Role of 3.0 Tesla magnetic resonance hysterosalpingography in the diagnostic work-up of female infertility

MRI of endometriosis in correlation with the #Enzian classification: applicability and structured report

Endometriosis represents one of the most common causes of life-impacting chronic pelvic pain and female infertility. Magnetic resonance imaging (MRI) plays an increasing role in the diagnosis and mapping of endometriosis, while diagnostic laparoscopy currently tends to be reserved for the patients with negative imaging results. The #Enzian, published in 2021, proposes a new comprehensive classification system of endometriosis, combining a complete staging of deep infiltrative endometriosis with the evaluation of peritoneal/ovarian/tubal localizations and the presence of adenomyosis. This article addresses in detail the applicability of the #Enzian classification, primarily based on surgical findings, to the MRI evaluation of the endometriosis. Overall, there is a significant matching between MRI features and the #Enzian classification criteria, two different perspectives of endometriosis mapping, with different goals and levels of detail. The main discrepancy lies in the evaluation of tubo-ovarian condition, which is not fully assessable by MRI. Furthermore, as endometriosis is a complex disease, usually multifocal, that can present with a myriad of imaging findings, MRI reporting should be clear and well organized. The authors group, both radiologists and gynecologists, propose a structured MRI report of endometriosis in correlation with the #Enzian classification, merging the detailed anatomical and pre-operative information provided by the MRI with the benefits of a comprehensive classification system of endometriosis in the clinical practice and research field.Critical relevance statement This article addresses in detail the applicability of the #Enzian classification, primarily based on surgical findings, to the MRI evaluation of the endometriosis and proposes a #Enzian-based structured MRI report.

Diagnostic accuracy of pelvis multiparametric MRI against CT virtual hysterosalpingography: a prospective study of tubal patency through female infertility assessment

OBJECTIVE

To evaluate the diagnostic accuracy of MRI-hysterosalpingogram (HSG) with semiquantitative dynamic contrast-enhanced perfusion, against the virtual multislice CT hysterosalpingogram (VHSG) as a reference standard.

METHODS AND MATERIALS

In this prospective study, 26 women (age >18 years) searching for infertility causes and with VHSG physician request. Thereafter, the assessment performance of both techniques was determined by two reader analyses. k statistics were used for the assessment of tubal patency. Receiver operating characteristic (ROC) analysis was used to compare the capability for tubal patency assessment between both exams on a per-patient and per-tube basis. The McNemar test was used to compare the diagnostic accuracy measures.

RESULTS

Tubal patency, uterine morphological, ovarian, and extrauterine abnormalities were evaluated through both exams in all 26 women. There was no significant difference between diagnostic performance measurements between the methods. The ROC curve of VHSG was 0.852 for both per-patient and per-tube analyses, and one and 0.938 for MRI-HSG. Sensitivity and specificity for per-patient and per-tube for VHSG were 95.2 and 97.7, 80 and 87.5%, and for MRI-HSG 100% for both analyses and 100 and 87.5%, respectively.

CONCLUSION

This study demonstrates the feasibility of diagnosing tubal patency through MRI, using a semi-quantitative dynamic contrast-enhanced perfusion sequence, and the satisfactory diagnosing of the uterine morphology, ovarian abnormalities, and ovarian and deep endometriosis.

ADVANCES IN KNOWLEDGE

Multiparametric MRI with a perfusion real-time sequence as a HSG method can be used in the evaluation not only for uterine and ovarian abnormilities but also tubal patency.

A Common Path: Magnetic Resonance Imaging of Müllerian and Wolffian Duct Anomalies

PURPOSE OF REVIEW

This review summarizes the pathway of Mullerian and Wolffian duct development, anomalies that result from disruptions to this pathway, and the characteristics on advanced imaging that identify them.

RECENT FINDINGS

In-office evaluation for reproductive anomalies is usually inadequate for the diagnosis of congenital reproductive anomalies. Magnetic resonance imaging (MRI) has usurped invasive diagnostic methods including laparoscopy, hysteroscopy, and vasography as the new gold standard. Because of its superior soft-tissue delineation and the availability of advanced functional sequences, MRI offers a sophisticated method of distinguishing reproductive anomalies from one another, characterizing the degree of defect severity, and evaluating for concomitant urogenital anomalies non-invasively and without radiation exposure to the patient. Congenital anomalies of the Mullerian and Wolffian duct can be incredibly nuanced, requiring prompt and accurate diagnosis for management of infertility. Definitive diagnosis should be made early with MRI.

