Reply: T‐shaped and dysmorphic uterus – misclassifications and low‐quality evidence promote unnecessary surgery

The diagnosis of T-shaped uterus is questionable as most of the existing definitions are arbitrary and subjective, largely based on expert opinion1. Some of the classification systems for uterine malformations were developed by researchers or societies with potential commercial bias and seem to overestimate their prevalence2. One should also be aware that uterine contractions3 and even changes during the menstrual cycle might affect features related to the diagnosis of T-shaped uterus and result in an erroneous diagnosis of a normal uterus as T-shaped or dysmorphic (Figure 1). The three different subtypes of T-shaped uterus described by Alonso Pacheco et al.4 (i.e. T-shaped, Y-shaped and I-shaped uterus) might be regarded as normal, arcuate or T-shaped uterus. This subclassification is arbitrary, non-reproducible and based on a report of three cases. There is no proven association between the diagnosis of T-shaped uterus and worse reproductive outcomes5. This raises the question of whether this diagnosis is clinically relevant. If women with a T-shaped uterus have similar reproductive outcomes to those with a normal uterus, then what is the rationale for treatment? Evidence regarding the benefit of intervention for T-shaped uterus is based on suboptimal studies, such as uncontrolled pre–post intervention studies that favor the intervention, with a risk of overestimating its effect. Such low-quality evidence cannot justify the expenses and risks associated with surgery in women with T-shaped uterus and the financial burden to healthcare systems. A systematic review and meta-analysis based on poor-quality and potentially biased studies6 is not better than the original evidence. The authors highlight the benefits of hysteroscopic metroplasty with respect to live-birth rate and low miscarriage rate in patients presenting with primary infertility or recurrent miscarriage, discourage expectant management and judge hysteroscopic metroplasty as being an adequate intervention, despite the absence of good-quality evidence to support this and the associated costs and possible complications. Clinical decisions should always be based on methodologically rigorous studies, such as randomized controlled trials (RCTs), and, to date, the effectiveness and safety of hysteroscopic metroplasty for T-shaped uterus have not been evaluated in a RCT. It would not be surprising if a future RCT shows that hysteroscopic procedures for T-shaped uterus are of no benefit. There should be no urgency to promote surgical intervention for a condition that might be only a variant of normal uterus1 rather than an anomaly, or that might be judged as normal if evaluated by a different examiner (subjectivity of the classification) or reassessed after a few minutes (waves of myometrial contraction3). Advocating procedures in the absence of proper evidence seems to be a strategy, supported by industry, to convince patients that new interventions should be used in clinical practice, not because they are helpful but because they are lucrative. The cost of office diagnostic hysteroscopy in the USA is about $300, but a cosmetic metroplasty costs an average of $15007. We echo the sentiments of Peter Gøtzsche regarding the corruption of medicine today (https://www.youtube.com/watch?v=GSsvSdk5WSk). The authors declare no competing interests.