The physical location of the uterus, a dynamic pelvic organ, differs significantly among women. The uterus is anteverted and anteflexed, resting forward over the bladder with the cervix pointing posteriorly in most females of reproductive age [1]. However, deviations such as retroversion, retroflexion, mid-position, and lateral deviation are often found during pelvic ultrasonography and routine gynecological examination.

While other positional anomalies are less prevalent, 15% to 30% of women of reproductive age have a retroverted uterus. In the past, these differences were thought to be only anatomical oddities with no practical implications [2]. However, recent research points to potential connections between uterine orientation and gynecological symptoms such infertility, pelvic pain, dysmenorrhea, dyspareunia, and obstetric problems.

About 50–90% of women of reproductive age suffer from dysmenorrhea, which is still one of the most frequent reasons why people miss work and school. Increased uterine contractions and poor menstrual outflow are two mechanical aspects of uterine position that may exacerbate pain [3].

Infertility is still a significant global public health issue. Uterine position may coexist with pelvic adhesions, endometriosis, or altered sperm transport mechanisms that could affect fertility potential, even though it is unlikely to be a direct cause of infertility.

Uterine orientation may potentially affect the course of a pregnancy. Urinary retention, discomfort, imprisonment of the gravid uterus, miscarriage, and surgical delivery have all been linked to a retroverted uterus in the early stages of pregnancy. Despite these findings, there is still conflicting and scant information about the actual clinical importance of uterine positional differences [4-5].

The present study was undertaken to evaluate the prevalence of different uterine positions and investigate their association with dysmenorrhea, infertility, and pregnancy outcomes among women attending a tertiary care center[6].

Present study is Hospital-based cross-sectional observational study, conducted at Department of Anatomy SN Medical College Agra in Collaboration of Department of Obstetrics & Gynecology S N Medical College Agra for 12 months, and antenatal clinics during the study period.

Sample Size: A total of 150 women fulfilling inclusion criteria were enrolled consecutively.

Inclusion Criteria

• Women aged 20–40 years.
• Married women with complete reproductive history available.
• Women consenting to pelvic examination and ultrasonography.
• Women willing to participate in the study.

Exclusion Criteria

• Congenital uterine malformations.
• Previous hysterectomy.
• Large fibroids distorting uterine anatomy.
• Pelvic inflammatory disease.
• Endometriosis diagnosed before enrolment.
• Pelvic malignancy.
• Previous pelvic reconstructive surgery.

Methodology

After obtaining informed consent, demographic and clinical information was recorded using a structured questionnaire. Detailed menstrual history, obstetric history, and infertility history were documented.

Pelvic examination was performed by experienced gynecologists. Uterine position was confirmed by ultrasonography and classified as:

• Anteverted anteflexed uterus
• Retroverted retroflexed uterus
• Mid-position uterus
• Laterally deviated uterus

Dysmenorrhea was graded using visual analogue scale:

• Mild (VAS 1–3)
• Moderate (VAS 4–6)
• Severe (VAS 7–10)

Infertility was defined as inability to conceive after one year of regular unprotected intercourse.

Pregnancy outcomes evaluated included:

• Live birth
• Miscarriage
• Preterm delivery
• Cesarean delivery
• Postpartum complications

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using SPSS version 26. Continuous variables were expressed as mean ± standard deviation, while categorical variables were expressed as frequencies and percentages.

Associations between uterine position and clinical variables were analyzed using Chi-square test and ANOVA where appropriate. A p-value less than 0.05 was considered statistically significant.

Table 1: Distribution of Anatomical Variations of Uterine Position among Study Participants (n=150)

The mean age of study participants was 29.8 ± 5.6 years. Most women belonged to the age group of 26–35 years (58.7%). The mean body mass index was 24.6 ± 3.8 kg/m². Multiparous women constituted 56.0% of the study population.

Table 2: Association between Uterine Position and Dysmenorrhea Severity

The anteverted anteflexed uterus represented the most common anatomical orientation accounting for nearly two-thirds of participants, whereas lateral deviation represented the least frequent variation.

Table 3: Association Between Uterine Position and Infertility

Women with retroverted retroflexed uterus demonstrated significantly higher frequencies of moderate and severe dysmenorrhea compared with women having anteverted uterus. Infertility was significantly more common among women with retroverted uterus compared with women having anteverted uterus.

Table 4: Association between Uterine Position and Pregnancy Outcomes

Women with retroverted uterus experienced significantly higher rates of miscarriage, preterm delivery, and cesarean section

In this study, 150 women's uterine positioning variations were assessed, and their associations with dysmenorrhea, infertility, and pregnancy outcomes were investigated. Our study's anteverted anteflexed uterine prevalence of 62% is in line with earlier publications showing frequencies between 60% and 80%. 24.7% of patients had a retroverted uterus, which is in striking agreement with the prevalence documented in international literature [7].

Our results showed a significant correlation between the severity of dysmenorrhea and a retroverted uterus. Compared to just 16.1% of women with an anteverted uterus, approximately one-third of women with a retroverted uterus had severe dysmenorrhea [8–9]. The hypothesis that posterior uterine orientation may impede menstrual drainage and enhance myometrial contractility is supported by this observation.

