Main cause of male infertility:
I. Testicular insufficiency.
• Orchitis (viral) .
• Testicular torsion .
• Cytotoxic therapy (chemotherapy).
• Radiotherapy .
• Genetic causes (Klinefelter’s syndrome, Y deletions).
II. Endocrine disorders.
• Kallmann’s syndrome .
• Pituitary gland disorders (adenoma, infection).
III. Obstructions of the male genital tract .
• Congenital absence of the vas deferens .
• Müllerian prostatic cysts .
• Epididymal obstructions (infections, congenital).
• After groin or scrotal surgery .
IV. Sperm antibodies .
Medication, environment, stress, illness.
Sexual problems/ejaculation disorders.
Causes of Male Infertility The various causes of male infertility can
be subcategorized as obstructive and nonobstructive azoo- or
hypospermia. Nonobstructive disease includes varicocele, endocrinopathy,
chromosomal abnormality, cryptorchidism, anabolic steroid abuse,
gonadotoxin exposure, primary testicular failure, and ejaculatory
disorders. Obstructive disorders include congenital bilateral absence of the
vas deferens, ejaculatory duct obstruction, and prostatic cysts.
The most common cause of correctable male infertility is a varicocele.
These are best imaged with gray-scale and color Doppler sonography .
Varicoceles are defined as internal spermatic veins that are dilated to
greater than 3 mm. Valsalva maneuvers can be used during ultrasound to
evaluate the change in size of the veins with increased abdominal
pressure. Varicoceles are found in 40% of men with primary infertility and
between 45 and 80% of men with secondary infertility. Even a subclinical
varicocele can have negative effects on spermatogenesis. When unilateral,
varicoceles are more commonly left-sided. If isolated right-sided
varicoceles are detected, which is uncommon, the possibility of a
retroperitoneal process compressing the right gonadal vein should be
On grey scale imaging a varicocele is seen as serpiginous tubules posterior
to the testis (a). Colour flow Doppler confirms flow within varicocele.
33-year-old man with low sperm count undergoing evaluation for infertility.
Sagittal sonograms of the superior aspect of the left hemiscrotum show
multiple dilated peritesticular veins on color Doppler imaging (A) and an
individual vein on gray-scale imaging (B) that measures 4.2 mm when
Valsalva maneuver is used. These findings are compatible with a varicocele.
(a) On grayscale imaging a varicocele is seen as serpiginous tubules inferior to the
testis (arrow). (b) Colour flow Doppler confirms flow within the varicocele (arrow).
Varicocele with a dilated venous plexus with reflux during straining The testis is normal.
26-year-old man with mildly elevated prolactin level. Coronal T1-weighted
(A), coronal T2-weighted (B), and coronal (C) and sagittal (D) T1-weighted
contrast-enhanced MR images show adenoma on the right side of the
pituitary gland (arrow) that has a central area of fluid or necrosis.
MRI showing pituitary microadenoma
(a, b) and stalk thickening (c)
34-year-old man with bilateral cryptorchidism. Sagittal sonograms show
both testes to be located in the inguinal canals and diminutive. Testicular
volume measured 2–3 mL each (normal range, 18–20 mL).
28-year-old man with history of left cryptorchidism after orchiopexy
at age 6 years. Sagittal sonograms of both testes show that the left
testis (B) is smaller than the right (A) and markedly heterogeneous.
Ultrasound image of the groin in a patient with undescended testis demonstrates
a hypoechoic, small testis in keeping an infracted undescended testis.
Heterogeneous testis with associated ectasia of the rete testis (short arrows) and
dilated body of the epididymis (long arrow) in keeping with long-standing obstruction.
26-year-old man with no palpable vas deferens on physical
examination. Midline transverse sonogram of both testes shows
dilatation of the rete testis in the medial aspect of each testis. These
findings are typical of congenital bilateral absence of the vas deferens.
Ultrasound of both
of the testes with
These finding are
suggestive of a
which should be
Heterogeneous testis with ectasia of the rete
testis in keeping with long standing obstruction.
Scrotal ultrasound demonstrating thickening and enlargement
of the epididymal body in a case of infective epididymitis.
Scrotal ultrasound demonstrating thickening and enlargement of the epididymal body
(arrow) in a case of infective epididymitis. The testis is spared from the infective process.
Epididymal head abnormalities in obstructive azoospermia. (a) Longitudinal
(left) and transverse (right) US images in a 31-year-old man with proved
CBAVD show tubular ectasia (arrowheads) in the epididymal head.
Longitudinal testicular ultrasound demonstrating an a dilated,
heterogeneous epididymis characteristic of the post vasectomy appearance.
A transrectal ultrasound examination demonstrating calcification within the ejaculatory
duct (short arrow) with dilatation of the vas deferens proximally (long arrow).
TRUS demonstrating calcification within the ejaculatory
duct with dilatation of the vas deferens proximally.
Bilateral dilatation of the vas deferens on TRUS.
(a) Longitudinal scan demonstrating a small testis with a heterogeneous echo-texture and
a varicocele (arrows) in a patient being investigated for infertility. (b) Focal dilatation of
the epididymis (arrow) in keeping with chronic obstruction secondary to infection.
Bilateral thickening of the vas deferens on a transrectal
ultrasound examination in keeping with vesiculitis (arrows).
Twenty five years
infertile man with
within the SV and
V; B: Bilateral
34-year-old hypospermic male. Axial (A) and coronal (B) T2-
weighted MR images using an endorectal coil show a normal
left seminal vesicle (arrows) but none on the right.
