TECHNIQUES AND INSTRUMENTATION

Accuracy of three-dimensional ultrasound in diagnosis

and classification of congenital uterine anomalies
Tullio Ghi, M.D., Ph.D., Paolo Casadio, M.D., Marina Kuleva, M.D., Anna Myriam Perrone, M.D.,
Luca Savelli, M.D., Susanna Giunchi, M.D., Maria Cristina Meriggiola, M.D.,
Giampietro Gubbini, M.D., Gianluigi Pilu, Professor, Carla Pelusi, Professor, and
Giuseppe Pelusi, Professor
Department of Obstetrics and Gynecology, University Hospital of Bologna, Italy

Objective: To assess the accuracy of three-dimensional (3D) ultrasound in the diagnosis of congenital uterine
anomalies.
Design: Prospective study.
Setting: University hospital.
Patient(s): Nulliparae with three or more consecutive miscarriages.
Intervention(s): All women underwent 3D transvaginal ultrasound study of the uterine cavity.
Main Outcome Measure(s): Women with negative ultrasound findings subsequently underwent office hysteroscopy,
whereas a combined laparoscopic-hysteroscopic assessment was performed in cases of suspected M€ ullerian anomaly.
Result(s): A specific M€ullerian malformation was sonographically diagnosed in 54 women of the 284 included in
the study group. All negative ultrasound findings were confirmed at office hysteroscopy. Among the women with
abnormal ultrasound findings, the presence of a M€ ullerian anomaly was endoscopically confirmed in all. Concor-
dance between ultrasound and endoscopy around the type of anomaly was verified in 52 cases, including all those
with septate uterus and two out of three with bicornuate uterus.
Conclusion(s): Volume transvaginal ultrasound appears to be extremely accurate for the diagnosis and classifica-
tion of congenital uterine anomalies and may conveniently become the only mandatory step in the assessment of
the uterine cavity in patients with a history of recurrent miscarriage. (Fertil Steril 2009;92:808–13. 2009 by
American Society for Reproductive Medicine.)
Key Words: Three-dimensional ultrasound, congenital uterine anomalies, recurrent miscarriage, office hystero-
scopy and laparoscopy

M€ullerian anomalies include a wide group of congenital
uterine malformations whose prevalence in the general pop-
ulation is around 3%–4% (1, 2). Most of them are reported to
increase the risk of infertility or adverse pregnancy outcome
(2–6). The reproductive outcome and treatment options
depend on the type of uterine malformation.
As the most common classification of M€ ullerian anomalies
is in accordance with either the external or internal morphol-
ogy of the uterus (7), assessment of both is mandatory for
a correct diagnosis of the type of malformation. Despite
being invasive, a combined hysteroscopic and laparoscopic
evaluation of uterine morphology and contour has tradition-
ally been the most widely used method in the differential
diagnosis of M€ullerian malformations (8).
Recently, thanks to the introduction of volume ultrasound,
a comprehensive evaluation of uterine morphology has be-
come feasible at transvaginal ultrasound (9). At volume ultra-
sound, both the external contours and internal morphology of
the uterus may be displayed on the coronal plane, and the
presence and type of uterine anomaly may be accurately
detected. The purpose of this study was to evaluate in a se-
lected group of women the accuracy of volume ultrasound
in the diagnosis and classification of M€ullerian anomalies.

Received January 16, 2008; revised May 22, 2008; accepted May 27,
2008; published online August 11, 2008.
T.G. has nothing to disclose. P.C. has nothing to disclose. M.K. has noth-
ing to disclose. A.M.P. has nothing to disclose. L.S. has nothing to dis-
close. S.G. has nothing to disclose. M.C.M. has nothing to disclose.
G.G. has nothing to disclose. G.P. has nothing to disclose. C.P. has
nothing to disclose. G.P. has nothing to disclose.
Reprint requests: Tullio Ghi, M.D., I Clinica Ostetrica-Ginecologica, Policli-
nico S.Orsola-Malpighi, Via Massarenti, 13, 40100 Bologna (FAX:
39-051-636-4411; E-mail: tullioghi@yahoo.com).
MATERIALS AND METHODS
From January 2004 to December 2006, all women consecu-
tively referred to our infertility clinic who were nulliparae
with a history of recurrent miscarriage (three or more consec-
utive abortions by 12 weeks of gestation) were prospectively
enrolled in the study and submitted to a volume ultrasound
evaluation of the uterine cavity in the midluteal phase of
the cycle. Patients were excluded if uterine fibroids or

