HYSTEROSALPHINGOGRAM

DR.C.OVIYA
MBBS MS(O&G)
• Definition of HSG
• Indications
• Contraindication
• Patient preparation and procedure
• Complication
• Advantages
• Contrast media and cannulas
• Recommendations
 HSG
• HSG is a fluoroscopic examination of the
uterus and the fallopian tubes where a
contrast medium is injected into the uterus
most commonly used in the investigation of
infertility or recurrent spontaneous abortions
 INDICATIONS
1.Infertility(Main role)
2.Congenital anomalies of uterus
3.Recurrent spontaneous abortions
4.Post operative evaluation following tubal
ligation and reversal of tubal ligation
5.Suspected case of genital tuberculosis
6.To prove tubal occlusion after insertion of
transcervical sterilization microinsert
 CONTRAINDICATION
1.Suspected pregnancy
2.Acute pelvic infection
3.Active vaginal bleeding
4.Uterine or tubal surgery within last 6weeks
5.Recent dilatation and curettage
6.Immediate pre and post menstrual phase
7.Contrast sensitivity
 COMPLICATIONS
• Pain
• Pelvic infection
• Bleeding
• Contrast allergy
• Uterine perforation
• Vascular or lymphatic intravasation
• Vasovagal episode
• Pregnancy irradiation
 ADVANTAGES
• Outpatient procedure
• Relatively inexpensive
• Associated with therapeutic effect
• Does not require general anesthesia
 PATIENT PREPARATION
• The procedure should be performed during the
proliferative phase of the patients menstrual
cycle(usually from day 6-12),when the endometrium is
thinnest
• This improves the visualization of the uterine
cavity and also minimize the possibility that the patient
may be pregnant
• If there is a uncertainty about patient pregnant
status , a beta HCG is warranted prior to commencing
• Exclude active pelvic infection
 PROCEDURE
• Informed consent to be obtained
• Bladder should be emptied before the procedure
• Antispasmodics to be given
• Scot film may be taken
• Patient is placed in lithotomy position
• Perineum cleansed with antiseptic solution and draped with sterile
towel. cervix is cleaned with povidone iodine solution. A speculum is
inserted into the vagina. cervix is cannulated with any of the
available cannulas which is made air free before administration of
the contrast.
• SCOUT radiograph is obtained with the catheter in place before
contrast material is instilled.
 Contrast media
• Lipid soluble contrast:
Lipiodol
• Water soluble contrast:
Iohexol-omnipaque
Meglumine
Diatrizoate-urograffin
Lipiodol was gradually replaced by water soluble
medias for the following reasons
 CONTRAST MEDIA
Lipid soluble Water soluble
• Sharp image • Ampullary rugae clearly
• Minimal pain visualised
• Delayed absorption • Pain persists after the
procedure
• Risk of lipogranuloma in case
of tubal block or hydrosalphinx • Get absorbed within hours
• • Granuloma formation rare
Intravasation of contrast and
risk of oil embolism there • Prompt demonstration of tubal
• patency delayed film no needed
Need of delayed film
• Widely used
• Less often used
• No effect on pregnancy
• Pregnancy rate doubled
 CANNULAS
• Leech wilkinson cannulas
• Acron tip metalic cannula
• Cervical vaccuum cup
• Balloon catheter or paediatric foleys catheter
Cervical vaccum cup
• Less fluroscopic time
• Small amount of contrast
needed
• Less pain
• Easier for physician to use
• Uterus cant be easily
manipulated need to reapply
cannula
• Superior to metal cannulas
cohen et al,2001
Balloon catheter
• Less fluroscopic time
• Small amount of contrast
needed
• Less pain
• Easier for physician to use
• Good seal at cervix
• Single use/disposable(costly)
• Superior to metal cannula
Tur kuspar et al,1998
• Balloon catheter obscures lower uterine
segment. Need to be deflated to visualise
lower segment
• Balloon catheter better tolerated over cervical
cup
 Antibiotic prophylaxis
• HSG can be performed without routine
antibiotic
• IF HSG demonstrates dilated fallopian tube, oral
doxycyline 100mg twice daily for 5 days should
be given
• With a history of PID, doxycycline can be
administered before the procedure and
continued if dilated fallopian tubes are found
during HSG.
Antibiotic prophylaxis for gynaec procedures:A systematic
review:2016
 NORMAL HSG
• The uterus is shown as a
triangular contrast filled
structure, with its base on
top and apex
caudally(inverted triangle)
and the uterine fundus on
the top which can be
flattened, concave or
slightly convex
• Free spillage of contrast to
the peritoneum noted.
Normal HSG:
Uterus:
Average size and shape
No filling defects and irregularities
Tube:
Average caliber, well outlined by contrast
free contrast spillage without peritoneal cavity
contrast loculation.
 HSG uterus
Congenital • Septate
anomalies • Unicornuate
(uterine • bicornuate
shape)

