Table of Contents  
Year : 2016  |  Volume : 26  |  Issue : 1  |  Page : 19-22

The role of imaging modalities in the management of infertility: A short communication

1 Department of Obstetrics and Gynaecology, Imo State University Teaching Hospital, Orlu, Nigeria
2 Department of Obstetrics and Gynaecology, Abia State University Teaching Hospital, Aba, Nigeria
3 Department of Radiology, University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu State, Nigeria

Date of Acceptance21-May-2016
Date of Web Publication20-Dec-2016

Correspondence Address:
Emmanuel C Ojiyi
Department of Obstetrics and Gynaecology, Imo State University Teaching Hospital, Orlu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1116-5898.196273

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Background: Infertility is a global problem that poses a lot of management dilemma to the practicing gynecologist. Diagnostic imaging techniques are invaluable in the traditional work-up of an infertile couple. Productive therapy can be instituted only after completion of a thorough evaluation that starts with a detailed, direct history, and physical examination. Objective: To evaluate the place of radioimaging in the work-up of the infertile couple. Materials and Methods: Data were sourced through Google search engine, Highwire press, Medline, PubMed, Cochrane database, and SAGES. Articles on diagnostic imaging techniques were identified and reviewed. Results: Radioimaging has continued to play a vital role in the evaluation of the infertile couple. This is due to the fact that they can detect most structural abnormalities and pathologies that can cause or/are associated with infertility. Conclusion: Diagnostic radioimaging has continued to play key roles in the evaluation of the infertile couple and this is further helped by the introduction and enhancement of newer imaging modalities. They can detect correctable abnormalities which can lead to a successful conception as well as reveal potentially life-threatening disorders in the course of an infertile evaluation.

Keywords: Diagnostic work-up, infertility, radioimaging

How to cite this article:
Anolue FC, Ojiyi EC, Dike EI, Okeudo C, Ejikem CE, Agwuna KK. The role of imaging modalities in the management of infertility: A short communication. Niger J Surg Sci 2016;26:19-22

How to cite this URL:
Anolue FC, Ojiyi EC, Dike EI, Okeudo C, Ejikem CE, Agwuna KK. The role of imaging modalities in the management of infertility: A short communication. Niger J Surg Sci [serial online] 2016 [cited 2023 Mar 27];26:19-22. Available from:

  Introduction Top

There is generally no accepted definition of infertility. In the United Kingdom, the updated National Institute for Health and Clinical Excellence guidelines do not include a specific definition, but recommend that "A woman of reproductive age who has not conceived after 1 year of unprotected vaginal sexual intercourse, in the absence of any known cause of infertility, should be offered further clinical assessment and investigation along with her partner, with earlier referral to a specialist if the woman is over 36 years of age." [1] The prevalence of infertility varies depending on the definition. Some estimates suggest that worldwide, "between three and seven percent of all couples or women have an unresolved problem of infertility." [1] There are varying reports as to the contribution of the various reproductive factors to infertility, but in general, male factor infertility accounts for 30% of infertile couple, 30% are female causes, and 10% are combined factors, while another 30% remain unexplained. [2] Factors implicated in female infertility include tubo-peritoneal, ovarian, uterine, cervical, and hormonal factors. [2] In men, abnormalities in sperm count, motility, and morphology are usually the major culprits. [2]

In fact, infertility is common in sub-Saharan Africa. Unlike in the West, secondary infertility is more common than primary infertility, being most often the result of untreated sexually transmitted infections or complications from pregnancy and childbirth. [3] An important factor in infertility in developing countries is the positioning of men within the paradigm of reproductive health, whereby as the rates of general infertility mask the differences between male and female infertility, men remain a largely invisible facet within the theorization and discourse surrounding infertility, as well as the related treatments and biotechnologies. [3] Advances in assisted reproductive technologies, such as in vitro fertilization, can offer hope to many couples where treatment is available, although barriers exist in terms of medical coverage and affordability. [4] Diagnostic imaging techniques may be indicated as a part of the complete fertility evaluation. [4] Due to the introduction and enhancement of newer imaging modalities, reliable adjuncts to clinical examination can be obtained to diagnose a variety of causes of infertility. [4]

  Materials and Methods Top

Literature covering a 14-year period from January 1, 2000 to December 31, 2014 was assessed and reviewed. Data were sourced through Google search engine, Highwire press, Medline, PubMed, Cochrane database, and SAGES. Articles on diagnostic imaging techniques were identified and reviewed.


