Female infertility

1. IMAGING IN FEMALE
INFERTILITY
Dr NIRANJAN B PATIL
Dept. of Radiodiagnosis
DY Patil medical college, hospital and research institute
Kolhapur

2. INTRODUCTION
• Infertility is defined as inability to achieve pregnancy after 12 months of regular unprotected Intercourse
• 40% cases are ascribed to the female factor cause.
• Workup for infertility in women less than 35 years of age is indicated after 1 year of regular unprotected
sexual intercourse and if the woman is more than 35 years of age, it is indicated after 6 months of
unprotected intercourse.
RISK FACTORS FOR INFERTILITY
 After the age of 37 years.
 Tobacco and alcohol use.
 Being overweight or underweight.
 Lack of or very strenuous exercise.
Imaging Modalities
 Hysterosalpingography (HSG)
 Saline Infusion Sonohysterography.
 Sonography including transvaginal sonography (TVS) and Sono hysterosalpingography.
 Hysterosalpingo Contrast Sonography (HyCoSy).
 Magnetic resonance imaging (MRI).

5. Hysterosalpingography
• Indications:
 Infertility—to assess tubal patency
 Recurrent miscarriages—investigation of suspected incompetent cervix, suspected congenital anomaly of uterus
 Following tubal surgery to establish tubal patency, post sterilization to confirm obstruction and prior to reversal of
sterilization
 Assessment of the integrity of a caesarean uterine scar (rare)
• Contraindications
 During menstruation
 Pregnancy or unprotected intercourse during the cycle
 A purulent discharge on inspection of the vulva or cervix, or diagnosed pelvic inflammatory disease (PID) in
the preceding 6 months
 Contrast sensitivity (relative)
• Performed during the first 6–10 days of menstrual cycle-second to fifth day interval just after the cessation
of menstruation.
• Intravenous buscopan- myasthenia gravis, mechanical stenosis in gastrointestinal tract, megacolon, and
prior known hypersensitivity-effective in relieving tubal spasm.

6. Contrast Medium
High osmolar iodinated contrast material (HOCM) or low osmolar iodinated contrast material (LOCM) 10–20
mL, contrast medium should be prewarmed to body temperature to avoid tubal spasm.
Equipment
 Fluoroscopy unit with spot film device
 Vaginal speculum
 Vulsellum forceps
 Hysterosalpingography balloon catheter 5-F to 7-F. In patients with narrow cervix or stenosis of cervical
os, Margolin HSG cannula may be used. It has a silicone tip and provides tight occlusion of the cervix for
contrast injection.
Technique
• The patient lies supine on the table with knees flexed, legs abducted.
• The vulva can be cleaned with chlorhexidine or saline. A disposable speculum is then placed using sterile
jelly, and the cervix is exposed.
• The cervical os is identified using a bright light, and the HSG catheter is inserted into the cervical canal.
It is usually not necessary to use a Vulsellum forceps to hold the cervix with forceps, but occasionally
this may be necessary. The catheter should be left within the lower cervical canal if cervical
incompetence is suspected.
• Care must be taken to expel all air bubbles from the syringe and cannula, as these would otherwise cause
confusion in interpretation. Contrast medium is injected slowly into the uterine cavity under intermittent
fluoroscopic observation.

7. Complications
Due to the contrast medium
Allergic phenomena—especially if contrast medium is
forced into
the circulation.
Due to the technique
1. Pain
2. Bleeding from trauma to the uterus or cervix
3. Transient nausea, vomiting and headache
4. Intravasation of contrast medium into the venous
system of the uterus results in a fine lace-like pattern
within the uterine wall. It may be precipitated by direct
trauma to the endometrium, timing of the procedure near
to menstruation or curettage, tubal occlusion or
congenital abnormalities.
5. Infection

15. CERVICAL FACTOR
Cervical Stenosis
 Cervical stenosis is clinically defined as
cervical narrowing that inhibits the insertion of
a 2.5 mm wide dilator.
 Amenorrhea, dysmenorrhea, and potential
Infertility
 HSG-narrowing of the endocervical canal
(normal diameter is 0.5–3 mm ).
 USG- hematometra-fluid-filled endometrial
cavity.
 Treatment- Gradual dilatation of the cervix with
ultrasound guidance.

