(Video Poster 09) Surgical Management of a Müllerian Anomaly in a Fertility-Seeking Patient

Objectives: This surgical video reviews the prevalence and classification of Müllerian anomalies, highlights the association between these anomalies and endometriosis, and demonstrates the value of a multidisciplinary surgical approach in evaluating and managing a patient with complex congenital anomalies who desires future fertility.

Methods: We present the case of a 22-year-old nulligravida with a history of uterine didelphys, transverse vaginal septum, right renal agenesis, and chronic pelvic pain. The patient was referred for surgical evaluation after unsuccessful in-office removal of a malpositioned copper IUD. Preoperative imaging, including transvaginal ultrasound and MRI, confirmed didelphic uterine morphology with communicating hemiuteri, two cervices, and a transverse vaginal septum. MRI also revealed right renal agenesis and a simple right ovarian cyst. The patient underwent robotic-assisted diagnostic laparoscopy with peritoneal biopsies for the evaluation of endometriosis, hysteroscopic removal of her malpositioned IUD, and resection of the remnant transverse vaginal septum. The Minimally Invasive Gynecologic Surgery (MIGS) and Urogynecology teams performed the surgery collaboratively. Intraoperatively, peritoneal surfaces were biopsied from multiple pelvic sites and final pathology ultimately confirmed endometriosis in the perirectal peritoneum. During vaginoscopy, both cervices and the strings of the embedded IUD were identified. The IUD was removed without complication, and a hysteroscopic evaluation revealed the right and left tubal ostia in the respective uterine cavities. The case was then turned over to the Urogynecology team, and the transverse vaginal septum was successfully resected. The patient was discharged on postoperative day zero and followed up closely in both the MIGS and Urogynecology clinics. Overall, this patient’s care team included an infertility specialist, MIGS, Urogynecology, and an expert in HRT.

Clinical Relevance: This case underscores the importance of considering endometriosis in patients with obstructive Müllerian anomalies, as up to 46% of such patients may be affected, particularly adolescents and young adults with cyclic pelvic pain. It also highlights the value of high-resolution imaging in surgical planning and the necessity of a multidisciplinary team to address anatomic anomalies, coexisting pathology, and fertility preservation. Surgical intervention not only facilitates symptom relief but also allows for the definitive diagnosis of endometriosis via histopathologic confirmation. The coordinated preoperative surgical approach demonstrated in this video provides a framework for comprehensive care in patients with complex congenital reproductive tract anomalies.