Hysterosalpingography (HSG) is a special type of X-ray that produces images of the parts of a woman's body needed to have a baby. This is called the reproductive tract. It helps to assess the size and shape of your womb (uterus). It can also assist in checking that your Fallopian tubes are open.
HSG is commonly used in women who are having difficulty becoming pregnant. This test allows the doctor to assess the shape and structure of the womb and any scarring in the region.
It also allows the doctor to check that the Fallopian tubes are not blocked.
The procedure may also be used to investigate repeated miscarriages, as these may result from problems with the womb (uterus).
HSG can also help to see whether there are other problems in the pelvis or uterus including:
- Polyps in your womb.
- An abnormal passage between two places that do not normally connect. This is called a fistula.
- Areas where the walls of the uterus are sticking together (adhesions).
- Non-cancerous growths in the wall of the uterus (uterine fibroids).
HSG is also used to check the Fallopian tubes are not blocked and to monitor the effects of surgery on the Fallopian tubes. This may include checking for:
- Blockage of the Fallopian tubes due to infection or scarring.
- The closure of the Fallopian tubes in a sterilisation procedure and a sterilisation reversal.
- The re-opening of the Fallopian tubes following a sterilisation or blockage.
How does hysterosalpingography work?
Normally, soft, hollow structures such as the womb are difficult to see on X-ray images. In HSG a dye that blocks X-rays is inserted into the womb (uterus) and ovarian tubes. This dye is called a contrast agent.
The person performing this test will be able to look at the pictures on a television screen. They can watch as the contrast agent fills your uterus and Fallopian tubes. They can then observe any problems or defects. In a normal hysterosalpingogram the contrast fills the uterus, enters the uterine tubes and spills out of the ends of these tubes into the body cavity.
In the image below, the small black triangle shape in the middle is a normal womb filled with dye. The dye comes in through the tube which is at the base of the triangle and goes out to the edge of the photo. There are two very thin lines of dye coming away from the points of the triangle and they are normal tubes, filled with dye. The larger areas of dye at either side is where the dye has spilled out of the normal tubes.
By jemsweb [CC BY-SA 2.0 (https://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons
What happens during hysterosalpingography?
Procedures may vary slightly in different hospitals, so this explanation is written as a guide. In some departments you may be given a tablet or injection to help you relax before the procedure takes place. This will not put you to sleep but may make you feel more relaxed. This is not needed for most women.
You will be asked to lie on the X-ray table. Then you may be asked to slide down to the end of the table, with your knees bent. The position is similar to the one you are in when you have a smear (cervical screening test) taken. Your pubic area will be cleaned. A speculum will be inserted into your vagina. This is the same instrument used in a smear. This allows the doctor or nurse to see the neck of your womb (cervix).
You may be given a local anaesthetic injection to your cervix, although this is not usually needed. The doctor or nurse will then place a thin tube through your cervix into your womb (uterus). This may be uncomfortable but should not hurt.
Then the contrast agent will be gently syringed through the catheter, gradually filling your uterus and Fallopian tubes. You may feel some pressure and possibly some crampy type pains. As the contrast enters your uterus the doctor will start taking the images using the fluoroscope. After the fluoroscopic images have been taken you may be asked to remain still for a final X-ray. Then the catheter and speculum will be removed. You will also be given a sanitary towel to absorb the contrast agent.
The procedure usually takes between 15 and 30 minutes.
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What should I do to prepare for hysterosalpingography?
Your local hospital should give you information about how to prepare before the test.
Women who are pregnant should not have hysterosalpingography. This is because the X-rays may damage the unborn child. You should inform your doctor if you are, or think you may be, pregnant. For this reason, some hospitals may ask you to take a pregnancy test before the procedure. Or, the procedure may be done soon after a period to minimise the chance that you may be pregnant.
There are a few instances when an HSG cannot be done. For example, it would not be done:
- If you are having a period.
- If there is any possibility of you being pregnant.
- If you have symptoms such as a high temperature with tummy (abdominal) pain and vaginal discharge.
What can I expect after hysterosalpingography?
Contrast agent that remains in your womb (uterus) will gradually leak out through the vagina. Any other contrast left in your pelvis will be absorbed safely by your body. Only a small amount of contrast is used during the examination and it has no odour or colour.
You may experience some cramping following the examination and some minor 'spotting' (light bleeding). Both should settle in a couple of days. You should use sanitary towels, rather than tampons, if the bleeding is a problem.
Low-dose X-rays are used so the total amount of radiation for the whole test is quite small and thought to be safe. The radiation that you are exposed to during this examination, like the radiation produced during any other X-ray test, passes through you immediately. You are not 'radioactive' and it is not necessary to take any precautions following this procedure.
There is a newer test similar to a hysterosalpingogram which involves ultrasound rather than X-rays. Ultrasound scans use sound waves instead of radiation to produce images. A contrast agent is still used but it is a different one. It may be that over time this will replace the traditional hysterosalpingogram test. At present it is not available everywhere.
What are the possible side-effects?
Most women experience only minor side-effects. These may include:
- Sticky vaginal discharge as some of the fluid drains out of the womb.
- Crampy pains.
- Feeling dizzy, faint, or sick.
- Slight vaginal bleeding.
Serious problems are rare. They may include an allergic reaction to the fluid, injury to the womb (uterus), or pelvic infection. See your doctor if you are unwell after the procedure, in particular if you have any of these symptoms:
- Being sick (vomiting).
- Severe tummy (abdominal) pain or cramping.
- Heavy vaginal bleeding.
- High temperature (fever) or chills.
Note: a normal HSG does not prove that there is no underlying problem in the parts of your body needed to have a baby (your reproductive tract). You may be referred to have further tests - for example, a laparoscopy. Your doctor will be able to explain the result of your test to you in detail.
Anatomy and function of the female reproductive system
If the parts of the reproductive system are not working properly then this can lead to problems with fertility. It is thought that the womb (uterus), Fallopian tubes and neck of your womb (cervix) are the cause of problems in 3 out of 10 couples with infertility. Hysterosalpingography can help to investigate some of the causes of these problems. For example, it may help to detect whether the Fallopian tubes are open. Blockage in the tubes can prevent an egg (ovum) from meeting a sperm.
Further reading and references
Fertility - Assessment and treatment for people with fertility problems; NICE Guidance (February 2013, updated Aug 2016)
Steinkeler JA, Woodfield CA, Lazarus E, et al; Female infertility: a systematic approach to radiologic imaging and diagnosis. Radiographics. 2009 Sep-Oct29(5):1353-70. doi: 10.1148/rg.295095047.
Maheux-Lacroix S, Boutin A, Moore L, et al; Hysterosalpingosonography for diagnosing tubal occlusion in subfertile women: a systematic review with meta-analysis. Hum Reprod. 2014 May29(5):953-63. doi: 10.1093/humrep/deu024. Epub 2014 Feb 26.
Kavanagh K, Wallace LA, Robertson C, et al; Estimation of the risk of tubal factor infertility associated with genital chlamydial infection in women: a statistical modelling study. Int J Epidemiol. 2013 Apr42(2):493-503. doi: 10.1093/ije/dyt011. Epub 2013 Mar 14.