16. UTERINE FACTOR
 Account for less than 10% ofcases of infertility
 Anatomic factors- uterine adhesions, leiomyomas or fibroids, and congenital uterine
malformations.
 Physiological factors- lack of normal endometrial response to hormonal stimulation.
 Assessment of the uterine cavity- HSG, standard TVS, TVS with saline contrast
(Sonohysterography), MRI, and hysteroscopy.
Endometrial Adhesions or Synechiae
• may obstruct the cervical os or fallopian tube or environment provided for implantation of
the embryo may be suboptimal.
• Tuberculosis or previous history of dilatation and curettage.
• Asherman’s syndrome- association of synechiae with hypomenorrhea or amenorrhea and
Infertility.

18. LEIOMYOMA
 Leiomyoma (fibroid or myoma) is the most common neoplasm of
the uterus found in up to 20–40% of women in the reproductive
age group, they can be single or multiple.

21. TYPES T1 T2 T1+C
LEIOMYOMAS Isointense(to
myometrium)
Hypointense(to
myometrium)
+similar to or less
than surrounding
myometrium
CELLULAR Isointense Homogenously
hyperintense
Avid enhancement
LIPOLEIOMYOMA Hyperintense Hypointense -
 Parasitic leiomyoma is a pedunculated subserosal fibroid that develops a new blood supply from
adjacent structures such as the omentum and becomes completely detached from the uterus.
 Disseminated peritoneal leiomyomatosis is a rare condition consisting of multiple peritoneal
smooth muscle nodules mimicking diffuse peritoneal carcinomatosis or retroperitoneal masses
resembling leiomyosarcoma.
 Benign metastasizing leiomyomas are leiomyomas that are present in both the uterus and
lung, manifested by single or multiple pulmonary nodules.

26.  Adenomyosis (endometriosis genitalis interna)
of the uterus affects premenopausal women
and is predominantly seen in multiparous
women and women over 30 years of age.
 Adenomyosis is a nonneoplastic condition
which results from the dislocation of basal
endometrial glands and stroma into the
underlying myometrium.
 Transvaginal sonography is generally the first
choice imaging modality in symptomatic
patients with adenomyosis.
 Junctional zone wider than 12 mm is
diagnostic of adenomyosis, whereas a width of
8 mm or less reliably excludes the condition.
Adenomyosis of the Uterus

31. o Endometrial polyps are benign nodular protrusions of the endometrial
surface, and one of the entities included in a differential
of endometrial thickening. Endometrial polyps can either be sessile
or pedunculated. They can often be suggested on ultrasound or MRI
studies but may require Sonohysterography or direct visualization for
confirmation.
o Common cause of postmenopausal bleeding . In premenopausal
women, they may cause intermenstrual bleeding, metrorrhagia, and
infertility.
o May appear isoechoic as a focal non-specific thickened endometrium,
without visualization of a discrete mass
o Can rarely appear as diffuse endometrial thickening as the
endometrial polyp fills the endometrial cavity, mimicking endometrial
hyperplasia
o Rarely cystic spaces could be seen corresponding to dilated glands
filled with proteinaceous fluid within the polyp may be surrounded by
endometrial fluid
Endometrial polyp

33. Müllerian Duct Abnormalities

35. Class I Anomalies: Dysgenesis:
Dysgenesis (segmental agenesis and
variable hypoplasia) of the Müllerian ducts,
Mayer–Rokitansky–Küster syndrome is the most
common form of Class I anomaly and includes
agenesis of uterus and vagina.
Class II Anomalies: Unicornuate Uterus
• Unicornuate uterus is the result of partial or complete
hypoplasia of one Müllerian Duct
• contralateral rudimentary horn-cavity noncommunicating
rudimentary horn, dysmenorrhea and hematometra may
occur
• Renal malformations are common-same side as the
rudimentary horn is found.

