Radiological imaging of male infertility.

DR/ ABD ALLAH NAZEER. MD.

Male infertility. Definition:Inability to conceive 1 year of unprotected sexual intercourse.

Male Factor Infertility:•Anatomic defects (hypospadias, undescended testis & Retrograde ejaculation).•Genetics Causes. •Trauma.•Infection(e.g, mumps, orchitis, epididymitis and HIV).•Endocrine disorders.•Varicocele.• Toxins(e.g, DPCP , glycol ethers.

Main cause of male infertility: I. Testicular insufficiency. • Cryptorchidism.• Orchitis (viral) .• Testicular torsion .• Cytotoxic therapy (chemotherapy). • Radiotherapy .• Genetic causes (Klinefelter’s syndrome, Y deletions).

II. Endocrine disorders. • Kallmann’s syndrome .• Pituitary gland disorders (adenoma, infection).

III. Obstructions of the male genital tract .• Congenital absence of the vas deferens .• Müllerian prostatic cysts .• Epididymal obstructions (infections, congenital). • After groin or scrotal surgery .

IV. Sperm antibodies .Medication, environment, stress, illness. Varicocele .Sexual problems/ejaculation disorders. Idiopathic .

Causes of Male Infertility The various causes of male infertility can be subcategorized as obstructive and nonobstructive azoo- or hypospermia. Nonobstructive disease includes varicocele, endocrinopathy, chromosomal abnormality, cryptorchidism, anabolic steroid abuse, gonadotoxin exposure, primary testicular failure, and ejaculatory disorders. Obstructive disorders include congenital bilateral absence of the vas deferens, ejaculatory duct obstruction, and prostatic cysts.The most common cause of correctable male infertility is a varicocele. These are best imaged with gray-scale and color Doppler sonography . Varicoceles are defined as internal spermatic veins that are dilated to greater than 3 mm. Valsalva maneuvers can be used during ultrasound to evaluate the change in size of the veins with increased abdominal pressure. Varicoceles are found in 40% of men with primary infertility and between 45 and 80% of men with secondary infertility. Even a subclinical varicocele can have negative effects on spermatogenesis. When unilateral, varicoceles are more commonly left-sided. If isolated right-sided varicoceles are detected, which is uncommon, the possibility of a retroperitoneal process compressing the right gonadal vein should be considered.

On grey scale imaging a varicocele is seen as serpiginous tubules posterior to the testis (a). Colour flow Doppler confirms flow within varicocele.

33-year-old man with low sperm count undergoing evaluation for infertility. Sagittal sonograms of the superior aspect of the left hemiscrotum show multiple dilated peritesticular veins on color Doppler imaging (A) and an individual vein on gray-scale imaging (B) that measures 4.2 mm when Valsalva maneuver is used. These findings are compatible with a varicocele.

(a) On grayscale imaging a varicocele is seen as serpiginous tubules inferior to the testis (arrow). (b) Colour flow Doppler confirms flow within the varicocele (arrow).

Varicocele with a dilated venous plexus with reflux during straining The testis is normal.

26-year-old man with mildly elevated prolactin level. Coronal T1-weighted (A), coronal T2-weighted (B), and coronal (C) and sagittal (D) T1-weighted contrast-enhanced MR images show adenoma on the right side of the pituitary gland (arrow) that has a central area of fluid or necrosis.

MRI showing pituitary microadenoma (a, b) and stalk thickening (c)

34-year-old man with bilateral cryptorchidism. Sagittal sonograms show both testes to be located in the inguinal canals and diminutive. Testicular volume measured 2–3 mL each (normal range, 18–20 mL).

28-year-old man with history of left cryptorchidism after orchiopexy at age 6 years. Sagittal sonograms of both testes show that the left testis (B) is smaller than the right (A) and markedly heterogeneous.

Ultrasound image of the groin in a patient with undescended testis demonstrates a hypoechoic, small testis in keeping an infracted undescended testis.

