1. Radiological imaging
of female infertility.
Dr/ ABD ALLAH NAZEER. MD.

2. Infertility.
Infertility is defined as failure to conceive a desired
pregnancy after 24 months of unprotected sexual
intercourse.
Approximate 10% of couple are infertile.
Male and female are equally affected.
Primary infertility is infertility in a couple who have
never had a child. Secondary infertility is failure to
conceive following a previous pregnancy. Infertility
may be caused by infection in the man or woman,
but often there is no obvious underlying cause.

3. 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. In most cases, 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. Hysterographic US helps differentiate among
uterine synechiae, endometrial polyps, and 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.
The appropriate selection of imaging modalities and accurate
characterization of the various pelvic causes of infertility are essential
because the imaging findings help direct subsequent patient care.

4. A systematic multimodalities imaging approach is
advocated in which initial hysterosalpingography
is followed by hysterographic US pelvic US, pelvic
MRI or a combination with a selection of
modalities depending on the finding on
hysterosalpingography.
An imaging study to evaluate female infertility
and uterine anomalies should necessary exhibit
many characteristic .
1- Non-invasive.
2- Low cost.
3- High accuracy.

5. Causes of infertility.
Uterine causes: Congenital anomalies, infections, uterine
synechiae, focal lesions, intra-uterine scar, cervical
stenosis, reduced uterine perfusion, alteration of the
endometrium thickness and vascularity.
Ovarian causes: Follicular and ovulation abnormalities,
stromal vascularity ad endometriosis.
Tubal causes: Infection and obstruction.
Hormonal Problems : These are the most common causes
of anovulation. The process of ovulation depends upon a
complex balance of hormones and their interactions to
be successful, and any disruption in this process can
hinder ovulation. There are three main sources causing
this problem.

6. Imaging modalities of infertility
In most cases, 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.
Hysterographic US helps differentiate among uterine synechiae,
endometrial polyps, and 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. The appropriate
selection of imaging modalities and accurate characterization of the
various pelvic causes of infertility are essential because the imaging
findings help direct subsequent patient care.

7. Hysterosalpingography (HSG) is a
radiological procedure used to demonstrate the uterine
cavity and the fallopian tube lumens using contrast
medium. It is a valuable technique in the evaluation of an
infertile female patient. Despite the development of other
diagnostic tools, such as, magnetic resonance imaging,
hysteroscopy, and laparoscopy; it remains the main
examination for the fallopian tubes in developing
countries.
HSG, uses fluoroscopic control to introduce radiographic
contrast material into the uterine cavity and fallopian
tubes.
Cycle consideration: HSG should not be performed if there
is a possibility of a normal intra-uterine pregnancy.

11. Fallopian Tube Abnormalities.
Fallopian tube abnormalities are the most
common cause of female infertility, accounting for
30%–40% of cases. Hysterosalpingography
provides optimal depiction of the fallopian tubes,
allowing detection of tubal patency, tubal
occlusion, tubal irregularity, and peritubal
disease. If there is evidence of occlusion due to
endometriosis, hysterosalpingography should be
followed by MR imaging. A process diagram for
diagnostic imaging of fallopian tube
abnormalities.

15. Left hydrosalpinx. Hysterosalpingogram shows dilatation of the
left fallopian tube (arrow) with an absence of contrast material
outflow, findings indicative of tubal occlusion, and a patent
normal right tube (arrowhead) with outflow of contrast material.

16. Tubal irregularity due to salpingitis isthmica nodosa. Spot (a) and
magnified (b) views from hysterosalpingography depict multiple
contrast material–filled luminal pouches (arrowheads) projecting
2–3 mm outward from the isthmic portion of both fallopian tubes.

17. Right peritubal pelvic adhesion due to previous pelvic inflammatory
disease. Early (a) and late (b) hysterosalpingograms show normal
contrast material filling of the right fallopian tube (arrow in a) and a
rounded collection of leaked contrast material (arrowheads in b) adjacent
to the ampullary portion of the right tube. The collection was due to
peritubal adhesions. The left fallopian tube appears normal and patent.

20. Asherman syndrome in a patient with a history of dilation and
curettage. (a) Hysterosalpingogram depicts several linear intrauterine
filling defects (arrowheads). (b) Sagittal image from transvaginal
hysterographic US shows multiple uterine synechiae (arrows).

21. Endometrial polyp. (a)
Hysterosalpingogram depicts a well-
circumscribed ovoid intrauterine filling
defect (arrow). (b, c) Sagittal gray-scale
(b) and color Doppler (c) US images from
subsequent transvaginal hysterographic
US show a posterior fundal endometrial
polyp (arrowheads in b) with a central
feeding vessel (arrow in c).

