Ultrasound Obstet Gynecol 2010; 35: 593–601

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.7551

Three-dimensional ultrasound in the diagnosis of Müllerian

duct anomalies and concordance with magnetic resonance
imaging
C. BERMEJO*, P. MARTÍNEZ TEN†, R. CANTARERO*, D. DIAZ*, J. PÉREZ PEDREGOSA‡,
E. BARRÓN†, E. LABRADOR§ and L. RUIZ LÓPEZ¶
*Gabinete Médico Velazquez, †DELTA-Ultrasound Diagnostic Center in Obstetrics and Gynecology, ‡Department of Obstetrics and
Gynecology, Hospital La Zarzuela and §Centro de Resonancia Magnética de Alto Campo Abirem, Madrid and ¶SESCAM, Spain

K E Y W O R D S: 3D US; congenital uterine malformations; magnetic resonance; MRI; Mullerian; Müllerian anomalies;
Müllerian duct anomalies; three-dimensional ultrasonography; UM; uterine malformations

ABSTRACT the two techniques occurred in four cases. There was

very good concordance in the diagnosis of associated
Objectives To demonstrate the value of three-dimensional findings (kappa index, 0.878 (95% CI, 0.775–0.980)),
(3D) ultrasound in the diagnosis of uterine malformations this analysis identifying differences in two cases.
and its concordance with magnetic resonance imaging
(MRI). Conclusions There is a high degree of concordance
between 3D ultrasound and MRI in the diagnosis of
Methods This study included 286 women diagnosed
uterine malformations, the relationship between cavity
with uterine malformation by 3D ultrasound, having
and fundus being visualized equally well with both
been referred to our clinics on suspicion of uterine
techniques. 3D ultrasound should be complemented by
malformation following clinical and/or conventional two-
careful gynecological exploration in order to identify any
dimensional ultrasound examination. With the exception
alterations in the cervix. Copyright  2010 ISUOG.
of three with intact hymen, patients underwent both
Published by John Wiley & Sons, Ltd.
bimanual examination and speculoscopy before and/or
after sonography. MRI was performed in 65 cases.
We analyzed the diagnostic concordance between the
techniques in the study of uterine malformations. INTRODUCTION

Results Using 3D ultrasound we diagnosed: one case
with uterine agenesis; 10 with unicornuate uterus, four of
which also underwent MRI; six with didelphic uterus, one
of which had MRI; 45 with bicornuate uterus, 12 of which
had MRI; 125 with septate uterus (18 with two cervices),
42 of which had MRI (six with two cervices); 96 with
arcuate uterus, three of which had MRI; and three with
diethylstilbestrol (DES) iatrogenic uterine malformations,
all of which had MRI. Among the 65 which underwent
MRI, the diagnosis was: four cases with unicornuate
uterus, 10 with bicornuate uterus (two with two cervices),
45 with septate uterus (five with two cervices), three
with arcuate uterus and three with DES-related uterine
malformations. The concordance between 3D ultrasound
and MRI was very good (kappa index, 0.880 (95%
CI, 0.769–0.993)). Discrepancies in diagnosis between
Uterine malformations make up a heterogeneous group
of congenital anomalies that can result from the
underdevelopment of the Müllerian ducts, disorders in
their fusion and/or alterations in septum resorption.
The prevalence of uterine malformations is difficult
to establish. They are estimated to occur in 0.4%
(0.1–3%)1,2 of the general population and in 4%
of infertile women (some authors do not distinguish
between these two groups3 ), and in patients with
repeated spontaneous miscarriages the figures fluctuate
between 3 and 38%4 – 8 . The discrepancy among different
publications stems from their use of different diagnostic
techniques, heterogeneous population samples and the
clinical diversity of Müllerian anomalies.
There are several classifications of uterine malforma-
tion, but the most widely accepted is that established in

Correspondence to: Dr C. Bermejo, Gabinete Médico Velázquez, Velazquez 25, 1◦ , 28001 Madrid, Spain
(e-mail: carminabermejo@yahoo.es)
Accepted: 28 August 2009

