includes imaging modalities and asssociated findings in different pathologies of male and female factor of infertility

1. IMAGING IN INFERTILITY
DR. PRABIN POUDEL
MDRD RESIDENT(1st year)
NAMS

2. Introduction
• Infertility is defined as a failure to conceive within one or more years of
regular unprotected coitus.
• Primary infertility
denotes those patients who have never conceived.
• Secondary infertility
Indicates previous pregnancy but failure to conceive subsequently.

3. FACTORS ESSENTIALS FOR CONCEPTION
• Healthy spermatozoa must be deposited high in the vagina or near
cervix
• The spermatozoa must undergo changes (capacitation and
acrosome reaction) and acquire motility.
• Motile spermatozoa must ascend through the cervix into uterine
cavity and the fallopian tubes.
• There should be ovulation.
• The fallopian tube must be patent and the ovum must be picked
by the fimbriated end of tube.
• Fertilization at ampulla of tube and embryo must reach the
endometrial cavity by day 3-4.
• The endometrium must be receptive for implantation and corpus
luteum should function adequately.

4. CAUSES OF INFERTILITY

5. ROLE OF IMAGING
First in the investigation of infertility and
 then in the subsequent management of patients undergoing stimulated
ovulation or assisted reproduction techniques

6. MALE INFERTILITY
• Male infertility is usually caused by conditions affecting
sperm production, sperm function, or both, or blockages
that prevent the delivery of sperm.
• Chronic health problems, injuries, lifestyle choices, anatomic
deformities, hormonal imbalances, and genetic defects can
have a role in male infertility.
• Accounts for 25 to 40% of causes( making a total of 50% as
10% are combined).

7. ETIOLOGY
• PRE-TESTICULAR:
Endocrine:
• Acquired or congenital gonadotrophin deficiencies
• Obesity
• Thyroid dysfunctiom
• Hyperprolactinemia
Drugs:
• Antipsychotics
• Anti- HTN
• TESTICULAR:
Orchits
Varicole
Primary testicular failure
Oligospermia
Immotile cilia
Cryto-orchidism
Malignancy

8. • Post- testicular:
Congenital absence of vas deferens
Post surgical
Retrograde ejaculation
Infections: TB
Erectile dysfunction
Post infective

9. Goals of male evaluation
1. Identification of potentially correctable conditions
2. Identification of irreversible conditions for which
alternative treatments (e.g., donor insemination) or adoption
may be used, preventing ineffective therapies
3. Detection of health-threatening conditions underlying
infertility
4. Detection of genetic abnormalities (e.g., cystic fibrosis) that
may affect the health of children if affected sperm are
harvested or used for assisted reproductive techniques

10. EVALUATION OF MALE
INFERTILITY
 The diagnostic workup of male infertility should include :
o Thorough medical and reproductive history
o Physical examination
o Semen analysis
o Imaging.
• Imaging is performed to look for an underlying structural abnormality
that may be:
• Obstructive
• Non-obstructive

11. IMAGING TECHNIQUE
• The three main imaging modalities used for investigation of
the male reproductive system are
• Ultrasound,
• MRI and
• invasive techniques such as venography and vasography.
• Role of imaging:
• Identifying possible causes of infertility
• Imaging often allows the selection of the best method for
impregnating the female partner, such as image-guided
sperm aspiration from the epididymis or seminiferous
tubules, allowing in vitro fertilization or
intracytoplasmic sperm injection.

12. USG
• Ultrasound remains the mainstay as it is non-invasive, safe
and widely available, and is able to define many of the
abnormalities relevant to male infertility.
• Scrotal US is the preferred modality because it is
noninvasive, safe, and inexpensive and allows multiplanar
imaging. This examination can be used to evaluate potential
testicular abnormalities, calculate the testicular volume, and
identify peri-testicular abnormalities.
• Transrectal US can be used to evaluate the prostate and
possibly identify more central sources of spermatic
obstruction.

13. Normal longitudinal ultrasound image of the testis, demonstrating a
uniform texture and reflectivity with a length of 5.0 cm (normal 3.5–5.0
cm). Volume measurement is calculated as length×height×width×0.51.
Normal volume is 15-20ml.

14. MR Imaging
• Owing to superior soft-tissue contrast and multiplanar
capabilities, MR imaging can depict the detailed anatomy
and pathophysiologic features of the reproductive tract,
including the prostate, seminal vesicles, and ejaculatory
ducts.
• Modality of choice for imaging the accessory sex glands and
their ducts and can help guide diagnostic or corrective
interventional procedures.

15. Computed Tomography
• Computed tomography (CT) facilitates limited soft-tissue
resolution and is used less frequently to evaluate infertility.
• CT is most useful for evaluating calcifications and stones
along the reproductive tract that are causing obstruction.

16. OBSTRUCTIVE AZOOSPERMIA
 Epididymal obstruction
• Congenital
• Acquired:
oPost infective : epididymitis
oPost surgical
 Vas deferens obstruction
• Congenital absence of vas deferens
• Acquired: post vasectomy, herniorraphy, chronic infection etc
 Ejaculatory duct obstruction
• Congenital : prostatic cysts (mullerian cysts)
• Acquired: Post-surgical, post-infective

17. EPIDIDYMAL OBSTRUCTION
Infection is a common cause of obstruction anywhere along the course of the
male reproductive tract, especially the epididymis .
Acute Gonococcus or subacute chlamydial infections can lead to scarring
and subsequent obstruction.
Iatrogenic epididymal obstruction may be sustained after surgical removal of
an epididymal cyst.

18. Figure : Inflammatory masslike lesion of epididymis in inflammatory-
associated obstructive azoospermia in 32-year-old man. Longitudinal US
image shows an enlarged coarsely hypoechoic masslike lesion (arrowheads)
in the caudal portion of the right hemiscrotum.

