Hysterosalpingography (HSG) is a radiographic procedure used to evaluate the uterine cavity and fallopian tubes. During an HSG, a radio-opaque contrast agent is injected through the cervix into the uterus and fallopian tubes. This allows visualization of the anatomy and any abnormalities. An HSG can detect conditions that cause infertility such as uterine anomalies, fibroids, adhesions, tubal blockages, and hydrosalpinges. It is an important tool for evaluating infertility. The procedure involves positioning the patient and inserting a cannula to inject contrast into the uterus under fluoroscopic imaging. Both normal anatomy and common pathological findings can be seen on an HSG.

1. HYSTEROSALPINGOGRAPHY

2. Introduction
 Hysterosalpingography(HSG) is
radiographic evaluation of uterine
cavity and fallopian tubes after
administration of radio-opaque
medium through cervical canal.
 HSG demonstrates:
-morphology of uterine cavity
-patency of fallopian tubes
 HSG remains an important radiologic
procedure in the investigation of
infertility

3. RelevantAnatomy
Uterus : HSG is
helpful in the evaluation of the uterine
cavity primarily & provides only indirect
information about the remainder of the
uterus.
The uterine cavity is triangular,
with the base directed cranially and the
apex caudally.
The cervix constitutes the most
inferior aspect of the uterus and extends
into the vagina.
The isthmus is the uterine portion
immediately above the cervix.
The majority of the uterus is composed of
the body, or corpus.
The uppermost aspect of the uterus is
the fundus.
The fallopian tubes connect to the fundus
at the cornua.

4. FT: The fallopian tubes serve as the
passageway for the ovum to travel from
the ovary to the uterus.
• They are 10–12 cm in length and
course along the superior aspect of the
broad ligament.
• Each fallopian tube can be divided into
three segments radiographically.
The interstitial or cornual region is the
short segment that traverses the
muscular wall of the uterus.
The isthmic portion is the longest of the
three segments and is the narrow
part between the interstitial and ampullary
regions.
The ampullary portion is the widened
region near the ovary.
The fimbriated part is the funnel-shaped
end of the tube and is not usually seen at
HSG.

6. • On HSG, the uterus
should look like an
inverted triangle with
well-defined, smooth
contours.
• the Fallopian tubes
should appear as thin,
smooth lines that widen
in the ampullary portion.
• There should be free
spillage of contrast
material into the
peritoneal cavity.

7. INDICATIONS
 Infertility (mc)
 Recurrent spontaneous abortions
Postoperative evaluation following tubal ligation or
reversal of tubal ligation
 Congenital anomalies of uterus
To prove tubal occlusion after insertion of transcervival
sterilization microinsert (‘essure’ device)

8. CONTRAINDICATIONS
 Suspected pregnancy
Avoided by : performing HSG before the ovulation phase,
“between the 7th to 12th day of the menstrual cycle”
 Active pelvic infection
 Active vaginal bleeding
 Recent dilation and curettage
 Contrast sensitivity

9. PATIENT PREPARATION
Timing:
HSG is performed between the 7th & 12th day of menstrual
cycle, i.e., 2-3 days after stoppage of menstruation.
(i) menstrual tissue or fluid is not carried with the contrast
into the oviduct or the peritoneal cavity.
(ii) Endometrium is thin during this proliferative phase,
which facilitates better image interpretation.
(iii) No chance of pregnancy
(If periods are irregular, do urine b- hcg test to rule out
pregnancy)

10. • The patient should be instructed to abstain from sexual
intercourse from the time menstrual bleeding ends until
the day of the study to avoid a potential pregnancy.
• Bowel preparation :Patient should be fasting 4 hours prior
to the procedure to avoid reproductive tract obscuring by
bowel gas.
• Bladder Voiding : empty bladder immediately before the
examination because full bladder will elevate the fallopian
tubes and may cause apparent tubal blockage with the
spurious radiological appearance of a hydrosalpinx.