• Fibroid
• Polyp
Luminal filling • Adhesions
defects • Air bubbles
• Uterine folds
a. Early filling phase-small filling defects are best seen at
this stage
b. Full uterine filling stage—allows evaluation for filling
defects and contour abnormalities
c. Tubal filling phase
d. Peritoneal spillage
• Pelvic adhesion: contrast media loculation in pelvic
cavity
• Peritoneal adhesion: convoluted tube, peritubal halo
effect contrast media loculation in peritoneal cavity
 DETECTABLE PATHOLOGY
Uterine Tubes
• Tubal block
1.uterine anomaly • Tubal spasm
2.Fibroid(submucosal) • Tubal polyp
3.Adenomyosis • Hydrosalphinx
4.Endometrial polyp • Salphingitis isthmica
5.Endometrial TB nodosum
6.Intrauterine adhesions • TB salphingitis
7.Uterine ca • Peritubal adhesion
8.Missed IUCD
 NON PATHOLOGIC FINDINGS
• Air bubble
• Normal myometrial folds
• Prominent cervical glands
• Previous caesarean section scar
 Air bubbles
• Manifest as well
circumscribed lucencies
that collect in the non
dependant portion of the
uterus.
• Often mobile or transient
when expelled into the
fallopian tubes
• This fact differentiates air
bubbles from fixed filling
defects. Spot radiograph shows air bubbles in the
left side of the uterus
 UTERINE FOLDS
• Normal variants that are
occasionally seen at HSG.
• Caused by infolding of
the inner aspects of the
myometrium in an
underdistended uterus
• Usually parallel the long
axis of the uterus and can
extend into the uterine
horns.
Cesarean section scar
Spot radiograph shows
the uterine incision
from a cesarean
section(arrows) in the
typical location.
At, HSG cesarean scar
can have a linear
appearance or can
occasionally manifest
as a wedge shaped
outpouching or
diverticulum.
CONGENITAL UTERINE ANOMALIES
CONGENITAL UTERINE ANOMALIES
• Congenital anomalies of the uterine shape are
due to abnormal fusion of the mullerian ducts
during early (6-12 week )gestation.
• Congenital abnormalities of uterus are often
accompanied by renal abnormalities
 UNICORNUATE UTERUS(class 2)
• Only one half of uterine cavity is
present.
• Endometrial cavity usually
assumes a fusiform(banana) shape
tapering at the apex draining into
a single fallopian tube.
• The uterus is generally shifted off
the midline.
• Unicornuate uterus cannot be
surgically corrected and are
associated with premature labor,
malpresentation requiring C-
section.
 DIFFERENTIAL DIAGNOSIS