19. VAS DEFERENS OBSTRUCTION
• Vasectomy is the most common cause.
• Other acquired causes include inguinal
hernia repair, scrotal sac surgery and
chronic infection
• Most common cause of congenital vas
deferens obstruction is congenital
bilateral absence of the vas deferens
(CBAVD).
• The post-vasectomy epididymis has a
characteristic dilated inhomogeneous
appearance on ultrasound described as
ectasia of the epididymis
Longitudinal ultrasound of the epididymis
demonstrating the classical appearance
associated with a vasectomy (long arrow)
and an additional less well appreciated
view of the dilated vas deferens (short
arrows).

20. Figure : Epididymal tube ectasia in obstructive azoospermia in 35-year-old man
with CBAVD. Longitudinal US image shows tubular ectasia (arrowheads) in the
epididymal head

21. Figure : Abnormalities of scrotal vas deferens in 37-year-old man with
inflammatory-associated obstructive azoospermia. Bilateral longitudinal US
images show dilated scrotal vasa deferentia (arrows). The course of the right
scrotal vas deferens is twisted, and echogenic fluid is seen in the lumen.

22. Ejaculatory duct obstruction
• A seminal vesicle diameter greater
than 1.5 cm and an ejaculatory duct
diameter greater than 2.3 mm are
suggestive of ejaculatory duct
obstruction.
• Sagittal transrectal US image in 30-
year-old man with inflammatory
obstruction of the ejaculatory duct
shows cystic dilatation of the
ejaculatory duct, with the cyst cavity
filled with inflammatory debris
(arrows); a hyperechoic region
suggestive of calcification
(arrowhead) is also noted in the
verumontanum.

23. NON-OBSTRUCTIVE
AZOOSPERMIA
The causes may be divided into
 Testicular abnormalities
Crypto-orchidism
Atrophy
Orchitis /Epididymo-orchitis
 Varicoceles and
 Testicular tumours.

24. CRYPTORCHIDISM
• Most common congenital abnormality of the male urogenital tract at birth.
• May be associated with prune belly syndrome, Beckwith-wiedeman
syndrome, congenital rubella and renal agenesis
• Scrotal ultrasound confirms the clinical diagnosis of cryptorchidism by
demonstrating the absence of the testis within the scrotal sac.
• As most undescended testis are located within the inguinal canal, ultrasound
may also directly visualize the testis in this location .
• Either abdominal CT or MRI evaluation is useful in cases where the
undescended testis is not identified with ultrasound

25. Fig. bilateral cryptorchidism.
A, Midline transverse sonogram of the scrotum
through the median raphe reveals no testis in
the scrotal sac. B and C, Sagittal sonograms
show both testes to be located in the inguinal
canals and diminished testicular volume
measured 2– 3 mL each (normal range, 18 –20
mL).

26. Fig: Axial non-enhanced T1-weighted MR image of the pelvis shows an ovoid
hypointense structure (arrow) within the soft tissues of the left side of the pelvis
and medial to the iliac vessels that is consistent with an undescended testis.

27. TESTICULAR ATROPHY
• Testicular atrophy is considered to be
important if the volume of the affected testis
is reduced to 50% of the volume of the
unaffected testis
• Testicular atrophy is associated with reduced
spermatogenesis and a reduction in fertility.
• Atrophy may occur following previous
inflammation, testicular torsion, varicocele,
mumps, liver cirrhosis, estrogen treatment,
hypopituitary disorders and aging.
• On ultrasound, there is a global reduction in
the volume of the testis.
• A decrease in both testicular reflectivity and
vascularity are common findings.
• The epididymis usually appears normal Unilateral testicular atrophy three months
after blunt scrotal trauma. Transverse (A)
and longitudinal (B) US
views.

28. ORCHITIS AND EPIDIDYMO-
ORCHITIS
 Infections and inflammations of the genital tract are considered the most
frequent causes of reduced male infertility.
 Chronic inflammatory conditions of the testes disrupt spermatogenesis and
irreversibly alter both the number and quality of sperm.
 Chronic epididymitis and epididymo-orchitis can also result in testicular
atrophy.
 A range of organisms including Neisseria gonorrhoea and Chlamydia
trachomatis may be implicated in acute epididymo-orchitis.
 Less frequent causes such as mumps and sarcoidosis tend to cause
bilateral changes
 USG:
 Enlarged epididymis
 Decreased echogenicity and is often coarse
 Increased vascularity

29. Epididymo-orchitis in a 25-year-old man who reported having
testicular pain during infertility workup. Longitudinal gray-scale
and color Doppler US images of the scrotum show
heterogeneous enlargement of the right testis (dashed arrow in
and epididymis (solid arrow in ), with increased flow in both
structures compatible with hyperemia.

30. VARICOCELE
 Dilated tortuous veins of the pampiniform
plexus, which can be demonstrated superior
and posterior to the testis.
 Affects approximately 15% of men but
occur in up to 40% of men attending
infertility clinics.
 Idiopathic or secondary to incompetents
valves in the spermatic vein and are
associated with infertility.
 Idiopathic are almost invariably left sided.
 Venous diameter of >2mm is widely used
cut off between normal and abnormal veins.
 2.7mm –subclinical and 3.6mm for clinical
varicocele.
Varicocele. serpentine, hypoechoic, dilated veins posterior to
the testis. The blood flow in a varicocele is slow and may be
detected only with low-flow Doppler settings or the Valsalva
maneuver.

31. Figure. Varicocele in a 30-year-old man with a history of infertility. Longitudinal
color Doppler US images of the left scrotum at rest (a) and during the Valsalva
maneuver (b) show dilated peritesticular veins with little venous flow at rest but
markedly increased venous flow during the Valsalva maneuver.

32. ERECTILE DYSFUNCTION
• Erectile dysfunction is defined as the persistent inability to achieve and/or
maintain a penile erection sufficient to engage in satisfactory sexual activity.
• due to organic causes, psychological causes, or both
• Organic causes of erectile dysfunction include vascular, endothelial,
myogenic, neurologic, local structural, and endocrine disorders.
• Penile Doppler US is reserved for those patients in whom arterial or venous
insufficiency is suspected and there is little or no functional response to
phosphodiesterase-5 inhibitor agents.
• The peak systolic velocity is considered normal if it is greater than 35
cm/sec, and the end-diastolic velocity is usually normal if it is a negative
value or close to 0 cm/sec.
• A peak systolic velocity of less than 25 cm/sec after papaverine or PGE1
indicates severe arterial disease. Less than 60% increase in cavernosal
diameter also indicates arterial dysfunction.

