Evaluation of Infertility 331
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Evaluation of Infertility 331 Evaluation of Infertility 16 Gertraud Heinz-Peer CONTENTS 16.1 Introduction 16.1 Introduction 331 16.2 Imaging Techniques 331 Infertility is defi ned as 1 year of unprotected inter- 16.2.1 Hysterosalpingography 331 16.2.1.1 Cycle Considerations 332 course that does not result in pregnancy [1]. Infer- 16.2.1.2 Technical Considerations 332 tility is estimated to affect up to 10% of women of 16.2.1.3 Side Effects and Complications 332 reproductive age [2]. Although uterine pathology 16.2.1.4 Anatomy and Physiology of accounts for less than 10% of cases, uterine imag- Fallopian Tubes 332 ing is important not only for establishing a specifi c 16.2.1.5 Pathological Findings 333 16.2.1.6 Limitations of HSG 336 diagnosis, but also for directing corrective therapy [3, 16.2.2 Sonohysterography and 4]. Knowledge of structural abnormalities may indi- Sonohysterosalpingography 336 cate potential pregnancy complications including 16.2.2.1 Cycle Considerations 336 spontaneous abortion, intrauterine growth retarda- 16.2.2.2 Technical Considerations 336 16.2.2.3 Accuracy 337 tion, preterm delivery, malpresentation, and retained 16.2.2.4 Side Effects and Complications 338 products of conception. 16.2.2.5 Limitations of Sono-HSG 338 An imaging study to evaluate female infertility and 16.2.3 Magnetic Resonance Imaging 338 uterine anomalies should necessarily exhibit many 16.2.3.1 Indications 338 characteristics, such as a noninvasive nature, low 16.2.3.2 Technical Considerations 338 16.2.3.3 Limitations 339 cost, and high accuracy, among other qualities. Imag- 16.2.3.4 Normal MR Anatomy in ing modalities currently used to evaluate infertile Reproductive-Age Women 339 women include hysterosalpingography, ultrasound, 16.2.3.5 Normal MR Anatomy of and magnetic resonance imaging. In this chapter, the Postmenopausal Women 339 use of these modalities to assess the various causes 16.3 Ovulatory Dysfunction 340 of infertility in females will be reviewed and specifi c 16.4 Pituitary Adenoma 340 attention will be drawn to anatomic and physiologic 16.5 Polycystic Ovarian Syndrome 341 uterine abnormalities. 16.6 Disorders of the Fallopian Tubes 341 16.7 Uterine Disorders 343 16.7.1 Müllerian Duct Anomalies 343 16.7.1.1 Class I: Hypoplasia or Agenesis 343 16.7.1.2 Class II: Unicornuate 343 16.2 16.7.1.3 Class III: Didelphys 345 Imaging Techniques 16.7.1.4 Class IV: Bicornuate 347 16.7.1.5 Class V: Septate 348 16.7.1.6 Class VI: Arcuate 349 16.2.1 16.7.1.7 Class VII: Diethylstilbestrol-Related 349 Hysterosalpingography 16.7.2 Adenomyosis 350 16.7.3 Leiomyoma 350 Hysterosalpingography (HSG) uses fl uoroscopic con- 16.7.4 Endometriosis 350 trol to introduce radiographic contrast material into References 352 the uterine cavity and fallopian tubes. While today G. Heinz-Peer, MD HSG is used primarily to assess tubal patency, this Department of Radiology, Medical University of Vienna, technique also provides indirect evidence for uter- Währinger Gürtel 18–20, 1090 Vienna, Austria 332 G. Heinz-Peer ine pathology through depiction of abnormal uterine and is presumably related to underlying pathology cavity contours. such as endometrial polyps. Other side effects such as vasovagal reactions and hyperventilation may occur 16.2.1.1 and their prevalence may be reduced if the examiner Cycle Considerations is experienced and calming. Pelvic infection is a serious complication of HSG, HSG should not be performed if there is a possi- causing tubal damage. In a private practice setting, bility of a normal intrauterine pregnancy. To avoid the overall incidence of post-HSG pelvic infection irradiating an early pregnancy, the “10-day rule” can was 1.4%, occurring predominantly in women with be used. That means the procedure should not be dilated tubes [9]. For this reason, if dilated tubes are performed if the interval of time from the start of the noted during the HSG procedure, particularly if there last menses is greater than 10–12 days. If the patient is a dilated tube with free spill, prophylactic antibiot- has cycles that are longer than 28 days (menses start ics (e.g., doxycycline 200 mg orally) should be given usually 14 days after ovulation), the 10-day rule can before the patient leaves the department and a pre- be stretched to 13–15 days. If the patient has irregu- scription for 5 days should be given to the patient. lar cycles or absent menses, a pregnancy test before An allergic or idiosyncratic reaction related to the performing HSG is recommended. contrast medium can occur after HSG, although the incidence is unknown and is presumably quite low. 16.2.1.2 Radiation exposure is a side effect not shared Technical Considerations