IMAGING OF FEMALE FEMALE INFERTILITY Dr charusmita chaudhary
Infertility Infertility is defined as failure to conceive a desired pregnancy after 12 month of unprotected sexual intercourse appprox 10% of couple are infertile male and female are equally affected
Abstract Imaging plays a key role in the diagnostic evaluation of women for infertility. The pelvic causes of female infertility are varied and range from tubal and peritubal abnormalities to uterine, cervical, and ovarian disorders. The imaging work-up begins with hysterosalpingography to evaluate fallopian tube patency. Uterine filling defects and contour abnormalities may be discovered at hysterosalpingography but typically require further characterization with hysterographic or pelvic ultrasonography (US) or pelvic magnetic resonance (MR) imaging. TUBAL OCCLUSION - MOST COMMON CAUSE
Hysterographic US ; differentiate uterine synechiae, endometrial polyps, submucosal leiomyomas. Pelvic US and MR imaging help further differentiate among uterine leiomyomas , adenomyosis, and the various müllerian duct anomalies, with MR imaging being the most sensitive modality for detecting endometriosis. The presence of cervical disease may be inferred initially on the basis of difficulty or failure of cervical cannulation at hysterosalpingography. Ovarian abnormalities are usually detected at US.
A systematic multimodality imaging approach is advocated in which initial hysterosalpingography is followed by hysterographic US, pelvic US, pelvic MR imaging, or a combination there of, with the selection of modalities depending on the findings at hysterosalpingography
An imaging study to evaluate female infertility and uterine anomalies should necessarily exhibit many characteristics1. noninvasive2. low cost3. high accuracy
Causes Uterine causes : congenital anomalies , infections, uterine synechae ,focal lesions intrauterine scar, cervical stenosis ,reduced uterine perfusion and alteration in endometrium thickness and vascularity Ovarian causes : follicular and ovulation abnormalities , stromal vascularity and endometrosis Tubal causes : infections, obstruction
Diagnostic armamentarium and its role USG ( TVS, TAS) : it is the first line investigation and can be coupled with color Doppler and 3D/4D scan USG helps in determining morphology perfusion ,thickness ,volume, vascularity . It detects pathological lesions , tubal lesions abnormalities of follicular maturation and ovulation . Tubal patency can be confirmed by sonosalphingography.
X ray hysterosalphingography Used to visualise uterine cavity and confirm tubal patency . Hysterosalpingography (HSG) uses fluoroscopic control to introduce radiographic contrast material into the uterine cavity and fallopian tubes Cycle considerations: HSG should not be performed if there is a possibility of a normal intrauterine pregnancy.
“10-day rule” means the procedure should not be performed if the interval of time from the start of the last menses is greater than 10–12 days. If the patient has cycles that are longer than 28 days (menses start usually 14 days after ovulation), the 10-day rule can be stretched to 13–15 days. If the patient has irregular cycles or absent menses, a pregnancy test before performing HSG is recommended
Technical Considerations The patient is placed supine with her knees flexed and heels apart The cervix is exposed with a speculum. Visualization of the cervix may be helped by elevating the patient’s pelvis, particularly in thin women The cervix and vagina are copiously swabbed with a cleansing solution such as Betadine and the HSG cannula is placed Once correct placement of the canella is confirmed, the speculum should be removed Using fluoroscopic guidance, contrast agent at room temperature is slowly injected, usually 5–10 ml over 1 min radiographs are obtained Injection of contrast agent is halted when adequate free spill into the peritoneal cavity is documented
Side Effects and Complications Mild discomfort or pain Reassurance and rapid and skilful completion of the examination are the best approach. Mild vaginal bleeding vasovagal reactions and hyperventilation Pelvic infection is a serious complication of HSG, causing tubal damage An allergic or idiosyncratic reaction Radiation exposure It is a concern, because the women being examined are of reproductive age
Diagram shows the appropriate steps in an imaging evaluation for fallopian tube abnormalities.
