imaging in the evaluation of female...

Kelly Epps, HMS 3Gillian Lieberman, MD

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Kelly Epps, Harvard Medical School Year IIIGillian Lieberman, MD

Imaging in the Evaluation of Female Infertility

May 2004

Kelly Epps, HMS 3Gillian Lieberman, MD

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The Case of EW

EW is a 40 year old G0P0 who hopes to conceive. She has been off oral contraceptive pills and has been having unprotected intercourse for 10 months. Thus far, her attempts to become pregnant have been unsuccessful. She presents to her Ob-Gyn for evaluation of infertility.

Kelly Epps, HMS 3Gillian Lieberman, MD

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Infertility

Inability to conceive after one year of intercourse without contraception

Kelly Epps, HMS 3Gillian Lieberman, MD

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Epidemiology

• Affects 1 in 7 American couples

• Rate has been stable over the past 50 years

• Advances in assisted reproductive technologies (ART) has increased interest in infertility treatment

Kelly Epps, HMS 3Gillian Lieberman, MD

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Infertility - CausesMale Factor – 40%• Azoospermia• Sperm defect or dysfunction• Chronic Illness

Female Factor – 40%• Advanced age• Anovulatory cycles• Congenital anomalies• Acquired structural defects• Endocrine abnormalities

Combined Factors – 10% Unexplained – 10%

Kelly Epps, HMS 3Gillian Lieberman, MD

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Infertility – Radiologic Evaluation

• Largely focuses on female factor infertility

• Several congenital and acquired conditions affect female reproductive function

• Complete evaluation of the female reproductive tract must include cervical, uterine, endometrial, tubal, peritoneal, and ovarian factors

Kelly Epps, HMS 3Gillian Lieberman, MD

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Menu of Tests

• Hysterosalpingogram (HSG)• Ultrasound (US)• Sonohysterogram (SHG)• Magnetic Resonance Imaging (MRI)

Kelly Epps, HMS 3Gillian Lieberman, MD

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Hysterosalpingogram

• Historically the mainstay in infertility imaging

• Indications: evaluation of uterine cavity and patency of tubes

• Limitations: does not aid in characterization of uterine wall or ovarian pathology

Kelly Epps, HMS 3Gillian Lieberman, MD

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Ultrasound• Test of choice for imaging the female pelvis

• No radiation exposure

• Indications: evaluation of ovarian, uterine wall, and adnexal pathology

• Limitations: additional imaging may be needed for pre-surgical characterization and localization of pathology

Kelly Epps, HMS 3Gillian Lieberman, MD

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Sonohysterogram• Combination of HSG and US - uses saline injection rather than

dye, US rather than fluoroscopy

• By virtue of distention, allows visualization of endometrial lining and intracavitary defects

• No radiation exposure

• Indications: evaluation of uterine cavity, uterine wall, tubes, ovaries, and adnexal structures

• Limitations: same as US

Kelly Epps, HMS 3Gillian Lieberman, MD

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MRI• Excellent soft tissue characterization

• Indications: guides interventional radiology and surgical management of infertility by identifying size, number, and location of pathology

Kelly Epps, HMS 3Gillian Lieberman, MD

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Female Reproductive Tract

www.ethal.org.my/.../ 181rmgUterus.html

Kelly Epps, HMS 3Gillian Lieberman, MD

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Cervix

Cervical Stenosis

• Narrowing of the cervix due to adhesions or scarring

• Patients complain of painful or absent periods

• Complication of cone biopsy

• Blocks entry of sperm

Fallopian Tube

vary

Ovary

Uterus

AdhesionsCervix

Vagina

www.drkline.com/ risks.html

Kelly Epps, HMS 3Gillian Lieberman, MD

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Cervical StenosisHSG Findings:

•Internal os < 1mm

•Inability to advance catheter

•Non-opacified uterine cavity

BIDMC, PACSVagina Cervical Stenosis

Normal

Kelly Epps, HMS 3Gillian Lieberman, MD

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Uterus

• Synechiae• Fibroids• Polyps• Congenital Anomalies

Kelly Epps, HMS 3Gillian Lieberman, MD

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Synechiae

Asherman Syndrome

• Intrauterine adhesions caused by trauma, infection, or instrumentation

• Healing granulation tissue forms bridges across the cavity

• Infertility may result from obliteration of the cavity or obstruction to implantation

