IMAGING OF FEMALE FEMALE IMAGING OF FEMALE FEMALE INFERTILITYINFERTILITY

Dr charusmita chaudhary Dr charusmita chaudhary

Infertility Infertility

Infertility is defined as failure to Infertility is defined as failure to conceive a desired pregnancy after conceive a desired pregnancy after 12 month of unprotected sexual 12 month of unprotected sexual intercourse intercourse

appprox 10% of couple are infertileappprox 10% of couple are infertile male and female are equally male and female are equally

affected affected

AbstractAbstract Imaging plays a key role in the diagnostic evaluation Imaging plays a key role in the diagnostic evaluation

of women for infertility.of women for infertility. The pelvic causes of female infertility are varied and The pelvic causes of female infertility are varied and

range from tubal and peritubal abnormalities to range from tubal and peritubal abnormalities to uterine, cervical, and ovarian disorders.uterine, cervical, and ovarian disorders.

The imaging work-up begins with The imaging work-up begins with hysterosalpingography to evaluate fallopian tube hysterosalpingography to evaluate fallopian tube patency. Uterine filling defects and contour patency. Uterine filling defects and contour abnormalities may be discovered at abnormalities may be discovered at hysterosalpingography but typically require further hysterosalpingography but typically require further characterization with hysterographic or pelvic characterization with hysterographic or pelvic ultrasonography (US) or pelvic magnetic resonance ultrasonography (US) or pelvic magnetic resonance (MR) imaging.(MR) imaging.

TUBAL OCCLUSION - MOST COMMON CAUSE TUBAL OCCLUSION - MOST COMMON CAUSE

Hysterographic US ; differentiate uterine Hysterographic US ; differentiate uterine synechiae, endometrial polyps, submucosal synechiae, endometrial polyps, submucosal leiomyomas.leiomyomas.

Pelvic US and MR imaging help further Pelvic US and MR imaging help further differentiate among uterine leiomyomas , differentiate among uterine leiomyomas , adenomyosis, and the various müllerian duct adenomyosis, and the various müllerian duct anomalies, with anomalies, with MR imaging being the most MR imaging being the most sensitive modality for detecting sensitive modality for detecting endometriosisendometriosis..

The presence of cervical disease may be inferred The presence of cervical disease may be inferred initially on the basis of difficulty or failure of initially on the basis of difficulty or failure of cervical cannulation at hysterosalpingography. cervical cannulation at hysterosalpingography.

Ovarian abnormalities are usually detected at US.Ovarian abnormalities are usually detected at US.

A systematic multimodality imaging A systematic multimodality imaging approach is advocated in which initial approach is advocated in which initial hysterosalpingography is followed by hysterosalpingography is followed by hysterographic US, pelvic US, pelvic MR hysterographic US, pelvic US, pelvic MR imaging, or a combination there of, with imaging, or a combination there of, with the selection of modalities depending on the selection of modalities depending on the findings at hysterosalpingographythe findings at hysterosalpingography

An imaging study to evaluate female An imaging study to evaluate female infertility and uterine anomalies should infertility and uterine anomalies should necessarily exhibit many characteristicsnecessarily exhibit many characteristics

1.1. noninvasivenoninvasive

2.2. low costlow cost

3.3. high accuracyhigh accuracy

Causes Causes

Uterine causes : congenital anomalies , Uterine causes : congenital anomalies , infections, uterine synechae ,focal lesions infections, uterine synechae ,focal lesions intrauterine scar, cervical stenosis ,reduced intrauterine scar, cervical stenosis ,reduced uterine perfusion and alteration in uterine perfusion and alteration in endometrium thickness and vascularityendometrium thickness and vascularity

Ovarian causes : follicular and ovulation Ovarian causes : follicular and ovulation abnormalities , stromal vascularity and abnormalities , stromal vascularity and endometrosis endometrosis

Tubal causes : infections, obstruction Tubal causes : infections, obstruction

Diagnostic Diagnostic armamentarium and its armamentarium and its

rolerole USG ( TVS, TAS) : it is the first line USG ( TVS, TAS) : it is the first line investigation and can be coupled with investigation and can be coupled with color Doppler and 3D/4D scancolor Doppler and 3D/4D scan

USG helps in determining morphology USG helps in determining morphology perfusion ,thickness ,volume, vascularity . perfusion ,thickness ,volume, vascularity . It detects pathological lesions , tubal It detects pathological lesions , tubal lesions abnormalities of follicular lesions abnormalities of follicular maturation and ovulation .maturation and ovulation .

