Hysterosalpingography (HSG), also known as uterosalpingography, is a

radiologic Radiology ( ) is the medical discipline that uses medical imaging to diagnose diseases and guide their treatment, within the bodies of humans and other animals. It began with radiography (which is why its name has a root referring to radiatio ...

procedure to investigate the shape of the uterine cavity and the shape and patency of the

Fallopian tubes The fallopian tubes, also known as uterine tubes, oviducts or salpinges (singular salpinx), are paired tubes in the human female that stretch from the uterus to the ovaries. The fallopian tubes are part of the female reproductive system. In ot ...

. It is a special x-ray using dye to look at the womb (

uterus The uterus (from Latin ''uterus'', plural ''uteri'') or womb () is the organ in the reproductive system of most female mammals, including humans that accommodates the embryonic and fetal development of one or more embryos until birth. The uter ...

) and

Fallopian tube The fallopian tubes, also known as uterine tubes, oviducts or salpinges (singular salpinx), are paired tubes in the human female that stretch from the uterus to the ovaries. The fallopian tubes are part of the female reproductive system. In ot ...

s. It injects a

radio-opaque Radiodensity (or radiopacity) is opacity to the radio wave and X-ray portion of the electromagnetic spectrum: that is, the relative inability of those kinds of electromagnetic radiation to pass through a particular material. Radiolucency or hypod ...

material into the

cervical In anatomy, cervical is an adjective that has two meanings: # of or pertaining to any neck. # of or pertaining to the female cervix: i.e., the ''neck'' of the uterus. *Commonly used medical phrases involving the neck are **cervical collar **cerv ...

canal, and usually

fluoroscopy Fluoroscopy () is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope () allows a physician to see the internal structure and functio ...

with image intensification. A normal result shows the filling of the uterine cavity and the bilateral filling of the Fallopian tube with the injection material. To demonstrate tubal rupture, spillage of the material into the

peritoneal cavity The peritoneal cavity is a potential space between the parietal peritoneum (the peritoneum that surrounds the abdominal wall) and visceral peritoneum (the peritoneum that surrounds the internal organs). The parietal and visceral peritonea are lay ...

needs to be observed. Hysterosalpingography has vital role in treatment of infertility, especially in the case of fallopian tube blockage.

Uses

HSG is considered a

diagnostic procedure Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine "cause and effect Causality (also ...

. It is used in the workup of infertile females to assess the patency of

fallopian tubes The fallopian tubes, also known as uterine tubes, oviducts or salpinges (singular salpinx), are paired tubes in the human female that stretch from the uterus to the ovaries. The fallopian tubes are part of the female reproductive system. In ot ...

, assess the competency of the cervix or congenital abnormality of the uterus in multiple

miscarriages Miscarriage, also known in medical terms as a spontaneous abortion and pregnancy loss, is the death of an embryo or fetus before it is able to survive independently. Miscarriage before 6 weeks of gestation is defined by ESHRE as biochemical ...

, assess the patency of fallopian tubes after surgery or

tubal ligation Tubal ligation (commonly known as having one's "tubes tied") is a surgical procedure for female sterilization in which the fallopian tubes are permanently blocked, clipped or removed. This prevents the fertilization of eggs by sperm and thus th ...

, or before reversal of tubal ligation. Rarely, HSG is used to assess the integrity of a Caesarean scar. HSG may also have

therapeutic A therapy or medical treatment (often abbreviated tx, Tx, or Tx) is the attempted remediation of a health problem, usually following a medical diagnosis. As a rule, each therapy has indications and contraindications. There are many different ...

benefits for

infertility treatment Assisted reproductive technology (ART) includes medical procedures used primarily to address infertility. This subject involves procedures such as in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), cryopreservation of gametes o ...

. When oil-based contrast is used, rates of pregnancy increase by about 10% compared to water-based contrast. A meta-analysis revealed 3.6 times greater

odds Odds provide a measure of the likelihood of a particular outcome. They are calculated as the ratio of the number of events that produce that outcome to the number that do not. Odds are commonly used in gambling and statistics. Odds also have ...