Bicornuate bicollis:
Two cervical canals
Cannulation of only one of these canals may
mimic unicornuate uterus on a hysterogram.
Unicornuate uterus account for 10% of uterine
anomalies and infertility is seen in 12.5 % of
cases.
 UTERUS DIDELPHYS
• Complete duplication of uterine horn as well as
duplication of cervix with no communication
between them.
• Account for 8% of mullerian anomalies.
• Associated with renal agenesis and vaginal septum
which may be either transverse or longitudinal.
• Differentiated from bicornuate uterus(separation
of horns only) and a septate uterus( midline
uterine septum)
 UTERUS DIDELPHYS(class 3)
• HSG demonstrates 2 separate
endocervical canals that open
into separate fusiform
endometrial cavities, with no
communication between two
horns.
• Each endometrial cavity ends in
a solitary fallopian tube.
• If the anomaly is associated with
an obstructed longitudinal
vaginal septum ,only one cervical
canal os may be depicted and it
may be cannulated mimicking a
unicornuate uterus.
 Bicornuate uterus(class 4)
• Represent 25% of mullerian duct anomalies.
• Most common presentation is with early pregnancy loss
and cervical incompetence.
• Infertility is not usually a problem with this type of
malformation because implantation of embryo is not
impaired. Two subtypes:
• Bicornuate bicollis:2 cervical canals ,central
myometrium extends to the external cervical canal
• Bicornuate unicollis: one cervical canal,central
myometrium extends to the internal cervical os.
 Bicornuate uterus
• The uterine cavity is divided
into two cornua.
• This usually does not require
surgical correction.
• It appears similar to a septum
on HSG.
• A MRI ,ultrasound or
laparoscopy is the best
technique for its diagnosis.
• MRI: intervening cleft>1cm
and intercornual distance
>5cm.
• Accuracy of HSG alone is only 55% in
differentiation between septate and bicornuate
uterus.
• An angle of less than 75 between the uterine
horns is suggestive of septate uterus
• An angle of more than 105 is more consistent
with a bicornuate uterus.
• This is mostly a problem with HSG pre operative
evaluation.
• HSG shows widely
spaced uterine horn
with an intercornual
distance greater than
100 degree and with
uterine fundi joined at
lower uterine segment
indicating a bicornuate
unicollis type.
 SEPTATE UTERUS(class 5)
• The uterine cavity is
clearly abnormal with a
septum dividing it.
• Uterine septum can cause
miscarriages and is easily
corrected with a minor
surgery.
• A HSG cannot differentiate
between uterine septum
and a bicornuate uterus
Septum may be complete or
incomplete septum
 BICORNUATE AND SEPTATE UTERUS

BICORNUATE UTERUS SEPTATE UTERUS

• Fundus indented
• Cavities widely
separated(>100 angle)
• Partial fusion of mullerian
defects
• Normal external surface
• Cavities are close together
• Defect in canalization or
resorption of midline
septum between mullerian
ducts
 ARCUATE UTERUS(class 6)
• The uterine cavity
shows a slight curve at
the top fundus.
• This is not significant
enough to be called a
septum.
• This is considered to be
an incidental finding
and does not need any
surgery.
DES related uterine
anomaly.
HSG demonstartes
a hypolplastic T
shaped uterus.
HYPOPLASTIC UTERUS
Small sized uterine cavity with normal
length of vagina
 ADENOMYOSIS
• Adenomyosis is a condition in
which endomerium extends
into myometrium
• Adenomyosis can be diffuse
or focal
• Adenomyosis may be imaged
with HSG if nests of
endometrial tissue connect to
the uterine cavity.
• At HSG, adenomyosis appears
as small divertucla extending
into the myometrium
• Spot radiograph shows
irregularity of the uterine
contour with small
outpouchings of contrast
material finding that
represent diffuse
adenomyosis

• Spot radiograph
demonstrates an irregular
mass like filling defects in
fundus with small contrast
material filled diverticula,
finding that represent
focal adenomyosis
 LEIOMYOMAS
• Leiomyomas are benign tumors of the smooth muscle of the
uterus.
• They may be subserosal, intramural or submucosal location within
the uterine wall.
• Manifest as well defined filling defects at HSG and can have a
variety of appearances depending on their size and their location
within the uterus.
• Only submucosal myomas are depicted at HSG.
• Can be best seen during early contrast material filling of the uterus
but may be obscured when uterus is completely opacified.
• Large myomas can distort the size and shape of the uterine cavity.
• Spot radiograph obtained
during early filling stage
shows a well defined
filling defects(arrow)in
the fundus.

