1. MALE INFERTILITY DR.KANNAN JUNIOR CONSLTANT DEPT OF RADIOLOGY &IMAGING KMCH

7.  Definition: 1 yr unprotected coitus without conception  10-15% couples affected  Etiology Couples: ○ 35% Tubal and pelvic pathology ○ 35 % Male problems ○ 15% Ovulatory dysfunction ○ 10% Unexplained ○ 5% unusual causes

8. Male Infertility 1. Production – Hypothalamus Congenital abnormalities of hypothalamus – e.g. Kallman’s syndrome Starvation, stress or severe illness Tumors (craniopharyngioma, metastatic tumor) Head injury Inflammation (sarcoidosis) Infection (tuberculosis) Drugs: marijuana,

9. Male Infertility 1. Production: – Pituitary Endocrine: thyroid, prolactin Tumors Inflammation: sarcoidosis, meningitis Infiltration Infarction Trauma/XRT Drugs: anabolic steroids

10. Male Infertility Production: – Testes: Congenital: Klinefelters (XYY), developmental disorders Disorders of gonadal steroidgenesis Infection: chlamydia, prostatitis, mumps orchitis Autoimmune Cryptorchidism Tumors; chemo/XRT Drugs / alcohol Vascular: testicular torsion

11. Male Infertility Delivery: Impotence/Ejaculation ○ Neurogenic: medications (α-blockers, methyldopa) ○ Endocrine: diabetes ○ Congenital: absence vas deferens (CF) ○ Genetic: cystic fibrosis ○ Primary ciliary dyskinesia: Kartagener syndrome ○ Hypospadia ○ Vasectomy

13. Causes of Male Infertifity Congenital Woifflan duct anomalies Renal agenesis or atrophy Vas deferens agenesis or cyst Seminal vesicle agenesis or cyst Ejaculatory duct cyst MUllerian duct anomalies Mulllerian duct cyst Utricle cyst Acquired Cowper duct cyst Peripheral-zone prostatic cyst Infectious Prostatitis Hormonal Seminal vesicle atrophy

14. Classification of obstructive azoospermias Epididymal obstruction Congenital Idiopathic epididymal obstruction Acquired Post-infective (epididymitis) Post-Surgical (epididymal cysts) Vas Deferens obstruction Congenital Congenital absence ofthe vas deferens Acquired Post vasectomy Post-surgical (hernia, scrotal surgery) Ejaculatory duct obstruction Congenital Prostatic cysts (Mu¨ llerian cysts) Acquired Post-surgical (bladder neck surgery) Post-infective

16. 26-year-old man with mildly elevated prolactin level. Coronal T1-weighted (A), coronal T2-weighted (B), and coronal (C) and sagittal (D) T1-weighted contrast-enhanced MR images show adenoma on the right side of the pituitary gland (arrow) that has a central area of fluid or necrosis.

17. MRI showing pituitary microadenoma (a, b) and stalk thickening (c)

18. Testis

19. Undescended testis

20. Testis volume

21. Testicular ruputure

22. Intratesticular hematomas

23. Testicular fracture.

24. 20-year-old man after scrotal trauma 1 week previously who presents with swelling of the scrotum. Transverse sonogram of the scrotum reveals a large amount of fluid surrounding the testicle, consistent with a hydrocele.

25. Testicular torsion

26. Microlithiasis Epididymal cyst

28. Seminoma

29. seminoma.

30. Nonseminomatous germ cell tumor

31. Heterogeneous testis with associated ectasia of the rete testis (short arrows) and dilated body of the epididymis (long arrow) in keeping with long-standing obstruction.

32. 26-year-old man with no palpable vas deferens on physical examination. Midline transverse sonogram of both testes shows dilatation of the rete testis in the medial aspect of each testis. These findings are typical of congenital bilateral absence of the vas deferens.

33. Ultrasound of both testes (sagittal images) demonstrates ectasia of the testes with formation of intratesticular cysts. These finding are suggestive of a seminal tract obstructive etiology which should be managed by epididymo-vasotomy.

34. Heterogeneous testis with ectasia of the rete testis in keeping with long standing obstruction.

35. Epididymis

36. Epididymo-orchitis

37. Scrotal ultrasound demonstrating thickening and enlargement of the epididymal body in a case of infective epididymitis.

38. Tuberculous epididymo-orchitis

39. Epididymal head abnormalities in obstructive azoospermia. (a) Longitudinal (left) and transverse (right) US images in a 31-year-old man with proved CBAVD show tubular ectasia (arrowheads) in the epididymal head.

40. Longitudinal testicular ultrasound demonstrating an a dilated, heterogeneous epididymis characteristic of the post vasectomy appearance.