Tubal patency can be confirmed by Tubal patency can be confirmed by sonosalphingography. sonosalphingography.

X ray X ray hysterosalphingographyhysterosalphingography

Used to visualise uterine cavity and confirm Used to visualise uterine cavity and confirm tubal patency . tubal patency .

Hysterosalpingography (HSG) uses Hysterosalpingography (HSG) uses fluoroscopic control to introduce fluoroscopic control to introduce radiographic contrast material into the radiographic contrast material into the uterine cavity and fallopian tubesuterine cavity and fallopian tubes

Cycle considerations: Cycle considerations: HSG should not be HSG should not be performed if there is a possibility of a performed if there is a possibility of a normal intrauterine pregnancy.normal intrauterine pregnancy.

““10-day rule”10-day rule” means the procedure should not be performed means the procedure should not be performed

if the interval of time from the start of the last if the interval of time from the start of the last menses is greater than 10–12 days.menses is greater than 10–12 days.

If the patient has cycles that are longer than If the patient has cycles that are longer than 28 days (menses start usually 14 days after 28 days (menses start usually 14 days after ovulation), the 10-day rule can be stretched to ovulation), the 10-day rule can be stretched to 13–15 days.13–15 days.

If the patient has irregular cycles or absent If the patient has irregular cycles or absent menses, a pregnancy test before performing menses, a pregnancy test before performing HSG is recommendedHSG is recommended

Technical ConsiderationsTechnical Considerations The patient is placed supine with her knees flexed and heels The patient is placed supine with her knees flexed and heels

apart apart The cervix is exposed with a speculum. Visualization of the The cervix is exposed with a speculum. Visualization of the

cervix may be helped by elevating the patient’s pelvis, cervix may be helped by elevating the patient’s pelvis, particularly in thin women particularly in thin women

The cervix and vagina are copiously swabbed with a cleansing The cervix and vagina are copiously swabbed with a cleansing solution such as Betadine and the HSG cannula is placedsolution such as Betadine and the HSG cannula is placed

Once correct placement of the canella is confirmed, the Once correct placement of the canella is confirmed, the speculum should be removed speculum should be removed

Using fluoroscopic guidance, contrast agent at room Using fluoroscopic guidance, contrast agent at room temperature is slowly injected, usually 5–10 ml over 1 min temperature is slowly injected, usually 5–10 ml over 1 min radiographs are obtainedradiographs are obtained

Injection of contrast agent is halted when adequate free spill Injection of contrast agent is halted when adequate free spill into the peritoneal cavity is documentedinto the peritoneal cavity is documented

Side Effects and Side Effects and ComplicationsComplications

Mild discomfort or painMild discomfort or pain

Reassurance and rapid and skilful Reassurance and rapid and skilful completion of the examination are the best completion of the examination are the best approach. approach.

Mild vaginal bleedingMild vaginal bleeding vasovagal reactions and hyperventilationvasovagal reactions and hyperventilation Pelvic infection is a serious complication of Pelvic infection is a serious complication of

HSG, causing tubal damageHSG, causing tubal damage An allergic or idiosyncratic reactionAn allergic or idiosyncratic reaction Radiation exposure It is a concern, because the Radiation exposure It is a concern, because the

women being examined are of reproductive agewomen being examined are of reproductive age

Fallopian Tube Fallopian Tube AbnormalitiesAbnormalities

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

Anatomy and Physiology Anatomy and Physiology of Fallopian Tubesof Fallopian Tubes

The fallopian tubes connect the The fallopian tubes connect the peritoneal cavity to the extra peritoneal peritoneal cavity to the extra peritoneal worldworld

conduction of sperm from the uterine conduction of sperm from the uterine end toward the ampulla, conduction of end toward the ampulla, conduction of ova in the other direction from the ova in the other direction from the fimbriated end to the ampulla, and fimbriated end to the ampulla, and support as well as conduction of the support as well as conduction of the early embryo from the ampulla into the early embryo from the ampulla into the uterus for implantationuterus for implantation

Fallopian TubesFallopian Tubes length from 7–16 cm length from 7–16 cm

(average, 12 cm(average, 12 cm

1-2cm

2-3cm

5-8cm

trumpet-shaped

The fallopian tubes have three segments that are visible at hysterosalpingography: the interstitial portion, which traverses the myometrium; the isthmic portion, which courses within the broad ligament; and the ampullary portion, which is adjacent to the ovary