Obstruction of ejaculatory ducts. In 28-year-old man, axial 3D T2-weighted MR
image shows two normal ejaculatory ducts entering the prostate gland (arrows).
Percutaneous right vasography in a patient with obstructed infertility shows
complete obstruction of the ejaculatory duct with retention of the dye in the
vas (arrowhead) and SV and non opacification of the urinary bladder.
Prostatic cysts. Axial (A) and sagittal (B) T2-weighted MR images
using an endorectal coil (asterisk) in a 26-year-old man show a large
midline cyst (arrow) limited to the prostate gland.
Small cyst lying within the midline within the prostatic
utricle (arrow) with dilated prostatic utricle.
A 27-year-old with
primary infertility. A:
TRUS shows a 3 cm × 2
cm thin walled midline
urogenital cyst; B:
opacification of the
cyst revealed that the
cyst was blind with no
the seminal tract.
of the sperm count 3 d
after complete cyst
A 29-year-old man with
infertility. TRUS (upper
image) and endorectal
magnetic resonance imaging
(middle image) show a well-
defined midline urogenital
cyst with intra-and
(lower image) shows the
seminal vesicle is
communicating with the
urogenital cyst with non
opacification of the urethra
or urinary bladder denoting
complete distal obstruction
(N.B. the left vas and seminal
vesicles were absent). Trans-
urethral incision of the cyst
lead to improvement of
A 33-year-old man with primary infertility. TRUS-guided contrast opacification
of midline prostatic cyst shows the presence of a large cyst communicating on
the right side with the right vas (arrowhead) and right SV. On the left side the
cyst is communicating with a blind tubular structure (arrow), which proved to
be an ectopic short ureter of a hypoplastic left kidney.
33-year-old asymptomatic, hypospermic man undergoing infertility
evaluation. Transverse sonogram of the right testicle shows multiple
hypoechoic masses in the parenchyma, consistent with multifocal
tumor. Pathology at surgical resection revealed seminoma.
Longitudinal ultrasound image of a testicular mass demonstrating increased
Doppler flow within the lesion; a histologically proven seminoma.
20-year-old man after scrotal trauma 1 week previously who presents with
swelling of the scrotum. Transverse sonogram of the scrotum reveals a large
amount of fluid surrounding the testicle, consistent with a hydrocele.
Longitudinal sonogram of a testicle of a 25-year-old man undergoing scrotal
sonography as part of an infertility evaluation shows multiple punctate calcifications
scattered throughout the parenchyma, consistent with testicular microlithiasis.
A severely affected testis following orchitis, demonstrating mixed reflectivity with
pockets of high reflectivity likely to represent areas of infarction and hemorrhage.
Longitudinal ultrasound image of orchitis demonstrating heterogeneous
echotexture, testicular enlargement and increased vascularity (A). Chronic
changes within the testis giving it a mottled post orchitis (b).
35-year-old asymptomatic man undergoing sonography as part of
an infertility evaluation. Longitudinal sonogram of the epididymal
head shows a cyst with posterior through-transmission.
37-year-old man with infertility and painful erections who was found on physical
examination to have a palpable abnormality along the shaft of the penis. Contrast-
enhanced axial (B) and sagittal (C) T1-weighted MR images of the penis show
enhancing plaque (arrows) along the anterior aspect of both the corpora cavernosum
in B and the anterior and posterior aspects of the left corpus cavernosum in C.
Axial fast SE MR image (7,700/147) shows a large,
midline, hemorrhagic ejaculatory duct cyst.
Coronal fast SE MR
Image shows a
cyst. (9b) Sagittal
fast SE MR image
of blood within the
cyst. (10) Axial (a)
and coronal (b)
fast SE MR images
show a utricle cyst.
Coronal fast SE MR image shows prostatitis. The peripheral gland demonstrates diffuse
decreased signal intensity (arrow). (15) Axial fast SE MR image shows tuberculous
prostatitis. Diffuse, abnormal low signal intensity is present in the peripheral zone (arrow).
Axial fast SE MR image shows atrophic seminal vesicles
(arrows) secondary to a low testosterone level.
Axial fast SE MR image shows congenital absence of the vasa deferentia. The
linear structures of high signal intensity anterior to the prostate gland are
vascular and mimic the vasa. The normal vasa are convoluted, not linear. Coronal
fast SE MR image shows congenital absence of the left seminal vesicle and vas
deferens. There is a seminal vesicle cyst in anatrophic right seminal vesicle
(arrow). Arrowhead indicates where the vas deferens should enter the prostate
Zinner syndrome. Shows absence of the right kidney. (b) Sagittal fast SE MR image shows an
ectopic, blind-ending ureter (arrow). (c) Sagittal fast SE MR image slightly lateral to b shows the
ureter (arrow) entering a dilated seminal vesicle (arrowheads). (d) Sagittal fast SE MR image
shows a dilated vas deferens (arrow). (e) Sagittal fast SE MR image shows a dilated seminal
vesicle. (I) Retrograde urethrogram of another patient with similar examination results shows left
renal agenesis and a blind ending, bifid ureter with ectopic insertion into a seminal vesicle cyst.
Given the prevalence of male infertility, the
radiologist's familiarity with its appropriate
imaging workup and recognition of the
commonly involved pathologic processes is
critical. Imaging plays a key role in the
evaluation of the hypospermic or azoospermic
man. It can detect correctable abnormalities,
which can lead to a successful conception. It can
also reveal potentially life-threatening disorders
in the course of an infertility evaluation.