Kelly Epps, HMS 3Gillian Lieberman, MD

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Synechia

HSG findings:

• Filling Defect

• Linear

• Irregular

SynechiaBIDMC, PACS

Kelly Epps, HMS 3Gillian Lieberman, MD

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Synechia

US Findings:

• Echoic

• Linear

• Extends from one wall to opposite wall

Synechia Courtesy of Dr. Tejas Mehta

Kelly Epps, HMS 3Gillian Lieberman, MD

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Fibroids• Benign, smooth muscle

tumors of the uterus

• Found in 20-30% of reproductive aged women

• Affects fertility by interfering with implantation

http://www.rassav.com/Code/RAS_UFE.htm

Kelly Epps, HMS 3Gillian Lieberman, MD

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FibroidsHSG Findings

Distorted uterine cavity, twisted uterus

Scalloped endometrial lining

BIDMC, PACS

Kelly Epps, HMS 3Gillian Lieberman, MD

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Fibroids

US Findings:• Hypoechoic mass

• May be submucosal, intramural, or subserosal

• Uterine enlargement or distortion may be seen

Courtesy of Dr. Tejas Mehta Fibroid

Ultrasound aids in characterization of fibroids.

Kelly Epps, HMS 3Gillian Lieberman, MD

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Fibroids

BIDMC, PACS

MRI aids in:

• characterization and localization of uterine wall pathology

•pre-surgical planning

Fibroids

Kelly Epps, HMS 3Gillian Lieberman, MD

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Polyps• Overgrowths of endometrial glands and stroma

projecting into the endometrial cavity

• Usually asymptomatic but may present with abnormal bleeding

• Found in 10% of women

• Affect fertility by impeding implantation

Kelly Epps, HMS 3Gillian Lieberman, MD

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Endometrial PolypBIDMC, PACS

PolypsHSG Findings:

• Filling defects• Single or multiple• Usually arise from

fundus• A few mm to

several cm in size

Kelly Epps, HMS 3Gillian Lieberman, MD

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Polyps

US Findings:

• Well defined mass

• Hyperechoic• Confined to the

cavity without distortion of the uterus

BIDMC, PACS

Ultrasound distinguishes polyps from fibroids.

Kelly Epps, HMS 3Gillian Lieberman, MD

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Polyp

Polyps

BIDMC, PACS

More PolypsSonohysterogram

Kelly Epps, HMS 3Gillian Lieberman, MD

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Uterine Anomalies

• A defect in the embryologic development of the Mullerian system can cause congenital uterine anomalies

• There are 7 classifications of anomalies

• All can be identified by imaging

Kelly Epps, HMS 3Gillian Lieberman, MD

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Uterine Anomalies

Normal Class II - Unicornuate

Class III - Didelphys Class IV - Bicornuate

Class V - Septate Class VII - DESClass VI - Arcuate

http://www.emedicine.com/radio/topic738.htm

Kelly Epps, HMS 3Gillian Lieberman, MD

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Uterine Anomalies

Bicornuate:

• Indented fundus but otherwise normal uterine wall

• No affect on fertility• No infertility treatment necessary

Septate:

• Fibrous band projecting from fundusinto uterine cavity

• Interferes with implantation• Surgical removal increases fertility

http://www.emedicine.com/radio/topic738.htm

Two classes must be differentiated in the infertility work-up:

Kelly Epps, HMS 3Gillian Lieberman, MD

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Uterine Anomalies

Irregularly shaped uterine cavity on HSG MRI

BIDMC, PACS

Kelly Epps, HMS 3Gillian Lieberman, MD

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MRI

BIDMC, PACS

Bicornuate or Septate?

Uterus

Kelly Epps, HMS 3Gillian Lieberman, MD

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Uterine Anomalies

The irregularly shaped uterus seen on HSG andMRI in the previous slides was determined to bean arcuate (class VI) uterus. It is on the spectrum of bicornuate and is believed to be a normalvariant with no affects on fertility.

