Anomalies of the genitals. Congenital anomalies in the development of the genital organs
Anomalies in the development and position of the female genital organs.
1. Malformations of the genital organs.
Anomalies in the development of the genital organs usually occur in the embryonic period, rarely in the postnatal period. Their frequency increases (2-3%), which is especially noted in Japan 15-20 years after the nuclear explosions in Hiroshima and Nagasaki (up to 20%).
Causes Abnormal development of the genital organs are considered teratogenic factors that act in the embryonic, possibly in the fetal and even postnatal periods. Teratogenic factors can be divided into external and internal (maternal organism). The external ones include: ionizing radiation, infection, drugs, especially hormonal, chemical, atmospheric (lack of oxygen), alimentary (poor diet, vitamin deficiency) and others that disrupt the processes of metabolism and cell division. Internal teratogenic effects include all pathological conditions of the maternal organism, as well as hereditary ones.
Classification of anomalies of the female genital organs according to severity:
lungs that do not affect the functional state of the genital organs;
medium, violating the function of the genital organs, but allowing the possibility of childbearing;
severe, excluding the possibility of performing a childbearing function.
In practical terms, classification by localization is more acceptable.
Malformations of the ovaries, as a rule, are caused by chromosomal abnormalities, are accompanied by or contribute to pathological changes in the entire reproductive system, and often in other organs and systems.
Of the anomalies of the pipes, one can note their underdevelopment, as a manifestation of genital infantilism. Rare anomalies include aplasia (absence), a rudimentary condition, additional holes in them and additional tubes.
Aplasia of the vagina- the absence of the vagina due to insufficient development of the lower sections of the Müllerian passages. Accompanied by amenorrhea. Sexual life is violated or impossible. Surgical treatment: bougienage from the lower section; creation of an artificial vagina from a skin flap, sections of the small or sigmoid colon, pelvic peritoneum in an artificially created canal between the rectum, urethra and the bottom of the bladder.
Malformations of the uterus are the most common. Hypoplasia, infantilism develop in the postnatal period and are combined with anomalies in the position of this organ (hyperanteflexia or hyperretroflexia). A uterus with such defects differs from a normal uterus in smaller body sizes and a longer neck (infantile uterus) or a proportional decrease in the body or cervix.
Uterine malformations formed in the embryonic period due to violations of the fusion of the Müllerian passages include combined uterine and vaginal malformations. The most pronounced and extremely rare form is the presence of independent two genital organs: two uterus (each with one tube and one ovary), two necks, two vaginas. With the division of the uterus in the area of the body of the uterus and a dense union in the neck, a bicornuate uterus is formed. It happens with two necks, and the vagina has a normal structure or with a partial septum. Bicornuity can be expressed slightly, a depression is formed only in the bottom area - a saddle uterus. Such a uterus may have a complete septum in the cavity or a partial one (in the area of the bottom or neck).
Diagnosis of anomalies in the development of the ovaries, uterus, tubes, vagina is carried out according to clinical, gynecological and special (ultrasound, radiography, hormonal) studies.
Ginatresia- violation of the patency of the genital canal in the area of the hymen, vagina and uterus.
Atresia of the hymen manifests itself during puberty, when menstrual blood accumulates in the vagina (haematocolpos), uterus (haematometra) and even tubes (haematosalpinx). Treatment is a cruciform incision of the hymen and removal of the contents of the genital tract.
Vaginal atresia can be localized in different departments (upper, middle, lower), have a different length. Symptoms are similar to those of atresia of the hymen. Treatment is surgical.
Uterine atresia usually occurs as a result of overgrowth of the internal os of the cervical canal after traumatic injuries or inflammatory processes. Treatment is surgical (opening the cervical canal and emptying the uterus).
Malformations of the external genital organs develop as manifestations of hermaphroditism.
True hermaphroditism is when there are functioning specific glands of the ovary and testis in the gonad. Pseudohermaphroditism is an anomoly in which the structure of the genital organs does not correspond to the gonads. Correction of defects of the external genitalia is achieved only by surgery, and not always with full effect.
2. Anomalies in the position of the female genital organs.
Anomalies in the position of the genital organs are considered to be such permanent states that go beyond the limits of physiological norms and violate the normal relationship between them.
Classification is determined by the nature of violations of the position of the uterus:
- displacements along the horizontal plane (of the entire uterus to the left, right, forward, backward; incorrect relationship between the body and the cervix in terms of inclination and severity of bending; rotation and twisting);
- displacements along the vertical plane (omission, prolapse, elevation and eversion of the uterus, prolapse and prolapse of the vagina).
Offsets in the horizontal plane.
The displacement of the uterus with the cervix to the right, left, forward, backward occurs more often with compression by tumors or with the formation of adhesive processes after inflammatory diseases of the genitals. The treatment is aimed at eliminating the cause: surgery for tumors, physiotherapy and gynecological massage during the adhesive process.
Pathological inclinations and bends between the body and the neck are considered simultaneously. Normally, according to bends and inclinations, there can be two options for the position of the uterus: inclination and bending anteriorly - anteversio-anteflexio, bending and inclination backwards - retroversio-retroflexio. The angle between the cervix and the body of the uterus is open anteriorly or posteriorly and averages 90°. In front of the vagina and uterus is the bladder and urethra, and behind is the rectum. The position of the uterus can normally vary depending on the filling of these organs.
Hyperanteversia and hyperanteflexia of the uterus is a position where anterior inclination is more pronounced, and the angle between the body and the cervix is sharp (<90°) и открыт кпереди.
Hyperretroversion and hyperretroflexia of the uterus is a sharp deviation of the uterus backwards, and the angle between the body and the cervix is acute (<90°) и также открыт кзади.
Inclination and bending of the uterus to the side (to the right or to the left) is a rare pathology and determines the inclination of the uterus and the bend between its body and the neck to one side.
The clinical picture of all variants of horizontal displacement of the uterus has much in common, it is characterized by painful sensations in the lower abdomen or in the sacrum, algomenorrhea, and prolonged menstruation.
Diagnosis is based on data from gynecological and ultrasound examinations, taking into account the symptoms.
Treatment should be aimed at eliminating the causes - anti-inflammatory drugs, correction of endocrine disorders. FTL, gynecological massage are used.
Uterine rotation and torsion are rare, usually due to uterine or ovarian tumors, and corrected at the same time as the tumors are removed.
