Accessory & Optional Equipment
Routinely, a sterile, disposable HSG tray is used.
speculum, cotton balls, cup, gauze, drapes, sponge-holding
forceps, 10 ml syringes, lubricating jelly extension tube.
In addition to the
HSG tray, sterile
a 6 fr foley’s or
contrast media are
Two categories of radio-opaque iodinated contrast used.
Water-soluble iodinated CM, e.g. Omnipaque 300.
does not leave a residue within reproductive tract,
provides adequate visualization.
however, cause pain &persist for hours after procedure.
In the past, oil-based contrast media was used.
Allowed maximal visualization of uterine
structures however very slow absorption rate
persists in body cavities for extended time.
Introduces risk of oil embolus that could reach
Amount of contrast medium to be
introduced is variable. On average,
approx. 5 ml is necessary to fill uterine
cavity, and additional 5 ml needed to
demonstrate uterine tube patency.
Fractional injections may be performed
Patient lies in lithotomy position.
Patient is draped & speculum inserted.
Vaginal walls & cervix are cleansed.
Catheter is inserted into cervical canal.
Dilation of balloon helps to occlude cervix,
preventing contrast medium from flowing out.
Once placement of catheter obtained, pt put in
slight Trendelenburg position.
This position facilitates flow of contrast media into
Contrast filled Syringe attached to catheter. Using
fluoroscopy, contrast slowly injected into uterine
• The pelvic ring as seen on an AP projection
should be centered within the collimation field.
• The cannula or balloon catheter should be
demonstrated within the cervix.
• An opacified uterine cavity and uterine tubes are
demonstrated centered to the IR.
Imaging most commonly acquired with use of spot-
film fluoroscopy or, digital fluoroscopy.
Scout image obtained.
During injection of contrast, series of images taken
while uterine cavity &tubes are filling.
After injection of contrast, additional image taken
to document spillage.
Pt most commonly remains in supine position during
imaging, but additional images may be taken with
pt in an LPO or RPO position to adequately
visualize pertinent anatomy.
Image taken at the end for evaluation of lower
Spot radiograph obtained during the early filling stage of the
uterus. Small filling defects are best seen at this stage.
On a radiograph obtained with the uterus fully distended with contrast
material, portions of both fallopian tubes are opacified. Like images
obtained during the early filling stage of the uterus, images obtained at full
uterine distention allow evaluation for filling defects and contour
abnormalities. However, small filling defects may be obscured when the
uterus is well opacified
Spot radiograph clearly depicts the interstitial, isthmic,
and ampullary portions of both fallopian tubes.
Spot radiograph shows intraperitoneal contrast material spillage from
the fallopian tubes. In this case, the spillage outlines the convexity
of the uterine fundus
Conditions which may be detected with HSG
uterine congenital anomalies . 15%
submucosal uterine fibroids
uterine (endometrial) polyps
Unicornuate uterus. Spot radiograph demonstrates a single uterine horn . A
single fallopian tube is also visualized.
HSG image shows a bicornuate bicollis uterus with two HSG cannulas due to two
cervices. There is a fundal linear defect (arrow) with filling of two symmetric
uterine horns through the right cannula (arrowhead) due to communication in the
lower uterine segment.
Septate and arcuate uterus. Spot radiograph demonstrates a
depression of the uterine fundus, a finding that may represent a
short septum or an arcuate deformity
Uterus didelphys. (a, b) HSG images show catheterization of two separate cervices
with opacification of two widely divergent noncommunicating endometrial cavities
Flush catheter thoroughly
Well- circumscribed filling defect
Non- dependent portion of uterus
Transient and mobile
Air bubbles. Spot radiograph shows air bubbles (arrow) in the left
side of the uterus.
Spot radiograph no longer depicts the air bubbles seen in the left cornua of
the uterus in . Air bubbles are often mobile or transient when they are
expelled into the fallopian tubes.
Linear filling defects
Due to under-distended uterus
Parallel to long axis of uterus
May extend into horns
Uterine folds. HSG spot radiograph demonstrates uterine folds (arrows)
as linear filling defects that parallel the longitudinal axis of the uterus.
Uterine folds are normal findings that are occasionally seen at HSG.