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd. ORIGINAL PAPER
594
1988 by the American Fertility Society (AFS)9 , which is
not only based on embryological factors, but also takes
into account clinical factors, prognosis and treatment
(Figure 1). It classifies uterine malformations into seven
groups, providing a very useful, but somewhat incom-
plete, categorization, as it requires the specification of any
associated malformations, when found.
There are several techniques available for the evaluation
of uterine malformations. When the cavity only is to be
assessed, hysterosalpingography (HSG) and hysteroscopy
are especially useful. Laparotomy and laparoscopy can be
also used for examination of the uterine fundus. There are
two techniques, however, that combine the study of both
these structures, which is indeed relevant for the diagnosis:
magnetic resonance imaging (MRI) and three-dimensional
(3D) ultrasound. While MRI is a useful option in the
diagnosis of Müllerian anomalies, with numerous studies
having proved its excellent efficacy in this field10 – 13 ,
3D ultrasound represents a valid alternative, because,
in addition to its lower cost and better tolerance by
patients, it provides images of very similar quality to those
yielded by MRI14 . There is a lack, however, of studies
comparing these two techniques for the diagnosis and
categorization of uterine malformations. The objective of
this study, therefore, was to demonstrate the value of 3D
ultrasound in the diagnosis of uterine malformations and
its concordance with MRI.
METHODS
Included in this study were 286 women diagnosed with
uterine malformation by 3D ultrasound between Novem-
ber 2004 and May 2009 in one of two centers (Gabinete
I Hypoplasia/agenesis
(a) Vaginal (b) Cervical (a) Communicating
(c) Fundal (d) Tubal (e) Combined
(c) No cavity
V Septate
(a) Complete (b) Partial
Figure 1 Classification of uterine malformations according to the American Fertility Society9 . DES, diethylstilbestrol.
Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd.
Bermejo et al.
Médico Velázquez, Madrid, Spain and Delta Ecografı́a
Madrid, Spain). They had been referred to our clinics
on suspicion of uterine malformation following clini-
cal and/or conventional two-dimensional (2D) ultrasound
examination. We performed 3D ultrasound in all cases,
bimanual examination and speculoscopy in 283 cases and
MRI in 65.
3D ultrasound examination of uterine cavity
and cervical canal
Examinations were performed using a Voluson Pro and
three Voluson 730 Expert (GE Medical Systems, Zipf,
Austria) ultrasound machines, equipped with convex
transabdominal probe RAB4-8L 4–8 MHz 4D and
endocavitary probe RIC5-9H 5–9 MHz 4D. In all cases
(except for three patients with intact hymen), we obtained
transvaginally between one and three static volumes of the
uterus, with a quality ranging from medium to maximum.
Initially we visualized the uterus on 2D ultrasound in
a strict mid-sagittal view, adjusting the capture window
to obtain the optimal 3D volume. The volume was then
obtained using a sweep angle of 90◦ from one side of the
uterus to the other, bisecting the capture plane (Figure 2).
In 25 cases with anomalies resulting in a large transverse
uterine diameter (didelphic uterus (n = 5), wide septate
uterus (n = 10), bicornuate uterus with ample separation
between horns (n = 8) and communicating unicornuate
uterus (n = 2)) the volume was obtained from a transverse
plane so that both uterine horns could be visualized,
in order to allow better estimation of the cavity/fundus
relationship in the 3D reconstruction (Figure 3). In seven
cases (with optimal ultrasound conditions including low
II Unicornuate III Didelphus
(b) Non-communicating IV Bicornuate
(d) No horn (a) Complete (b) Partial
VI Arcuate VII DES drug related
Ultrasound Obstet Gynecol 2010; 35: 593–601.
3D ultrasound and MRI in uterine anomalies 595

Figure 2 Procedure to obtain a rendered image of a Müllerian anomaly, in this case an arcuate uterus. (a) The initial plane for obtaining
three-dimensional volumes was generally mid-sagittal (Window A). Acquisition was carried out with a sweep angle of 90◦ . The image
corresponds to the bisector of the angle made by the volumetric probe as it is moved from one side of the uterus to the other. Window B is
the axial plane and Window C the coronal plane. (b) The rendering box was then adjusted (Window A) and the green line adapted to the
curved plane of the uterine cavity so it became positioned on the endometrium. The midline was verified (Window B). In the bottom right is
the rendered image of the surface of the arcuate uterus.

