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IMAGING OF FEMALE
INFERTILITY
Dr Deepak Garg
Resident radiodiagnosis
GMC patiala
Infertility.
 Infertility is defined as failure to conceive a desired
pregnancy after 12 months of unprotected sexual
int...
Causes of female infertility-
Genital factors
• Tubal factors (25%-30%) –PID (tubercular and non
tubercular) ,IUD use, Tub...
SYSTEMIC FACTORS
• Age over 35 yrs , Obesity
• Endocrinopathy- Thyroid , hypogonadism ,PCOD(10%)
• Psychological
• Immunol...
Radiological investigations
Ultrasonography
Hysterosalphingography
Sonohysterography
Magnetic resonance imaging
Hysterosalphingography
Used to visualise uterine cavity and confirm
tubal patency .
Hysterosalpingography (HSG) uses flu...
1) Female infertility aimed at assessing tubal and uterine factors
2) Evaluation of tubal patency after tubal surgery.
3) ...
Technical Considerations
 The patient is placed supine with her knees flexed and heels
apart
 The cervix is exposed with...
PATIENT PREPARATION
 Hsg should be done in first half of menstrual cycle in
proliferative phase between 8th to 12th day
...
COMPLICATION
 Pain (because of dilatation of uterus , spillage of contrast
into peritonium).
 Infection (pelvic).
 Blee...
CONTRAINDICATION
 Suspected pregnancy
 Acute pelvic infection
 Active vaginal bleeding
 Recent dilation and curettage
...
NORMAL
HSG
 The uterine cavity is shown during HSG
as a triangular contrast-filled structure,
with its base on top and th...
At least 4 spot films taken
17-Oct-16
14
4.Peritoneal
spillage
2. Uterus
fully
distended
1.Early filling
phase
3.Tubal
fil...
Causes of female infertility-
Genital factors
• Tubal factors (25%-30%) –PID (tubercular and non
tubercular) ,IUD use, Tub...
Pelvic inflammatory desease
Genital tuberculosis-
• It is an important cause of infertility in india
• HSG is the intial d...
HSG FINDINDS IN GENITAL
TUBERCULOSIS
FALLOPIAN TUBES
 SPECIFIC
Beaded tube
Golf club tube
Pipestem tube
Floral appearance...
calcification
Lt –Isthmic obstruction
Rt – Interstitial obstruction
Endometrial irregularity
GENITAL TUBERCULOSIS
BEADED TUBE
Multiple constrictions along the fallopian tube giving
rise to a " beaded" appearance [arrows]
17-Oct-16
19
GOLF CLUB TUBE
Sacculation of both tubes in distal portion with an
associated hydrosalpinx giving a Golf club-like
appeara...
PIPE STEM APPEARANCE
Absence of normal tortuosity and a curved or straight pipe
like appearance show fibrotic stage of tub...
FLORAL APPEARANCE
Twisted hydrosalpinx resembles a floral
appearance of left side tube (arrow).
17-Oct-16
22
LEOPARD SKIN APPEARANCE
Multiple rounded filling defects following intraluminal
granuloma formations within the hydrosalpi...
COBBLE STONE APPEARANCE
Intraluminal scarring of the tube gives rises a cobblestone
like appearance which is an effective ...
CORK SCREW APPEARANCE
Vertically fixed tubes secondary to dense peritubal adhesions.
Dense connective tissue causes the la...
PERITUBAL HALO
17-Oct-16
26
Thickening of the tubal walls due to peritubal adhesions (arrows)
represents a cloudy sign on ...
TOBACCO POUCH APPEARANCE
Terminal hydrosalpinx with the conical narrowing is seen
in the right tube (arrow). Eversion of t...
Dilatation of ampula
With prominent mucosal folds
TUBAL TB
Loculated spill on right side –s/o adhesions
TUBAL TB
HSG FINDINDS IN GENITAL
TUBERCULOSIS
FALLOPIAN TUBES
 SPECIFIC
Beaded tube
Golf club tube
Pipestem tube
Floral appearance...
17-Oct-16
31
A. Pseudo-unicornuate uterus. Unilateral scarring of the cavity makes an
asymmetric intrauterine obliteration...
T –SHAPED TB UTERUS DES RELATED T SHAPED UTERUS
17-Oct-16
32
T-shaped configuration in two different patients.
A. " T-shap...
T shaped uterus in GTB
Small contracted uterus with irregular outline
ENDOMETRIAL TB
TRIFOLIATE SHAPED UTERUS
Synechia formation at the uterine borders and partial
obliteration in the fundus produce a trifol...
17-Oct-16
36
A.Uterine cavity is normal in shape and size. Terminal sacculation are seen
in both tubes.
B. Irregularity, m...
Isthmic obstruction
Beaded appearance of tube
Intravasation of the contrast
Irregularityof the endometrium
Isthmica nodosa...
Two lucent defects – S/O I/U -synechia
ENDOMETRIAL TB
KLEINS CRITERIA FOR GTB-
• Calcified LN ,Smaller or irregular calcification in adnexal area
• Obstruction of the FT in the...
Role of ultrasound in GTB (TVS)
Echogenic heterogenous adnexal mass ( Echogenic periphery with low central
echoes)
TB endo...
Ultrasonographic image of the pelvis
shows left tubo-ovarian abscess
resulting from tuberculosis
COGWHEEL SIGN
MRI –GTB
Cystic or solid and cystic mass usually bilateral ,
With Ascitis ,omental , mesentric infiltration , peritonial t...
Coronal T2-weighted MR image shows the abscess (arrows). The diagnosis
was confirmed with culture of a US-guided aspiratio...
T2
Tuberculous TOA with endometritis
1 Sag CE T1 W Well enhancing thickened endometrium with hydrometra
2 Axial CE T1 W Septa...
T2 W T1 W
CE T1 AXIAL MS CE T1
PELVIC INFLAMMATORY DESEASES ( NON TUBERCULAR)
Pelvic inflammatory disease (PID) is one of the most serious complications ...
Uterus: The uterus may be ill defined because of inflammation;
Endometrium: Endometritis may result in central-endometrial...
