Uterine Cavity Abnormalities and Mullerian Anomalies with Dr. Allison Rodgers

Jordan D’Nelle 0:01
Welcome to vaginas vulvas and vibrators with Jordan D’Nelle this is a safe place to learn about women’s health and sexual wellness. I’m your host Jordan D’Nelle, physician assistant, women’s sexual educator and intimacy coach.

On today’s episode, I have a special guest joining me to talk all about malarian anomalies. This is something that I learned about working in infertility and I thought it is really important to bring this up so that women are more aware of this in case they are ever diagnosed with a diploid uterus or septum or some other type of uterine abnormality. So I am excited for her to join us today.

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Joining me today is Dr. Allison Rogers. She is a Board Certified ob-gyn and REI or reproductive endocrinology specialist in Chicago, Illinois. She has a personal experience with secondary infertility and pregnancy loss, which has given her a unique insight into Reproductive Medicine. She is well known for her compassionate and individualized patient care. She has published many original research articles in top medical journals. She’s active on social media platforms such as Instagram, and Tiktok, educating women all about health and infertility. That is actually how I found her when I was looking for a guest to talk about this topic. I had come across her Tick Tock and was like yes, that is the woman that I need on my podcast to help spread the word about something that affects a handful of women. And when you don’t know that this is possible, and you kind of get blindsided by this information, it can be very overwhelming and scary, which is why I love to educate women on different things that potentially could affect them in their lifetime. So Dr. Rogers, would you like to go ahead and tell us a little bit about yourself?

Dr. Allison Rodgers 3:29
Sure. So I am a Chicago based ob-gyn and board certified reproductive endocrinologist and infertility specialist. So I did an OB-GYN residency and then did a fellowship for three years in reproductive endocrine and infertility. I’ve been in practice for about 10 years and really spend a lot of most of my time obviously with patient care but also really love educating patients about their health and their bodies so that they can make informed decisions and not only am I a fertility doctor but I actually went through a fertility journey myself so I we had my first child in residency and then when I was a fellow when I was an infertility fellow I had a hard time getting pregnant and needed to go through a lot of fertility treatment and had recurrent loss and it was quite a journey and I think that just sort of shapes my view of helping patients.

Jordan D’Nelle 4:23
Absolutely that totally can impact how you relate to your patients and you just have a little bit different understanding as far as practice Are you currently delivering babies and doing DINE or just REI?

Dr. Allison Rodgers 4:37
Yeah, So at this point, I’m just doing REI so I did my while I was doing my fellowship I also was an attending for the residency program at that point of general ob-gyn attending so I did at that point, deliver babies and do all the GYN stuff. But really my focus is for the last 10 years just since I’ve graduated fellowship, just infertility. So IReally focus on hormones, and then, obviously technology to help people with infertility and recurrent loss.

Jordan D’Nelle 5:07
Absolutely. So I work in fertility as well. And so I’m really familiar with kind of like the fertility background and all of that something that I see more often than I would have ever thought is uterine cavity abnormalities. And that’s something I really wanted to bring somebody on the show to talk about, because this is not something that women know about or have even heard of, most of the time, like, nobody knew that you could have a polyp. Nobody knew you have it stepped up like so do you want to maybe just tell us a little bit about some uterine cavity abnormalities, and we can go from there.

Dr. Allison Rodgers 5:44
Yeah, so we think about uterus, the uterus, obviously, you need three things to make a baby, you need a uterus, sperm, and an egg, that’s pretty straightforward. And from a uterine perspective, we need a healthy uterus to allow implantation and growth for baby. And there can be inherent or anomalies or abnormalities with the uterus that you’re born with. And there can also be ones that you acquire in your life. So when we think about polyps, and fibroids, scar tissue, those are things that certainly can impact pregnancy, and miscarriages. But those polyps in fibroids and scar tissue are things that you’re not born with. Those are things that you acquire during your life. polyps grow fibroids grow, scar tissue occurs, usually after some sort of infection or trauma event to the uterus. Obviously, there are the others type, which you’re born with called malarian and anomalies. And we use the term malarian. That’s sort of the Latin word that refers to the female reproductive tract. And we’ve talked about them as being malarian and anomalies, and they’re very common. And I will tell you that women who come to see me that say they have a problem with the shape of their uterus, or they were told that they have a specific defect, I will say, it’s a little bit scary. 90% of those people, if not more, are told that they have a uterine shape abnormality, and they are diagnosed with the wrong uterine shape abnormality, which is actually pretty scary. There are some pretty subtle and sort of delicate differences between them. And I think most you know, General ob-gyn and most maybe human radiologists are not necessarily know all those differences. And that’s where really the fertility, you know, like board certified reproductive endocrinologist, people who have had that extra training, really need to be able to look at imaging, diagnose abnormalities, and need to help people understand what is going on with their bodies. And certainly there I’m sure there are some really fantastic ob-gyn who do a great job with it. And pa is right and all the things but I think that it’s concerning to me as a fertility provider, how many women come in, are diagnosed with one thing, and then I start evaluating them and realize that’s not what they have at all.

