“Complex uterine malformation, reconstructive surgery and a successful pregnancy”

Extract:

A 33-year-old patient with a complex uterine malformation requiring a comprehensive approach to achieve a safe pregnancy. The case presents an added complication due to previous surgery, which has altered the anatomy and clinical presentation.

History:

A 33-year-old woman with primary infertility for one year. Regular periods, not heavy, not painful. Only one functional ovary. As a teenager, she had regular, painful and debilitating periods that led her to A&E on several occasions. She has been taking contraceptive pills for one year.

No previous treatments have been undertaken

Diagnosis:

A new comprehensive assessment was carried out using

• High-resolution gynaecological ultrasound.
• Pelvic MRI.
• Diagnostic hysteroscopy.

All of this concludes that the patient presents with: a congenital malformation called unicornuate uterus, with a left uterine remnant that had no outlet to the cervix. Each month, menstrual blood became trapped in this closed cavity, causing:

• Intense pain.
• Progressive inflammation.
• Development of secondary adenomyosis.

Treatment plan:

A treatment plan is designed to meet two objectives:

1. To definitively resolve the anatomical problem and the pain
2. To preserve and optimise future reproductive capacity

For this reason, we structured the treatment into three phases.

Phase 1: Embryo preservation prior to surgery

The strategy was based on achieving a good embryo yield; 13 oocytes were retrieved, resulting in 3 chromosomally normal embryos analysed by PGTA and 1 low-grade mosaic.

This allowed us to have healthy embryos before performing surgery on the uterus, increasing safety and reducing subsequent risks.

Phase 2: Highly complex reconstructive surgery

Advanced laparoscopic surgery was performed.

• Complete resection of the left rudimentary horn (left hemihysterectomy).
• Right salpingectomy.
• Left ovarian fixation.

Why was this surgery necessary?

• To remove the cavity where blood was accumulating.
• To halt the progression of adenomyosis.
• To leave a uterus that is anatomically safe for pregnancy.

Phase 3: Hysteroscopic optimisation

Months later, we performed a surgical hysteroscopy, a guided uterine repair microsurgery to:

• Slightly enlarge the cavity of the unicornuate uterus to improve uterine distensibility and functionality

This step is essential in complex cases: it is not enough to remove the malformation; it is necessary to prepare the uterus to receive an embryo.

Phase 4: Endometrial preparation with embryo transfer

Following six months of surgical recovery and highly personalised endometrial preparation:

• We transferred a single chromosomally normal embryo.
• Implantation was achieved.
• The pregnancy progressed normally.
• Discharge from obstetric care.

Conclusion

At Equipo Juana Crespo, we treat complex infertility from a holistic perspective:

• Advanced anatomical diagnosis.
• Specialised reconstructive gynaecological surgery.
• Transfer at the optimal time.

This case demonstrates that, even in the face of severe uterine malformation with secondary adenomyosis, it is possible to achieve a successful pregnancy when treatment is correctly sequenced and personalised.