36. Class III Anomalies: Uterus Didelphys
• Result of complete nonfusion of the Müllerian
ducts forming a complete uterine duplication
with no communication between each other.
• Associated with a longitudinal (75%) or, more
rarely, a transverse vaginal septum.
• Renal agenesis
• Endometriosis, as a result of retrograde
menstruation.

38. Class IV Anomalies: Bicornuate Uterus
• Bicornuate uterus is the result of
incomplete fusion of the cranial
parts of the Müllerian ducts.
• Leading imaging feature is a fundal
cleft greater than 1 cm of the
external uterine contour that helps
to distinguish bicornuate uterus
from septate uterus.
• Bicornuate unicollis uterus or
bicornuate bicollis uterus as well as
with a longitudinal vaginal septum
that coexists in up to 25% of
bicornuate uterus.
• Degree of communication is always
present between both uterine
cavities, higher rate of cervical
incompetence seems to be
associated with bicornuate uterus.

39. Class V Anomalies: Septate
Uterus
• Septate uterus is the result of
partial or complete nonregression
of the midline Uterovaginal
septum.
• Main imaging feature is that the
external contour of the uterine
fundus may be either convex or
mildly concave <1 cm.
• Most common Müllerian duct
anomaly and is unfortunately
associated with the poorest
reproductive outcome.

40. Class VI Anomalies: Arcuate Uterus
• Arcuate uterus is the result of a near
complete regression of the uterovaginal
septum forming a mild and broad, saddle-
shaped indentation of the fundal
endometrium.
• Differentiation from bicornuate uterus is
based on the complete fundal unification;
however, a partial septate uterus with a
broad-based muscular septum is difficult
to distinguish from an arcuate uterus.
• Higher risk of second term miscarriage.

41. Class VII Anomalies
DES induces abnormal myometrial
hypertrophy in the fetal uterus forming
small T-shaped endometrial cavities

43. TUBAL FACTOR
 Fallopian tube pathology accounts for infertility in
up to 40% of women and is among the most
common causes of infertility.
Causes-
 Tubal obstruction
 Salpingitis isthmica nodosa (SIN)
 Tuberculous salpingitis
 Compared with laparoscopy (which is the gold
standard test for assessing tubal patency HSG
has only moderate sensitivity but relatively high
specificity proximal tubal obstruction.
 Damage to the epithelium secondary to infection
causes abnormal rugal folds and these usually
coexist with a dilated and at times a distally
obstructed tube.
 Abnormal rugal folds may be found in a patent
tube, and they imply decreased chances for
conception.
 Even a unilateral hydrosalpinx is capable of
disrupting natural fertility and preventing the
success of IVF.

46. PERITONEAL FACTOR
 Pelvic adhesions resulting from previous
infection, endometriosis or surgery
 oocyte pick up is hampered.
 Gold standard for visualization of pelvic
adhesions and endometriosis is laparoscopy.
 Loculated spill of contrast is seen in the
peritoneal cavity, or it is seen to track along the
outside of the tube producing “halo effect” or
double contour appearance to tubal wall,
convoluted, kinked, stretched or vertically
oriented fallopian tube
 loculated fluid collections in the adnexae on
TVS.
 Adhesions may be suggested by en masse
movement of the tethered organs when pressure
is applied simultaneously by the operator’s hand
transabdominally and by the probe
transvaginally

47. • Endometriosis is defined as the presence of endometrial glands and stroma in ectopic locations
outside the uterus.
• Symptoms-dysmenorrhea, dyspareunia, chronic pelvic pain, and dysfunctional uterine bleeding,
infertility.
• implants from the uterine endometrium, possibly from lymphatic or hematogenous dissemination of
endometrial cells or retrograde menstruation, coelomic metaplasia with transformation of peritoneal
tissue to ectopic endometrial tissue or embryonic müllerian rests that develop into endometriotic
lesions under the influence of oestrogen.
• Most common sites-surface of the ovary, uterine suspensory ligaments, uterus or fallopian tube, and
the peritoneal surfaces of the pouch of Douglas
• Less common sites- vagina, bladder, cervix, intestine, cesarean delivery scars, abdominal scars, or
the inguinal ligament.
• Deep pelvic endometriosis- invasive tissue that infiltrates structures at a depth of more than 5 mm
from the peritoneal surface and is associated with fibrosis and muscular hyperplasia, dependent
portions of the posterior peritoneal spaces, most commonly the uterosacral ligaments, torus uterinum,
rectovaginal pouch, rectum, and rectovaginal septum
Endometriosis

51. • Mimics- hemorrhagic cysts, TOAs, dermoid, and
cystic ovarian neoplasms.
• Most common misdiagnoses were hemorrhagic
cysts and dermoid, hemorrhagic cyst should
resolve whereas an endometrioma will persist.

