Anatomical Causes of RPL, the Role of 3D Ultrasound and the Significance of Determining Fetal Abnormalities

Müllerian uterine anomalies and acquired uterine abnormalities are important factors in the evaluation and treatment of patients with RPL. It is reasonable to estimate that uterine anomalies are found in approximately 0.1-4% of the general population and in approximately up to 15% of patients with RPL.

An anatomical workup is recommended for RPL patients according to the ASRM guidelines. The initial diagnostic modality is 2D followed by 3D trans-vaginal ultrasonography.

These modalities will provide the diagnosis in more than 95% of the cases. The findings of Müllerian uterine anomalies should be classified using the newer and simplified ESHRE classification from 2013. Following diagnosis, appropriate interventions should be considered when indicated, like septectomy for a septate uterus who will bring higher livebirth rate in the next pregnancy. Other (non-septate) Müllerian anomalies require close monitoring and a few of them may benefit if cervical cerclage is performed. For acquired malformation, adhesiolysis as well as synechiae are recommended in the setting of RPL and resection of uterine myomas should be considered if the myoma is greater than 5 cm and it is located submucosal.

The evaluation of the couple with RPL is focusing mainly on the female partner assuming that the embrio/fetus was normal. In RPL, an effort should be made in order to determine if the fetus karyotype is normal and this can be done by referring the patient to cytogenetic evaluation of the product of the conception before evacuating the uterus. In addition, due to the tremendous development in the ultrasound equipment and the ability to evaluate the fetal anatomy, it is crucial to refer the patient for those tests that can tell if the fetus is normal or not. This include the nuchal tranclucency exam (NT) and the anatomy scan ( specifically early anatomy scan).

In conclusion, the anatomy evaluation of patients with RPL includes the uterine evaluations before new pregnancy for congenital and acquired malformations as well as the evaluation of the fetus for anatomy abnormalities, both by ultrasounds exams.