This is an imaging technique that uses electromagnetic radiation other than visible light, especially X-rays to view the internal structure of a nonuniformly composed and opaque object (i.e., a nontransparent object of varying density and composition) such as the human body. [5] To create the image, a heterogeneous beam of X-rays is produced by an X-ray generator and is projected toward the object. A certain amount of X-ray is absorbed by the object which is dependent on the particular density and composition of that object. The X-rays that pass through the object are captured behind the object by a detector (either photographic film or a digital detector). [5] The detector can then produce a superimposed two-dimensional (2D) representation of all the objects' internal structures. [5] It is not routinely done as part of a fertility work-up, except when it is done as a scout film during hysterosalpingography.


This is a radiologic procedure to investigate the shape of the uterine cavity and the shape and patency of the fallopian tubes. [6] It entails the injection of a radio-opaque material into the cervical canal and usually fluoroscopy with image intensification. To demonstrate tubal patency, spillage of the contrast material into the peritoneal cavity needs to be observed. The procedure involves X-rays. It is done in the follicular phase of the cycle. It is useful in diagnosing uterine malformations, intra-uterine adhesions (Asherman's syndrome), tubal occlusion, and cervical incompetence. [6] Using catheters, an interventional radiologist can open tubes that are proximally occluded. [6] It can also demonstrate uterine myomas and tuberculous changes on the fallopian tubes and salpingitis isthmica nodosa. Common complications of the procedure include pain, infection, allergic reaction to the contrast medium, intravasation of the dye, and if oil-based material is used, embolization. [6]

Ultrasound scan

This is an oscillating sound pressure wave with a frequency greater than the upper limit of the human hearing range. Although this limit varies from person to person, it is approximately 20 kHz (20,000 Hz) in healthy, young adults. [7] Ultrasound scan devices operate with frequencies from 20 kHz up to several gigahertz. [7] The technology is relatively inexpensive and portable, especially when compared with other techniques such as magnetic resonance imaging (MRI) and computed tomography (CT).

Ultrasound can determine the size of the uterus and its zones as well as pick up congenital malformations of the female genital tract that can be an etiological factor in female subfertility. [7] It can also detect abnormalities of the endometrial echo through measurements of endometrial thickness. [7] Ultrasound can also diagnose uterine leiomyoma with a very high sensitivity and specificity. [7] Using transvaginal probes, the development of the ovarian follicles could be monitored (ultrasound folliculography) to assess the ovulatory factor in infertility. Ultrasound can easily diagnose polycystic ovary disease syndrome which contributes to as much as 25% of the causes of female subfertility. It can also diagnose many causes of male factor subfertility such as undescended testis (cryptorchidism), epididymo-orchitis, and varicoceles. [7]

In men with possible nonobstructive azoospermia and at times, in men with a previous vasectomy (who do not want a reversal), and men with spinal cord injuries (who fail electro-ejaculation or vibratory ejaculation), recent studies have illustrated that it is likely to find active spermatogenesis in areas with good blood supply within the testicle, utilizing detailed color Doppler ultrasonography and needle guidance techniques to localize areas of spermatogenesis within the testicle. [7]


This is also called sonohysterography and is a noninvasive technique that involves the slow infusion of sterile saline solution into uterus during ultrasound imaging. [8] It helps to evaluate abnormal uterine growths, endometrial abnormalities, or disorders affecting the deeper tissue layers. [8] It does not require either radiation or contrast media or invasive surgical procedures. In women with fertility problems, it can pick up endometrial or tubal polyps, submucous leiomyomas, or intra-uterine or tubal adhesions. [8] It can also be used as a follow-up after uterine surgery to evaluate its success. [8] It is contraindicated in women with active pelvic inflammatory disease (PID), chronic PID, or heart disease. The main complications of the procedure are mild spotting and cramping. [8]


This is an X-ray study of the vas deferens to see if there is blockage, often times in the context of male infertility. [9] An incision is made in the scrotum, a contrast is injected in the vas deferens, and X-ray is taken from different angles. [9] Thus, it is an invasive procedure and carries the risk of iatrogenic scarring and obstruction of the vas. [9] It is absolutely indicated if:

  1. Azoospermia is present
  2. Testis biopsy shows complete spermatogenesis and many more mature spermatids
  3. There is at least one palpable vas. [9] It may also be indicated if there is severe oligospermia with a normal testis biopsy, high levels of sperm bound antibodies, or low semen volume and poor sperm motility. [9]

The complications of the procedure include stricture, injury to the vassal blood supply, hematoma, and sperm granuloma. [9]