• Spot radiograph obtained

with the uterus more
distended with contrast
material, the
fibrod(arrow)is less
apparent
MYOMA
Large myoma distorting the
endometrial cavity
 ENDOMETRIAL POLYP
• Endometrial polyp are focal
outgrowths of the
endometrium
• Usually manifest as well
defined filling defects and are
best seen during the early
filling stage.
• Small polyps may be obscured
when contrast media
completely fills the uterine
cavity and may be
indistinguishable from small
submucosal myoma.
ENDOMETRIOSIS
Sack shaped projection full of contrast medium
UTERINE CANCER
Large contrast deficiency with abnormal border at
the left lateral uterus wall
 SYNECHIAE
• ASHERMAN syndrome also known as uterine synechiae is a condition characterised
by the formation of inrauterine adhesions,which are usually sequale from injury to
the endometrium and is often associated with infertility.

Clinical presentation:
• Infertility
• Secondary amenorrhea
• Abdominal pain
PATHOLOGY:
Results secondary to trauma to the basal layer of the endometrium with subsequent
scarring. This may be from
• Previous pregnancy
• Dilation and curettage
• Intrauterine Surgery
• Infection

They can often be treated surgically(operative hysteroscope)

Multiple irregular filling defects
in uterine cavity, most
commonly arising from one of
the uterine walls.
 MISPLACED IUCD
HSG showing IUD outside the uterine
HSG showing extrauterine broken IUCD cavity
 HSG based categories of tubal patency
• CATEGORY 1(Normal):
1.Patency with free spill
2.Preserved distal tubal folds
3.Normal proximal, mid,distal
tubal dimension ands
appearance
4.No detected peritubal disease
5.Normal tubal pressures with
free flow
6.Lack of sharp pain on forceful
Spot radiograph demonstrates interstitial,
flushing isthmic and ampullary portion of both
fallopian tube
CATEGORY 2(patent tube with tubal disease)

1.Patency with good spill

2.Almost fully preserved distal tubal folds
3.Normal or slightly altered tubal dimensions
4.Fimbrial end clumping
5.Peritubal disease
7.Normal or elevated tubal pressure
Highest incidence of ectopic
pregnancy
CATEGORY3(patent or blocked tubes, severe tubal disease)

1.Patent or blocked tubes

2.Loss of distal tubal folds
3.Altered proximal, mid distal tubal dimensions and
appearance with dilatation/narrowing/scarring/tubal
rigidity
4.Fimbrial end dilatation/narrowing with clumping present
5.Peritubal disease may or may not be seen
6.Usually elevated tubal pressures but may be normal
ART ideal
 SALPHINGITIS ISTHMICA NODOSA
• Unknown cause
• Associated with infertility,
PID and ectopic pregnancy
• Can affect one or both
tubes
• Appears as small
outpouchings or
diverticula from the
isthmic portion of the
fallopian tube
 Tubal obstruction

Proximal obstruction: filling of

intramural/isthmus part without passage of
contrast to distal part

Distal obstruction: absence of contrast spillage

to peritoneal cavity after its passage to distal
part with or without ampullary dilatation
 Causes of distal tubal
Causes of proximal tubal disease disease
1.Pelvic inflammatory
Pseudo obstruction True anatomic blockage disease
85% sexually transmitted
1.Plugs of mucus and Salpingitis isthmica disease
amorphous debris nodosa
2.Tuberculosis

2.Mucosal agglutination Pelvic inflammatory

and viscous secretion disease
3.Peritonitis of any cause

3..cornual spasm endometriosis 4.Tubal damage from

previous surgery
Cornual polyps

Intrauterine synechiae 5.endometriosis

• The cornual portion of the fallopian tube is
encased by the smooth muscle of the uterus
• If there is a spasm of the muscle during HSG ,one
or both tubes may not fill beyond interstitial
portion.
• At HSG tubal spasm cannot be distinguished from
tubal occlusion.
• Administration of spasmolytic agent can result in
uterine muscle relaxation and consequent tube
opacification thus differentiating cornual spasm
from true occlusion
 TUBAL OCCLUSION
• Spot radiograph
demonstrates cutoff of
contrast material in
isthmic portion of both
fallopian tubes with
bulbous dilatation of distal
aspects of opacified
portions
• These findings seen with
postsurgical occlusion.
(tubal ligation)
 TUBAL SPASM:
Abrupt cut off of both fallopian tubes
at interstitial region

