HSG: Indications, Contraindications, and Procedure

Hysterosalpingography (HSG)

• HSG is used to assess tubal patency in infertility cases
• It's also used to investigate suspected incompetent cervix, suspected congenital anomaly of uterus in cases of recurrent miscarriages
• Additionally, it's used to establish tubal patency after tubal surgery, post sterilization to confirm obstruction, and prior to reversal of sterilization
• Rarely, it's used to assess the integrity of a cesarean uterine scar

Contraindications

• HSG should not be performed during menstruation
• Pregnancy or unprotected intercourse during the cycle are also contraindications
• Purulent discharge on inspection of the vulva or cervix, or diagnosed pelvic inflammatory disease (PID) in the preceding 6 months are contraindications
• Contrast sensitivity is a relative contraindication

Contrast Medium

• High osmolar iodinated contrast material (HOCM) or low osmolar iodinated contrast material (LOCM) is used (270/300 mg I mL−1, 10–20 mL)
• The contrast medium should be pre-warmed to body temperature to avoid tubal spasm

Equipment

• Fluoroscopy unit with spot film device
• Vaginal speculum
• Vulsellum forceps
• Hysterosalpingography balloon catheter (5-F to 7-F)
• In patients with narrow cervix or stenosis of cervical os, Margolin hysterosalpingography (HSG) cannula may be used

Patient Preparation

• Appointment should be made before day 21, or between the 4th and 10th days in a patient with a regular 28-day cycle
• Patient should abstain from unprotected intercourse between booking the appointment and the time of the examination
• Apprehensive patients may need premedication, and analgesics before the procedure may also help
• Informed consent should be obtained

Technique

• Patient lies supine on the table with knees flexed, legs abducted
• Vulva is cleaned with chlorhexidine or saline, and a disposable speculum is placed using sterile jelly
• Cervix is exposed, and the HSG catheter is inserted into the cervical canal
• Contrast medium is injected slowly into the uterine cavity under intermittent fluoroscopic observation
• Spasm of the uterine cornu may be relieved by intravenous (i.v.) Buscopan or glucagon

Images

• Radiation dose should be kept as low as possible
• Intermittent screening should be performed to the minimal requirement
• Images should demonstrate the following:
  • Endometrial cavity, demonstrating or excluding congenital abnormalities or filling defects
  • Full view of the tubes demonstrating spill
  • If there is abnormal loculation of contrast, a delayed view may be useful

Aftercare

• Patient should be ensured to be in no serious discomfort nor have significant bleeding before leaving
• Patient should be advised that they may have spotting or occasional vaginal bleeding for 1–2 days and pain which may persist for up to 2 weeks
• Prophylactic broad-spectrum antibiotics are routinely given in several centers and are good practice

Complications

• Allergic phenomena due to the contrast medium
• Pain may occur during the procedure, uterine or tubal distension, or peritoneal irritation
• Bleeding from trauma to the uterus or cervix
• Transient nausea, vomiting, and headache
• Intravasation of contrast medium into the venous system of the uterus
• Infection, which may be delayed, occurs in up to 2% of patients