unification disorders, while Kim et al.
(2021) identified this increased risk only in patients
with unicornuate uterus. Perinatal mortality is also
associated with unification defects. In our study
all the unification defects had increased perinatal
mortality, whereas Kim’s meta-analysis detected
this increase for unicornuate, bicornuate and septate
uterus (Kim et al., 2021).
Strengths and limitations
Strengths of our study derive from the strict selection
criteria. This meta-analysis is the first to estimate
pooled effects of T-shaped uterus on pregnancy
outcomes obtaining estimates on relevant outcomes
(miscarriage, ectopic pregnancy, and prematurity).
Our study also provides the first estimation of CUA
effects on preterm delivery <32 weeks. Additionally,
meta-regression models were applied as an effort to
analyse and control the observed heterogeneity.
Retrospective design of most included studies
and differences in population of interest, sample
sizes, procedures applied for the diagnosis –such
as hysterosalpingography or 2D ultrasound–,
characteristics of non-exposed patients and design of
included studies should be considered as limitations.
In addition, classification categories used in includes
studies do not correspond with more recent and
widely accepted classification schemes of CUA.
We have not performed the re-classification of the
exposure categories into actual classifications, to
avoid the risk of bias potentially associated. Certain
outcomes, such as placental abruption and preterm
REPRODUCTIVE IMPACT OF MÜLLERIAN ANOMALIES – CABALLERO CAMPO et al.
delivery, have been analysed from single studies.
Furthermore, several of the ‘effect’ estimates present
high levels of statistical heterogeneity, which have
not been substantially reduced by meta-regression.
Specifically, 30 of the 71 estimates of global effects
were affected by high statistical heterogeneity
(I2>50%), despite the 10 adjustments.
Implications for clinical practice
The accurate estimation of risks associated with a
specific CUA requires a precise diagnosis and an
appropriate standardised classification. In clinical
practice, 3-D ultrasound constitutes actually the first-
choice image assessment of CUA. In certain cases,
complementary tests such as MRI or hysteroscopy
may be necessary. There is increasing evidence
about the usefulness of hysteroscopic metroplasty
in reducing the risk of miscarriage by correction
of septate and subseptate uterus (Carrera et al.,
2022; Jiang et al., 2023), as well as dysmorphic
uterus (Garzon et al., 2020). The surgical treatment
of unification defects is more complex with no
evidence of improving perinatal prognosis.
Implications for research
Most studies diagnose and classify CUA according
to the first version of the AFS classification. It
may be of interest to re-analyse the reproductive
risks associated with CUA using the ESHRE/
ESGE or ASRM revised classification, which may
help to better estimate the risks associated with
these characterised anomalies. The development
of prospective studies that apply the most recent
classifications are needed.
Conclusions
CUA are associated with an increased risk
of complications in early and late pregnancy.
Complications associated with most of the CUA
were preterm delivery, malpresentation at delivery,
and caesarean delivery. Moreover, our results do not
clearly define a profile of preferential association
between type of Müllerian defects and category of
complications.
Acknowledgements: The authors thank the Spanish
Fertility Society for the logistical support received for
the preparation of this article.
Conflict of interest: The authors have no conflicts of
interest to declare.
19
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