How Is a Hysterosalpingography (HSG) Performed?

By BSc, MSc (embryologist), (embryologist), MD (gynecologist), BSc, MSc (embryologist) and (invitra staff).
Last Update: 06/23/2020

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 resort to assisted reproduction have to have hysterosalpingography to check if there is any uterine or tubal factor that prevents pregnancy. This test is much feared by women because of the discomfort it causes, but it is not dangerous.

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, etc.

Depending on the information collected, both men and women will then undergo a series of tests to analyze the state of their fertility. Tests that are ordered to check female fertility include, for example, hysterosalpingography.

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

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.

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.

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, it is necessary for the man's ejaculated sperm during intercourse to reach the egg expelled by the woman's ovary in a fallopian tube. The fertilized embryo from this union then travels through the fallopian tube to the uterus, where it implants in your endometrium and begins a 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, therefore, 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.

In short, hysterosalpingography helps a lot 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.

In assisted reproduction, like any medical treatment, it is necessary for you to trust the professionalism of the doctors and the clinic you choose.

This Tool generates you a personalized report with all information necessary about the treatment you will need. Besides, there is a list of clinics in your area which we have chosen based on our selection criteria with their budget plan included. Last but not least, you will find a series of useful tips for your first clinic visit.

What alterations does HSG detect?

Once the hysterosalpingography is done, it will be 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, etc.
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.

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 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.

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 will begin to be passed into the uterine cavity.

During hysterosalpingography, the woman may feel mild abdominal pain. Some women feel even more intense discomfort. However, these pains disappear once the contrast is stopped.

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.

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 corresponds 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.

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.

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.

FAQs from users

How is a Hysterosalpingogram performed?

By Óscar Oviedo Moreno MD (gynecologist).

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?

By Zaira Salvador BSc, MSc (embryologist).

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?

By Zaira Salvador BSc, MSc (embryologist).

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

What are the risks of hysterosalpingography?

By Zaira Salvador BSc, MSc (embryologist).

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.

Suggested for you

As we said, the hysterosalpingography test is used to see if the fallopian tubes are blocked. There are several causes of this 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?

Our editors have made great efforts to create this content for you. By sharing this post, you are helping us to keep ourselves motivated to work even harder.

References

Authors and contributors

 Laura Gil Aliaga
Laura Gil Aliaga
BSc, MSc
Embryologist
Bachelor's Degree in Biology & Biochemistry from the Miguel Hernández University of Elche (UMH) and the University of Alicante (UA). Master's Degree in Biology of Human Assisted Reproduction. Embryologist at clinic UR Vistahermosa (Alicante, Spain). More information about Laura Gil Aliaga
 Marta Barranquero Gómez
Marta Barranquero Gómez
Embryologist
Graduated in Biochemistry and Biomedical Sciences by the University of Valencia (UV) and specialized in Assisted Reproduction by the University of Alcalá de Henares (UAH) in collaboration with Ginefiv and in Clinical Genetics by the University of Alcalá de Henares (UAH). More information about Marta Barranquero Gómez
License: 3316-CV
 Óscar Oviedo Moreno
Óscar Oviedo Moreno
MD
Gynecologist
Bachelor's Degree in Medicine & Surgery from the University of Caldas (Colombia). Specialist in Internal Medicine by the Pontificia Universidad Javeriana of Bogotá. Degree standardized in Spain in 2003. Specialist in Gynecology & Obstetrics from the Complutense University of Madrid, with residence at Hospital Clínico Universitario San Carlos de Madrid. Expert in Reproductive Medicine and Certification in Obstetric-Gynecologic Ultrasound (levels I, II and III). More information about Óscar Oviedo Moreno
License: 282858310
 Zaira Salvador
Zaira Salvador
BSc, MSc
Embryologist
Bachelor's Degree in Biotechnology from the Technical University of Valencia (UPV). Biotechnology Degree from the National University of Ireland en Galway (NUIG) and embryologist specializing in Assisted Reproduction, with a Master's Degree in Biotechnology of Human Reproduction from the University of Valencia (UV) and the Valencian Infertility Institute (IVI) More information about Zaira Salvador
License: 3185-CV
Adapted into english by:
 Romina Packan
Romina Packan
inviTRA Staff
Editor and translator for the English and German edition of inviTRA. More information about Romina Packan

Find the latest news on assisted reproduction in our channels.