Ultrasound Causes of Female Infertility at the Fertilia Medical Clinic in Bamako

Aims: Infertility is a major problem in our current societies and the Fertilia medical clinic in Bamako is a center for medical assistance in procreation (MAP) where there is an increasingly growing demand for ultrasound. The

of our study was to investigate the ultrasound causes li kely to pre- vent the occurrence of pregnancy in a group of infertile and subfertile wo m- en. Subjects and Methods: This was a 5-year cross-sectional and prospective study, between January 2017 and January 2022, which involved 250 women wishing to become pregn ant (infertile or subfertile), who came for pelvic u l- trasound or follicular monitoring and who agreed to participate in our study. The parameters used were ultrasound reports including uterine, ovarian and tubal pathologies. It should be noted that in some cases no ultrasound cause of infertility was found. Data were entered and analyzed in SPSS. Results : 250 women were recruited into our. The average age was 32 years with extremes ranging from 17 to 51 years. 179 patients or 71.6% were between 17 and 35 years old. 139 patients or 55.6% had secondary infertility against 44.4% pr i- mary infertility. 202 patients or 80.8% had at least one ultrasound lesion and 48 patients or 19.2% had no significant ultrasound abnormality. The most represented ultrasound lesions were of uterine origin with 72.20%, 23.7% ovarian lesions and 04% tubal lesions. Uterine lesions were dominated by myomas, adenomyosis, endometrial polyps, uterine malformations and syn- echiae. As for ovarian lesions we noted cysts, polycystic ovary syndro me (PCOS), ovarian endometriosis, non -follicular ovaries and tubal ultrasound lesions showed unilateral or bilateral hydrosalpinx. Conclusion: In our study, ultrasound was an invaluable contribution to the diagnosis of the causes likely How to cite this paper: Dembele, M ., Kouma, A ., Guindo, I ., Berete, Z .C., Sano- go, S., N’diaye, M., Doumbia, B., Diarra, O., Traore, O ., Cisse, I ., N’Diaye, A .S., Dou- coure, B ., Yalcouye, Y ., Keita, A .D. and Sidibe, S. (2023) Ultrasound Causes of Female Infertility at the Fertilia Medical Clinic in Bamako. Open Journal of Medical Imaging, 13, 107-113. https://doi.org/10.4236/ojmi.2023.133011 Received: August 7, 2023 Accepted: August 27, 2023 Published: August 30, 2023 Copyright © 2023 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access M. Dembele et al. DOI: 10.4236/ojmi.2023.133011 108 Open Journal of Medical Imaging to explain subfertility and infertility in our respondents. She highlighted ut e- rine, ovarian and tubal lesions, some of which could be corrected and pre g- nancies ensued.

Ultrasound, Female Infertility, Myomas, Polycystic Ovaries, Hydrosalpinx 1. Introduction According to the World Health Organization (WHO), infertility is defined as the absence of conception after at least 12 months of normal, regular, complete and unprotected sexual intercourse [1]. It affects around 180 million people worl d- wide and around one in six couples face primary or secondary infertility [1] [2]. The rate of infertility varies from one country to another, ranging from 5 % to 8% in developed countries and from 5.8% to 44.2% in developing countries [3]. The woman is still considered the main culprit of marital infertility. Many women remain marginalized, even repudiated because of this confusion linked to ignorance of the etio-pathogenic data of marital infertility. It is a social drama experienced mainly by women in the African environment who are the first to be questioned [4]. The most effective imaging techniques in female infertility are endoscopy (hysteroscopy and laparoscopy) and MRI. Conventional imaging

