T-shaped uterine anomalies are rare and can develop as a result of intrauterine exposure to diethylstilbestrol (DES) or other factors resulting in congenital anomalies, or as a result of peripheral uterine adhesions giving the uterine cavity a T-shaped appearance.T-shaped uteruses have a narrow cavity and a higher incidence of infertility and obstetric complications than normal uteruses. Several publications have reported that T-shaped uterus due to intrauterine exposure of DES can lead to infertility, ectopic pregnancy, cervical insufficiency, recurrent miscarriage, preterm delivery and perinatal death [1,2,3,4].Hysteroscopic orthopedic surgery of T-shaped uterus improves the reproductive prognosis with a significant increase in the rate of full-term pregnancy after surgery [5,6,7]. Three patients with congenital T-type uterine anomalies underwent hysteroscopic uterine wall incision (TCUI) at our center, and live infants were obtained after surgery, as reported later. Case 1, Feng, 36 years old, Yunnan Xuanwei, hospitalization number 185346, was admitted to the hospital on July 13, 2005 for infertility after 6 years of marriage and a “T” type uterus. On January 31, 2005, the external HSG showed a “T”-shaped uterus (Figure 2) and obstruction of one of the fallopian tubes. Preoperative diagnosis: 1) primary infertility; 2) “T” shaped uterus. The hysteroscopy was performed on July 18, 2005 under intravenous general anesthesia with a monopolar electrodescreen. Postoperative pathology: 04-4043 basal endometrium with smooth muscle tissue underneath. The patient was pregnant in April 2006 and delivered a healthy baby girl, 3300 g, by cesarean section in December, who is alive. Case 2, Wang, 36 years old, from Funing, Jiangsu, hospitalization number 210919, was hospitalized on October 10, 2009 for 6 spontaneous abortions and 4 years of uterine stenosis. The patient had 6 recurrent spontaneous miscarriages without any cause since 1996, all of which occurred in the second month of pregnancy, and the treatment with Chinese and Western medicine was ineffective. The last miscarriage was in 2007. In 2002, the combined hysteroscopy and laparoscopy of the external hospital indicated uterine stenosis, and the HSG showed patent fallopian tubes. on October 12, 2009, the combined hysteroscopy and ultrasound showed that the uterine cavity was 8.5 cm deep, the fundus was narrow and there were adhesions. the ultrasound showed a 1 cm diameter fibroid in the middle of the posterior wall of the uterus. On October 15, a hysteroscopic electrosurgery was performed under intravenous general anesthesia, and the uterine cavity was found to be 8 cm deep, the ectocervix was 6 cm from the upper edge of the uterine stenosis, the fundus of the uterus was stenosed and the uterine cavity was narrow with deeper corners (Figure 3), and the fundus was “T” shaped with the uterine body. The uterine fundus and uterine body were “T” shaped. The opening of the fallopian tubes was visible bilaterally. A plasma bipolar electrosurgery needle electrode was used to separate the adherent endoplasmic tissue of the fundus of the uterus by about 1 cm, and the myometrial tissue of the lateral wall of the uterus was cut from the uterine horns by about 4 cm, and the morphology of the uterine cavity was trimmed to basically normal (Figure 4). A T-type intrauterine device was inserted. Two months after the operation, the hysteroscope was secondly explored and the uterine cavity morphology was basically normal, and the IUD was removed. 24 May 2011 38+5W cesarean delivery of a healthy male baby weighing 3450 g was performed and is now established. Case 3, Wang, 27 years old, Taiyuan, Shanxi, hospitalization number 219619, G1P0, 1 year of secondary infertility, external HSG showed a patent fallopian tube. Admitted to the hospital on December 10, 2010 with the diagnosis of secondary infertility. On December 14, 2010, she underwent combined hysterolaparoscopic surgery under general anesthesia with intravenous complex tracheal intubation and merocyanine lavage with bilateral tubal merocyanine overflow. The uterine cavity was 7 cm deep, the walls of both sides of the uterine cavity were coalescing, and the upper middle section was obscuring the opening of both fallopian tubes. At the end of 2011, the right ovarian pregnancy was cured by laparoscopic surgery in our hospital, and the uterine cavity was normal at the time of the second hysteroscopy. The patient’s last menstrual period was on December 16, 2011. a healthy baby boy weighing 4000 g was delivered by cesarean section at 40 weeks of gestation on September 23, 2012 and is still alive. Discussion Since the application of DES for the prevention of premature abortion in 1940 [8], its adverse effects female fetal reproductive organs may be malformed, with uterine hypoplasia and cavity narrowing, have attracted widespread medical attention. This malformation is characterized by a proximal stenosis of the uterus that resembles a T-shaped uterus with an arch-shaped base [9]. It has a high rate of