Intra uterine adhesions
Post curettage and infection
Linear filling defect
Arising from one wall
Synechiae. Spot radiograph shows a central oval filling defect within the
uterus, a finding that represents a synechia
Polyps: Endometrial over growths.
Leiomyoma's: sub-serosal, intra mural,
only sub mucosal depicted,
early stage filling
Endometrial polyp. Anteroposterior (left) and oblique (right)
hysterosalpingograms demonstrate a pedunculated filling defect within
the uterine cavity (arrows).
Leiomyomas. Spot radiograph obtained during the early filling stage
shows a well-defined filling defect (arrow) in the fundus
On a spot radiograph obtained with the uterus more distended with
contrast material, the fibroid (arrow) is less apparent
Spot radiograph obtained in a different patient reveals a large leiomyoma
distorting the endometrial cavity as it drapes over a mass in the left
Submucosal fibroids. Oblique (left) and anteroposterior (right)
hysterosalpingograms demonstrate smooth filling defects distorting the uterine
cavity and representing submucosal fibroids..
Endometrium extends into
Focal or diffuse.
Nests of endometrium connect to
Out pouching of endometrial cavity.
Diffuse adenomyosis. Spot radiograph shows irregularity of the uterine
contour with small outpunching's of contrast material, findings that
represent diffuse adenomyosis.
Spot radiograph demonstrates an irregular mass-like filling defect in the
fundus with small contrast material–filled diverticula, findings that
represent focal adenomyosis
Cesarean section scar. Spot radiograph shows the uterine incision from a
cesarean section (arrows) in the typical location (i.e., oriented transverse in
the lower uterine segment in the region of the isthmus). At HSG, a cesarean
section scar can have a linear appearance (as in this case) or can occasionally
manifest as a wedge-shaped outpouching or diverticulum.
obliteration of fallopian tubes : usually secondary
to previous pelvic inflammation. must be
differentiated from incomplete tubal opacification
due to tubal spasm, or underfilling of uterus with
tubal polyps .
salpingitis isthmica nodosa (SIN) .
tubal spasm : can be physiological
Out pouchings of isthmus
Unilateral or bilateral
Associated with infertility, PID and
SIN. Spot radiograph demonstrates SIN as small outpouchings or
diverticula from the isthmic portion of the fallopian tubes. SIN can be
either unilateral or (as in this case) bilateral.
Cornual portion encased in
If msl spasm tube appears occluded
HSG cannot differntiate b/w spasm
& true occlusion
Msl relaxant can occasionally help.
Cornual spasm. On an HSG spot radiograph obtained during the early filling stage of
the uterus, the right fallopian tube does not opacify beyond the cornual portion
(arrow), whereas the left fallopian tube opacifies to the ampullary portion.
Arrowheads indicate amorphous calcifications on the right side of the pelvis. These
calcifications were also present on the scout image
On a spot radiograph obtained after the instillation of additional contrast material,
the right fallopian tube opacifies to the ampullary portion. Right-sided SIN and a left-
sided hydrosalpinx are also noted. Amorphous calcifications (arrowheads) are again
seen on the right side of the pelvis
Hydrosalpinx. Steep right oblique spot radiograph shows dilatation of the ampullary
portion of the 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 material within the tubes
Spot radiograph shows dilatation of the ampullary portion of the left fallopian tube, a
finding that is consistent with a hydrosalpinx. No contrast material spillage is seen on
the left side. The right fallopian tube is abruptly cut off, a finding that is consistent
with previous tubal ligation.
Peritubal adhesions. Spot radiograph demonstrates a round collection of contrast
material adjacent to the left fallopian tube, a finding that suggests peritubal
adhesions. Note the free contrast material spillage on the right side.
Spot radiograph demonstrates cutoff of contrast material in the isthmic portions of
both fallopian tubes, with bulbous dilatation of the distal aspects of the opacified
portions. These findings can be seen with postsurgical occlusion (eg, following tubal
Irreversible tubal occlusion with a microinsert. Scout radiograph obtained prior to the
instillation of contrast material shows a microinsert that has been placed
hysteroscopically into the proximal fallopian tube.
Radiograph obtained after instillation shows no contrast material filling of
the fallopian tube beyond the microinsert, a finding that helps document
Tubal polyp. Spot radiograph shows a small filling defect (arrow) in the
proximal left fallopian tube, a finding that typically represents a tubal
Common but self limiting
Rare but serious