such as hysterosalpingography (HSG), and transvaginal ultrasound (ETV) are classified as screening ex aminations [5]. But in black Africa, MRI is not widely available and expensive. ETV and HSG remain the only feasible means of imaging during the exploration of fema le infertility. [6]. The aim of our study was to show the role of this accessible and available imaging tool in the assessment of female infertility in a low -income country like Mali. Few studies have been carried out in our country on this subject, so our study will serve to shed light on many people on female infertility given the interest of the subject. Internationally many studies have been done on fem ale infertility but they are full of some shortcomings that we have tried to fill in our study. 2. Materials and Method This was a 5 -year cross-sectional and prospective study, between January 2017 and January 2022, which involved 250 women wishing to become pregnant (i n- fertile or subfertile), who came for pelvic ultrasound or follicular monitoring and who agreed to participate in our study. We gave ourselves a study duration of 5 years and all the patients who presented for ultrasound in a context of p ri- mary or secondary infertility at the time of our study and who agreed to partic i- pate in our study constituted the size of our sample, i.e. 250 patients. The par a- meters used were ultrasound reports including uterine, ovarian and tubal p a- thologies. It should be noted that in some cases no ultrasound cause of infertility M. Dembele et al. DOI: 10.4236/ojmi.2023.133011 109 Open Journal of Medical Imaging was found. Data were entered and analyzed in SPSS. 2.1. Exploration Techniques We used different types of ultrasound machines such as Voluson E8, Logic9 and Vivid3. The pelvic ultrasound was done in 95% of cases by the endovaginal route and generally on the second day of menstruation for cases of medically assisted procreation and randomly for other cases. 2.2. Data Processing and Analysis The data collected on the technical sheets were enter ed and analyzed using SPSS software. Spearman’s and Pearson’s correlation tests were used to determine the degree of significance during comparisons at the 5% level. 3. Results 250 women were recruited into our study. The average age was 32 years with ex- tremes ranging from 17 to 51 years. 179 patients or 71.6% were between 17 and 35 years old. 139 patients or 55.6% had secondary infertility against 44. 4% pri- mary infertility. 202 patients or 80.8% had at least one ultrasound lesion and 48 patients or 19.2% had no significant ultrasound abnormality. (Table 1 ) The most represented ultrasound lesions were of uterine origin with 72.20%, 23.7% ovarian lesions and 04% tubal lesions. (Table 2) Uterine lesions were dominated by myomas, adenomyosis, endometrial polyps, uterine malformations and sy n- echiae. (Table 3) As for ovarian lesions we noted cysts, polycystic ovary sy n- drome (PCOS), ovarian endometriosis, non -follicular ovaries and tubal ultr a- sound lesions showed unilateral or bilateral hydrosalpinx. (Table 4) 202 patients or 80.8% had at least one ultrasound lesion and 48 patients or 19.2% had no significant ultrasound abnormality. Uterine ultrasound lesions dominated with 72.20% of cases. Table 1 . Distribution of patients according to the presence of echographic anomaly. Ultrasound Lesions Number Percentage (%) YES 202 80.80 NO 48 19.20 TOTAL 250 100% Table 2 . Distribution of patients according to the origin of the ultrasound lesion. ULTRASOUND LESION LOCALISATION NUMBER PERCENTAGE (%) UTERINE 146 72.20 OVARIAN 48 23.70 TUBAL 8 4 TOTAL 202 100% M. Dembele et al. DOI: 10.4236/ojmi.2023.133011 110 Open Journal of Medical Imaging Table 3 . Distribution of patients by type of uterine abnormality. Ultrasound Abdbnormality Number Percentage (%) SINGLE MYOMA 28 19.17 MULTIPLE MYOMAS 85 58.21 ADENOMYOSIS 26 17.80 ENDOMETRIAL POLYP 5 3.42 UTERINE MALFORMATION 1 0.68 SYNECHIA 1 0.68 TOTAL 146 100% Table 4 . Distribution of patients by type of ovarian anomaly. Ultrasound Abnormality Number