spontaneous abortion after pregnancy (47%) and a low rate of full-term pregnancy (21%) [2]. Hysteroscopic uterine wall incision (TCUI) removes excessive muscle tissue located in the lateral wall of the uterus or cuts through the hypertrophied muscular layer of both walls to enlarge the volume of the uterine cavity and obtain a triangular uterine cavity.Hysteroscopic orthopedic surgery of the T-shaped uterus improves the reproductive prognosis, with a significant increase in the rate of full-term pregnancies after surgery [6, 7]. In 2011 Fernandez et al [5] introduced the concept of acquired T-shaped uterus, such as Asherman syndrome, which according to the European Society for Gynecologic Endoscopy [10] regarding the classification of uterine adhesions, degree Va, as adhesions with scarring resulting in extreme deformation and stenosis of the uterine cavity, consistent with an acquired acquired T-shaped uterus. Nowadays, DES intrauterine exposure is history and there are no new cases, however, all types of congenital and acquired uterine malformations are still common, leading to infertility, recurrent miscarriage and preterm delivery. In-depth discussion of the diagnosis and treatment of T-shaped uterus, uterine dysplasia and other malformations can play an important role in improving the reproductive prognosis of infertile women. 1. In the diagnosis of T-shaped uterus, transabdominal, transvaginal, two-dimensional and three-dimensional ultrasonography and hysterosonography are available, but combined hysterolaparoscopy is the gold standard for accurate diagnosis of septate uterus [11]. Kipersztok et al [12] performed a double-blind controlled comparative study of the role of HSG, MRI and TVS in the diagnosis of T-type uterus in women with a history of DES exposure. MRI and HSG detected 60% of uterine cavity stenosis and 25% of T-type uterus, while TVS failed to found. HSG is still considered to be the method of choice for the evaluation of uterine malformations associated with DES exposure. Therefore, MRI should be performed instead of TV-US in cases where HSG shows uterine anomalies. van Gils et al [13] studied the value of MRI in diagnosing uterine anomalies in women with a history of DES exposure and showed excellent agreement between MRI and HSG in detecting uterine cavity, uterine body and cervix dysplasia, T-shaped uterus, uterine cavity narrowing and bilateral hydrocele, but MRI failed to detect disorganized margins of the uterine cavity and tubal diverticula. In this paper, case 1 was suggestive of HSG and confirmed by hysteroscopy. In case 2, hysteroscopy at an outside hospital and ultrasound at our hospital both suggested uterine stenosis, and the hysteroscopy revealed a “T”-shaped fundus and uterine body. Case 3 was also found during hysteroscopic surgery, which indicates that it is important to improve the hysteroscopic recognition of “T” type uterus for the diagnosis of “T” type uterus. The development of hysteroscopy for orthopedic surgery of T-shaped uterus has replaced open orthopedic uterine surgery. Today, hysteroscopic monopolar or bipolar electrosurgery is practical and effective and has become the method of choice for orthopedic uterine deformities. The procedure is performed in the early follicular phase or 1 month after progesterone or gonadotropin-releasing hormone, with endometrial pre-treatment [5]. The pretreatment of cervical softening is done the night before surgery, and the procedure is performed by carefully slicing or excising the excessive myometrium of the lateral wall of the uterus vertically from the horn to the isthmus with a needle electrode or ring electrode under direct hysteroscopic vision, cutting no deeper than 5-7 mm, gradually decreasing in depth the further down the uterus, thinning the uterine wall and expanding the volume of the uterine cavity until the uterine cavity is normal in shape and has a symmetrical inverted triangle. Care was taken not to cut the uterine wall too thinly during the operation. Fernandez et al. reported [5] 97 cases with one uterine rupture during TCUI, which was cured conservatively. Postoperative estrogen artificial cycle was given for 2 months and hysteroscopy was performed at 2 months postoperatively on second visit to determine the presence of circumferential adhesions, to assess the uterine cavity morphology and to trim the uterine cavity if necessary. Five cases were found to have postoperative adhesions or incomplete morphology at postoperative follow-up and were reoperated without affecting the reproductive prognosis. In this paper, case 1 was performed by excision of excessive myometrium of the lateral wall of the uterus, and cases 2 and 3 were performed by delineation of the myometrium of the lateral wall of the uterus, and all of them resulted in live infants. 