Anatomy and Physiology of Fallopian Tubes The fallopian tubes connect the peritoneal cavity to the extra peritoneal world conduction of sperm from the uterine end toward the ampulla, conduction of ova in the other direction from the fimbriated end to the ampulla, and support as well as conduction of the early embryo from the ampulla into the uterus for implantation
Fallopian Tubes length from 7–16 cm (average, 12 cm 5- 8cm 2-3cm 1-2cm trumpet-shapedThe fallopian tubes have three segments that are visible athysterosalpingography: the interstitial portion, which traverses themyometrium; the isthmic portion, which courses within the broadligament; and the ampullary portion, which is adjacent to the ovary
Pathological Findings Diverticula in the isthmic segment of the tube are caused by salpingitis isthmica nodosa (SIN difficult to appreciate by sonography irregular benign extensions of the tubal epithelium into the myosalpinx, associated with reactive myohypertrophia and sometimes inflammation Obstruction of the mid isthmicportion may be missed by sonography Multiple tiny diverticula in the right isthmic portion (arrows) partial tubectomy on the left side (arrow head)
Endometrial polyps. A Stalked fi lling defect within the endometrial cavity probablyarising from the cervical canal(arrow).B a fi lling defect in the intramural portion of the left tube (arrows)causing narrowing but no obstruction;normal fi lling of the fallopian tubes
Synechiae. On hysterosalpingogram, irregular borders (arrows) andnarrowing of the cervical canal (arrowhead) depicted (a).HSG shows synechiae causing partial obstruction of theendometrial cavity and occlusion ofthe right fallopian tube (b). Note: HSG may not rule outmullerian duct anomaly with certainty in this particular case
Limitations of HSG Active vaginal bleeding active pelvic infection pregnancy, uterine surgery, tubal surgery, or uterine curettage The major limitations of the procedure are the ability to characterize only patent canals and the inability to evaluate the external uterine contour adequately.HSG also entails exposure to ionizing Radiation
Sonohysterography and Sonohysterosalpiaphy used to evaluate uterine pathology because of its excellent diagnostic accuracy, minimal patient discomfort, low cost, and widespread availability. With the addition of transvaginal sonography, colour Doppler imaging, and sonohysterography, ultrasound has become a sensitive technique for detecting endometrial and myometrial pathology.
Cycle Considerations during the secretory phase of the menstrual cycle, when the endometrial thickness and echo complex are better characterized for congenital anomaly evaluation, the timing of the sonography examination is not critical
Sonohysterosalphingography ( sono hsg) It involves airless, sterile , saline infusion through a soft plastic catheter in the cervix with simultaneous endovaginal usg. It allows excellent visualization of the endometrial cavity and its linings . The procedure can also confirms tubal patency by demonstrating spillage of saline from a distended tube into pelvic cavity.
Normal TVUS Clear demarcation of the relatively thick and hyperechoic endometrium (arrowheads) during the secretory phase (a), minimal fl uid retention during the proliferation phase of the cycle (b)
Side Effects andComplications Limitations of Sono-HSG most part the same as for operator dependency conventional HSG LARGE BODY HABITUS LARGE FIBROID
MRI It is best for delineating the morphology and orientation of pelvic structures . Detects pathological lesions, including tubal lesions and pituitary adenoma .
Technical Considerations best imaged with a phased array MR surface coil. for infertility evaluation axial, sagittal, and coronal fast spin echo sequence images of the uterus, which can be supplemented by oblique Gd-enhanced MR imaging is important for diagnosis of complex adnexal masses and distinguishing them from malignant processes
Limitations higher cost, limited availability, longer scanning time, MRimaging is often used as a problem solving modality when sonography findings are inconclusive
Normal MR Anatomy in Reproductive-Age Women Sagittal T2w MR image clearly demonstrates uterine zonal anatomy with high signal intensity of the endometrium (E), low signal of junction zone (J), and intermediate signal of the myometrium (M).
Pituatory adenoma Prolactin-producing hypophyseal adenoma Hyperprolactinemia can be a cause of infertility and is associated with diminished gonadotropin secretion, secondary amenorrhea, and galactorrhea.
Pituatory adenoma Mri is the modality of choice for detection. Microadenoma ( <1cm) is usually hypointense to the normal pituatory on T1W images. Pituitary adenoma. Unenhanced (a) and contrast- enhanced (b) T1w MR images show a small right- Convex pituatory sided pituitary prolactinoma (arrow) leading to contour and deviation of hyperprolactinemia with consecutive infertility pituatory stalk are inditect sign.
