What is hysterosalpingography (HSG): why and how is it performed?

Hysterosalpingography (HSG) is a gynecological test used to study the structures of the uterine cavity and the Fallopian tubes, as well as their permeability. It is, therefore, a test for the study of female fertility.

Usually, patients who turn to assisted reproduction have a hysterosalpingography to check if there is any uterine or tubal factor that prevents pregnancy. This test is not dangerous, but many women fear it because of the discomfort it causes.

The different sections of this article have been assembled into the following table of contents.

Fertility tests

When a couple or woman with fertility problems visits a fertility clinic for the first time, a medical history will be carried out in which different aspects of their reproductive life are evaluated. For example, whether they have previous children, how long they have been trying to get pregnant, and so on.

Depending on the information collected, both men and women will then undergo a series of tests to analyze the state of their fertility.  One of the tests that is frequently ordered to check female fertility is hysterosalpingography.

In general, this diagnostic test is very feared by women because of the discomfort it causes and subsequent recovery. However, it can provide doctors with a lot of information about the causes of infertility and the possible treatment needed to achieve pregnancy.

First fertility test in women

Other medical tests that are requested along with the HSG are the ultrasound and the hormone profile, which provide information about the ovarian reserve and the woman's ovulatory capacity.

Definition of Hysterosalpingography

Hysterosalpingography is one of the main diagnostic tests to find out the possible causes of female sterility. This test involves taking an x-ray of the woman's uterus and fallopian tubes. To do this, the specialist uses a type of iodized contrast that is introduced through the cervix with the help of a cannula.

As the contrast fluid flows into the uterine cavity and tubes, the radiologist will take the necessary images using a special x-ray technique that allows internal organs to be seen in motion: fluoroscopy.

How is hysterosalpingography performed

Unlike ultrasound, hysterosalpingography is not routinely performed in gynecology practices until there is a specific indication for it.

Types of HSG

Today, there is an improved version of hysterosalpingography that allows this test to be performed in less time and with less discomfort for the patient.

This new variant is known as hysterosalpingosonography (HSSG) and, as the name suggests, uses ultrasound to obtain the images instead of X-rays, which is already a great advantage.

Types of hysterosalpingography

Furthermore, depending on the contrast medium used, the following types of HSSG are differentiated:

• HyCoSy: is short for Hysterosalpingo-Contrast-Sonography, a type of HSSG that uses saline or a galactose solution as contrast. This contrast is injected through the cervix and, through a transvaginal ultrasound, is followed through the uterus and fallopian tubes.
• HyFoSy: is short for Hysterosalpingo-Foam-Sonography, an even newer type of HSSG that does not use contrast agents. Instead, a foaming gel is injected vaginally that fills the uterine cavity and diffuses into the fallopian tubes, providing much clearer and sharper images via ultrasound.

Indications of the HSG

For fertilization and natural pregnancy to take place, the sperm ejaculated during intercourse need to reach the egg released by the woman's ovary in the Fallopian tube. The fertilized embryo from this union then travels through the Fallopian tube to the uterus, where it implants in the endometrium and begins gestation.

If there is a tubal obstruction that prevents contact between the egg and sperm in both Fallopian tubes, then obviously pregnancy cannot occur naturally until this obstruction is cleared.

Hysterosalpingography allows both the anatomical integrity of the female reproductive system and the functionality of the Fallopian tubes to be assessed, as it provides information on tubal patency.

Natural fertilization in the fallopian tubes

In short, hysterosalpingography is a great help in determining the cause of infertility and deciding which assisted reproduction technique has the greatest chance of success, either artificial insemination (AI) or in vitro fertilization (IVF).

Hysterosalpingography is also indicated for the study of women with menstrual disorders, pelvic pain, pelvic tumors, and congenital malformations. It can also be done to test the success of tubal ligation.

What alterations does HSG detect?

Once the hysterosalpingography is done, it is possible to check for abnormalities at the level of the cervix, the uterine cavity or the Fallopian tubes. Here are some examples:

In the cervix

cervical incompetence if the cervix is too narrow or wide, the cervix is duplicated in a possible uterus didelphys, elongated cervix, and so on.