Comparison between X-ray-hysterosalpingography and 3 Tesla magnetic resonance-hysterosalpingography in the assessment of the tubal patency in the cause of female infertility

OBJECTIVES

XR-hysterosalpingography currently represents the gold standard for tubal pathology evaluation. Magnetic resonance-HSG is an innovative technique. With our study, we aim to comprehend if and how MR-HSG, compared to traditional XR-HSG, could give us this additional information in the diagnostic/therapeutic process.

MATERIALS AND METHODS

This study included 19 patients between 30 and 42 years old (average age 37.7) affected by infertility. Patients underwent contextually both XR-HSG and MR-HSG, using a single catheterization. The dynamic MR-HSG exam consisted a MR sequence during contrast administration through the cervical catheter.

RESULTS

Both XR-HSG and MR-HSG documented that 15 of the 19 patients had bilateral tubal patency, while four patients had monolateral tubal patency. However, MR-HSG allowed us to diagnose additional findings: Two active endometriosis foci in adnexal localization and a condition of adenomyosis A unicornuate uterus malformation A submucous uterine myoma near the tubal ostium A decrease of the ovarian reserve in a patient So MR-HSG could potentially detect in 10/19 (52%) women the cause of their infertility, compared to 4/19 (21%) detected with XR-HSG and about 30% of women would have resulted as false negatives if we only used XR-HSG. Finally, with a questionnaire, we demonstrated that MR-HSG is less painful than XR-HSG.

CONCLUSIONS

These data thus confirm that XR-HSG and MR-HSG present the same diagnostic of assessing tubal patency. We also demonstrated that MR-HSG is able to detect further collateral findings that could likewise be a possible therapeutic target and it could possibly become the new gold standard in female infertility diagnostics.

Clinical Significance of Increasing Pressure Curve's Slope When Injecting Ultrasound Contrast Agent During Evaluation of Fallopian Tubal Patency

OBJECTIVE

To explore the association between Fallopian tubal patency and the slope of the increasing pressure curve for ultrasound contrast agent.

MATERIALS AND METHODS

A total of 136 patients underwent transvaginal 4-dimensional hysterosalpingo-contrast sonography (TVS 4D HyCoSy) between August 2015 and January 2016. We divided the patients into 3 groups according to different Fallopian tubal patency status: 71 patients (48.97%) in bilateral tubal patency group, 45 (31.03%) in unilateral tubal patency group, and 20 in bilateral tubal nonpatent group. The ultrasound contrast agent was injected and the pressure curve was recorded automatically in real time using a liquid-injecting machine that traces it as a pressure curve. The slopes of the different groups are compared through independent sample t test.

RESULTS

The slopes of the 3 groups were 1.242 ± 0.572, 1.472 ± 0.638, and 2.068 ± 1.236 kPa/s. A correlation was observed between the slope of the increasing pressure curve and tubal patency (R = 0.287, P < .05). The slopes differed significantly between the bilateral tubal patency group and bilateral tubal nonpatent group (P = .001) and between the unilateral tubal patency group and bilateral tubal nonpatent group (P = .012). However, the difference between the bilateral tubal patency and unilateral tubal patency groups was not significant (P = .266).

CONCLUSION

The increase of the injecting pressure curve's slope for contrast agent during 4D HyCoSy is associated with the nonpatent degree of the tube. This condition can be used as an objective index of tubal patency and can be a reference in diagnosis and treatment.

Conventional and magnetic resonance hysterosalpingography in assessing tubal patency-A comparative study

Context:

Tubal factors, one of the leading causes of female infertility, have been conventionally evaluated by hysterosalpingography (HSG). The role of magnetic resonance imaging (MRI) in assessing female infertility is gaining importance because of its inherent efficiency in detecting structural abnormalities. Magnetic resonance hysterosalpingography (MR HSG) is less invasive and avoids exposure of ovaries to ionizing radiation. Its utility is extrapolated to visualize fallopian tubes.

Aims:

To assess the diagnostic accuracies of dynamic MR HSG and conventional HSG (cHSG) in identifying tubal patency in women with infertility using diagnostic laparoscopy (DL) as gold standard.

