Taking the Fear Out of HSG

Infertility treatments require lots of poking, lots of prodding, and lots of testing. One test that seems to stand out for many patients is the hysterosalpingogram (HSG). In fact, our guest blogger, Sara, had this to say about the HSG procedure she had during her initial consultation at CHR:

“I have a pretty high tolerance for pain and I did NOT enjoy the HSG. Ok, I don’t know anyone who enjoys them but I found it pretty uncomfortable. Although, I did have another HSG at CHR’s office months later and it really wasn’t that bad. Maybe at the time of the first procedure I was so mentally sad and overly sensitive which triggered my pain sensors.  Yeah, on second thought, let’s go with the emotional mess excuse – I am a rock!”

But HSGs don’t have to be scary. We asked Dr. Barad to share some information and insight on just what HSG is all about:

Dr. Barad explains HSG“Hysterosalpingogram (HSG) is a test that many patients are scared of and that most cannot pronounce.  The name derives from the Greek word for Uterus (Hystero), tubes (Salpinx) and  Gram meaning a ‘drawing’ or a written record.  Thus it is an image of the inside of your uterus and fallopian tubes.  Actually a good HSG will be comprised of several images.

A true HSG is always made with an X-Ray of the pelvis.  Normally such an X-Ray would only reveal the bony structures in your pelvis, because the calcium in bones blocks X-Ray exposure of the image.  When we perform an HSG, a small amount of fluid is injected into the uterus and from there flows into the fallopian tubes and then through the tubes into the pelvis.  In this way the image created is of the space inside the uterus and tubes, not of the actual uterus and tubes.  It is like seeing an image of the hole inside a bagel, or the filling inside the cannoli not the bagel or cannoli shell itself.

In the past, performing an HSG required the use of some fairly complicated equipment.  The doctor had to grasp the cervix with a sharp instrument called a tenaculum and attach a spring loaded metal cannula.  This led to the procedure being fairly uncomfortable… even painful.  We often tried to lessen the pain with local anesthesia, but it was still, for many women, a terrible experience. Thankfully, this is no longer the case.

When you have an HSG at CHR we will ask you to schedule the test early in your cycle, a few days after the ending of your menstrual flow.

The first step is to adjust your position on the table so that the X-Ray exposure is correct.  We will take a few ‘scout’ images to confirm that you are properly placed.  Our machine records all of our images digitally so there is less X-Ray exposure than there would be in old fashioned film exposures.

Once you are in position we will place the catheter. Today we generally use a disposable plastic catheter with a small balloon on the end.  We very rarely ever need to use a tenaculum.  The plastic has a memory so we can put a small bend in the end of it conforming to the shape of your cervical canal.  We, of course, still need to place a speculum to be able to see your cervix.  We then clean off the face of the cervix with some cleansing solution.  Next the plastic catheter is given a small bend on its end and then threaded through your cervix and into your uterus, just above opening of the cervix into the uterus.  Next we inflate the balloon on the end of the catheter.  If the balloon is inflated slowly it gives time for the uterus to adjust to its volume and at most feels like a mild menstrual cramp.  Many women don’t feel the balloon at all.

We will then begin to slowly push the contrast material into the catheter.   As the contrast flows you will be able to see a triangular shaped cloud appear on the fluoroscope image.  The peak of the triangle points toward your cervix, but will generally be obscured by the inflated balloon that is acting like a “cork” keeping the contrast in your uterus and not letting it spill back to the cervix.

As the uterus fills with contrast a small amount will begin to flow into the first part of the fallopian tubes.  The first part of the tubes is very narrow and so may look like a very thin squiggly line on the image.  As the contrast continues down, the tube gets larger, like a trumpet, which is the literal translation of the Greek word ‘salpinx.’   If the tubes are normal we may be able to see some folds in this last “trumpet-like” part of the tube.  Finally the dye will come out of the end of the tube and will begin to coat the outside of your intestines.  Since the intestines are always moving around with peristalsis, the image will begin to look very ‘busy’ as dark ‘clouds’ of contrast leave the tubes and start moving around your abdomen.

If we are unable to see this usual progression of images, there may be some problem with your uterus or tubes.  A fibroid or polyp may occupy space inside your uterus leading to what we call a ‘filling defect’ where the contrast cannot flow.  Instead of seeing the normal triangular space in your uterus there will be an area that appears to be ‘punched-out’ of the triangle.  Similarly, if you have a uterus that is abnormally formed from birth, the shape of the cavity will not appear to be normal.

If contrast cannot flow into the tubes because they are blocked where the tubes attach to the uterus, then only the uterus will appear and contrast will not flow into the tubes.

Sometimes the contrast will flow part-way into the tube and will then stop.  This means your tube is blocked part-way down its length.

If contrast flows to the end of the tubes but cannot get out the tube will blow up like a small balloon.  This leads to a sausage shaped area of contrast on the image.  This is known as a hydrosalpinx.

In some cases contrast will flow from the ends of the tubes but will not be freely distributed around your pelvis.  If the dye is caught up in one place this may mean that you have some scarring in your pelvis that restricts the free movement of the contrast.

At the end of your procedure we will preliminarily review with you what we have found.  A discussion about what you should do about the findings may need to wait until you can schedule time to meet with your primary CHR physician.  (Please try to schedule that visit as soon as you can.)

Sometimes the simple act of performing an HSG clears the tubes enough to allow a pregnancy.  Many patients ask if they should refrain from intercourse after having an HSG.  No, you should not.  It may be that because of the flushing effect of the contrast your fertility will be increased.  Please do have intercourse in the cycle that you have an HSG.  If there is a rare circumstance in which we think this is not advisable, we will tell you.

If all goes well you should not have any post procedure pain or bleeding.  Call the CHR personnel on call to report pain, bleeding or fever arising after your test.”

We hope this explanation by Dr. Barad took some of the burden of worry from your mind. After all, HSG is a very important diagnostic step in your fertility treatment!

Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned reproductive endocrinologist, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.