Normal Normal hysterosalpingogramhysterosalpingogram

Pathological FindingsPathological Findings

Diverticula in the isthmic Diverticula in the isthmic segment of the tube are segment of the tube are caused by salpingitis caused by salpingitis isthmica nodosa (SIN difficult isthmica nodosa (SIN difficult to appreciate by sonographyto appreciate by sonography

irregular benign extensions irregular benign extensions of the tubal epithelium into of the tubal epithelium into the myosalpinx, associated the myosalpinx, associated with reactive with reactive myohypertrophia and myohypertrophia and sometimes inflammationsometimes inflammation

Obstruction of the mid Obstruction of the mid isthmicisthmic

portion may be missed by portion may be missed by sonographysonography

Multiple tiny diverticula in the right isthmic portion (arrows) partial tubectomy on the left side (arrowhead)

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

Endometrial polyps

. A Stalked fi lling defect within the endometrial cavity probably arising from the cervical canal(arrow). B a fi lling defect in the intramural portion of the left tube (arrows) causing narrowing but no obstruction;normal fi lling of the fallopian tubes

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

Limitations of HSGLimitations of HSG Active vaginal bleedingActive vaginal bleeding active pelvic infectionactive pelvic infection pregnancy, uterine surgery, tubal pregnancy, uterine surgery, tubal

surgery, or uterine curettagesurgery, or uterine curettage The major limitations of the procedure The major limitations of the procedure

are the ability to characterize only are the ability to characterize only patent canals and the inability to patent canals and the inability to evaluate the external uterine contourevaluate the external uterine contour

adequately.adequately.

HSG also entails exposure to ionizing HSG also entails exposure to ionizing Radiation Radiation

Sonohysterography andSonohysterography andSonohysterosalpiaphySonohysterosalpiaphy

used to evaluate uterine pathology used to evaluate uterine pathology because of its excellent diagnostic because of its excellent diagnostic accuracy, minimal patient discomfort, low accuracy, minimal patient discomfort, low cost, and widespread availability. cost, and widespread availability.

With the addition of transvaginal With the addition of transvaginal sonography, colour Doppler imaging, and sonography, colour Doppler imaging, and sonohysterography, ultrasound has sonohysterography, ultrasound has become a sensitive technique for detecting become a sensitive technique for detecting endometrial and myometrial pathology.endometrial and myometrial pathology.

Cycle ConsiderationsCycle Considerations

during the secretory phase of the during the secretory phase of the menstrual cycle, when the menstrual cycle, when the endometrial thickness and echo endometrial thickness and echo complex are better characterizedcomplex are better characterized

for congenital anomaly evaluation, for congenital anomaly evaluation, the timing of the sonography the timing of the sonography examination is not criticalexamination is not critical

SonohysterosalphingograSonohysterosalphingography ( sono hsg) phy ( sono hsg)

It involves airless, sterile , saline It involves airless, sterile , saline infusion through a soft plastic catheter infusion through a soft plastic catheter in the cervix with simultaneous in the cervix with simultaneous endovaginal usg. It allows excellent endovaginal usg. It allows excellent visualization of the endometrial cavity visualization of the endometrial cavity and its linings .and its linings .

The procedure can also confirms tubal The procedure can also confirms tubal patency by demonstrating spillage of patency by demonstrating spillage of saline from a distended tube into pelvic saline from a distended tube into pelvic cavity.cavity.

Normal TVUSNormal TVUS

Clear demarcation of the relatively thick and Clear demarcation of the relatively thick and hyperechoic endometrium (hyperechoic endometrium (arrowheads) during thearrowheads) during the

secretory phase (secretory phase (a), minimal fl uid retention a), minimal fl uid retention during the proliferation phase of the cycle (b)during the proliferation phase of the cycle (b)

Side Effects and Side Effects and ComplicationsComplications

most part the same most part the same as for conventional as for conventional HSGHSG

Limitations of Sono-HSGLimitations of Sono-HSG

operator dependencyoperator dependency LARGE BODY LARGE BODY

HABITUS LARGE HABITUS LARGE FIBROIDFIBROID

MRIMRI It is best for delineating the It is best for delineating the

morphology and orientation of pelvic morphology and orientation of pelvic structures . structures .

Detects pathological lesions, Detects pathological lesions, including tubal lesions and pituitary including tubal lesions and pituitary adenoma . adenoma .