53. Gonadal Dysgenesis
Replacement of the gonadal tissue by fibrous stroma,
no germ cells are present secondary to Turner
syndrome, small oval to linear fibrous tissue within
the broad ligament with absence of normal appearing
ovaries

54. Polycystic Ovary Syndrome
 PCOS is a complex endocrinologic disorder
characterized by inappropriate gonadotropin
secretion that results in chronic anovulation.
 Clinical manifestations of PCOS range from mild
signs of hyperandrogenism in thin, normally
menstruating women to the classic Stein-
Leventhal syndrome (oligomenorrhea or
amenorrhea, hirsutism, and obesity).
 Another feature is metabolic disorders including
increased risk of diabetes, cardiovascular
disease, and endometrial hyperplasia or
endometrial cancer.
 At least 12 or more follicles, measuring between 2
and 9 mm and/or an ovarian volume >10 cm3.
 MRI is as an adjunct to US to exclude a virilizing
ovarian tumor and to assess the adrenal glands.

56. Ovarian Reserve
• Day 3 serum FSH and estradiol measurements- high values of
>10–20 IU/L-poor ovarian stimulation and failure to conceive.
• Clomiphene citrate challenge test.
• Serum AMH -Low AMH levels (<1 ng/mL)- poor responses to
ovarian stimulation, poor embryo quality, and poor pregnancy
outcomes in IVF.
• Antral follicle count (AFC)
Antral Follicle Count
• Antral follicles are identified by USG when they reach 2 mm in
diameter, coinciding with higher sensitivity to FSH.
• Between 2 mm and 10 mm are “recruitable” & >10 mm are
“dominant follicles.
• counted in the early follicular phase of the menstrual cycle,
decreases the chance of presence of an ovarian cyst or CL cyst.
• AFC <5–7 is associated with small number of oocytes retrieved
and reduced pregnancy rate, whereas AFC more than or equal to
20-OHSS

57. Indications for counting ovarian follicles include the following:
• Woman >35 years of age attempting pregnancy for >6 months
• Risk for diminished ovarian reserve—history of cancer treatment with gonadotoxic drugs or history
of irradiation
• Surgery for endometriosis.
Accessed using:-
 Real-time Two-dimensional Ultrasonography.
 Three-dimensional Manual Mode
 Sono Automated Volume Calculations (SonoAVC)- semi-automated technique that permits
counting and measuring of diameters and volumes of anechoic structures within a particular region of
interest of an acquired 3D dataset
Luteinized Unruptured Follicle
Failure to detect follicular collapse but with infilling of the follicle suggests luteinization without
ovulation.

59. Ovulatory Function Tests
• Ovulation Monitoring can be done by:
• Basal body temperature recordings
• Endometrial biopsy
• Measurement of a serum progesterone (generally done 1 week before the expected onset of next menses)
• Urinary LH determination using ovulation predictor kits to identify midcycle LH surge which occurs 1–2 days
before ovulation.
• Follicular monitoring using USG.
Development and Evolution of Ovarian Follicles
 TVS is used for monitoring the follicles during ovarian induction using clomiphene citrate or human
menopausal gonadotropin (hMG).
 Done from the 7th day of the menstrual cycle and preferably on a daily basis, which can help in adjustment of
the patient’s medication.
 A follicle is considered mature when it measures 15–18 mm in mean diameter.
 Presence of fine echoes within the mature follicle is an indication of ovulation.
 Collapse of the preovulatory follicle, a loss of clearly defined follicular margins and increase in cul-desac fluid
volume