Jordan D’Nelle 8:04
Yeah, I’ve seen that actually a lot in practice to where patients come in, and it’s, they say that they have a diploid uterus or whatever. And you find out that it’s, that’s not what it is or . . . So tell me a little bit about the different types of malarian anomalies that you maybe commonly see.

Dr. Allison Rodgers 8:23
So of when we think about the American Society of Reproductive Medicine, they’ve really grouped these into seven categories. And so I like to think about them in these categories. So we can sort of talk through those seven so the first one is called segmental or complete agenesis or hyperplasia, meaning there’s something missing either part of it or the whole thing is missing. And that can be missing vagina, missing cervix, missing top of the uterus, missing fallopian tubes, and then there is a what I would call malarian in agenesis meaning there’s a complete lack of the malarian and structures or the female reproductive track. People call that Mayor Rockitansky Kuster Hauser Syndrome, so M.R.K.H., do you may hear of it, but it really means you have no tubes, no uterus, and then you have no top of the vagina, the top actually the top of the bottom of the vagina form separately, and they have no top of the vagina. And so they on the outside look normal on the outside look normal. And on the inside, they don’t they only have like a blind vagina. And that’s the kind of thing that typically prevents, they do have ovaries. So they go through menopause, they go through minarchy they have puberty and then they might turn 15 have breasts have pubic hair or not have a period because they don’t have a uterus. Usually it’s diagnosed at the time of puberty sort of the time or they should have be getting their period and don’t. Certainly if it’s everything’s gone, that’s one thing sometimes like the uterus is there, but the cervix is gone or vagina is gone. And that often also presents sort of a puberty time because blood will sort of back up and cause severe pain. So first class, something missing agenesis. Second Class is called unicornuate or without a rudimentary horn. So this is where the sort of to take things back to embryology, our uterus and fallopian tubes actually start off as a tube. And that tube folds in like this, and sort of my elbows maybe represent the end of the tube, those become the fallopian ends the fallopian tube, and that my hands which sort of are folding, but that becomes the uterus. And that has to happen in the correct way. And a lot of times one side of that doesn’t form correctly, and you have like a half of a uterus. So typically, these people have a half of a uterus and on one side of a fallopian tube, sometimes the other side, you know, has what we call a rudimentary horn. I recently did a tictok about this, that like a rudimentary horn is maybe part or like an underdeveloped uterus. Usually they don’t cause trouble. The only time they really cause a lot of trouble is when they have the endometrium or the lining of the uterus in it because then when the hormones change, it produces blood period blood and there’s nowhere because it’s not connected to anything for it to go. And so that’s where that can go backwards throughout that if they have a tube or it can like fill up with blood and cause severe pain. So a lot of times people don’t necessarily know they have unicorn at uteruses, cornea uteruses are also really associated because the kidneys and the uterus formed together. So if you’re missing side at one half of the uterus, you’re often missing a kidney on that side. So it is important for sort of general health as well. Often these patients can get pregnant and a lot of times you know, I will tell you one of the first c sections I ever did as an intern a baby doctor, I, you know, patient wasn’t progressing and labor we did a C section. I usually we used to anyway, back in the day, like exteriorize, the uterus and I saw I take the uterus out to look at it. And I thought I ripped the tube off because there was only one tube attached to it, my friends, I was like, No, no, this is a unicorn uterus. She just had never been diagnosed before. So sometimes people go through their whole lives and don’t necessarily know they have that. That second, or sorry, the third category is called di delta S. And this is a complete duplication. So when that tube is sort of coming together, it doesn’t actually come together. So you sort of have two separate unicorn you at uteruses that are completely separate. So you have two uteruses, they’re not those triangular uteruses, though they’re sort of the teardrop uteruses, and they each are attached to a fallopian tube and the ovaries form separate. So when all of these usually people have ovaries. The third one is important to sort of differentiate from the fourth one, which is called by cornea, it is important to differentiate from dite delvis, because it is a doubling, but it’s mainly a doubling only at the top of the uterus and not the bottom. So usually, it’s a single vagina, single cervix, and then the uterus is more like a heart shape. And it’s important to realize obviously, it’s interesting because a lot of times didelphys uteruses have what we call by call us, meaning that they have two cervixes and and sometimes even have a septum inside so they actually have two vaginal canals, usually with bicornuate uterus is sometimes you can have a bicollis, which means you have to serve to cervixes as well. But usually, that when that when that that tube comes together and forms that sort of connected the right way at the bottom, but didn’t at the top. And then the fifth category is complete, or partial septum. And a septum is a heart shaped uterus that is normal on the outside. So then outside is a nice that nice triangular shape. But the inside is heartshaped, which is different than didelphys and bicornuate, where the outside is heart shaped. And the reason this matters is because the outside is normal. But that septum that comes down the inner part of the heart is fibrotic tissue, not tissue that can support pregnancy. And these are women who have a very, very high risk of miscarriage. Sometimes, some studies have shown it up to 90% risk of miscarriage. And sometimes those symptoms are the complete length of the uterus. And sometimes they’re not, they’re just sort of more heart shaped. And it’s important to differentiate a septum from the sixth category, which is arcuate. Now arcuate is a small septum. And I we differentiate that we can do a three dimensional ultrasound and look at the depth of that inner part of the heart. And if it’s more than a centimeter, then we call it a septum if it’s less than a centimeter, we consider that an arcuation or an arcuate uterus, which is considered a normal variation. So we see it, we mentioned it, but it doesn’t really have any clinical consequences. So I have patients all the time, who come in with a arcuate uterus and actually have a septum or are told they have a septum but actually it’s an arcuate and the same was sort of didelphys and bicornuate. People get those really confused, even doctor people. So and then the last category, we’re not seeing much any more, it’s called DES related abnormalities and DES was a medication we used mainly in the early, I think it was banned in the early 70s. And so these are people who are now into their late 40s. And not necessarily having babies very much. But it did cause uterine abnormalities, and also puts them at very high risk for cancer. And so usually those anomalies because you were exposed to it in utero, and those are some things that you sort of usually know at the time you’re born. And so those are sort of some of the malarian anomalies and how we classify them from each other.

