Imaging in Male Infertility

US of the Penis: Beyond Erectile Dysfunction

High-frequency US, with a linear transducer and gray-scale, color, and spectral Doppler US techniques, is the primary imaging modality for evaluation of the penis. It can allow delineation of anatomy and assessment of dynamic blood flow; it is easily available and noninvasive or minimally invasive; it is cost effective; and it is well tolerated by patients. US assessment after pharmacologic induction of erection is an additional tool in assessing patients with suspected vasculogenic impotence, and also in selected patients with penile trauma and suspected Peyronie disease. Penile injuries, life-threatening infections, and vascular conditions such as priapism warrant rapid diagnosis to prevent long-term morbidities due to clinical misdiagnosis or delayed treatment. US can facilitate a timely diagnosis in these emergency conditions, even at the point of care such as the emergency department, which can facilitate timely treatment. In addition, color and spectral Doppler US are valuable applications in the follow-up of patients treated with endovascular revascularization procedures for vasculogenic erectile dysfunction. Image optimization and attention to meticulous techniques including Doppler US is vital to improve diagnostic accuracy. Radiologists should be familiar with the detailed US anatomy, pathophysiologic characteristics, scanning techniques, potential pitfalls, and US manifestations of a wide spectrum of vascular and nonvascular penile conditions to suggest an accurate diagnosis and direct further management. The authors review a range of common and uncommon abnormalities of the penis, highlight their key US features, discuss differential diagnosis considerations, and briefly review management. ©RSNA, 2024 Supplemental material is available for this article.

Imaging in Male Infertility

Infertility is defined as inability to conceive despite regular unprotected sexual intercourse for greater than 1 year. Conditions involving the male partner accounts for the infertility in approximately 50% of cases. The goals of imaging in male infertility are to detect treatable/ reversible causes, imaging for sperm retrieval from testis or epididymis for assisted reproductive techniques like in vitro fertilization or intracytoplasmic sperm injection and to provide appropriate genetic counselling for prevention of occurrence of disease in future offspring. The purpose of this article is to describe imaging features in various causes of male infertility to acquaint radiologists with various imaging appearances of causes of male infertility to avoid missing these pathologies.

Sonography in male infertility: a useful yet underutilized diagnostic tool

PURPOSE

To assess the utility of comprehensive sonographic examination including scrotal sonography, Testicular Doppler and Transrectal Ultrasound (TRUS) to evaluate the male reproductive system and differentiate between obstructive (OG) and non-obstructive (NOG) causes of azoospermia.

METHODS

30 infertile men with azoospermia and 30 control subjects with normospermia underwent sonographic evaluation. FNAC/biopsy findings were used for assigning a final diagnosis of obstructive or non-obstructive azoospermia. Qualitative and quantitative imaging parameters were retrospectively compared between the groups using Chi-square/Fisher's exact test and unpaired t-test, respectively. P < 0.05 was considered significant.

RESULTS

Ectasia of rete testis/epididymal tubules, altered epididymal echogenicity, dilated terminal vas deferens were significantly more common in OG while inhomogeneous testicular echo-texture and reduced testicular vascularity were more common in NOG (P < 0.05). Testicular volume and epididymal head size were significantly higher in OG than in NOG and controls (18.2 ml/10 mm Vs 8.2 ml/7.2 mm and 13.4 ml/8.8 mm respectively; P < 0.05); while Resistive Index (RI) of intra-testicular vessels was higher in NOG as compared to OG and controls (0.65 vs 0.54 and 0.52 respectively; P < 0.05). On ROC curve analysis, cut-off values of testicular volume (AUC: 0.939; P < 0.001), epididymal head size (AUC: 0.772; P = 0.001) and testicular RI (AUC: 0.761; P = 0.001) to differentiate between the groups were 12.1 ml (sensitivity-94.4%; specificity-83.3%), 9 mm (sensitivity-66.7%; specificity-71%) and 0.62 (sensitivity-62%; specificity-100%) respectively.

CONCLUSION

Comprehensive sonographic evaluation can be used to differentiate obstructive from non-obstructive infertility and should be routinely incorporated in the diagnostic workup of infertile men with azoospermia.

Obstructive oligospermia: the role of interventional radiology in its diagnosis and treatment

Purpose

According to the latest World Health Organization guidelines (2010), oligo-sperm it is due to a sperm concentration of less than 15 million/ml of seminal fluid. The cause can be obstructive and non-obstructive. Interventional radiology allows diagnosis and, in some cases, minimally invasive treatment.

Case presentation

A 28-year-old man with oligospermia (7 million/ml of seminal fluid), surgically treated 2 years ago for clinical grade III bilateral varicocele (according to Dubin’s classification), was admitted to the Urology Department for suspected accidental surgical ligation of the left vas deferens. The patient underwent several diagnostic tests including phlebography of the left pampiniform plexus, bilateral vesico-deferentography. The steno-occlusion of the ejaculatory ducts was diagnosed, which was resolved through an innovative interventional radiology treatment.

Conclusions

Interventional radiology has played a decisive role in the diagnosis and treatment of the causes of male infertility. In our experience, it has considerable potential in the minimally invasive treatment of steno-obstructive pathologies of the vesico-deferential system.

