Imaging in female infertility

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
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.

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

SYSTEMIC FACTORS
• Age over 35 yrs , Obesity
• Endocrinopathy- Thyroid , hypogonadism ,PCOD(10%)
• Psychological
• Immunological-
Immunological incompatibility
Antiphospholipid antibody syndrome
SLE

Radiological investigations
Ultrasonography
Hysterosalphingography
Sonohysterography
Magnetic resonance imaging

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.

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

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

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)
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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
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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
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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 .
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At least 4 spot films taken
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4.Peritoneal
spillage
2. Uterus
fully
distended
1.Early filling
phase
3.Tubal
filling
phase
NORMAL HSG

Genital factors
Acquired- Fibroid , adenomyosis,synechiae,
infections
Narrow introitus
endometriosis

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

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
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17

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]
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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

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

FLORAL APPEARANCE
Twisted hydrosalpinx resembles a floral
appearance of left side tube (arrow).
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LEOPARD SKIN APPEARANCE
Multiple rounded filling defects following intraluminal
granuloma formations within the hydrosalpinx, resembling a "
leopard skin" appearance [arrows]
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COBBLE STONE APPEARANCE
Intraluminal scarring of the tube gives rises a cobblestone
like appearance which is an effective radiographic sign of
intraluminal adhesions
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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

PERITUBAL HALO
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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.

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.
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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
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
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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.

T –SHAPED TB UTERUS DES RELATED T SHAPED UTERUS
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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.

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 trifoliate like appearance.
Both tubes are obstructed in the isthmic portion
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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

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

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 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

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)

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 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

Coronal T2-weighted MR image shows the abscess (arrows). The diagnosis
was confirmed with culture of a US-guided aspiration sample.

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

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

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.

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

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

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

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

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

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.

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

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 shows uterine cavity
deviated toward left side with patent left fallopian tube
(b). In another patient, HSG shows 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 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

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.

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 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 than
105° and with uterine fundi joined at the lower uterine segment,
indicating a bicornis unicollis subtype

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

slight separation (forming acute angle <75).
SEPTATE UTERUS
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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°

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.
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73
Intervening cleft > 1 cm & intercornual distance > 5cm
in bicornuate uterus

 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.

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)
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

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

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 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.

FIBROID UTERUS
SUBMUCOSAL FIBROID

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

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).

*+
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.

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.

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.

SAG MRI – Showing thickening of junctional zone
T1
T2

Enlargment of uterus
Thickening of junctional zone
High signal intensity areas –
endometrial glands , cysts ,
Haemorrhage
ADENOMYOSIS
T2

Genital factors
infections
• Ovarian factors(30-40%) -Anovulation , PID
,endometriosis, ovarian tumors, OHSS
Narrow introitus
endometriosis

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

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

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)

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
areas of wall irregularity (arrowhead

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)

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

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

OVARIAN HYPERSTIMULATION
SYNDROME
Iatrogenic complication of ovulation induction
Enlarged ovaries , mild -<5cm , severe >10cm
Ascitis , pleural effusion

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

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

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 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.

 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.

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

Both the right and left ovaries
show numerous
cysts arranged around the
periphery of the ovaries
producing the "string-of-pearls"
sign.

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

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

Genital factors
• Tubal factors (25%-30%) –PID (tubercular and non tubercular) ,IUD
use, Tubal surgery
infections
• 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

NABOTHIAN CYST
Associated with chronic healing cervicitis
Few millimeters to 4cm
Interfere with passage of sperms
Chronic cervicitis

Sagittal T2 weighted MRI
demonstrating a large cervical fibroid
with characteristic low signal

CERVICAL POLYP
SONOHYSTEROGRAPHY

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

MRKH Syndrome-absence of uterus and
vagina

HYPOGONADISM
TWO TYPES
Hypergonadotrophic hypogonadism(Pheripheral)
Hypogonadotrophic hypogonadism(Central )
Hypergonadotrophic hypogonadism
Turners syndrome
Gonadal dygenesis
Noonans syndrome
PCOD
Galactosemia
LH,FSH Receptor mutations

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

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

Imaging in female infertility

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