(OR = 3.6) of pregnancy with oil-based contrast compared to no hysterosalpingography. This effect is thought to be due to tubal flushing with the oil-based contrast rather than the imaging procedure itself. HSG is contraindicated during menstruation, pregnancy, unprotected sexual intercourse during the

menstrual cycle The menstrual cycle is a series of natural changes in hormone production and the structures of the uterus and ovaries of the female reproductive system that make pregnancy possible. The ovarian cycle controls the production and release of eggs a ...

, any purulent discharge from the vagina, or if the individual was diagnosed with

pelvic inflammatory disease Pelvic inflammatory disease, also known as pelvic inflammatory disorder (PID), is an infection of the upper part of the female reproductive system, namely the uterus, fallopian tubes, and ovaries, and inside of the pelvis. Often, there may be no ...

six months previously. For those with hypersensitivity to contrast, HSG is relatively contraindicated.

Procedure

Either high osmolar contrast material (HOCM) or low osmolar contrast material (LOCM) can be used. 10 to 20 ml of LOCM can be used at a concentration of 270 to 300 mg/ml. The contrast media should be prewarmed to room temperature before administered into the cervix, so as to prevent spasm of

. 5Fr to 7Fr hysterosalpingogram balloon catheter can be used. Margolin HSG cannula is used if the cervix is narrow or stenosed. HSG appointment is usually made during the 4th to 10th days of regular menstrual cycle (

follicular phase The follicular phase, also known as the preovulatory phase or proliferative phase, is the phase of the estrous cycle (or, in primates for example, the menstrual cycle) during which follicles in the ovary mature from primary follicle to a ful ...

). The subject should not undergone any sexual intercourse before HSG. Anxious subjects may need painkillers or other medications.

Informed consent Informed consent is a principle in medical ethics and medical law, that a patient must have sufficient information and understanding before making decisions about their medical care. Pertinent information may include risks and benefits of treatme ...

should be taken before the procedure. The subject lies down on table in supine position with legs flexed and abducted.

Vulva The vulva (plural: vulvas or vulvae; derived from Latin for wrapper or covering) consists of the external sex organ, female sex organs. The vulva includes the mons pubis (or mons veneris), labia majora, labia minora, clitoris, bulb of vestibu ...

is cleaned with

chlorhexidine Chlorhexidine (CHX) (commonly known by the salt forms chlorhexidine gluconate and chlorhexidine digluconate (CHG) or chlorhexidine acetate) is a disinfectant and antiseptic that is used for skin disinfection before surgery and to sterilize surgi ...

normal saline Saline (also known as saline solution) is a mixture of sodium chloride (salt) and water. It has a number of uses in medicine including cleaning wounds, removal and storage of contact lenses, and help with dry eyes. By injection into a vein it ...

. A speculum is inserted to the

vagina In mammals, the vagina is the elastic, muscular part of the female genital tract. In humans, it extends from the vestibule to the cervix. The outer vaginal opening is normally partly covered by a thin layer of mucosal tissue called the hymen ...

with the help of sterile jelly, and the

cervix The cervix or cervix uteri (Latin, 'neck of the uterus') is the lower part of the uterus (womb) in the human female reproductive system. The cervix is usually 2 to 3 cm long (~1 inch) and roughly cylindrical in shape, which changes during ...

is exposed. The cervical opening is identified using a bright light. The HSG catheter is then inserted into the

cervical canal The cervical canal is the spindle-shaped, flattened canal of the cervix, the neck of the uterus. Anatomy The cervical canal communicates with the uterine cavity via the internal orifice of the uterus (or internal os) and with the vagina via the ...

