Endometrial ossification and infertility: the diagnostic value of different imaging techniques W. Ombelet, 1,2 M. Lauwers, 1 G. Verswijvel, 2 M. Grieten, 2 P. Hinoul, 1 G. Mestdagh 1 1 Department of Obstetrics and Gynecology, Ziekenhuizen Oost-Limburg, Schiepse Bos 6, 3600 Genk, Belgium 2 Department of Radiology, Ziekenhuizen Oost-Limburg, Genk, Belgium Receieved: 1 February 2003/Accepted: 18 February 2003 Abstract We present a case of longstanding secondary subfertility caused by endometrial ossification. Of all diagnostic tech- niques performed, magnetic resonance imaging and hys- terosalpingography did not detect the abnormality. Trans- vaginal ultrasound and computed tomography clearly showed the endometrial pathology. After successful op- erative hysteroscopy with removal of the osseous tissue, the patient became pregnant spontaneously within 2 months. Key words: Computed tomography—Endometrial ossi- fication—Hysterosalpingography—Hysteroscopy—In- fertility—Magnetic resonance imaging—Transvaginal ultrasound. The occurrence of cartilage or bony tissue in the endo- metrium is a rare condition. The first report of a piece of cartilage contiguous with the wolffian duct in a 14-cm fetus was made by Mayer in 1910 [1]. The first descrip- tion of endometrial cartilage was reported by Thaler in 1923 [2]. The common feature is a previous history of termination of pregnancy and retention of fetal bones [3–5]. Only a few cases of endometrial ossification can be explained by osseous metaplasia [6]. The clinical presen- tation may include abnormal vaginal bleeding or dis- charge, dysmenorrhea, pelvic pain, and infertility [7]. The relation between infertility and endometrial ossification was reported in fewer than 20 cases worldwide. This is the first case report on endometrial ossification in which five different diagnostic tools were judged on their abil- ities to correctly diagnose this unusual endometrial pa- thology. Case report A 30-year-old nullipara attended our infertility clinic with a 4-year history of secondary infertility. She mentioned a history of a voluntarily induced abortion 7 years previ- ously. The pregnancy was terminated at a gestational age of 17 weeks. The personal and family histories were noncontributory. After her menarche at age 13, she had regular menstrual cycles 27–30 days in length. Endocrine testing showed no abnormalities, and a postcoital test was normal. On hysterosalpingography (HSG), a uterus arc- uatus with normal tubal patency was visualized. No ab- normalities were found in the uterine cavity on HSG (Fig. 1). In the luteal phase of the cycle, a transvaginal ultra- sound was performed to rule out ovarian cysts and to evaluate the endometrial pattern. Ultrasound images showed a bright hyperechogenic band with posterior shadowing (Fig. 2). Because of the association of the history of a previous abortion and the typical hyperecho- genic area within the uterine cavity, a diagnostic hyster- oscopy was done and confirmed the diagnosis of endo- metrial ossification. At that stage, and in agreement with the couple (written informed consent) and the radiology department, it was decided to investigate the value of computed tomography and magnetic resonance imaging (MRI) in the diagnosis of patients with this rare endome- trial pathology. On MRI it was impossible to make the diagnosis of endometrial ossification (Fig. 3), whereas on computed tomography the area of endometrial ossifica- tion was easily visible (Fig. 4A,B). An infertility work-up of the male revealed moderate teratozoospermia, with 8% ideal forms when using strict criteria of sperm morphology [8]. An operative hysteroscopy was performed, and the bony fragment within the uterine cavity could be visual- ized (Fig. 5). The osseous fragment was removed with the resectoscope. Histology established the diagnosis of os- Correspondence to: W. Ombelet Abdom Imaging 28:893– 896 (2003) DOI: 10.1007/s00261-003-0046-6 Abdominal Imaging © Springer-Verlag New York Inc. 2003