Endometritis-USG (ET is thickened and hetrogenous)
 ( a ) “Waist sign” of a hydrosalpinx, marked by the asterisks ( b ) “Beads
on a string” sign of a hydrosalpinx
PYOSALPHINX
HYDROSALPHINX –
Showing increased blood
flow
Causes of female infertility-
Genital factors
• Tubal factors (25%-30%) –PID (tubercular and non
tubercular) ,IUD use, Tub...
Müllerian Duct Anomalies
prevalence of approximately 3%Mullerian duct
anomalies may be depicted by HSG;
the complex situ...
Uterine anomalies (Mόllerian duct anomalies)
● Considered as causes of infertility when all other causes have
been exclude...
UTERINE ANOMALIES
class anomaly
i Partial / complete
agenesis
ii Unicornuate
iii Didelphys
iv Bicornuate
V Septate
Vi Arcu...
During embryogenesis female reproductive tract develops from two mullerian ducts and
later on their fusion. In MDA there i...
Class I: Hypoplasia or Agenesis
Failure of normal development of the mullerian
ducts causes uterine agenesis or hypoplasi...
Class I
Class I. Uterine agenesis. Sagittal
midline sonogram shows normal
vagina, small (curved arrows) cervix
(straight a...
Class II: Unicornuate
 one normally developed mullerian duct,
with the contralateral duct either
hypoplastic (subtypes 2a...
Class II. Left unicornuate uterus. HSG shows uterine cavity
deviated toward left side with patent left fallopian tube
(b)....
Class III: Didelphys
 Complete failure of fusion of
the two mullerian ducts results
in two complete uteri, each with
its ...
a)HSG demonstrates two separate endocervical canals that open into
separate fusiform endometrial cavities, with no communi...
Coronal T2 w images at different sections
showing didelphys
Class IV: Bicornuate
Partial fusion of two mullerian ducts
results in a bicornuate uterus with
one cervix
 HSG of a bico...
Class IV.
widely splayed uterine horns with an intercornual angle greater than
105° and with uterine fundi joined at the l...
Class V: Septate
 Septate uterus results from failure of resorption of a
septum after complete fusion of the mullerian du...
slight separation (forming acute angle <75).
SEPTATE UTERUS
17-Oct-16
71
Class V.
(a). Sonography (b) and coronal T2 w MRI clearly demonstrate the uterine
cavity divided by a thick septum extendi...
Bicornuate and Septate Uteri
 Bicornuate:
 Fundus indented
 Cavities widely
separated( > 105 degree)
 Partial fusion o...
 Figure 6 To distinguish bicornuate
uteri from septate uteri with three-
dimensional ultrasound we used
the formula propo...
Class VI: Arcuate
 Arcuate uterus should be
considered a normal
variant and it has no
effect on fertility.
 HSG of the a...
Class VII: Diethylstilbestrol-
Related
 These anomalies comprise
sequelae of in utero
diethylstilbestrol (DES)
exposure
C...
FIBROID
LEIOMYOMA- It causes infertility coz of-
• Distortion of the uterine cavity
• Poor nidation of zygote
• Cornual tubal bloc...
HYDROSONOGRAM
HSG –Showing Fibroid ,
Smooth filling defects
Distortion of uterine cavities
Fibroid uterus
CT SCAN - showing multiple hypodense areas
Fibroids are sharply marginated areas of low-to-intermediate signal intensity on
and T2-weighted MRI scans
One third of fi...
FIBROID UTERUS
SUBMUCOSAL FIBROID
ADENOMYOSIS
ADENOMYOSIS
Characterised by the presence of endometrial glands and stroma within the
myometrium
Sonographic criteria for ...
A B C
 Adenomyosis on transvaginal scans: spectrum of appearances. A,
Subendometrial cyst (arrowhead, endometrium). B, Cy...
*+
C D E
 Adenomyosis on transvaginal scans: spectrum of appearances. D,
Multiple subendometrial cysts and echogenic nodu...
Thickened junctional zone to greater than 12 millimeters.
MRI features of ADENOMYOSIS
On T2 weighted images, foci of incre...
MRI can be used to distinguish a focal adenomyoma from a leiomyoma.
Adenomyomas lack distinct borders and any mass effect ...
SAG MRI – Showing thickening of junctional zone
T1
T2
Enlargment of uterus
Thickening of junctional zone
High signal intensity areas –
endometrial glands , cysts ,
Haemorrhage
...
Causes of female infertility-
Genital factors
• Tubal factors (25%-30%) –PID (tubercular and non
tubercular) ,IUD use, Tub...
The most frequent site of endometriosis is the ovary. Other
frequent locations include the following:
* Uterine ligaments
...
DIFFUSE FORM
Consists of endometrial implants involving pelvic viscera and ligaments
Hormonally responsive and bleeds duri...
The typical US scan finding in endometrioma is a cystic mass ,may be unilocular or
multilocular, with diffuse ,homogenous ...
Endometrioma with diffuse ,homogenous low-level echoes
Endometriotic cyst in the ovary-
bright focus in the ovary
Endometriosis in post op scar
Blader wall endometriotic nodule
Endometrioma with thick septations in a 35-year-old woman.
(a) Transvaginal US scan shows thick septations (arrow) with
ar...
Large atypical endometrioma in a 32-year-old woman with right-sided abdomina
pain and infertility. (a) CT image shows a co...
MRI demonstrates these endometriomas as cystic masses with very high signal
intensity on T1-weighted images and very low s...
T1 CE T1
CE T1 FS
SPD SE
TA FS T1CE
OVARIAN TUMORS RELATED TO INFERTILITY
Virilizing mesenchymal tumors (Sex –cord stromal tumors)
Arrhenoblastoma
Hilus cell ...
OVARIAN HYPERSTIMULATION
SYNDROME
Iatrogenic complication of ovulation induction
Enlarged ovaries , mild -<5cm , severe >1...
FOLLICULAR MONITORING
SPONTANEOUS CYCLE--
The selection of dominant follicle occurs by 5-7th day of the cycle
,detected on...
Sonographic features that denotes IMPENDING OVULATION are-
• Appearance of line of decreased reflectivity around the folli...
Ovulation failure
• hemorrhagic anovulatory follicles
• Cystic anovulatory follicle
 Images from a woman who developed hemorrhagic anovulatory follicles during a
study of natural cycle folliculogenesis and...