33. • Dampened waveform and high velocity jets are indicative of proximal arterial
stenosis.
• An end-diastolic velocity greater than 5 cm/sec suggests failed cavernosal
engorgement and venous incompetence, which manifest as persistent diastolic
flow.

34. PRIMARY TESTICULAR
TUMOURS
• Testicular cancer dominates as the leading
cancer in young males aged 15–34 years.
• They often have decreased semen quality
and reduced fertility that appears to be
specific for germ cell tumours.
• As testicular cancer usually affects young
males, preservation of semen prior to
therapy (either surgery or radiotherapy) is
an important consideration, and semen
cryopreservation may be indicated. Longitudinal ultrasound image of a
testicular mass demonstrating
increased Doppler flow within the
lesion; a histologically proven
seminoma.

35. Fig: Testicular tumor in a 30-year-old man who reported having a left testicular mass
at infertility workup. Longitudinal gray-scale (a) and color Doppler (b) US images
show a heterogeneous lobulated mass with increased vascularity, consistent with a
seminoma, in the left testis

36. FEMALE INFERTILITY
CAUSES:

37. IMAGING EVALUATION
 Typically takes place after a clinical assessment.
 Imaging plays a crucial role in diagnostic work up and treatment
planning in female infertility
 Imaging Modalities for evaluation of female infertility are –
 Hysterosalpingography(HSG)
 Sonography including transvaginal sonography and
sonohysterosalphingography
 MRI.

38. HYSTEROSALPINGOGRAPHY
Hysterosalpingogram (HSG) is a fluoroscopic examination of the
uterus and the fallopian tubes.
Most commonly used in the investigation of infertility or recurrent
spontaneous abortions
Findings at HSG help the referring clinician and radiologist to
determine the next appropriate step in diagnosis and management.
Hysterosalpingography provides optimal depiction of the fallopian
tubes, allowing detection of:
 Tubal patency and tubal occlusion,
Tubal irregularity and
Peritubal disease.

39. INDICATIONS
 The main current indications for
HSG are:
 Infertility
 Recurrent miscarriage.
 Other indications include
 checking the efficacy of tubal
sterilisation and
 assessment of the tubes prior to
attempted reversal of
sterilisation

40. TECHNIQUE
Performed in the first half of the menstrual cycle following cessation of
bleeding. (6-10 day).
The patient is asked to refrain from unprotected sexual intercourse from
the date of her period until after the investigation to be certain there is no
risk of pregnancy.
Numerous different types of cannula are available. All possess some
means of preventing reflux of contrast through the cervix and ideally
should allow traction on the uterus.
 Once the cannula is in place, water-soluble contrast medium is injected
slowly under fluoroscopic control until the uterine cavity is distended, the
tubes filled and contrast is seen to spill freely from the distal ends of the
tubes.

41.  Spot films should be taken during
 early filling phase to ensure small filling defects are
not obliterated by contrast,
 during early tubal filling before the isthmic portions
are obscured by contrast, and
 after complete filling of the tubes to demonstrate
free peritoneal spill .

42. (a) Spot radiograph obtained during the early filling stage of the uterus.b) On a radiograph
obtained with the uterus fully distended with contrast material, portions of both fallopian
tubes are opacified. Images obtained at full uterine distention allow evaluation for filling
defects and contour abnormalities. (c) Spot radiograph clearly depicts the interstitial,
isthmic, and ampullary portions of both fallopian tubes. (d) Spot radiograph shows
intraperitoneal contrast material spillage from the fallopian tubes.

43. Normal hysterosalpingogram(HSG), with bilateral intraperitoneal spill of contrast.

44. Complications
• Pain—due to utero-tubal distension or peritoneal spill. Minimized by
slow injection of contrast and the use of iso-osmolar contrast agents.
• Infection—rare, but more frequent in patients with a past history of
pelvic inflammatory disease and hydrosalpinges.
• Vasovagal reactions—usually from manipulation of the cervix or inflation
of an occlusion balloon in the cervical canal
• Venous intra-vasation— of no clinical significance but can make
interpretation of the images difficult. It occurs more commonly in the
presence of fibroids or tubal obstruction.
• Allergic reaction to contrast media—very rare.

45. CONTRAINDICATIONS
• pregnancy
• active pelvic infection
• recent uterine or tubal surgery

46. TECHNICAL ARTIFACTS
• Air Bubbles:
During hysterosalpingography, air bubbles can incidentally be
introduced into the uterine cavity and may be mistaken for other
filling defects .
An air bubble appears as a round, well-defined filling defect in non-
dependent position; multiple air bubbles are often seen, and they are
usually identifiable by their mobility.
Introduction of air bubbles can be prevented by careful removal of air
bubbles trapped in the cannula.
 When present, air bubbles must be eliminated by additional
injection of contrast material, which flushes them out of the uterine
cavity through the fallopian tubes
• Venous or Lymphatic Intravasation:
can occur in up to 6% of patients undergoing hysterosalpingography
Although it can occur in healthy patients, there are some
predisposing factors such as recent uterine surgery or increased
intrauterine pressure because of tubal obstruction or excessive
injection pressure

47. Air bubbles in uterine horns of29-year-old asymptomatic woman. A.
Hysterosalpingogram obtained with balloon catheter shows multiple rounded
filling defects (arrows), which are mobile, at both uterine horns. B.
Hysterosalpingogram obtained with additional injection of contrast material
shows bubbles have been flushed out of uterine cavity through fallopian tubes.

48. Fig: Venous intravasation in healthy 28-year-old woman. Hysterosalpingogram shows
network of thin vessels (arrow) can be opacified during hysterosalpingography in
healthy patients

49. Normal variants
• Myometrial folds:
• broad longitudinal folds parallel to the uterine cavity are seen on
hysterosalpingograms with otherwise normal findings.
• Double Uterine Contour:
• In the few patients in whom hysterosalpingography is performed
during the late secretory phase of the menstrual cycle—for example,
in the evaluation for cervical incompetence—a double contour can
be seen as a thin line of contrast medium surrounding the uterine
cavity
• The contrast medium does not penetrate into the myometrial
vessels, and therefore there is no filling of the myometrial, uterine, or
ovarian veins.

