1. health and fitness
2. disease
3. infertility

MR Imaging
Infertility1
in Male
Rosaleen
B. Parsons,
MD
Andrea
M Fisher,
MD
Natan
Bar-Chama,
MD
Harold
A. Mitty,
MD
In patients
with male infertility,
endorectal
magnetic
resonance
(MR)
provides
high-resolution
images
of the prostate
gland and ejaculatory
apparatus.
The multiplanar
capability
of MR imaging
allows
production
of a detailed
map of the reproductive
tract for guiding
treatment.
Causes
of male infertility
can be classified
as congenital,
acquired,
infectious,
or hormonal.
Wolifian
duct abnormalities
include
agenesis
of
the kidney,
vas deferens,
or seminal
vesicle
and cysts of the vas deferens,
seminal
vesicle,
or urogenital
sinus-ejaculatory
duct. M#{252}llerian duct abnormalities
are less common
and consist
of mUllerian
duct cysts and
utricle
cysts. Cowper
duct cysts and peripheral-zone
prostatic
cysts are
acquired
causes
of male infertility.
Prostatitis,
an infectious
cause of male
infertility,
may mimic
carcinoma
on long repetition
time/echo
time images. A low testosterone
level is one of the hormonal
causes
of male infertility.
Pitfalls
in the interpretation
of MR images
can be avoided
by famiiarity
with normal
and abnormal
findings
in patients
with male infertilimaging
ity.
INTRODUCTION
.
Fifteen
percent
is usually
to
of couples
attributable
half
of the
ejaculatory
(US)
duct)
cases
and
is the
US
endo-
rectal
high-resolution
Abbreviation:
Gustave
ceived
print
RSNA,
spin
1997;
July
15,
requests
accurately
depict
(MR)
of the
the
the
has
gland
vas
(Fig
deferens
it
(2).
used
However,
tortuous
US
genital
noninvasive
tract.
nonis opCT
technique,
capability
adjacent
1).
tract,
commonly
multiplanar
and
(deferent
genital
tract.
A third
imaging,
prostate
male
most
a dilated,
ultrasound
deferens
apparatus
of the
are
capability.
with
vas
ejaculatory
reproductive
in close
of the
and
pro-
structures.
echo
system,
of Radiology
Pt, New
1996;
(CT)
found
imaging
of the
the
in conceiving
be
performed
of evaluating
male
multiplanar
resonance
be
stricture
the
can
abnormalities,
84.
147
-
Genitourinarv
system,
MR.
8.
12149
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Sterility
17:627-637
Departments
L. Levy
method
Difficulty
suspected,
can
tomography
not
(1).
factor
cannulation
of postprocedure
images
Genitourinary
RadloGraphics
the
lacks
magnetic
SE
terms:
may
and
infertile
a male
to opacify
investigating
and
are
is clinically
requires
traditional
computed
for
radiation
vides
From
and
dependent
involves
factor
material
a risk
techniques
erator
I
carries
States
however,
Vasography
and
vasography
Transrectal
a male
guidance
of contrast
and
invasive
When
injection
is invasive
United
sterility;
is performed.
fluoroscopic
Although
Index
(1).
apparatus
or
in the
to female
York,
revision
(R.B.P.,
NY 10029.
requested
A.M.F..
Presented
September
HAM.)
and
as a scientific
5 and
received
Urology
exhibit
December
(N.B.C.).
at the
26;
Mount
1995
RSNA
accepted
Sinai
Medical
scientific
1)cccmher
Center.
assembly.
3 1 . Address
One
Rere-
to R.B.P.
1997
627
Table 1
Embryologic
Tract
Origins
of the
Male
Embryologic
Structure
Permanent
Structures
Mesonephric
Wolffian
tubules
Efferent
duct
Knowledge
of the
pearances
of the
images
can
this
help
one
we
present
article,
of lesions
ian
include
duct
avoid
with
anomalies),
(Cowper
are
imaged
Our
(Signa;
GE
Medical
disposable
tum
and
In
mUllerduct
vesicle
coil
and
at-
in the
planes.