Percentage (%) SINGLE FUNCTIONAL CYST 8 16.66 BILATERAL FUNTIONAL CYST 5 10.41 POLYCYSTIC OVARIAN SYNDROME 29 60.41 ORGANIC CYST 1 02.08 OVARIAN ENDOMETRIOSIS 3 06.25 NON-FOLLICULAR OVARIES 2 04.16 TOTAL 48 100% The polymyomatous uterus was the most represented on the ultrasound, 58.21%, and almost all of these myomas were submucosal. Uterine myomatosis accounted for more than 77% of all uterine lesions observed, followed by ad e- nomyosis. Polycystic ovary syndrome (PCOS) was the most represented ovarian ultra- sound anomaly with just over 60%. In some cases , there were more than twenty follicles per ovary with cycle disorders, hirsutism and a deep voice, witness to a fairly pronounced androgenism. Tubal abnormalities were hydrosalpinx, 8 patients or 04%. Of the 8 pat ients, 5 had bilateral hydrosalpinx and 3 had unilateral hydrosalpinx. 4. Discussion 250 women were recruited into our study. The average age was 32 years with ex- tremes ranging from 17 to 51 years. 179 patients or 71.6% were between 17 and 35 years old. Th is result is similar to that of Tiemtore K. et al. [7] who found 63.64% of subfertile women in Ouagadougou in 2016. 139 patients or 55.6% had secondary infertility against 44.4% primary infertil- ity. This score is similar to that of Dembélé N. [8] who in 2021 had found 55.70% secondary infertility versus 44.30% primary infertility. In our study, ultrasound found abnormalities in 80.8% of respondents. Several M. Dembele et al. DOI: 10.4236/ojmi.2023.133011 111 Open Journal of Medical Imaging authors have reported similar figures [9] [10] [11]. This could be explained by the fact that ultrasound is the first-line examination in the infertility assessment. 72.20% of ultrasound abnormalities were of uterine origin. This score is above that of Shalev J. [12] who found 50.3% uterine causes and different from that of Tiemtore K. et al. [7] who found 67% lesions of rather ovarian origin. Myomas accounted for more than 77% of all causes of uterine origin. This figure is very close to that found by Gandji et al. [13] who found 76.8% of causes of infertility linked to myomas, especially submucosal. Polycystic ovary syndrome (PCOS) is the most represented ovarian ultra- sound anomaly with 60.41%. Biao et al. [14] reported similar results in their s e- ries in 2008 (61%). Many other authors have reported that the main etiology of infertility is related to an ovulation abnor mality such as polycystic ovary sy n- drome (PCOS). [15] [16] [17] [18]. (Figure 1 ) Tubal lesions were represented by hydrosalpinxes. They were not very repre- sentative in our study (04%). Camus E et al. [19] reported 06% of cases of h y- drosalpinx and determined its role in in vitro fertilization (IVF) failures and r e- duction in the rate of natural and induced pregnancies. (Figure 2 & Figure 3) Limits of the Study Since this is a prospective study, the frequency of female infertility would be un- derestimated in Bamako but also the causal diagnosis as well made difficult b e- cause of meager means paraclinical exploration. Figure 1. (a) Pelvic ultrasound by vaginal route on the 3rd day of menstruation with more than 16 follicles per ovary; (b) Polyfollicular ovary on the 8th day of stimulation: High risk of ovarian hyperstimulation. Figure 2. Functional ovarian cyst. M. Dembele et al. DOI: 10.4236/ojmi.2023.133011 112 Open Journal of Medical Imaging Figure 3. (a) Polymyomatous uterus with nuclei compressing the cavity line; (b) Left hy- drosalpinx. 5. Conclusion Ultrasound in the assessment of female infertility in our context has been really contributory because it has made it possible to diagnose uterine pathologies mostly resolved by polymyomectomy, ovarian pathologies marked by dysovulation treated by ovulation inducers and ovarian and finally tubal monitoring. Conflicts of Interest The authors declare no conflicts of interest regarding the publication of this p a- per.

