O-057 Prevalence of T-shaped uterus among women undergoing fertility treatments based on ESHRE/ESGE and Congenital Uterine Malformation by Experts (CUME) criteria.
Authors: Bilgory A , Atzmon Y , Aslih N , Shibli Y , Raya Abu , Sharqawi M , Shavit M , Shalom-Paz E 
Published: June 2023

Abstract

Study question
What is the prevalence of a T-shaped uterus among women undergoing fertility treatments based on ESHRE/ESGE (Grimbizis et al.,2013) and CUME (Ludwin et al.,2020)?

Summary answer
The prevalence of T-shaped uterus was 4.1% according to the ESHRE/ESGE, and according to the CUME, 1.1% T-shaped uterus and 0.9% borderline T-shaped uterus.

What is known already
The definition of a T-shaped uterus by the ESHRE/ESGE consensus (Grimbizis et al., 2013) was based on three-dimensional ultrasound (3D-US) images, defining it as a narrow uterine cavity caused by thickened lateral walls with a ratio of two-thirds uterine body and one-third cervix. This definition is subjective and therefore makes giving an objective diagnosis difficult. The CUME group (Ludwin et al., 2020) described practical diagnostic criteria for a T-shaped uterus according to 3D-US images. As there is no consensus regarding the definition, the overall prevalence according to different studies varied from 0.2 to 10.0%.

Study design, size, duration
A retrospective cohort study with prospective analysis of 3D-US images was conducted. All women who were admitted to our unit for fertility treatments and underwent 3D-US between 12/2017-12/2021 were included. Women were grouped according to infertility type. All 3D-US images of uteri suspected to be T-shaped according to ESHRE/ESGE were assessed according to the CUME criteria, based on the following three measurements: lateral indentation angle ≤130°, lateral indentation depth ≥7 mm, and T-angle ≤40°.

Participants/materials, setting, methods
The study was conducted in a single university-affiliated hospital. Women who underwent fertility treatments due to various indications were included. The exclusion criteria were women undergoing fertility preservation, egg donation and oocyte recipients. All 3D-US were performed by well-trained ultrasound technicians. We first screened all images and calculated the prevalence of T-shaped uteri in our population based on the ESHRE/ESGE consensus. Next, we performed the three measurements according to the CUME criteria.

Main results and the role of chance
Altogether 451 women were admitted to our fertility unit. Nine cases were excluded due to unsatisfactory 3D-US images because of technical difficulties. Finally, 442 women were included in the study and divided into in the following groups: anovulation 10.6% (n = 47), mechanical factor 11.1% (n = 49), male factor 38.7% (n = 171), and unexplained infertility 39.6% (n = 175).
The prevalence of T-shaped uterus according to the ESHRE/ESGE was 4.1% (n = 18). Among them, 3.2% (n = 3) were from the female factor groups (anovulation + mechanical), 4.1% (n = 7) from the male factor group, and 4.6% (n = 8) from the unexplained infertility group.
Afterwards, the 3D-US images were analyzed according to the CUME criteria. T-shaped uterus was defined when all three criteria were met, and borderline T-shaped uterus was defined when two out of three criteria were met. According to CUME criteria, the prevalence of T-shaped uterus was only 1.1% (n = 5), three being from the male factor group and two from the unexplained infertility group. No T-shaped uteri were found in the female factor groups. Additionally, 0.9% (n = 4) were considered borderline T-shaped.

Limitations, reasons for caution
The ESHRE/ESGE consensus is subjective and may lead to either under- or over-diagnosis. On the other hand, the CUME criteria are objective and well-defined, but due to their strictness, dysmorphic uteri with very narrow uterine cavities and thickened lateral walls may not be diagnosed as T-shaped uteri.

Wider implications of the findings
Diagnosis and management of women with T-shaped uteri are very controversial topics. Therefore, making the diagnosis more precise and objective can help us to screen for the most significant cases and tailor the management accordingly. The similar prevalence among different infertility groups reflects the incidental nature of this diagnosis.

Trial registration number
Not applicable.