Offset of the genital organs along the vertical axis.
This pathology is especially common in women of the perimenopausal period, less often in young women.
Prolapse of the uterus a condition when the uterus is below the normal level, the external cervical os is below the spinal plane, the bottom of the uterus is below the IV sacral vertebra, but the uterus does not come out of the genital slit even when straining. Prolapse of the uterus - the uterus is sharply displaced downward, partially or completely exits the genital slit when straining. Incomplete prolapse of the uterus - when only the vaginal part of the cervix comes out of the genital slit, and the body remains above the genital slit even when straining. Complete prolapse of the uterus - the cervix and body of the uterus are located below the genital gap, at the same time there is an eversion of the walls of the vagina.
Prolapse and prolapse of the vagina usually accompanied by prolapse of the bladder (cystocele) and the walls of the rectum (retrocele). When the uterus prolapses, the tubes and ovaries simultaneously descend, the location of the ureters changes.
The main factors of prolapse and prolapse of the genital organs: traumatic injuries of the perineum and pelvic floor, endocrine disorders (hypoestrogenism), hard physical labor (lifting weights for a long time), stretching of the ligamentous apparatus of the uterus (multiple births).
The clinical picture is characterized by a protracted course and steady progression of the process. Prolapse of the genital organs is aggravated by walking, coughing, lifting weights. There are pulling pains in the groin, sacrum. Possible violations of menstrual function (hyperpolymenorrhea), the function of the urinary organs (incontinence and urinary incontinence, frequent urination). Sex life and pregnancy are possible.
Diagnosis is carried out according to the anamnesis, complaints, gynecological examination, special research methods (ultrasound, colposcopy).
Treatment for prolapse and prolapse of the genital organs can be conservative and surgical. Conservative treatment is reduced to the use of a set of gymnastic exercises aimed at strengthening the muscles of the pelvic floor and abdominals.
There are many methods of surgical treatment, and they are determined by the degree of pathology, age, the presence of concomitant extragenital and genital diseases.
After the operation, you can’t sit down for a week, then for a week you can only sit down on a hard surface (stool), for the first 4 days after the operation, you must observe general hygiene, diet (liquid food), give a laxative or cleansing enema for 5 days, treat the perineum 2 times a day, removal of stitches for 5-6 days.
Eversion of the uterus is an extremely rare pathology, occurs in obstetrics at the birth of an unseparated placenta, in gynecology - at the birth of a submucosal myomatous node of the uterus. In this case, the serous membrane of the uterus is located inside, and the mucous membrane is outside.
Treatment consists in taking urgent measures to anesthetize and reduce the everted uterus. In case of complications (massive edema, infection, massive bleeding), surgical intervention is indicated to remove the uterus.
The elevated position of the uterus is secondary and may be due to fixation of the uterus after surgical interventions, tumors of the vagina, accumulation of blood in the vagina with atresia of the hymen.
Prevention of anomalies in the position of the genital organs includes:
elimination of etiological factors,
correction of damage to the birth canal during childbirth (careful suturing of all tears),
optimal birth control
gymnastic exercises with a tendency to omissions,
compliance with the rules of labor protection and women's health,
prevention and treatment of constipation,
timely surgical treatment for omissions to prevent prolapse of the genital organs.
development of the embryo, but sometimes incorrect formation occurs after labor. Such obvious anatomical defects are incompatible with life. heavy anomalies in the development of the female genital organs should be detected as early as possible, as they have a direct negative impact on a woman's health. This requires the definition of symptoms by gynecological examination and external examination. Based on all the data and set the degree anomalies of the sexual development of the female organs.
Abnormal formation of female genital organs occurs in early pregnancy and may be due to such factors:
- genetic predisposition of the mother to infertility, spontaneous abortions, a similar defect in the development of the genital organs;
- pathological disorders in the work of the organs of the endocrine system, chronic diseases of the heart, blood vessels and other organs;
- alcoholism, taking drugs and strong drugs;
- infectious inflammation of a viral and bacterial nature before and during pregnancy;
- severe toxicosis or previous poisoning, exposure of various etiologies.
Sometimes cause abnormal deviations of the female genital organs consider the age of the father and mother after 35 years.
The underlying factor of defects is a violation of the development of the brain and abnormal histogenesis, which ends by the end of the formation of the embryo. Therefore, the most severe defects occur in the early stages of pregnancy, when, moreover, there is an external negative impact. So there are symptoms of pathologies. They depend on the form of defects of the organs of the reproductive system.
Mutations are:
- lack of menstruation in sexually mature girls;
- pathology of the menstruation itself, expressed in scarcity, profusion, soreness or excessive duration;
- late sexual development upon reaching childbearing age;
- violation or impossibility of normal sexual relations due to the anatomical structure of organs;
- persistent infertility, threatening and spontaneous miscarriages, stillbirth.
They can manifest themselves in three forms: defects in the external and internal genital organs (vagina and uterus), fallopian tubes and ovaries.
Incorrect anagenesis of the genital organs can be attributed to the pathology of the structure of the vagina, its agenesis, infection of the vagina and, as a result, obstruction, the presence of partitions, at the same time two separate vaginas and uterus. Because of this, menstrual blood cannot find a way out, which leads to its accumulation, severe pain in the lower abdomen, the physical impossibility of sexual relations or their complications.
Defects in the formation of uterine tubes can be expressed in underdevelopment, irregular symmetry, absence, bifurcation, anatomical obstruction. The fallopian tubes may have an unnatural shape for the organ.
Defects of the female ovaries are associated with the incorrect function of some internal organs, but they can also have independent defects - the absence of one or both paired organs, doubling or insufficient formation.
Anyway, abnormally located genitals women can give a woman a lot of trouble and illness.
Diagnostics anomalies of the female genital organs
Diagnose anomalies of the female genital organs preferably as soon as possible. An external obstetric examination after childbirth can already give an idea of the presence of deviations in the development of a newborn child. But a more detailed examination can be carried out at a later age. Vaginal-abdominal examination is performed using local and sometimes general anesthesia. So you can find out the size of the vagina and uterus, to establish the presence of longitudinal and transverse growths. In cases where there is no vagina, one has to resort to a ureteroscope and vaginal speculums for children.