Validity of measurements of testicular volume obtained by a built-in software of ultrasound systems: with formula recommended by updated guidelines as reference

Aim: To investigate the validity of measurement of testicular volume acquired by a built-in software in different ultrasound systems with reference to the updated guidelines. Materials and methods: Archives of 1,976 patients who had undergone scrotal ultrasound evaluation were reviewed. A total of 973 patients with 1,909 testes, who had undergone ultrasound measurement of the testicular volume, were included in the study, and 1,003 patients were excluded. The age of enrolled patients ranged from 17 to 66 years (median age of 39 years). The ultrasound systems included Siemens Sonoline S2000, Philips EPIQ5, GE Logiq E9, Hitachi Aloka prosoundα7, Mindray DC-8 and Mindray Resona7. The transducers have imaging frequencies of 5–14 MHz. Validity of the measurement of testicular volume acquired by a built-in software in different ultrasound systems was assessed with reference to the formula that Volume (V) = Length (L) × Width (W) × Height (H) × 0.71, recommended by the updated guidelines, by recalculating the original numbers using a calculator. Results: The values obtained by the built-in software of Mindray DC-8 and Mindray Resona7 ultrasound systems and measurements recalculated on a computer were all in concordance; and the values obtained by the built-in software of Siemens Sonoline S2000, Philips EPIQ5, GE Logiq E9, and Hitachi Aloka prosoundα7 ultrasound systems and measurements recalculated on computer were all discordant. The same testicular measurements calculated with different formulas (V = L×W×H×0.71 vs. V = L×W×H×0.52) produced 26.76% difference. Conclusion: Values of testicular volume obtained by some ultrasound systems are not accurate with reference to the formula recommended by the updated guidelines.

Testicular ultrasound score: A new proposal for a scoring system to predict testicular function

Background

Testicular ultrasound (US) is routinely employed in the evaluation of reproductive and sexual function. However, its use for characteristics other than testicular volume is hampered by a lack of information on the prognostic value of its findings, which to date have only been incorporated in a score proposed by Lenz et al in 1993.

Objectives

We sought to explore whether testicular US examination can predict the quality of spermatogenesis and provide information on testicular endocrine function.

Materials and methods

We retrospectively reviewed 6210 testicular US examinations, finally selecting examinations from 2230 unique men. The following variables were considered: bitesticular volume and testicular asymmetry, parenchymal echotexture, echogenicity and presence of microlithiasis, solid lesions and varicocoele. Concurrent fasting hormonal data were available for 1160 men, while 979 had a semen sample available from the same day as the US examination.

Results

We derived a new US score, termed TU score, that can predict both impaired spermatogenesis (AUC 0.73, sensitivity 72%, specificity 61%, P < .001) and hypogonadism (AUC 0.71, sensitivity 71%, specificity 53%, P < .001) more accurately than the Lenz's score. In a multivariate analysis, a reduced sperm composite index (defined as total spermatozoa × total motility × normal forms) was independently predicted by bitesticular volume and by inhomogeneous echotexture, while hypogonadism was independently predicted also by reduced echogenicity and presence of microlithiasis.

Discussion and conclusions

We describe the testicular US characteristics that are independently associated with impaired spermatogenesis and hypogonadism and propose the TU score as a simple screening method for use in subjects referred for testicular US.

MRI findings of obstructive azoospermia: lesions in and out of pelvic cavity

Obstructive azoospermia (OA) is caused by excurrent duct obstruction, which can occur anywhere along the course of the male reproductive tract and is classically characterized by normal spermatogenesis. To be familiar with the imaging anatomy of normal and abnormal male genital ducts is essential to the diagnosis of OA. In some circumstances, OA can also be related to some specific syndromes; thus, making an accurate diagnosis may require an integral view of the whole abdomen and pelvis. MR is a great complementary imaging modality either for the detection of obstructive factors, especially for characterization of those indeterminate features on ultrasound, or for the identification of specific syndromes related to OA. In this article, a series of patients with OA caused by different kinds of lesions in and out of the pelvic cavity (abdomen) shown on MR imaging were included, and some cases of specific syndromes related to OA were also reviewed.

Penile Doppler Ultrasound for Erectile Dysfunction: Technique and Interpretation

OBJECTIVE. Erectile dysfunction (ED) is a common medical condition that has a high prevalence and incidence worldwide and may have a significant impact on both physical and psychosocial health. The purpose of this article is to review the role of penile Doppler sonography in the assessment of ED. CONCLUSION. Penile Doppler sonography is an essential tool for differentiating between vascular and nonvascular causes of ED; therefore, radiologists must be familiar with the imaging protocol, the limitations of the technique, and interpretation of its findings, to warrant an accurate diagnosis and appropriate patient management.

Sonography in male infertility: a look beyond the obvious

Infertility affects 15-20% of the reproductive age range population; the male factor accounts for up to 40-60% of these. With female factor infertility catching most of the limelight in research, diagnosis and treatment, the other half of the problem has not been duly addressed. Imaging has an important role to play in the evaluation of male infertility, especially to identify correctible (obstructive) causes. We review the scrotal, trans-rectal sonographic and Doppler findings in infertile men to aid in the accurate diagnosis and proper management of such patients.