by sono-HSG. It is a concern, because the women being examined are of reproductive age. The inci- The patient is placed supine with her knees fl exed and dence of irradiating an early pregnancy is quite low heels apart. Stirrups on the table to support the feet when HSG is routinely performed in the follicular can be used. The cervix is exposed with a speculum. phase of the cycle. Although cases are few, there is Visualization of the cervix may be helped by elevat- nothing to suggest that inadvertent performance ing the patient’s pelvis, particularly in thin women. of HSG in early pregnancy is harmful to the fetus The cervix and vagina are copiously swabbed with a [10]. Radiation exposure to the ovaries is minimal cleansing solution such as Betadine and the HSG can- and can be further reduced by using good fluoro- nula is placed. A variety of cannulas can be used for scopic technique and obtaining only the number of HSG [5–7]. Once correct placement of the cannula is radiographs necessary to make an accurate diag- confi rmed, the speculum should be removed. Leaving nosis. the speculum in is uncomfortable for the patient and a metal speculum obscures fi ndings. Using fl uoro- 16.2.1.4 scopic guidance, contrast agent at room temperature Anatomy and Physiology of Fallopian Tubes is slowly injected, usually 5–10 ml over 1 min, and radiographs are obtained. Injection of contrast agent The fallopian tubes connect the peritoneal cavity to is halted when adequate free spill into the peritoneal the extraperitoneal world. Their function and anat- cavity is documented, when myometrial or venous omy is complex and includes conduction of sperm intravasation occurs, or when the patient complains from the uterine end toward the ampulla, conduction of increased cramping, which usually occurs when of ova in the other direction from the fi mbriated end the tubes are blocked. to the ampulla, and support as well as conduction of the early embryo from the ampulla into the uterus 16.2.1.3 for implantation. The normal fallopian tube ranges Side Eff ects and Complications in length from 7 cm to 16 cm, with an average length of 12 cm (Fig. 16.1a). The tube is divided into four Mild discomfort or pain is commonly experienced regions: (a) the intramural or interstitial portion, in by women undergoing HSG [8]. Routine analgesia is the wall of the uterine fundus and 1 cm to 2 cm long, not necessary, although oral ibuprofen is a reasonable (b) the isthmic portion, which is about 2–3 cm long, preprocedure medication. Reassurance and rapid and (c) the ampullary portion, 5–8 cm long, and (d) the skillful completion of the examination are the best infundibulum, which is the trumpet-shaped distal approach. Mild vaginal bleeding is common after end of the tube terminating in the fi mbria. Patency HSG. Severe bleeding requiring curettage is unusual of the fallopian tubes is established when contrast Evaluation of Infertility 333 a b Fig. 16.1. a Scheme of normal fallopian tubes. The normal fallopian tube ranges in length from 7–16 cm (average, 12 cm). The tube is divided into four regions: (I) intramural or interstitial portion (1–2 cm), (II) isthmic portion, (2–3 cm), (III) ampullary portion (5–8 cm), and (IV) infundibulum terminating into the fi mbria. b Normal hysterosalpingogram. The uterus (U) has a normal contour and shape. The fallopian tubes fi ll bilaterally with evidence of free spill into the pelvic peritoneum (arrows) medium fl ows through them and freely around the an association between SIN and pelvic infl ammatory ovary and loops of bowel at the time of salpingogra- disease; however, it is not clear whether SIN is caused phy, using either fl uoroscopic or sonographic guid- by pelvic infl ammation or is congenital and predis- ance (Fig. 16.1b). poses to infl ammation. Obstruction of the tubes can occur anywhere along 16.2.1.5 their length (Fig. 16.3). Obstruction of the midisth- Pathological Findings mic portion may be missed by sonography, because of the small caliber of the tube and the absence of Diverticula in the isthmic segment of the tube are dilation when there is obstruction at this level. caused by salpingitis isthmica nodosa (SIN) (Fig. 16.2). Polyps are small, smooth, fi lling defects, which can These would be diffi cult to appreciate by sonogra- be single or multiple, and do not distort the overall phy. SIN was described more than 100 years ago as size and shape of the uterine cavity (Fig. 16.4). Leio- irregular benign extensions of the tubal epithelium myomas are usually single, larger lobulated masses, into the myosalpinx, associated with reactive myo- which only partially project into the cavity, and often hypertrophia and sometimes infl ammation. There is enlarge and distort the cavity (Fig.