Technical ConsiderationsTechnical Considerations best imaged with a phased array MR best imaged with a phased array MR

surface coil.surface coil. for infertility evaluation for infertility evaluation

axial, sagittal, and coronal fast spin echo axial, sagittal, and coronal fast spin echo sequence images of the uterus, which sequence images of the uterus, which can be supplemented by obliquecan be supplemented by oblique

Gd-enhanced MR imaging is important Gd-enhanced MR imaging is important for diagnosis of complex adnexal masses for diagnosis of complex adnexal masses and distinguishing them from malignant and distinguishing them from malignant processesprocesses

LimitationsLimitations

higher cost, higher cost, limited availability,limited availability, longer scanning time,longer scanning time,

MRimaging is often used as a MRimaging is often used as a problem solving modality when problem solving modality when sonography findings are inconclusivesonography findings are inconclusive

Normal MR AnatomyNormal MR Anatomy in Reproductive-Age Womenin Reproductive-Age Women

SagittalT2w MR image clearly demonstrates uterine zonal anatomywith high signal intensity of the endometrium (E), low signalof junction zone (J), and intermediate signal of the myometrium

(M).

Pituatory adenoma Pituatory adenoma

Prolactin-producing hypophyseal Prolactin-producing hypophyseal adenomaadenoma

Hyperprolactinemia can be a cause Hyperprolactinemia can be a cause of infertility and is associated with of infertility and is associated with diminished gonadotropin secretion, diminished gonadotropin secretion, secondary amenorrhea, and secondary amenorrhea, and galactorrhea.galactorrhea.

Pituatory adenoma Pituatory adenoma Mri is the modality of Mri is the modality of

choice for detection. choice for detection. Microadenoma Microadenoma ( <1cm) is usually ( <1cm) is usually hypointense to the hypointense to the normal pituatory on normal pituatory on T1W images. T1W images.

Convex pituatory Convex pituatory contour and deviation contour and deviation of pituatory stalk are of pituatory stalk are inditect sign. inditect sign.

Pituitary adenoma. Unenhanced (a) and contrast-enhanced (b) T1w MR images show a small right-sidedpituitary prolactinoma (arrow) leading to hyperprolactinemiawith consecutive infertility

EndometriosisEndometriosis Ovary m/c secondaily involves other pelvic Ovary m/c secondaily involves other pelvic

structures . structures . Usg ishows a typical endometrioma locate in the ovary Usg ishows a typical endometrioma locate in the ovary

cystic lesion with low level internal echoes ( chocolate cystic lesion with low level internal echoes ( chocolate cyst of ovary)cyst of ovary)

Mri hyerintense on T1 and hypo on T2 fat suupersed Mri hyerintense on T1 and hypo on T2 fat suupersed T1w images are very useful for detecting peritoneal T1w images are very useful for detecting peritoneal implanimplants . ts .

The tubes may be involveed in form of hematosalphinx The tubes may be involveed in form of hematosalphinx or with peritubal adhesions, a posteriorly displaced or with peritubal adhesions, a posteriorly displaced uterus , kissing ovaries ,angulated small bowel loops , uterus , kissing ovaries ,angulated small bowel loops , elevated posterior vaginal fornices , multilocuilated fluid elevated posterior vaginal fornices , multilocuilated fluid collections are indirect indicator of pelvic adhesionscollections are indirect indicator of pelvic adhesions

EndometriosEndometriosisis

Endometriosis is Endometriosis is found in 25%–50% found in 25%–50% of infertile women, of infertile women, and 30%–50% of and 30%–50% of women with women with endometriosis are endometriosis are infertile infertile

Laparoscopy is the Laparoscopy is the mainstay for mainstay for diagnosisdiagnosis

Endometrioma right ovary. Sharply demarcatedinhomogeneous cystic mass (M) in the right ovary with predominantlybright signal intensity on axial T2W (a), intermediatesignal intensity on axial T1w images

Polycystic Ovarian Polycystic Ovarian SyndromeSyndrome

Characterised by combination of Characterised by combination of multiple clinical manifestationsmultiple clinical manifestations

( hirsutism, anovultory cycle and ( hirsutism, anovultory cycle and infertility) infertility)

hormonal imbalance hormonal imbalance

Polycystic Ovarian Polycystic Ovarian SyndromeSyndrome

The diagnosis of polycystic The diagnosis of polycystic ovarian syndrome is based ovarian syndrome is based on hormone imbalance and on hormone imbalance and laboratory findingslaboratory findings