Figure 3 In uterine malformations with a large transverse diameter, such as this bicornuate uterus, three-dimensional (3D) volumes were
generally obtained from an axial plane (Window A) so that both horns would fit in the same field of view, enabling the cavity/fundus
relationship to be better established in the 3D reconstruction (bottom right).

body mass index) and in the three patients with intact
hymen, we captured the volume transabdominally, with
initial sagittal, coronal or transverse planes, and in 25
cases we obtained two volumes, one to study the fundus
and cavity and another to study the cervix and cervical
canal (Figure 4). The volumes were manipulated until
a satisfactory surface rendered image was obtained of
the fundus and uterine cavity as well as the cervical
canal. When a mid-sagittal plane was used to capture
the volume, we adjusted the rendering box in Window
A (capture image) to include the uterine fundus and
adjusted the green rendering line (from front to back),
tracing the sagittal curve plane of the uterine cavity so that
the line was located on the endometrium, and checking
in Window B that we were in the midline (Figure 2).
When studying the cervix we readjusted the rendering
box and the green line. When the volume was obtained
in a transverse plane, we included both uterine horns in
the rendering box and adjusted the green line so that a
good quality image showing both cavity and fundus was
obtained in the rendered view. Luminosity and contrast
curves were adjusted for both multiplanar and rendered
images, as well as for threshold and transparency. The
rendering modes used were a mixture of surface/gradient
of light of 10/60 to 60/10.
Physical examination
With the exception of the three patients with intact
hymen, patients underwent bimanual examination and

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2010; 35: 593–601.
596 Bermejo et al.

Figure 4 Three-dimensional surface rendered ultrasound images of the uterine cervix in three women with uterine malformations:
(a) incomplete cervical septum in a case of septate uterus; (b) complete cervical septum in a case of septate uterus; (c) two diverging cervical
canals in a case of septate uterus with two cervices.

Table 1 Indications for magnetic resonance imaging (MRI) (n = 65)

Indication for MRI (n)

Uterine type on Complex Poor reproductive Poor reproductive outcome and

3D ultrasound n malformations outcome complex malformations

Unicornuate uterus 4 (1 communicating) 2 (1 communicating) 0 2

Didelphic uterus 1 1 0 0
Bicornuate uterus 12 3 7 2
Septate uterus 42 (6 with 2 cervices) 4 (3 with 2 cervices) 34 4 (3 with 2 cervices)
Arcuate uterus 3 0 3 0
Iatrogenic uterine malformations 3 1 0 2
Total 65 11 44 10

3D, three-dimensional; MRI, magnetic resonance imaging.

speculoscopy before and/or after the ultrasound exami-
nation to confirm the ultrasound findings. We looked for
associated findings, i.e. vaginal septum, cervical septum
or duplicity and abnormal pelvic masses.
Magnetic resonance imaging
Sixty-five patients underwent MRI after 3D ultrasound
and physical examinations. MRI was indicated for
patients with previous poor obstetric outcome (two
or more spontaneous miscarriages, premature birth or
impossibility to accomplish pregnancy) and for those
with complex anomalies (Table 1). The examination was
performed by the same observer (E.L.) in all cases, using
a Siemens Magneton Avanto 1.5 Tesla machine (Siemens
Medical Solutions, Mountain View, CA, USA). All studies
included coronal high-resolution T2-weighted turbo spin-
echo imaging with the following parameters: TR/effective
TE, 3410/114; refocusing flip angle, 180◦ ; turbo factor,
25; rectangular field of view, 250 × 100 mm; matrix,
320 × 320; slice thickness, 4 mm; 195 Hz/pixel; 19 slices;
1–3 signal averages; average time of acquisition, 2 min
49 s.
Findings were classified according to the AFS9
(Figures 1 and 5), describing the associated malformations
found. In order to distinguish bicornuate from septate
uteri using 3D ultrasound we used the formula proposed
by Troiano and McCarthy15 : a line was traced, joining
both horns (Figure 6). If this line crossed the fundus
or was ≤ 5 mm from it, the uterus was considered
bicornuate, while if it was > 5 mm from the fundus, the
uterus was considered septate, regardless of whether the
fundus was dome-shaped, smooth or discretely notched
(Figure 6). When differentiating bicornuate from septate
uteri using MRI, all cases with an incision > 1 cm
deep in the fundus were considered to be bicornuate
uterus. Differentiation between arcuate and septate uteri
was carried out in the coronal plane on both 3D
ultrasound and MRI. While both types of uterus have a
normal contour, in arcuate uterus the fundal indentation
appears as an obtuse angle at the central point16 , with
a depth of up to 1.5 cm17 , whereas septate uterus is
characterized by a fundal indentation with an acute angle
at the central point, with a depth of 1.5 cm or more
(Figure 7).