 Failure of ovulation and development of “cystic” follicle. The follicle
typically grows larger than the mean preovulator...
Polycystic ovarian syndrome (PCOS), also known as, Stein-Leventhal
syndrome, includes
o Polycystic ovaries
o Obesity
o Hir...
Both the right and left ovaries
show numerous
cysts arranged around the
periphery of the ovaries
producing the "string-of-...
Ovarian volume is not always increased.Almost 30% of patients with a biochemical
and pathologic diagnosis of polycystic ov...
On T1-weighted images, the ovaries have homogeneously low signal intensity, and
they are easily distinguished from the sur...
Causes of female infertility-
Genital factors
• Tubal factors (25%-30%) –PID (tubercular and non tubercular) ,IUD
use, Tub...
NABOTHIAN CYST
Associated with chronic healing cervicitis
Few millimeters to 4cm
Interfere with passage of sperms
Chronic ...
Sagittal T2 weighted MRI
demonstrating a large cervical fibroid
with characteristic low signal
CERVICAL POLYP
SONOHYSTEROGRAPHY
HSG Showing cervical stenosis
CERVICAL STENOSIS
Causes of female infertility-
Genital factors
• Tubal factors (25%-30%) –PID (tubercular and non
tubercular) ,IUD use, Tub...
Transeverse vaginal septum
In McKusick-Kaufman syndrome, an autosomal recessive disorder, vaginal atresia is
associated with hydrometrocolpos, postax...
MRKH Syndrome-absence of uterus and
vagina
HYPOGONADISM
TWO TYPES
Hypergonadotrophic hypogonadism(Pheripheral)
Hypogonadotrophic hypogonadism(Central )
Hypergonadotr...
Hypogonadotrophic hypogonadism
•Tumors
•Craniopharyngioma
•Germinoma
•Other germ cell tumors
•Hypothalamic and optic gliom...
Miscellaneous disorders
Prader-Willi syndrome
,
Laurence-Moon syndrome,
Bardet-Biedl syndrome,
Functional gonadotropin def...
Thank you
Imaging in female infertility
Imaging in female infertility
Imaging in female infertility
Imaging in female infertility
Imaging in female infertility
Imaging in female infertility
Imaging in female infertility
Imaging in female infertility
Imaging in female infertility
Imaging in female infertility
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Imaging in female infertility

imaging in female infertility radiological aspect. (hsg, usg, ct and mri)
dr deepak resident radiodiagnosis, gmc patiala

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Imaging in female infertility

  1. 1. IMAGING OF FEMALE INFERTILITY Dr Deepak Garg Resident radiodiagnosis GMC patiala
  2. 2. Infertility.  Infertility is defined as failure to conceive a desired pregnancy after 12 months of unprotected sexual intercourse.  Primary infertility is infertility in a couple who have never had a child.  Secondary infertility is failure to conceive following a previous pregnancy.  Approximate 10% of couple are infertile.  Male and female are equally affected.
  3. 3. Causes of female infertility- Genital factors • Tubal factors (25%-30%) –PID (tubercular and non tubercular) ,IUD use, Tubal surgery • Uterine factors-(10%) Congenital – Agenesis ,unicornuate ,bicornuate Didelphys ,septate uterus Acquired- Fibroid , adenomyosis,synechia, infections • Ovarian factors(30-40%) -Anovulation , PID ,endometriosis • Cervical factors (5%)–Cervicitis , polyps ,Cervical scarring • Vaginal factors – Vaginitis , Vaginismus ,Vaginal atresia, Narrow introitus • Peritonial factors(5%) –peritonial adhesions , Pelvic endometriosis
  4. 4. SYSTEMIC FACTORS • Age over 35 yrs , Obesity • Endocrinopathy- Thyroid , hypogonadism ,PCOD(10%) • Psychological • Immunological- Immunological incompatibility Antiphospholipid antibody syndrome SLE
  5. 5. Radiological investigations Ultrasonography Hysterosalphingography Sonohysterography Magnetic resonance imaging
  6. 6. 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.
  7. 7. 1) Female infertility aimed at assessing tubal and uterine factors 2) Evaluation of tubal patency after tubal surgery. 3) Demonstration of congenital abnormalities or other lesions in patients with abortion. 4) Assessment of proximal tubal segment before tubal ligation reversal 5) Amenorrhea unresponsive to hormonal stimulation 6) Evaluation of uterine cavity after metroplasty 7) Fibroid uterus 8) In staging and grading of uterine synechia. INDICATIONS OF HSG
  8. 8. 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 cannula 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
  9. 9. PATIENT PREPARATION  Hsg should be done in first half of menstrual cycle in proliferative phase between 8th to 12th day  It should not be done in secretive phase because of higher chances of vascular intravasation  Patient to avoid unprotected sexual intercourse from the date of her period until investigation is over to avoid possible risk of pregnancy  If periods are irregular , do urine b- hcg test to rule out pregnancy  Exclude active pelvic infection  Prophylactic antibiotics not routinely recommended (considered in case of bacterial endocarditis) 17-Oct-16 10
  10. 10. COMPLICATION  Pain (because of dilatation of uterus , spillage of contrast into peritonium).  Infection (pelvic).  Bleeding.  Vascular or lymphatic Intravasation  Vasovagal episode.  Pregnancy irradiation.  Allergic reaction (to iodinated contrast media).  Uterine perforation 17-Oct-16 11
  11. 11. CONTRAINDICATION  Suspected pregnancy  Acute pelvic infection  Active vaginal bleeding  Recent dilation and curettage  Immediate pre and post menstrual phase  Tubal or uterine surgery within last 6 wks  Contrast sensitivity 17-Oct-16 12