The pathology of the structure of the genital female organs can be detected when complaints are received from women of childbearing age about the difficulty of conceiving and maintaining a normal sexual life. A gynecologist should conduct a thorough analysis of the frequency and pathologies of the monthly cycle, the presence of pain and other parameters of menstruation. This uses a two-handed (bimanual) examination of the vagina, a study using a hysteroscope to examine the condition of the uterus, an ultrasound examination for abnormally formed female genital organs and kidney defects.
Laparoscopy is used as an additional tool to detect defects.
To do this, an endoscope equipped with a camera is inserted into the abdominal cavity through an incision in the form of a cross, with the help of which it is possible to fully examine the uterus and its features, as well as the state of adjacent internal organs.
- identify serious anomalies of the female genital organs a magnetic resonance tomograph also helps, after this study an accurate diagnosis is established.
- By comparing these symptoms of the disease and the data of the medical examination, the doctor can begin to prescribe the necessary measures.
Treatment anomalies of the female genital organs
Methods of treatment depend on the nature of the pathology and are prescribed individually.
Some anomalies of the female genital organs do not require surgical intervention. These include defects that do not affect the ability to conceive and bear children, and also do not affect sexual function (the ability to have sexual relations). An example of such a defect can be considered a "non-standard" shape of the uterus. Other cases of deviations, as a rule, require surgical intervention.
With pathological fusion of the walls of the vagina (hereditary or acquired), a complex operation is required to create and form the vagina. After such plastic surgery, a woman is capable of fertilization and childbearing. When available anatomical anomalies of the female genital organs in the form of two uteruses or vaginas, a surgical operation is prescribed to remove one of their double organs. The simplest is the operation in the absence of the hymen. This interferes with the outflow of monthly bleeding, which leads to severe headaches, cramps and other negative health effects. The purpose of the operation is an incision, as a result of which accumulated blood that has no way out is removed from the uterine cavity and vagina. In such situations, the risk of infection penetration is very high, if the accumulated content no longer carries such complications. Therefore, a doctor may prescribe antibacterial drugs that can stop and stop the infection. In some cases, when there is a risk of death, you have to remove the uterus - then the woman remains infertile.
Meet anomalies of the female genital organs and in the form of hereditary hermaphroditism. But even if the genitals of a woman, in general, have the correct shape and structure, conception and pregnancy, in principle, cannot occur.
Prevention anomalies of the female genital organs
Anomalies of the female genital organs require timely examination, and regular consultation with a doctor.
When it comes to the impossibility of full-fledged sexual relations and the desired pregnancy, such actions are especially important. Even when it comes to congenital anomalies of the female genital organs, early diagnosis will help avoid further disappointment. You should avoid the use of toxic substances - alcohol, strong drugs, low-quality food, prevent infectious infections and follow the necessary instructions. Then anomalies of the female genital organs will never become an obstacle to a happy family life.
So, anomalies of the female genital organs are not a judgment at all. Laziness, unwillingness and fear should not make you hesitate in making important decisions - if you diagnose hereditary problems in a timely manner abnormal development of the female genital organs, conduct surgical or therapeutic treatment, positive results will follow without fail.
Acquired pathologies are due only to inattention to one's own body. Gynecologists, not for their pleasure, remind you that you should be examined twice a year - this is a necessary condition for maintaining health and quality of life.
Anomalies in the development of the genital organs. These include: septum, saddle, unicornuate and bicornuate, double uterus and double vagina, bicornuate uterus with one closed vestigial horn, infantilism.
Some anatomical anomalies after plastic surgery do not exclude the possibility of childbearing. Sometimes the diagnosis (vaginal septum, saddle-shaped or bicornuate uterus) is established at the time, causing difficult labor and surgical intervention.
Sexual infantilism is expressed by: a delay in the formation of external and internal genital organs, undeveloped or poorly developed mammary glands and others, a violation, possible dysfunctional uterine bleeding, amenorrhea, or spontaneous.
Causes of anomalies in the development of the genital organs
Hereditary, exogenous, multifactorial factors lead to the occurrence of anomalies in the development of female genital organs. The occurrence of malformations of the genitals is attributed to the critical period of intrauterine development. It is based on the absence of fusion of the caudal sections of the paramesonephric Müllerian ducts, deviations in the transformations of the urogenital sinus, as well as the pathological course of gonadal organogenesis, which depends on the development of the primary kidney. These deviations account for 16% of all anomalies.
Anomalies in the development of the genital organs often occur in the pathological course of pregnancy in the mother at different stages of pregnancy. These are early and late gestosis, infectious diseases, intoxication, endocrine disorders in the mother's body.
In addition, anomalies in the development of female genital organs can occur under the influence of harmful environmental factors, occupational harmful effects in the mother, poisoning with toxic substances.
Along with anomalies of the genitals, in 40% of cases there are anomalies of the urinary system (unilateral kidney agenesis), intestines (anal atresia), bones (congenital scoliosis), as well as congenital heart defects.
There are the following types anomalies in the development of the genital organs
Pregnancy in the rudimentary horn proceeds by type and is subject to surgical treatment.
4. Uterus bicornis - a bicornuate uterus arises from the fusion of paramesonephric passages. As a result, there is a common vagina, and other organs are bifurcated. As a rule, the organs on one side are less pronounced than on the other.
With a bicornuate uterus, there may be two necks - uterus bicollis. In this case, the vagina has a normal structure or it may have a partial septum.
Sometimes, with a bicornuate uterus, there may be one neck, which is formed from the complete fusion of both halves - the uterus bicornis uncollis. An almost complete fusion of both horns is possible, with the exception of the bottom, where a saddle-shaped depression is formed - the saddle-shaped uterus (uterus arcuatus). In the saddle uterus, there may be a septum that extends to the entire cavity, or a partial membrane in the fundus or cervix.
With the satisfactory development of one uterine horn and a pronounced rudimentary state of the other, a unicorn uterus is formed - uterus unicornus.
Clinical picture. Doubling of the uterus and vagina may be asymptomatic. With a sufficiently satisfactory development of both or even one uterus, menstrual and sexual functions are not disturbed.
Pregnancy can occur in one or the other uterine cavity, perhaps the normal course of childbirth and the postpartum period. If different degrees of doubling are combined with underdevelopment of the ovaries and uterus, symptoms appear that are characteristic of developmental delay (disturbance of menstrual, sexual and reproductive functions). Often there are spontaneous miscarriages, birth weakness, bleeding in the postpartum period. Hematocolpos and hematometra are accompanied by pain, fever. Palpation of the abdomen reveals a painless, displaced tumor.
