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\begin{document}

\title{Recommendations for m\selectlanguage{ngerman}üllerian anomalies classification\selectlanguage{english}}



\author[1]{Si Su}%
\author[1]{Lan Zhu}%
\affil[1]{Peking Union Medical College Hospital Department of Obstetrics and Gynecology}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\selectlanguage{ngerman}\textbf{Recommendations for müllerian anomalies classification}

Si Su\textsuperscript{1,2}, Lan Zhu\textsuperscript{1}*

1 Department of Obstetrics and Gynecology, Peking Union Medical College
Hospital, Chinese Academy of Medical Science and Peking Union Medical
College, National Clinical Research Center for Obstetric and Gynecologic
Diseases, Beijing, China

2 Department of Pathology, Peking Union Medical College Hospital,
Chinese Academy of Medical Sciences and Peking Union Medical College,
Beijing, China

*Corresponding Author: Lan Zhu, MD, Department of Obstetrics and
Gynecology, Peking Union Medical College Hospital, Chinese Academy of
Medical Science and Peking Union Medical College, National Clinical
Research Center for Obstetric and Gynecologic Diseases, No. 1
Shuaifuyuan, Dongcheng District, 100730, Beijing, China
(zhu\_julie@vip.sina.com)

The word count for the main text: 506.

In 2021, a new müllerian Anomalies Classification was proposed by
American Society for Reproductive Medicine (ASRM 2021),
\textsuperscript{1} which was based on the American Fertility Society
(AFS) 1988 \textsuperscript{2} and combined the benefits of existing
classifications. However, mullerian anomalies is a group of complex
diseases with various manifestations. And no consensus has been reached
about the classification and diagnosis in clinical practice. The purpose
of this study is to test the clinical application value of this new
classification through the analysis of the cases from Peking Union
Medical College Hospital in the past 20 years, and put forward valuable
recommendations.

A retrospective study was conducted using clinical data of hospitalized
patients from January 2003 to December 2022 from Peking Union Medical
College Hospital. Inclusion criteria included patients with 46, XX
karyotype, diagnosed of müllerian anomalies, and clearly identified
alterations of the uterus, cervix, and vagina. Clinical data of patients
were collected through the hospital information system, and
classification was performed based on the ASRM 2021. SPSS 25.0 version
was used for data analysis.

2671 patients were included, with an average visiting age of 28.9±10.0
years. The most common is septate uterus with 1144 cases (42.8\%),
followed by MRKH syndrome (20.4\%), Herlyn-Werner-Wunderlich syndrome
(HWWS) (10.4\%), unicornuate uterus (7.4\%), cervical agenesis (6.5\%),
uterus didelphys (5.6\%), bicornuate uterus (2.9\%), longitudinal
vaginal septum (without uterine malformation) (2.0\%), transverse
vaginal septum (1.2\%), complex anomalies (0.5\%) and other anomalies
(0.3\%) (Table 1). It should be emphasized that HWWS was taken as an
independent classification for statistical analysis, with reference to
the clinical definition (uterus didelphys, obstructed hemivagina and
ipsilateral renal agenesis).\textsuperscript{3,4} 13 cases of complex
anomalies were identified and 8 cases that could not be classified were
classified as other anomalies (Supplement table 1).

ASRM 2021 was proposed based on the AFS 1988, which is the most widely
used classification in the past 30 years. We found ASRM 2021could
distinguish most clinical patients well, but there are still some
shortcomings. First, the classification of patients with uterine
malformations and longitudinal/transverse/oblique vaginal septum is not
clear. We recommend that patients with longitudinal vaginal septum and
uterine anomalies should be classified into the uterine anomalies
respectively, while others without uterine anomalies should be included
in longitudinal vaginal septum. All transverse vaginal septum should be
included in transverse vaginal septum, because the symptoms of
transverse septum are prominent. A new type of HWWS should be added.
Because the obstructive symptom is prominent. Second, we found several
cases of complex anomalies. For these patients, multidisciplinary and
individualized treatment should be carried out. The anomalies we found
that are not currently classified include T-shaped uterus, congenital
vaginal stenosis, and accessory and cavitated uterine masses (ACUM).
With the deeper insight into this field, there may be a better way to
classify them. The limitation of this study is that as a single-center
retrospective study, there could be statistical biases.

In conclusion, we put forward following suggestions for ASRM 2021
classification: 1) Minimize overlaps of classification and add a type of
HWWS; 2) Update complex anomalies timely; 3) Add other anomalies
classification.

\textbf{AUTHOR CONTRIBUTIONS}

Si Su came up with the idea and wrote the first draft of the research
letter. M. M. Ebrahim, Lan Zhu revised and made substantial changes to
the manuscript. All authors reviewed the final version of the
manuscript.

\textbf{ACKNOWLEDGMENTS}

We would also like to extend our gratitude to the study participants,
data collectors, and supervisors.

\textbf{CONFLICT OF INTEREST STATEMENT}

The authors report no conflict of interest.

\textbf{ETHICS APPROVAL}

This study was approved by the Ethics Review Committee of Peking Union
Medical College Hospital (I-23PJ411) On March 8, 2023 and patients'
informed consent was exempted.

\textbf{FUNDING INFORMATION}

This study was supported by CAMS Innovation Fund for Medical
Sciences\selectlanguage{english}(CIFMS\selectlanguage{english})2021-I2M-C\&T-A-008.

\textbf{DATA AVAILABILITY}

The data that support the findings of this study are available from the
corresponding author upon reasonable request.

\textbf{REFERENCES}

1. Pfeifer SM, Attaran M, Goldstein J, et al. ASRM mullerian anomalies
classification 2021. \emph{Fertility and
sterility.}2021;116(5):1238-1252.

2. The American Fertility Society classifications of adnexal adhesions,
distal tubal occlusion, tubal occlusion secondary to tubal ligation,
tubal pregnancies, mullerian anomalies and intrauterine
adhesions.\emph{Fertility and sterility.} 1988;49(6):944-955.

3. Herlyn U, Werner H. Simultaneous occurrence of an open Gartner-duct
cyst, a homolateral aplasia of the kidney and a double uterus as a
typical syndrome of abnormalities. \emph{Geburtshilfe
Frauenheilkd.}1971;31(4):340-347.

4. Wunderlich M. Unusual form of genital malformation with aplasia of
the right kidney. \emph{Zentralbl Gynakol.} 1976;98(9):559-562.

Table 1. Types and proportions of malformations\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
Types & Cases No. (\%)\tabularnewline
\midrule
\endhead
Septate uterus & 1144 (42.8)\tabularnewline
Mullerian agenesis & 544 (20.4)\tabularnewline
HWWS & 278 (10.4)\tabularnewline
Unicornuate uterus & 198 (7.4)\tabularnewline
Cervical agenesis & 173 (6.5)\tabularnewline
Uterus didelphys & 150 (5.6)\tabularnewline
Bicornuate uterus & 77 (2.9)\tabularnewline
Longitudinal vaginal septum & 54 (2.0)\tabularnewline
Transverse vaginal septum & 32 (1.2)\tabularnewline
Complex anomalies & 13 (0.5)\tabularnewline
Other anomalies & 8 (0.3)\tabularnewline
Overall & 2671 (100.0)\tabularnewline
\bottomrule
\end{longtable}

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