Female Infertility

Variant: 1 Adult 50 years of age or younger. Female infertility. Evaluation of uterus and ovaries. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US pelvis transabdominal	Usually Appropriate	O
US pelvis transabdominal and US pelvis transvaginal	Usually Appropriate	O
US pelvis transvaginal	Usually Appropriate	O
MRI pelvis without and with IV contrast	May Be Appropriate	O
MRI pelvis without IV contrast	May Be Appropriate	O

Variant: 2 Adult 50 years of age or younger. Female infertility. Clinical features or history of polycystic ovary syndrome. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US pelvis transabdominal and US pelvis transvaginal	Usually Appropriate	O
US pelvis transvaginal	Usually Appropriate	O
US pelvis transabdominal	May Be Appropriate	O
MRI pelvis without and with IV contrast	May Be Appropriate	O
MRI pelvis without IV contrast	May Be Appropriate	O

Variant: 3 Adult 50 years of age or younger. Female infertility. Evaluation of the fallopian tubes. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US pelvis transvaginal	Usually Appropriate	O
US sonohysterography with tubal contrast agent	Usually Appropriate	O
Fluoroscopy hysterosalpingography	Usually Appropriate	☢☢
US pelvis transabdominal	May Be Appropriate	O
US pelvis transabdominal and US pelvis transvaginal	May Be Appropriate (Disagreement)	O
US sonohysterography	May Be Appropriate (Disagreement)	O
MRI pelvis without and with IV contrast	May Be Appropriate	O
MRI pelvis without IV contrast	May Be Appropriate	O

Panel Members

Wendaline VanBuren, MD^a; Myra K. Feldman, MD^b; Esma A. Akin, MD^c; Adrian A. Dawkins, MD^d; Lisa Po-Lan Jones, MD^e; Kira Melamud, MD^f; Krupa K. Patel-Lippmann, MD^g; Gary M. Plant, MD^h; Kimberly L. Shampain, MDⁱ; Belinda J. Yauger, MD^j; Ashish P. Wasnik, MD^k.

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (ie, only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (ie, more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

Discussion of Procedures by Variant

Variant 1: Adult 50 years of age or younger. Female infertility. Evaluation of uterus and ovaries. Initial imaging.

Variant 1: Adult 50 years of age or younger. Female infertility. Evaluation of uterus and ovaries. Initial imaging.
A. MRI pelvis without and with IV contrast

Variant 1: Adult 50 years of age or younger. Female infertility. Evaluation of uterus and ovaries. Initial imaging.
B. MRI pelvis without IV contrast

Variant 1: Adult 50 years of age or younger. Female infertility. Evaluation of uterus and ovaries. Initial imaging.
C. US pelvis transabdominal

Variant 1: Adult 50 years of age or younger. Female infertility. Evaluation of uterus and ovaries. Initial imaging.
D. US pelvis transabdominal and US pelvis transvaginal

Variant 1: Adult 50 years of age or younger. Female infertility. Evaluation of uterus and ovaries. Initial imaging.
E. US pelvis transvaginal

Variant 2: Adult 50 years of age or younger. Female infertility. Clinical features or history of polycystic ovary syndrome. Initial imaging.

Variant 2: Adult 50 years of age or younger. Female infertility. Clinical features or history of polycystic ovary syndrome. Initial imaging.
A. MRI pelvis without and with IV contrast

Variant 2: Adult 50 years of age or younger. Female infertility. Clinical features or history of polycystic ovary syndrome. Initial imaging.
B. MRI pelvis without IV contrast

Variant 2: Adult 50 years of age or younger. Female infertility. Clinical features or history of polycystic ovary syndrome. Initial imaging.
C. US pelvis transabdominal

Variant 2: Adult 50 years of age or younger. Female infertility. Clinical features or history of polycystic ovary syndrome. Initial imaging.
D. US pelvis transabdominal and US pelvis transvaginal

Variant 2: Adult 50 years of age or younger. Female infertility. Clinical features or history of polycystic ovary syndrome. Initial imaging.
E. US pelvis transvaginal

Variant 3: Adult 50 years of age or younger. Female infertility. Evaluation of the fallopian tubes. Initial imaging.

Variant 3: Adult 50 years of age or younger. Female infertility. Evaluation of the fallopian tubes. Initial imaging.
A. Fluoroscopy hysterosalpingography

Variant 3: Adult 50 years of age or younger. Female infertility. Evaluation of the fallopian tubes. Initial imaging.
B. MRI pelvis without and with IV contrast

Variant 3: Adult 50 years of age or younger. Female infertility. Evaluation of the fallopian tubes. Initial imaging.
C. MRI pelvis without IV contrast

Variant 3: Adult 50 years of age or younger. Female infertility. Evaluation of the fallopian tubes. Initial imaging.
D. US pelvis transabdominal

Variant 3: Adult 50 years of age or younger. Female infertility. Evaluation of the fallopian tubes. Initial imaging.
E. US pelvis transabdominal and US pelvis transvaginal

Variant 3: Adult 50 years of age or younger. Female infertility. Evaluation of the fallopian tubes. Initial imaging.
F. US pelvis transvaginal

Variant 3: Adult 50 years of age or younger. Female infertility. Evaluation of the fallopian tubes. Initial imaging.
G. US sonohysterography

Variant 3: Adult 50 years of age or younger. Female infertility. Evaluation of the fallopian tubes. Initial imaging.
H. US sonohysterography with tubal contrast agent

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

References

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.