Endometriosis Ovary m/c secondaily involves other pelvic structures . Usg ishows a typical endometrioma locate in the ovary cystic lesion with low level internal echoes ( chocolate cyst of ovary) Mri hyerintense on T1 and hypo on T2 fat suupersed T1w images are very useful for detecting peritoneal implants . The tubes may be involveed in form of hematosalphinx or with peritubal adhesions, a posteriorly displaced uterus , kissing ovaries ,angulated small bowel loops , elevated posterior vaginal fornices , multilocuilated fluid collections are indirect indicator of pelvic adhesions
Endometriosis Endometriosis is found in 25%–50% of infertile women, and 30%–50% of women with endometriosis are infertile Laparoscopy is the mainstay for diagnosis Endometrioma right ovary. Sharply demarcated inhomogeneous cystic mass (M) in the right ovary with predominantly bright signal intensity on axial T2W (a), intermediate signal intensity on axial T1w images
Polycystic Ovarian Syndrome Characterised by combination of multiple clinical manifestations ( hirsutism, anovultory cycle and infertility) hormonal imbalance
Polycystic Ovarian Syndrome The diagnosis of polycystic ovarian syndrome is based on hormone imbalance and laboratory findings USG rounded ovaries , normal or increased volume . Multiple subcentrimetric follicles ( 15) with no dominant follicle ( string of pearl appearance ) . Thickened walll and echogenic and Vascular stroma)
Tubal disease Destruction or obstruction and peritubal adhesions Hsg is useful for assessing tubal patency. Mri is superior to usg in assessing tubal disease Dilated tube appear as fluid filled tortuous sausage shaped masses adjacent to the uterus with incomplete septae appearing as hyperechoic mural nodules ( beads of string sign) and short linear projections ( cogwheel appearance) the presence of partially effaced longitudional folds inside the masses is specific for fallopian tubes on mri. The presence of a normally appearing ipsilateral ovary is a clue to the presence of tubal masses
Pelvic inflammatory disease Common cause on infertility and can manifest as pelvic collections , tubo ovarian collections uterine or broad ligament infection Usg and mri are equally sensitive in detecting tubo ovarian collections. The presence of peripheral vascualrity of high resistance type on colour Doppler USG is suggestive of an infective mass other signs of PID include probe tenderness , thickness of tubes ( mural thickness more than 5mm) and tubo ovarian masses
Disorders of the Fallopian Tubes MR imaging aids in noninvasive assessment of tubal dilatation and peritubal disease. Bilateral hydrosalpinx. Sausage-, C-, or S-shaped cystic masses in the small pelvis as shown by these axial (a) and coronal (b) T2w MR images are clearly indicative of dilated fallopian tubes (FT Tubo-ovarian abscess. T2w (a) and contrast-enhanced (b) T1w MR images show a left-sided adnexal mass (M) with rim-like enhancement (arrows) on contrast T1WI, which proved to be an abscess.
Uterine DisordersThey are considered a anomalies when all other causes are excluded Multiplanar mri is diagnostic
Müllerian Duct Anomalies prevalence of approximately 3%Mullerian duct anomalies may be depicted by HSG; the complex situation of the various classes of anomalies seem to be better defined by sonography or MR imaging Classification of MDAs according to the system adapted by the American Fertility Society can be readily achieved based on MR finding MR imaging attained 100% accuracy for diagnosis of uterine anomalies, as compared with 92% for ultrasound and less than 20% for HSG
Class I: Hypoplasia or Agenesis Failure of normal development of the mullerian ducts causes uterine agenesis or hypoplasia 5% of mullerian duct anomalies Vaginal agenesis is the most common subtype Mayer-Rokitansky-Kuster-Hauser syndrome congenital absence of the uterus and upper vagina The ovaries and fallopian tubes are usually normal. Women with acquired uterine hypoplasia due to drugs, pelvic irradiation, or ovarian failure may have a disproportionately small uterine corpus. In these patients, the ratio of the uterine body to the cervix is reduced to less than the normal 2:1, similar to a premenarchal uterus
Class IClass I. Uterine agenesis. Sagittalmidline sonogram shows normalvagina, small (curved arrows) cervix(straight arrow), and absent uterinecorpus
Class II: Unicornuate one normally developed mullerian duct, with the contralateral duct either hypoplastic (subtypes 2a–c) or absent (subtype 2d). Types 2a–c comprise approximately 90% of cases Agenesis of a unilateral mullerian duct causes a single banana- shaped uterus with a single fallopian tube
Class II. Left unicornuate uterus. HSG showsuterine cavity deviated toward left side withpatent left fallopiantube (a). Axial T2w MRI in this patient showsno rudimentaryhorn on the right side (b). In another patient,HSGshows right unicornuate uterus with hydrosalpinx