22. DES-related uterine anomaly. Hysterosalpingogram
demonstrates a hypoplastic T-shaped uterus. The
patient had been exposed to DES while in utero.

23. Adenomyosis. Left posterior oblique hysterosalpingogram shows
characteristic saccular contrast material collections (arrowheads)
protruding beyond the normal contour of the endometrial cavity.

24. Submucosal leiomyomas. (16) Hysterosalpingogram shows a large
intrauterine filling defect (arrows) due to a large submucosal leiomyoma that
produces a mass effect on almost the entire uterus. (17) Axial T2-weighted
MR image demonstrates a region of heterogeneous increased signal intensity
that represents a fundal intramural fibroid (arrow) with a submucosal
component (arrowheads). Nabothian cysts are visible in the cervix.

26. Sonohysterography and sonohysterosalpingography.
Used to evaluate uterine pathology because of its excellent
diagnostic accuracy, minimal patient discomfort, low cost and
wide -spread availability.
With the addition of transvaginal sonography, color Doppler
imaging, and sonohysterography, Ultrasound has become a
sensitive technique for detecting endometrial and myometrial
pathology.
During the excretory phase of the menstrual cycle, when the
endometrial thickness ad the echo complex are better characterized.
For congenital anomaly evaluation, the timing of the sonography
examination is not critical.
It involve airless, sterile, saline infusion through a soft plastic
catheter in the cervix with simultaneous endovaginal US. It allow
excellent visualization of the endometrial cavity and its lining.
The procedure can also confirms tubal patency by demonstrating
spillage of saline from a distended tube into pelvic cavity.

28. MRI.
MR imaging is the best imaging modalities for delineating
the morphology and orientation of the pelvic structures.
Detects pathological lesions like adenomyosis,
endometriosis and leiomyoma.
Detect tubal lesions, Müllerian duct abnormality and
ovarian pathology.
Detect extra-pelvic causes like pituitary adenoma.
MR imaging is often used as a problem solving modality
when sonography finding are inconclusive.
Limitations:
Higher cost, limited availability and longer scanning time.

30. Endometriosis
An estimated 30%–50% of women with endometriosis are infertile, and 20%
of infertile women have endometriosis, a condition defined by the presence of
endometrial glands and stroma outside the uterus The US features of
endometriosis are variable; US has low sensitivity for the detection of focal
implants, but it may depict endometriomas . Endometriomas have a variable
appearance, with the most specific US signs being an adenxial mass with faint
internal echoes and highly echogenic mural foci . They generally occur within
the ovary, often bilaterally. The sensitivity and specificity of MR imaging for
the identification of endometriosis are higher (71% and 82%, respectively)
than those of US . MR imaging features of endometriosis include cystic masses
with thickened walls and loss of the interface between the lesion and adjacent
organs. The masses have internal high signal intensity on T1-weighted images
and low signal intensity on T2-weighted images. Other high signal- intensity
features seen on T1-weighted images may include hydrosalpinx (the luminal
contents of which may include blood products) and endometrial implants .
However, the sensitivity (13%) of MR imaging for the detection of endometrial
implants is low . For this reason, MR imaging alone cannot take the place of
laparoscopy for the definitive diagnosis of endometriosis.

31. Endometrioma. Sagittal transvaginal US image obtained
in a woman with a history of endometriosis shows an
ovarian mass with multiple fine internal echoes (arrows)
and several hyperechoic mural foci (arrowheads).

32. Endometriosis. Unenhanced axial T1- weighted fat-suppressed MR image
shows dilatation of the right fallopian tube (arrow) with internal high
signal intensity due to blood products, findings indicative of
hematosalpinx. Smaller high-signal-intensity foci along the posterior
uterine serosa (arrowhead) are indicative of endometrial implants.

34. Ovarian Abnormalities
Ovarian causes of infertility include primary conditions such as
nonfunctional ovaries, premature ovarian failure, and absence of
ovaries (gonadal dysgenesis). These conditions are usually
diagnosed on the basis of clinical and biochemical findings.
Imaging is more valuable for diagnosing the secondary ovarian
causes of infertility, which include polycystic ovary syndrome,
endometriosis, and ovarian cancer. Pelvic US is usually performed
for initial evaluation of the ovaries. Polycystic ovary syndrome
reportedly affects approximately 8% of women and may be one of
the most common causes of female infertility . Women with this
syndrome have hyperandrogenism, which leads to morphologic
changes in the ovary, and elevated serum levels of luteinizing
hormone . The overproduction of luteinizing hormone results in
incomplete ovulatory cycles. Clinical manifestations of the
condition include hirsutism, obesity, and oligoamenorrhea.

