HSG is a common procedure, minimally invasive, and quick to perform. It is also cost-effective and usually gives a clear status of the uterus and fallopian tubes.
Are you scheduled to have an HSG test? Are you unsure of what to expect? This article tries to answer all your questions about hysterosalpingography.
What is HSG?
A hysterosalpingogram or hysterosalpingography (HSG) is a technique your doctor may perform to see if you have blocked fallopian tubes or uterine abnormalities. This is usually part of your fertility workup, in which, if initial tests are inconclusive, a doctor may suggest a HSG test to explore further why you are experiencing fertility problems.
HSG test consists of a special dye (a contrast medium) that is injected into the uterus and allowed to flow throughout the uterine cavity and fallopian tubes. Shortly after injecting the dye, X-rays are performed. The dye allows all the structures to be fully visualised by creating an outline of the structures. If the X-ray detects that the dye does not flow into all areas of the uterine cavity, it suggests that there is a blockage somewhere. This could be the reason for fertility issues.
HSG is a common procedure, minimally invasive, and quick to perform. It is also cost-effective and usually gives a clear status of the uterus and fallopian tubes.
Why might a doctor propose this procedure?
If you are struggling to get pregnant—meaning you are having regular unprotected sex at the optimal timing around your ovulation and have not been able to fall pregnant within 6–12 months—then there may be an underlying reason, such as blocked fallopian tubes or uterine abnormalities. The HSG test is a diagnostic option for doctors to assess your uterine and tubal status. Data varies among studies, but tubal blockage or disease of the fallopian tubes has been reported to be as high as 54% detected through HSG tests in women with infertility seeking fertility treatment.
What does it mean to have blocked fallopian tubes or uterine abnormalities?
Diagnosing infertility is a complex workup where your doctor will assess hormonal, structural or partner-based complications to determine why you are having issues with your fertility. An HSG test covers the structural approach, as it is used to check the structure and potential function of your fallopian tubes and uterine cavity.
The fallopian tubes transport the egg from the ovaries to the uterus, where the sperm first makes contact with the egg, and fertilisation occurs. If the tubes are blocked for some reason, these processes cannot happen, and you will be unable to get pregnant naturally. Equally, irregularities in the uterus, such as fibroids or polyps, could alter the shape or block regions of the uterus, cervix or fallopian tubes, impacting fertility and natural conception. Uterine abnormalities that are present from birth (called congenital abnormalities) can also occur due to improper development of the reproductive organs. These will often impact fertility.
The main causes of infertility related to tubal factors are:
- Sexually transmitted diseases e.g. chlamydia
- Pelvic or abdominal surgery e.g. surgical removal of an ovary (salpingectomy) or removal of fibroids (myomectomy)
- Fibroids
- Peritonitis (an inflammation of the inner lining of the abdominal cavity)
- Endometriosis (scarring from adhesions or lesions from the endometrial-like tissue)
- Infection
If you have a history of any of the above issues, or are experiencing unexplained infertility, you should be offered an HSG test to determine if there are tubal factors causing infertility.
A laparoscopy may be the preferred option to investigate infertility causes in women with a history of pelvic inflammatory disease, ectopic pregnancy, or endometriosis.
HSG is also performed to check the success of tubal ligation (when the tubes have been surgically closed for sterilisation), for the reversal of sterilisation, or for procedures to re-open fallopian tubes following disease-related blockage.
What do I need to know about the HSG test?
Who will perform the procedure?
The procedure will be carried out by a specialist who is trained and experienced in performing the procedure, usually a gynecologist, a radiologist or a reproductive endocrinologist.
Do I need to take any medication before the procedure?
If you have a history of pelvic infection, the doctor may give you antibiotics before the procedure to prevent you from developing a pelvic inflammatory disease (PID) or infection.
It is also advised to take over-the-counter pain relief an hour or so before the HSG test to manage pain after the procedure, such as abdominal cramping. Some studies have also confirmed that local application of EMLA cream (a pain relief cream containing lidocaine) to the cervix can help relieve pain when the doctor uses the instruments for the test. This may be useful for women who are experiencing high amounts of pelvic or vaginal pain.
When will the procedure be done?
The doctor will perform the test in the first half of your menstrual cycle before you ovulate. This prevents exposing a potentially undetected fertilised egg to the dye and X-ray (you will be asked to refrain from unprotected sex from the date of your period until after the HSG test). This part of the cycle is also where the endometrial wall/lining is thinnest and therefore helps to get a better image of the uterus. Your doctor may do a pregnancy test beforehand to ensure you are not pregnant.
Are there some women who can’t have this procedure done?
There may be instances where having an HSG test is not advisable:
- If you are allergic to the dye
- If you are pregnant
- If you have signs of a current pelvic infection
Your doctor should ask you about these limitations during a previous consultation. If you are concerned about an allergy, it is best to let your doctor know. The dye comes in two forms: a water-based medium and oil-based medium. Your doctor will make sure they use the best solution for you.
What will the doctor do exactly?
The procedure can be done fairly quickly, within 5 to 15 minutes, and is relatively non-invasive. You will be awake and aware during the procedure, anaesthesia is not needed. The procedure is usually performed as follows:
- You will lie in a position as you do for a pelvic examination, with your legs elevated and knees apart; being as relaxed as possible helps with the ease of the procedure.
- Your doctor will insert a lubricated speculum into the vagina, which is used to widen the vagina and visualise the cervix.
- The doctor will then insert a small (in diameter) tube known as a cannula through the cervix into your uterus. Some doctors may use a small balloon-tip catheter on the end, which is inflated inside the uterus to inject the dye.