Diagnostics. In most cases, it is not difficult to recognize doubling of the uterus and vagina; this is done using conventional examination methods (bimanual, examination with a mirror, probing, ultrasound). If necessary, apply metrosalpingography, laparoscopy.
Treatment. Doubling of the uterus and vagina are asymptomatic and do not require treatment.
If there is a septum in the vagina that prevents the birth of the fetus, it is dissected.
In the presence of symptoms of delayed development of the genitals, cyclic hormonal therapy is prescribed.
If blood accumulates in an atrezated vagina or in a rudimentary horn, surgical treatment is required. In the presence of uterine anomalies, a surgical correction is performed - the operation of metroplasty.
: use knowledge for health
RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2014
Congenital malformations [malformations] of the body and cervix (Q51) Congenital malformations [malformations] of the ovaries, fallopian tubes and broad ligaments (Q50) Other congenital malformations [malformations] of the female genital organs (Q52)
obstetrics and gynecology
general information
Short description
Approved by the Expert Commission
For Health Development
Ministry of Health of the Republic of Kazakhstan
Congenital malformations of the genital organs- persistent morphological changes in the organ that go beyond variations in their structure. Congenital malformations occur in utero as a result of a violation of the developmental processes of the embryo or (much less often) after the birth of a child, as a result of a violation of the further formation of organs.
I. INTRODUCTION
Protocol name: Congenital anomalies in the development of the genital organs
Protocol code:
ICD-10 code(s):
Q50 Congenital malformations [malformations] of ovaries, fallopian tubes and broad ligaments:
Q50.0 Congenital absence of ovary.
Q50.1 Cystic malformation of ovary.
Q50.2 Congenital torsion of ovary.
Q50.3 Other congenital malformations of ovary
Q50.4 Embryonic cyst of fallopian tube.
Q50.5 Embryonic cyst of the broad ligament.
Q50.6 Other congenital malformations of fallopian tube and broad ligament
Q51 Congenital malformations [malformations] of body and cervix:
Q51.0 Agenesis and aplasia of uterus
Q51.1 Duplication of body of uterus with duplication of cervix and vagina
Q51.2 Other uterine duplications.
Q51.3 Bicornuate uterus.
Q51.4 Unicornuate uterus
Q51.5 Agenesis and aplasia of the cervix.
Q51.6 Embryonic cyst of cervix.
Q51.7 Congenital fistula between uterus and digestive and urinary tracts
Q51.8 Other congenital malformations of body and cervix
Q51.9 Congenital malformation of body and cervix, unspecified
Q52 Other congenital malformations [malformations] of female genital organs:
Q52.0 Congenital absence of the vagina.
Q52.1 Doubling of the vagina.
Q52.2 Congenital rectovaginal fistula
Q52.3 Hymen completely covering the entrance to the vagina.
Q52.4 Other congenital malformations of the vagina
Q52.5 Fusion of lips.
Q52.6 Congenital malformation of clitoris
Q52.7 Other congenital malformations of vulva
Q52.8 Other specified congenital malformations of female genital organs
Q52.9 Congenital malformation of female genital organs, unspecified
Abbreviations used in the protocol:
ALT - alanine aminotransferase
Anti-Xa - antithrombotic activity
ASAT - aspartate aminotransferase
APTT - Activated partial thromboplastin time
PID - inflammatory diseases of the pelvic organs
HIV - human immunodeficiency virus
DG - gonadal dysgenesis
ELISA - enzyme immunoassay
INR - International Normalized Ratio
MRI - magnetic resonance imaging
KLA - complete blood count
OAM - general urinalysis
PT - prothrombin time
PHC - primary health care
STF - testicular feminization syndrome
LL/R - level of evidence/level of recommendation
Ultrasound - ultrasonography
ECG - electrocardiogram
IVF - in vitro fertilization
HS - hysteroscopy
LS - laparoscopy
MRSA - Methicillin-resistant Staphylococcus aureus
RW - Wasserman reaction
Protocol development date: year 2014.
Protocol Users: obstetricians-gynecologists, urologists, surgeons, general practitioners, therapists, pediatricians, neonatologists, emergency doctors.
Criteria developed by the Canadian Task Force on Preventive Health Care to assess the evidence of recommendations*
|
Levels of Evidence |
Recommendation levels |
|
I: Evidence based on at least one randomized controlled trial II-1: Evidence based on evidence from a well-designed controlled trial but not randomized II-2: Evidence based on evidence from a well-designed cohort study (prospective or retrospective) or a case-control study, preferably multicentre or multi-study group II-3: Evidence based on comparative study with or without intervention. Convincing results obtained from uncontrolled experimental trials (such as the results of penicillin treatment in the 1940s, for example) could also be included in this category. III: Evidence based on the opinions of reputable experts based on their clinical experience, data from descriptive studies or reports from expert committees |
A. Evidence to recommend clinical preventive intervention B. Strong Evidence Supports Recommendations for Clinical Preventive Intervention C. Existing evidence is conflicting and does not allow recommendations for or against the use of clinical prophylaxis; however, other factors may influence the decision D. There is good evidence to recommend no clinical preventive effect. E. There is evidence to recommend against clinical preventive action L. There is insufficient evidence (either quantitatively or qualitatively) to make a recommendation; however, other factors may influence the decision |
Classification
Clinical classification
Anatomical classification of congenital malformations of the genital organs:
1) Class I- hymen atresia (variants of the hymen structure);
2) Class II- complete or incomplete aplasia of the vagina and uterus:
Complete aplasia of the uterus and vagina (Rokitansky-Küster-Mayer-Hauser syndrome);
Complete aplasia of the vagina and cervix with a functioning uterus;
Complete aplasia of the vagina with a functioning uterus;
Partial aplasia of the vagina to the middle or upper third with a functioning uterus;
3) Class III- defects associated with the absence of fusion or incomplete fusion of paired embryonic genital ducts:
Complete doubling of the uterus and vagina;
Doubling of the body and cervix in the presence of one vagina;
Doubling of the body of the uterus in the presence of one cervix and one vagina (saddle uterus, bicornuate uterus, uterus with a complete or incomplete internal septum, uterus with a rudimentary functioning closed horn);
4) Class IV- defects associated with a combination of doubling and aplasia of paired embryonic genital ducts:
Doubling of the uterus and vagina with partial aplasia of one vagina;
Doubling of the uterus and vagina with complete aplasia of both vaginas;
Doubling of the uterus and vagina with partial aplasia of both vaginas;
Doubling of the uterus and vagina with complete aplasia of the entire duct on one side (unicornuate uterus).