Jordan D’Nelle 15:38
I love that. And I see the handful of bicornuates and multiple cervixes in office. What would you say and tons of septums, tons of septums, what do you say you see the most of?

Dr. Allison Rodgers 15:52
I think arcuate truthfully, like I see tons of arcuates. And also because I do three dimensional ultrasounds and everybody three dimensional saline sonograms on pretty much all my patients to really get a good look at what’s happening with their uterus. And, you know, arcuates are just super common. And then of course, the next most common is certainly septums. And then and then we see the unicornuate didelphys and bicornuate, it’s sort of after that. Typically patients, I don’t see very many complete agenesis of the uterus, except when we’re maybe using gestational carriers. So these women have ovaries, so we take out their ovaries, and usually use a gestational carrier for them. But these are women who are like diagnosed way before they can get to me. Whereas I think a lot of women come to see me for recurrent loss or infertility have not do not have a diagnosed uterine anomaly. And then I diagnose it. Whereas I think people who have complete aplasia those are people not getting periods. And so they are diagnosed as teenagers. And by the end come to see me already diagnosed for Reproductive for Reproductive treatment, but it’s sort of already diagnosed. So obviously, the nice thing is that the most common thing we see is the thing that needs no medical intervention is considered a normal variation.

Jordan D’Nelle 17:04
So when you do see a septum or something else, what type of treatments do you have available?