35. Polycystic ovary syndrome. (a) Transvaginal US image of the right
ovary depicts multiple peripheral subcentimetric follicles (arrow). (b)
Coronal T2-weighted MR image from the same patient shows bilateral
ovarian enlargement with multiple peripheral follicles (arrows).

36. Müllerian Duct Anomalies
Müllerian duct anomalies are another potential cause of
alteration in the normal uterine contour and, thus, of
female infertility. It is estimated that approximately 1% of
all women and 3% of women with recurrent pregnancy
losses have a uterovaginal anomaly. As many as 25% of
women with müllerian duct anomalies (compared with
only 10% of the general population) have reproductive
problems, including increased risk for spontaneous
abortion, prematurity, intrauterine growth retardation,
abnormal fetal lie, and dystocia at delivery. Accurate
characterization of müllerian duct anomalies is essential
because pregnancy outcomes and treatment options vary
between the different classes of anomalies.

37. Class I: Uterine Hypoplasia and Agenesis:
Hypoplasia and agenesis of the uterus and proximal
vagina, which result from failed or incomplete
development of both müllerian ducts, account for
5%–10% of müllerian duct anomalies. Patients
may present with primary amenorrhea and often are
initially evaluated with pelvic US or MR imaging, which
reveals a small or absent uterus and proximal vagina.
Mayer-Rokitansky-Küster- Hauser syndrome, the most
common variant in this class of anomalies, is manifested
by complete vaginal agenesis and, in most cases, uterine
agenesis. The reproductive potential of patients with
uterine hypoplasia is limited, and that of patients with
uterine agenesis is absent.

39. Mayer-Rokitansky-Küster-Hauser syndrome in an 18-year-old female patient
with primary amenorrhea. Sagittal T2-weighted MR image shows absence of
the uterus, cervix, and proximal vagina, with an anomalous pelvic location
of the kidney (arrow). A remnant distal vagina (arrowheads) is seen.

41. Class II: Unicornuate Uterus.
A unicornuate uterus is the result of failed or incomplete
development of one of the müllerian ducts. Unicornuate uteri
account for approximately 20% of all müllerian duct anomalies .
Hysterosalpingography, US, and MR imaging characteristically
reveal a laterally deviated, banana-shaped uterine horn with a
single fallopian tube. In many cases, there is a rudimentary horn
on the contralateral side, with or without an endometrial cavity
that may or may not communicate with the dominant horn.
Rudimentary horns are usually best visualized with MR imaging,
which also readily demonstrates the absence of an endometrium
in the rudimentary horn. Rudimentary horns with an
endometrium often are resected because they are associated
with an increased risk of endometriosis and a risk of pregnancy in
the rudimentary horn.

43. Right unicornuate uterus. (21) Axial (a)
and coronal oblique (b) T2-weighted MR
images demonstrate a laterally deviated,
banana-shaped right unicornuate uterus
(arrow) with a non-cavitary rudimentary left
horn (arrowhead in b). (22)
Hysterosalpingogram shows opacification of
a single right uterine cavity and a single right
fallopian tube with contrast material spillover

46. Class III: Uterus Didelphys.
A uterus didelphys (also known as didelphic uterus), which
results from failed ductal fusion, is characterized by two
symmetric, widely divergent uterine horns and two cervixes at
hysterosalpingography, US, and MR imaging. Didelphic uteri
account for approximately 11% of müllerian duct anomalies.
MR imaging may be required to fully characterize the
complex anomalies in this group. In approximately 75% of
cases, a longitudinal vaginal septum is present, with or
without a unilateral horizontal vaginal septum and resultant
unilateral hematometrocolpos . Metroplasty may be
performed in patients who have experienced recurrent
spontaneous abortions or preterm deliveries, but the benefit
of such surgery remains unclear.

48. Uterus didelphys. (a, b) Transverse transabdominal pelvic US image (a) and oblique axial
T2-weighted MR image (b) demonstrate two divergent uterine horns (arrows) with
distention of the right endometrial cavity (arrowheads in b). (c) Sagittal T1-weighted fat-
suppressed MR image depicts high-signal-intensity material distending the right
endometrial cavity and cervix (arrowheads), a finding indicative of right
hematometrocolpos. An obstructive horizontal right vaginal septum was subsequently
resected. (d) Coronal T2-weighted MR image demonstrates associated right renal agenesis.

