Hysterosalpingogram (HSG)

What is a hysterosalpingogram (HSG)? A hysterosalpingogram or HSG is an x-ray

procedure performed to determine whether the fallopian tubes are open and to see if the
shape of the uterine cavity is normal. An HSG is an outpatient procedure that takes less
than one half-hour to perform. It is usually done after menses have ended but before
ovulation to prevent interference with an early pregnancy.
How is a hysterosalpingogram done? A patient is positioned under a fluoroscope !a
real-time x-ray imager" on a table. #he gynecologist or radiologist then examines her
uterus and places a speculum in her vagina. Her cervix is cleaned and a device !cannula"
is placed into the opening of the cervix. #he physician then gently fills the uterus with a
li$uid containing iodine !contrast" through the cannula. #he contrast then enters the tubes
outlines the length of the tubes and spills out their ends if they are open. Any
abnormalities in the uterine cavity or fallopian tubes will be visible on a monitor. #he
HSG is not designed to evaluate the ovaries or diagnose endometriosis. %re$uently side
views of the uterus and tubes are obtained by having the patient change her position on
the table. After the HSG a patient can immediately resume normal activities although
some physicians ask that the woman refrain from intercourse for a few days.
Is it uncomfortable? An HSG usually causes mild or moderate uterine cramping for
about five minutes& however some women may experience cramps for several hours. #he
symptoms can be greatly reduced by taking medications used for menstrual cramps.
Does a hysterosalpingogram enhance fertility? It is controversial whether this
procedure enhances fertility. Some studies indicate a slight increase in fertility lasting
about three months after a normal HSG. 'ost physicians perform the HSG only for
diagnostic reasons.
What are the risks and complications of HSG? An HSG is considered a very safe
procedure. However there is a set of recogni(ed complications some serious which
occur less than )* of the time.
Infection - #he most common serious problem with HSG is pelvic infection. #his
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
her doctor if she experiences increasing pain or a fever within one to two days of
the HSG.
ainting - +arely the patient may get light-headed during or shortly after the
procedure.
!adiation "#posure - +adiation exposure from a HSG is very low less than a
kidney or bowel study and there have been no demonstrated ill effects from this
radiation even if conception occurs later the same month. #he HSG should not be
done if pregnancy is suspected.
Iodine $llergy - +arely a patient may have an allergy to the iodine contrast used
in an HSG. A patient should inform her doctor if she is allergic to iodine
intravenous contrast dyes or seafood. ,atients who are allergic to iodine may
have a sonohysterogram performed instead of HSG since that procedure uses non-
iodine containing fluids. Sonohysterograms provide good detail concerning the
uterine cavity but limited information about the fallopian tubes. If a patient
experiences a rash itching or swelling after the procedure she should contact her
doctor.
Spotting - Spotting commonly occurs for one to two days after the HSG. -nless
instructed otherwise a patient should notify her doctor if she experiences heavy
bleeding after the HSG.
%ubal disease&pel'ic adhesi'e disease
Another cause of infertility is damaged fallopian tubes or pelvic adhesions surrounding the fallopian tube
and ovary.
(ormal physiology
After release of an egg !ovulation" the fallopian tube is thought to move across the surface of the ovary and
pick up the egg. #he figure below depicts the normal female anatomy. If the fallopian tube is open sperm
can ascend the female reproductive tract and fertili(e the egg at the end of the tube. #he fertili(ed egg !early
embryo" then moves down the fallopian tube and enters the uterine cavity five days later where it can
implant into the endometrial lining and establish a pregnancy. A normal fallopian tube must be open and
free of adhesive disease !scar tissue" in order to serve these functions. ,elvic adhesions may interfere with
the ability of the fallopian tube to capture the released egg. If the fallopian tube is completely or partially
blocked sperm may not reach the egg or the embryo may be stopped as it moves toward the uterine cavity.
#his may result in infertility or an ectopic !outside the uterus" or tubal !fallopian tube" pregnancy.

What can lead to damaged fallopian tubes or pel'ic adhesions?
Sexually transmitted infections
#he most common cause of damaged fallopian tubes would be prior sexually transmitted infection
including gonorrhea and chlamydia. #hese organisms are known to ascend the female reproductive tract
and infect the fallopian tubes leading first to pelvic pain and fever and then to tubal damage and adhesions.