500/1
msec)
for
fast
The
and
(Fig
Three
paired
pathologic
and
forms
in the
bules
that
ducts
fetus:
enter
ducts.
and
4,000/i
(Fig
50
2).
fetal
the
the
development
3. Drawing
(lateral
view)
shows
a 5week-old
embryo.
A = pronephros,
B = mesonephros,
C
= wotffian
(mesonephric)
duct,
D = metanephros,
E = ureteric
bud, F = doaca, G = allantois.
(Adapted
and reprinted,
with permission,
from reference
3.)
of the
in understanding
features
organs
the
metanephros.
3rd
join
are
time
of male
in-
1).
excretory
in the
nephros,
is helpful
3) (Table
quentially
parameters
images
of the
tract
anatomic
fertility
secand
DEVELOPMENT
knowledge
genitourinary
a
Figure
U EMBRYOLOGIC
A basic
a
with
msec/echo
images
(SE)
is ad-
obtaining
sagittal,
time
A
rec-
contiguous
following
Ti-weighted
spin-echo
in the
image
axial,
2 (repetition
unit
of glucagon
4-mm-thick
acquired
coronal
wolffian
1 mg
localizer
coil,
are
MR
Wis).
is placed
After
Ti-weighted
used:
a 1 .5-T
Milwaukee,
intramuscularly.
phased-array
week
bilateral
cloaca
appear
pronephros,
The
pronephros
and
consists
pronephric
and
evolve
semesoThe
of iiiducts.
into
the
kidney,
generates.
The
Scientific
Exhibit
a temporary,
appears
as the
ureteric
buds
ducts)
branch
from
the
weeks.
These
buds
detach
nephric
U
mesonephros,
primitive
ducts,
628
duct.
IMAGING
with
Systems,
insufflated,
sagittal
tions
MR
endorecta!
ministered
The
paramesonephric
infectious
(seminal
OF
patients
the
the
Such
and
cysts),
called
features
infertility.
acquired
*Also
tatic utricle
Urinary
bladder,
prostate gland,
prostatic
utricle
sinus
entities.
U TECHNIQUE
for
male
MR
pitfalls.
prostatic
hormonal
on
imaging
(wotffian
and
ap-
tract
MR
congenital
(prostatitis),
abnormal
diagnostic
the
peripheral-zone
rophy)
and
reproductive
associated
lesions
and
normal
male
of epi-
ulatory
duct,
epididymis, appendix
of
epididymis
Appendix
of testis,
pros-
M#{252}llerian duct*
Urogenital
ductules
didymis
Renal
collecting
system,
ureter,
vas deferens,
seminal
vesicle,
ejac-
Figure
1.
Vasogram
obtained
to confirm
patency
of the vasa deferentia
(arrowhead)
shows
an opacifled right seminal
vesicle
(arrow).
The left seminal
vesicle
was not evaluated.
Genital
extend
blastemas.
caudally,
de-
(metanephric
wolifian
ducts
from
and
Each
functioning,
pronephros
bud
Volume
meet
the
the
eventually
17
at 5 fetal
wolffian
metabe-
Number
3
b.
a.
C-
Figure
2.
(a) Axial fast SE MR image
(4,000/140)
shows
peripheral
zone (arrow).
B = rectal
balloon,
C = prostatic
muscle,
N = neurovascular
bundle,
0 = obturator
internus
image
(5,500/147)
shows
the vasa deferentia
(arrows).
BL
age (5,500/147)
shows
the seminal
vesicles
(arrows).
(d)
the ejaculatory
ducts (arrows).
comes
a ureter
blastemas
form
and
collecting
the
metanephros
system,
while
the
or permanent
kidney.