50. Class IV: Bicornuate Uterus.
Incomplete fusion of the müllerian ducts results in a bicornuate
uterus, a condition that accounts for approximately 10% of
uterine anomalies. In patients with this condition,
hysterosalpingography shows two symmetric but divergent
uterine horns. US and MR imaging may help confirm the presence
of a bicornuate uterus by depicting a deep (> 1 cm) fundal cleft in
the outer uterine contour and an intercornual distance of more
than 4 cm. In some patients, US and MR imaging show two
separate cervical canals; in such a case, the anomaly is
characterized as bicornuate bicollis. A bicornuate bicollis uterus is
distinguished from a uterus didelphys by a greater degree of
myometrial fusion between the horns along the lower uterine
segment. Patients with infertility related to a bicornuate uterus
may undergo metroplasty to prevent recurrent second- and third-
trimester pregnancy losses.

53. Bicornuate uterus. Oblique coronal T2-weighted MR image shows
two symmetric uterine horns (arrowheads) with a deep fundal cleft
(arrow). The low-signal-intensity change in the right endometrial
cavity is due to biopsy-proved endometrial carcinoma.

55. Class V: Septate Uterus.
Partial or incomplete septal resorption after müllerian duct fusion results
in a septate uterus, which is the most common uterine anomaly,
accounting for approximately 55% of müllerian duct anomalies . Similar
to a bicornuate uterus, a septate uterus has two cavities that are visible
at hysterosalpingography. US and MR imaging may help differentiate a
septate from a bicornuate uterus by depicting a normal convex, flat, or
minimally concave (< 1-cm-deep) external fundal contour with a septate
uterus . MR imaging also readily demonstrates the composition and
extent of the septum: A fibrous septum is typically thin, with low signal
intensity on T2-weighted images, whereas a muscular septum tends to
be thicker, with intermediate signal intensity on T2-weighted images .
Patients with a septate uterus have the poorest reproductive and
obstetric outcomes, with spontaneous abortion rates ranging from 26%
to 94%. A septectomy may be performed in those who have experienced
recurrent spontaneous abortions. A fibrous septum can be resected
hysteroscopically, whereas a muscular septum may require metroplasty

57. Septate uterus. (a, b) Oblique coronal
T2-weighted MR images show a
normal external uterine fundal
contour (arrow in a) and a low-signal-
intensity fibrous septum (arrowhead)
that extends to the external cervical os
(arrow in b). (c) Axial T2-weighted MR
image shows septal
extension into the vagina, with
separate right and left vaginal canals
(arrows).

60. Class VI:
Arcuate Uterus. An arcuate uterus is the mildest anomaly
and may be considered a normal variant. Near complete
septal resorption results in a shallow, smooth, broad-
based impression on the uterine cavity, which may be
depicted at hysterosalpingography, US, and MR imaging.
Observation of a normal outer uterine contour at US and
MR imaging helps confirm the diagnosis.
An arcuate uterus usually has no effect on fertility or
obstetric outcomes.
HSG of arcuate uterus may also show smooth indentation
into the fundal cavity which cause saddle shaped
appearance.

61. Arcuate uterus. Three-dimensional coronal US image (26) and coronal
oblique T2-weighted MR image (27), obtained in different patients,
show a smooth, broad-based, shallow endometrial impression (arrow)
with a normal external contour of the uterine fundus (arrowhead).

63. Class VII:
DES-related Uterine Anomalies. Between 1945 and
1970, DES was used for prevention of spontaneous
abortions and treatment of hyperemesis gravidarum.
Female fetuses exposed to DES in utero are at risk for
developing a hypoplastic, irregular, T-shaped uterus
and hypoplastic and strictured fallopian tubes, and
they have an increased incidence of vaginal clear cell
carcinoma later in life (38,39). In pregnant women
who underwent in utero exposure to DES, the
hypoplastic whom the presence of this condition is
suspected may be assessed with a postcoital test that
does not involve imaging.

64. DES-related uterine anomaly. Hysterosalpingogram
demonstrates a hypoplastic T-shaped uterus. The
patient had been exposed to DES while in utero.