Sometimes a history of an infection is known and in other cases no such history is recalled. .hlamydia in
particular can cause few symptoms though tubal damage can be severe.
Other infections
It is also possible for other bacteria to ascend the reproductive tract and cause pelvic adhesions. In addition
appendicitis particularly if the appendix ruptures can damage fallopian tubes.
Prior pelvic surgery.
Surgeries on the fallopian tubes !ectopic pregnancy tubal ligation" ovaries !ovarian cysts" or uterus
!myomectomy / the removal of uterine fibroids" can lead to scarring in the pelvis. Significant bowel
surgery can sometimes cause scarring and tubal damage.
Endometriosis (see below)
How are the fallopian tubes tested?
Hysterosalpingogram (HS)
#he most commonly used test to determine tubal patency !the state of being freely open" is the
hysterosalpingogram. #his is a radiological !x-ray" test where contrast is in0ected through the cervix into
the uterus and fallopian tubes. 1y x-ray the contrast can be seen to spill from the end of the fallopian tube
into the peritoneal cavity. If the tubes are blocked they can either not fill at all or they may fill but then the
contrast may not exit the end of the fallopian tube. A tube that is greatly dilated and filled with fluid is
called a hydrosalpinx. A normal HSG is shown in the top figure and an HSG with obstruction and dilated
fallopian tubes is shown in the bottom figure2

How is an HSG performed?
#his test is best obtained shortly after menses has stopped but before ovulation has occurred !cycle days
five through )3 in most women". Since this test can cause cramping pain women should take a pain
reliever such as ibuprofen !'otrin" one hour prior to the test. #he HSG is usually $uite good for detecting
tubal patency but it is less sensitive for picking up some pelvic adhesions that may restrict movement and
proper access of the fallopian tube to the surface of the ovary. Sometimes muscular spasm of the fallopian
tube will lead to the false impression that the tube is permanently blocked.
!ltrasound determination of tubal patency
Some experts can determine tubal patency by in0ecting saline though the cervix and observing flow of
saline through the tubes by ultrasound. #he fluid can then be seen exiting the fallopian tubes giving a 4yes5
or 4no5 answer to whether the tubes are open. #his test can be performed in the office and has the
advantage of avoiding radiation exposure but it is not as good as HSG for viewing fine details about the
tubal anatomy.
"aparoscopy
6ccasionally a laparoscopy !surgical procedure to view the pelvic organs" is warranted to evaluate tubal
patency. #his test is being used with less and less fre$uency due to its high cost and invasive nature.
However in some women laparoscopy is done to evaluate and treat pelvic adhesive disease at the same
time. 7uring laparoscopy dye can be instilled through the cervix and tubal patency can be confirmed by
seeing dye exiting the end of the tube.
How can fallopian tube damage be treated?
If the fallopian tubes are badly damaged the best modern treatment is I8% which has the advantage of
4bypassing5 the fallopian tubes entirely. In fact if hydrosalpinges !dilated and blocked fallopian tubes" are
present studies have shown that removing the tubes entirely leads to improved pregnancy rates with I8% so
this may be recommended to you.9:);
If the scarring is less severe then surgical removal of adhesions by laparoscopy is a reasonable option that
will likely improve fertility. However there is still great risk that adhesions that are removed surgically will
reform in the future.
#here is one instance where tubal surgery may be particularly helpful. If a couple desires a pregnancy
following a tubal ligation tubal ligation reversal can be considered. Some types of tubal ligations can<t be
successfully reversed and the presence of other infertility factors must be assessed. However if a couple is
a good candidate for surgery tubal ligation reversal is associated with about a =>* tubal patency rate and a
?>-@>* chance of conceiving a baby in one year. #hese benefits must be weighed against the risks of
having a surgical procedure and a ?-)>* chance of having an ectopic !tubal" pregnancy following the
reversal. An attractive alternative treatment to consider is I8%.
"ndometriosis
Andometriosis is a disease in which endometrial glands are growing in the peritoneal cavity. 7uring a
normal menstrual period the endometrium or the lining of the uterus is sloughed and exits the cervix and
vagina with menstrual bleeding. However some of the blood and sloughed endometrium also refluxes
through the fallopian tubes allowing it to attach and grow in the pelvic cavity causing endometriosis.