808 Fertility and Sterility Vol. 92, No. 2, August 2009 0015-0282/09/$36.00
Copyright ª2009 American Society for Reproductive Medicine, Published by Elsevier Inc. doi:10.1016/j.fertnstert.2008.05.086
endometrial polyps were incidentally detected at ultrasound.
For each patient, a control of uterine cavity by office hystero-
scopy was arranged in the early follicular phase of the subse-
quent cycle.
Hysteroscopy and ultrasound were performed by different
operators (hysteroscopy by PC, ultrasound by TG) with se-
lective competence for each technique. Ultrasound findings
were not made available to the operator doing the hystero-
scopy. Whenever a specific uterine malformation was sono-
graphically diagnosed, a combined laparoscopic-
hysteroscopic evaluation instead of office hysteroscopy was
proposed to the patient and arranged within a month from ul-
trasound. The study was approved by the Institutional Review
Board of our hospital. In addition, a signed declaration of no
conflict of interest has been provided by all the authors in-
volved in the study.
Ultrasound scan was performed using a Voluson 730 Ex-
pert and a Voluson 730 Pro machine (GE, Milan, Italy) equip-
ped with a multifrequency volume endovaginal probe. The
insonation technique was standardized according to the fol-
lowing criteria: probe frequency set at 9 mHz, a midsagittal
view of the uterus filling 75% of the screen, three-dimen-
sional (3D) box size including the uterus from fundus to
the cervix, sweep angle of 90 , and sweep velocity adjusted
FIGURE 1
Multiplanar imaging of a normal uterus at volume ultrasound: the volume rendering box is as narrow as possible in
the sagittal plane (panel B) and adjusted on the uterine corpus in the coronal plane (panel A). A rendered image of
the normal uterus on the coronal plane is displayed on panel D.
Ghi. 3D ultrasound in M€
ullerian anomalies. Fertil Steril 2009.
Fertility and Sterility
to maximum quality. Each volume data set was stored on
the hard disk of the ultrasound machine and made available
for offline analysis by one of authors (TG or MK).
As shown in Figure 1, the volume reconstruction technique
was standardized according to the following criteria: the vol-
ume rendering box as narrow as possible in the sagittal plane
and adjusted on the uterine corpus in the coronal plane, cut
plane scrolled in anterior-posterior fashion with slice thick-
ness set at 1 cm, transparency low (<50%), and volume ren-
dering by a mix of surface and maximum mode. The analysis
of uterine morphology was performed in a standardized re-
formatted section with the uterus in the coronal view using
the interstitial portions of fallopian tubes as reference points.
Specific ultrasound diagnosis of uterine anomalies was based
on the classification system originally proposed by the Amer-
ican Fertility Society and subsequently modified according to
3D ultrasound landmarks (10) (Table 1).
RESULTS
During the study period, 312 nulliparae attending our center
with a history of recurrent abortions were submitted to trans-
vaginal volume ultrasound. In 28 cases, women were consid-
ered not eligible for the study owing to incidental detection of
uterine fibroids (n ¼ 19) or endometrial polyps (n ¼ 9) at
809
 TABLE 1
Classification of congenital uterine anomalies according to volume transvaginal ultrasound (10).
Uterine morphology Fundal contour External contour
Normal Straight or convex Uniformly convex or with indentation
<10 mm
Arcuate Concave fundal indentation with Uniformly convex or with indentation
central point of indentation at <10 mm
obtuse angle (>90 )
Subseptate Presence of septum, which does not Uniformly convex or with indentation
extend to cervix, with central point <10 mm
of septum at an acute angle (<90 )
Septate Presence of uterine septum that that Uniformly convex or with indentation
completely divides cavity from <10 mm
fundus to cervix
Bicornuate Two well-formed uterine cornua Fundal indentation >10 mm dividing
the two cornua
Unicornuate with or without Single well-formed uterine cavity with
rudimentary horn a single interstitial portion of
Fallopian tube and concave fundal
contour
Ghi. 3D ultrasound in M€
ullerian anomalies. Fertil Steril 2009.

