The document describes a hysterosalpingography procedure used to evaluate the uterine cavity and fallopian tubes. Key points include: HSG involves injecting radiopaque contrast medium under fluoroscopy to visualize the uterus and tubes. It is commonly used to investigate infertility. The procedure involves catheterizing the cervix and injecting contrast. Findings are interpreted to evaluate for abnormalities like tubal blockages. Common findings and their differential diagnoses are discussed. Risks are generally minor but can include infection, reaction to contrast, or radiation exposure.

1. HYSTEROSALPINGOGRAPHY
PRESENTER-DR.NABA KUMAR BARMAN, JR 1
MODERATOR-DR. SUNIL KUMAR MD

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

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.

12. • Why normal ?

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

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

18. DIFFERENTIALS
Fibroid.
Endometrial polyp.
Synechiae
Air bubbles.
(often mobile or transient and are expelled into the tubes)

19. RIGHT SUBMUCOSAL MYOMA Synechiae

21. SAMPLE FOOTER TEXT 10/3/2018 21

22. RADIOCONTRAST
AGENT IS NOT
PASSING
BEYOND THE
LEVEL OF CORNUA

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.

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

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

31. Criterias used for diagnosis-
Intercornual distance
<2 cm- septate uterus.
>4 cm- bicornuate uterus.
2-4 cm- indeterminate.
Intercornual angle
<75°- septate uterus.
>105°- bicornuate uterus.

32. FINDINGS MORE SUGGESTIVE OF BICORNUATE
UNICOLLIS UTERUS
Intercornual angle Intercornual distance
41mm
110°

33. Twisted
hydrosalpinx
resembles a
floral
appearance of
left side tube.

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

36. TB SIN-like
Penetration of
contrast
medium
between the
mucosal folds
produces
small
diverticular-
like
outpouchings
with a bizarre
pattern. Entire

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

38. cotton-wool plug appearance
Distribution of contrast medium in a
reticular pattern
producing a " cotton-wool plug"
appearance [arrow]

39. BEADED TUBE
Multiple constrictions along the
fallopian tube giving rise to
a " beaded" appearance [arrows]

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41. SAMPLE FOOTER TEXT 10/3/2018 41

42. LEOPARD SKIN
APPEARANCE

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COBBLE STONE
APPEARANCE

44. CORK SCREW
APPREANCE
Vertically fixed tubes leading to lack of
tubal mobility.
The hyper convoluted tube
manifests a "cork screw" like
appearance.

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

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