USG rounded ovaries , USG rounded ovaries , normal or increased volume . normal or increased volume . Multiple subcentrimetric Multiple subcentrimetric follicles ( 15) with no follicles ( 15) with no dominant follicle ( string of dominant follicle ( string of pearl appearance ) . pearl appearance ) . Thickened walll and Thickened walll and echogenic and Vascular echogenic and Vascular stroma)stroma)

Tubal diseaseTubal disease Destruction or obstruction and peritubal adhesionsDestruction or obstruction and peritubal adhesions Hsg is useful for assessing tubal patency. Mri is Hsg is useful for assessing tubal patency. Mri is

superior to usg in assessing tubal diseasesuperior to usg in assessing tubal disease Dilated tube appear as fluid filled tortuous sausage Dilated tube appear as fluid filled tortuous sausage

shaped masses adjacent to the uterus with incomplete shaped masses adjacent to the uterus with incomplete septae appearing as hyperechoic mural nodules septae appearing as hyperechoic mural nodules ( beads of string sign) and short linear projections ( beads of string sign) and short linear projections ( cogwheel appearance)( cogwheel appearance)

the presence of partially effaced longitudional folds the presence of partially effaced longitudional folds inside the masses is specific for fallopian tubes on mri. inside the masses is specific for fallopian tubes on mri.

The presence of a normally appearing ipsilateral ovary The presence of a normally appearing ipsilateral ovary is a clue to the presence of tubal massesis a clue to the presence of tubal masses

Pelvic inflammatory Pelvic inflammatory disease disease Common cause on infertility and can Common cause on infertility and can

manifest as pelvic collections , tubo ovarian manifest as pelvic collections , tubo ovarian collections uterine or broad ligament collections uterine or broad ligament infection infection

Usg and mri are equally sensitive in Usg and mri are equally sensitive in detecting tubo ovarian collections. The detecting tubo ovarian collections. The presence of peripheral vascualrity of high presence of peripheral vascualrity of high resistance type on colour Doppler USG is resistance type on colour Doppler USG is suggestive of an infective masssuggestive of an infective mass

other signs of PID include probe tenderness other signs of PID include probe tenderness , thickness of tubes ( mural thickness more , thickness of tubes ( mural thickness more than 5mm) and tubo ovarian masses than 5mm) and tubo ovarian masses

Disorders of the Disorders of the Fallopian TubesFallopian Tubes

MR imaging aids in MR imaging aids in noninvasive noninvasive assessment of tubal assessment of tubal dilatation and dilatation and peritubal disease.peritubal disease. Bilateral hydrosalpinx. Sausage-, C-,

or S-shaped cystic masses in the small pelvis as shown by these axial (a) andcoronal (b) T2w MR images are clearly indicative of dilated fallopian tubes (FT

Tubo-ovarian abscess. T2w (a) and contrast-enhanced (b) T1w MR images show a left-sided adnexal mass (M)with rim-like enhancement (arrows) on contrast T1WI, which proved to be an abscess.

Uterine Uterine DisordersDisorders

They are considered a They are considered a anomalies when all other anomalies when all other

causes are excluded causes are excluded

Multiplanar mri is diagnostic Multiplanar mri is diagnostic

Müllerian Duct Müllerian Duct AnomaliesAnomalies prevalence of approximately 3%Mullerian prevalence of approximately 3%Mullerian

duct anomalies may be depicted by HSG; duct anomalies may be depicted by HSG; the complex situation of the various classes of the complex situation of the various classes of

anomalies seem to be better defined by anomalies seem to be better defined by sonography or MR imagingsonography or MR imaging

Classification of MDAs according to the Classification of MDAs according to the system adapted by the system adapted by the American Fertility American Fertility Society Society can be readily achieved based on MR can be readily achieved based on MR findingfinding

MR imaging attained 100% accuracy for MR imaging attained 100% accuracy for diagnosis of uterine anomalies, as compared diagnosis of uterine anomalies, as compared with 92% for ultrasound and less than 20% for with 92% for ultrasound and less than 20% for HSGHSG

Class I: Hypoplasia or Class I: Hypoplasia or AgenesisAgenesis Failure of normal development of the Failure of normal development of the

mullerian ducts causes uterine agenesis or mullerian ducts causes uterine agenesis or hypoplasiahypoplasia