50. Myometrial folds in 34-year-old woman. A, Hysterosalpingogram shows broad
longitudinal folds (arrows) parallel to uterine cavity that must be identified at early
underfilled view of uterus.B and C, Delayed radiographs obtained with larger
volumes of contrast material show that contrast material progressively obliterates
view of folds

51. Fig: Double uterine contour (asterisk and arrows) in 30-year-
old woman. Hysterosalpingogram obtained during late
secretory phase of menstrual cycle shows double uterine
contour.

52. TRANS-VAGINAL SONOGRAPHY(TVS)
 Helps in determining the morphology
of the uterus and ovaries, uterine and
ovarian perfusion, and endometrial
thickness, volume, and vascularity.
 It detects pathological lesions,
including tubal lesions and
abnormalities of follicular maturation
and ovulation.
 USG can guide oocyte retrieval and
embryo transfer in in vitro fertilization
procedures and drainage of pelvic
collections or cystic lesions.

53. SONOHYSTEROSALPINGOGRAPHY
(SONO-HSG
 Sonohysterography, also referred as saline-infused sonohysterography
(SIS), is an ultrasound technique that better characterizes the uterine
cavity, endometrium and fallopian tubes.
 SIS should be scheduled between days 4 and 10 of the patient's
menstrual cycle, when the endometrium is at its thinnest, and
physiologic changes during the secretory phase are not present.
 Airless, sterile, saline infusion through a soft plastic catheter in the
cervix with simultaneous endovaginal USG.
 BENEFITS
 Excellent visualization of endometrial cavity and its lining
 Evaluate anatomical causes of infertility, particularly submucosal
myomas, endometrial polyps, and intrauterine adhesions
 Can also confirm tubal patency by demonstrating spillage of saline
from a distended tube into the pelvic cavity
.

54. Figure : Simulation of pathologic conditions during the secretory phase in a 32-year-old woman
on day 16 of her menstrual cycle. Transverse transvaginal US image of the uterus shows
thickened lobulated endometrium (*), a finding that may simulate endometrial polyps.

55. Contraindications
• Pregnancy
• performing the study after day 14 in a woman's menstrual
cycle is a relative contraindication
• the presence of an intrauterine device
• Pelvic inflammatory disease

56. Multiple manifestations of endometrial polyps. A: Sonohysterographical image of a cervical
polyp (arrow); B, C: Sonohysterograms with Doppler demonstrating endometrial polyps with
feeding vessels (arrows); D: Sonohysterogram shows elongated bilobed mass (arrow) attached
to endometrial and projecting into the endometrial canal, representing an endometrial polyp;

58. Normal MR Anatomy
Sagittal T2w MRI
clearly demonstrates
uterine normal
anatomy with high
signal intensity of
endometrium, low
signal of junctional
zone and
intermediate signal of
myometrium,

59. TUBAL FACTORS
 Fallopian tube abnormalities are the most common cause of
female infertility, accounting for 30%–40% of cases.
 Hysterosalpingography provides optimal depiction of the
fallopian tubes, allowing detection of tubal patency, tubal
occlusion, tubal irregularity, and peritubal disease.
 If there is evidence of occlusion due to endometriosis,
hysterosalpingography should be followed by MR imaging.

60. Diagram shows the appropriate steps in an imaging evaluation for fallopian tube
abnormalities.

61.  Fallopian tubes have three segments that are visible at
hysterosalpingography:
 Interstitial portion,
 Isthmic portion; and
 Ampullary portion
 Occlusion may occur at any site along the course of the tube. The
differential diagnosis of tubal occlusion typically includes
 tubal spasm,
 infection, and
 prior surgery.
 Rare causes of tubal occlusion include granulomatous salpingitis
due to tuberculosis, intraluminal endometriosis, parasitic infection,
and congenital atresia of the fallopian tubes.
TUBAL OCCLUSION

62. Tubal occlusion in the proximal or interstitial portion of the
fallopian tube - tubal spasm should be considered as the
possible cause.
• Delayed radiography help differentiate tubal spasm from true
tubal occlusion
• A spasmolytic agent such as glucagon may be administered
to relax the uterine muscle and relieve a tubal spasm.
• Place the patient prone and re-inject contrast material into the
uterus.
If a proximal tubal occlusion is confirmed at
hysterosalpingography, fluoroscopically guided trans-cervical
fallopian tube recanalization may be performed.

63. Hydrosalpinx
• Hydrosalpinx results from occlusion at the
ampullary end of the fallopian tube, a
condition most commonly caused by
pelvic inflammatory disease. On HSG:
• tube appears dilated, and
• there is an absence of intraperitoneal
spillover of contrast material.
• If hydrosalpinx is seen at
hysterosalpingography, it is important to
prescribe post-procedural antibiotic
prophylaxis..
• Treatment of distal tubal occlusion may
include fluoroscopically guided
transcervical fallopian tube recanalization;
however, tubal microsurgery may be
performed if recanalization is not
successful.
Fig: Hysterosalpingogram shows
dilatation of the left fallopian tube
(arrow) with an absence of contrast
material outflow, findings indicative of
tubal occlusion, and a patent normal
right tube (arrowhead) with outflow of
contrast material.

64. USG:
A hydrosalpinx has four distinct features:
• tubular shape;
• folded configuration , C shaped or S shaped ;
• well-defined echogenic wall; and
• short linear echoes protruding into the lumen.
• The folds may produce a characteristic “cogwheel” appearance when
imaged in cross section. These folds are pathognomonic of a hydrosalpinx.
• The waist sign arises from the folding of a distended tube upon itself
producing indentations on diametrically opposite sides. The waist sign is
specific for hydrosalpinx and virtually pathognomonic when seen in
association with a tubular-shaped cystic mass.
• "beads on a string" sign

65. Fig: Cystic, elongated anechoic structure
in the left adnexa features incomplete
septations and lack of vascularity.
Fig: Left hydrosalpinx with post
hysterectomy status. The right ovary and
uterus are absent.