Dr. Allison Rodgers 17:12
So it depends on what we find. So when we think about the different anomalies, you know, just so obviously, if something’s missing, sometimes we can correct it. Like, if there’s sort of a missing connection in the vagina, sometimes we can do you know, surgery and that kind of stuff. But typically, those are not necessarily fixable. Unicoruate uteruses also we don’t usually have to do surgery for those, same with didelphys and bicornuate. Back in the day, they used to take bicornuates and didelphys to try to put them together, I was involved with some of those surgeries and back back in the day in residency, we really don’t do that anymore. And we kind of leave those as is understanding that there is a higher risk of pregnancy complications like preterm labor and male presentation where the babies are not coming head down, but that it actually causes sometimes more harm than good to try to fix those. The main thing and then arcuate is a normal variation, the main thing that we surgically correct is septums. And I will tell you, it’s one of my favorite surgeries to do, when I’ve learned how to do these, it was all in the operating room with laparoscopy at the same time has hysteroscopy. So camera in the belly button and camera in the uterus, and making sure you weren’t going through the uterus and making sure you know evaluating outside and evaluated inside. Now, that’s how it was trained to do in fellowship. Now that our ultrasound technology is so good, I’m able to do three dimensional ultrasounds really get a good idea of what’s happening on the outside of the uterus. And so I can feel really confident doing surgery, I do it right in my office procedure suite in my office, I do a hysteroscopy through the cervix, I use like an itty bitty five millimeter camera. It’s like literally the size of a pen. And I have ultrasound guidance. So I have ultrasonographer watching my instruments to make sure that I’m not doing anything to the outside of the uterus, right, we just follow the inside it’s one of my absolute favorite surgeries to do mainly because it is so like just like rewarding and satisfying to be able to like cut the septum away. And the nice thing is the uterus is a muscle. So it’s contracting and contracting. So while you’re cutting the septum, it’s contracting and opening up and opening up. And it’s and so I typically after a septum surgery, you’re not necessarily going to have that upside down triangle shape, it still may be heartshaped. But the goal is to get rid of the fibrotic tissue that doesn’t have blood supply so that if a baby an embryo implants there, it’s going to have the blood supply that it needs. And so what I typically do is typically I use our ceiling inside the uterus to hold pressure so I can see and what I do during these procedures is I cut away a little bit and then I lower the pressure and I see if there’s blood flow or not. Right when you take away the pressure there’s then it allows the blood to flow if there’s blood there and so then I like to put the pressure back up and then I cut it little bit more. And then I put the pressure down to see if there’s blood flow. And I’m able to like be very delicate and methodical and really take that septum back to the point where there’s decent what flow. Obviously nobody’s like hemorrhaging or anything but like you want there to be good blood flow to the tissue, and you don’t want it to be fibrotic tissue.

Jordan D’Nelle 20:20
Absolutely, that’s the whole point of the procedure is to ensure that there’s blood flow there for attachment of baby. As far as like life long effects. Are there any lifelong effects besides fertility implications and miscarriage?

Dr. Allison Rodgers 20:35
There can be so one of the things that we really think about is that when the blood comes the uterus contracts for during a period, the blood goes to the path of least resistance, meaning most blood comes out through the cervix, a little bit of blood goes backwards through the tubes called retro grade menstruation. And that almost everybody has retrograde menstruation and now people who are prone to things like endometriosis, that blood that goes backwards doesn’t just get absorbed by the body, it’s sort of those glands land and start growing. People who are have malarian anomalies. So we think about disordered like muscle, the muscles are not necessarily put together in a nice concentric way to squeeze like those people often have higher risks of needing c sections because the uterus can’t like in an organized way, squeeze a baby out, like a normal uterus would and doesn’t necessarily have the strength and when we think about things being blocked, so you think maybe a unicornuate uterus, you know, a lot of blood is gonna go or even up bicornuate didelphys a lot of blood is actually a lot more blood is going to go backwards through the tubes, when things get blocked, and things are not normally shaped. And so these women have a very high incidence of endometriosis, which of course can interfere with, you know, pain, infertility, painful intercourse, higher risk of ovarian cancer. So there are obviously some longer life situations there. In general, women who have a outflow tracts of blood in the lining of the uterus can get out tend to do well don’t typically need surgeries. Obviously also, from a pregnancy perspective, we know that these women are at higher risk for preterm labor, which is the main thing and what we call malpresentation now so interesting. So women who have a unicornuate uterus, one of my nurses, like, loves to call them unicorns, which I think is just hilarious because unicorns are like these magical amazing creatures. And I think just obviously just means one horn right? But being able to sort of, you know, say that, unicornuate uterus is like this magical thing. I love it. So women who have unicornuate uteruses in general tend to have preterm delivery. But let’s say your first babies born at 30 weeks or normal pregnancies, 40 weeks, it tends to be that once that unicorn universe stretched out, following and subsequent pregnancies will go longer and longer and be healthier and healthier. And so it’s so fascinating because doctors do, it’s important for women to understand that there are high risk, they can always use a gestational carrier. But often these women do well, higher risk of C section, higher risk of preterm labor, but like often do really well. And it’s so fascinating because maybe their first baby’s gonna be born at 32 weeks, and then their next one might be born at 36. The next one might be born at term, the uterus sort of grows and contracts, right? I mean, it’s one of the amazing parts of the human body that you have this organ the size of your fist, and that has to grow to the size of a watermelon, right? And so I think when we look at unicornuate uteruses, they do better and better as they have had more, more stretching and more babies of their

