Imaging of Infertility, Part 2: Hysterosalpingograms to Magnetic Resonance Imaging

Key points

Congenital causes: müllerian duct anomalies

Müllerian duct anomalies (MDAs) represent a complex spectrum of congenital abnormalities resulting from failed development of the müllerian ducts, which normally give rise to the uterus, cervix, fallopian tubes, and upper third of the vagina (Table 1). In keeping with the wide spectrum of anatomic appearances of MDAs, their presenting clinical features are also varied and include primary amenorrhea, endometriosis, spontaneous abortion, intrauterine growth restriction, and preterm labor.¹

Uterine agenesis or hypoplasia

Accounting for approximately 5% to 10% of all MDAs, early developmental failure of the müllerian ducts results in complete agenesis or hypoplasia of the uterus, cervix, fallopian tube, and upper vagina.¹⁵ A wide spectrum of findings can be seen with this entity, with the most extreme (and most common) form showing complete absence of the uterus, cervix, fallopian tubes, and upper vagina known as Mayer-Rokitansky-Küster-Hauser syndrome.¹¹ Because physiologic ovarian function is usually

Unicornuate uterus

Accounting for approximately 20% of all MDAs, complete or near-complete arrested development of 1 müllerian duct with normal development of the contralateral duct results in unicornuate uterus.¹⁵ There are 4 subtypes commonly described, which relate to the potential presence of a rudimentary horn (RH) and its associated features: (1) communicating cavitary RH, (2) noncommunicating cavitary RH, (3) noncavitary RH, and (4) no RH. Approximately half of the cases of unicornuate uterus show a

Uterus didelphys

Accounting for approximately 5% of all MDAs, complete failure of müllerian duct fusion results in a uterus didelphys in which each duct develops fully with duplication of the uterine horns, cervixes, and (in most cases) the proximal vagina. Duplication of the proximal vagina is often associated with a hemivaginal septum, which, if transversely oriented, can result in symptoms related to ipsilateral hemivaginal obstruction and hematometrocolpos.¹¹ As with other MDAs, this subtype is associated

Bicornuate uterus

Accounting for approximately 10% of all MDAs, incomplete fusion of the paired müllerian ducts results in a bicornuate uterus, which is thought to represent a milder spectrum of uterus didelphys.¹¹ This entity is characterized by 2 divergent uterine horns that are fused at the level of the lower uterine segment and can occur with a single cervix (unicollis) and duplicated cervixes (bicollis). Similar to uterus didelphys, bicornuate uterus is occasionally associated with the presence of a vaginal

Septate uterus

Accounting for approximately 55% of all MDAs, complete or partial failure of resorption of the uterovaginal septum results in a septate uterus.^35,36 The residual septum may be of variable length and composition, consisting of varying proportions of fibrous tissue and myometrium.^20,37 Rarely the septum can extend to the vagina, which then usually is longitudinal rather than transverse. Septate uterus is associated with the poorest reproductive outcomes, with a reported pregnancy loss up to 65%

Arcuate uterus

Often thought of as a normal variant, arcuate uterus represents the mildest MDA subtype and occurs in the setting of near-complete uterovaginal septal resorption, which results in a focal bulge at the level of the uterine internal fundal contour. Although clinical data are disparate, currently most clinicians agree that arcuate uterus is associated with minimal if any adverse reproductive outcomes.

Imaging of arcuate uterus depicts a normal external fundal contour with a broad-based smooth

Diethystilbusterol-exposed uterus

Diethystilbusterol (DES) is a nonsteroidal estrogen that was prescribed from the late 1940s until 1971 to prevent miscarriages in women with a history of poor reproductive outcomes. This medication was discontinued after adverse outcomes were discovered in the female infants who were exposed to the drug in utero, which included vaginal clear-cell carcinoma and uterine hypoplasia.⁴²

Although now more of historical interest (given the length of time since discontinuation), DES-exposed uteruses

Summary/what referring physicians need to know

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  Infertility is often a multifactorial medical condition requiring a comprehensive approach for diagnosis and treatment.

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  The imaging investigation of female infertility consists of a multimodality approach.

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  MR imaging and sometimes 3D US are the imaging examinations of choice when MDAs are suspected.

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  Hysterosalpingogram is the gold standard study to evaluate tubal patency, although hysterosalpingo contrast sonography is a promising imaging tool that is increasingly used.

Conflict of interest

The authors report no conflicts of interests concerning the materials, methods, or results in this article.