Materials and Methods:

A prospective study of 40 patients was conducted over a period of 6 months. The patients were subjected to MR HSG followed by cHSG during the preovulatory period. If tubes were blocked, the patients were subjected to DL in the next menstrual cycle. If the tubes were patent and there was failure of conception, they were subjected to DL in the interval of 3 months.

Results:

Twenty-four patients had bilateral tubal spill which was confirmed using cHSG and DL. One patient had discordant MR HSG and cHSG results and six patients had discordant MR HSG and DL results. No statistical difference was observed between MR HSG and cHSG.

Conclusion:

Pelvic MRI is an inevitable tool in infertility evaluation. MR HSG can be used in addition as it avoids exposure of the reproductive organs to radiation and has the same efficacy as cHSG.

Hysterosalpingography using Magnetic Resonance Imaging for infertility patients

OBJECTIVE

Some studies have shown that it is possible to evaluate tubal permeability through MRI. Our aim is to perform a prospective study and to perform a comprehensive review in the literature regarding HSG-MRI.

METHODS

We carried out a PUBMED search using the following keywords: hysterosalpingogram, hysterosalpingography, magnetic resonance imaging and MRI. As inclusion criteria, we included only papers published in English, and exams ran on humans. We also conducted a prospective inclusion of patients who had visited a human reproduction clinic between May/2017 and April/2019 for laboratory image diagnoses using HSG-MRI.

RESULTS

Following the inclusion and exclusion criteria, we included seven original papers. Review papers and those written in a language other than English, were excluded. Between the period of May/2017 and April/2019, we selected ten patients for our study. The average exam duration was 30 minutes. Cervical catheterization was possible in all cases. There were no major complications. We highlight that in 8/9 of patients, we could directly visualize uterine tubes with contrast (excluding one patient with bilateral tubal ligation).

CONCLUSIONS

Our initial experience with HSG-MRI shows promise. We demonstrated an optimized protocol for conducting an HSG-MRI (with excellent image quality). HSG-MRI had some advantages, such as not using ionized radiation, less pain and being able to analyze pelvic anatomy. Patients referred for a pelvic MRI as part of a more detailed investigation into infertility can also benefit from undergoing a simultaneous HSG using MRI.

Magnetic Resonance Imaging in the Evaluation of Female Infertility

Pelvic MRI plays an important adjunctive role in the clinical workup of female infertility. Hysterosalpingography is the first line imaging modality in evaluation of female infertility, and hysterosalpingo-contrast sonography can also be used to evaluate both the uterine cavity and fallopian tubes. Pelvic MRI can be helpful in the workup of female infertility, particularly in cases of Mullerian duct anomalies, fibroids, adenomyosis, endometriosis, and tubal disease. These conditions and their appearance on imaging will be reviewed in this article.

The role of diagnostic magnetic resonance hysterosalpingography in the evaluation of fallopian tubal occlusion of female infertility: A meta-analysis

OBJECTIVE

To evaluate the diagnostic performance of magnetic resonance hysterosalpingography for fallopian tubal occlusion in the context of female infertility when compared to the diagnostic performance of conditional X-ray hysterosalpingography.

METHODS

PubMed, EMBASE, Web of Science, EBSCO, Cochrane Library database, Scopus were searched for studies in which magnetic resonance hysterosalpingography and X-ray hysterosalpingography were used as diagnostic tools for tubal occlusion assessment; databases were searched through April 2020. Two researchers conducted study inclusion assessment, data extraction, a systematic review, and pooled meta-analysis independently. Stata 15.1 software was used to analyze the pooled sensitivity, specificity, diagnostic odds ratio, positive and negative likelihood ratios, and the area under the summary receiver-operating characteristic curve of magnetic resonance hysterosalpingography.

RESULTS

A total of five studies involving 101 patients and 198 fallopian tubes were finally included. Compared with the conditional X-ray hysterosalpingography (the imaging gold standard), the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio and the area under the curve of magnetic resonance hysterosalpingography for tubal occlusion were 0.91 (95% CI: 0.48-0.99), 1.00 (95% CI: 0.87-1.00), 230.47 (95% CI: 6.79-7824.72), 0.09 (95% CI: 0.01-0.80), 2676.10 (95% CI: 61.35-120,000), and 1.00 (95% CI: 0.99-1.00), respectively. Subgroup analyses revealed that viscosity of contrast agent (P = 0.024) and test order (P = 0.036) affected the accuracy of MR-HSG to evaluate tubal occlusion.