11. Techniques
1. Using
Cannula
11
2. Using Foleys
catheter
1. Leech Wilkinson
canula
2. Jercho type
3. Spackman

12. PROCEDURE
• Informed consent is taken
• The patient is placed in lithotomy position on the screening table prior to
bimanual pelvic examination.
• After a bimanual vaginal examination during which the size & position of
the uterus are determined then vaginal speculum is inserted.
• The vaginal vault is cleaned well with a non-irritant antiseptic solution.
• If a cannula is to be inserted ,topical anesthesia such as 20% benzocaine
gel can be applied to the cervix, prior to grasping the anterior lip of the
cervix by tenaculum forcep.
• The cannula (Leech Wilkinsons cannula) is then inserted through the
external os ,followed by removal of speculum.
• Contrast material is injected into the uterine cavity through the catheter
and images are taken.

14. Radiological Views
• We obtain four spot radiographs after the scout radiograph.
• The first image is obtained during early filling of the uterus and
is used to evaluate for any filling defect or contour abnormality.
Small filling defects are best seen at this stage.
• The second image is obtained with the uterus fully distended.
The shape of the uterus is best evaluated at this stage,
although small filling defects may be obscured when the uterus
is well opacified.
• The third image is obtained to demonstrate and evaluate the
fallopian tubes.
• The fourth image should exhibit free intraperitoneal spillage of
contrast material.

15. At least 4 spot films taken
4.Peritoneal
spillage
2. Uterus fully
distended
1.Early filling
phase
3.Tubal filling
phase
NORMAL HSG

16. CONTRAST MEDIA
WATER SOLUBLE CONTRAST
(iohexol-omnipaque,meglumine
diatrizoate-duroscan)
• Gets absorbed within hours, does not leave residue
• Granuloma formation rare
• Prompt demonstration of tubal patency, delayed film not needed.
• Mild Pain may persist after procedure
• Widely used and preferred

17. LIPID SOLUBLE CONTRAST
(lipiodol)
• Delayed absorption
• Risk of lipogranuloma formatation
• Intravasation of contrast and
possible risk of oil embolism
• Need of delayed film
• Less often used

18. Amount of contrast medium to be introduced is variable.
Initially 3-5 ml is given to take spot film 1(Ut size,shape,endometrial
cavity).
Slow gradual injection of another 5cc to delineate fallopian tubes .
Another 3-5ml can be given if spillage is still not seen

19. COMPLICATIONS
Common complications of HSG:
Bleeding :The patient should be made aware that
she may experience light spotting after the
procedure,usually lasting less than 24 hours.
Uterine contractions and discomfort
 Postprocedural infection
Vasovagal reaction
 Allergic reaction to contrast media:

20. NON PATHOLOGIC
FINDINGS
 Air bubbles
 Normal myometrial folds
 Prominent cervical glands
 Previous caeserean section scar
 Venous or Lymphatic Intravasation
 Postmyomectomy Diverticulum
 Gartner’s Duct Cyst

21. Air bubbles:
• During HSG, air bubbles can incidentally be introduced
into the uterine cavity and may be mistaken for filling
defects.
• An air bubble appears as a round, well-defined filling
defect; multiple air bubbles are often seen, and they are
usually identifiable by their mobility and non dependant
location

22. Spot radiograph shows air bubbles (arrow) in the left
side of the uterus.
AIR BUBBLE

23. Hysterosalpingogram obtained
with balloon-catheter shows
multiple rounded filling defects
(arrows), at both uterine horns.
Hysterosalpingogram obtained with
additional injection of contrast material
shows bubbles have been flushed out
of uterine cavity through fallopian
tubes.

24. • Normal myometrial folds
In a small percentage of patients, broad longitudinal folds
parallel to the uterine cavity are seen on HSG’s with
otherwise normal findings. These folds are not associated
with endometrial abnormalities.

