AFS classification of Müllerian anomalies

Last revised by Henry Knipe ◉ on 21 Mar 2025

Citation, DOI, disclosures and article data

Citation:

Gaillard F, Knipe H, Silverstone L, et al. AFS classification of Müllerian anomalies. Reference article, Radiopaedia.org (Accessed on 28 Mar 2025) https://doi.org/10.53347/rID-6322

DOI:

https://doi.org/10.53347/rID-6322

Permalink:

https://radiopaedia.org/articles/6322

rID:

6322

Article created:

6 Jun 2009, Frank Gaillard ◉ ◈

Disclosures:

At the time the article was created Frank Gaillard had no recorded disclosures.

View Frank Gaillard's current disclosures

Last revised:

21 Mar 2025, Henry Knipe ◉

Disclosures:

At the time the article was last revised Henry Knipe had the following disclosures:

Micro-X Ltd, Shareholder (past)

These were assessed during peer review and were determined to not be relevant to the changes that were made.

View Henry Knipe's current disclosures

Revisions:

29 times, by 18 contributors - see full revision history and disclosures

Systems:

Gynaecology

Sections:

Classifications

Tags:

uterus

Synonyms:

Müllerian duct anomaly classification (AFS classification)
Classification of Mullerian duct anomalies
Mullerian duct anomaly classification

The American Fertility Society (AFS) classification of Müllerian anomalies is a seven-class system published in 1988, which is used to describe several embryonic Müllerian duct anomalies.

The American Fertility Society is now known as the American Society of Reproductive Medicine (ASRM), and the AFS classification is sometimes referred to as the ASRM classification ¹¹. However, using "AFS classification" is preferred to differentiate the 1988 classification from the more recent ASRM Müllerian anomalies classification 2021 ¹².

The AFS classification, published in 1988, is one of the most widely used and recognised (c. 2022) classification systems for Mullerian duct anomalies. However, there are other classification systems with no clear consensus on use ^9-11. It is based on a classification system published in 1979 by Buttram and Gibbons ^1,9. Criticisms of this system include the focus on uterine anomalies only (excluding cervical and uterine anomalies), unclear criteria, and complex anomalies being difficult to classify ⁹.

Classification

class I: uterine agenesis/uterine hypoplasia
- a: vaginal (uterus: normal/variety of abnormal forms)
- b: cervical
- c: fundal
- d: tubal
- e: combined
class II: unicornuate uterus/unicornis unicollis, ~15% (range 6-25%)
- a: communicating contralateral rudimentary horn contains endometrium
- b: non-communicating contralateral rudimentary horn contains endometrium
- c: contralateral horn has no endometrial cavity
- d: no horn
class III: uterus didelphys, ~7.5% (range 5-11%)
class IV: bicornuate uterus: 2nd most common type ~25% (range 10-39%)
- a: complete division, all the way down to the external os (bicornuate bicollis)
- b: partial division, not extending to the internal os (bicornuate unicollis)
class V: septate uterus: commonest anomaly, ~45% (range 34-55%)
- a: complete division, all the way down to the internal or external os
- b: incomplete division, involving the endometrial cavity but not the cervix
class VI: arcuate uterus, ~7%
class VII: in utero diethylstilboestrol (DES) exposure (T-shaped uterus)

Quiz questions

References

1. Buttram V & Gibbons W. Müllerian Anomalies: A Proposed Classification. (An Analysis of 144 Cases). Fertil Steril. 1979;32(1):40-6. doi:10.1016/s0015-0282(16)44114-2 - Pubmed
2. Carrington B, Hricak H, Nuruddin R, Secaf E, Laros R, Hill E. Müllerian Duct Anomalies: MR Imaging Evaluation. Radiology. 1990;176(3):715-20. doi:10.1148/radiology.176.3.2202012 - Pubmed
3. Ronald J. Zagoria. Genitourinary Radiology. (2004) ISBN: 9780323018425 - Google Books
4. Troiano R & McCarthy S. Mullerian Duct Anomalies: Imaging and Clinical Issues. Radiology. 2004;233(1):19-34. doi:10.1148/radiol.2331020777 - Pubmed
5. Mueller G, Hussain H, Smith Y et al. Müllerian Duct Anomalies: Comparison of MRI Diagnosis and Clinical Diagnosis. AJR Am J Roentgenol. 2007;189(6):1294-302. doi:10.2214/AJR.07.2494 - Pubmed
6. Steinkeler J, Woodfield C, Lazarus E, Hillstrom M. Female Infertility: A Systematic Approach to Radiologic Imaging and Diagnosis. Radiographics. 2009;29(5):1353-70. doi:10.1148/rg.295095047 - Pubmed
7. Saleem S. MR Imaging Diagnosis of Uterovaginal Anomalies: Current State of the Art. Radiographics. 2003;23(5):e13. doi:10.1148/rg.e13 - Pubmed
8. Imaoka I, Wada A, Matsuo M, Yoshida M, Kitagaki H, Sugimura K. MR Imaging of Disorders Associated with Female Infertility: Use in Diagnosis, Treatment, and Management. Radiographics. 2003;23(6):1401-21. doi:10.1148/rg.236025115 - Pubmed
9. Acién M & Acién P. Classification of Müllerian Anomalies: Is a Consensus Possible? Case Rep Womens Health. 2022;34:e00413. doi:10.1016/j.crwh.2022.e00413 - Pubmed
10. Ludwin A & Ludwin I. Comparison of the ESHRE-ESGE and ASRM Classifications of Mullerian Duct Anomalies in Everyday Practice. Hum Reprod. 2014;30(3):569-80. doi:10.1093/humrep/deu344 - Pubmed
11. Behr S, Courtier J, Qayyum A. Imaging of Müllerian Duct Anomalies. Radiographics. 2012;32(6):E233-50. doi:10.1148/rg.326125515 - Pubmed
12. Pfeifer S, Attaran M, Goldstein J et al. ASRM Müllerian Anomalies Classification 2021. Fertil Steril. 2021;116(5):1238-52. doi:10.1016/j.fertnstert.2021.09.025 - Pubmed

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Cases and figures

Figure 1: uterine anatomical abnormalities (illustrations)
Case 1: uterine agenesis (class I)
Case 2: uterus didelphys (class III)
Case 3: uterus didelphys (class III)
Case 4: bicornuate uterus (class IV)
Case 5: septate uterus (class V)
Case 6: arcuate uterus (class VI)
Case 7: T-shaped uterus (class VII)
Case 8: unicornuate uterus- Class II
Case 9: uterine hypoplasia (class I)
Case 10: uterine hypoplasia (class I)
Case 11: Bicornuate uterus with triamniotic dichorionic triplet pregnancy (3D ultrasound)
Case 12: complete septate uterus with duplicated cervix
Case 13: partial bicornuate uterus with bilateral tubal block
Case 14: Male with PMDS