Clinical and anatomical classification of malformations of the uterus and vagina :
I class. Aplasia of the vagina
1. Complete aplasia of the vagina and uterus:
Rudiment of the uterus in the form of two muscle rollers
Rudiment of the uterus in the form of one muscular roller (right, left, center)
Muscle rollers are absent
2. Complete aplasia of the vagina and a functioning rudimentary uterus:
Functioning rudimentary uterus in the form of one or two muscle rollers
Functioning rudimentary uterus with cervical aplasia
Functioning rudimentary uterus with aplasia of the cervical canal
With all variants, hemato/pyometra, chronic endometritis and perimetritis, hemato- and pyosalpinx are possible.
3. Aplasia of a part of the vagina with a functioning uterus:
Aplasia of the upper third
Aplasia of the middle third
Aplasia of the lower third
II class. unicorn uterus
1. Unicornuate uterus with a rudimentary horn communicating with the cavity of the main horn
2. Rudimentary horn closed
In both cases, the endometrium can be functioning or non-functioning.
3. Rudimentary horn without cavity
4. Absence of a vestigial horn
III class. Double uterus and vagina
1. Doubling of the uterus and vagina without disturbing the outflow of menstrual blood
2. Doubling of the uterus and vagina with a partially aplastic vagina
3. Doubling of the uterus and vagina with a non-functioning one uterus
IV class. bicornuate uterus
1. Incomplete form
2. Full form
3. Saddle shape
V class. Intrauterine septum
1. Complete intrauterine septum - to the internal os
2. Incomplete intrauterine septum
VI class. Malformations of the fallopian tubes and ovaries
1. Aplasia of the uterine appendages on one side
2. Aplasia of the tubes (one or both)
3. Availability of additional pipes
4. Ovarian aplasia
5. Ovarian hypoplasia
6. Presence of accessory ovaries
VII class. Rare forms of genital malformations
1. Urogenital malformations: bladder exstrophy
2. Intestinal-genital malformations: congenital rectovestibular fistula, combined with aplasia of the vagina and uterus; congenital recto - vestibular fistula, combined with a unicornuate uterus and a functioning rudimentary horn. They occur alone or in combination with malformations of the uterus and vagina.
Diagnostics
II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT
List of basic and additional diagnostic measures during hospitalization
The main (mandatory) diagnostic examinations carried out at the outpatient level:
General blood analysis;
General urine analysis;
Biochemical blood test (urea, creatinine, total protein, Alat, Asat, dextrose, total bilirubin);
Wasserman reactions in blood serum;
Determination of p24 HIV antigen in blood serum by ELISA method;
Determination of HbeAg of hepatitis B virus in blood serum by ELISA method;
Determination of total antibodies to hepatitis c virus in blood serum by ELISA - method
Ultrasound of the pelvic organs;
Additional diagnostic examinations performed at the outpatient level:
Cytological examination of the karyotype (if chromosomal abnormalities in the development of internal genital organs are suspected)
Colposcopy/vaginoscopy;
Diagnostic hysteroscopy;
Hysterosalpingography.
The minimum list of examinations that must be carried out when referring to planned hospitalization:
General blood analysis;
General urine analysis;
Coagulogram (PV, fibrinogen, APTT, INR);
Biochemical blood test (urea, creatinine, total protein, ALT, AST, glucose, total bilirubin);
Determination of the blood group according to the ABO system with coliclones;
Determination of the Rh factor of blood;
Wasserman reactions in blood serum;
Determination of p24 HIV antigen in blood serum by ELISA - method;
Determination of HbeAg of hepatitis B virus in blood serum by ELISA method;
Determination of total antibodies to the hepatitis C virus in blood serum by ELISA method;
Determination of the degree of purity of a gynecological smear;
Ultrasound of the pelvic organs;
The main (mandatory) diagnostic examinations carried out at the hospital level:
Determination of the blood group according to the ABO system with coliclones;
Determination of the Rh factor of blood.
Additional diagnostic examinations carried out at the hospital level:
Coagulogram;
Ultrasound of the pelvic organs;
MRI of the pelvic organs (indications: abnormal development of the internal genital organs);
Dopplerography of the pelvic organs;
Diagnostic laparoscopy (indications: anomalies in the development of internal genital organs);
Diagnostic hysteroscopy.
Diagnostic measures taken at the stage of emergency care:
Collection of complaints and anamnesis;
Physical examination.
Diagnostic criteria(LE/LE IA), , (LE/LE IIB)
Complaints and anamnesis
Complaints: on the absence of menstruation, pain in the lower abdomen on the expected days of menstruation, the impossibility of sexual intercourse, the absence of pregnancy.
Physical examination
With complete aplasia of the vagina and uterus: the external opening of the urethra is expanded and displaced downwards (it is necessary to carry out a differential diagnosis with the presence of a hole in the hymen).
Malformations of the vestibule of the vagina:
Smooth surface from urethra to rectum;
Hymen without a recess in the perineum;
The hymen with a hole through which a blindly ending vagina 1–3 cm long is determined;
Deep, blindly ending channel.
Atresia of the hymen:
Bulging of perineal tissues in the area of the hymen;
Translucence of dark content;
During recto-abdominal examination in the cavity of the small pelvis, the formation of a tight or soft elastic consistency is determined, at the top of which a denser formation is palpated - the uterus.
Complete or incomplete aplasia of the vagina with a functioning rudimentary uterus:
Gynecological examination reveals the absence or shortening of the vagina;
During recto-abdominal examination in the small pelvis, an inactive spherical uterus is palpated, sensitive to palpation and attempts to displace. The cervix is not defined. In the region of the appendages there are formations of a retort-shaped form (hematosalpinxes).
Aplasia of the vagina with a full functioning uterus:
Palpation of the abdomen and recto-abdominal examination at a distance of 2 to 8 cm from the anus reveal the formation of a tight elastic consistency (hematocolpos). At the top of the hematocolpos, a denser formation (uterus) is palpated, which can be enlarged in size (hematometra). In the region of the appendages, spindle-shaped formations (hematosalpinxes) are determined.
When doubling the external genitalia: 2 external openings of the vagina are determined.