66. Fig: Reliable signs of hydrosalpinx. a) Transvaginal US. Axial image shows cyst tubular structure
with C shaped. b) Pelvic MR. Axial T2-weighted image shows incomplete septations secondary to
distension and tubaric folding (waist sign). c) Transvaginal US. Axial image shows round
projections and thicked longitudinal folds (cogwheel appearance)

67. MRI
 MR imaging is the modality of choice for the
characterization and localization of adnexal
masses that are inadequately evaluated with
ultrasound.
 A dilated fallopian tube is interposed between
the uterus and ovary and demonstrates fluid
signal intensity.
 Incomplete septa or folds can be seen. The
mucosal plicae are usually effaced, and the
tube wall is uniformly smooth and thin.
Signal characteristics of the dilated tube(s)
include:
 T1: typically hypointense although can be
hyperintense if there is proteinaceous fluid
 T2: hyperintense
 T1 C+ (Gd): the mucosal plicae and the tube
walls may show mild enhancement
Fig: Bilateral adnexal cystic cavities.
The one on the left shows a tubular
appearance and can be followed to the
tubouterine junction.

68. TUBAL IRREGULARITY
Tubal irregularity at hysterosalpingography may be due to salpingitis
isthmica nodosa, an inflammatory process within the fallopian tube.
The exact cause of this process is unknown, but associations with pelvic
inflammatory disease, infertility, and ectopic pregnancy have been reported.
At hysterosalpingography, tubal irregularity and subcentimetric protrusions
from the isthmic portion of the tube are seen in patients with this disease.
Because tubes affected by this disease are not readily amenable to
recanalization, patients typically are offered in vitro fertilization.

69. Fig: Tubal irregularity due to salpingitis isthmica nodosa. Spot (a) and
magnified (b) views from hysterosalpingography depict multiple contrast
material–filled luminal pouches (arrowheads) projecting 2–3 mm outward
from the isthmic portion of both fallopian tubes.

70. PERITUBALABNORMALITIES
Peritubal adhesion is suspected on HSG if:
• Peritubal pooling of contrast material
• convoluted fallopian tube
• ampullary dilatation
Both endometriosis and pelvic inflammatory disease may lead
to peritubal adhesions with resultant infertility.
When evidence of peritubal adhesions is seen at
hysterosalpingography, pelvic MR imaging is particularly helpful
for further noninvasive evaluation.

71. Figure . Right peritubal pelvic adhesion due to previous pelvic inflammatory disease. Early (a) and late
(b) hsterosalpingograms show normal contrast material filling of the right fallopian tube (arrow in a)
and a rounded collection of leaked contrast material (arrowheads in b) adjacent to the ampullary
portion of the right tube. The collection was due to peritubal adhesions. The left fallopian tube appears
normal and patent.

72. ENDOMETRIOSIS
 Endometrial tissue outside the uterine cavity is termed endometriosis.
 Common endometriosis deposit locations include the ovaries, uterine
ligaments, fallopian tubes, rectovaginal septum, pouch of Douglas, bladder
wall and umbilicus.
 An estimated 30%–50% of women with endometriosis are infertile, and
20% of infertile have endometriosis.
 Almost exclusively in reproductive years.
 Imaging
• US
• MRI.
 Endometriotic cysts, referred to as endometriomas, result from repeated
hemorrhage within an implant.
 The US features of endometriosis are variable; US has low sensitivity for
the detection of focal implants, but it may depict endometriomas.
 cystic masses with diffuse uniform low-level echoes.
 Fluid-fluid or fluid-debris levels can form, with a dependent
hyperechoic component.

73. Figure: Endometrioma. Sagittal transvaginal US
image obtained in a woman with a history of endo-
metriosis shows an ovarian mass with multiple fine
internal echoes (arrows) and several hyperechoic
mural foci (arrowheads).
Large left ovarian well defined cyst showing
internal low level echoes, with no vascularity.

74. MRI: best imaging investigation for the
depiction of endometriosis, due to its
ability to detect old hemorrhage, deep
pelvic lesions and fibrosis.
• The masses have internal high
signal intensity on T1-weighted
images and low to variable signal
intensity on T2-weighted images.
• T2- Shading sign
• T2- dark spot sign (T2 hypointense
focus within ovarian lesion )
Figure . Endometriosis. Unenhanced axial T1-
weighted fat-suppressed MR image shows dilatation
of the right fallopian tube (arrow) with internal high
signal intensity due to blood products, findings
indicative of hematosalpinx. Smaller high-signal-
intensity foci along the posterior uterine serosa
(arrowhead) are indicative of endometrial implants.

75. INTRAUTERINE FILLING
DEFECTS
 Intrauterine filling defects seen at hysterosalpingography may be
caused by
• Air bubbles in the contrast material injection,
• Intrauterine adhesions,
• Submucosal leiomyomas
• Endometrial polyps
• Blood clots.
 Bilateral oblique views may help identify mobile, nondependent,
round filling defects caused by air bubbles and to avoid mistaking
these findings for intrauterine disease.
 More contrast material may be injected into the endometrial cavity
to cause air bubbles to be ejected via the fallopian tubes.

76. Figure . Diagram shows the appropriate steps in an imaging
evaluation for intrauterine abnormalities.

77. UTERINE SYNECHIAE
 May be the result of:
 Previous pregnancy,
 Dilation and curettage
 Surgery
 Infection.
 At hysterosalpingography:
 Appear as irregular linear filling defects
 Endometrial cavity may appear distorted or may not expand as expected
with the injection of contrast material.
 Infertility secondary to uterine adhesions is known as Asherman syndrome.
 Hysterographic US has greater sensitivity than hysterosalpingography for the
identification of intrauterine adhesions, which appear as echogenic bands that
traverse the endometrial cavity.

