The Hysterosalpingogram (HSG)
What is a Hysterosalpingogram?
The Hysterosalpingogram (HSG) is an office x-ray procedure performed to find out if there are any uterine or tubal abnormalities. The procedure is completed in less than 5 minutes.
It is one of three simple fertility tests to find out what the problem is. The other two tests are:
- Hormone tests and pelvic ultrasound.
- Semen analysis.
When is the test done?
The test is performed 5-9 days after your menstrual period begins.
Is the HSG procedure painful?
Few other fertility procedures raise the fear and anxiety levels 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 25 years, Dr. Peress will personally perform your HSG in a calm and reassuring setting to make sure your procedure is also pain free. You will be prescribed a non steroidal, anti-inflammatory medication (Naproxen) and an antibiotic. In addition, Dr. Peress` gentle catheter placement and unique method of slowly filling the uterus with contrast dye will 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. A pregnancy test will be performed before your test to confirm that you are not 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 the HSG done?
You will meet Doctor Peress at the x-ray room just before the procedure and you will have an opportunity to ask any last minute questions you may have.
During the procedure, you will be positioned on a table under a fluoroscope (a real-time x-ray imager). Doctor Peress will place a speculum in the vagina and cleanse the cervix with antiseptic solution.
A special soft catheter) is gently inserted into the uterine cavity. Liquid containing iodine (contrast) is slowly injected into the uterus. The contrast liquid then flows into the tubes and spills out of their ends into the abdominal cavity confirming that the tubes are open.
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.
What is a normal HSG?
As the contrast liquid is injected into the uterus, the normal triangular shaped uterine cavity is readily recognized (Fig. 1). The x-ray liquid then enters the fallopian tubes (Fig. 2). If there are no abnormalities, the liquid contrast travels through the delicate fallopian tubes and spills into the abdominal cavity. The “cloudy” collection of contrast liquid outside the fallopian tubes (Fig. 3) confirms that the tubes are open.
fig. 1fig. 2fig. 3
The two most common types of tubal blockage are:
- Distal tubal occlusion (hydrosalpinx) when the tubes are blocked off at their ends.
- Proximal tubal occlusion (PTO) when the tubes are blocked at a point where they closest to the uterus.
1. Distal tubal occlusion (hydrosalpinx)
The tubal x-ray test demonstrates that the fallopian tubes are closed off at their ends. It is most frequently caused by pelvic inflammatory disease (PID).
The contrast liquid flows into a normal uterine cavity and into the tubes (Fig. 4), but does not exit the tubes because they are closed off at their ends (Fig. 5). The more liquid enters the tubes the more swollen they get (Fig. 6).
Surgery to reopen the tubes is not very effective because recurrent scarring and closure of the tube occurs quite frequently after surgery. Pregnancy rates after surgery, especially in severe cases, tend to be low with a significant risk of tubal pregnancy (ectopic pregnancy). IVF has, for the most part, replaced reconstructive tubal surgery for women with hydrosalpinx who want to conceive. It is necessary 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. Removal of the tubes or salpingectomy is accomplished by a minimally invasive outpatient Laparoscopic surgery.
fig. 4fig. 5fig. 6
2. Proximal tubal occlusion (PTO)
The tubes are not visualized during the test because the x-ray liquid injected into the uterus can not enter the fallopian tubes (arrows in Fig. 7). In such cases, the tube can be opened utilizing a small guide wire and a catheter (Fig. 8) inserted through the cervix and guided into the tube during the x-ray procedure (Fluoroscopic Tubal Cannulation). Contrast fluid is injected through the catheter flows out of the tube confirming that the tube is now open (Fig. 9). The procedure is successful 90% of the time. IVF, is advised when cannulation has not been successful.
fig. 7fig. 8fig. 9
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 utilized to remove the fibroids (myomectomy).
Intrauterine adhesions (scar tissue) inside the uterus are seen as irregular dark shadows (white arrows) within the triangular shaped uterine cavity. This may result from a D&C, uterine surgery or from an infection. The scar tissue has poor blood supply and is hostile to implantation of the embryo. When the scar tissue is severe enough, it may cause complete cessation of menses, or amenorrhea (Asherman’s syndrome).
Polyps can grow within the uterine cavity. They are seen as darker shadows (white 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
- Uterine Septum (septate uterus)
The uterine cavity is divided by an elongated fibrous tissue or septum. The septum lacks adequate blood supply and this may prevent embryo implantation. It is associated with a higher risk of premature labor and miscarriage. The external shape of the uterus when viewed through the laparoscope is indistinguishable from a normal uterus. The uterus is externally unified.
A bicornuate uterus is another form of uterine congenital abnormality. As in the case of a septate uterus, the uterine cavity is divided into two elongated uterine horns instead of the normal unified triangular shaped uterine cavity. The external appearance of the bicornuate uterus however is also heart shaped. The two conditions can be differentiated by 3D ultrasound, MRI test or hysteroscopy.
This anomaly is associated with a higher risk of kidney abnormalities, premature labor and miscarriages.
In summary, the bicornuate uterus has a heart shaped configuration both internally and externally, whereas the septate uterus is heart shaped internally only, while, externally, it is indistinguishable from the normal uterus.
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. The reason for this is that the flow of x-ray dye into the fallopian tubes can flush away mucus plugs or minor scar tissue which may interfere with normal tubal function.
- If an abnormality is noted on the HSG, your doctor will discuss with you the steps necessary to correct the problem.