Infertility is an increasingly prevalent issue in developed countries, with 20% of couples having trouble conceiving. There might be some underlying issues that radiologists can help to diagnose and treat, experts will explain during a Special Focus session.

Infertility occurs in both men and women and can have multiple causes, including abnormal sperm production or function due to undescended testicles for men, uterine fibroids for women, and consequences of previous infections, such as chlamydia, for both. However, some conditions are particularly likely to be causes of infertility, including varicoceles in men and blocked fallopian tubes in women.

The initial assessment for an infertile couple is a standard physical examination. Radiology can help assess the patency of the fallopian tubes, mainly – although not exclusively – with a fluoroscopic examination, according to Dr. Raman Uberoi, a consultant interventional radiologist and Honorary Senior Lecturer at the John Radcliffe Hospital in Oxford, UK. “You can also use contrast ultrasound, so you do not have radiation and are able to assess the uterus at the same time, but generally people favour fluoroscopic technique because it provides more detail and allows you to potentially undertake recanalisation. If ultrasound shows that there is spill on both sides, then it is fine, but if it does not, then I would still want to do an FDG scan,” he said.

36-year-old man, unable to conceive. Left sided varicocele embolised with 6mm x 300mm and 8mm x 300mm coils.

For men, radiology can help look for varicoceles, which affect about 10% of all men and 30% of men among infertile couples. Varicoceles are varicose veins of the testicle and scrotum that may cause pain, testicular atrophy or shrinkage, or fertility problems. “Patients usually describe their condition as looking like a bag of worms. They do not always cause pain, but can be very uncomfortable,” Uberoi said.

In such cases, a multiparametric ultrasound examination of the scrotum is recommended, to look at veins around the testes, according Michele Bertolotto, Associate Professor of Radiology at the University of Trieste, Italy. “You may use grayscale, elastography, vascularity and contrast-enhanced ultrasound; these techniques have proven their efficiency,” said Bertolotto, who is chair of the recently created European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG).

The group published guidelines and recommendations for the detection, classification, and grading of ultrasound evaluation of varicoceles in July 2019, and will present a new position paper on infertility, again focused mainly on ultrasound, at ECR 2020.

During the ultrasound examination, it is important to look for potential tumours, Bertolotto recommended. “You often have a rising of small testicular lesions, which are in most cases benign. The testes’ cells may often look like nodules on ultrasound, but they may not be. So it is important to make sure they are not tumours,” he said.

Some research work has recently focused on functional MRI and techniques such as diffusion weighted imaging, that try to look at different signal intensities in patients who have non-obstructive aspermia – another cause of infertility. “It is very experimental and not commonly used in clinical practice. We need more results,” he said.

There is an ongoing discussion about whether varicoceles can really cause infertility. A lot of men with varicoceles are still able to conceive.

“It is very much a matter of debate whether varicoceles are really a cause for infertility or not. Usually it is not varicoceles that causes infertility in young patients,” Bertolotto said.

Knowledge and perception of infertility are constantly evolving, and specialists recommend a comprehensive approach to the problem. “There used to be more focus on women, but we need a much more complete holistic vision of a couple together. Examining women is still the first step, but you would assess both the man and woman as a unit,” Uberoi said.

22-year-old man with left sided varicocele. 3x300mm coils were used to embolise the testicular vein and the collateral vein.

Increasingly, interventional radiology can be used to help treat underlying causes of infertility. Open surgical ligation performed by a urologist remains the most common treatment for symptomatic varicoceles, but varicocele embolisation, a nonsurgical treatment performed by an interventional radiologist, is as effective as surgery, but with less risk, pain and recovery time.

Embolisation, which consists of reversing blood flow down the testicular vein, can be quite successful and about a third of couples get pregnant after the procedure.

However, there is a small risk of recurrence. “Just over 10% of these varicoceles can come back, because vein connections can be complex. There can be several veins that supply this area, or cross connections. So, during the embolisation, it is important to try to identify all these cross connections to try and minimise them,” Uberoi said.

To treat blocked fallopian tubes in women, radiologists can pass a simple guide wire through the tubes and pass a catheter into the cavity to help increase the breadth of the channel.

Treatment can be applied right after the initial imaging examination. “We often do the exam first to check if tubes are blocked, and as a second stage we offer the procedure to unblock them if necessary,” he said.

Unfortunately, not many centres offer IR treatment and surgeons often prefer to clear the tubes laparoscopically. “This kind of IR procedure could be much more commonly used than it is today,” Uberoi concluded.

Embolisation can also help treat uterine fibroids less invasively than myectomy. However, one paper has suggested there may be higher miscarriage rates among women who have undergone fibroid embolisation than among those who have had fibroids removed surgically; radiologists must now discuss and gather further results on the topic.

LIVE
Special Focus Session, Thursday, September 17, 17:00–18:00
SF 7b How radiologists can help the infertile couple

  • Chairperson’s introduction
    Mustafa Secil; Izmir/TR
  • Andrology expert’s view on the role of radiology in infertility
    Davor Jezek; Zagreb/HR
  • Imaging the infertile men: when and how?
    Michele Bertolotto; Trieste/IT
  • Imaging the infertile women: when and how?
    Rosemarie Forstner; Salzburg/AT
  • Interventional radiology in male and female infertility
    Raman Uberoi; Oxford/UK
  • Live Q&A: What is the role of the radiologist in the workup of infertility?

FURTHER READING

Freeman S, Bertolotto M, Richenberg J et al (2019) Ultrasound evaluation of varicoceles: guidelines and recommendations of the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) for detection, classification, and grading. Eur Radiol. doi: 10.1007/s00330-019-06280-y: european-radiology.org/6280

Volondat M, Fontas E, Delotte J, Fatfouta I, Chevallier P, Chassang M (2019) Magnetic resonance hysterosalpingography in diagnostic work-up of female infertility – comparison with conventional hysterosalpingography: a randomised study. Eur Radiol. 29(2):501-508: european-radiology.org/5572

Foti PV, Farina R, Palmucci S (2018) Endometriosis: clinical features, MR imaging findings and pathologic correlation. Insights Imaging. 9(2):149-172: i3-journal.org/591

Saha S, Knox SJ (2016) Female pelvic MRI for infertility: Radiological findings in a cohort of patients referred by a fertility specialist. ECR 2016 / C-0684: myESR.org/16684

Karczagi L, Bartha E, Pasztor N et al (2019) The possible role of strain-elastography in the investigation of male infertility. ECR 2019 / C-2624: myESR.org/192624