78. Figure . Asherman syndrome in a patient with a history of dilation and curettage.
(a) Hysterosalpingogram depicts several linear intrauterine filling defects (arrowheads).
(b) Sagittal image from transvaginal hysterographic US shows multiple uterine synechiae
(arrows)

79. ENDOMETRIAL POLYPS AND
SUBMUCOSAL LEIOMYOMAS
 Hysterographic US can depict endometrial lesions that are not visible with pelvic US
and can help distinguish endometrial polyps from submucosal leiomyomas.
 Also allows a more accurate assessment of the number and location of endocavitary
lesions, thus providing guidance for their subsequent management with hysteroscopic
biopsy or excision.
 Submucosal leiomyomas –
 hypoechoic masses that distort the normal appearing endometrium on US images.
 may have a peduncular attachment and thus mimic an endometrial polyp.
 Endometrial polyps –
 echogenic intracavitary masses.
 color Doppler US may help identify the characteristic central vascular stalk-
‘pedicle artery sign’
 occasionally contain cystic foci
 Intra-cavitary fibroids tend to be larger than polyps, and homogeneous hyperechoic
masses in the uterine cavity observed by SHG are highly suggestive of endometrial
polyps

80. Figure: Endocavitary leiomyoma (fibroid). Sagittal transvaginal gray-scale (a) and color
Doppler (b) US images depict a solid mass (arrowheads) with internal echogenicity
similar to that of the myometrium. The mass has a pedunculated attachment (arrow) to
the uterus and extends into the cervical canal.

81. Figure . Endometrial polyp. (a)
Hysterosalpingogram depicts a well-
circumscribed ovoid intrauterine filling
defect (arrow). (b, c) Sagittal gray-scale
(b)and color Doppler (c) US images from
subsequent transvaginal hysterographic
US show a posterior fundal endometrial
polyp (arrowheads in b) with a central
feeding vessel (arrow in c).

82. UTERINE CONTOUR IRREGULARITIES
Uterine contour irregularities observed at hysterosalpingography may be due
Adenomyosis
Uterine leiomyomas
Müllerian duct anomalies
Pelvic US, pelvic MRI, or both are often required for further characterization of
contour abnormalities found at hysterosalpingography.

83. ADENOMYOSIS
 Adenomyosis is the presence of endometrial
tissue within the myometrium with
secondary smooth-muscle hyperplasia.
 Most commonly occurs as a diffuse
abnormality, with less common focal disease
referred to as an adenomyoma.
 May be associated with infertility due to
impaired uterine contractility, which is
necessary for directed sperm transport
through the uterus.
Hysterosalpingography –
• multiple linear or saccular contrast material
collections that protrude beyond the normal
contour of the endometrial cavity.
Figure . Adenomyosis. Left posterior
oblque hysterosalpingograhy shows
characteristic saccular contrast material
collections (arrowheads) protruding
beyond the normal contour of the
endometrial cavity

84. ULTRASONOGRAPHY:
 Diffuse, sometimes globular uterine enlargement
 Heterogeneous myometrial echotexture
 Asymmetric myometrial thickening
 Myometrial cysts
 Indistinct endometrial-myometrial interface
 Sub-endometrial echogenic nodules or linear striations
MRI:
 On T2 weighted image MRI, adenomyosis appears as ill-defined areas of
low myometrial signal intensity, due to smooth muscle hyperplasia, which
presents as focal or diffuse thickening of the junctional zone (JZ).
 When diffuse, a widened low-intensity JZ ≥12 mm predicts adenomyosis
with high accuracy, while a JZ ≤8 mm excludes it with high accuracy.
 For indeterminate cases (JZ 8–12 mm), ancillary criteria are used including
high T2 signal intensity foci within low signal myometrium, representing
islands of ectopic endometrial tissue and cystic dilatation of glands.
 High T2 signal linear striations (finger-like projections) extending from
endometrium and into myometrium may also be seen, representing direct
myometrial invasion.

85. Fig: Adenomyosis. Sagittal transvaginal US image illustrates globular uterine enlargement
with asymmetric thickening and heterogeneity of the myometrium (arrows) and poor
definition of the endomyometrial junction (arrowheads). E = endometrium

86. Fig: Diffuse myometrial thickening showing heterogenous echopattern, multiple tiny
echogenic nodular striations,increased vascularity.

87. Figure . Sagittal T2-weighted image shows an ill-defined myometrial lesion of low signal
intensity in the anterior myometrium. Innumerable hyperintense foci (arrows) are embedded in
the lesion.

88. LEIOMYOMAS
 Fibroids, or leiomyomas, are benign smooth muscle tumours found in
up to 40% of women. They are usually multiple and are classified
according to their location:
submucosal (projecting into and distorting the uterine cavity);
intramural (within the myometrium); and
subserosal (protruding out of the serosal surface of the uterus).
 Infertility may result when leiomyomas are numerous or have
submucosal or intracavitary locations that interfere with embryo
transfer and implantation.
 In addition, patients with multiple leiomyomas are at an increased risk
for early spontaneous fetal loss,
 Hysterosalpingogram:
 A finding of uterine enlargement, distortion, or mass effect on the
endometrial cavity on is suggestive of uterine leiomyoma
 If the lesion is located near the uterine cornua, it may obstruct the
ipsilateral fallopian tube and thus cause a lack of tubal opacification.

89. • VARIABLE APPEARANCE AT PELVIC US.
The uterus may be enlarged or lobulated .
Solid, round, well-circumscribed, hypoechoic mass
Acoustic shadowing if calcified.
Anechoic foci within leiomyoma (cystic degeneration)
Distortion of external uterine contour or endometrium depending on its
size and location.
• PELVIC MR IMAGING is the most accurate imaging modality for
evaluating the size, location, and number of uterine leiomyomas.
uterus often appears enlarged and lobulated.
Typically T1 isointense and T2 hypointense to the myometrium
The appearance after IV contrast administration is variable, although
most myomas enhance similar to or less than the surrounding
myometrium.