[1] World Health Organization (WHO) (2020) Infertility. WHO, Geneva. https://www.who.int/fr/news-room/fact-sheets/detail/infertility [2] Le Goff, S., Lédée, N. and Bader, G. (2008) Obesity and Reproduction: Review of the Literature. Gynécologie Obstétrique & Fertilité, 36, 543-550. https://doi.org/10.1016/j.gyobfe.2008.03.005 [3] Meng, Q., Ren, A., Zhang, L., et al. (2015) Incidence of Infertility and Risk Factors for Impaired Fertility in Newly Married Couples in a Chi nese Population. Repro- ductive BioMedicine Online, 30, 92-100. https://doi.org/10.1016/j.rbmo.2014.10.002 [4] Sakande, J., Sandjon, L.O., Ouedraogo, C., Konyaole, E., Kabre, E. and Sawadogo, M. (2012) Female Hormonal Profile and Prognosis of the Response to Ovarian Sti- mulation during Medically Assisted Procreation: Experience from Burkina Faso. International Journal of Biological and Chemical Sciences, 6, 950-958. https://doi.org/10.4314/ijbcs.v6i3.4 [5] Ikechebelu, J.I., Eke, N.O., Eleje, G.U. and Umeobika, J.C. (2010) Comparism of the Diagnostic Accuracy of Laparoscopy with Dye Test and Hysterosalpingography in the Evaluation of Infertile Women in Nnewi, Nigeria. Tropical Journal of Laparo Endoscopy, 1, 39-44. [6] Kouamé, N., N’goan-Domoua, A.M., Konan, N., Sétchéou, A., Tra-Bi, O., N’gbesso, R.D. and Kéita, A.K. (2012) Contribution of Transvaginal Ultrasound Combined with Hysterosalpingography in the Etiological Research of Female Infertility in A b- idjan (Ivory Coast). African Journal of Reproductive Health, 16, 43-49. [7] Kambou, T. (2016) Ultrasound Etiologies of Female Infertility in Ouagadougou. [8] Nana, D. (2021) Pelvic Ultrasoun d and Hysterosalpingography in Etiological Re- search on Female Infertility at Somine Dolo Hospital in Mopti . Thesis Med., FMOS, M. Dembele et al. DOI: 10.4236/ojmi.2023.133011 113 Open Journal of Medical Imaging Bamako, 94 p. [9] Blanc, B., Zarka, V., Boubli, L. and Bautrant, E. (1992) Diagnostic Contribution of Explorations of the Female Genital Tract in a Sterility Assessment. Concept Fertil- sex, 20, 198-204. [10] Thurmond, A.S. (2003) Imaging of Female Infertility. Radiologic Clinics of North America, 41, 757-767. https://doi.org/10.1016/S0033-8389(03)00064-2 [11] Launay, S., Moisan, S., Partouche, A., Mestdagh, P., Rocourt, N. and Robert, Y. (2001) Female Infertility: Role of Ultrasound. Ultrasound in Medicine and Biology , 41, 459-472. [12] Shalev, J., Meizner , I., Bar -Hava, I., Dicker , D., Mashiach , R. and Ben-Rafael, Z. (2000) Predictive Value of Transvaginal Sonography Performed before Routine D i- agnostic Hysteroscopy for Evaluation of Infertility. Fertility and Sterility , 73, 412-417. https://doi.org/10.1016/S0015-0282(99)00533-6 [13] Gandji, S., Bankolé , H.S., Dougnon , T.V., Da Silva , J., Zannou , C. and Biaou, O. (2013) Occurrence of Tubal Obstructions in Women in Cotonou (Benin, Role of Bacteria). International Journal of Biological and Chemical Sciences, 7, 1338-1343. https://doi.org/10.4314/ijbcs.v7i3.39 [14] Biaou, O., Adisso, S., Hounsossou, H., Takpara, I., Gandji, S. and Padonou, J. (2008) Contribution of Ovarian Ultrasound in the Exploration of Female Infertility in B e- nin. Review CAMES-Series A, 6, 15-20. [15] Barillier, H. (2007) Current Management of Female Sterility in France. Thesis Doc- tor of Pharmacy, No. 4023, FMOS, Bamako. [16] Gianni, F. and Csilla, K. (1998) Evaluation and Treatment of the Infertile Couple. The Journal of Clinical Endocrinology & Metabolism, 83, 4177-4188. https://doi.org/10.1210/jc.83.12.4177 [17] Rezigua, H., Zouaghi, C., Bouguisen , S., Oueslati , H. and Marrakchi, H. (1994) Conjugal Sterility Analytical Study about 430 Cases. Medical Tunisia, 72, 681-685. [18] Ohl, J., Bettahar-Lebugle, K., Rongières, C. and Nisand, I. (2000) Role of Ultrasound in the Diagnosis of Female Infertility. Gynécologie Obstétrique & Fertilité , 28, 234-239. [19] Camus, E., Poncelet, C., Goffinet, F., Wainer, B., Merlet, F., Nisand, I. and Philippe, H.J. (1999) Pregnancy Rates after In-Vitro Fertilization in Cases of Tubal Infertility with and without Hydrosalpinx: A Meta- Analysis of Published Comparative St u- dies. Human Reproduction, 14, 1243-1249. https://doi.org/10.1093/humrep/14.5.1243