X-ray computed tomography

Computed axial tomography scan, also called computer-assisted tomography, is a technology that uses computer-processed X-rays to produce tomographic images (virtual "slices") of specific areas of the scanned object, allowing the user to see what is inside it without cutting open. [10] Digital geometry processing is used to generate a three-dimensional image of the inside of an object from a large series of two-dimensional radiographic images taken around a single axis of rotation. [10] Medical imaging is the most common application of X-ray CT. [10] CT produces a volume of data that can be manipulated to demonstrate various bodily structures based on their ability to block the X-ray beam. [10]

MRI, nuclear magnetic resonance imaging, or magnetic resonance tomography is a medical imaging technique used in radiology to investigate the anatomy and function of the body. [11] MRI scanners use strong magnetic fields and radiowaves to form images of the body. [11] It is without exposure to ionizing radiation. Since MRI does not use any ionizing radiation, its use is recommended in preference to CT when either modality could yield the same information. [11]

MRI is the imaging of choice for cryptorchidism situated at or beyond the internal ring of the inguinal canal. [11] It can also reveal inflammation or malignant change in cryptorchidism. [11] It also has a high sensitivity and specificity in detecting uterine leiomyoma and adenomyosis. [12] MRI spectral imaging can be employed to differentiate between normal healthy testes and those with markedly decreased spermatogenesis presenting with oligospermia or azoospermia, in whom spermatogenesis is completely absent. [12]

  Results Top

A total of 24 papers were reviewed during this search. Radioimaging has continued to play a vital role in the evaluation of the infertile couple. This is due to the fact that they can detect most structural abnormalities and pathologies that can cause are associated with infertility.

  Conclusion Top

Diagnostic radioimaging has continued to be an integral part of the conventional evaluation of the infertile couple. This is further helped by the introduction and enhancement of newer imaging modalities. This is because they can detect correctable abnormalities which can lead to a successful conception as well as reveal potential life-threatening disorders in the course of an infertility evaluation.

  Recommendations Top

Sources should be channeled toward the provision of these facilities, including newer modalities in all facilities caring for infertile couples. The capacity building to man and maintain the high-technology equipment should also be developed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Himmel W, Ittner E, Kocher MM, Michelmann HW, Hinney B, Rueter M, et al. Voluntary childlessness and being child free. Br J Gen Pract 1997;47:111-8.  Back to cited text no. 1
Khan K, Janesh K, Gray M. Core Clinical Cases in Obstetrics and Gynaecology: A Problem-Solving Approach. London: Holder Arnold; 2005. p. 152.  Back to cited text no. 2
Okonufua FE. Infertility in Sub-Saharan Africa. In: Okonufua F, Odunsi K, editors. Contemporary Obstetrics and Gynaecology for Developing Countries. Benin-City: Women's Health and Action Research Centre; 2003. p. 128-56.  Back to cited text no. 3
Spiegel PK. The first clinical X-ray made in America - 100 years. AJR Am J Roentgenol 1995;164:241-3.  Back to cited text no. 4
Shi BY, Alan DW. A review of the subject of medical x-ray examinations and metal based contrast agents. Chem Rev 1999;99:2353-78.  Back to cited text no. 5
Baramki TA. Hysterosalpingography. Fertil Steril 2005;83:1595-606.  Back to cited text no. 6
Takeda S, Morioka I, Miyashita K, Okumura A, Yoshida Y, Matsumoto K. Age variation in the upper limit of hearing. Eur J Appl Physiol Occup Physiol 1992;65:403-8.  Back to cited text no. 7
Hangiandreou NJ. AAPM/RSNA physics tutorial for residents. Topics in US: B-mode US: Basic concepts and new technology. Radiographics 2003;23:1019-33.  Back to cited text no. 8
Donkol RH. Imaging in male-factor obstructive infertility. World J Radiol 2010;2:172-9.  Back to cited text no. 9
Wagenknecht LV, Becker H, Langendorff HM, Schäfer H. Vasography - Clinical and experimental investigations. Andrologia 1982;14:182-9.  Back to cited text no. 10
Bueschen AJ, Lockhart ME. Evolution of urological imaging. Int J Urol 2011;18:102-12.  Back to cited text no. 11
Hollingworth W, Todd CJ, Bell MI, Arafat Q, Girling S, Karia KR, et al. The diagnostic and therapeutic impact of MRI: An observational multi-centre study. Clin Radiol 2000;55:825-31.  Back to cited text no. 12


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