ultrasound scan. The remaining 284 women agreed to partic-
ipate in the study protocol. The median age of the patients
was 34 years (range, 26–44), and their ethnicity was distrib-
uted as follows: Caucasian, n ¼ 272 (95.8%); Afrocaribbean,
n ¼ 10 (3.5%); and Asian n ¼ 2 (0.7%).
The quality of volume ultrasound was satisfactory in all
cases. Offline analysis of uterine morphology was success-
fully carried out within 5 minutes in each case. A normal uter-
ine cavity was demonstrated at ultrasound in 230 (81%)
patients, whereas a specific diagnosis of uterine anomaly
was sonographically performed in 54 cases (19%). Unicorn-
uate uterus (one case) was sonographically diagnosed when
an asymmetric laterally deviated uterine corpus of tubular
shape with an accessory noncommunicating rudimental
horn was demonstrated on the coronal plane. A single tubal
ostium was detectable on this section. Bicornuate uterus (n
¼ 9) was sonographically diagnosed when two separated
uterine cornua with external fundal indentation R10 mm di-
viding the cornua were demonstrated on the coronal plane
(Fig. 2A).
Septate uterus (n ¼ 35) was sonographically diagnosed
when a septum dividing the endometrial cavity was demon-
strated on the coronal plane and the external uterine surface
was normal or showed a sagittal notch of <1 cm (Fig. 2B).
Septate uterus was further classified as complete (n ¼ 14)
or incomplete (subseptate uterus, n ¼ 21) as far as the septum
itself bridged or did not bridge the fundus to the internal os of
the uterine cervix. In subseptate uterus, the fundal indentation
at the central point of the septum appeared as an acute angle
(Fig. 2D). Arcuate uterus (n ¼ 9) was sonographically diag-
nosed when normal external uterine contour and concave fun-
dal indentation of the endometrial cavity were demonstrated
on the coronal plane. In these cases, the fundal indentation at
the central point appeared as an obtuse angle (Fig. 2C).
After volume ultrasound, office hysteroscopy was per-
formed in the 230 (81%) patients with negative ultrasound
findings, and combined hysteroscopy-laparoscopy under
general anesthesia was carried out in the 54 (19%) cases
with a M€ullerian anomaly suspected at ultrasound. The diag-
nostic accuracy of 3D ultrasound is summarized in Table 2.
All women with negative ultrasound findings showed normal
uterine cavity at office hysteroscopy. A complete list of the 54
abnormal cases detected at ultrasound with the volume ultra-
sound diagnosis and corresponding findings subsequently
achieved at endoscopy is provided in the table. At endoscopy,
the presence of a M€ullerian anomaly was confirmed in all
cases. Exact concordance between ultrasound and endoscopy
around the type of anomaly was verified in 52 cases, includ-
ing all those with septate uterus (partial and complete) and
two out of three with bicornuate uterus. Ultrasound diagnosis
proved inaccurate in two cases, including an arcuate and a bi-
cornuate uterus that at endoscopy were, respectively, classi-
fied as a subseptate and a complete septate uterus.
DISCUSSION
Our data seem to confirm in a large series of cases that in a se-
lected group of patients volume transvaginal ultrasound is ex-
tremely accurate for the diagnosis and classification of
congenital uterine anomalies. All women sonographically
classified as normal in fact showed no evidence of M€ ullerian
anomaly at office hysteroscopy. On the other hand, in all pa-
tients sonographically classified as abnormal, a M€ ullerian

810 Ghi et al. 3D ultrasound in M€ullerian anomalies Vol. 92, No. 2, August 2009
 FIGURE 2
(A) Rendered image of a bicornuate uterus at volume ultrasound: on the coronal plane, two divergent cornua
divided by a sagittal cleft >10 mm (arrow) are noted. (B) Rendered image of a septate uterus at volume
ultrasound: on the coronal plane, a septum dividing the endometrial cavity and extending to the cervix with
a normal external uterine surface is demonstrated. (C) Rendered image of an arcuate uterus at volume
ultrasound: on the coronal plane, normal external uterine contour and concave fundal indentation of the
endometrial cavity at obtuse angle are demonstrated. (D) Rendered image of a subseptate uterus at volume
ultrasound: on the coronal plane, the septum is noted not to extend to the cervix, and fundal indentation at its
central point appears as an acute angle.

