Friday, November 26, 2010

Causes of intertility in men and women:

Among the causes of infertility in women are diseases of the uterus and ovaries:
This middle aged lady has a very small uterus (called hypoplasia of the uterus). Such a uterus is incompatible with the ability to conceive and have a child. The ultrasound video clip below shows a sagittal (midline) section through the uterus. It was obtained via the transvaginal route. The vagina itself was sufficiently large enough to insert the transvaginal probe.
The inner lining of the uterine cavity- the endometrium appears markedly thinned, and again this is incompatible with conceiving a child. 

The ultrasound video clip below is a transverse section through the uterus of the same patient:
In men, similarly, absence of or hypoplasia (very small) of parts of the reproductive system can result in infertility:
This male patient underwent sonography of the prostate and seminal vesicles via the transrectal route:
Ultrasound video clip shows normal sized prostate-

Observe the TRUS video clip as we pan the probe from the upper most part of the prostate showing the clear absence of the seminal vesicles and the vas deferens (agenesis) on both sides. This type of congenital absence of an important part of the route through which sperms pass from the testes to the penile urethra will result in total absence of spermatozoa in the ejaculated semen. This condition is called a azoospermia in the male.

Other and more common causes of infertility in men-
Perhaps one of the commonest cause of male infertility is a condition called varicocele.
Here, there is a dilatation of the veins around the testes, inside the scrotum. These veins are called the Pampiniform veins, and are responsible for draining blood from the testes. Due to decreased efficiency of the draining process, these veins swell and blood collects within these vessels resulting in increased temperature within the scrotum and the testes. The testes then lose some of their spermatogenic (sperm producing) functions. Depending on the degree of varicocele (grade of varicocele), the man may suffer from infertility.  
Color Doppler Ultrasound can help in diagnosing this condition; see this link for more on this topic:
Diseases of the testes and the epididymis (a small structure next to the testis) can cause poor or impaired production of sperms. This can result in infertility. One such common condition is an inflammatory disease called orchitis and epididymo-orchitis. (see:
Another cause of impaired spermatogenesis (sperm formation) is chronic or past infection of the testes resulting in atrophy (shrinking) of the testes. This happens in mumps inflammation of the testes, a condition called mumps orchitis. See :
This condition causes decreased function of the testes with small shrunken testes. Atrophy of the testes is usually irreversible.
Another condition that involves another part of the male reproductive system is prostatitis or inflammation of the prostate. The prostate helps to form a bulk of the fluid in the semen. Inflammation of the prostate is common and can impair the production of semen and its release during ejaculation. This color Doppler video clip shows a severely inflamed prostate:

This prostate was visualized via the transrectal route. The color Doppler mode shows massively increased blood flow in the prostate (hyperemia), a hall mark of prostatitis. This condition of the prostate can be corrected to a large extent using medical treatment.

The above still color Doppler image shows the TRUS (transrectal ultrasound) view of the same prostate.

Sunday, November 07, 2010

Fibroids of the uterus (leiomyoma):

Fibroids are the commonest tumors of the uterus and have a reported incidence of at least 25 to 30 % in the female population. Uterine fibroids are benign tumors (lumps) of the uterine musculature (called smooth muscles) and have varying prognosis from slowly growing tumors to those that may actually regress (become smaller). A small percentage of fibroids of the uterus may actually undergo malignant transformation (become cancerous); these cancerous tumors are called leiomyosarcoma. Another aspect about a fibroid is that this uterine tumor may be single or it may be multiple.
What are the symptoms of a uterine fibroid?
The earliest symptoms of a fibroid can be pain the lower abdomen (the pelvis) of the woman (usually after the age of 30). The other symptoms of uterine fibroids include dysmenorrhea (pain during menses), increased frequency or amount of bleeding during menses (polymenorrhea or menorrhagia) and other menstrual abnormalities. Other symptoms include those produced by pressure of the fibroids of the uterus on the adjacent organs in the female pelvis including the urinary bladder (increased frequency of urination and obstructed urination). Pressure on the rectum may cause constipation in women where the uterine mass (tumor/ fibroid) arises from the posterior (back) of the uterus. Fibroids are also a common cause of infertility in women.
 So how does one diagnose fibroid of the uterus?
If a woman has one or more of the symptoms mentioned above, she should consult the doctor/ gynecologist immediately. Per abdominal examination (palpation) of the pelvis can sometimes help detect a relatively larger fibroid. In addition, a per vaginal examination may also help to detect a lump of the uterus. In any case, the safest and best method to diagnose a fibroid of the uterus is ultrasound examination. The sonologist or radiologist conducts a transabdominal examination of the pelvis (on a full bladder) to visualize the uterine mass. The uterine tumor is seen from various angles to determine its size, number, location and pressure effects on the adjacent bladder or rectum.
Here is some examples of what a uterine fibroid looks like on ultrasound imaging:
There are commonly three types of fibroid based on ultrasound imaging:
a) Intramural- the fibroid is within the wall of the uterus.
b) Subserosal- the fibroid is just below the outer covering serosa of the uterus.
c) Sub mucous- the fibroid is just below the inner lining of the uterus (the endometrium).