With complete and incomplete doubling of the internal genital organs:
During a gynecological examination, 2 necks are determined in the vagina, a septum in the vagina;
Bimanual examination: 2 formations in the pelvic cavity are determined.
Rectovaginal fistula:
Isolation of meconium, gases, feces through the genital gap from the first days of life;
The anal opening is absent;
The fistulous opening is located above the hymen.
Laboratory research
Karitotype study(UD / UR - IA) :
Abnormal set of chromosomes (45X, 46XY, 46XX);
Mosaicism (X0/XY, XO/XXX, XO/XX, etc.);
Defect in the short arm of the X chromosome.
Instrumental Research
Ultrasound of the pelvic organs .:
1) with uterine aplasia:
The uterus is absent or presented in the form of one or two muscle rollers;
The ovaries are located high against the walls of the small pelvis.
2) with aplasia of the vagina with a rudimentary functioning uterus:
The cervix and vagina are absent;
The uterus is presented in the form of one or two muscular rollers;
Hematosalpinx.
3) With aplasia of the vagina with a full uterus:
Several echo-negative formations filling the pelvic cavity, hematocolpos, hematometra, hematosalpinx.
MRI of the pelvic organs: the presence of anomalies in the development of the genitals in the form of changes in the shape, quantity, location of the internal genital organs
Diagnostic laparoscopy: visualization of anomalies in the development of the genitals in the form of changes in the shape, quantity, location of the internal genital organs.
Indications for expert advice:
Consultation of a therapist in the presence of extragenital diseases;
Consultation of a urologist, surgeon in the presence of defects in other, adjacent organs and systems.
Differential Diagnosis
Differential Diagnosis
Differential diagnosis is carried out depending on the karyotype and clinical picture (Tables 1, 2).
Table 1. Differential diagnosis of anomalies in the development of the genital organs depending on the karyotype
|
Nosology/ signs |
Karyotype | Sex chromatin level | Phenotype |
| Complete aplasia of the vagina and uterus | 46, XX | positive | Female (normal development of the mammary glands, hair growth and development of the external genital organs according to the female type) |
| Gonadal dysgenesis | 46, XY; 46 X0; 46 XO/XX; 46 xoxy | negative | Male, signs of masculinization (clitoral hypertrophy, virile hair growth) |
| testicular femenization syndrome | 46 XY | negative | Female phenotype (normal development of the mammary glands, hair growth and development of the external genital organs according to the female type) |
table 2. Differential diagnosis of anomalies in the development of the genital organs depending on clinical signs
|
Nosology signs |
menstrual function | Echo signs | Objective research |
| Anomalies of the genital organs | Lack of menstrual function during puberty | The absence of the cervix and body of the uterus, a rudimentary horn, an intrauterine septum, a bicornuate uterus are revealed | Signs of anomalies of the genital organs are revealed |
| Adenomyosis | Menstrual function is disturbed (scanty or heavy periods, brown discharge, pain before and after menstruation) are not associated with age | An increase in the anteroposterior size of the uterus, areas of increased echogenicity in the myometrium, small (up to 0.2 - 0.6 cm) rounded anechoic inclusions. | An increase in the size of the uterus, moderate soreness, the presence of nodes (endometriomas) of the uterus. |
| Dysmenorrhea | Menstrual function is preserved, but accompanied by severe pain | No characteristic echoes | There are no characteristic data of gynecological examination. |
| PID | Menometrorrhagia | An increase in the size of the uterus, the thickness of the endometrium, increased vascularization of the endometrium, the presence of fluid in the small pelvis, thickening of the walls of the fallopian tubes, an uneven decrease in the echogenicity of the myometrium. | An increase in the size of the uterus, soreness, soft consistency of the uterus, the presence of tubo-ovarian formations. Signs of intoxication. |
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Treatment
Treatment goals:
Elimination of anomalies of the genital organs;
Restoration of menstrual, sexual, reproductive functions;
Improving the quality of life.
Treatment tactics
Medical treatment
Hormonal Therapy:
In the presence of anomalies in the development of the ovaries, gonadal dysgenesis:
Estrogens in continuous mode - in puberty;
Estrogens in the first phase of the cycle, gestagens in the second phase - during the formation of primary genital organs for cyclic hormone therapy.
With a delay in general somatic development:
Thyroid hormones (levothyroxine sodium 100-150 mcg / day);
Anabolic steroids (methandrostenolone 5 mg 1-2 r / day, depending on the degree of developmental disorder).
Antibacterial therapy is carried out with the aim of:
1) prevention of infectious complications:
Ampicillin / sulbactam (1.5g IV),
Amoxicillin / clavulanate (1.2g IV),
Cefazolin (2g IV)
Cefuroxime (1.5 gv / v).
Terms of antibacterial prophylaxis:
One time (intraoperatively);
From 1 to 3 days of the postoperative period - with the duration of the surgical intervention for more than 4 hours, if there are technical difficulties during the operation, especially when performing hemostasis, as well as at the risk of microbial contamination.
2) treatment of infectious complications(depending on the results of the microbiological examination)
Ampicillin/sulbactam:
With a mild course of infection - 1.5 g 2 r / day in / in, the duration of treatment is up to 3 - 5 days;
In moderate course - 1.5 g 4 r / day in / in, the duration of treatment is 5-7 days;
In severe cases - 3 g 4 r / day in / in, the duration of treatment is up to 7 - 10 days.
Amoxicillin/clavulanate (calculation based on amoxicillin):
With a mild infection: 1 g IV, 3 times a day, the duration of treatment is up to 3-5 days;
Cefazolin:
With a mild infection: 0.5-1 g IV, 3 times a day, the duration of treatment is up to 3-5 days;
In severe infection: 2 g IV, 3 times a day, the duration of treatment is 5-10 days.
Cefuroxime:
With a mild infection: 0.75 g IV, 3 times a day, the duration of treatment is up to 3-5 days;
In severe infection: 1.5 g IV, 3 times a day, the duration of treatment is 5-10 days.
Metronidazole:
With a mild infection: 500 mg IV, drip, 3 times a day, the duration of treatment is up to 5-7 days;
In severe infection: 1000 mg IV, 2-3 times a day, the duration of treatment is 5-10 days.
Vancomycin: (for beta-lactam allergy, documented case of MRSA colonization).