.ommon sites for endometriosis are the area 0ust behind the uterus called the cul-de-sac as well as around
the fallopian tubes and ovaries. Andometriosis causes infertility and pelvic pain. #he pain commonly
worsens around the time of the menstrual period.
Andometriosis can vary both in amount of disease and severity of symptoms. 'ild endometriosis is
characteri(ed by small implants of tissue causing essentially no distortion of pelvic anatomy. #he way that
this degree of disease impairs fertility is not clear. Severe endometriosis can essentially invade the entire
pelvis leading to blood-filled ovarian cysts !endometriomas" and great amounts of scarring that can disrupt
the fallopian tubes. In this case infertility may be caused by distortion of the normal anatomy.
How can endometriosis be detected?
%or many cases of endometriosis the presence of the disease can be suggested by pain symptoms andBor
findings on pelvic or ultrasound exam. However the only way to diagnose endometriosis with certainty is
by laparoscopy.
Should I ha'e a laparoscopy to e'aluate for endometriosis?
As recently as ten years ago experts were suggesting that a laparoscopy should always be done as part of
the infertility evaluation when no other causes had been found. Axperts now feel that laparoscopy should
only be done in selected patients. Chen extensive endometriosis is suggested by severe pain symptoms or
findings on exam laparoscopy is often warranted both to diagnose and treat the disease as it will likely
improve both the pain and fertility. In the absence of pain symptoms or abnormal findings on exam
laparoscopy is likely not necessary. #he reason is that at least half the women in this circumstance will have
no endometriosis and therefore no benefit from surgery. #he other half of women may have some
endometriosis present but treatment of mild endometriosis improves fertility only slightly. In other words
in the case of mild endometriosis making the diagnosis or treating the disease has little impact on ultimately
achieving a pregnancy. In this circumstance saving the expense of surgery and applying it to an I8% cycle
for example is likely a more cost-effective approach.9::;
)terine factor infertility
6ccasionally abnormalities of the uterus are thought to contribute to infertility. #hese lesions are most
often diagnosed by ultrasound examination of the pelvis.
ibroids
%ibroids !myomas leiomyomas" are very common smooth muscle tumors of the uterus. 1ecause fibroids
are so common it is difficult to know if the fibroids are actually causing the infertility or if they are merely
present but having no impact on fertility. 'ost infertility experts will consider fibroids to be the cause of
infertility only if all other factors have been ruled out. %ibroids that are located next to the endometrial
lining of the uterus have the biggest impact on fertility. Chen appropriate fibroids can be surgically
removed leading to improved fertility.9:3;
"ndometrial polyps
Andometrial polyps are small growths of the endometrium that are usually benign in premenopausal
women. Darger polyps tend to persist and there is some evidence that removing these by surgery improves
fertility. Andometrial polyp is shown before and after removal2
)terine scarring ($sherman*s syndrome)
Intra-uterine scars can be present from a past uterine surgery / most commonly a 7ilation and .urettage a
procedure to scrape and collect the tissue from inside the uterus / and these can cause infertility.
Inade+uate endometrial de'elopment or ,luteal phase defect-
,rogesterone is critical for implantation and pregnancy. Some have theori(ed that inade$uate progesterone
production or endometrial response to progesterone is a cause of infertility. %or many years infertility
experts recommended that an endometrial biopsy be done to diagnose luteal phase defect. However a
recent large study found that luteal phase defect was present 0ust as often in fertile women as in infertile
women raising $uestions as to whether this is truly a cause of infertility.9:E; In addition it is known that
interpretation of the endometrial biopsy is $uite difficult and varies significantly from one pathologist to
another. #hese findings suggest that endometrial biopsy should seldom if ever be performed solely for the
evaluation of infertility.
.er'ical factor infertility
It is possible for the cervical mucus to be thickened impairing the normal transport of sperm from the
vagina into the reproductive tract. However this is a rare cause of infertility and testing for this is seldom
done.