Jordan D’Nelle 23:26
Wow, I did not know that. That’s so interesting. Now, with the S exposure. That’s one way that you sometimes can see this, what are some other causes of malarian anomalies?

Dr. Allison Rodgers 23:37
So that’s a great question. And so we do see from time to time, some genetic causes. So some genetic disorders are, and I’m not just talking about like, I’m talking about these like genetic disorders that affect like, your spine. Like there’s some of these disorders that affect like the spine and the kidney formation and skeletal bones. And those are some genetic disorders that are typically associated with developmental delay, and intellectual disabilities, you can sometimes see issues with uterine shape abnormalities. Well, I would say, that is the rare percentage of these malarian anomalies, almost all of them are not genetic. It’s not necessarily something that runs in families. They are sporadic mutations, because remember, it is really about how the uterus develops in utero. So there’s that like tube that has to like form like this to become the uterus, and then my arms are like the fallopian tubes, and it has to fold correctly and the inside gets absorbed. And all of that needs to happen in a very unique and complex way. And if it doesn’t happen exactly right, then you see these malarian track abnormalities. And listen, I think these sort of birth, it’s more or less a birth defect, right, and birth defects happen in all organs. But if you had a birth defect in your brain or in your heart, those are miscarriages, a lot of them not all of them, but a lot of them right those babies don’t survive. Luckily the uterine track is not necessarily you know, essential for her survival, you know, in an individual. And so these are people who are able to grow and a lot of times don’t even know they have an issue. But they’re actually a lot more common than I think we might know. And I think that it’s so amazing to sort of bring light to this topic because there are a lot of people who, and obviously, I don’t want to be like, we don’t want to be scaring people. But I also think that like I’ve had patients who, you know, septums are associated with a 90% risk of miscarriage rate. And I’ve had patients who’ve had like four or five miscarriages, their doctors are like adding progesterone and maybe have checked a carrier type, and never looked at the shape of their uterus. They come see me. I do a simple 20 minute office procedure remove their septum, and they go on and they’re successful. And it’s like, Whoa, you probably could have prevented a lot of miscarriages in these patients. And that’s where I see patients aren’t served well, when these things are not, you know, being diagnosed. So I think if you’ve had two miscarriages, you’re having trouble getting pregnant, you really owe it to yourself to get evaluated. And you can’t just do a regular ultrasound to evaluate this, you need some sort of either saline ultrasound, fluid inside the uterus into a three dimensional ultrasound, or so you can sometimes get started with a history of a picogram, which is an X ray of the fallopian tubes, that is not going to be able to differentiate septum versus bicornuate versus didelphys, because it’s only looking at the shape of the inside, which all looks the same. So really, if you can start off that way, and if you see something funny, then you would need an MRI or three dimensional sailing sonogram. And a simple ultrasound just doesn’t cut it. And I think that there’s a lot of people out there who a lot of well intending ob-gyn or general doctors who are intending well to help their patients. But maybe that’s not their sort of area of expertise. And so they’re kind of like half doing the workup or maybe not fully diagnosing things. And that really doesn’t serve anybody. And unfortunately, I do see a good number of patients who’ve had recurrent losses that have had a losses, and then I diagnose things that like could have been picked up long ago.