90. Fig: Isoechoeic well defined mass in the uterus.
.

91. GENITAL TUBERCULOSIS
Genital TB is important cause of infertility in developing countries.
Almost always acquired by hematogenous spread from extragenital source.
Primary site of genital TB is fallopian tubes, almost always affected BL but
not symmetrically.
HSG is the initial investigation procedure.
Findings include:
A. Fallopian tubes; B. Uterus :
Beaded tube T- shaped uterus
Golf club tube Trifoliate uterus
Pipe steam tube Synechiae
Cock screw appearance Hydrosalpinx
Mucosal thickening Venous extravasation
Tobacco pouch appearance

92. Figure: Thickened mucosal folds in a 26-year-old woman with primary infertility.
HSG exam shows that both fallopian tubes are dilated, crowded, and coiled on
themselves, giving a corkscrew appearance. There are subtle radiolucent filling
defects in the tubes suggestive of thickened mucosal folds (arrow). No peritoneal
spill of contrast is seen.

93. Fig: pipe stem fallopian tubes in a 31-year-old woman
with primary infertility. HSG shows narrowed rigid
pipe stem-like right fallopian tube (arrow) which is
displaced downward and fixed deep within the pelvis.
The left tube is also irregularly narrowed.

94. BEADED APPEARANCE..
Fig: Multiple constrictions along the course of fallopian tube on HSG due to fibrotic strictures.

95. Fig: HSG shows the classic tobacco pouch appearance due to disproportionate
dilatation of the club-shaped ampullary ends of both fallopian tubes (arrow).
The left fallopian tube is vertically oriented and fixed. There is no spill of radio-
opaque contrast into the peritoneal cavity.

96. Fig: Spot radiograph shows a central oval filling defect within the uterus, a finding
that represents a synechia. (b) Spot radiograph obtained in a different patient
demonstrates a short linear defect (arrow) along the inferior left side near the
uterine isthmus.

97. Fig: HSG of a 25-year-old woman with primary infertility shows classic cork
screw fallopian tubes on both sides.

98. Fig: " Golf club" tube. Sacculation of both tubes in distal portion with an
associated hydrosalpinx giving a Golfclub-like appearance (arrows). Uterine
cavity has normal size and shape.

99. Fig: Trifoliate shaped uterus. Synechiae formation at the uterine borders and partial
obliteration in the fundus produce a trifoliate like appearance.

100. T-shaped uterus

101. Müllerian Duct Anomalies
It is estimated that approximately 1% of all women and 3% of women
with recurrent pregnancy losses have a uterovaginal anomaly.
As many as 25% of women with müllerian duct anomalies (compared
with only 10% of the general population) have reproductive problems,
including increased risk for spontaneous abortion, prematurity,
intrauterine growth retardation, abnormal fetal lie, and dystocia at
delivery.
Accurate characterization of müllerian duct anomalies is essential
because pregnancy outcomes and treatment options vary between the
different classes of anomalies

102. HSG
HSG provides high-resolution images of the contour of the uterine cavity
and fallopian tubes and remains the key imaging test for assessing tubal
abnormalities that may cause infertility.
Typically, the suspicion of müllerian duct anomaly arises during HSG
examination if the typical trigone configuration of the cavity is not
demonstrated.
A common finding is separation of the uterine cavity into right and left
compartments. A divided uterine cavity can result from septate, bicornuate,
or didelphys uterus. Certain criteria are used to increase confidence in
diagnosing entities.
•.

103. Intercornual distance: If the distance between the distal ends of the horns
(ends that are continuous with fallopian tubes)
 Measurements of 2-4 cm -typical distance in a normal uterus
< 2 cm : septate uterus
 >4 cm : didelphys uterus/ bicornuate
Intercornual angle: This is the angle formed by the most medial aspects of
the two uterine hemicavities.
<60°: septate uterus
 For larger angles, the anomaly is more likely to be a bicornuate uterus .

104. Hysterosalpingography does not allow reliable differentiation between septate
and bicornuate anomalies because the outer uterine contour is not visible; by
contrast, US has a reported accuracy of 90%–92% for the characterization of
anomalies, particularly with the use of three dimensional techniques.
However, US may not fully demonstrate the extent of septal and vaginal
anomalies or uterine remnants.
MR imaging has the highest reported accuracy (nearly 100%) for the
characterization of müllerian duct anomalies, because of its excellent soft-
tissue resolution and multiplanar imaging capabilities.
Key features that should be evaluated with US and MR imaging are the
presence, size, and shape of the uterus, in particular the external fundal
contour.
The presence, location, and appearance of the kidneys also should be
routinely evaluated because of the high frequency of associated renal anomalies
in patients with müllerian duct anomalies.

105. MRI
MRI is the technique of choice in assessment and evaluation of these congenital
lesions.
MRI can demonstrate unicornuate, bicornuate and septate uteri, and uterine
didelphys .
MRI is able, unlike other imaging techniques, to differentiate a septate from a
bicornuate uterus.
The importance of making this distinction is that the surgical approach for
treating the two anomalies is different: a bicornuate uterus requires abdominal
surgery, whereas the septate uterus can be repaired hysteroscopically.
MRI, as with other imaging methods, can be used to assess any renal tract
abnormalities coexistent with these mullerian duct anomalies.

106. Classification system of müllerian duct anomalies by the American Fertility Society.

107. CLASS I (HYPOPLASIA/AGENESIS):
 Findings of agenesis include absence of the uterus, cervix, and/or upper two thirds of
the vagina.
 This anomaly is part of the Mayer-Rokitansky-Küster-Hauser syndrome and represents
the most extreme form of MDA.
 In uterine agenesis, no identifiable uterine tissue is noted. Partial agenesis of
müllerian duct derivatives also can be visualized.
 In uterine hypoplasia, the endometrial cavity is small, with a reduced
intercornual distance (<2 cm).
Fig: Sagittal T2-weighted MR
image shows complete absence
of the cervix and uterus with an
abnormally truncated vagina
ending in a blind pouch
(arrowhead) between the
rectum (r) and urinary bladder(b).

108. • Mayer-Rokitansky-Küster-
Hauser syndrome in an 18-
year-old female patient with
primary amenorrhea. Sagittal
T2-weighted MR image shows
absence of the uterus, cervix,
and proximal vagina, with an
anomalous pelvic location of
the kidney (arrow). A remnant
distal vagina (arrowheads) is
seen.