Kelly Epps, HMS 3Gillian Lieberman, MD

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Fallopian Tubes

Obstruction• Pelvic Inflammatory Disease• Fibroids• Endometriosis• Adhesions• Tubal spasm

Kelly Epps, HMS 3Gillian Lieberman, MD

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Fallopian Tubes

www.student.ccbcmd.edu/.../reproductive/ img016.gif

Fimbria

Ampulla

Isthmus

Infundibula

Kelly Epps, HMS 3Gillian Lieberman, MD

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Fallopian Tubes

Left Proximal Obstruction Right Proximal Obstruction

BIDMC, PACS

Kelly Epps, HMS 3Gillian Lieberman, MD

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Peritoneal Cavity

Adhesion• Endometriosis• Post surgical• Post infection

Difficult to image directly but an irregular pattern of dye overflow on HSG may raise suspicion.

Kelly Epps, HMS 3Gillian Lieberman, MD

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Ovaries

• Endometriosis• Polycystic Ovary Syndrome (PCOS)

Kelly Epps, HMS 3Gillian Lieberman, MD

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Ovarian stroma

Bilateral Endometriomas

Endometriosis

Courtesy of Dr. Tejas Mehta

US Findings:

•Round

•Symmetric

•Hypoechoic cysts

•Low-level echoes

•Persistent

Kelly Epps, HMS 3Gillian Lieberman, MD

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PCOSUS Findings of PCO:

• Bilateral

• Round, echogenic ovaries

• 10-12 small follicles

BIDMC, PACS

PCOS is a clinical diagnosis. US findings of polycystic ovaries is neither necessary nor sufficient, but in the right clinical setting may be indicative of the diagnosis.

Kelly Epps, HMS 3Gillian Lieberman, MD

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Back to Our Patient

BIDMC, PACS

Surprise! You have already seen EW’s images in previous slides. Can you guess her diagnosis?

Kelly Epps, HMS 3Gillian Lieberman, MD

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Follow-up

EW was diagnosed with intramural fibroids.

She went on to have Uterine Artery Embolization.

And…….

Kelly Epps, HMS 3Gillian Lieberman, MD

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Congratulations!EW is 9 weeks pregnant today.

Early OB Ultrasound at 7 weeks 4 days.BIDMC, PACS

Kelly Epps, HMS 3Gillian Lieberman, MD

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Summary

• Infertility affects 10-15% of reproductive aged women• Infertility evaluation referrals have increased with

advances in ART• Radiologic evaluation is a mainstay in the work-up of

infertility:HSG, SHG– uterine cavity and patency of tubes

US, SHG, MRI – uterine wall, ovaries, and adnexa

• Radiologic evaluation is essential not only to diagnosis but also to the treatment of infertility

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References• Amesse, Lawrence, Pfaff-Amesse, Theresa. Surgical

Management of Mullerian Duct Anomalies. www.emedicine.com 2003

• Garcia, Jario. Infertility. www.emedicine.com 2004.• Guzick, David. Evaluation of the Infertile Couple. Up to Date

2004. • Lindheim, S, Adsuar, N, Kushner, D, Pritts, E.

Sonohystography: A Valuable Tool in Evaluating the Female Pelvis. Obsterical and Gynecological Survey 2003; 58(11): 770-784

• Syed, Ibrahim. Uterus, Mullerian Duct Abnormalities. www.emedicine.com 2002.

• Thurmond, Amy S. Imaging of Female Infertility. Radiologic Clinics of North America 2003; 41(4):757-767

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References• www.ethal.org.my/.../181rmgUterus.html• http://www.rassav.com/Code/RAS_UFE.htm• http://www.emedicine.com/radio/topic738.htm• www.student.ccbcmd.edu/.../reproductive/ img016.gif• www.drkline.com/ risks.html

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Acknowledgements• Tejas Mehta, MD• Cristina Cavazos, MD• Michelle Swire, MD• Gillian Lieberman, MD• Pamela Lepkowski• Larry Barbaras• Gia Landry• Ola Ayodele• Shelley Day