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2010; 35: 593–601.
3D ultrasound and MRI in uterine anomalies 597

Figure 5 Three-dimensional surface rendered ultrasound images showing different types of uterine malformation using the American
Fertility Society9 classification: (a) normal uterus; (b) unicornuate uterus (Type IId); (c) didelphic uterus (Type III); (d) complete bicornuate
uterus (Type IVa); (e) partial bicornuate uterus (Type IVb); (f) septate uterus with two cervices (Type Va); (g) partial septate/subseptate
uterus (Type Vb); (h) arcuate uterus (Type VI); and (i) uterus with diethylstilbestrol (DES) drug-related malformations (Type VII).

Statistical analysis malformations using the AFS classification, with a

Two kappa indices were calculated in order to study the
diagnostic concordance between 3D ultrasound and MRI
for the diagnosis of uterine malformations, one taking into
account the diagnosis of the type of anomaly according
to AFS classification9 alone, and the other according
to AFS classification in combination with the associated
malformations found18,19 .
RESULTS
There was a high degree of concordance between 3D
ultrasound and MRI, with a kappa index of 0.880
(95% CI, 0.769–0.993), for the diagnosis of uterine
discrepancy between sonography and MRI in only four
cases (Table 2).
On analysis of associated findings there was discor-
dance in two cases: one bicornuate uterus in which
MRI revealed the presence of a cervical septum that
was not confirmed on hysteroscopy for its resection,
and a septate uterus that appeared to have two cer-
vices on 3D ultrasound (in one of the three patients
who did not undergo clinical examination) but which
MRI showed to have a complete septum with low
signal intensity. There was very good concordance
(kappa index, 0.878 (95% CI, 0.775–0.980) between
3D ultrasound and MRI for the diagnosis of associated
anomalies.

Table 2 Diagnosis of uterine malformations on three-dimensional (3D) ultrasound and magnetic resonance imaging (MRI)

Uterine type 3D ultrasound diagnosis (n) Underwent MRI MRI diagnosis

Agenesis 1 0 —
Unicornuate uterus 10 (2 communicating) 4 (1 communicating) 4 (1 communicating)
Didelphic uterus 6 1* 0
Bicornuate uterus 45 (1 with two cervices) 12† 10 (2 with 2 cervices)
Septate uterus 125 (18 with 2 cervices) 42 (6 with 2 cervices) 45 (5 with 2 cervices)
Arcuate uterus 96 3 3
Iatrogenic uterine malformations 3 3 3
Total 286 65 65

*One of the three patients who were not examined clinically was diagnosed as having didelphic uterus on 3D ultrasound but was found to
have bicornuate uterus with two cervices on MRI. †Three uteri diagnosed as bicornuate on 3D ultrasound were found to be septate on MRI.

