2. The radiographic evaluation of the uterine cavity and
fallopian tubes after the administration of a radio-
opaque medium under fluoroscopic control
3. Most common indication – infertility- primary/ secondary
Other indications include
• Recurrent abortions.
• Pelvic pain.
• Prior to or after tubal surgery, tubal recanalization or other
intervention.
• Prior to treatment with assisted reproductive techniques.
• Congenital abnormalities or anatomic variants.
Uterine and tubal lesion like tuberculosis ,submucous fibroid
polyp synechiae
4. • Suspected pregnancy
• Acute pelvic infection
• Active vaginal bleeding, during menstruation
• Recent dilation and curettage
• Tubal or uterine surgery within last 6 weeks
• Contrast sensitivity
5. Means the procedure should not be performed beyond 10 days
from the start of the last menses.
Other considerations-
If the patient has cycles longer than 28 days, the 10-day rule
can be stretched to 12-13 days.
• Patient to avoid unprotected sexual intercourse from the date
of her period until investigation is over to avoid possible risk of
pregnancy
If the patient has irregular cycles or absent menses, a
6. MAJOR EQUIPMENT
• fluoroscope room
• Table
INSTRUMENTS
Routinely, a sterile, disposable HSG tray is used.
speculum, cotton balls, cup, gauze, drapes, sponge-holding
forceps, 10 ml syringes, lubricating jelly
In addition to the HSG tray, sterile
gloves, an antiseptic solution,
a 6 fr foley’s and
contrast media are
necessary.
7. Informed consent of the patient.
• Bladder should be empty prior to HSG . A full bladder will elevate the
fallopian tube and may cause apparent tubal blockage
Premedications administered.
The patient is placed supine with her knees flexed and heels apart.
A speculum is inserted into the vagina.The cervix is exposed with a
speculum.
The cervix and vagina are copiously swabbed with a cleansing solution such
as Betadine
The catheter is inserted through cervical os using a cervical forceps to guide
it when the balloon lies within uterine cavity, it is gently inflated with water
(2-3 ml ).Before the injection of contrast ,the balloon is pulled downward
against internal os .The speculum is withdrawn and catheter is attached to
8. Water-soluble iodinated contrast media is preferred.
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 tubal patency.
The contrast is diluted in the ratio of 2: 1 .
Using fluoroscopic guidance, contrast agent is slowly injected,
usually 5–10 ml over 1 min and radiographs are obtained.
9. Early filling phase of the uterus -to evaluate for any filling
defect or contour abnormality.
Fully distended uterus – best for evaluating the shape.
Filled fallopian tube to demonstrate and evaluate the fallopian
tube.
Free intraperitoneal spillage to document tubal patency.
• Additional oblique views may be taken for optimal visualisation
of pelvic pathology and tortuous fallopian tubes( to see
retroverted or anteverted)
• After end of the procedure , antibiotic course is given and
patient is informed about vaginal spotting for 1-2 days
10.
11. Mild discomfort or pain.
Mild vaginal bleeding.
Vasovagal reactions and hyperventilation.
Pelvic infection - a serious complication of HSG.
Venous or lymphatic intravasation of contrast media.
An allergic or idiosyncratic reaction.
Radiation exposure - a cause of concern.
13. ONE SHOULD LOOK FOLLOWING POINTS
UTERINE CAVITY
• NUMBER
• SIZE
• SHAPE
• MARGIN
• LASTLY FILLING DEFECT
FALLOPIAN TUBES
• EXTENT ,SPILLAGE OF DYE INTO
PERITONEAL CAVITY OR NOT
(CONCAVO CONVEX APPEARANCE)
• IF BLOCK –LEVEL OF
BLOCK,HYDROSALPINX,TOBACCO
POUCH ,BEADED APPEARANCE
• LYMPHATIC OR VENOUS
INTRAVASATION OF DYE OR NOT
14.
15.
16. Filling defects on consecutive
images at the uterine fundus, that
disappear
progressively after the
administration of contrast,
compatible with air bubbles
17. Filling defects on consecutive images at the
uterine fundus, that disappear
progressively after the administration of contrast,
compatible with air bubbles
23. Most common finding- may be d/t
Tubal block
Tubal spasm
Attempt to differentiate-
• Administration of spasmolytic.
• Progressive administration of contrast medium.
• Selective cannulation of the fallopian tubes may be performed.
These cannot be reliably differentiated on radiography – a limitation.
24.
25. Almost always a result of a past pelvic infection.
Most common are - gonorrhea, chlamydia,
staphylococcus, streptococcus,
pelvic tuberculosis.
Other causes-
Endometriosis.
Adhesion formation from surgery.