Numerous researchers have proposed that resistance to menstrual outflow is influenced by the angle between the cervix and uterine body. Painful uterine contractions and prostaglandin release may be caused by increased intrauterine pressure brought on by poor drainage [10].

The association between uterine position and infertility remains contentious. Infertility prevalence among women with retroverted uteruses was 37.8% in the current study, which is substantially greater than the 12.9% seen among women with anteverted uteruses [11].

Changes in sperm transport, poor cervical mucus distribution, or the coexistence of pelvic adhesions and endometriosis—both of which may lead to infertility and retroversion—are some possible factors. However, in the absence of further illness, retroversion should not be considered a stand-alone cause of infertility [12].

Our study's results are similar to those of previous researchers who found that women with retroverted uteruses had greater rates of infertility, especially when endometriosis or pelvic adhesions were present [13]. Uterine position also had a major impact on pregnancy outcomes. Miscarriage and premature delivery were more common in women with retroverted uteruses than in those with anteverted uteruses.

Urinary retention, pelvic discomfort, and obstetric problems can occasionally result from the retroverted gravid uterus becoming trapped inside the pelvis during the early stages of pregnancy. These difficulties highlight the significance of early detection and monitoring, despite their rarity.

The greater cesarean section rate seen among women with retroverted uterus may indicate aberrant fetal positioning, labor dysfunction, or clinician predilection for operational delivery in complex pregnancies[14].

It is interesting to note that women with laterally deviated and mid-position uteruses showed results comparable to those with anteverted uteruses, indicating that these differences may have little clinical importance. This study's merits include the inclusion of several reproductive outcomes in a comparatively large sample size and the ultrasonographic confirmation of uterine location [15–16].

It is important to recognize some restrictions, though. Causal inference is limited by the cross-sectional design. It is possible that endometriosis and pelvic adhesions went undiagnosed in some patients, which could have complicated the associations found. Additionally, the study's single-center design may restrict its generalizability. To more clearly identify the clinical significance of uterine positioning differences, more multicenter prospective studies with bigger populations and long-term follow-up are needed.,

Anteverted anteflexed uterus remains the most common uterine orientation among reproductive-age women. Retroverted retroflexed uterus was identified in approximately one-quarter of participants and demonstrated significant associations with dysmenorrhea, infertility, and adverse pregnancy outcomes. Women with retroverted uterus experienced higher rates of moderate to severe dysmenorrhea, infertility, miscarriage, preterm delivery, and cesarean section compared with women having anteverted uterus.

Routine assessment of uterine position during gynecological examination and ultrasonography may provide useful information for counseling women regarding reproductive health and pregnancy expectations.

1. Cicinelli E, Matteo M, Tinelli R, Pinto V, Marinaccio M, Indraccolo U. Prevalence of uterine retroversion and reproductive outcome. Fertil Steril. 2010;94(3):1121-1124.
2. Dietz HP, Benness CJ, Grace M. Pelvic organ position and uterine orientation assessed by ultrasound imaging. Ultrasound Obstet Gynecol. 2008;32(3):335-339.
3. Fedele L, Bianchi S, Frontino G. Clinical implications of uterine malposition. Curr Opin Obstet Gynecol. 2009;21(4):312-316.
4. Rock JA, Jones HW. Te Linde's Operative Gynecology. 12th ed. Philadelphia: Wolters Kluwer; 2019.
5. Cunningham FG, Leveno KJ, Bloom SL, Dashe JS. Williams Obstetrics. 26th ed. New York: McGraw-Hill; 2022.
6. Berek JS. Berek and Novak's Gynecology. 16th ed. Philadelphia: Lippincott Williams and Wilkins; 2020.
7. Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 8th ed. Philadelphia: Wolters Kluwer; 2018.
8. Hricak H, Alpers C, Crooks LE, Sheldon PE. Magnetic resonance imaging of the female pelvis. Radiology. 1983;147(3):751-756.
9. Kjerulff KH, Erickson BA, Langenberg PW. Chronic gynecological conditions and quality of life. Obstet Gynecol. 1996;87(6):946-951.
10. Dawood MY. Primary dysmenorrhea: advances in pathogenesis and management. Obstet Gynecol. 2006;108(2):428-441.
11. Farquhar CM. Endometriosis. BMJ. 2007;334:249-253.
12. Brosens I, Puttemans P, Benagiano G. Endometriosis and infertility. Best Pract Res Clin Obstet Gynaecol. 2004;18(2):311-328.
13. Grimbizis GF, Campo R. Congenital malformations and reproductive outcome. Hum Reprod Update. 2010;16(6):643-658.
14. Burton GJ, Jauniaux E. Maternal uterine anatomy and placentation. Placenta. 2011;32:S20-S25.
15. Jurkovic D, Wilkinson H. Diagnosis and management of miscarriage. BMJ. 2011;342:d3676.
16. Creasy RK, Resnik R, Iams JD. Creasy and Resnik's Maternal Fetal Medicine. 8th ed. Philadelphia: Elsevier; 2019.