  12. 12. NORMAL HSG  The uterine cavity is shown during HSG as a triangular contrast-filled structure, with its base on top and the apex caudally (inverted triangle) and the uterine fundus on top, which can be flattened, concave or slightly convex . 17-Oct-16
  13. 13. At least 4 spot films taken 17-Oct-16 14 4.Peritoneal spillage 2. Uterus fully distended 1.Early filling phase 3.Tubal filling phase NORMAL HSG
  14. 14. Causes of female infertility- Genital factors • Tubal factors (25%-30%) –PID (tubercular and non tubercular) ,IUD use, Tubal surgery • Uterine factors-(10%) Congenital – Agenesis ,unicornuate ,bicornuate Didelphys ,septate uterus Acquired- Fibroid , adenomyosis,synechiae, infections • Ovarian factors(30-40%) -Anovulation , PID ,endometriosis • Cervical factors (5%)–Cervicitis , polyps ,Cervical scarring • Vaginal factors – Vaginitis , Vaginismus ,Vaginal atresia, Narrow introitus • Peritonial factors(5%) –peritonial adhesions , Pelvic endometriosis
  15. 15. Pelvic inflammatory desease Genital tuberculosis- • It is an important cause of infertility in india • HSG is the intial diagnostic procedure of choice for the evaluation of infertility • Genital TB – Almost always acquired by haematogenous route from the extragenital source • Primary focus is FT – Affected bilaterally but not symetrically Plain films- shows linear streaks of calcifications in the course of fallopian tubes Or appear as faint or dense tiny nodules HSG – The most common site for tubal occlusion is Cornua and ampulla
  16. 16. HSG FINDINDS IN GENITAL TUBERCULOSIS FALLOPIAN TUBES  SPECIFIC Beaded tube Golf club tube Pipestem tube Floral appearance Cobblestone tube Leopard skin tube  NON SPECIFIC Hydrosalpinx Mucosal thickening Peritubal adhesion (Convoluted or corkscrew tube, Peritubal halo,tobacco pouh appearance, Loculated spillage UTERUS  SPECIFIC T shaped uterus Pseudounicornuate uterus Trifoliate uterus  NONSPECIFIC endometritis Synecia distortion of uterine contour Venous, lymphatic intravasation 17-Oct-16 17
  17. 17. calcification Lt –Isthmic obstruction Rt – Interstitial obstruction Endometrial irregularity GENITAL TUBERCULOSIS
  18. 18. BEADED TUBE Multiple constrictions along the fallopian tube giving rise to a " beaded" appearance [arrows] 17-Oct-16 19
  19. 19. GOLF CLUB TUBE Sacculation of both tubes in distal portion with an associated hydrosalpinx giving a Golf club-like appearance (arrows). 17-Oct-16 20
  20. 20. PIPE STEM APPEARANCE Absence of normal tortuosity and a curved or straight pipe like appearance show fibrotic stage of tuberculous salpingitis. Irregular contour of the uterine cavity with diminished capacity in the fundual portion resembling a septate uterus.17-Oct-16 21
  21. 21. FLORAL APPEARANCE Twisted hydrosalpinx resembles a floral appearance of left side tube (arrow). 17-Oct-16 22
  22. 22. LEOPARD SKIN APPEARANCE Multiple rounded filling defects following intraluminal granuloma formations within the hydrosalpinx, resembling a " leopard skin" appearance [arrows] 17-Oct-16 23
  23. 23. COBBLE STONE APPEARANCE Intraluminal scarring of the tube gives rises a cobblestone like appearance which is an effective radiographic sign of intraluminal adhesions 17-Oct-16 24
  24. 24. CORK SCREW APPEARANCE Vertically fixed tubes secondary to dense peritubal adhesions. Dense connective tissue causes the lack of tubal mobility. The hyperconvulated right tube manifests a " cork screw" like appearance [arrows] 17-Oct-16
  25. 25. PERITUBAL HALO 17-Oct-16 26 Thickening of the tubal walls due to peritubal adhesions (arrows) represents a cloudy sign on hysterosalpingograms. This finding is a non-specific feature of tubal tuberculosis.
  26. 26. TOBACCO POUCH APPEARANCE Terminal hydrosalpinx with the conical narrowing is seen in the right tube (arrow). Eversion of the fimbria secondary to adhesions, with a patent orifice produces the tobacco pouch appearance in the left terminal. 17-Oct-16 27
  27. 27. Dilatation of ampula With prominent mucosal folds TUBAL TB
  28. 28. Loculated spill on right side –s/o adhesions TUBAL TB
  29. 29. HSG FINDINDS IN GENITAL TUBERCULOSIS FALLOPIAN TUBES  SPECIFIC Beaded tube Golf club tube Pipestem tube Floral appearance Cobblestone tube Leopard skin tube  NON SPECIFIC Hydrosalpinx Mucosal thickening Peritubal adhesion (Convoluted or corkscrew tube, Peritubal halo,tobacco pouh appearance, Loculated spillage UTERUS  SPECIFIC T shaped uterus Pseudounicornuate uterus Trifoliate uterus  NONSPECIFIC endometritis Syneciae distortion of uterine contour Venous, lymphatic intravasation 17-Oct-16 30
  30. 30. 17-Oct-16 31 A. Pseudo-unicornuate uterus. Unilateral scarring of the cavity makes an asymmetric intrauterine obliteration, resembling a unicornuate uterus. the irregular contour and vertical orientation of long axis. B. True unicornuate uterus. the smooth contour, more horizontal orientation of long axis and normal ipsilateral fallopian tube.
  31. 31. T –SHAPED TB UTERUS DES RELATED T SHAPED UTERUS 17-Oct-16 32 T-shaped configuration in two different patients. A. " T-shaped" tuberculosis uterus. Irregular contour of the uterine cavity with diminished capacity resembling a T-shaped uterus. Both tubes are obstructed from isthmic portion B. T-shaped uterus due to DES exposure. Narrow endocervical canal and small uterine cavity. Note both tubes are normal.
