1. IMAGING OF FEMALE FEMALE
INFERTILITY
Dr charusmita chaudhary

2. 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

3. 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

4.  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.

5.  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

6.  An imaging study to evaluate female infertility and
uterine anomalies should necessarily exhibit many
characteristics
1. noninvasive
2. low cost
3. high accuracy

7. 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

8. 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.

9. 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. “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

11. 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

12. 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

13. Fallopian Tube Abnormalities

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

15. 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

16. Fallopian Tubes
 length from 7–16 cm
(average, 12 cm
5-
8cm
2-3cm
1-2cm trumpet-shaped
The fallopian tubes have three segments that are visible at
hysterosalpingography: the interstitial portion, which traverses the
myometrium; the isthmic portion, which courses within the broad
ligament; and the ampullary portion, which is adjacent to the ovary

17. Normal hysterosalpingogram

18. 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 isthmic
portion may be missed by sonography Multiple tiny diverticula in the right
isthmic portion (arrows) partial tubectomy
on the left side (arrow
head)

19. A, dilated, obstructed tube on the left
(hydrosalpinx) and obstruction of the right
intramural portion
(b), nondilated obstruction on both sides at the
isthmic/ampullary portion
©huge bilateral dilatation without spill into
the peritoneum–bilateral hydrosalpinx

20. Endometrial polyps
. A Stalked fi lling defect within the endometrial cavity probably
arising 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

21. Synechiae. On hysterosalpingogram, irregular borders (arrows) and
narrowing of the cervical canal (arrowhead) depicted (a).
HSG shows synechiae causing partial obstruction of the
endometrial cavity and occlusion of
the right fallopian tube (b). Note: HSG may not rule out
mullerian duct anomaly with certainty in this particular case

22. 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

23. 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.

24. 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

25. 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.

26. 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)

27. Side Effects and
Complications Limitations of Sono-HSG
 most part the same as for operator dependency
conventional HSG  LARGE BODY HABITUS
LARGE FIBROID

28. MRI
 It is best for delineating the morphology and
orientation of pelvic structures .
 Detects pathological lesions, including tubal
lesions and pituitary adenoma .

29. 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

30. Limitations
 higher cost,
 limited availability,
 longer scanning time,
MRimaging is often used as a problem solving
modality when sonography findings are
inconclusive

31. 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).

32. Pituatory adenoma
 Prolactin-producing hypophyseal adenoma
 Hyperprolactinemia can be a cause of infertility
and is associated with diminished gonadotropin
secretion, secondary amenorrhea, and
galactorrhea.

33. 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.

34. 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

35. 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

36. Polycystic Ovarian Syndrome
Characterised by combination of
 multiple clinical manifestations
( hirsutism, anovultory cycle and infertility)
 hormonal imbalance

37. 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)

38. 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

40. 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

42. 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.

43. Uterine Disorders
They are considered a anomalies when
all other causes are excluded
Multiplanar mri is diagnostic

44. 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

45. 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

46. Class I
Class I. Uterine agenesis. Sagittal
midline sonogram shows normal
vagina, small (curved arrows) cervix
(straight arrow), and absent uterine
corpus

47. 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

48. Class II. Left unicornuate uterus. HSG shows
uterine cavity deviated toward left side with
patent left fallopian
tube (a). Axial T2w MRI in this patient shows
no rudimentary
horn on the right side (b). In another patient,
HSG
shows right unicornuate uterus with hydrosalpinx

49. 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

50. 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

51. Class IV.
widely splayed uterine horns with an intercornual angle greater than
100° and with uterine
fundi joined at the lower uterine segment, indicating a bicornis
unicollis subtype

52. 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

53. Class V.
On HSG one cervical opening was missed; only
one uterine cavity was spilled with contrast
media; a unicornuate uterus was assumed
(a). Sonography (b) and coronal T2 w MRI
(c) clearly demonstrate the uterine cavity
divided by a thick septum extending
to the level of the cervix. The angle formed by
the medial borders of the two uterine hemi-
cavities is greater than 75°

54. 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

55. 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

56. 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

57. Adenomyosis
Adenomyosis. Multiple high-signal foci
predominantly in the posterior aspect of the
uterus on these axial (a) and
sagittal (b) T2w MR images, indicating a
more focal adenomyosis. Poor delineation of
the junctional zone is shown

58. 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

59. Cervical Abnormalities
Cervical Factor Infertility Cervical Stenosis
 postcoital test that does not  cervical narrowing that
involve imaging. prevents the insertion of a
2.5-mm-wide dilator

60. 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

61. 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

62.  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.

63. THANK YOU