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2010; 35: 593–601.
598
(a)
Figure 6 To distinguish bicornuate uteri from septate uteri with three-dimensional ultrasound we used the formula proposed by Troiano and
McCarthy15 : a line was traced joining both horns of the uterine cavity. If this line crossed the fundus or was ≤ 5 mm from it, the uterus was
considered bicornuate (a and b); if it was > 5 mm from the fundus it was considered septate, regardless of whether the fundus was
dome-shaped (c), smooth or discretely notched.
Figure 7 (a) Three-dimensional surface rendered ultrasound image
(coronal view) showing the normal outer uterine contour of a
uterus that was identified as arcuate (rather than partial septate)
because the fundal indentation appeared as an obtuse angle at the
central point16 , < 1.5 cm deep17 . (b) A partial septate uterus
characterized by a normal outer uterine contour, which could be
differentiated from arcuate uterus because the fundal indentation
was an acute angle at the central point, > 1.5 cm deep.
Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd.
Bermejo et al.
(b) (c)
DISCUSSION
In the majority of uterine malformations, especially
the less extreme forms (arcuate, septate and bicornuate
uteri) two cavities and little further detail are seen on
conventional 2D ultrasound. On 3D ultrasound, however,
the relationship of the cavity with the fundus is evident,
enabling precise diagnosis due to the contribution of the
C-plane (coronal), which is impossible to obtain in the
majority of cases on 2D ultrasound yet is crucial to the
diagnosis of these anomalies. Distinction between these
less extreme cases is vital due to their differing prognoses
and management. Additionally, 3D ultrasound enables us
to make measurements such as the length and thickness of
the septum, calculate the volume of the cavity (achieving
high intra- and interobserver reproducibility20 – 22 ) and
study the vascularization, which can affect fertility
prognosis, thus aiding the choice of treatment20 – 22 .
The success of 3D ultrasound in the diagnosis of uterine
malformations is well recorded. In 1995 Jurkovic et al.23
compared 2D and 3D ultrasound and HSG, finding both
Ultrasound Obstet Gynecol 2010; 35: 593–601.
3D ultrasound and MRI in uterine anomalies 599

Figure 8 Comparison of three-dimensional ultrasound and magnetic resonance imaging in cases of uterine malformation; the two imaging
modalities are extremely similar. Images, according to the American Fertility Society9 classification, show: (a) unicornuate uterus (Type IId);
(b) bicornuate bicollis uterus (Type IVb); (c) septate uterus with two cervices (Type Va); (d) partial septate uterus (Type Vb); (e) uterus with
diethylstilbestrol (DES) drug-related malformations (Type VII).

ultrasound modalities to be more efficient in the diagnosis

of arcuate uterus and to have a high predictive value
for larger anomalies, especially in the differentiation
of bicornuate and partial septate uteri. Raga et al.24
found 3D ultrasound to have a 91.6% accuracy in the
study of the fundus and 100% in that of the cavity,
using laparoscopy and HSG, respectively, for reference.
Wu et al.25 , comparing the technique with laparoscopy
and/or hysteroscopy, found 3D ultrasound to have a 92%
accuracy in the diagnosis of septate uterus and 100% for
bicornuate uterus. Also comparing it with laparoscopy
and hysteroscopy, Mohamed et al.26 recorded a sensitivity
of 97%, specifity of 96%, positive predictive value of 92%
and negative predictive value of 99% in the diagnosis of
Müllerian anomalies while Ghi et al. recorded both a
sensitivity and a specificity of 100% in the diagnosis of
uterine malformations and 96% concordance between
ultrasound and endoscopy with respect to the type of
anomaly diagnosed27 .
In this study we have shown that images obtained
with 3D ultrasound and MRI are practically equivalent
(Figure 8). The relationship between fundus and uterine
cavity can be established perfectly either with sonographic
reconstructions in the coronal plane or with the coronal
sequences obtained by MRI. Their diagnostic accuracy
is similar, as demonstrated by the excellent concordance
achieved when classifying anomalies according to the AFS.
The few differences observed occurred only when the
lower part of the uterus was studied. Ultrasonographic
studies of the cervix are fundamental for this type of
pathology. The probe should be moved outwards gently
to study the cervical canal and myometrium, assessing
whether there are one or two cervices, and whether there
is a complete or incomplete septum in the cervical canal
(Figure 4). The presence of two, generally thick canals
Figure 9 Septate uterus with an incomplete cervical septum on
three-dimensional surface-rendered ultrasound (a) and magnetic
resonance imaging (b).
which diverge in their inferior section would suggest a
double cervix (Figure 4c) rather than a septum (Figure 4a
and b). However, although in the majority of cases
the ultrasonographic impression will be correct, only
confirmation by speculoscopy allows us to be absolutely
sure. MRI can discriminate a septum (although the
majority of septa contain myometrium in their upper
regions) from cervical myometrium by the different signal
intensities obtained from each (Figures 9 and 10). In
terms of intensity, myometrium is the reference, low
signal intensity indicating fibrous tissue and isosignal
intensity indicating muscle. MRI can also differentiate
vaginal septa as these have a less intense signal than does
the vaginal wall. This differentiation cannot, however,
be made on 3D or 2D ultrasound, necessitating careful
bimanual examination. If bimanual examination is always
performed in conjunction with 3D ultrasound, the
two imaging techniques are comparable in terms of