  32. 32. T shaped uterus in GTB
  33. 33. Small contracted uterus with irregular outline ENDOMETRIAL TB
  34. 34. TRIFOLIATE SHAPED UTERUS Synechia formation at the uterine borders and partial obliteration in the fundus produce a trifoliate like appearance. Both tubes are obstructed in the isthmic portion 17-Oct-16 35
  35. 35. 17-Oct-16 36 A.Uterine cavity is normal in shape and size. Terminal sacculation are seen in both tubes. B. Irregularity, multiple filling defects and obliteration of right ostium secondary to extensive synechia formation in this site. A B INTRAUTERINE ADHESION AND DISTORTION
  36. 36. Isthmic obstruction Beaded appearance of tube Intravasation of the contrast Irregularityof the endometrium Isthmica nodosa like appearance Multiple small diverticular collections of contrast protruding from the lumen into the wall of the isthmic portion of the fallopian tubes
  37. 37. Two lucent defects – S/O I/U -synechia ENDOMETRIAL TB
  38. 38. KLEINS CRITERIA FOR GTB- • Calcified LN ,Smaller or irregular calcification in adnexal area • Obstruction of the FT in the transitional zone of isthmus and ampulla • Multiple constrictions along the course of fallopian tube • Endometrial adhesions ,deformity or obliteration of the endometrial cavity in the absence of curettage or surgical termination of pregnancy
  39. 39. Role of ultrasound in GTB (TVS) Echogenic heterogenous adnexal mass ( Echogenic periphery with low central echoes) TB endometritis – jagged endometrium to thick calcified plaque Synechia and adhesions – thick echogenic endometrial bands Acute salphingitis – Dilated fluid filled thick walled elongated cystic structure Chronic hydrosalphinx – Thin tubal wall which protrudes into the lumen – cogwheel appearance ,contents are homogenous and echogenic Chronic pyosalphinx – Homogenous and particulate Thickned peritonium , thickened omentum ,septated ascitis , loculated fluid endometrial involvement , adnexal masses (wet TB) Adnexal masses , Adhesions , loculated fluid (Dry TB)
  40. 40. Ultrasonographic image of the pelvis shows left tubo-ovarian abscess resulting from tuberculosis COGWHEEL SIGN
  41. 41. MRI –GTB Cystic or solid and cystic mass usually bilateral , With Ascitis ,omental , mesentric infiltration , peritonial thickening Thickned salphinges , Nodularity along tubo-ovarian surfaces Walls of the TOA often irregular shows low signal intensity on T2 Serrated and nodular inner wall Dense adhesions with uterus or adjecent organ Loculated fluid collections with internal septations adjecent to masses Or in cul-de –sac Associated necrotic LN
  42. 42. Coronal T2-weighted MR image shows the abscess (arrows). The diagnosis was confirmed with culture of a US-guided aspiration sample.
  43. 43. T2
  44. 44. Tuberculous TOA with endometritis 1 Sag CE T1 W Well enhancing thickened endometrium with hydrometra 2 Axial CE T1 W Septate cystic masses in both adenexal region
  45. 45. T2 W T1 W
  46. 46. CE T1 AXIAL MS CE T1
  47. 47. PELVIC INFLAMMATORY DESEASES ( NON TUBERCULAR) Pelvic inflammatory disease (PID) is one of the most serious complications of sexually transmitted diseases. It is an infection of the female upper genital tract that encompasses a broad category of diseases, including endometritis, salpingitis, salpingo-oophoritis, tubo- ovarian abscess (TOA), and pelvic peritonitis. PID most commonly occurs as a result of Chlamydia trachomatis or Neisseria gonorrhoeae infection of the cervix or vagina that then spreads into the endometrium, fallopian tubes, ovaries, and adjacent structures
  48. 48. Uterus: The uterus may be ill defined because of inflammation; Endometrium: Endometritis may result in central-endometrial-cavity echo thickening and heterogeneity Fallopian tube: Hydrosalpinx is depicted as a fluid-filled tube. If the tube walls are thickened and if debris is present within the tube, pyosalpinx should be considered in the differential diagnosis. However, a pyosalpinx may occasionally be imaged as an echoless tube, whereas an imaged echo-filled tube may be due to proteinaceous but noninfected fluid in a hydrosalpinx Ovaries: Oophoritis results in enlarged ovaries with ill-defined margins that often appear adherent to the uterus. Adjacent free fluid may be present in the adnexa or cul-de-sac. TOAs are depicted as complex adnexal masses with thickened walls and central fluid.
  49. 49. Endometritis-USG (ET is thickened and hetrogenous)
  50. 50.  ( a ) “Waist sign” of a hydrosalpinx, marked by the asterisks ( b ) “Beads on a string” sign of a hydrosalpinx
  51. 51. PYOSALPHINX HYDROSALPHINX – Showing increased blood flow
  52. 52. Causes of female infertility- Genital factors • Tubal factors (25%-30%) –PID (tubercular and non tubercular) ,IUD use, Tubal surgery • Uterine factors-(10%) Congenital – Agenesis ,unicornuate ,bicornuate Didelphys ,septate uterus Acquired- Fibroid , adenomyosis,synechia, infections • Ovarian factors(30-40%) -Anovulation , PID ,endometriosis • Cervical factors (5%)–Cervicitis , polyps ,Cervical scarring • Vaginal factors – Vaginitis , Vaginismus ,Vaginal atresia, Narrow introitus • Peritonial factors(5%) –peritonial adhesions , Pelvic endometriosis
  53. 53. 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
  54. 54. Uterine anomalies (Mόllerian duct anomalies) ● Considered as causes of infertility when all other causes have been excluded ● Multiplanar MRI is diagnostic ● MR imaging attained 100% accuracy for diagnosis of uterine anomalies, as compared with 92% for ultrasound and less than 20% for HSG ● Classified according to the American Fertility Society criteria as follows
  55. 55. UTERINE ANOMALIES class anomaly i Partial / complete agenesis ii Unicornuate iii Didelphys iv Bicornuate V Septate Vi Arcuate vii DES-associated anomalies 17-Oct-16 59 American Fertility Society
  56. 56. During embryogenesis female reproductive tract develops from two mullerian ducts and later on their fusion. In MDA there is defect in development or fusionof these ducts. So MDA are classified acc to the stage at which fusion stops
  57. 57. 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.
  58. 58. Class I Class I. Uterine agenesis. Sagittal midline sonogram shows normal vagina, small (curved arrows) cervix (straight arrow), and absent uterine corpus
  59. 59. 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
  60. 60. Class II. Left unicornuate uterus. HSG shows uterine cavity deviated toward left side with patent left fallopian tube (b). In another patient, HSG shows right unicornuate uterus with hydrosalpinx
  61. 61. Class III: Didelphys  Complete failure of fusion of the two mullerian ducts results in two complete uteri, each with its own cervix a sagittal vaginal septum is seen in majority of cases (75% cases)  uterus didelphys is associated with the highest successful pregnancy rate,  Uterus didelphys with an obstructed hemivagina is termed Wunderlich syndrome
  62. 62. a)HSG demonstrates two separate endocervical canals that open into separate fusiform endometrial cavities, with no communication between the two horns. Each endometrial cavity ends in a solitary fallopian tube. b) If the anomaly is associated with a sagittal vaginal septum, only one cervical os may be depicted, and it may be cannulated with the endometrial configuration mimicking a unicornuate uterus.