BILATERAL FALLOPIAN TUBAL

LIGATION:
No peritoneal spillage of contrast
 HYDROSALPHINX
• Accounts for 10-30% of tubal disease
• It is a distension or dilatation of the fallopian tube in
the presence of a distal tubal occlusion and the most
common cause is pelvic inflammatory disease.
• Women with hydrosalphinx have lower implantation
rate and pregnancy rates in assisted reproductive
technology due to a combination of mechanical and
chemical factors thought to disrupt endometrial
environment.
• One or both fallopian tubes may be affected.
 HYDROSALPHINX
• Steep right oblique spot
radiograph shows dilatation
of the ampullary portion of
right fallopian tube(arrow).
• The left fallopian tube is
normal in caliber.
• Mucosal folds are visible in
the ampullary portions of
both fallopian tubes, a finding
that helps confirm the
presence of contrast media
within the tubes.
Ampullary dilatation of both fallopian
tubes
 TUBAL POLPYS
• Tubal polyps are rare.
• They represent ectopic
endometrial tissue located in
the interstitial portion the
tube
• Manifest as smooth, rounded
filling defects in this location
without concomitant
dilatation or tubal occlusion.
• Can be unilateral or bilateral
• Association with infertility is
not established.
 PERITUBAL ADHESION
• HSG findings shows following
radiographic criteria alone or
in combination:
1.Convoluted fallopian tube
2.Loculation of spillage of
contrast medium into
peritoneal cavity.
3.Ampullary dilatation
4.Peritubal halo effect(double
contour appearance of tubal A round collection of contrast media
wall) adjacent to the left fallopian tube
suggesting peritubal adhesion
5.Vertical fallopian tube
Post ESSURE HSG
 Intravasation
• Venous and lymphatic
intravasation is due to
destruction and ulceration of
the endometrium.
• Not specific for TB
• Seen in HSG done early in
the menstrual cycle, shortly
after endometrial
instrumentation and in any
pathology causing
obstruction to the flow of
contrast media.
HSG findings in genital tuberculosis
uterus Fallopian tubes
Specific: Specifc:
• Beaded tube • T shaped uterus
• Pipestem tube • Pseudounicornuate uterus
• Golf club tube • Trifoliate uterus
• Cobblestone tube
• Leopard skin tube
 HSG FINDINGS IN GENITAL TB
• As given by various authors:
1.Calcified lymph nodes or irregular calcification in the pelvic(adnexal) area.
2.Tubal obstruction between isthmus and the ampullary portion of the fallopian
tube
3.Multiple strictures in the fallopian tube or beaded appearance.
4.Tobacco pouch appearance secondary to an everted fimbria with a patent orifice
5.Pipe stem appearance due to striated rigid contour of the fallopian tube
6.Golf club appearance with slight or moderate dilatation of the ampullary portion
of the fallopian tube.
7.Rosette type appearance secondary to multiple small diverticular like out
pouching surrounding the ampulla produced by caseous ulceration
8.Endometrial adhesion, synechiae and deformity or obliteration of the uterine
cavity in the absence of clinical history of curettage or surgery.
CALCIFICATION
Small uterine cavity
and linear streaks of
calcification in the
course of he fallopian
tube
GLOVES FINGER APPEARANCE:
HSG showing complete obstruction
of uterine cavity with gloves finger
appearance.
Pelvic calcification (probably lymph
node calcification )is detected.
BEADED APPEARANCE:
Irregular uterine cavity and clover
leaf appearance.
Irregular border and beaded
appearance in both fallopian
tubes.
PIPE STEM APPEARANCE
uterine cavity with normal shape and
size.
Rigid stem appearance of the
fallopian tube.
TUFFED APPEARANCE
Small uterine cavity with irregular
contour and resembling septate
appearance. Diverticular outpouching
around ampulla in both fallopian tubes
which make tuffed appearance.
HYDROSALPHINX:
HSG shows terminal sacculation
and occlusion of both fallopian
tubes causing hydrosalphinx.
Uterine cavity has normal
appearance
PERITONEAL ADHESION
HSG demonstrates evidence of
peritoneal adhesion associated with a
mild locculated spill on the left side.
The contour of the uterine cavity is
irregular.
GOLF CLUB APPEARANCE:
FLORAL APPEARANCE:
Small size uterine cavity with irregular
Twisted hydrosalphinx shows a
contour and septate appearance
floral appearance at the left side.
Obstruction in distal isthmic portion of both
Right tube is occluded.
tubes and golf club appearance.
Uterine cavity has a normal size
and shape.
 Leopard skin appearance:
Cotton wool appearance:
Multiple rounded filling defects
following intraluminal granuloma
Distribution of contrast
formation within the hydrosalphinx
medium in a reticular pattern
resembling a leopard skin appearance
producing a cotton wool plug
appearance
Cobble stone appearance:
Intraluminal scarring of the tube gives rise
a cobblestone like appearance which is an
effective radiographic sign of intraluminal
adhesions
Cork screw appearance:
Vertically fixed tubes secondary to
dense peritubal adhesion. Dense
connective tissue causes lack of tubal
mobility. The hyperconvolated right
tube manifest a cork screw like
appearance
 NORMAL CERVIX ON HSG
• The cervical canal is
usually spindle
shaped ,narrower at the
external and internal os
and wider in the
midportion
• The shape varies from
patient to patient(ball
shaped, pear, pyramid,
olive and cylindrical)
 MUCUS PLUG
• Mucus plug in the
cervical canal is
presented with a linear
shaped filling defect
without a rounded
contour. Subsequent
image showed
disappearing of this
mobile filling defect.
CERVICAL POLYP: An oval Large intramural myoma
shaped filling defect seen distorting the cervical canal
in the cervical canal
CERVICAL CANCER
Elongated cervical
canal with an irregular
contour and a
heterogenous filling
defect owing to
cervical cancer
 DIAGNOSTTIC ACCURACY
• Superior to laparoscopy for detecting intrinsic tubal and
uterine pathology.