109. CLASS II (UNICORNUATE UTERUS):
As the result of failed or incomplete development of one of the müllerian ducts.
Hysterosalpingography, US, and MR imaging characteristically reveal a laterally
deviated, banana-shaped uterine horn with a single fallopian tube.
 In many cases, there is a rudimentary horn on the contralateral side, with or
without an endometrial cavity that may or may not communicate with the
dominant horn.
Rudimentary horns with an endometrium often are resected because they are
associated with an increased risk of endometriosis and a risk of pregnancy in the
rudimentary horn.
Fig: HSG image shows a small,
oblong uterine cavity (*) deviated to
the right of midline with a single
fallopian tube (arrowhead).

110. Axial T2-weighted MR image shows a single uterine horn (*) and cervix
(arrowhead).

111. CLASS III: DIDELPHYS
• Uterus didelphys results from
complete failure of müllerian
duct fusion. Each duct
develops fully with duplication
of the uterine horns, cervix,
and proximal vagina’
• Coronal T2-weighted image of a
uterus didelphys, obtained in
plane with the uterus, shows
two widely divergent uterine
horns (arrows) separated by a
deep fundal cleft

112. Fig: transverse transabdominal US image shows a uterus didelphys,
with two uterine horns (u) separated by echogenic fat (*)

113. CLASS IV (BICORNUATE UTERUS)
 Incomplete fusion of the
müllerian ducts results in a
bicornuate uterus.
 Two uterine cavities are seen
with normal endometrium.
 US and MR imaging may help
confirm the presence of a
bicornuate uterus by depicting
a deep (> 1 cm) fundal cleft in
the outer uterine contour and
an intercornual distance of
more than 4 cm. Fig: HSG image shows a bicornuate
bicollis uterus with two HSG cannulas
due to two cervices.

114. Fig: Axial T2-weighted MR image shows a uterine fundal cleft (arrow)
greater than 1 cm with soft tissue separating the two symmetric
uterine cavities.

115. CLASS V (SEPTATE UTERUS)
 Partial or incomplete septal
resorption after müllerian duct fusion
results in a septate uterus, which is
the most common uterine anomaly.
 The outer fundal contour is convex,
flattened, or mildly concave (fundal
cleft <1 cm).
 The intercornual distance is usually
normal and each uterine cavity is
usually small.
 On MRI, a fibrous septum is
hypointense to the myometrium and
a muscular septum is isointense to
the myometrium
Fig: Axial T2-weighted MR image of a complete septate uterus shows a normal external
uterine contour (black arrow). The hypointense fibrous septum (white arrows) originates
from the isointense muscular septum and extends into the cervical os (arrowhead).

116. CLASS VI (ARCUATE UTERUS):
• An arcuate uterus occurs with near reabsorption of the
uterovaginal septum and is characterized at imaging by a mild
indentation of the external fundal contour.
• MRI may detect this abnormality but, typically, it is not clinically
significant because arcuate uterus has no significant negative
effects on pregnancy outcome.
CLASS VII (DES RELATED):
MRI may detect this abnormality as a hypoplastic uterus. Typically,
the DES-related anomaly is diagnosed confidently using HSG.

117. Fig: HSG image shows a broad-based uterine fundal filling defect (black arrowhead).
White arrowheads = patent fallopian tubes. (b) T1-weighted fat-saturated MR
image shows the convex external uterine contour (arrow) and the broad-based
prominent fundal myometrium (*).

118. Fig: DES-related uterine anomaly. Hysterosalpingogram demonstrates a hypoplastic T-shaped uterus.
The patient had been exposed to DES while in utero.

119. CERVICAL FACTORS
CERVICAL FACTOR INFERTILITY
• inadequate quality or volume of cervical mucus
• assessed with a postcoital test that does not involve imaging
CERVICAL STENOSIS
• Defined as cervical narrowing that prevents the insertion of a 2.5-mm-wide
dilator
• congenital or secondary to infection or trauma or ,asses such as cervical polyps,
fibroids, and neoplasms also may cause narrowing of the cervical lumen
• At hysterosalpingography, cervical stenosis may appear as narrowing of the
endocervical canal or it may manifest as complete obliteration of the cervical os,
preventing insertion of the hysterosalpingographic catheter.
• At US, hematometra manifests as dilatation of the fluid-filled endometrial cavity,
often with a fluid-fluid level caused by sedimentation of red blood cells.

120. OVARIAN ABNORMALITIES
Ovarian causes of infertility include
primary conditions : non-functional ovaries, premature ovarian
failure, and absence of ovaries (gonadal dysgenesis).
secondary conditions - polycystic ovary syndrome,
endometriosis, and ovarian cancer.
Primary conditions are usually diagnosed on the basis of clinical
and biochemical findings.
 Imaging is more valuable for diagnosing secondary
conditions.

121. Polycystic ovarian syndrome may be one of the most
common causes of female infertility
 USG:
 enlarged ovaries (vol > 10 cm3),
 increased echogenicity and vascularity of the
ovarian stroma,
 increased number of small follicular-type cysts
(a finding of at least 12 cysts was proved
diagnostically specific but not sensitive) with no
dominant follicle
 Peripherally arranged (string of pearls
appearance)
 At MR imaging, the ovaries in patients with polycystic
ovary syndrome classically demonstrate a bulky and
thick walled ovaries with low-signal-intensity central
stroma surrounded by small peripheral cysts on T2-
weighted images.
Fig: Transvaginal US image of the right ovary depicts multiple peripheral sub-centimetric
follicles (arrow). (b) Coronal T2-weighted MR image from the same patient shows bilateral
ovarian enlargement with multiple peripheral follicles (arrows).

123. REFERENCES
GRAINGER AND ALLISON’S DIAGNOSTIC RADIOLOGY 7TH
EDITION
CT AND MRI OF WHOLE BODY, HAAGA 6TH EDITION
TEXT BOOK OF RADIOLOGY AND IMAGING DAVID SUTTON 7th
EDITION
DIAGNOSTIC ULTRASOUND RUMACK 5TH EDITION
RADIOGRAPHICS.RSNA.ORG
RADIOPEDIA
PUBMED
AMERICAN JOURNAL OF RADIOLOGY

124. THANKYOU