Niche role of MRI in the evaluation of female infertility

Abstract

Infertility is a major social and clinical problem affecting 13–15% of couples worldwide. The pelvic causes of female infertility are categorized as ovarian disorders, tubal, peritubal disorders, and uterine disorders. Appropriate selection of an imaging modality is essential to accurately diagnose the aetiology of infertlity, since the imaging diagnosis directs the appropriate treatment to be instituted. Imaging evaluation begins with hystero- salpingography (HSG), to evaluate fallopian tube patency. Uterine filling defects and contour abnormalities may be discovered at HSG but usually require further characterization with pelvic ultrasound (US), sono-hysterography (syn: hystero-sonography/saline infusion sonography) or pelvic magnetic resonance imaging (MRI), when US remains inconclusive. The major limitation of hysterographic US, is its inability to visualize extraluminal pathologies, which are better evaluated by pelvic US and MRI. Although pelvic US is a valuable modality in diagnosing entities comprising the garden variety, however, extensive pelvic inflammatory disease, complex tubo-ovarian pathologies, deep-seated endometriosis deposits with its related complications, Mulllerian duct anomalies, uterine synechiae and adenomyosis, often remain unresolved by both transabdominal and transvaginal US. Thus, MRI comes to the rescue and has a niche role in resolving complex adnexal masses, endometriosis, and Mullerian duct anomalies with greater ease. This is a review, based on the authors’ experience at tertiary care teaching hospitals and aims to provide an imaging approach towards the abnormalities which are not definitively diagnosed by ultrasound alone.

Keywords

Complex tubo-ovarian pathologies - endometriosis - female infertility - HSG - MR imaging - MRI - Mullerian duct anomalies