• False positive rate due to tubal spasm, inadequate

contrast injection, undetected peritubal adhesion
• False negative rate due to incomplete filling of a dilated
hydrosalphinx
• HSG is considered to have 81.2% sensitivity and 80.4%
specificity in comparison with hysteroscopy in the
detection of intrauterine abnormalities.(Roma et al,2004)
Validity of HSG in infertility workup
Egyptian journal of radiology and nuclear medicine(NOV 2019)

• 200 infertile women underwent this HSG, Hysteroscopy

and laparoscopy
• Result:
• overall accuracy of HSG in diagnosing

Tubes 95.5%
Uterine cavity 95%
Peritoneal abnormalities 89%

• Laparoscopy is recommended in patients who had a pelvic

disease or showing tubal obstruction on HSG
 HSG versus laparoscopy
Inexpensive
Does not need general anesthesia
Risk of radiation exposure
No need of trained personnel
Complications are less
Can assess only uterine cavity and
tubes
Operative procedures cannot be
combined to it
costly
Need general anesthesia
No risk of exposure
Need experienced skilled person
Risk and complications are more
compared to HSG
Ovarian, Pelvic and peritoneal
lesions can be diagnosed. Uterine
contour can be seen.
Operative procedures can be done
in the same sitting
RCOG RECOMMENDATIONS for investigation of
suspecting tubal and uterine abnormalities

• HSG offered to women with no suspicion of

comorbidities(PID, endometriosis) to screen for
tubal occlusion
• Laparoscopy is not indicated for routine infertility
workup in the absence of pelvic pathology
• Laparoscopy is indicated for women with risk
factor for peritoneal disease(pelvic
infection,endometriosis and surgery)
• Do not offer hysteroscopy as part of initial
investigation unless clinically indicated.
 ESHRE recommendations,2008
• ESHRE recommends that a Semen analysis and
ovulation assessment before a test of tubal
patency is performed.

• Women suspected to have comorbidities should

be offered laparoscopic assessment directly so
that any treatable tubal or pelvic pathology can
be evaluated and managed at the same time
 ASRM recommendations
• ASRM suggested specific ruling out of tubal
disease by tubal patency tests and chlamydia
antibody testing.

• More than one technique is often required for

accurate diagnosis and treatment of tubal
obstruction tests for tubal function.