  63. 63. Coronal T2 w images at different sections showing didelphys
  64. 64. 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
  65. 65. Class IV. widely splayed uterine horns with an intercornual angle greater than 105° and with uterine fundi joined at the lower uterine segment, indicating a bicornis unicollis subtype
  66. 66. Class V: Septate  Septate uterus results from failure of resorption of a septum after complete fusion of the mullerian ducts  It is the commonest uterine anomaly (accounts for ~55% of such anomalies).  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 less 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
  67. 67. slight separation (forming acute angle <75). SEPTATE UTERUS 17-Oct-16 71
  68. 68. Class V. (a). Sonography (b) and coronal T2 w MRI 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 lesser than 75°
  69. 69. Bicornuate and Septate Uteri  Bicornuate:  Fundus indented  Cavities widely separated( > 105 degree)  Partial fusion of mullerian ducts  Septate:  Normal external surface  Cavities are close together  Defect in canalization or resorption of midline septum between mullerian ducts. 17-Oct-16 73 Intervening cleft > 1 cm & intercornual distance > 5cm in bicornuate uterus
  70. 70.  Figure 6 To distinguish bicornuate uteri from septate uteri with three- dimensional ultrasound we used the formula proposed by Troiano and McCarthy15: a line was traced joining both horns of the uterine cavity. If this line crossed the fundus or was ≤5 mm from it, the uterus was considered bicornuate (a and b); if it was >5 mm from fundus it was considered septate, regardless of whether the fundus was dome-shaped (c), smooth or discretely notched.
  71. 71. 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
  72. 72. Class VII: Diethylstilbestrol- Related  These anomalies comprise sequelae of in utero diethylstilbestrol (DES) exposure Class VII. Hypoplastic T-shaped deformity of the uterus, with normal fallopian tubes with filling of dilated glands in the cervix in a proven DES uterus
  73. 73. FIBROID
  74. 74. LEIOMYOMA- It causes infertility coz of- • Distortion of the uterine cavity • Poor nidation of zygote • Cornual tubal block • Obstruction to sperm ascent(cervical fibroid) USG features May be enlarged ,globular uterus Hypoechoic or heterogenous echopattern Acoustic attenation or posterior shadowing Minimal contour irregularity at the interface b/n uterus and bladder is a subtle diagnostic sign
  75. 75. HYDROSONOGRAM
  76. 76. HSG –Showing Fibroid , Smooth filling defects Distortion of uterine cavities
  77. 77. Fibroid uterus CT SCAN - showing multiple hypodense areas
  78. 78. Fibroids are sharply marginated areas of low-to-intermediate signal intensity on and T2-weighted MRI scans One third of fibroids have a hyperintense rim on T2-weighted images as a result o dilated veins, lymphatics, or edema MRI An inhomogeneous area of high signal intensity may be depicted on T2-weighted images; this results from hemorrhage, hyaline degeneration, edema, or highly cellular fibroids On contrast, Fibroids usually enhance later than does the healthy myometrium. Fibroid enhancement can be hypointense (65%), isointense (23%), or hyperinten (12%) in relation to that of the myometrium.
  79. 79. FIBROID UTERUS SUBMUCOSAL FIBROID
  80. 80. ADENOMYOSIS
  81. 81. ADENOMYOSIS Characterised by the presence of endometrial glands and stroma within the myometrium Sonographic criteria for adenomyosis Diffuse uterine enlargement Diffusely heterogeneous myometrium Asymmetrical thickening of myometrium Inhomogenous hypoechoic areas Myometrial cysts (2-6 mm) Poor definition of endometrial –myometrial borders Focal tenderness elicited by vaginal transducer Subendometrial linear echogenic striations Subendometrial echogenic nodules
  82. 82. A B C  Adenomyosis on transvaginal scans: spectrum of appearances. A, Subendometrial cyst (arrowhead, endometrium). B, Cysts and in anterior myometrium with poorly defined anterior endometrial border (arrowhead). C, Myometrial heterogeneity with poorly defined borders (arrowheads).
  83. 83. *+ C D E  Adenomyosis on transvaginal scans: spectrum of appearances. D, Multiple subendometrial cysts and echogenic nodules. E, Diffuse heterogeneous myometrium with multiple cysts and poorly defined endometrial borders . F, Large area of myometrial heterogeneity producing a focal mass effect and displacing endometrium. This may mimic a fibroid.
  84. 84. Thickened junctional zone to greater than 12 millimeters. MRI features of ADENOMYOSIS On T2 weighted images, foci of increased signal are seen, representing islands of endometrium within the hypertrophied myometrium Variable enhancement patterns are seen depending on the present of cystic areas. A common and useful finding is the relatively mild distortion of the endometrial cavity that occurs with even advanced adenomyosis Focal adenomyomas were 2-7 cm in diameter, round or oval, and located in the posterior wall. With poorly defined margin. On T1-weighted images, most of these masses were isointense relative to the surrounding myometrium. Seen as a localized, low – signal-intensity mass within the myometrium on both T2- weighted and contrast-enhanced T1-weighted MRIs.
  85. 85. MRI can be used to distinguish a focal adenomyoma from a leiomyoma. Adenomyomas lack distinct borders and any mass effect on both T2-weighted and contrast-enhanced T1-weighted MRI scans. Most focal adenomyomas are in the posterior myometrium. Leiomyomas do not have this predilection. Both adenomyomas and leiomyomas have low signal intensity, although some leiomyomas with hemorrhage have high signal intensity. The bright foci seen in the myometrium on T2-weighted images in 50% of patients are islands of heterotopic endometrial tissue, cystic dilation of heterotopic glands, or hemorrhage.