25. 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.
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UTERINE FOLDS

26.  Prominent cervical glands:
Filling of normal endocervical glands may be observed
as multiple tubular structures that originate from
both cervical walls

27. PROMINENT CERVICAL GLANDS
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28. Spot radiograph shows the uterine incision from a cesarean section (arrows) in the
typical location (i.e., oriented transverse in the lower uterine segment).
CESAREAN SECTION SCAR

29. Postmyomectomy Diverticulum : After the
resection of a fibroid, small diverticula—generally less
than1 cm in diameter—can be found in some patients at
the site of resection.
Hysterosalpingogram
obtained after patient underwent
myomectomy shows small
diverticulum at site of resection
with no distortion of uterine cavity

30. Venous or Lymphatic Intravasation
The radiographic appearance of intravasation of contrast
is characterized by filling of multiple thin beaded channels
and an ascendant course.
Hysterosalpingogram
shows network of thin vessels
(arrow) which can be opacified
during hysterosalpingography
in healthy patients.

31. Gartner’s Duct Cyst
Gartner’s duct is a remnant of the caudal portion of the
wolffian duct that fails to resorb normally in the female.
They appear as tubular structures that run parallel to the
uterine cavity , sometimes with cystic or saccular
dilatations.
Secretion by persistent glandular tissue may allow cysts to
form in its course.
They are visible on HSG when they communicate with the
uterine lumen.

33. Gartner’s duct cyst in 25 yo
asymptomatic woman.
HSG shows tubular structure,
running parallel to uterine
cavity (arrows), that represents
Gartner’s duct communicating
with uterine lumen.
Gartner’s duct cyst in 32yo
woman. HSG reveals course of
Gartner’s duct cyst running
along vaginal wall. Saccular
dilatations (large arrow) can be
present

34. DETECTABLE PATHOLOGY
• UTERINE
Congenital Uterine anomaly
Fibroid ( submucosal)
Adenomyosis
Endometrial polyp
Intrauterine
adhesions/synaechiae
• TUBAL
Tubal block
Tubal spasm
Hydrosalpinx
Salpingitis isthmic
nodosum (SIN)
Peritubal adhesions
3
4

35. SALPINGITIS ISTHMICA NODOSA
SIN appears as small outpouchings or
diverticula from the isthmic portion of the
fallopian tube and can affect one or both
tubes
• Associated with infertility, PID and ectopic
pregnancy
• Unknown cause

36. SALPINGITIS ISTHMIC NODOSUM (SIN)
Small outpouchings or diverticula from the isthmic
portion of the fallopian tubes
53

37. Tubal spasm
• The cornual portion of the fallopian tube is encased by the
smooth muscle of the uterus. If there is spasm of the
muscle during HSG, one or both tubes may not fill beyond
the interstitial portion
• At radiography, tubal spasm cannot be distinguished from
tubal occlusion. Administration of a spasmolytic agent
such as glucagon/buscopan can occasionally result in
uterine muscle relaxation and consequent tube
opacification thereby helping differentiate cornual spasm
from true occlusion.

38. Cornual spasm. (a) 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..
(b) 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 leftsided hydrosalpinx are also noted.

39. Tubal block & Hydrosalpinx
Tubal occlusion
• Tubal occlusion is defined as the blockage of the fallopian
tube, and most commonly occurs secondary to infection,
with causes such as pelvic inflammatory disease, septic
abortion, and abdominal infection.
• HSG is the preffered imaging modality in the diagnosis of
tubal occlusion, demonstrating an abrupt cutoff in contrast
within the fallopian tube & non-opacification of the distal
tube, which can occur at any point along the length of the
tube; and lack of intraperitoneal free spillage of contrast .

40. HSG demonstrating tubal occlusion on the right and free spill of
contrast on the left.

41. HSG demonstrating bilateral tubal occlusion
If the obstruction is identified within the proximal/corneal portion of the
fallopian tube, differentiation from spasm must be considered, with delayed
imaging or administration of a spasmolytic agent to determine whether the
obstruction is permanent or temporary

42. Cutoff of contrast material in the isthmic portions of both fallopian tubes, with
bulbous dilatation of the distal aspects of the opacified portions.
TUBAL LIGATION
60

43. Hydrosalpinx: It occurs when the ampullary portion of the
fallopian tube becomes blocked, causing dilatation of the
proximal tube, taking on a classic sausage-shaped
appearance.
• It is caused by scarring and/or adhesions of the distal
tube, secondary usually to pelvic inflammatory disease.
• HSG demonstrates a dilated proximal tube with absence
of free intraperitoneal spillage of contrast .
• If detected on HSG, postprocedural antibiotic prophylaxis
is recommended to prevent infection from stasis of
contrast material within the obstructed tube.

44. HSG demonstrating occlusion and dilatation of the distal right fallopian tube with
absence of free intraperitoneal spillage of contrast. (B) US image demonstrates an
enlarged hypoechoic tubular structure in the region of the right adnexa with the
appearance of incomplete septa (arrow). (C) T2-weighted MR
image shows an enlarged fluid signal mass in the region of the right adnexa.

45. Peritubal adhesions
• Another sequela of PID is scarring in the peritoneal cavity
surrounding the fallopian tube. Peritubal adhesions
prevent contrast material from flowing freely around the
bowel loops and most commonly manifest as loculation of
the contrast material around the ampullary portion of the
tube.

46. LEFT PERITUBAL ADHESION
A round collection of contrast material adjacent to the left
fallopian tube, a finding that suggests peritubal adhesions. Note
the
3-Ja
f
nr
-1
e
6 e contrast material spillage on the right side. 61

47. Tubercular salpingitis
Tubercular salpingitis is one of the most common causes
of primary infertility in low socio-economic countries.
The bilateral fallopian tubes are the initial focus of female
genital tuberculosis.
HSG can present tubal tuberculosis in many forms, such
as hydrosalpinx to specific patterns such as beaded tube,
golf club tube, pipestem tube, cobblestone tube, and the
leopard skin tube.

48. cotton-wool plug appearance
Distribution of contrast medium in a reticular pattern
producing a " cotton-wool plug" appearance [arrow]
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49. BEADED TUBE
Multiple constrictions along the fallopian tube giving rise to
a " beaded" appearance [arrows]
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50. GOLF CLUB TUBE
Sacculation of both tubes in distal portion with an
associated hydrosalpinx giving a Golf club-like appearance
(arrows).
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0

51. LEOPARD SKIN APPEARANCE
Multiple rounded filling defects following intraluminal granuloma
formations within the hydrosalpinx, resembling a " leopard skin"
appearance [arrows]
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52. COBBLE STONE APPEARANCE
Intraluminal scarring of the tube gives rises a cobblestone
like appearance which is an effective radiographic sign of
intraluminal adhesions
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53. 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.
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3

54. Essure
• A new irreversible occlusion device called Essure was
recently introduced.
• This soft, flexible microinsert is placed hysteroscopically
into each fallopian tube.
• The microinsert induces scar tissue formation around
itself after a few months. At that time, HSG is usually
performed to evaluate for tubal occlusion

55. Irreversible tubal occlusion with a microinsert. (a) Scout radiograph obtained
prior to the instillation of contrast material shows a microinsert that has been
placed hysteroscopically into the proximal fallopian tube
. (b) Radiograph obtained after instillation shows no contrast material filling of
the fallopian tube beyond the microinsert, a finding that helps document tubal
occlusion.

56. DETECTABLE PATHOLOGY
• UTERINE
Uterine anomaly
Fibroid ( submucosal)
Adenomyosis
Endometrial polyp
Intrauterine
adhesions/synaechiae
• TUBAL
Tubal block
Tubal spasm
Hydrosalpinx
Salpingitis isthmic
nodosum (SIN)
Peritubal adhesions
5
6

57. Intrauterine adhesions/synaechiae
• Uterine synechiae, also known as intrauterine adhesions,
are permanent adhesions of the endometrial canal
leading to partial or complete loss of the uterine cavity.
• The condition is thought to arise from any cause that is
destructive to the endometrial lining including infection,
missed abortion, and previous curettage.
• When the finding is associated with clinical symptoms of
infertility and/or recurrent pregnancy loss, the term
Asherman syndrome may be applied.
• HSG is the imaging technique of choice for the diagnosis
of this condition, demonstrating irregular, well-defined,
angular, and/or straight linear filling defects within the
endometrial canal .

58. Central oval filling defect within the uterus
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SYNECHIAE

59. SYNECHIAE
Multiple irregular filling defects in uterine
cavity
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60. Fibroid
• Leiomyomas manifest as well-defined filling defects at
HSG and can have a variety of appearances depending
on their size and their location within the uterus.
• Submucosal fibroids, best visualized early in uterine filling
phase,appear as well defined filling defects in the uterine
cavity. However, this finding is nonspecific and
differentiation from other causes,such as endometrial
polyps, may be needed.
• Large intramural myomas can be indirectly seen as they
distort the size and shape of the uterine cavity.

61. RIGHT SUBMUCOSAL MYOMA

62. Spot radiograph obtained during the early filling stage shows a
well-defined filling defect (arrow) in the fundus.

63. Spot radiograph reveals a large leiomyoma distorting
the endometrial cavity as it drapes over a mass in the left
myometrium.

64. Endometrial polyps
Endometrial polyps are focal overgrowths of the
endometrium. They usually manifest as well defined filling
defects and are best seen during the early filling stage.
Small polyps may be obscured when contrast material
completely fills the uterine cavity and may be
indistinguishable from a small submucosal myoma.
 Sonohysterography has become the preferred method of
imaging endometrial polyps.

65. Endometrial polyps. (A) Sonohysterographic image demonstrating a focal
echogenic mass protruding into the endometrial lumen, and a feeding
vessel identified on Doppler imaging.
(B) HSG shows a small filling defect within the left uterine horn.

66. Adenomyosis
• Adenomyosis is a benign process whereby the
endometrial glands and stroma invade the
myometrium,causing hyperplastic and hypertrophic
changes of the myometrium.
• Adenomyosis generally manifests as pelvic pain or
abnormal bleeding, it is more commonly detected with MR
imaging or US and is an incidental finding at HSG
performed in an infertile woman.

67. (a, b) Diffuse adenomyosis. (a) Spot radiograph shows irregularity of the
uterine contour with small outpouchings of contrast material, findings that
represent diffuse adenomyosis. (b) Sagittal T2-weighted MR image
shows thickening of the junctional zone to more than 1 cm, especially in the
anterior fundus.

68. Congenital Uterine Anomalies
The female reproductive tract develops
from a pair of Müllerian ducts that form the
fallopian tubes, uterus, cervix and the
upper two-thirds of the vagina.
First there is formation of the paired
Müllerian ducts, followed by fusion of the
two ducts into a single uterus, cervix and
upper vagina.
Finally resorption of the septum will lead to
a normal cavum.

69. Embryology
Agenesis
Hypoplasia
Bicornuate
Didelphys
Septate
Arcuate

71. Class 1
Uterine hypoplasia and/or agenesis occur when both mullerian
ducts fail to or incompletely develop, causing absence or
rudimentary development of the uterus and proximal vagina.
It is seen in Mayer-Rokitansky-Kuster-Hauser
syndrome(MRKH)
• genetic female (46,XX)
• normal external genitalia
• primary amenorrhea
• partial or absent uterus.
• Additional renal anomalies may also be present.
HSG evaluation is not indicated for this condition.

72. Class II: Unicornuate Uterus
Incomplete or failed development of one of the mullerian ducts
results in a functional uterine cavity with a single uterine horn.
There may be an associated rudimentary horn on the
contralateral side, with or without a communication with the
dominant uterine horn.
• It may also be associated with cyclic pelvic pain when the
rudimentary horn is non communicating and contains functional
endometrium.
• When Unicornuate uterus is detected, MR imaging should be
performed to evaluate for a rudimentary horn, as this structure
is associated with an increased risk of endometriosis and/or
ectopic pregnancy.
• In addition, urinary tract anomalies are often associated with
this condition, with renal agenesis contralateral to the dominant
uterine horn most commonly seen.

74. • Class 2 :Unicornuate uterus.
At HSG an off- midline fusiform uterine cavity is seen with contrast opacification of a
solitary fallopian tube. While a communicating rudimentary uterine horn may be
visualized, HSG cannot be used to exclude it.