The
wolifian
the
male
the
epididymis,
duct
internal
deferens,
ejaculatory
The
of the
fuse
ducts
grow
with
May-June
an
outgrowth
1997
into
appendix
of
epididymis,
duct,
seminal
vas
vesicle,
join
This
induced
weeks.
in the
of the
by
The
becomes
has
no
ducts
involute
factor,
which
cells
of the
testis.
m#{252}llerian duct
The
the
gland
utricle,
The
m#{252}llerian
to m#{252}llerian regres-
is secreted
The
by
the
appendix
Sertoli
of the
testis
is a
remnant.
urogenital
develops
prostate
prostatic
function.
secondary
sion
and
the
known
sinus
into
the
derives
arises
from
bladder
from
and
the
cloaca
urethra.
the
urethra
et al
U
The
(3-6).
mUllerian
midline,
urogenital
region
which
and
are
at 5 fetal
caudally,
matures
the
bladder.
m#{252}llerian ducts
wolffian
and
tract:
paradidymis,
hemitrigone
ducts
persists
genital
the central
prostate
gland (arrowhead)
and
capsule,
I = ischiorectal
fossa, L = levator
ani
muscle,
R = rectal
wall. (b) Axial fast SE MR
= urinary
bladder.
(c) Axial fast SE MR imAxial fast SE MR image
(5,500/147)
shows
and
sinus.
Parsons
RadioGraphics
U
629
Duct
Cyst
Deferens
of
inal
e
Figure
4.
Drawing
and periprostatic
reprinted,
with
erence
8.)
U CAUSES
shows
OF MALE
abnormalities
endorectal
MR
as congenital,
(Table
that
often
early
congenital
(before
the
ducts
and
ureteric
bud.
8 weeks
usually
may
Woiffian
and
Defects
cause
oc-
isolated
(7).
abnormalities
manifest
as prostatic
Lesions
Duct
normalities
are
Anomalies.
more
of the
vesicles,
Less
common
duct
cysts
cysts.
and
vas
include
deferens,
and
anomalies
and
-Wolifian
common
abnormalities
seminal
7 weeks)
wolifian
4).
Congenital
agenesis
abnorerrors
involve
(Fig
duct
or hormonal
and
urogenital
than
renal
absent
seminal
include
U
Scientific
duct
ab-
m#{252}llerian
Infertifity
agenesis,
or small
vesicle
cysts
(6).
ejaculatory
sinus-ejaculatory
Zinner
esis
duct
syndrome
with
is renal
ipsilateral
Unilateral
of the
Exhibit
of Male
Congenital
Woifflan
duct anomalies
Renal agenesis
or atrophy
Vas deferens
agenesis
or cyst
Seminal
vesicle
agenesis
or cyst
Ejaculatory
duct cyst
MUllerian
duct anomalies
Mflllerian
duct cyst
Utnicle
cyst
Acquired
Cowper
duct cyst
Peripheral-zone
prostatic
cyst
Infectious
Prostatitis
Hormonal
Seminal
vesicle
atrophy
teric
630
2
Causes
classified
Developmental
abnormalities
cysts
.
experience,
Table
with
be
infectious,
or m#{252}llerian duct
These
can
in gestation
after
wolffian
seen
severe
mUllerian
cumng
be
They
predominate.
occur
are
can
imaging.
In our
and
ref-
INFERTIliTY
acquired,
2).
malities
prostatic
cysts. (Adapted
permission,
from
Numerous
Vesicle
Cyst
renal
agenesis
population
(5).
bud
fails
tema
and
induce
ney.
There
genital
tract
which
are
to meet
the
is a high
or dysgen-
vesicle
is seen
It occurs
the
cysts
in about
when
the
of the
with
most
17
kid-
ipsilateral
common
abnormalities
Volume
ureblas-
development
vesicle
(9, iO).
0.1%
the
metanephric
association
anomalies,
seminal
agenesis
seminal
of
(Fig
Number
5).
3
b.
a.
d.
Figure
e.
Zinner
quence
(100/13.8)
topic,
blind-ending
ter (arrow)
entering
dilated
vas deferens
rograde
ending,
May-June
c.