#hroughout most of the cycle cervical mucus is thick and slows sperm from ascending the female
reproductive tract. Around mid-cycle when ovulation occurs cervical mucus both increases in amount and
thins out allowing sperm to more readily ascend the female reproductive tract. Abnormal cervical mucus
may contribute to infertility if it is too thick most commonly as a side effect of the ovulation-inducing
medication clomiphene citrate !see below". Although clomiphene citrate has beneficial effects on ovulation
it can have negative effects on cervical mucus production and thickness.
How .an /ou %est for .er'ical 0ucus 1roblems?
#he test for abnormal cervical mucus is called the post-coital test which is performed by obtaining a
cervical mucus sample at mid- cycle several hours following intercourse to look for the presence of motile
!mobile" sperm by microscopic examination. #his test has fallen out of favor because of a lack of
standardi(ation of the test and because the common treatment for an abnormal test intrauterine
insemination is often used even when the test is normal. In other words the results do not often change the
management.
Summary of the Infertility "'aluation
.ommonly infertility specialists will investigate all common causes of infertility by the following tests2
7ay :) progesterone level which detects ovulation
Seminal fluid analysis.
HSG
,elvic ultrasound and ovarian reserve testing in some women
)ne#plained Infertility
7espite a thorough workup at least :? to 3>* of couples will have no obvious explanation for their
infertility. #his is called unexplained infertility a diagnosis that can be $uite frustrating to couples.
However it is reassuring to note that pregnancy rates with treatments in couples with this disorder are as
good or better than in couples who have a known cause.

Istilah dari hysterosalpingogram 0uga dikenal sebagai HSG meru0uk kepada x-ray pada
kandungan dan tuba. -terus dan tuba %allopi tidak akan terlihat pada F-ray. -ntuk
membuat mereka terlihat dengan 0elas di hysterosalpingogram suatu cairan F-ray khusus
!contrast medium" disuntikkan melalui leher kandungan. .ontrast medium akan terlihat
secara 0elas pada F-ray dan memperlihatkan bentuk dan kontur dari uterine cavity serta
dapat menelusuri tuba. HSG biasanya direkomendasikan untuk pasien-pasien dengan
resiko rendah untuk memperlihatkan hambatan pada tuba. Ia 0uga dapat memperlihatkan
kelainan di dalam kandungan. ,rosedur Hysterosalpingogram akan dilakukan di dalam
departemen F-ray dan biasanya mengambil waktu sekitar )?-:> menit.
#he hysterosalpingogram procedure is performed in the F-ray department and usually
takes about )?-:> minutes.
How is the HSG procedure carried outG #he patient lays on a table under the F-ray
imager. #he doctor inserts a speculum !an instrument inserted into the vagina to visuali(e
the cervix" cleans the cervix from any discharge then a fine tube is inserted through the
cervix and a special contrast medium is in0ected. #he flow of the dye from the uterus to
the tubes is observed through an F-ray image intensifier !which looks like a #8 screen".
%ilms of the HSG are usually taken for the record.
Ultrasound scans
Serial ultrasound scanning can detect the development of the follicle !a thin-walled
structure containing fluid with an attached egg to its wall" and its collapse after ovulation.
8aginal ultrasound scan is not only much more comfortable to the patient but it also gives
a much clearer picture than the abdominal ultrasound scan. #he follicle is usually ready
for ovulation when it measures ).H - :.? cm in diameter.
Ultrasound scan
#he use of high fre$uency ultrasound waves to examine the cervix uterus ovaries and
%allopian tubes. #he reflection of these waves can be used to produce an image on a
screen similar to an F-ray but with the added advantage that the ultrasound scan is $uite
harmless. -ltrasound examination is routinely performed as an outpatient procedure and
takes about )> minutes.
It is used as a diagnostic procedure to assess pelvic organs and detect abnormalities in the
womb e.g. a forgotten coil !used for contraception" polyp malformation abnormalities
in the %allopian tubes e.g. hydrosalpinx !water in the tubes" and abnormalities in the
ovaries e.g. polycystic ovaries etc.
-ltrasound scan showing ovarian cyst
-ltrasound scan showing hydrosalpinx
-ltrasound scan showing large polyp
It is also used to monitor treatments such as insemination and I8% by assessing the
development of the follicles and measuring the thickness of the endometrium.