5% of mullerian duct anomalies5% of mullerian duct anomalies Vaginal agenesis is the most common subtypeVaginal agenesis is the most common subtype Mayer-Rokitansky-Kuster-Hauser syndrome Mayer-Rokitansky-Kuster-Hauser syndrome

congenital absence of the uterus and upper congenital absence of the uterus and upper vagina The ovaries and fallopian tubes are vagina The ovaries and fallopian tubes are usually normal.usually normal.Women with acquired uterine hypoplasia due

todrugs, pelvic irradiation, or ovarian failure may havea disproportionately small uterine corpus. In these patients, the ratio of the uterine body to the cervixis reduced to less than the normal 2:1, similar to apremenarchal uterus

Class IClass I

Class I. Uterine agenesis. Sagittalmidline sonogram shows normalvagina, small (curved arrows) cervix(straight arrow), and absent uterinecorpus

Class II: UnicornuateClass II: Unicornuate one normally developed one normally developed

mullerian duct, with the mullerian duct, with the contralateral duct either contralateral duct either hypoplastic (subtypes 2a–c) hypoplastic (subtypes 2a–c) or absent (subtype 2d). or absent (subtype 2d).

Types 2a–c comprise Types 2a–c comprise approximately 90% of cases approximately 90% of cases

Agenesis of a unilateral Agenesis of a unilateral mullerian duct causes a mullerian duct causes a single single banana-shaped banana-shaped uterus with a single uterus with a single fallopian tubefallopian tube

Class II. Left unicornuate uterus. HSG showsuterine cavity deviated toward left side with patent left fallopiantube (a). Axial T2w MRI in this patient shows no rudimentaryhorn on the right side (b). In another patient, HSGshows right unicornuate uterus with hydrosalpinx

Class III: DidelphysClass III: Didelphys

Complete failure of fusion Complete failure of fusion of the two mullerian ducts of the two mullerian ducts results in two complete results in two complete uteri, each with its own uteri, each with its own cervix a sagital vaginal cervix a sagital vaginal septum is seen in ,majority septum is seen in ,majority of cases of cases

uterus didelphys is uterus didelphys is associated with the highest associated with the highest successful pregnancy rate,successful pregnancy rate,

Uterus didelphys with an Uterus didelphys with an obstructed hemivagina is obstructed hemivagina is termed Wunderlich termed Wunderlich syndromesyndrome

Class IV: BicornuateClass IV: Bicornuate Partial fusion of two mullerian ducts Partial fusion of two mullerian ducts

results in a bicornuate uterus with one results in a bicornuate uterus with one cervixcervix

HSG of a bicornuate uterus will HSG of a bicornuate uterus will demonstrate separate uterine cavities demonstrate separate uterine cavities with an intercornual angle that usually with an intercornual angle that usually exceeds 105°.exceeds 105°.

Sonographic diagnosis of a bicornuate Sonographic diagnosis of a bicornuate uterus is made by analysis of both the uterus is made by analysis of both the outer fundal contour as well as outer fundal contour as well as visualization of a separate endometrial visualization of a separate endometrial stripe in each hornstripe in each horn

Class IV.Class IV.

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

Class V: SeptateClass V: Septate Septate uterus results from failure of resorption Septate uterus results from failure of resorption

of a septum after complete fusion of the of a septum after complete fusion of the mullerian ducts mullerian ducts

HSG of a septate uterus demonstrates two HSG of a septate uterus demonstrates two narrowly diverging cavities, yielding a V-shape narrowly diverging cavities, yielding a V-shape configuration with relatively straight medial configuration with relatively straight medial bordersborders

angle formed by the medial borders of the two angle formed by the medial borders of the two uterine hemi-cavities is usually greater than 75°. uterine hemi-cavities is usually greater than 75°. The external uterine contour is normally convex, The external uterine contour is normally convex, fl at, or minimally indented by less than 1 cm , in fl at, or minimally indented by less than 1 cm , in contrast to that of a bicornuate uteruscontrast to that of a bicornuate uterus

Class Class V.V.

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

Class VI: Class VI: ArcuateArcuate

Arcuate uterus should Arcuate uterus should be considered a be considered a normal variant and it normal variant and it has no effect on has no effect on fertility.fertility.