60. Follicular Monitoring: Spontaneous Cycles
There is usually development of one or sometimes
two dominant follicles
3-5mm 10mm 7 days before LH surge, a dominant follicle takes over
5 days prior to ovulation the dominant follicle grows at the rate of 2–3 mm/day
17 mm to 25 mm.
Follicular Monitoring: Induced Cycles
• Ovulation induction is indicated- ovulation abnormality or anovulation in women with normal ovulation before
assisted conception techniques such as IVF-ET or gamete intrafallopian transfer to increase the number of
oocytes aspirated.
• Baseline scanning of the pelvis-If one or more cysts, larger than approximately 2 cm in diameter are found,
especially if accompanied by serum estradiol concentration of more than 100 pg/mL, it may interfere with
treatment and induction may be postponed to the next cycle or cysts treated by aspiration.
• Clomiphene citrate, aromatase inhibitors (e.g. letrozole), and gonadotropins [FSH, LH, hMG, hCG], examined
every other day starting at day 10.
• Larger follicles on a given date may not be the same one that is the largest 2 days later and it may not even be
the same one that is most mature one that is most mature.

61. • Maximum preovulatory diameter can range from 19 mm to 24 mm.
• HMG does not require an intact hypothalamopituitary axis-Sonographic assessment of follicle size is critical
because hCG is best administered once follicles reach 15–18 mm.
Prediction of Ovulation
• Follicular rupture occurs at a wide range of diameters between 2 cm and 2.7 cm, In the unstimulated ovary,
follicles are approximately spherical.
• Follicular size of >22 mm or a volume >5 mL was correlated with poor oocyte retrieval probably due to
postmature follicle.
• Also be predicted by noting collapse of a follicle that was previously seen, development of internal echoes
within the follicle, crenation of follicular walls, visualization of cumulus, perifollicular halo, and visualization
of fluid in the cul-de-sac (if not previously seen).
• Ultrasound Doppler studies reveal an increase in blood flow to the ovary carrying the dominant Follicle.
• Intrafollicular neovascularization occurs over the hours preceding ovulation and becomes massive after
follicular collapse as blood vessels invade the luteinizing follicular (or granulosa) cells, in patients with LPD
and high CL-RI (>0.51) vitamin E or L-arginine treatment improved luteal function by decreasing CL blood
flow impedance

62. Ovarian Hyperstimulation Syndrome
 It occurs during the luteal phase of menstrual cycle or in early pregnancy and mostly follows administration
of endogenous or exogenous LH or hCG
 It occurs after hCG administration to patient with a large number of immature follicles and high serum
estradiol levels and is more likely to occur in those with a polycystic ovarian morphology.
 Third-space fluid accumulation and electrolyte abnormalities.
 Usually more severe if pregnancy follows ovulation.
 Clinical features:-nausea, vomiting, ascites, and pleural and pericardial effusion. These worsen
hemoconcentration causing hyperviscosity and hypercoagulability which predispose to thrombosis,
embolism, and renal failure.

64.  Can be differentiated from ovarian neoplasms by
absence of any abnormal enhancing soft tissue in
or around the cystic ovarian mass and the normal
central ovarian stroma.
 Similar appearance of bilateral enlarged ovaries
with multiple cysts resulting in a “spoke wheel”
appearance can be seen with theca lutein cysts, in
response to raised levels of beta-hCG.

65. Follicle Aspiration
• Ultrasound directed follicle aspiration (UDFA)- direct
transabdominal, transabdominal through full bladder,
transvaginal, trans vesical, and per-urethral approach.
• With all these aspiration techniques, a long (30 cm) 18-
gauge needle is used that is scored at the tip, which results
in its enhanced sonographic visualization.
• Performed under local anesthesia and with supplemental
intravenous or intramuscular medication.
• Associated with low complication rates that include vaginal
haemorrhage and pelvic infection.
• When a transvesical or transurethral approach is used
postoperative clot retention or occasionally urine
extravasation may occur.
• Ultrasound has also been used to guide ET to the uterine
cavity, to assist accurate placement of the embryos in the
uterine cavity rather than cervical canal