5-
urethrogram
bifid ureter
1997
syndrome.
(a) Coronal
MR image
obtained
with a fast multiplanar
spoiled
gradient-echo
seshows
absence
of the right kidney.
(b) Sagittal
fast SE MR image (4,00()/147)
shows
an ccureter
(arrow).
(c) Sagittal
fast SE MR image
(4,000/147)
slightly
lateral
to b shows
the urea dilated
seminal
vesicle
(arrowheads).
(d) Sagittal
fast SE MR image
(4,0()0/147)
shows
a
(arrow).
(e) Sagittal
fast SE MR image
(4,000/147)
shows
a dilated
seminal
vesicle.
(I) Retof another
with ectopic
patient
with similar
examination
insertion
into a seminal
vesicle
results
cyst.
shows
left renal
Parsons
agenesis
Ct al
and
U
a blind-
RadioGraphics
U
631
6, 7. (6) Axial fast SE MR
image
(4,000/147)
shows
congenital
absence
of the vasa deferentia.
The
linear structures
of high signal intensity
anterior
to the prostate
gland are
vascular
and mimic
the vasa. The normal vasa are convoluted,
not linear.
(7) Coronal
fast SE MR image
(3,000/
1 30) shows
congenital
absence
of the
left seminal
vesicle
and vas deferens.
There
is a seminal
vesicle
cyst in an
atrophic
right seminal
vesicle
(arrow).
Arrowhead
indicates
where
the
vas deferens
should
enter the prosFigures
tate
gland.
6.
Unilateral
present
agenesis
in
(i 1). Bilateral
infertile
and
6).
may
be
seminal
than
but
i% of
cystic
fibro-
with
unilat-
seminal
vesicle
volume,
in width
spermatozoa
are
Urogenital
duct
and
ejaculatory
cysts
may
gland
are
defined
The
semen
and
absent
has
large
as smaller
is low
an acid
enter
The
Because
cysts,
These
Figure
8.
Axial fast
shows
a large, midline,
duct cyst.
are
the
sinus.
extend
(Fig
from
these
spermatozoa.
and
cysts
derived
urogenital
in
pH.
( 1 4 , i 5).
duct
cysts
(8,i6,i7)
in width.
or dysmotile
ducts
contain
tate
(13).
Hypo-
as smaller
7 mm
than
prostatic
both
extremely
defined
sinus-ejaculatory
midline
be
are
fructose,
7) semi-
(Fig
of infertility.
vesicles
lacks
wolffian
or absent
a cause
greater
seminal
7 mm
rare
have
vesicles
1 1 mm
Atrophic
than
in about
with
all patients
atrophic,
vesicles
plastic
is
males
(1 1).
Hypoplastic,
nal
is present
agenesis
abnormalities
deferens
normal
is associated
Almost
or bilateral
vas
of otherwise
agenesis
men
sis (1 2) (Fig
eral
of the
1%-7%
7.
beyond
the
can
pros-
8).
cysts
and
(1 8, i 9).
DuctAnomalies.
utricle
The
the
m#{252}llerian duct,
rives
cysts
-M#{252}llerian
are
m#{252}llerian duct
from
separate
entities
cyst
is derived
duct
and
ejaculatory
from
utricle
cysts
U
Scientific
Exhibit
whereas
a dilatation
these
cysts.
may
cause
M#{252}llerian duct
cysts
and
are
cyst
can
Large
de-
utricle.
be
urogenital
identical
sinus-
m#{252}llerian duct
and
obstruction.
occur
in i% of men
discovered
utricle
prostatic
entities
from
duct
cysts
the
of the
indistinguishable
newborns
632
(7,700/147)
ejaculatory
the
cysts
Radiographically,
M#{252}llerian
SE MR image
hemorrhagic
in 4%-5%
(20).
of male
Usually,
in infertile
men
Volume
17
the
in the
Number
3rd
3
Figures
(9a)
9, 10.