Publication History

Received: 13 September 2019

Accepted: 11 February 2020

Article published online:
19 July 2021

• References

• 1 Kamel RM. Management of the infertile couple: An evidence-based protocol. Reprod Biol Endocrinol 2010; 8: 21
• 2 Kaproth-Joslin K, Dogra V. Imaging of female infertility: A pictorial guide to the hysterosalpingography, ultrasonography, and magnetic resonance imaging findings of the congenital and acquired causes of female infertility. Radiol Clin North Am 2013; 51: 967-81
• 3 Olpin J, Kennedy A. Secondary infertility in women: Radiologic evaluation. Reports in Medical Imaging 2011; 4: 1-14
• 4 Steinkeler J, Woodfield C, Lazarus E, Hillstrom M. Female infertility: A systematic approach to radiologic imaging and diagnosis. Radiographics 2009; 29: 1353-70
• 5 Cipolla V, Guerrieri D, Pietrangeli D, Santucci D, Argirò R, de Felice C. Role of 3.0 tesla magnetic resonance hysterosal pingography in the diagnostic work-up of female infertility. Acta Radiol 2016; 57: 1132-9
• 6 Rastogi R. Role of imaging in female infertility [Dr. K.M. Rai memorial oration award]. Indian J Radiol Imaging 2010; 20: 168-73
• 7 Imaoka I, Wada A, Matsuo M, Yoshida M, Kitagaki H, Sugimura K. MR imaging of disorders associated with female infertility: Use in diagnosis, treatment, and management. Radiographics 2003; 23: 1401-21
• 8 Montoliu-Fornas G, Martí-Bonmatí L. Magnetic resonance imaging structured reporting in infertility. Fertil Steril 2016; 105: 1421-31
• 9 Badawy ME, Elkholi DG, Sherif MF, Hefedah MA. Magnetic resonance imaging for diagnosis of pelvic lesions associated with female infertility. Middle East Fertil Soc J 2015; 20: 165-75
• 10 Revzin MV, Mathur M, Dave HB, Macer ML, Spektor M. Pelvic inflammatory disease: Multimodality imaging approach with clinical-pathologic correlation. Radiographics 2016; 36: 1579-96
• 11 Kim SH, Kim SH, Yang DM, Kim KA. Unusual causes of tubo-ovarian abscess: CT and MR imaging findings. Radiographics 2004; 24: 1575-89
• 12 Sweet RL. Pelvic inflammatory disease: Current concepts of diagnosis and management. Curr Infect Dis Rep 2012; 14: 194-203
• 13 Tukeva TA, Aronen HJ, Karjalainen PT, Molander P, Paavonen T, Paavonen J. MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US. Radiology 1999; 210: 209-16
• 14 Wang T, Li W, Wu X, Yin B, Chu C, Ding M. et al. Tubo-ovarian abscess (with/without pseudotumor rea) mimicking ovarian malignancy: Role of diffusion weighted MR imaging with apparent diffusion coefficient vales. PLoS One 2016; 11: e0149318
• 15 Manganaro L, Anastasi E, Vinci V, Saldari M, Bernardo S, Sollazzo P. et al. Endometriosis: 10 key points for MRI. J Endometr Pelvic Pain Disord 2015; 7: 10-8
• 16 Wall D, Javitt M, Glanc P, Bhosale P, Harisinghani M, Harris R. et al. ACR appropriateness criteria® infertility. Ultrasound Q 2015; 31: 37-44
• 17 Lo GM, Wenger JM, Petignat P, Marci R. Role of imaging in endometriosis. Clev Clin J Med 2014; 81: 361-6
• 18 Kinkel K, Frei K, Balleyguier C, Chapron C. Diagnosis of endometriosis with imaging: A review. Eur Radiol 2005; 16: 285-98
• 19 Siegelman ES, Oliver ER. MR imaging of endometriosis: Ten imaging pearls. Radiographics 2012; 32: 1675-91
• 20 Troiano R, McCarthy S. Müllerian duct anomalies: Imaging and clinical issues. Radiology 2004; 233: 19-34
• 21 Behr S, Courtier J, Qayyum A. Imaging of müllerian duct anomalies. Radiographics 2012; 32: E233-50
• 22 El Ameen NF, Ebraheem MA, El Dien NM. MR assessment of müllerian duct anomalies: Does it help?. Egypt J Radiol Nucl Med 2014; 45: 561-7
• 23 Olpin JD, Moeni A, Willmore RJ, Heilbrun ME. MR imaging of müllerian fusion anomalies. Magn Reson Imaging Clin 2017; 25: 563-75
• 24 Bermejo C, Ten PM, Cantarero R, Diaz D, Pedregosa P, Barron E. et al. Three dimensional ultrasound in the diagnosis of mullerian duct anomalies and concordance with magnetic resonance imaging. Ultrasound Obstet Gynecol 2010; 35: 593-601
• 25 Dueholm M, Lundorf E, Hansen ES, Ledertoug S, Olesen F. Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, mapping and measurement of uterine myomas. Am J Obstet Gynecol 2002; 186: 409-15
• 26 Levens ED, Wesley R, Premkumar A, Blocker W, Nieman LK. Magnetic resonance imaging and transvaginal ultrasound for determining fibroid burden: Implications for research and clinical care. Am J Obstet Gynecol 2009; 200: 537e1-7
• 27 Hindley J, Gedroyc WM, Regan L, Stewart E, Tempany C, Hynyen K. et al. MRI Guidance of focused ultrasound therapy of uterine fibroids: Early results. AJR Am J Roentgenol 2004; 183: 1713-9
• 28 Dueholm Margit, Lundorf Erik. Transvaginal ultrasound or MRI for diagnosis of adenomyosis. Curr Opin Obstet Gynecol 2007; 19: 505-12
• 29 Kenigsberg L, Agarwal C, Sin S, Shifteh K, Isasi C, Crespi R. et al. Clinical utility of magnetic resonance imaging and ultrasonography for diagnosis of polycystic ovary syndrome in adolescent girls. Fertil Steril 2015; 104: 1302-9