Image below shows multiple fibroids:

This ultrasound image shows a fibroid extending from the subserous to the intramural location of the uterus-

What does the sonologist or radiologist see in this ultrasound image of the subserosal fibroid? The uterine fibroid is pressing upon the anteriorly (front) located urinary bladder. The mass or tumor is located to the right side of the uterus and extends from the intramural to the subserosal location of the upper part of the uterus (called the fundus).
See another ultrasound picture of the same case:

The uterine fibroid also appears to compress upon the inner lining of the uterus (EM= endometrium).(FIB= fibroid; BL= bladder; UT= uterus). Thus this patient is likely to have a number of complaints- from bladder compression to irritation of the inner lining (endometrium) of the uterus with resultant menstrual problems.
Broad ligament fibroid:
In rare cases the uterine fibroids may be located to either side of the uterus- the so called broad ligament fibroids- see the ultrasound pictures/ ultrasound video clips of one such case of broad ligament fibroid:
The uterine tumor in this case is seen in the left broad ligament of the uterus. Such a broad ligament fibroid may interfere with the function of the left fallopian tube (the duct that transmits the ovum from the left ovary to the uterine cavity). Hence such a patient might have problems conceiving or may be infertile.
See this ultrasound video clip of the same case (left broad ligament fibroid):

Pedunculated fibroid:
The next case we shall discuss is another relatively rare entity called the pedunculated fibroid of the uterus. Here, the fibroid in the uterus is connected to the uterus by a short or sometimes long pedicle or stalk. See the ultrasound images of one such case of pedunculated fibroid of the uterus:

In this patient, the uterine fibroid is seen extending just above the fundus (top) of the uterus and is connected to it by a short stalk. It is almost like a floating tumor suspended from the main body - the uterus by a stalk or cord. Such pedunculated uterine fibroids can cause severe pain due to torsion of the uterine tumor mass (twisting of the stalk) resulting in cutting off of the blood supply to the tumor from the uterus.
Have a look at these ultrasound video clips of the pedunculated fibroid described above:

Such an event resulting in twisting of the stalk of the pedunculated fibroid can be a medical emergency and urgent surgery might be required to remove the mass immediately.

This color Doppler ultrasound video clip shows the stalk is very vascular (ie: a number of blood vessels are seen between the pedunculated uterine fibroid and the fundus of the uterus. For more details of the various other types of fibroids of the uterus and ultrasound images of each case, visit:

Case-2 (pedunculated fibroid of uterus):
This is another example of a large fibroid with a stalk connecting the tumor (6 x 7 cms.) to the fundus of uterus via a stalk or peduncle. The peduncle measures about 2 cms. in thickness. I managed to visualize the peduncle by applying pressure onto the area between the fibroid and the fundus of the uterus. See the ultrasound video below:

Color Doppler video clip (above) shows multiple blood vessels within the short and relatively thick pedicle connecting the fundus to the fibroid.
This is how the mass (fibroid) and pedicle appeared on still images (see below):

 Observe the presence of a second fibroid within the lower part of body of the uterus in these sagittal sections of the uterus. This fibroid appears intramural in location.
It is beyond the scope of this article to describe in detail the other methods of diagnosing tumors of the uterus. However, it must be added that CT (CAT) scan imaging and MR imaging can also offer additional information on  fibroids of the uterus, in certain cases.
For information on treatment of fibroid of the uterus visit:
Degenerative changes in fibroid:
This case of a large fibroid with a most unusual appearance:
This is a sagittal section of the huge mass in the uterus. Note the markedly inhomogenous appearance of the mass. The ultrasound video clip below shows a transverse section of the mass:

Now, the color doppler video of the tumor (fibroid) of the uterus:

For more images and details of this case see:

Multiple fibroids:
Uterine fibroids can very often be multiple. This middle aged lady has 3 fibroids seen in this sagittal section ultrasound video clip of the uterus:
Of these, the one labeled as (1)- towards the fundus, shows degenerative changes- it is hypoechoic, inhomogenous, suggesting possible cystic changes within it.
Another video clip shows the presence of all 3 fibroids in this uterus: