A hysterosalpingogram (HSG) is a fluoroscopic examination of the uterus and the fallopian tubes, most commonly used in the investigation of infertility or recurrent spontaneous abortions.

Indications

• infertility: to assess uterine morphology and tubal patency

Contraindications

• pregnancy

• active pelvic infection

• recent uterine or tubal surgery

Procedure

Technique

• the procedure should be performed during the proliferative phase of the patient’s menstrual cycle (days 6-12) when the endometrium is thinnest 

  • this improves visualisation of the uterine cavity and also minimises the possibility that the patient may be pregnant ¹

  • if there is any uncertainty about the patient’s pregnancy status, a beta hCG is warranted before commencing

• after an antiseptic cleaning of the external genital area, a vaginal speculum is inserted with the patient in the lithotomy position; the cervix is cleaned with an aseptic solution

• catheterisation of the cervix is then performed; the type of device used depends on local practice preferences, and the main options are:

  • a 6 Fr Foley catheter with balloon inflation

    • a Foley catheter has several technical disadvantages, such as difficult insertion in an:

      • angulated or problematic cervix

      • acutely anteverted or retroverted uterus

      • cervical stenosis

      • highly positioned cervix due to pelvic adhesions, previous surgery, or uterine leiomyoma

    • a Foley catheter should be placed just beyond the internal os of the cervix; if the catheter is placed within the cervical canal, it can be easily dislodged

    • inadequate seal of the balloon with the internal os will result in leakage of the contrast through the cervical canal, generating inadequate intrauterine pressure to push the contrast out of the bilateral fallopian tubes; this results in a false positive result of fallopian tube blockage ²

  • a hysterosalpingography catheter or metal acorn-tipped cannula ³ (e.g. Leech Wilkinson, Margolin, etc.)

    • a Leech Wilkinson catheter allows the passage of the angiographic tip to perform Fallopian tube clearance ¹⁰

    • a tenaculum is also used to provide traction on the cervix

    • a Margolin catheter has a silicon tip that can be inserted within a narrow cervical lumen

  • a cervical vacuum cup

• whatever the device, it should be primed with contrast before insertion to avoid the introduction of gas bubbles which may provide a false positive appearance of a filling defect

• water-soluble iodinated contrast is subsequently injected slowly under fluoroscopic guidance

  • some radiologists use iodinated oil (Lipiodol) as contrast when the indication is for lack of fertility, as some authors report increased fertility after its use; however, this remains controversial ⁸

• a typical fluoroscopic examination includes a preliminary frontal view of the pelvis, as well as subsequent spot images that demonstrate the uterine endometrial contour, filled fallopian tubes, and bilateral intraperitoneal spill of contrast to establish tubal patency

Complications

Common but self-limiting

• abdominal cramping

• per vaginal spotting

• venous intravasation

Rare but serious

• pelvic infection

• contrast reaction

• tubal or uterine perforation

Detectable pathology 

Conditions that may be detected with hysterosalpingography include:

Uterine

• uterine congenital anomalies

• submucosal uterine fibroids

• uterine malignancy

• adenomyosis

• intrauterine adhesions

• uterine (endometrial) polyps

Tubal

• obliteration of fallopian tubes: usually secondary to previous pelvic inflammation

  • it must be differentiated from incomplete tubal opacification due to tubal spasm, or underfilling of the uterus with contrast ⁹

• tubal polyps ¹

• tubal malignancy

• hydrosalpinx

• salpingitis isthmica nodosa (SIN) ⁴

• tubal spasm ⁶: can be physiological

• salpingectomy