7.5 mg/kg every 6 hours or 15 mg/kg every 12 hours IV, duration of treatment 7-10 days
Ciprofloxacin 200 mg IV bid, duration of treatment 5-7 days
Macrolides:
Azithromycin 500 mg once a day IV. The course of treatment - no more than 5 days. After the end of the intravenous administration, it is recommended to prescribe azithromycin orally at a dose of 250 mg until the completion of the 7-day general course of treatment.
Infusion detox therapy: carried out for the purpose of treating intoxication syndrome, preventing infectious complications, in the provision of emergency medical care - with active bleeding.
Crystalloid solutions in a total volume of up to 1500-2000 ml.
Sodium chloride solution 0.9%;
Sodium chloride/sodium acetate solution;
Sodium chloride/potassium chloride/sodium bicarbonate solution
Sodium acetate trihydrate/sodium chloride/potassium chloride solution
Ringer Locke's solution;
Glucose solution 5%.
Antimycotic therapy:
Fluconazole 50-400 mg once a day, depending on the risk of developing a fungal infection.
Prevention of thromboembolic complications carried out for 3 days with low molecular weight heparins:
Dalteparin, 0.2 ml, 2500 IU, s.c.;
Enoxaparin, 0.4 ml (4000 Anti-Xa MO), s.c.;
Nadroparin, 0.3 ml (9500 IU / ml 3000 Anti-Xa MO), s / c;
Reviparin, 0.25 ml (1750 anti-Xa ME), s.c.;
Certoparin sodium 0.4 ml (3000 Anti-Xa MO), s.c.
For pain relief:
1) non-steroidal anti-inflammatory drugs:
Ketoprofen, IM, IV, 100 mg/2 ml up to 4 times a day;
Ketorolac inside, in / m, in / in 10-30 mg up to 4 times a day;
Diclofenac 75-150 mg per day IM up to 3 times a day.
2) synthetic opioids
Tramadol in / in, in / m, s / c at 50-100 mg to 400 mg per day, orally at 50 mg to 0.4 g per day) no more than every 4-6 hours.
3) narcotic analgesics with severe pain during the early postoperative period
Trimeperidine, 1.0 ml of 1% or 2% solution i / m;
Morphine, 1.0 ml of 1% i.m. solution.
Uterotonic therapy(indications: hematometer, serozometer, operations with violation of the integrity of the muscular layer of the uterus)
Oxytocin (from 5-40 IU / ml intravenously, intramuscularly);
Methylergometrine from 0.05-0.2 mg intravenously, intramuscularly).
Medical treatment provided on an outpatient basis:
Estrogens
Combined oral contraceptives
Gestagens
2) list of additional medicines
Levothyroxine sodium, tablets 100-150 mcg
Methandrostenolone tablets 5 mg
Medical treatment provided at the hospital level:
1) list of essential medicines:
Cefazolin, powder for the preparation of an injection solution for intravenous administration 500 and 1000 mg;
Ketoprofen, ampoules 100 mg / 2 ml;
Enoxaparin, 0.4 ml disposable syringe (4000 Anti-Xa MO).
Anomalies in the development of the ovary
Agenesia (aplasia) of the ovary (syn.: agonadism) - the absence of the ovaries. Anovaria is the absence of two ovaries.
Ovarian hyperplasia - early maturation of glandular tissue and its functioning.
Hypoplasia of the ovary is the underdevelopment of one or both ovaries.
Ovarian cyst - it can be single and multiple, one- and two-sided. It occurs in approximately 1 in 2500 newborns. They are usually functional cysts caused by stimulation of the fetal ovary by maternal hormones.
Retention of the ovary - incomplete lowering of the ovary together with the uterus into the small pelvis.
Ectopic ovary - displacement of the ovary from its usual place in the pelvic cavity. It may be located in the thickness of the labia. at the entrance to the inguinal canal, in the canal itself.
Additional ovary - occurs in 4% of cases near the main ovaries in the folds of the peritoneum. Differs in small size. Occurs when an additional laying of the sex gland is formed in the genital folds.
Bifurcated ovary - an unusual shape of the ovary as a result of nonunion of the Wolf body.
Anomalies in the development of the uterus
complete absence of the uterus due to its failure to form, is rare
Rice. 301. Congenital absence of the uterus (Kupriyanov V.V., Voskresensky N.V.. 1970)
Agenesh uterine cervix - the absence of the cervix, a rare anomaly. May be an isolated defect or be associated with vaginal agenesis and a double uterus.
Aplasia of the uterus - congenital absence of the uterus. The uterus usually has the form of one or two rudimentary muscle rollers (Fig. 302). The frequency ranges from 1:4000-5000 to 1:5000-20000 newborn girls. Often associated with vaginal aplasia. A combination with anomalies in the development of other organs is possible: the spinal column (18.3%), heart (4.6%), teeth (9.0%), gastrointestinal tract (4.6%), urinary organs (33.4 %). There are 3 variants of aplasia: 
Rice. 302. The structure of internal organs in aplasia of the uterus and vagina (. Adamyan JI. V., Kulakov V. I., Khashukoeva A 3., 1998)
a) the rudimentary uterus is defined as a cylindrical formation, located
placed in the center of the small pelvis, on the right or left, measuring 2.5-3.0x2.0-1.5 cm;
b) the rudimentary uterus has the form of two muscular ridges located parietal
in the cavity of the small pelvis, each measuring 2.5x1.5x2.5 cm;
c) muscle rollers (rudiments of the uterus are absent).
Atresia of the uterus - infection of the uterine cavity, usually observed in the cervical region, while the body of the uterus is connected to the vagina only by a tissue cord, devoid of lumen. It is associated with atresia of the vagina and tubes.
Hypoplasia of the uterus (syn.: uterine infantilism) - the uterus is reduced in size, has an excessive anterior bend and a conical neck. There are 3 degrees:
a) embryonic uterus (syn.: rudimentary uterus) - an underdeveloped uterus (up to 3 cm long), not divided into a neck and body, sometimes without a cavity;
b) infantile uterus - a uterus of reduced size (3-5.5 cm long) with a conical elongated neck and excessive anteflexion;
c) adolescent uterus - length 5.5-7 cm.
Uterine hemiatresia - infection of one half of the double uterus.