41. Seminal vesicle &vas deferens

42. Agenesis of the SV

43. hypospermic male

44. Bilateral dilatation of the vas deferens on TRUS.

45. Bilateral thickening of the vas deferens on a transrectal ultrasound examination in keeping with vesiculitis (arrows).

46. Axial fast SE MR image shows atrophic seminal vesicles (arrows) secondary to a low testosterone level.

47. Zinner syndrome. Shows absence of the right kidney. (b) Sagittal fast SE MR image shows an ectopic, blind-ending ureter (arrow). (c) Sagittal fast SE MR image slightly lateral to b shows the ureter (arrow) entering a dilated seminal vesicle (arrowheads). (d) Sagittal fast SE MR image shows a dilated vas deferens (arrow). (e) Sagittal fast SE MR image shows a dilated seminal vesicle. (I) Retrograde urethrogram of another patient with similar examination results shows left renal agenesis and a blind ending, bifid ureter with ectopic insertion into a seminal vesicle cyst.

48. Zinner syndrome

50. absence of the vasa deferentia seminal vesicle cyst

52. Vasogram - non opacfied left seminal vesicle

53. Percutaneous right vasography in a patient with obstructed infertility shows complete obstruction of the ejaculatory duct with retention of the dye in the vas (arrowhead) and SV and non opacification of the urinary bladder.

54. A 33-year-old man with primary infertility. TRUS-guided contrast opacification of midline prostatic cyst shows the presence of a large cyst communicating on the right side with the right vas (arrowhead) and right SV. On the left side the cyst is communicating with a blind tubular structure (arrow), which proved to be an ectopic short ureter of a hypoplastic left kidney.

55. Ejaculatory ducts

56. A transrectal ultrasound examination demonstrating calcification within the ejaculatory duct (short arrow) with dilatation of the vas deferens proximally (long arrow).

57. TRUS demonstrating calcification within the ejaculatory duct with dilatation of the vas deferens proximally.

58. Twenty five years infertile man with azospermia. A: Multiple calculi within the SV and V; B: Bilateral echogenic calculi impacted within the ejaculatory ducts (arrows).

59. Obstruction of ejaculatory ducts

60. ejaculatory duct cyst.

61. long-standing obstruction.

62. Prostate

63. prostatitis

64. Prostatic cysts

65. Utricle cyst

67. A 29-year-old man with primary obstructive infertility. TRUS (upper image) and endorectal magnetic resonance imaging (middle image) show a well- defined midline urogenital cyst with intra-and extraprostatic components. TRUS-seminal vesiculography (lower image) shows the seminal vesicle is communicating with the urogenital cyst with non opacification of the urethra or urinary bladder denoting complete distal obstruction (N.B. the left vas and seminal vesicles were absent). Trans- urethral incision of the cyst lead to improvement of sperm count.

69. Mullerian duct cyst

70. Cowper duct cyst

71. Interventions

75. On grey scale imaging a varicocele is seen as serpiginous tubules posterior to the testis (a). Colour flow Doppler confirms flow within varicocele.

76. 33-year-old man with low sperm count undergoing evaluation for infertility. Sagittal sonograms of the superior aspect of the left hemiscrotum show multiple dilated peritesticular veins on color Doppler imaging (A) and an individual vein on gray-scale imaging (B) that measures 4.2 mm when Valsalva maneuver is used. These findings are compatible with a varicocele.

77. ( a) On grayscale imaging a varicocele is seen as serpiginous tubules inferior to the testis (arrow). (b) Colour flow Doppler confirms flow within the varicocele (arrow).

79. varicocoele

82. Testicular biopsies Testicular sperm aspiration Seminal vesicle aspiration

83. ERECTILE DYSFUNCTION

91. FLACCID STATE

92. Phase I

93. Phase II

94. Phase III

95. Phase IV

96. Phase V

97. Varient

98. Arterial insuffiency

102. Penile angiogrram

103. Conclusion Given the prevalence of male infertility, the radiologist's familiarity with its appropriate imaging workup and recognition of the commonly involved pathologic processes is critical. Imaging plays a key role in the evaluation of the hypospermic or azoospermic man. It can detect correctable abnormalities, which can lead to a successful conception. It can also reveal potentially life-threatening disorders in the course of an infertility evaluation.

104. THANK YOU

105. ROLE OF MRI IN SCROTAL LESIONS

106. Seminoma

107. Burnt-out seminoma

108. Tunica albuginea cyst

109. Intratesticular cyst

110. Dilated rete testis

111. Epidermoid inclusion cyst

112. Leydig cell hyperplasia

113. Adenomatoid tumor

114. Epididymal cystadenoma

115. Lipoma

116. Fibrous pseudotumor

117. THANK YOU

118. atrophic seminal vesicles

121. Prostatic retention cyst