Heterogeneous testis with associated ectasia of the rete testis (short arrows) and dilated body of the epididymis (long arrow) in keeping with long-standing obstruction.

26-year-old man with no palpable vas deferens on physical examination. Midline transverse sonogram of both testes shows dilatation of the rete testis in the medial aspect of each testis. These findings are typical of congenital bilateral absence of the vas deferens.

Ultrasound of both testes (sagittal images) demonstrates ectasia of the testes with formation of intratesticular cysts. These finding are suggestive of a seminal tract obstructive etiology which should be managed by epididymo-vasotomy.

Heterogeneous testis with ectasia of the rete testis in keeping with long standing obstruction.

Scrotal ultrasound demonstrating thickening and enlargement of the epididymal body in a case of infective epididymitis.

Scrotal ultrasound demonstrating thickening and enlargement of the epididymal body (arrow) in a case of infective epididymitis. The testis is spared from the infective process.

Epididymal head abnormalities in obstructive azoospermia. (a) Longitudinal (left) and transverse (right) US images in a 31-year-old man with proved CBAVD show tubular ectasia (arrowheads) in the epididymal head.

Longitudinal testicular ultrasound demonstrating an a dilated, heterogeneous epididymis characteristic of the post vasectomy appearance.

A transrectal ultrasound examination demonstrating calcification within the ejaculatory duct (short arrow) with dilatation of the vas deferens proximally (long arrow).

TRUS demonstrating calcification within the ejaculatory duct with dilatation of the vas deferens proximally.

Bilateral dilatation of the vas deferens on TRUS.

(a) Longitudinal scan demonstrating a small testis with a heterogeneous echo-texture and a varicocele (arrows) in a patient being investigated for infertility. (b) Focal dilatation of the epididymis (arrow) in keeping with chronic obstruction secondary to infection.

Bilateral thickening of the vas deferens on a transrectal ultrasound examination in keeping with vesiculitis (arrows).

Twenty five years infertile man with azospermia. A: Multiple calculi within the SV and V; B: Bilateral echogenic calculi impacted within the ejaculatory ducts (arrows).

34-year-old hypospermic male. Axial (A) and coronal (B) T2-weighted MR images using an endorectal coil show a normal left seminal vesicle (arrows) but none on the right.

Obstruction of ejaculatory ducts. In 28-year-old man, axial 3D T2-weighted MR image shows two normal ejaculatory ducts entering the prostate gland (arrows).

Percutaneous right vasography in a patient with obstructed infertility shows complete obstruction of the ejaculatory duct with retention of the dye in the vas (arrowhead) and SV and non opacification of the urinary bladder.

Prostatic cysts. Axial (A) and sagittal (B) T2-weighted MR images using an endorectal coil (asterisk) in a 26-year-old man show a large midline cyst (arrow) limited to the prostate gland.

Small cyst lying within the midline within the prostatic utricle (arrow) with dilated prostatic utricle.

A 27-year-old with primary infertility. A: TRUS shows a 3 cm × 2 cm thin walled midline intraprostatic urogenital cyst; B: TRUS-guided contrast opacification of the cyst revealed that the cyst was blind with no communication with the seminal tract. Semen analysis showed improvement of the sperm count 3 d after complete cyst aspiration.

A 29-year-old man with primary obstructive infertility. TRUS (upper image) and endorectal magnetic resonance imaging (middle image) show a well-defined midline urogenital cyst with intra-and extraprostatic components. TRUS-seminal vesiculography (lower image) shows the seminal vesicle is communicating with the urogenital cyst with non opacification of the urethra or urinary bladder denoting complete distal obstruction (N.B. the left vas and seminal vesicles were absent). Trans-urethral incision of the cyst lead to improvement of sperm count.

A 33-year-old man with primary infertility. TRUS-guided contrast opacification of midline prostatic cyst shows the presence of a large cyst communicating on the right side with the right vas (arrowhead) and right SV. On the left side the cyst is communicating with a blind tubular structure (arrow), which proved to be an ectopic short ureter of a hypoplastic left kidney.

33-year-old asymptomatic, hypospermic man undergoing infertility evaluation. Transverse sonogram of the right testicle shows multiple hypoechoic masses in the parenchyma, consistent with multifocal tumor. Pathology at surgical resection revealed seminoma.

Longitudinal ultrasound image of a testicular mass demonstrating increased Doppler flow within the lesion; a histologically proven seminoma.

20-year-old man after scrotal trauma 1 week previously who presents with swelling of the scrotum. Transverse sonogram of the scrotum reveals a large amount of fluid surrounding the testicle, consistent with a hydrocele.

Longitudinal sonogram of a testicle of a 25-year-old man undergoing scrotal sonography as part of an infertility evaluation shows multiple punctate calcifications scattered throughout the parenchyma, consistent with testicular microlithiasis.

A severely affected testis following orchitis, demonstrating mixed reflectivity with pockets of high reflectivity likely to represent areas of infarction and hemorrhage.

Longitudinal ultrasound image of orchitis demonstrating heterogeneous echotexture, testicular enlargement and increased vascularity (A). Chronic changes within the testis giving it a mottled post orchitis (b).

35-year-old asymptomatic man undergoing sonography as part of an infertility evaluation. Longitudinal sonogram of the epididymal head shows a cyst with posterior through-transmission.

37-year-old man with infertility and painful erections who was found on physical examination to have a palpable abnormality along the shaft of the penis. Contrast-enhanced axial (B) and sagittal (C) T1-weighted MR images of the penis show enhancing plaque (arrows) along the anterior aspect of both the corpora cavernosum in B and the anterior and posterior aspects of the left corpus cavernosum in C.

Axial fast SE MR image (7,700/147) shows a large, midline, hemorrhagic ejaculatory duct cyst.

Coronal fast SE MR Image shows a hemorrhagicand debris-filled müllerian duct cyst. (9b) Sagittal fast SE MR image shows thehematocrit effect of blood within the cyst. (10) Axial (a) and coronal (b) fast SE MR images show a utricle cyst.

Coronal fast SE MR image shows prostatitis. The peripheral gland demonstrates diffuse decreased signal intensity (arrow). (15) Axial fast SE MR image shows tuberculous prostatitis. Diffuse, abnormal low signal intensity is present in the peripheral zone (arrow).

Axial fast SE MR image shows atrophic seminal vesicles (arrows) secondary to a low testosterone level.

Axial fast SE MR image shows congenital absence of the vasa deferentia. The linear structures of high signal intensity anterior to the prostate gland are vascular and mimic the vasa. The normal vasa are convoluted, not linear. Coronal fast SE MR image shows congenital absence of the left seminal vesicle and vas deferens. There is a seminal vesicle cyst in anatrophic right seminal vesicle (arrow). Arrowhead indicates where the vas deferens should enter the prostate

Zinner syndrome. Shows absence of the right kidney. (b) Sagittal fast SE MR image shows an ectopic, blind-ending ureter (arrow). (c) Sagittal fast SE MR image slightly lateral to b shows the ureter (arrow) entering a dilated seminal vesicle (arrowheads). (d) Sagittal fast SE MR image shows a dilated vas deferens (arrow). (e) Sagittal fast SE MR image shows a dilated seminal vesicle. (I) Retrograde urethrogram of another patient with similar examination results shows left renal agenesis and a blind ending, bifid ureter with ectopic insertion into a seminal vesicle cyst.

Conclusion Given the prevalence of male infertility, the radiologist's familiarity with its appropriate imaging workup and recognition of the commonly involved pathologic processes is critical. Imaging plays a key role in the evaluation of the hypospermic or azoospermic man. It can detect correctable abnormalities, which can lead to a successful conception. It can also reveal potentially life-threatening disorders in the course of an infertility evaluation.

Thank You.