CONCLUSIONS

Our meta-analysis indicated magnetic resonance hysterosalpingography may serve as an alternative for further evaluation of fallopian tubal occlusion of female infertility.

Comparison between magnetic resonance hysterosalpingography and conventional hysterosalpingography: direct visualization of the fallopian tubes using a novel MRI contrast agent mixture

BACKGROUND

Magnetic resonance hysterosalpingography (MR-HSG) is a promising technique in the work-up of female infertility. Few existing MR-HSG studies focus on the comparison between MR-HSG with gold standard examination.

PURPOSE

To compare the diagnostic value of MR-HSG with conventional HSG in patients receiving both exams in one day.

MATERIAL AND METHODS

This study included 33 infertile women who completed pelvic MR scanning, HSG, and MR-HSG in that order. A traditional HSG contrast agent (iohexol) and a magnetic resonance imaging (MRI) contrast agent (1 mL gadopentetate dimeglumine (Gd-DTPA) blended with 100 mL iohexol) were used to achieve image enhancement. Inter-observer and inter-modality agreements of HSG and MR-HSG exams were assessed. The results were calculated by using the kappa test. Three radiologists who were blinded to the clinical data independently reviewed the MR images. Extratubal abnormalities were analyzed.

RESULTS

A total of 62 fallopian tubes of 33 women were included in the study. MR-HSG imaging findings to depict tubal patency were similar to these of HSG (AUC 0.911, sensitivity 0.821, specificity 1.000, positive predictive values 1.000, and negative predictive values 0.872). Pairwise inter-observer agreement among three observers and inter-modality agreement of the diagnosis were excellent (mean kappa 0.863 and 0.835, respectively). In addition, 29 extratubal abnormalities in 21 patients were found on pelvic MR scanning.

CONCLUSION

MR-HSG and HSG demonstrated similar results in assessing tubal patency. Because it offers the comprehensive assessment of female pelvic structures, and avoids ionizing radiation, MR-HSG may be used as an alternative imaging technique for evaluation of female infertility.

Hysterosalpingo-contrast-sonography vs. magnetic resonance-hysterosalpingography for diagnosing fallopian tubal patency: A systematic review and meta-analysis

PURPOSE

To compare hysterosalpingo-contrast-sonography (HyCoSy) and magnetic resonance-hysterosalpingography (MR-HSG) in the diagnosis of fallopian tubal patency.

MATERIALS AND METHODS

The databases of PubMed, Embase, and the Cochrane Library were searched for records up to November 30, 2019. Studies involved in the diagnostic detection of HyCoSy or MR-HSG for fallopian tubal patency using conventional HSG or laparoscopy as the reference test were included. Data was analyzed by meta-analysis. We compared sensitivity, specificity, positive and negative likelihood ratios (PLR and NLR), diagnostic odds ratio (DOR), and summary receiver operating characteristic (sROC) plots of both HyCoSy and MR-HSG. Quality was assessed using the QUADAS-2 tool.

RESULTS

The analysis included 24 articles involving 1340 patients. HyCoSy was studied in 17 studies, and MR-HSG was studied in seven studies. For HyCoSy in diagnosis of fallopian tubal patency, pooled sensitivity was 89 % (95 % confidence interval [CI], 87 %-91 %), and specificity was 93 % (95 % CI, 91 %-94 %). For MR-HSG in diagnosis of fallopian tubal patency, pooled sensitivity was 100 % (95 % CI, 98 %-100 %), and specificity was 82 % (95 % CI, 74 %-89 %). The sROC showed similar diagnostic accuracy for MR-HSG and HyCoSy. 3D/4D HyCoSy with ultrasound microbubbles had equal sensitivity (95 % vs. 100 %, P = 0.186) and significantly higher specificity (94 % vs. 82 %, P = 0.005) compared with MR-HSG.

CONCLUSIONS

HyCoSy and MR-HSG showed similar overall diagnostic performance for diagnosing fallopian tubal patency. 3D/4D HyCoSy with ultrasound microbubbles could significantly improve the diagnostic specificity of HyCoSy.

Niche role of MRI in the evaluation of female infertility

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.