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The Hysterosalpingogram (HSG)

What is a Hysterosalpingogram?

A hysterosalpingogram or HSG is an x-ray procedure performed to make sure that the fallopian tubes are open and that the shape of the uterine cavity is normal. It is an outpatient procedure that can be performed in less than 5 minutes. It is done after menses have ended, but before ovulation (between days 5-9 of the menstrual cycle).

It is one of three basic fertility tests ordered by your doctor. The other two tests are:

Measurement of progesterone level to make sure that ovulation is normal.
Male partner’s semen analysis to see if there are any sperm abnormalities.

Is the HSG procedure painful?

Few other fertility procedures raise your fear and anxiety level as does the HSG test. You may have already looked it up on the internet or heard from someone that the test is very painful. You can rest assure that having done thousands of painless HSG procedures for over 20 years, Dr. Peress will personally perform your HSG in a calm and reassuring setting to make sure your procedure is also pain free. To do this, Dr. Peress will prescribe a non steroidal, anti-inflammatory medication (Naproxen) and local anesthetic before beginning the procedure. In addition, Dr. Peress` gentle catheter placement and unique method of slowly filling the uterus with contrast dye will altogether make this test surprisingly uneventful. Many of South Florida’s gynecologists have been referring their patients to Dr. Peress, for pain-free HSG procedures.

Preparing for the HSG

Tell your doctor if you are or might be pregnant.
The HSG should not be performed if you currently have a pelvic infection.
You should inform the doctor if you are allergic to iodine dye or shellfish.
Talk to your doctor about the HSG test, how it is done, what are its risks and how the test will help with your treatment.
You will be asked to sign a consent form that says you agree to have the HSG test done, and that you fully understand the benefits, risks and complications of the procedure.

How is a Hysterosalpingogram done?

You will meet Doctor Peress at the x-ray room just before the procedure and you will have an oppurtunity to ask any last minute questions you may have. During the procedure, you will be positioned under a fluoroscope (a real-time x-ray imager) on a table. Doctor Peress will place a speculum in the vagina and cleanse the cervix with antiseptic solution. Local anesthetic will be given to make the procedure a little bit more comfortable. A special catheter device (cannula) is gently placed into the opening of the cervix. The uterus is gently filled with liquid containing iodine (contrast). The contrast then flows into the tubes, outlining their length, and spills out of their ends if they are open. Only abnormalities in the uterine cavity or fallopian tubes will be visible on a monitor screen.
You will be able to watch the procedure on the screen together with Doctor Peress who will explain to you what you are seeing. You will be informed of the test results immediately after the procedure is completed and Doctor Peress will address any questions or concerns you may have. After all your fertility tests are completed you will meet with the doctor to review the results and discuss your treatment options.

Normal HSG

The uterine cavity is the triangular structure filled with the contrast dye. The uterus is normal and both tubes are open.
Note the contrast fluid (dye) delineating the thin tubes extending from the uterus. The "cloudy" appearance at the end of the tubes indicates that dye has spilled out of the tubes, and that they are open.

Abnormal HSG – Blocked Tubes (hydrosalpinx)

No dye is flowing out of the end of either tube indicating that they are closed off at their ends. As contrast liquid flows into the tubes, it is unable to exit the tubes, causing them to distend with dye and become dilated. This type of tubal blockage is called distal tubal occlusion or "hydrosalpinx". It is most frequently caused by Pelvic Inflammatory Disease (PID).

Surgery to reopen the tubes is not effective because recurrent scarring and closure of the tube occur frequently after surgery. Pregnancy rates after surgery tend to be low with a significant risk of tubal or ectopic pregnancy.

IVF bypasses the need for tubal function and has replaced surgery for women with hydrosalpinx who want to conceive.

It is necessary, however, to remove the abnormal tubes prior to undergoing the IVF procedure, because inflammatory cells present in the tubal fluid can enter the uterine cavity and prevent implantation of the embryo during IVF. Removal of the tubes or salpingectomy can be accomplished by a minimally invasive outpatient Laparoscopic surgery.