Class III: Didelphys Complete failure of fusion of the two mullerian ducts results in two complete uteri, each with its own cervix a sagital vaginal septum is seen in ,majority of cases uterus didelphys is associated with the highest successful pregnancy rate, Uterus didelphys with an obstructed hemivagina is termed Wunderlich syndrome
Class IV: Bicornuate Partial fusion of two mullerian ducts results in a bicornuate uterus with one cervix HSG of a bicornuate uterus will demonstrate separate uterine cavities with an intercornual angle that usually exceeds 105°. Sonographic diagnosis of a bicornuate uterus is made by analysis of both the outer fundal contour as well as visualization of a separate endometrial stripe in each horn
Class IV.widely splayed uterine horns with an intercornual angle greater than100° and with uterinefundi joined at the lower uterine segment, indicating a bicornisunicollis subtype
Class V: Septate Septate uterus results from failure of resorption of a septum after complete fusion of the mullerian ducts HSG of a septate uterus demonstrates two narrowly diverging cavities, yielding a V-shape configuration with relatively straight medial borders angle formed by the medial borders of the two uterine hemi- cavities is usually greater than 75°. The external uterine contour is normally convex, fl at, or minimally indented by less than 1 cm , in contrast to that of a bicornuate uterus
Class V.On HSG one cervical opening was missed; onlyone uterine cavity was spilled with contrastmedia; a unicornuate uterus was assumed(a). Sonography (b) and coronal T2 w MRI(c) clearly demonstrate the uterine cavitydivided by a thick septum extendingto the level of the cervix. The angle formed bythe medial borders of the two uterine hemi-cavities is greater than 75°
Class VI: Arcuate Arcuate uterus should be considered a normal variant and it has no effect on fertility. HSG of the arcuate uterus reveals a broad smooth indentation into the fundal cavity, which causes a saddle-shaped appearance
Class VII: Diethylstilbestrol- Related These anomalies comprise sequelae of in utero diethylstilbestrol (DES) exposu Class VII. Hypoplastic T-shaped deformity of the uterus with fi lling of dilated glands in the cervix in a proven DES uterus
Adenomyosis Reducing uterine and endometrial receptibility usg findings diffusely elarged or globular uterus , asymmetrical walls ( > 2.5cm) , ill defined areas of diffusely altered uterine echogenicity , myometrial or subendometrial cysts , indistinct endometrial myometrial interface
AdenomyosisAdenomyosis. Multiple high-signal focipredominantly in the posterior aspect of theuterus on these axial (a) andsagittal (b) T2w MR images, indicating amore focal adenomyosis. Poor delineation ofthe junctional zone is shown
Leiomyoma Uterine leiomyoma, especially submucous leiomyoma, may be associated with pregnancy loss rather than infertility causind distorsion of uterine cavity and contour Colour doppler reveals peripheral vascularity of mild to moderate resistence which differentiate it from adenomyoma with central or peripheral vascularity of loew resistencec Enlarged uterus with large fi broids (F) in the anterior and posterior aspect of the uterus being of typical low signal intensity on this axial (a) and sagittal (b) T2w MR images. B (urinary bladder), E (endometrial cavity
Cervical AbnormalitiesCervical Factor Infertility Cervical Stenosis postcoital test that does not cervical narrowing that involve imaging. prevents the insertion of a 2.5-mm-wide dilator
Newer modalities A newer technique using MR for the visualization of the tubal patency, so called 3D MR-HSG, is a promising imaging alternative, although still in the development stage, to the conventional HSG and avoids exposure of the ovaries to ionizing radiation
Conclusion Usg is the investigation of first choice in infertile females as it is highly accurate in determining common causes of infertility . Mri should be used as second line tool in patients with complex clinical manifestations with normal usg The pelvic causes of female infertility include tubal, peritoneal, uterine, endometrial, cervical, and ovarian abnormalities
A multimodality imaging approach may be useful for determining the cause of infertility and guiding clinical management in specific cases An imaging evaluation for female infertility typically begins with an assessment of tubal patency at hysterosalpingography, which may be followed by pelvic US, pelvic MR imaging, or both to further characterize any additional findings (eg, intrauterine filling defects or uterine contour abnormalities). Failure to cannulate the cervix at hysterosalpingography is suggestive of a cervical abnormality, whereas a normal hysterosalpingographic examination may point toward the possibility of an ovarian cause of infertility.