Jordan D’Nelle 27:05
Yeah, and I see that too. And I know that other providers have good intentions. I did a whole fertility month for fertility Awareness Week, talking about fertility. And that’s one of the big things that I brought up is that we have these patients who are seeing their primary ob’s, who keep doing the same thing and aren’t getting a different outcome, and not sending them off to REI soon enough. And this is another one of those similar situations.

Dr. Allison Rodgers 27:36
Well, and it’s interesting, there was a study that looked at people and their desires. And like people, like, I think some ob-gyn feel like patients are disappointed when they send them to a specialist. But when you ask when you look at the data, patients actually typically appreciate that and have better satisfaction and are more likely to come back to their ob-gyn when they are sent off to a specialist. And there’s a variety of there’s a big range ob-gyn, I mean, obviously, everyone’s trained in it. But some people focus more on general wellness and surgical, like hysterectomy and myomectomy. Isn’t that kind of stuff. And some people have a real interest in what they’re doing, and some people don’t. And so obviously, that’s hard, because there’s a lot of really, really good ob-gyn out there who do the right thing, but then certainly there are some that just don’t quite hit the mark, and then know that the patients are the ones that suffer.

Jordan D’Nelle 28:32
Absolutely, I have a lot of friends who have gone to see REI, and they’re primary hadn’t referred them, and then they’re not happy when their primary ob didn’t tell them hey, go ahead and take that next step.

Dr. Allison Rodgers 28:44
Well, I think that for people who are listening to this, it’s important to just really understand if you’re having trouble getting pregnant, if you’ve had two losses, it’s probably time to see a reproductive endocrinologist to get a full evaluation. And part of that evaluation, of course, is the uterus and the uterine health. And we really look at sort of the shape of the uterus and its ability to to function.

Jordan D’Nelle 29:07
I love that yes. And October is Miscarriage Pregnancy loss Awareness Month. And so I think this is a perfect episode to tie into all of that, since it does have so many implications as far as loss and being able to share this information with women so that they feel when they get this diagnosis, they have maybe a resource to go to so that they feel less alone they know that it’s not just them there are other women who are affected by this. We’re just not talking about it. It’s not being looked for a lot of the times. So if the listeners take one thing away from today’s conversation, what would you want it to be?

Dr. Allison Rodgers 29:46
So I would recommend so the like biggest take home is get evaluated and advocate for yourself. And I think that making sure even if you’re you get the imaging and they it’s mainly imaging And even if you get imaging and they say everything’s totally normal, and we have no idea why you keep having miscarriages, I think it’s worth checking things off the box because if something’s treatable, you should be able to get it treated. And the only way to figure out if there’s a problem is to look for it. So if you’ve had two losses, you deserve to be evaluated.

Jordan D’Nelle 30:20
Absolutely, absolutely. Well, thank you so much for chatting with me. Where can listeners find you at?

Dr. Allison Rodgers 30:26
So I am on tiktok and Instagram at Dr. dot Allison a Ll i s o n dot Rogers r o d g ers.

Jordan D’Nelle 30:39
Perfect and you guys have to go check it out because she has some great educational stuff on her Tiktok and Instagram, so highly recommend giving her a follow

Dr. Allison Rodgers 30:47
Awe, Thank you so much, Jordan. That’s how I found you. It was great. It was like oh, this is like part of my mission is ensuring that women get this information. Yeah, you go.

Jordan D’Nelle 30:57
Well, thank you so much.

Dr. Allison Rodgers 30:59
Well, it’s been a pleasure. Yes. Thank you for having me.

Jordan D’Nelle 31:02
This episode is sponsored by pure romance by Jordan Jones offering top bath and beauty products and relationship enhancement items. Check out the link in the bio to start shopping today. Go shopping you are supporting this podcast.

Thank you for joining today and continuing to bring awareness to women’s health. If you love the show, please subscribe so you never miss another episode. And leave a review for others to see. If you want to see me on the daily you can check out my bio for links to all my pages. Be sure to share this episode with your girlfriends thanks again and see you next episode.

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