Abnormal HSG – Proximal Tubal Occlusion (PTO)

The tube is blocked at a point where it is closest to the uterus. It is the narrowest part of the tube and consists of mostly muscle. Spasm of the tube muscle may occur during the HSG, especially if the procedure is unusually painful, preventing contrast dye from flowing into the tube. At other times, it is a mucus "plug" within the narrowest portion of the tube which prevents the x-ray dye from entering the tube (left illustration). In such cases, the tube can be opened utilizing a small wire which is inserted into the uterus and guided into the tube using x-rays (Fluoroscopic Tubal Cannulation). The procedure is successful 80% of the time. IVF, which bypasses the need for functional tubes, is advised when cannulation has not been successful.

Abnormal HSG – Uterine Fibroid

Note the dark shadow within the uterus, representing a fibroid tumor. Fibroids within the uterine cavity often cause infertility or miscarriages, pelvic pain and abnormal bleeding. Laparoscopic or Hysteroscopic surgery is sometimes necessary to remove the fibroids (myomectomy).

Abnormal HSG – Uterine Scar Tissue

Asherman's syndrome or intrauterine adhesions is characterized by the formation of scar tissue inside the uterus. The scar tissue is seen as irregular dark shadows within the white shadow outlining the uterine cavity (left photo top). This may result from D&C, uterine surgery or from an infection. The scar tissue has poor blood supply, is hostile to implantation of the embryo, and may cause infertility. If severe scarring (left photo bottom) is present within the uterine cavity, it may cause complete cessation of menses, or amenorrhea. If the menstrual tissue flow out of the uterus is blocked by scar tissue, it often back flows through the fallopian tubes into the abdominal cavity, a process that can cause endometriosis.

Abnormal HSG – uterine (endometrial) polyps

Polyps can grow within the uterine cavity. They are seen as darker shadows (arrows) within the uterine cavity. Their cause is not known, but they seem to grow in the presence of high estrogen levels. They may cause irregular or excessive menstrual bleeding, miscarriages, and infertility. The polyps can be removed by a minor procedure called hysteroscopic polypectomy.

Abnormal HSG – Uterine Septum (septate uterus)

The uterine cavity is divided by an elongated fibrous tissue or septum. It lacks adequate blood supply, and interferes with implantation. It is associated with a higher risk of premature labor and miscarriage. The appearance of the uterus when viewed through the laparoscope is indistinguishable from a normal uterus. On HSG, the septate uterus may be indistinguishable from the bicornuate uterus. The two conditions can be differentiated during laparoscopy or MRI test. The bicornuate uterus has a heart shaped configuration whereas the external configuration of the septate uterus is entirely normal.

Bicornuate uterus

A bicornuate uterus is another form of uterine congenital abnormality. The external appearance of the bicornuate uterus is heart shaped. The uterine cavity is made out of two elongated uterine horns instead of a normal unified triangular shaped uterine cavity. This anomaly is associated with a higher risk of kidney abnormalities, premature labor and miscarriages.

What are the risks of HSG?

An HSG is considered a very safe procedure. However, there are recognized complications which occur in less than 1% of the time.

Infection - the most serious complication of HSG. This usually occurs in the presence of previous tubal disease. In rare cases, infection can damage the fallopian tubes or necessitate their removal. A woman should call the doctor if she experiences increasing pain or a fever within one or two days of the HSG. An antibiotic is sometimes prescribed to individuals susceptible to infection.
There may be cramping during or following the HSG. This may be greatly reduced by taking medications used for menstrual cramps.
Fainting - Rarely happens but one may get light headed during or shortly after the procedure.
Radiation exposure - The risk from an HSG is very low, less than a kidney or bowel study. There have been no demonstrable ill effects from this radiation, even if conception occurred later in the same cycle.
Allergic reaction - Rarely, a woman may have an allergy to the iodine contrast used for the HSG procedure. She should inform the doctor if she is allergic to iodine, intravenous contrast dyes or seafood.

What to expect after the HSG

You can immediately resume normal activities, but you may be asked to refrain from intercourse for several days.
Spotting may commonly occur for a day or two after the HSG. Some of the dye will leak out of the vagina, so you may want to use sanitary napkins.
HSG may help you conceive because the flow of dye may force out a mucus plug from the tube or break through thin scar tissue.
If an abnormality is noted on the HSG, your doctor will discuss with you the steps necessary to correct the problem.

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