3, Orthopedic surgical results in T-shaped uterus In 1980, Viscomi et al [6] reported ultrasound scan results in 18 DES intrauterine exposed women and 20 matched controls of the same age, the uterine volume was 49.4 cm3 ± 25.5 SD in the exposed group and 90 cm cm3 ± 22 SD in the unexposed group, indicating that such malformations are dominated by uterine hypoplasia and cavity stenosis. TCUI for the treatment of T-shaped uterus is a procedure that enlarges the uterine cavity by removing excessive muscle located in the uterine wall.In 1993 Nagel and Malo reported [14] the first report of 8 cases of TCUI for DES-induced uterine malformations, 5 cases of secondary infertility with live infants after surgery and 3 cases of primary infertility without pregnancy.Katz et al [6] reported 8 cases of HSG and hysteroscopic diagnosis of T-shaped uterus, cutting the uterine lateral wall until the uterine cavity was normal and the postoperative uterine cavity morphology was satisfactory. There were 10 spontaneous abortions and 1 ectopic pregnancy preoperatively. Postoperatively, there was one ectopic pregnancy and three of the seven cases obtained four full-term pregnancies without miscarriage.Garbin et al [15] reported 24 cases of dysplastic uterus due to DES and the rate of miscarriage after TCUI decreased from 88% to 12.5% and the rate of full-term delivery increased from 3% to 87.5% preoperatively.Aupriot et al [16] reported 51 cases of TCUI with T-shaped uterus 16 months after surgery Barranger et al [17] reported 29 patients with dysplastic uterus malformations with infertility, recurrent miscarriage, and preterm delivery, and the delivery rate increased from 3.8% to 63.2% after TCUI. aubriot & Chapron reported [9] 61 cases of T-type uterus TCUI 16 months after surgery. 37 pregnancies. giacomucci et al [7] reported an increase in the rate of full-term delivery from 5.5% to 59% after surgery in 170 cases of TCUI with malformed uterus, Fernandez et al [5] reported 94% hysteroscopy with good anatomical findings after surgery in 97 cases of TCUI with T-type uterus. 48 (49.5%) had 57 pregnancies, the rate of early abortion decreased from 78.2% to 26.9% (p<0.05) before surgery, and the live birth The rate of live births increased from 0% to 73% before surgery. It is evident that TCUI does improve the prognosis of pregnancy and increase the live birth rate in patients with T uterus with primary infertility, recurrent miscarriage or preterm delivery. The indication for the possibility of vaginal delivery after orthopedic surgery, but the high rate of cesarean delivery, is not the indication for orthopedic surgery itself nor for obstetrics, but the feeling that pregnancy is really precious in infertile patients. 4. evaluation of TCUI procedure Among all types of uterine anomalies, the highest rate of full-term pregnancy after orthopedic surgery was observed in T-shaped uterus (66.7%), 62.8% in complete and incomplete septate uterus and 55.6% in arcuate uterus [7]. These results suggest that hysteroscopic orthoplasty of T-shaped uterus improves the reproductive prognosis. However, hysteroscopic orthoplasty is not a treatment for infertility in T-shaped uteri, much less the first choice, and is not recommended when the uterine cavity is less than 4 cm. Because of the possible presence of other factors of infertility, such as insemination, overdue miscarriage and preterm delivery, the outcome of a successful postoperative pregnancy is difficult to estimate. Therefore, it is generally recommended only for patients with a stenotic ring in the uterus as the only infertility factor, treatment failure after diagnosis of infertility, ART failure of unknown cause, and those with unexplained repeat miscarriages [16].Uterine perforation has been reported during TCUI [5]. Several cases of spontaneous uterine rupture in postoperative pregnancy have been reported in the literature, and in 2003 Porcu, France, reported [18] a case of a 28-year-old patient, uncomplicated, whose uterus had a history of DES exposure. With no history of uterine surgery, acute abdominal pain at 12 weeks of gestation was seen on opening with rupture of the anterior wall of the uterus near the base and normal bilateral fallopian tubes. This case is the first report of spontaneous rupture of a DES-exposed non-scarred uterus in early pregnancy. 2008 Velemir et al. reported [19] a case of uterine rupture at 26 weeks of gestation in a DES-exposed woman after correction of uterine dilation. In addition, Golan et al [2] reported that 30% of T-shaped uteri and unicornuate uteri had cervical insufficiency with a 50% rate of preterm and late miscarriage in those with cervical cerclage and 21% in those without (p<0.001). kaufman reported [20] 33% (178) cervical abnormalities in 537 women with a history of intrauterine DES exposure. Therefore, to improve the outcome, attention should be paid to cervical insufficiency after orthopedic T-uterine surgery, either by prophylactic cervical cerclage or emergency cervical cerclage in case of symptoms. In this paper, three cases did not undergo prophylactic cervical cerclage and were not monitored for changes in the endocervical opening during pregnancy, and all of them were pregnant to full term, which is a fluke and should be noted in the future.