Coronal
fast SE MR
image
(3,000/126)
shows
a hemorrhagic
and debris-filled
mullerian duct cyst. (9b) Sagittal fast SE MR image
(5,000/126)
shows
the
hematocrit
effect
of
blood
within
the cyst.
(10) Axial (5,000/140)
(a) and coronal (3,000/
130) (b) fast SE MR images show
a utricle
cyst.
or 4th
decade
common
of life;
cause
in this
subgroup
anomalies
(2,2
are
cysts
not
communicate
When
are
large,
the
prostate
and
debris
Most
do
not
tract.
Both
May-June
the
most
cysts
obstruction
genital
spherical
with
extend
and
(Fig
cysts
and
intraprostatic
tract
the
prostatic
and
superolaterally
may
contain
can
researchers
m#{252}llerian duct
contain
(23,24).
Utricle
dias,
cysts
and
are
intersex
manifest
often
agenesis
above
cysts,
utricle
cysts
prostate
gland.
the
prostatic
(Fig
10).
do
They
urethra
an increased
in the
associated
disorders,
renal
whether
that
with
carcinoma
lateral
spermatozoa
believe
associated
urethra.
hemorrhage
9). It is debatable
communicate
1997
are
prostatic
of life
they
(16)
(2 1 ,22).
are
duct
1). Associated
gland
m#{252}llerian duct
cysts
cysts
rare.
The
do
such
of ejaculatory
rate
first
2 decades
with
hypospa-
cryptorchidism,
(8).
Unlike
not
extend
or ipsi-
m#{252}llerian duct
beyond
communicate
and
contain
of
freely
the
with
spermatozoa
these
with
the
genital
cysts
and
utricle
Parsons
et a!
U
RadioGraphics
U
633
11.
12a.
Figures
11, 12.
(11)
Retrograde
urethrogram
retrograde
filling of the Cowper
glands
(arrows).
blood
within
a Cowper
duct cyst (arrow).
(12b)
per duct cyst (arrow).
P = prostate
gland.
.
Acquired
Lesions
Cowper
(bulbourethral)
The
accessory
Bartholin
tion,
the
rial
cant
organs
glands
in females.
Cowper
that
for
the
the
drains
into
the
2.3%
the
(28).
structed
form
of prenatal
and
early
to urinary
obstruction
been
have
trauma
duct
large
retention
(29-34).
In adults,
(26,28,35).
Most
such
cysts
are
however,
large
cysts
may
cause
including
discharge,
and
coronal
the urogenital
(Fig 12).
Acquired
peripherally
as parasitic
be
prostate
cysts
located
cysts.
cysts
or
asymp-
helpful
Sagittal
are
smooth-walled,
are
categorized
with
noma,
and
do
communicate
not
contain
carci-
The
creases
with
U
Scientific
Exhibit
(4,000/147)
found
prostatic
retention
left peripheral
zone.
cysts
retention
spermatozoa
with
age,
prostatic
(Fig
with
the
1 3). These
genital
of prostatic
however,
benign
cysts
cysts
tract
or
(8,36).
pathogenesis
is unknown;
634
Axial fast SE MR image
in identifying
of these
associated
13.
shows
an incidentally
cyst (arrow)
in the
urethral
origin
They
Figure
urinary
bloody
dribbling.
can
diaphragm
cysts,
to infection
hematuria,
postvoiding
images
cases
secondary
due
symptoms
and
obSeveral
occur
tomatic;
cysts
in an
lesions
death
from
1 1).
rare;
become
postnatal
reported
(Fig
are
cysts.
lies
duct
of such
can
retention
cysts
gland
(25-27)
glands
ducts
lubri-
The
urethra
mate-
and
main
prevalence
The
and
Cowper
The
Cowper
ejacula-
a mucoid
diaphragm.
bulbar
study,
was
before
milieu
spermatozoa.
of the
autopsy
Just
an alkaline
paired
to the
secrete
urogenital
Lesions
are
analogous
glands
provides
within
glands
sexual
12b.
shows
an anterior
urethral
stricture
(arrowhead)
and
(12a)
Axial fast SE MR image
(4,000/147)
shows
Sagittal
fast SE MR image
(4,000/147)
shows
a Cow-
and
their
they
retention
frequency
are
seen
hypertrophy
Volume
in patients
(37).