Carcinoma of the tube, ovary or other surrounding organs.
26. MANAGEMENT
Treatment options available- Tubal repair surgeries
IVF
The prognosis of repair may be assessed by degree of
dilatation-
• <1.5 cm favourable prognosis
• >3 cm unfavourable prognosis
27. CASE
The uterus is noted
shifted off the
midline with
visualisation of single
cornua and left sided
patent fallopian tube.
Diagnosis
Unicornuate uterus
28.
29.
30. Two widely separated uterine
cavities noted with no
passage of contrast agent
beyond the right cornua and
beyond the proximal 1/3rd of
left tube.
Differentials
Bicornuate uterus
Septate uterus
34. HSG FINDINDS IN GENITAL
TUBERCULOSIS
FALLOPIAN TUBES
SPECIFIC
Beaded tube
Golf club tube
Pipe stem tube
Cobblestone tube
Leopard skin tube
NON SPECIFIC
Hydrosalpinx
Mucosal thickening
Peri tubal adhesion
SPECIFIC
T shaped uterus
Pseudounicornuate
uterus
Trifoliate uterus
NONSPECIFIC
endometritis
Synechiae
distortion of uterine Contour
Venous, lymphatic intravasation
UTERUS
35. TUFTED TUBE
Multiple small
diverticular like
appearance
surrounding
the ampulla
produced by
caseous ulceration
gives the
tubal outline a
Rosette-like
appearance
37. • Out pouching of isthmus
• Unilateral or bilateral
• Unknown cause
• Associated with infertility, PID and ectopi
pregnancy
LEFT SALPINGITIS ISTHIMICA
NODOSUM
Multiple outpouchings from isthmus
45. PERITUBAL HAL0
Thickening of the tubal walls due to peri tubal
adhesions
(arrows) represents a cloudy sign on
hysterosalpingograms.
This finding is a non-specific feature of tubal
tuberculosis
46. TOBACCO POUCH APPREANCE
Terminal hydrosalpinx with the
conical narrowing is seen in the
right tube (arrow). Eversion of
the fimbria secondary to
adhesions,
with a patent orifice produces
the tobacco pouch appearance
in the
left terminal.
47. INTRAUTERINE ADHESION AND DISTORTION
A.Uterine cavity is normal in shape and size. Terminal
sacculation are seen
in both tubes. B. Irregularity, multiple filling defects
and obliteration of right
ostium secondary to extensive synechiae formation in
this site. Obstruction of
left tube is also seen.
48. A. Pseudo-unicornuate uterus. Unilateral scarring of the cavity makes an
asymmetric intrauterine obliteration, resembling a unicornuate uterus. the
irregular contour and vertical orientation of long axis. B. True unicornuate
uterus. the smooth contour, more horizontal orientation of long axis and
normal ipsilateral fallopian tube.
49. TRIFOLIATE SHAPED UTERUS
Synechiae formation at the uterine borders and partial
obliteration in the fundus produce a trifoliate like
appearance. Both tubes are obstructed in the isthmic
portion
.(needs to be ruled out performing the examination before the ovulation phase)
(menses start usually 14 days after ovulation)
absorbed easily,
does not leave a residue within reproductive tract,
provides adequate visualization, however, cause pain &persist for hours after procedure.
Particularly if an oil-based contrast agent is used,
injection should be halted immediately if myometrial or venous intravasation is observed.
(2 parts contrast & 1 part NS)
Small filling defects are best seen at this stage.
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
because the women being examined are of reproductive age.
Spot radiograph shows air bubbles (arrow) in the left
side of the uterus
HSG findings-
B/l distal tubal block leading to hydrosalpinx
is the distance between the distal ends of the horns (ends that are continuous with fallopian tubes).
is the angle formed by the most medial aspects of the 2 uterine hemicavities
GOLF CLUB TUBE
Sacculation of both tubes in distal portion with an
associated hydrosalpinx giving a Golf club-like appearance
(arrows)
Absence of normal tortuosity and a curved or straight pipe like
appearance show fibrotic stage of tuberculous salpingitis. Irregular
contour of the uterine cavity with diminished capacity in the fundual
portion resembling a septate uterus
Multiple rounded filling defects following intraluminal granuloma
formations within the hydrosalpinx, resembling a " leopard skin"
appearance [arrows]
Intraluminal scarring of the tube gives rises a cobblestone
like appearance which is an effective radiographic sign of
intraluminal adhesions
Vertically fixed tubes secondary to dense peritubal
adhesions. Dense connective tissue causes the lack of tubal
mobility. The hyperconvulated right tube and manifests a "
cork screw" like appearance [arrows]
