Hysterosalpingography (HSG): Procedure, Indications, Findings & Interpretation

Hysterosalpingography (HSG) is a fluoroscopic X-ray contrast study evaluating the uterine cavity and fallopian tube patency. Performed in the follicular phase (days 6–12) to avoid pregnancy and optimize visualization.

Procedure

1. Speculum, cervical cleansing, tenaculum on anterior lip.
2. Catheter (balloon or cuff) inserted into cervical canal.
3. Water-soluble iodinated contrast instilled under fluoroscopy.
4. Real-time imaging: uterine filling → tubal filling → peritoneal spill.
5. Delayed films (10–30 min) assess spillage, loculations.

Key Indications

• Infertility workup (tubal factor ~25–35%).
• Recurrent pregnancy loss (congenital uterine anomalies).
• Post-tubal ligation reversal/sterilization confirmation.
• Suspected Asherman syndrome (intrauterine adhesions).
• Pre-IVF baseline (some protocols).

Diagnostic Findings

Finding	HSG Appearance	Clinical Significance
Normal	Triangular uterine cavity; bilateral tubular filling; free peritoneal spill	Patent tubes, normal cavity
Unicornuate/Bicornuate/Septate/DES uterus	Characteristic cavity shapes	Congenital anomalies → reproductive risk
Intrauterine adhesions (Asherman)	Filling defects, synechiae, obliterated cavity	Post-curettage, infection; cause infertility/loss
Submucosal fibroids/polyps	Filling defects with smooth margins	May impair implantation
Proximal tubal occlusion	No tubal filling; cornual cutoff	Salpingitis isthmica nodosa, plugs, spasm
Distal occlusion (hydrosalpinx)	Dilated tube, no spill, "beads on string" mucosa	Prior PID, endometriosis, surgery; IVF indicated
Peritubal adhesions	Spill but loculated, delayed, asymmetric	May impair fimbrial pickup
Tubal spasm	Transient non-filling; repeats with antispasmodic	False positive for occlusion

Risks & Considerations

• Pain/cramping (NSAID premedication).
• Infection (<1%) — screen for GC/CT; doxycycline prophylaxis if high risk.
• Radiation: Low (ovarian dose ~1 mGy).
• Contrast allergy (rare with water-soluble).
• False positives: Spasm, mucus plugs. False negatives: Minimal spill not seen.

Alternatives

• Sonohysterography (SHG): Saline + ultrasound — better for cavity, no tubal info.
• HyCoSy / Foam Sono: Ultrasound contrast — tubal patency, no radiation.
• Diagnostic Laparoscopy + Chromopertubation: Gold standard for tubal/peritoneal factor; invasive.