  86. 86. SAG MRI – Showing thickening of junctional zone T1 T2
  87. 87. Enlargment of uterus Thickening of junctional zone High signal intensity areas – endometrial glands , cysts , Haemorrhage ADENOMYOSIS T2
  88. 88. Causes of female infertility- Genital factors • Tubal factors (25%-30%) –PID (tubercular and non tubercular) ,IUD use, Tubal surgery • Uterine factors-(10%) Congenital – Agenesis ,unicornuate ,bicornuate Didelphys ,septate uterus Acquired- Fibroid , adenomyosis,synechia, infections • Ovarian factors(30-40%) -Anovulation , PID ,endometriosis, ovarian tumors, OHSS • Cervical factors (5%)–Cervicitis , polyps ,Cervical scarring • Vaginal factors – Vaginitis , Vaginismus ,Vaginal atresia, Narrow introitus • Peritonial factors(5%) –peritonial adhesions , Pelvic endometriosis
  89. 89. The most frequent site of endometriosis is the ovary. Other frequent locations include the following: * Uterine ligaments * Pelvic cul-de-sac (pouch of Douglas) * Pelvic peritoneum * Fallopian tubes * Rectosigmoid * Bladder Two types Diffuse Localised form (Endometrioma or choclate cysts ) ENDOMETRIOSIS Complications of endometriosis consist of bowel and ureteral obstruction resulting from pelvic adhesions. Endometriosis is defined as presence of functional endometrial tissue outside the uterus
  90. 90. DIFFUSE FORM Consists of endometrial implants involving pelvic viscera and ligaments Hormonally responsive and bleeds during menses ,resulting in inflammation and adhesions Rarely diagnosed by sonography as the implants are too small to be imaged
  91. 91. The typical US scan finding in endometrioma is a cystic mass ,may be unilocular or multilocular, with diffuse ,homogenous low-level echoes Fluid –fluid levels may be seen sometimes Small implants typically are not seen with US scanning Doppler waveform analysis is not helpful in differentiating endometriomas from other masses. Low-resistance waveforms resembling malignancy are encountered in endometriomas It can be mimicked by hemorrhagic cysts, (Reticular internal echoes with free fluid in cul de sac ) ,tubo-ovarian abscesses, and cystadenomas. US scanning is not a sensitive technique to diagnose endometriosis. CHOCLATE CYSTS( localised form)
  92. 92. Endometrioma with diffuse ,homogenous low-level echoes
  93. 93. Endometriotic cyst in the ovary- bright focus in the ovary Endometriosis in post op scar
  94. 94. Blader wall endometriotic nodule
  95. 95. Endometrioma with thick septations in a 35-year-old woman. (a) Transvaginal US scan shows thick septations (arrow) with areas of wall irregularity (arrowhead
  96. 96. Large atypical endometrioma in a 32-year-old woman with right-sided abdomina pain and infertility. (a) CT image shows a complex right adnexal mass extending the upper abdomen. Note the irregular nodular enhancement within the wall of mass (arrows)
  97. 97. MRI demonstrates these endometriomas as cystic masses with very high signal intensity on T1-weighted images and very low signal intensity on T2-weighted image This pattern of signal intensities results from the high iron concentration in the endometrioma and is rarely seen in other masses of any type The appearance of endometriomas on magnetic resonance images is variable and depends on the concentration of iron and protein in the fluid, products of blood degradation. Multiple high-signal lesions, usually in the ovaries, on T1-weighted images also are highly suggestive of endometriosis. Larger, fibrotic implants of endometriosis on the peritonium are seen on magnetic resonance images as spiculated nodules of very low signal intensity on T2-weighted images. These commonly occur in the cul-de-sac; They less commonly appear on the bladder dome, rectum, or umbilicus or in pelvic surgical scars. Dilated fallopian tubes occasionally MRI
  98. 98. T1 CE T1
  99. 99. CE T1 FS
  100. 100. SPD SE
  101. 101. TA FS T1CE
  102. 102. OVARIAN TUMORS RELATED TO INFERTILITY Virilizing mesenchymal tumors (Sex –cord stromal tumors) Arrhenoblastoma Hilus cell tumours Gynandroblastoma ARRHENOBLASTOMA Unilateral , solid lesion , age group 3rd decade Endocrine activity –Testosterone Musculinization Hirusitism Clitoromegally
  103. 103. OVARIAN HYPERSTIMULATION SYNDROME Iatrogenic complication of ovulation induction Enlarged ovaries , mild -<5cm , severe >10cm Ascitis , pleural effusion
  104. 104. FOLLICULAR MONITORING SPONTANEOUS CYCLE-- The selection of dominant follicle occurs by 5-7th day of the cycle ,detected on TVS by 8th day Follicle grows in a linear manner by 2-3 mm a day , reaches the mean diameter of 20-24 mm by the time of ovulation Maximum preovulatory diameter ranges from 15-30mm -This alone acts as a absolute predictor of ovulation The non dominant follicle rarely exeeds 11mm in diameter
  105. 105. Sonographic features that denotes IMPENDING OVULATION are- • Appearance of line of decreased reflectivity around the follicle • Crenated pattern to the lining of follicle , • Detection of cumulus oopharus- detection of small echogenic focus on the wall of dominant follicle • Sudden reduction in size of preveously enlarged folicle • Appearance of fluid in cul-de-sac Following ovulation a mature corpus luteam is seen in only 50% of cases -Seen as small irregular cyst with echogenic crenated walls It should not be visible beyond 72hrs of subsequent cycles Role of TVS in management and treatment- Guided follicular or cyst aspiration Guided transecervical canalisation of FT
  106. 106. Ovulation failure • hemorrhagic anovulatory follicles • Cystic anovulatory follicle
  107. 107.  Images from a woman who developed hemorrhagic anovulatory follicles during a study of natural cycle folliculogenesis and ovulation (A, B). There is evidence of extravasated blood in the lumen of the structure and the walls are thin, did not develop any visual evidence of luteinization( ie absence sonolucent halo, pattern, or cumulus oopharus). Progesterone levels were below those accepted as clinically normal.
  108. 108.  Failure of ovulation and development of “cystic” follicle. The follicle typically grows larger than the mean preovulatory follicle diameter of 23 mm, thin atretic follicle walls are observed and small flecks of particulate matter are frequently seen in the lumen or aggregated at the side of the structure.