In the uterus

structural abnormalities of the uterus (septua, unicornis or bicornuate uterus, etc.), fibroids and uterine polyps, adhesions in a possible Asherman's syndrome, adenomyosis, hypoplasia, etc.

In the Fallopian tubes

salpingitis, hydrosalpinx, endometriosis, blocked tubes, etc.

Alterations detected by HSG

All alterations affecting the Fallopian tubes can cause them to swell and become blocked.

How is hysterosalpingography done?

HSG is a test very similar to an x-ray, in which radiopaque contrast dye is injected into the cervix to view the anatomy of the cervix, uterus, and fallopian tubes through an x-ray machine.

Below, we will discuss all the details to be taken into account when performing a hysterosalpingogram, what it consists of, and how your recovery will be.

Preparation

It is important to make sure that the woman is not pregnant at the time of the hysterosalpingogram, as the x-rays would be harmful to the fetus.

Therefore, the following considerations are very important before doing this test, in addition to other recommendations:

• Performing HSG between days 8 and 10 of the menstrual cycle, when menstrual bleeding is already over and before ovulation occurs.
• Take a laxative or enema the night before or a few hours before the test to empty your bowels. This allows the uterus and tubes to be seen more clearly.
• There is no need to fast since no anesthesia will be administered. However, it is advisable not to eat any food in the previous hours.
• It is possible to take a painkiller earlier to reduce the discomfort of hysterosalpingography.
• A woman should not have this test if she has a genital infection. Her gynecologist may prescribe a pre and post HSG antibiotic to avoid this risk.

Recommendations for hysterosalpingography

There are other contraindications to hysterosalpingography apart from those already mentioned in this section, such as the following: pelvic inflammatory disease, inflammation, metrorrhagia (bleeding between periods), or in the case of having recently ingested a contrast for some other radiological study of the digestive system.

Procedure

Hysterosalpingography is a test that takes approximately 20-30 minutes and is very easy to perform by the medical specialist. In addition, this technique does not require anesthesia.

The placement of the woman will be the same as for a gynecological exam, placing her feet in stirrups, as if she were going to have a simple pap smear.

Once the patient is in the proper position, a speculum will be placed in the vagina so that the cervical area can be washed with a saline solution. Then, through a cannula that will be introduced through the cervix, the contrast dye will begin to be passed into the uterine cavity.

The x-ray machine will be positioned above the patient's abdomen and will take the necessary images.

Recovery after HSG

After hysterosalpingography, it is not necessary for the woman to rest, although it is also not advisable to do heavy activity during the rest of the day.

The patient may feel slight discomfort during the day of the hysterosalpingogram. If you have more severe abdominal pain, cramping, or other subsequent discomforts, your doctor may prescribe a drug such as buscapine to relieve the pain. It is also possible to have slight vaginal bleeding or brownish discharge during the days following HSG.

Advice after hysterosalpingography

In general, it is recommended that the patient continue with her normal life and follow any specific directions from the doctor.

Hysterosalpingography results

The interpretation of the results should be done by a specialist, who is usually the gynecologist who monitors the patient.

In the image obtained, the uterine cavity can be seen as an oval or inverted pear-shaped accumulation and, in addition, two thin lines coming out of the upper part that correspond to the Fallopian tubes.

With regard to tubal permeability, the results of the HSG are summarized as follows:

HSG Positive

indicates that the tubes are permeable and therefore contrast is seen to pass through the two tubes and be expelled into the abdominal cavity. Therefore, the patient does not present any alteration.

HSG Negative

Whether unilateral or bilateral, it means that one or both tubes are blocked and, as a consequence, do not allow contrast to pass through their structure, causing them to inflate. It is also possible that the Fallopian tubes may not be visible due to a tubal or uterine malformation.

HSG and blocked fallopian tubes

Choosing a fertility treatment

Based on the results obtained from the HSG, in addition to other medical tests, it will be possible to determine which infertility treatment is the most appropriate for attempting a pregnancy.

Artificial insemination

as long as the tubes are permeable, the seminal quality is good and the woman has a good ovarian reserve. In addition, the indicated age of the woman to do a successful AI is before the age of 36.