. Occasionally, Vulsellum forceps may be used to hold the cervical lips open. If

cervical weakness Cervical weakness, also called cervical incompetence or cervical insufficiency, is a medical condition of pregnancy in which the cervix begins to dilate (widen) and efface (thin) before the pregnancy has reached term. Definitions of cervical weak ...

is suspected, the catheter should be left inside the lower cervical canal. Air bubbles should be expelled from the syringe and the catheter, otherwise it will cause confusion of interpretations on HSG. Contrast medium is injected slowly into the uterine cavity with intermittent

fluoroscopic Fluoroscopy () is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope () allows a physician to see the internal anatomy, structure and ...

screening. If there are no spills from bilateral fallopian tubes bilaterally, intravenous buscopan and

glucagon Glucagon is a peptide hormone, produced by alpha cells of the pancreas. It raises concentration of glucose and fatty acids in the bloodstream, and is considered to be the main catabolic hormone of the body. It is also used as a Glucagon (medicati ...

can be given to relieve spasm of fallopian tubes.

Opiate An opiate, in classical pharmacology, is a substance derived from opium. In more modern usage, the term ''opioid'' is used to designate all substances, both natural and synthetic, that bind to opioid receptors in the brain (including antagonis ...

s should not be given, as it may increase pain because of increased smooth muscle contractions. The procedure involves x-rays (

). Images are taken to demonstrate the filling of endometrial cavity, which shows full view of the fallopian tubes demonstrating the spillage of contrast material into

peritoneum The peritoneum is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some invertebrates, such as annelids. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of mesoth ...

, the extent of the block if no spillage is present, or a delayed view in the case of abnormal cavities (

locule A locule (plural locules) or loculus (plural loculi) (meaning "little place" in Latin) is a small cavity or compartment within an organ or part of an organism (animal, plant, or fungus). In angiosperms (flowering plants), the term ''locule'' usu ...

) within. Subject may have vaginal spotting for one to two days, accompanied with pain that may persist for up to two weeks. Some medical centres routinely give

prophylactic Preventive healthcare, or prophylaxis, consists of measures taken for the purposes of disease prevention.Hugh R. Leavell and E. Gurney Clark as "the science and art of preventing disease, prolonging life, and promoting physical and mental hea ...

antibiotics before subject is allowed home.

Complications

Possible complications of the procedure include

infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...

allergic Allergies, also known as allergic diseases, refer a number of conditions caused by the hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include hay fever, food allergies, atopic der ...

reactions to the materials used,

intravasation Intravasation is the invasion of cancer cells through the basement membrane into a blood or lymphatic vessel. Intravasation is one of several carcinogenic events that initiate the escape of cancerous cells from their primary sites. Other mechanisms ...

of the contrast material, pain during the procedure, nausea, vomiting, and headache. Some subjects may develop

neurogenic shock Neurogenic shock is a distributive type of shock resulting in hypotension (low blood pressure), often with bradycardia (slowed heart rate), caused by disruption of autonomic nervous system pathways. It can occur after damage to the central nerv ...

during the inflation of balloon in the cervical canal.

History

For the first HSG, Carey used collergol in 1914.

Lipiodol Lipiodol, also known as ethiodized oil, is a poppyseed oil used by Injection (medicine), injection as a radio-opaque contrast agent that is used to outline structures in radiological investigations. It is used in Transcatheter arterial chemoemboli ...

was introduced by Sicard and Forestier in 1924, and remained a popular contrast medium for many decades. Later, water-soluble contrast material was generally preferred as it avoided the possible complication of oil embolism.

Follow up

If the HSG indicates further investigations are warranted, a

laparoscopy Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medlin ...

, assisted by

hysteroscopy Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention (operative hysteroscopy). Hysteroscope A hyst ...

, may be advised to visualize the area in three dimensions, with the potential to resolve minor issues within the same procedure.

References

External links

HSG Test
- HSG Test : Cost, Results, Expert Advice, Preparation
HSG
- HSG Test -HSG Film Advice, Preparation {{Medical imaging Projectional radiography Female genital procedures