  109. 109. Polycystic ovarian syndrome (PCOS), also known as, Stein-Leventhal syndrome, includes o Polycystic ovaries o Obesity o Hirsutism o Infertility Most common cause of secondary amenorrhoea associated with hyperandrogenic state Imaging o Ultrasound is the imaging modality of choice o Polycystic ovaries are enlarged and rounder than normal with increased stromal echogenicity o There are numerous small cysts, less than 8mm, that line up on the periphery in a “string-of-pearls” appearance o Ultrasonographic criteria for establishing the diagnosis of PCOS are 10 or more cysts that are 2-8 mm in diameter and are peripherally arranged around an echodense stroma The luteinizing hormone level is elevated, with reversal of the LH/FSH ratio as LH becomes higher than FSH throughout the menstrual cycle PCOD
  110. 110. Both the right and left ovaries show numerous cysts arranged around the periphery of the ovaries producing the "string-of-pearls" sign.
  111. 111. Ovarian volume is not always increased.Almost 30% of patients with a biochemical and pathologic diagnosis of polycystic ovaries have no increase in ovarian volume Less than 50% of patients with biochemical features of polycystic ovaries and increased ovarian volume have the classic finding of multiple, small, peripheral follicles. In a patient with a biochemical diagnosis of polycystic ovaries, ultrasonographic findings may confirm the clinical diagnosis, but they cannot exclude it. Alternatively, the incidental discovery of polycystic ovaries during ultrasonography is not a reliable indicator of polycystic ovarian syndrome. Pitfalls in ultrasonography Ultimately, the diagnosis should be made on clinical and biochemical grounds
  112. 112. On T1-weighted images, the ovaries have homogeneously low signal intensity, and they are easily distinguished from the surrounding pelvic fat. T2-weighted images reveal high signal intensity within the fluid-filled follicles of the ovarian cortex. The ovarian stroma remains dark on these images. Polycystic ovaries are characterized by numerous, small (<1 cm), peripheral cysts that are located throughout the cortex. The ovaries may be slightly larger than normal; however, the ovarian stroma is hypertrophic. Often, the fibrous capsule surrounding the ovary is prominent. MRI
  113. 113. Causes of female infertility- Genital factors • Tubal factors (25%-30%) –PID (tubercular and non tubercular) ,IUD use, Tubal surgery • Uterine factors-(10%) Congenital – Agenesis ,unicornuate ,bicornuate Didelphys ,septate uterus Acquired- Fibroid , adenomyosis,synechia, infections • Ovarian factors(30-40%) -Anovulation , PID ,endometriosis • Cervical factors (5%)–Chronic cervicitis, Cervical fibroid, Cervical polyp, Cervical carcinoma, Cervical stenosis, Radiation therapy, Previous cone biopsy • Vaginal factors – Vaginitis , Vaginismus ,Vaginal atresia, Narrow introitus • Peritonial factors(5%) –peritonial adhesions , Pelvic endometriosis
  114. 114. NABOTHIAN CYST Associated with chronic healing cervicitis Few millimeters to 4cm Interfere with passage of sperms Chronic cervicitis
  115. 115. Sagittal T2 weighted MRI demonstrating a large cervical fibroid with characteristic low signal
  116. 116. CERVICAL POLYP SONOHYSTEROGRAPHY
  117. 117. HSG Showing cervical stenosis
  118. 118. CERVICAL STENOSIS
  119. 119. Causes of female infertility- Genital factors • Tubal factors (25%-30%) –PID (tubercular and non tubercular) ,IUD use, Tubal surgery • Uterine factors-(10%) Congenital – Agenesis ,unicornuate ,bicornuate Didelphys ,septate uterus Acquired- Fibroid , adenomyosis,synechia, infections • Ovarian factors(30-40%) -Anovulation , PID ,endometriosis • Cervical factors (5%)–Cervicitis , polyps ,Cervical scarring • Vaginal factors – Vaginitis , Vaginismus ,Vaginal atresia, Narrow introitus • Peritonial factors(5%) –peritonial adhesions , Pelvic endometriosis
  120. 120. Transeverse vaginal septum
  121. 121. In McKusick-Kaufman syndrome, an autosomal recessive disorder, vaginal atresia is associated with hydrometrocolpos, postaxial polydactyly, imperforate anus, and congenital heart defects. The patient still has secondary sexual characteristics. Bardet-Biedl syndrome is a genetically heterogeneous group of autosomal recessive disorders. Vaginal atresia in Bardet-Biedl syndrome is associated with retinal dystrophy or retinitis pigmentosa (appears at age 10-20 y), postaxial polydactyly, obesity, nephropathy, and mental disturbances. If ear anomalies are seen in conjunction with vaginal atresia, Fraser syndrome should be considered. MRKH SYNDROME- absence of uterus and vagina. VAGINAL ATRESIA
  122. 122. MRKH Syndrome-absence of uterus and vagina
  123. 123. HYPOGONADISM TWO TYPES Hypergonadotrophic hypogonadism(Pheripheral) Hypogonadotrophic hypogonadism(Central ) Hypergonadotrophic hypogonadism Turners syndrome Gonadal dygenesis Noonans syndrome PCOD Galactosemia LH,FSH Receptor mutations
  124. 124. Hypogonadotrophic hypogonadism •Tumors •Craniopharyngioma •Germinoma •Other germ cell tumors •Hypothalamic and optic glioma •Astrocytoma •Pituitary tumor •Miscellaneous causes •Langerhans histiocytosis •Postinfectious lesions of the CNS •Vascular abnormalities of the CNS •Radiation therapy •Congenital malformations (especially associated with craniofacial anomalies) •Head trauma •Genetic causes •Kallmann syndrome (mutation in the KAL [anosmin] gene), with hyposmia or anosmia or without anosmia
  125. 125. Miscellaneous disorders Prader-Willi syndrome , Laurence-Moon syndrome, Bardet-Biedl syndrome, Functional gonadotropin deficiency (psychogenic amenorrhea, hypothyroidism, diabetes mellitus, Cushing syndrome) , Hyperprolactinemia, Marijuana use, and Gaucher disease
  126. 126. Thank you

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