75. Class II: unicornuate uterus. (A) HSG imaging demonstrates a “banana-
shaped” endometrial canal, laterally deviated to the right with a single
fallopian tube. (B) MR T2-weighted image of the same patient demonstrates
a unicornuate uterus (arrow) on the right with rudimentary horn on the left,
which was not detected by HSG
(arrowhead).

76. Class III: Didelphys Uterus
• It occurs when there is complete failure of fusion of the
mullerian ducts, resulting in a duplicated pair of uteri and
cervices.
• Imaging with HSG, US, and MR demonstrates 2
symmetric, widely spaced uterine horns each with its own
cervix
• Failure to identify and cannulate both cervices during
HSG may lead to the false diagnosis of unicornuate
uterus.

77. • Class 3: Didelphys uterus
• HSG demonstrates two separate, oblong endometrial cavities with contrast
opacification of fallopian tubes

78. Bicornuate uterus
• It occurs when the superior portions of the mullerian ducts
fail to fuse with normal fusion of the inferior uterine
segment.
• The central myometrium can extend to the level of the
internal cervical os (bicornuate unicollis) or external
uterine os (bicornuate bicollis).

79. • HSG demonstrates two fusiform symmetric size
endometrial canals, with possible visualization of a
communication between the inferior segments of the
uterine horns.
• US and MR imaging demonstrate a fundal uterine cleft
larger than 1 cm separating divergent uterine horns.
• A widened angle(>105) between the uterine horns with an
intercornual distance of greater than 4 cm is suggestive of
bicornuate uterus on HSG

80. (A)MR image demonstrates a fundal uterine cleft, which is greater than 1 cm,
separating divergent uterine horns. (B) HSG examination of the same patient is
suggestive of bicornuate uterus, as there is a widened angle (>105) between
the uterine horns with a widened intercornual distance of more than 4 cm.

81. Spot radiograph shows two markedly splayed uterine horns.
BICORNUATE UTERUS

82. BICORNUATE UNICOLLIS UTERUS
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83. BICORNUATEBICOLLIS
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84. A widened angle(>105) between the uterine horns with an
intercornual distance of greater than 4 cm is suggestive of
bicornuate uterus on HSG; however,the imaging technique is
limited in its differentiation from a septate uterus, as the external
uterine contour can not be evaluated.

85. Septate uterus
• Failure of the fibromuscular septum between the two mullerian
ducts to resorb after ductal fusion leads to the development of
a septate uterus.
• US and MR demonstrate either a normal, or flat, or contour
depression of the uterine fundus of less than 1 cm .
• On HSG , a narrow angle between the uterine horns and an
intercornual distance of less than 4 cm is suggestive of septate
uterus.
• Of the mullerian duct anomalies, this condition is associated
with the highest rate of reproductive failures.
• US and MR imaging have improved the diagnostic accuracy for
septate uterus, with hysteroscopy and laparoscopy serving as
gold standards for diagnosis

86. Class V: septate uterus. (A) MR image demonstrating a normal
external uterine contour with 2 symmetric endometrial cavities, which
are narrower and smaller than normal. Note the thickened septum
isointense with the adjacent myometrium (arrow). (B) HSG
demonstrating a double endometrial canal with an acute uterine horn
angle of less 75

87. Class 6:Arcuate uterus
• Incomplete resorption of the septum results in a focal
bulge at the level of the uterine fundus.
• HSG, US, and MR imaging demonstrate a single
endometrial canal,with a smooth, broad indentation of the
myometrium(<1 cm) at the uterine fundus.
• The external uterine contour is normal on US and
MRimaging

88. • Class 6: Arcuate uterus
• .
• At HSG, a single uterine cavity with a broad saddle-shaped indentation at the uterine
fundus is seen

89. (A) HSG demonstrating a single endometrial canal with a smooth broad
indentation of the myometrium (<1 cm) at uterine fundus. (B) US image
demonstrating a single endometrial canal with a smooth broad indentation
of the myometrium (<1 cm) at the uterine fundus. Note the smooth external
uterine
contour

90. • Class 7: DES uterus
• HSG image shows the classic T-shaped uterine cavity due to DES exposure.