Multimodal Radiographic Diagnosis of a Complex Müllerian Anomaly: A Case Report

As evidenced by the 2021 American Society for Reproductive Medicine Müllerian Anomaly Classification (ASRM MAC), there are numerous possible configurations of the female genitourinary system. Some anomalies place patients at higher risk of infertility, miscarriage, fetal malpresentation, and preterm labor. Correct characterization of Müllerian anomalies is critical for proper infertility treatment and pregnancy counseling. This case study of a 32-year-old nulliparous woman describes the radiographic modalities utilized in the diagnosis of a complex Müllerian anomaly. To characterize the Müllerian anomaly, the patient underwent a 2D transvaginal ultrasound (TVUS), saline infusion sonohysterogram (SIS) with 3D reconstruction, and second-opinion interpretation of a previous MRI. Radiographic diagnoses were conflicting among different modalities. While the saline infusion sonohysterogram suggested a bicornuate uterus, the MRI of the anomaly was interpreted as a uterine didelphys. Furthermore, TVUS and MRI indicated the presence of two cervices, while only one cervix was appreciated with SIS. Given the inconsistent interpretation of her anomaly, the patient was brought to the operating room. After direct visualization with exam and hysteroscopy, the patient was ultimately diagnosed with a uterine didelphys with a communication of endometrial cavities in the lower uterine segment, two cervices, a hypoplastic right vagina, and a longitudinal vaginal septum extending to the hymen. The patient was counseled that this anomaly is not expected to impact natural conception and would not require surgical resection. The patient went on to conceive spontaneously in the right uterine horn, with a plan for primary cesarean delivery. This case was of sufficient complexity that an accurate diagnosis was not made until physical exam and hysteroscopic visualization verified findings from MRI and ultrasonographic imaging. Appropriately describing a Müllerian anomaly according to the 2021 ASRM MAC is crucial, and multiple forms of imaging and physical examination may be necessary to accurately characterize uterine anomalies.