17
cysts
inInfer-
Number
3
14.
15.
Figures
14, 15
(14) Coronal
fast SE MR image
(4,000/1
30) shows
prostatitis.
peripheral
gland demonstrates
diffuse
decreased
signal intensity
(arrow).
(15)
fast SE MR image
(5,500/147)
shows
tuberculous
prostatitis.
Diffuse,
abnormal
signal intensity is present in the peripheral zone (arrow).
prostatitis
appear
malities
in the
guishable
as low-signal-intensity
peripheral
from
(39,40)
(Fig
vesicles
have
rial
The
Axial
low
the
14).
been
usually
age
Primary
common;
can
of carcinoma
cause
seminal
of bacte-
infertility
(Fig
affects
(41).
1 5) is rare.
persons
20-40
tuberculous
secondary
indistin-
in cases
prostatitis
infection
are
or atrophic
identified
which
Tuberculous
abnor-
that
abnormalities
Stenotic
prostatitis,
(42).
zone
The
years
prostatitis
infection
develops
passage
of infected
urine
through
urethra.
Ejaculatory
duct
strictures
of
is unafter
the
prostatic
can
develop
(21).
I
Figure
16.
Axial fast
shows
atrophic
seminal
ary to a low testosterone
Hormonal
The
SE MR image
(4,000/138)
vesicles
(arrows)
secondlevel.
nificant
which
is produced
cells,
have
prevalence
trol
been
of retention
patients
found
cysts
to have
than
a higher
fertile
con-
(2).
Infectious
Prostatitis
gland.
The
however,
inflammation
causes
of prostatitis
nonbacterial
(38).
On
ages,
chronic
May-June
long
of the
are
causes
for
by the
(43).
A low
testosterone
causes
of male
testosterone
tion
Kansas
of luteinizing
City,
can
Mo),
vesicle
level
(Fig
improved
Marion
which
se-
is one
infertility
be
(Clomid;
Tesprostate
of seminal
levels
citrate
is the
Leydig
spermatogenesis,
cretions
Dow,
gland,
synthesis.
production
hormonal
a sig-
of
16).
with
Merrell
induces
produc-
hormone.
predominate
repetition
time/echo
prostatitis
and
1997
prostate
numerous;
pituitary
is produced
is required
clomiphene
is acute
in the
which
plays
hormone,
of testosterone
and
the
Lesions
patient
Luteinizing
growth,
Low
.
of the
in fertility.
regulator
tosterone,
patients
status
role
major
tile
Lesions
hormonal
time
MR
im-
granulomatous
Parsons
Ct
al
U
RadioGraphics
U
635
U CONCLUSIONS
MR
imaging
place
transrectal
patients
be
whom
We
for
multiplanar
selected
in identifying
and
ureters
the
extent
vas
deferens,
ages
can
and
serve
ACknowledgments:
for help
MR
7.
in
definithe
beneficial
paths
of ectopic,
and
quantify-
seminal
vesicle,
gland
(44).
MR im-
map”
for
guiding
interven-
8.
9.
procedures.
We thank
in the
of
of the
or corrective
re-
imaging
found
imaging
in detecting
“
not
have
the
prostate
as a
diagnostic
Gail Aguilar
script.
tracing
not
evaluation
US are
of MR
of disease
and
will
patients
investigators
capability
ing
initial
of transrectal
other
tract
Endorectal
reserved
and
tortuous
genital
infertility.
results
tive.
male
US in the
with
should
tional
6.
of the
Gifty
preparation
Mensah
of the
and
manu-
10.
I 1.
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