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2010; 35: 593–601.
600
Figure 10 Septate uterus with two cervices on three-dimensional surface-rendered ultrasound (a and d) and magnetic resonance imaging (b,
c, e and f). Axial plane showing the two cervices can be observed in (e) and sagittal planes of the two hemiuteri, each with a cervix, can be
observed in (c) and (f).
accuracy/efficacy, giving 3D ultrasound the advantage
over MRI as it is cheaper and better tolerated by patients.
Furthermore, the gynecological examination is simple and
is part of our usual work-up.
3D ultrasound was of most use when distinguishing
between arcuate, septate and bicornuate uteri. Alcázar28
confirmed this, also noting its lower accuracy in diagnos-
ing didelphic uteri. However, the differential diagnosis
between these three it is not always easy for 3D ultrasound
or MRI. There are intermediate and incomplete forms of
bicornuate and septate uteri, due to simultaneous lack of
fusion and reabsorption of Müllerian ducts. For example,
septate uteri with very wide septa have a large separation
between the horns, and the structure of the septum on
ultrasound is similar to that of myometrium. In these
cases, the morphology of the cavity and the type of signal
obtained from the septum on MRI, indicating the pres-
ence of myometrium, which is theoretically only present
in the wall of bicornuate uteri, would lead to an incor-
rect diagnosis of bicornuate uterus. Applying Troiano and
McCarthy’s15 formula to distinguish between these two
types would allow the correct diagnosis of septate uterus
to be made (Figure 11). We found it difficult to decide
Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd.
Bermejo et al.
whether some intermediate forms should be assigned to
Group V or Group VI, as some deeply arcuate uteri could
be partially septate with a short, thick septum. Markedly
arcuate uteri have a worse reproductive prognosis than
do those with a minor cavitary incision, as Troiano and
McCarthy15 and Salim et al.29 found.
Our study was limited by the fact that the radiologist
who carried out the MRI examination was not blinded to
the 3D ultrasound diagnosis, and only those cases found
to be positive for uterine malformations by 3D ultrasound
were later analyzed by MRI. Thus, we remain ignorant
as to whether any of the negative cases on 3D ultrasound
would have proved positive on MRI.
We believe that 3D ultrasound is a useful complement
to 2D ultrasound on many occasions in gynecology, but
that it is in the diagnosis of uterine malformations that it is
fundamental. We propose that, on suspicion of Müllerian
anomalies, 3D ultrasound be carried out, accompanied by
complete gynecological examination. In doubtful or com-
plex cases, MRI should be performed, particularly for the
assessment of the cervix and vagina. Surgery should be
reserved for malformations that could benefit from this
treatment.
Ultrasound Obstet Gynecol 2010; 35: 593–601.
3D ultrasound and MRI in uterine anomalies
Figure 11 Septate uteri with a very wide septum have a large
separation between the horns and the three-dimensional
sonographic structure of the septum is similar to that of the
myometrium. The morphology of the cavity and the type of signal
obtained from the septum on magnetic resonance imaging indicates
the presence of myometrium, leading to an incorrect diagnosis of
bicornuate uterus, but applying Troiano and McCarthy’s15 formula
leads to the correct diagnosis of septate uterus.
ACKNOWLEDGMENTS
We thank Maria Luisa Bermejo for her illustrations and
Manuel Recio for his participation and his iconographic
collaboration.
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