Ghi. 3D ultrasound in M€
ullerian anomalies. Fertil Steril 2009.

anomaly was subsequently confirmed at combined hystero-
scopy-laparoscopy. Furthermore, volume ultrasound proved
highly valuable in suggesting the type of uterine anomaly,
as ultrasound classification was endoscopically confirmed
in 52 out of 54 abnormal cases (92.3%).
Adequate ultrasound imaging of the uterine cavity was ob-
tained within a few minutes in all cases. According to other
investigators (11), all women with concurrent uterine abnor-
malities such as polyps or fibroids were excluded from the
study group, so that only the effect of a malformation on
the uterine cavity morphology was subjected to ultrasound
evaluation. Owing to the excellent positive (96.3%) and neg-
ative predictive value (100%) registered in this series, volume
ultrasound may be proposed as an accurate tool for detecting
uterine anomalies in high-risk patients such as those with re-
current abortion. In this group, the option of office hystero-
scopy has traditionally been considered as a mandatory step
for uterine cavity assessment (12). Being an invasive tech-
nique, however, hysteroscopy may cause some discomfort
to the patient, and even performed by expert hands, it is cer-
tainly more unpleasant than ultrasound for the patient.
According to our data, in women with negative ultra-
sound findings, indication for hysteroscopy certainly
becomes debatable, as it does not seem to improve the

Fertility and Sterility 811

 TABLE 2
Comparison between ultrasound and endoscopic findings in the study group.
Confirmed findings Different findings
Ultrasound diagnosis n at endoscopy at endoscopy
Normal uterus 230 230 —
Unicornuate uterus 1 1 —
Bicornuate uterus 9 8 1 (septate uterus)
Septate uterus 14 14 —
Subseptate uterus 21 21 —
Arcuate uterus 9 8 1 (subseptate uterus)
Ghi. 3D ultrasound in M€
ullerian anomalies. Fertil Steril 2009.

