Background

Hysterosalpingography (HSG) is a radiographic diagnostic study of the uterus and fallopian tubes most commonly used in the evaluation of infertility. (See the images below.) Uterine abnormalities are thought to be a contributing factor in approximately 10% of infertile women and 50% of women with recurrent early pregnancy loss, while the prevalence of tubal abnormalities in infertility is approximately 20%.^{[1, 2]}Thus, assessment of the uterine cavity and fallopian tubes is a standard practice in the baseline infertility workup.

Examples of hysterosalpingogram (HSG) images showing: (A) normal tubal patency, (B) endometrial polyp, (C) submucosal leiomyomata, (D) intrauterine synechiae, (E) hydrosalpinges, and (F) salpingitis isthmica nodosum.

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Indications

HSG has long been recognized for its use in detecting tubal patency, polyps, submucosal leiomyomas, synechiae, müllerian anomalies, hydrosalpinges, salpingitis isthmica nodosum (SIN), and peritubal adhesions.^[3] It does not, however, provide significant information about the ovaries, other areas of the pelvis, or the microbiologic environment of the endometrium, the latter of which may contribute to poor reproductive outcome in approximately 25% of subfertile women.^[4]

Contraindications

Known contrast allergy, pregnancy, and active pelvic infection are absolute contraindications to the procedure.

Procedure planning

The procedure should be performed in the late follicular phase of the menstrual cycle to ensure that the patient is not pregnant and to prevent false-positive intrauterine filling defects and proximal tubal occlusion due to endometrial thickening. Some facilities perform routine pregnancy tests prior to the procedure, but this practice results in an unfavorable cost–to-benefit ratio.

Periprocedure

Brown SE, Coddington CC, Schnorr J, Toner JP, Gibbons W, Oehninger S. Evaluation of outpatient hysteroscopy, saline infusion hysterosonography, and hysterosalpingography in infertile women: a prospective, randomized study. Fertil Steril. 2000 Nov. 74(5):1029-34. [QxMD MEDLINE Link].
Brunham RC, Maclean IW, Binns B, Peeling RW. Chlamydia trachomatis: its role in tubal infertility. J Infect Dis. 1985 Dec. 152 (6):1275-82. [QxMD MEDLINE Link].
Simpson WL Jr, Beitia LG, Mester J. Hysterosalpingography: a reemerging study. Radiographics. 2006 Mar-Apr. 26 (2):419-31. [QxMD MEDLINE Link].
Roma Dalfó A, Ubeda B, Ubeda A, et al. Diagnostic value of hysterosalpingography in the detection of intrauterine abnormalities: a comparison with hysteroscopy. AJR Am J Roentgenol. 2004 Nov. 183 (5):1405-9. [QxMD MEDLINE Link].
Noorhasan D, Heard MJ. Gadolinium radiologic contrast is a useful alternative for hysterosalpingography in patients with iodine allergy. Fertil Steril. 2005 Dec. 84(6):1744. [QxMD MEDLINE Link].
Silberzweig JE, Khorsandi AS, Caldon M, Alam S. Gadolinium for hysterosalpingography. J Reprod Med. 2008 Jan. 53(1):15-9. [QxMD MEDLINE Link].
Beaty AD, Lieberman PL, Slavin RG. Seafood allergy and radiocontrast media: are physicians propagating a myth?. Am J Med. 2008 Feb. 121 (2):158.e1-4. [QxMD MEDLINE Link].
Karande VC, Pratt DE, Balin MS, Levrant SG, Morris RS, Gleicher N. What is the radiation exposure to patients during a gynecoradiologic procedure?. Fertil Steril. 1997 Feb. 67(2):401-3. [QxMD MEDLINE Link].
Nikolic B, Spies JB, Lundsten MJ, Abbara S. Patient radiation dose associated with uterine artery embolization. Radiology. 2000 Jan. 214(1):121-5. [QxMD MEDLINE Link].
Eng CW, Tang PH, Ong CL. Hysterosalpingography: current applications. Singapore Med J. 2007 Apr. 48(4):368-73; quiz 374. [QxMD MEDLINE Link].
Saunders RD, Shwayder JM, Nakajima ST. Current methods of tubal patency assessment. Fertil Steril. 2011 Jun. 95(7):2171-9. [QxMD MEDLINE Link].
Volpi E, Zuccaro G, Patriarca A, Rustichelli S, Sismondi P. Transvaginal sonographic tubal patency testing using air and saline solution as contrast media in a routine infertility clinic setting. Ultrasound Obstet Gynecol. 1996. 7:43-8.
Swart P, Mol BW, van der Veen F, van Beurden M, Redekop WK, Bossuyt PM. The accuracy of hysterosalpingography in the diagnosis of tubal pathology: a meta-analysis. Fertil Steril. 1995. 64:486-91.
Gaglione R, Valentini AL, Pistilli E, Nuzzi NP. A comparison of hysteroscopy and hysterosalpingography. Int J Gynaecol Obstet. 1996 Feb. 52(2):151-3. [QxMD MEDLINE Link].
Golan A, Eilat E, Ron-El R, Herman A, Soffer Y, Bukovsky I. Hysteroscopy is superior to hysterosalpingography in infertility investigation. Acta Obstet Gynecol Scand. 1996 Aug. 75(7):654-6. [QxMD MEDLINE Link].
Holz K, Becker R, Schürmann R. Ultrasound in the investigation of tubal patency. A meta-analysis of three comparative studies of Echovist-200 including 1007 women. Zentralbl Gynakol. 1997. 119(8):366-73. [QxMD MEDLINE Link].
Boudghene FP, Bazot M, Robert Y, Perrot N, Rocourt N, Antoine JM, et al. Assessment of tubal patency by HyCoSy: comparison of a positive contast agent with saline solution. Ultrasound Obstet Gynecol. 2001. 18:525-30.
Exacoustos C, Zupi E, Carusotti C, Lanzi G, Marconi D, Arduini D. Hysterosalpingo-contast sonography compared to hysterosalpingography and laparoscopic dye pertubation to evaluate tubal patency. J Am Assoc Gyn Lap. 2003. 10:367-72.
Stumpf PG, March CM. Febrile morbidity following hysterosalpingography: identification of risk factors and recommendations for prophylaxis. Fertil Steril. 1980 May. 33(5):487-92. [QxMD MEDLINE Link].
American College of Obstetrics and Gynecology. ACOG practice bulletin no. 104: antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol. 2009. 113:1180-9.
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Lindequist S, Justesen P, Larsen C, Rasmussen F. Diagnostic quality and complications of hysterosalpingography: oil- versus water-soluble contrast media--a randomized prospective study. Radiology. 1991 Apr. 179(1):69-74. [QxMD MEDLINE Link].
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Media Gallery

