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FLUOROSCOPY
Uterus and Fallopian TubesDemonstration data

Hysterosalpingography (HSG)

Hysterosalpingography is a fluoroscopic study of the uterine cavity and fallopian tubes performed by instilling iodinated contrast through the cervix. It is a core investigation in the infertility workup, assessing uterine cavity morphology and tubal patency, and can demonstrate congenital anomalies, synechiae, polyps and tubal occlusion. Timing within the menstrual cycle is important both to avoid an early pregnancy and to optimise image quality.

Indications

  • Infertility workup to assess tubal patency and the uterine cavity
  • Recurrent pregnancy loss and suspected uterine cavity abnormality
  • Suspected congenital uterine anomaly such as septate or bicornuate uterus
  • Assessment of tubal occlusion, hydrosalpinx or post-reversal patency
  • Confirmation of tubal occlusion after sterilisation procedures

Contraindications & Cautions

  • Pregnancy: perform in the early proliferative phase (approximately cycle day 7-10) after menses and before ovulation to avoid irradiating a possible pregnancy
  • Active pelvic infection or pelvic inflammatory disease: risk of flare and peritonitis
  • Active uterine bleeding which degrades the study and may embolise clot
  • Recent uterine or tubal surgery
  • Iodinated contrast allergy requires an alternative approach or premedication

Patient Preparation

  • Schedule during the early proliferative phase, typically cycle day 7-10, after bleeding has stopped
  • Confirm the patient is not pregnant and has abstained or used contraception since the last menses
  • Screen for and treat pelvic infection; consider prophylactic antibiotics if hydrosalpinx or infection risk
  • Simple analgesia (an NSAID) beforehand reduces cramping
  • Explain the procedure, obtain consent and empty the bladder

Technique & Parameters

  • Position the patient supine in lithotomy and insert a speculum to visualise the cervix
  • Place a cervical cannula, balloon catheter or vacuum cup and remove the speculum
  • Obtain a scout image then slowly instil water-soluble iodinated contrast under intermittent fluoroscopy
  • Acquire spot films of early cavity filling, full cavity distension, tubal filling and peritoneal spill
  • Oblique views help profile the cornua and unravel overlapping tubes
  • Instil contrast slowly to avoid venous or lymphatic intravasation and undue cramping

Systematic Review

  • Assess cervical canal and lower uterine segment
  • Evaluate uterine cavity contour, size and any filling defects
  • Inspect the cornua and the interstitial, isthmic and ampullary tubal segments
  • Confirm free peritoneal spill of contrast around bowel loops on each side
  • Look for hydrosalpinx, loculation or peritubal adhesions
  • Note any contrast intravasation into veins or lymphatics

Key Findings & Significance

  • Free peritoneal spill of contrast confirms tubal patency
  • Hydrosalpinx: dilated tube with a distended ampulla and absent or loculated spill
  • Septate uterus: a normal external fundal contour with a partition producing two cavities (best distinguished on 3D imaging)
  • Bicornuate uterus: two widely divergent horns with a cleft in the external fundal contour
  • Intrauterine synechiae (Asherman): irregular filling defects and a distorted cavity
  • Cornual occlusion: abrupt termination of contrast at the uterotubal junction

Differential Considerations

  • Filling defect in the cavity: air bubble, polyp, submucosal fibroid, synechiae or blood clot
  • Uterine anomaly: septate versus bicornuate versus unicornuate uterus
  • Tubal occlusion: true occlusion versus cornual spasm (may relax with time or antispasmodic)
  • Tubal irregularity: salpingitis isthmica nodosa, tuberculous salpingitis or endometriosis
  • Beaded tubal contour: tuberculosis or prior pelvic inflammatory disease

Pearls & Pitfalls

  • Perform between the end of menses and ovulation (about day 7-10) to avoid an early pregnancy and endometrial thickening
  • Cornual spasm can mimic proximal tubal occlusion; a repeat run or antispasmodic may demonstrate patency
  • Water-soluble contrast is used; an oil-based contrast flush may have a therapeutic fertility benefit but carries intravasation and granuloma risks
  • Air bubbles introduced with contrast can mimic polyps or fibroids; instil slowly and check with repeat filling
  • A normal external fundal contour distinguishes a septate from a bicornuate uterus and matters for management

Structured Report

  • State the timing in the cycle, contrast used and catheter type
  • Describe the uterine cavity contour and any filling defects
  • Report tubal patency on each side and describe any hydrosalpinx or occlusion
  • Comment on peritoneal spill and any intravasation
  • Give an impression and recommend pelvic ultrasound or MRI to clarify uterine anomalies

References

  • ACR-SPR-SRU Practice Parameter for the Performance of Hysterosalpingography
  • Simpson WL et al. Hysterosalpingography: A Reemerging Study. RadioGraphics
  • Chalazonitis A et al. Hysterosalpingography: Technique and Applications. Current Problems in Diagnostic Radiology
  • Royal College of Radiologists iRefer: Making the Best Use of Clinical Radiology

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.