HSG of the arcuate HSG of the arcuate uterus reveals a broad uterus reveals a broad smooth indentation smooth indentation into the fundal cavity, into the fundal cavity, which causes a which causes a saddle-shaped saddle-shaped appearanceappearance

Class VII: Class VII: Diethylstilbestrol-Diethylstilbestrol-

RelatedRelated These anomalies These anomalies

comprise sequelae comprise sequelae of in utero of in utero diethylstilbestrol diethylstilbestrol (DES) exposu(DES) exposu

Class VII. Hypoplastic T-shaped deformity of the uterus with fi lling of dilated glands in the cervix in a proven DES uterus

AdenomyosisAdenomyosis

Reducing uterine and endometrial Reducing uterine and endometrial receptibilityreceptibility

usg findings diffusely elarged or usg findings diffusely elarged or globular uterus , asymmetrical walls globular uterus , asymmetrical walls ( > 2.5cm) , ill defined areas of ( > 2.5cm) , ill defined areas of diffusely altered uterine diffusely altered uterine echogenicity , myometrial or echogenicity , myometrial or subendometrial cysts , indistinct subendometrial cysts , indistinct endometrial myometrial interface endometrial myometrial interface

AdenomyosisAdenomyosis

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

LeiomyomLeiomyomaa

Uterine leiomyoma, especially Uterine leiomyoma, especially submucous leiomyoma, may be submucous leiomyoma, may be associated with pregnancy loss associated with pregnancy loss rather than infertilityrather than infertility

causind distorsion of uterine causind distorsion of uterine cavity and contour cavity and contour

Colour doppler reveals peripheral Colour doppler reveals peripheral vascularity of mild to moderate vascularity of mild to moderate resistence which differentiate it resistence which differentiate it from adenomyoma with central or from adenomyoma with central or peripheral vascularity of loew peripheral vascularity of loew resistencec resistencec

Enlarged uterus with large fi broids (F) in the anterior and posterior aspect of the uterus being oftypical low signal intensity on this axial (a) and sagittal (b) T2w MR images. B (urinary bladder), E (endometrial cavity

Cervical AbnormalitiesCervical Abnormalities

Cervical Factor InfertilityCervical Factor Infertility

postcoital test that postcoital test that does not involve does not involve imaging.imaging.

Cervical StenosisCervical Stenosis

cervical narrowing cervical narrowing that prevents the that prevents the insertion of a 2.5-mm-insertion of a 2.5-mm-wide dilator wide dilator 

Newer modalities Newer modalities A newer technique using MR for the visualization A newer technique using MR for the visualization

of the tubalof the tubal

patency, so called 3D MR-HSG, is a promising patency, so called 3D MR-HSG, is a promising imaging alternative, although still in the imaging alternative, although still in the development stage, to the conventional HSG and development stage, to the conventional HSG and avoids exposure of the ovaries to ionizing avoids exposure of the ovaries to ionizing radiationradiation

Conclusion Conclusion

Usg is the investigation of first choice in Usg is the investigation of first choice in infertile females as it is highly accurate infertile females as it is highly accurate in determining common causes of in determining common causes of infertility . Mri should be used as second infertility . Mri should be used as second line tool in patients with complex clinical line tool in patients with complex clinical manifestations with normal usgmanifestations with normal usg

The pelvic causes of female infertility The pelvic causes of female infertility include tubal, peritoneal, uterine, include tubal, peritoneal, uterine, endometrial, cervical, and ovarian endometrial, cervical, and ovarian abnormalities abnormalities

A multimodality imaging approach may be useful A multimodality imaging approach may be useful for determining the cause of infertility and for determining the cause of infertility and guiding clinical management in specific cases guiding clinical management in specific cases

An imaging evaluation for female infertility An imaging evaluation for female infertility typically begins with an assessment of tubal typically begins with an assessment of tubal patency at hysterosalpingography, which may be patency at hysterosalpingography, which may be followed by pelvic US, pelvic MR imaging, or followed by pelvic US, pelvic MR imaging, or both to further characterize any additional both to further characterize any additional findings (eg, intrauterine filling defects or findings (eg, intrauterine filling defects or uterine contour abnormalities).uterine contour abnormalities).

Failure to cannulate the cervix at Failure to cannulate the cervix at hysterosalpingography is suggestive of a cervical hysterosalpingography is suggestive of a cervical abnormality, whereas a normal abnormality, whereas a normal hysterosalpingographic examination may point hysterosalpingographic examination may point toward the possibility of an ovarian cause of toward the possibility of an ovarian cause of infertility.infertility.

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