Doubling of the uterus - occurs during embryogenesis as a result of the isolated development of the paramesonephric ducts, while the uterus and vagina develop as a paired organ (Fig. 303, 304). There are several doubling options: 
a) double uterus (uterus didelphys) - the presence of two separate unicornuate uterus, each of which is connected to the corresponding part of the bifurcated vagina, is due to the non-fusion of correctly developed paramesonephric (Mullerian) ducts throughout their entire length. Both genital apparatus are separated by a transverse fold of the peritoneum. Each side has one ovary and one fallopian tube.
b) doubling of the uterus (uterus duplex, synonym: bifurcation of the body of the uterus) - in a certain area of \u200b\u200bthe uterus and vagina are in contact or united by a fibromuscular layer, usually the cervix and both vaginas are fused. 
There may be options: one of the vaginas may be closed, one of the uterus may not communicate with the vagina. One of the uterus is usually smaller in size and its functional activity is reduced. From the side of the uterus reduced in size, aplasia of the part of the vagina can be observed Fig. 304. Double uterus
OR cervix" (Kupriyanov V.V., Voskresensky N.V., 1970)
c) uterus bicornis bicollis - the uterus is outwardly bicornuate with two necks, but the vagina is divided by a longitudinal septum.
Two-horned uterus (uterus bicornus) - division of the body of the uterus into 2 parts with one neck, without dividing the vagina (Fig. 305, 306). The division into parts begins more or less high, but in the lower parts of the uterus they always merge. The division into 2 horns is read in the area of the body of the uterus in such a way that both horns diverge in opposite directions at a greater or lesser angle. With pronounced splitting into two parts, two unicornuate uteruses are defined, as it were. It often consists of two rudimentary and non-fused horns that do not have cavities. It is formed at 10-14 weeks of fetal development as a result of incomplete or very low fusion of the paramesonephric (Müllerian) ducts. According to the severity, 3 forms are distinguished:
a) full form - the rarest option, the division of the uterus into 2 horns begins almost at the level of the sacro-uterine ligaments. With hysteroscopy, it can be seen that two separate hemicavities begin from the internal pharynx, each of which has only one mouth of the fallopian tube;
b) incomplete form - division into 2 horns is observed only in the upper third of the body of the uterus; as a rule, the size and shape of the uterine horns are not the same. Hysteroscopy reveals one cervical canal, but closer to the bottom of the uterus there are two hemicavities. In each half of the body of the uterus, only one mouth of the fallopian tube is noted;
c) saddle shape (syn.: saddle uterus, uterus arcucitus) - division of the body of the uterus into 2 horns only in the bottom area with the formation of a small depression on the outer surface in the form of a saddle (the bottom of the uterus does not have the usual rounding, pressed or concave inward). With hysteroscopy, both mouths of the fallopian tubes are visible, the bottom, as it were, protrudes into the uterine cavity in the form of a ridge.
Unicorn uterus (uterus unicomus) - a form of the uterus with a partial reduction of one half. The result of atrophy of one of the Mullerian ducts. A distinctive feature of the unicornuate uterus is the absence of its bottom in the anatomical sense. In 31.7% of cases, it is combined with anomalies in the development of the urinary organs. It occurs in 1-2% of cases among malformations of the uterus and vagina (Fig. 307, 308).
Separate uterus (syn.: bipartite uterus, intrauterine septum) - observed when there is a septum in the uterine cavity, making it two-chamber. Frequency - 46% of cases of the total number of malformations of the uterus. The intrauterine septum can be thin, thick, on a wide base (in the form of a tricycle). There are 2 forms:
a) uterus septus - full form, completely divided uterus;
b) uterus subseptus - incomplete form, partially divided uterus, septum length ¦ 1-4 cm.
Rice. 305. Anomalies of the uterus (Patten V. M., 1959):
a - uterus subseptus unicollis; b - uterus septus duplex; c - uterus septus duplex in combination with a double vagina; d - atresia of the cervix; e - uterus bicomus unicollis; d - uterus bicornus septus; g - uterus didelphys in combination with a double vagina; g - uterus bicornus unicollis with one isolated rudimentary vagina
Rice. 306. Spiral X-ray computed tomography.
Bicornuate uterus (axial plane) (Adamyan JT. V., Kulakov V. I., Khashukoeva A. 3., 1998): 1 - bladder; 2 - right horn of the uterus; 3 - left horn of the uterus
Rice. 307. Unicornuate uterus (Adamyan JT. V., Kulakov V. I., Khashukoeva A. 3., 1998):
a - rudimentary horn communicating with the cavity of the main horn; b - rudimentary closed horn; c - rudimentary horn without a cavity; d - absence of a rudimentary horn
Rice. 308. Unicornuate uterus with a functioning rudimentary horn (Adamyan JI V., Kulakov V. I., Khashukoeva A. 3., 1998): a - hematometer of the rudimentary horn; b - rudimentary horn removed
Retrodeviation of the uterus - the position of the uterus, in which its body is tilted backwards, the neck is anteriorly (retroversion), and the angle between them is open backwards (retroflexion). 
Rice. 309. Options for the position of the uterus (Kupriyanov VV, Voskresensky NV, 1970): a - three degrees of retroversio; b - anteversio; c - retroflexio; d - anteflexio. The dotted line indicates the normal position of the uterus
Transposition of the uterus is a change in its normal position (Fig. 309). Several forms are possible:
a) retroversio - backward tilt,
b) retroflexio - back bend,
c) retropositio - back position,
d) lateropositio - lateral position,
e) anteropositio - forward position.
Anomalies in the development of the fallopian tube
Fallopian tube atresia - infection of the lumen of the fallopian tube, atresia is unilateral or bilateral, local or total. The result of congenital obliteration of the tubes.
The openings of the fallopian tubes are additional - they are found near the abdominal opening of the tube.
Taylor syndrome (Taylor syndrome, synonym: congestiopelvica, oophoritis sclerocystica, hyperaemia ovariomm, congestio-flbrosis-syndromus) - congenital underdevelopment of the fallopian tubes: the tube is short, not reaching the utero-sacral ligaments, short fimbriae; in the pelvic organs, especially in the uterus and fallopian tubes, venous congestion is observed, later turning into fibrosis.
Doubling of the fallopian tube - can be on one or both sides.
Elongation of the fallopian tube - may be accompanied by kinks and twists of the tubes.
Shortening of the fallopian tube is the result of its hypoplasia. If the abdominal opening does not reach the ovary, the egg is unlikely to enter the tube.
Additional passages of the fallopian tubes are narrow blind protrusions of the wall or microdiverticula.