Examples of hysterosalpingogram (HSG) images showing: (A) normal tubal patency, (B) endometrial polyp, (C) submucosal leiomyomata, (D) intrauterine synechiae, (E) hydrosalpinges, and (F) salpingitis isthmica nodosum.
Instruments required for hysterosalpingogram (HSG) include an open-sided speculum, tenaculum, sponge stick, antiseptic, contrast medium, and an acorn (Cohen) cannula (A) or a balloon-tip catheter (B).
Positioning the uterus parallel to the x-ray beam is critical for evaluation. In panel A, the uterus is not positioned correctly, obscuring the uterine septum seen in panel B when the uterus is repositioned.
Dramatic extravasation of contrast media is seen in the myometrial and uterine veins.
Hysterosalpingogram Part 1
Hysterosalpingogram Part 2
Hysterosalpingogram Part 3
Hysterosalpingogram Part 4
Hysterosalpingogram Part 5

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Author

Ryan G Steward, MD Director of Assisted Reproduction Technologies and Pre-Implantation Genetic Testing, Aspire Houston Fertility Institute

Ryan G Steward, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, American Society for Reproductive Medicine, Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas Michael Price, MD Associate Professor, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Director of Reproductive Endocrinology and Infertility Fellowship Program, Duke University Medical Center

Thomas Michael Price, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, Phi Beta Kappa, Society for Reproductive Investigation, Society for Reproductive Endocrinology and Infertility, American Society for Reproductive Medicine

Disclosure: Received research grant from: Insigtec Inc<br/>Received consulting fee from Clinical Advisors Group for consulting; Received consulting fee from MEDA Corp Consulting for consulting; Received consulting fee from Gerson Lehrman Group Advisor for consulting; Received honoraria from ABOG for board membership.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Richard Scott Lucidi, MD, FACOG Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine

Richard Scott Lucidi, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Vuk P Jovanovic, MD, FACOG Assistant Professor of Obstetrics and Gynecology, Mercer University School of Medicine; Sub-specialist in Reproductive Endocrinology and Infertility, Georgia Center for Reproductive Medicine, Memorial University Medical Center

Vuk P Jovanovic, MD, FACOG is a member of the following medical societies: American Society for Reproductive Medicine, Society for Reproductive Endocrinology and Infertility, American Congress of Obstetricians and Gynecologists, European Society of Human Reproduction and Embryology

Disclosure: Nothing to disclose.

Hysterosalpingogram

Background