- The doctor will remove the speculum and your legs can be lowered and straightened.
- At this point, your doctor will slowly inject the dye using the cannula attached to the tube placed in the uterus. About 1 to 5 ml will be injected.
- You may be asked to move your hips and pelvis around to help the dye solution flow freely into your uterus and fallopian tubes.
- Your doctor will then take a series of X-rays from different angles. The X-ray machine will be positioned above you, and you will need to lie still while the images are being taken. Your doctor may leave the room when they take the X-ray to limit their exposure to radiation.
- Once completed, the tube is removed without having to insert the speculum again.
- You can get fully dressed and will be allowed to go home immediately after the test.
Do I need to take medication afterwards?
After the procedure, you may feel abdominal cramping for a couple of days. Taking over-the-counter non-steroidal anti-inflammatories (NSAIDS), such as ibuprofen or paracetamol, may help with pain relief.
Will I bleed after the procedure?
After the test, you may experience bleeding and vaginal discharge; this may include some of the dye and could continue for a few days. This is normal. During this time, you may want to wear a sanitary pad.
Can I go home the day of the procedure?
Yes, you should be able to go home immediately after the procedure. You may experience some discomfort, so it might be best to have someone accompany you to take you home.
Some women do not experience problems after the procedure and can even return to work the same day. Listen to your body and take rest if you need.
If immediately after the procedure, you feel lightheaded or poorly, inform your doctor before you leave the clinic. They may ask you to stay longer to monitor you.
Will I suffer from side effects, and for how long?
The two main common side effects are pain and infection. The dye fills up (dilates) the uterine cavity, which may trigger contractions of the uterus (abdominal cramping). You may experience pain and discomfort due to this. It is normal to bleed after the procedure, as the tube going through the cervix can irritate the cells of the cervix.
Infection is rare but can occur. If you start experiencing fever, chills, extreme pelvic pain or excessive blood loss, then call your doctor immediately.
What happens to the dye that is put inside me?
If there are no blockages in your fallopian tubes, the dye will flow through the fallopian tubes and exit by the ovary, where it will flow into the abdominal cavity. The body will absorb it and break it down. Some will come away through the cervix, much like a period; this may be why you experience some vaginal discharge that contains the solution.
Is it a safe test?
The HSG test is classed as a safe and standard procedure. All X-rays lead to some exposure to radiation, but the exposure is minimal and short during this procedure, so it is not considered high-risk.
Are there other tests that the doctor might do?
Transvaginal ultrasound is often used to assess uterine abnormalities, as it can easily visualise the lining of the uterus (endometrial lining), uterine cavity, and ovaries. It can be more specific than the HSG test—meaning it can detect more structures clearly, however, it is harder to determine if there are blockages in the fallopian tubes with an ultrasound.
In some cases, HSG has been used to assess the diameter and anatomical structure of the cervical canal. If malformations in or of the cervical canal are found, it can affect conception. However, doctors will usually perform an internal pelvic examination to help assess this further.
Many doctors also use hysterosonosalpingography. In this similar procedure, the uterine cavity and fallopian tubes are assessed by injecting a different solution and performing an ultrasound instead of X-ray. It is considered safer, cheaper and easier to use than HSG, but HSG provides a superior visual of the fallopian tubes.
Can I get pregnant afterwards?
It is advisable to wait for your first period after the procedure before trying to conceive.
What results will I get?
If a radiologist performs the test, they will prepare a report with the findings and send this to your specialist doctor. If your gynecologist performed the test, they can usually provide their findings straight after the procedure once the X-rays are developed.
The findings should be able to determine if your tubes are blocked or if there are any obvious anatomical irregularities with your uterus. They will suggest further investigation and/or treatment options if they detect something. If your tubes are not blocked, and there are no obvious signs of malformations of the uterus, the doctor will continue your fertility workup with further tests.
Can the procedure help unblock my fallopian tubes?
The procedure is a diagnostic test and doesn’t aim to unblock tubes. However, if the tubes are only slightly blocked, then the pressure of the dye being injected into the uterus and fallopian tubes may be enough to help unblock them naturally, known as tubal flushing.
If the test confirms blockage of the fallopian tubes, then your doctor will go through the procedures that they can try to unblock them, this may consist of:
- laparoscopy (a small incision under the belly button in which a small camera and tools are inserted into to help visualise or unblock the tubes)
- salpingectomy (often done to remove an ectopic pregnancy by removing part or all of the fallopian tube, it is also performed if the tubes are damaged in some way)
- tubal cannulation (a tube inserted into the fallopian tube to encourage blockage removal).
How could I avoid having an HSG test done?
If you already know you will go through in vitro fertilisation (IVF) and have no known abnormalities with your uterus, then your doctor may skip performing a HSG test, as IVF does not require your fallopian tubes.
Takeaway
An HSG test is a standard procedure that many fertility experts may perform to help determine if you have a blockage of the fallopian tubes or signs of an irregular uterus. It is a safe procedure, with minimal pain and discomfort.
During an HSG test, a small tube is inserted into your uterus, and a special dye in injected. The dye flows throughout the uterine cavity and fallopian tubes, and a series of X-rays are performed to visualise the structure. If there is a blockage or abnormality, it is highly likely the HSG test will reveal it and the procedure could even flush the tubes and unblock the tubes if the blockage is not severe.
Through this procedure, you and your doctor can gain a clearer understanding of your reproductive health and how to move forward with fertility testing and treatments.
Our compassionate team at Cada can offer in-depth information about the procedures and treatments for blocked fallopian tubes. Make your appointment for a free consultation today to discuss things further.