65. Adenomyosis.
Adenomyosis may be detected with various imaging modalities, including
hysterosalpingography, US, and MR imaging. At hysterosalpingography,
adenomyosis is identifiable with a finding of multiple linear or saccular
contrast material collections that protrude beyond the normal contour of
the endometrial cavity . The endometrial cavity may appear enlarged or
distorted. US and MR imaging may be performed if the findings at
hysterosalpingography are suggestive but inconclusive. US features of
adenomyosis include globular uterine enlargement, heterogeneous
myometrial echo texture The sensitivity of endovaginal US for detecting
adenomyosis is 53%–89%, with a specificity of 67%–98%. MR imaging also is
highly accurate for the diagnosis of adenomyosis and may be useful for
problem solving. The reported sensitivity and specificity of pelvic MR
imaging for the detection of adenomyosis are 78%–88% and 67%–93%,
respectively. The diagnostic finding at MR imaging is diffuse or focal
thickening of the junctional zone to more than 12 mm in association with
low signal intensity on T2-weighted images. A junctional zone thickness of
less than 8 mm virtually excludes the diagnosis, whereas a thickness of 8–12
mm requires additional investigation.

66. Adenomyosis. Sagittal transvaginal US image illustrates globular
uterine enlargement with asymmetric thickening and
heterogeneity of the myometrium (arrows) and poor definition of
the endomyometrial junction (arrowheads). E = endometrium.

67. Adenomyosis. Sagittal T2-weighted MR
image shows high-signal-intensity foci
(arrow) indicative of ectopic
endometrial glandular implants with
associated thickening of the junctional
zone (> 12 mm) (arrowheads) due to
smooth-muscle hypertrophy in a patient
with focal anterior body adenomyosis.
Adenomyosis and leiomyoma. Coronal
T2-weighted fat-saturated MR image
depicts focal thickening of the junctional
zone (arrowheads), which is a characteristic
finding of focal adenomyosis, and an
adjacent well-defined intramural leiomyoma
(arrow) that produces a greater mass effect
on the outer uterine contour.

68. Leiomyomas
Uterine leiomyomas are the most common benign pelvic mass
lesions and the most common cause of uterine enlargement in
non pregnant women (23). Leiomyomas may be found in any
part of the uterus, in submucosal, intramural, and sub-serosal
locations. They most often occur in multiples but also may occur
singly. Infertility may result when leiomyomas are numerous or
have submucosal or intra-cavitary locations that interfere with
embryo transfer and implantation.
In addition, patients with multiple leiomyomas are at an
increased risk for early spontaneous fetal loss . A finding of
uterine enlargement, distortion, or mass effect on the
endometrial cavity on hysterosalpingograms is suggestive of
uterine leiomyoma. If the lesion is located near the uterine
cornua, it may obstruct the ipsilateral fallopian tube and thus
cause a lack of tubal opacification.

69. Submucosal leiomyomas. (16) Hysterosalpingogram shows a large
intrauterine filling defect (arrows) due to a large submucosal leiomyoma that
produces a mass effect on almost the entire uterus. (17) Axial T2-weighted
MR image demonstrates a region of heterogeneous increased signal intensity
that represents a fundal intramural fibroid (arrow) with a submucosal
component (arrowheads). Nabothian cysts are visible in the cervix.

70. Endocavitary leiomyoma. within and distending the endometrial
cavity, a finding characteristic of an endocavitary leiomyoma.
Several intramural fibroids (arrowheads) also are visible.

71. Cervical Abnormalities
Cervical Stenosis:
The term cervical stenosis is clinically defined as cervical narrowing
that prevents the insertion of a 2.5-mm-wide dilator . This condition
may be congenital or secondary to infection or trauma.
Risk factors include previous cone biopsy, cryotherapy, laser
treatment, and biopsy for cervical dysplasia . The more severe the
stenosis, the more likely it is to be symptomatic . Consequences of
cervical stenosis include obstruction of menstrual flow with resulting
amenorrhea, dysmenorrhea, and potential infertility due to inability
of sperm to enter the upper genital tract . Cervical stenosis also may
be a serious impediment to assisted fertility techniques including
embryo transfer and intrauterine insemination. At
hysterosalpingography, cervical stenosis may appear as narrowing
of the endocervical canal (normal diameter, 0.5–3.0 cm), or it may
manifest as complete obliteration of the cervical os, preventing
insertion of the hysterosalpingographic catheter.

72. Conclusions.
The pelvic causes of female infertility include tubal, peritoneal,
uterine, endometrial, cervical, and ovarian abnormalities. A
multimodality imaging approach may be useful for
determining the cause of infertility and guiding clinical
management in specific cases. An imaging evaluation for
female infertility typically begins with an assessment of tubal
patency at hysterosalpingography, which may be followed by
pelvic US, pelvic MR imaging, or both to further characterize
any additional findings (e.g., 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.

73. Process diagram shows a systematic approach to diagnostic imaging for female
infertility. Findings from each imaging examination help determine whether further
examinations are needed and what modality or modalities would be most useful.

74. Thank You.