sensitivity of volume ultrasound in detecting uterine anom-
alies. On the other hand, because of the high precision of
volume ultrasound in characterizing uterine anomalies,
women diagnosed with a specific malformation that may
be treated by means of resectoscope may be conveniently
addressed to an operative hysteroscopy rather than to a diag-
nostic endoscopic step. Owing to the high accuracy of 3D
ultrasound for the diagnosis of bicornuate uterus, patients
diagnosed with this condition can avoid further diagnostic
steps, as operative hysteroscopy is not useful for treating
such an abnormality.
As mentioned above, in two of our cases, 3D ultrasound di-
agnosis proved to be inaccurate, and a specific comment on
that is certainly required. In the first case, a woman with ul-
trasound suspicion of bicornuate uterus was endoscopically
diagnosed as having a complete septate uterus. This is cer-
tainly a major mistake, but it was made at the beginning of
the study when experience in volume reconstruction was still
limited. The same volume data set has been subsequently
reassessed by the same operator, and performing a volume
reconstruction of the uterus on a different plane led to the cor-
rect ultrasound picture of a septate uterus. We believe that
misdiagnosis was due to an incorrect angle of scrolling
through the uterine fundus. In fact, if the section cut through
the fundus of a septate uterus is not perpendicular to that due
to an excessive rotation of the volume, a false impression of
a cleft in the fundal contour compatible with the diagnosis of
bicornuate uterus may be raised. The use of a combination of
rendered and mutiplanar images in interpreting the pictures
should make the differential diagnosis between the two
conditions more accurate.
In the second case, ultrasound diagnosis of arcuate uterus
was endoscopically changed to subseptate uterus. This is
a mild inaccuracy as a certain variability in distinguishing be-
tween these two forms of uterine anomalies is not uncommon
even among experienced endoscopists because the diagnosis
is based on subjective impression rather than on objective cri-
teria. Furthermore, as far as the clinical management is con-
cerned, patients with both arcuate and subseptate uteri with
a history of recurrent miscarriage are usually treated by
means of resectoscopic metroplasty, as was the case for our
patient. However, ultrasound impression of arcuate uterus
has been possibly favored by the presence of synechiae at
the level of tubal ostia due to repeated uterine curettages.
Before metroplasty, synechiae have been hysteroscopically
removed, and this has permitted a more reliable evaluation
of fundal indentation.
The use of volume ultrasound in the noninvasive diagnosis
of uterine anomalies has been previously suggested. Most
relevant studies have compared the accuracy of 3D ultrasound
to laparoscopy supported by hysterosalpingography (13)
or hysteroscopy (14), showing a high agreement between
the different techniques. On the other hand, as demonstrated
by other investigators (15), compared with conventional
two-dimensional ultrasound, volume ultrasound has a higher
specificity in detecting uterine anomalies. Furthermore, as
reported by other investigators, the reproducibility of 3D
ultrasound in the diagnosis and classification of congenital
uterine anomalies is extremely high (16).
In our study, all women were submitted at least to office
hysteroscopy, which is considered the most valuable method
to detect congenital anomalies of the uterine cavity (12). How-
ever, a combined hysteroscopic and laparoscopic evaluation
has been proposed for all cases with abnormal findings at
ultrasound. This policy has been judged reasonable to achieve
in a single step the final diagnosis and, when indicated, the
appropriate treatment. Some M€ullerian anomalies such as
bicornuate or septate uterus in fact are not amenable to be dif-
ferentiated at hysteroscopy only and may be confidently clas-
sified when laparoscopic view of the fundus is simultaneously
available. Furthermore, when the diagnosis of uterine anoma-
lies that may benefit from metroplasty is laparoscopically
ascertained, under the external control of the fundus, resecto-
scopic surgery may be more safely undertaken.
As shown by our series, M€ullerian anomalies may be de-
tected and correctly classified by volume ultrasound thanks
to its ability to provide a simultaneous reconstructed view
of the internal and external surface of the uterus itself on
the coronal plane. On this basis, women may be treated
with a combined laparoscopic-hysteroscopic approach only
when a curative step is clinically indicated and not for

812 Ghi et al. 3D ultrasound in M€ullerian anomalies Vol. 92, No. 2, August 2009
diagnostic purposes as previously recommended. Further-
more, in cases with septate uterus undergoing metroplasty,
the width of the septum or the thickness of the free uterine
wall above the septum may be measured by volume ultra-
sound before surgery to make the resectopic procedure safer.
In our study population, the prevalence of M€ullerian anom-
alies is higher than what was reported in previous ultrasound
series as one out of five patients turned out to be abnormal.
However, among women with recurrent abortion, such
a high prevalence of uterine anomalies had been previously
documented (11, 12, 17). Accurate detection of uterine mal-
formations in women with recurrent miscarriage is of critical
importance since the clinical management and obstetric out-
come of such patients are greatly influenced by the presence
and type of the anomaly itself. In women with recurrent mis-
carriage who have a uterine malformation that may be surgi-
cally amended, the risk of a recurrent abortion or adverse
perinatal outcome is dramatically decreased after metro-
plasty (6, 18–21).
In contrast, in women with recurrent abortion, even discov-
ering a M€ ullerian anomaly that is not treatable is clinically
relevant, as this may provide a reasonable explanation of
the infertility and may be looked at as a permanent risk factor
for adverse pregnancy outcome and not simply as a miscar-
riage for the individual patient herself. In pregnant women
with bicornuate uterus not experiencing first trimester mis-
carriage, the risks of preterm delivery, preeclampsia, or pla-
cental insufficiency (22) are reported to be significantly
increased.
In conclusion, our data demonstrate that volume transvagi-
nal ultrasound is an accurate and simple method to detect and
classify uterine M€ ullerian anomalies and should become the
first diagnostic step in the assessment of the uterine cavity of
patients with a history of recurrent miscarriage.
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