In vitro fertilization

is the right choice when the above requirements are not met, i.e. when the tubes are obstructed, the seminal quality is not optimal and the woman is over 36 years of age with the affected ovarian reserve.

Fertility treatment based on HSG result

Obviously, each particular case must be studied individually and the most appropriate technique must be recommended to the woman or the couple according to their possibilities.

Hysterosalpingography video

In the following video, Michelle Emblenton, a biochemist at inviTRA explains in detail what hysterosalpingography is:

FAQs from users

What are the recommendations prior to hysterosalpingography?

Hysterosalpingography is a radiological procedure that aims to assess the morphology of the uterine cavity, the contours of the endometrium and tubal patency, the latter factor being responsible for between 25 and 35% of the causes of infertility and a necessary aspect to know as part before an artificial insemination procedure.

As it is a somewhat invasive gynecological procedure, it is contraindicated to perform it if the patient has pelvic infection, but even in the absence of it, as a prophylactic measure, the administration of antibiotics is indicated the day or days prior to the study. Likewise, to avoid pain or discomfort after the procedure, it is recommended to take anti-inflammatory analgesic from the night before.

The procedure should be performed in the first half of the menstrual cycle (7 to 10 days after the onset of the last menstrual period) during the proliferative phase of the endometrium, which facilitates the interpretation of the image. In addition, it is recommended not to have unprotected sex in that cycle, which ensures that there is no ongoing pregnancy. Studies performed in the second phase of the cycle may lead to false results.

How is a Hysterosalpingogram performed?

A HSG is a type of x-ray examination that aims to examine the presence of pathologies in the uterine cavity, and well as tubal patency. It is recommended to evaluate potential causes of primary sterility. It involves inserting a cannula until the entrance of the uterus, through which a special radio-opaque contrast material dye is inserted. The contrast material dye will fill in the cavity and the tubes. Then, a series of x-rays will be done to detect potential abnormalities or blockages in the different structures. It is a simple procedure that is typically done in the first 10 days of the cycle. During its performance, the woman may feel period-like symptoms. Hospitalization is not required, and its duration ranges between 15 and 30 minutes approximately.

Can I get pregnant after hysterosalpingography?

Yes, in cases of mild tubal obstruction, the passage of liquid contrast through the tubes during hysterosalpingography may remove the obstruction. Therefore, pregnancy can be easily achieved after hysterosalpingography.

How much does hysterosalpingography cost?

The approximate price of hysterosalpingography is from $200 to approximately $900 depending on the fertility center. However, most insurances cover hysterosalpingography as it is a diagnostic test.

What is virtual hysterosalpingography?

Virtual hysterosalpingography is an advance over the conventional test, in which hysterosalpingography is performed by Multislice Computed Tomography, similar to the CT scan we are all familiar with. The advantages of this new technique are that it does not present any discomfort to the woman, it is non-invasive and, in addition, it offers more complete information with its images.

What are the risks of hysterosalpingography?

Although not very frequent, some complications that may arise as a result of hysterosalpingography are the following: allergic reaction to contrast (iodine), endometritis, salpingitis, perforation of the uterus, etc., in addition to the added risks of any test in which the patient is exposed to x-rays.

Can hysterosalpingography cause changes in premenstrual symptoms and/or menstruation?

The answer is no. No changes in the menstrual cycle should occur, as the ovaries are not compromised. However, some women do experience occasional premenstrual discomfort as a result of the use of contrast fluid.
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Is hysterosalpingography covered by Social Security?

If the woman is eligible for assisted reproduction treatment under the Social Security system, the cost of the hysterosalpingography will also be covered, as well as the other medical tests.

However, it is possible that there is a waiting list for the test and, when the time comes, the woman is not at the ideal time in her menstrual cycle. In that case, the woman can take a pregnancy test to prove that she is not pregnant.

Recommended reading

As we have discussed, the hysterosalpingography test is used to see if the Fallopian tubes are blocked. There can be several causes of tubal obstruction. In the following post, you can find more information about all of them: Blocked Fallopian tubes.

In the event of a positive HSG result, i.e. there are no apparent uterine or tubal problems in the woman, it will be possible to perform artificial insemination to attempt a pregnancy. If you want to learn more about this reproductive technique, we recommend reading the following article: What is AI?

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