Hysterosalpingogram (HSG)

As a woman, conceiving and having a baby is not a simple process. Instead, it involves various parts of the body that must work right to achieve what you want. This includes the ovaries that produce the egg each month (ovulation), the fallopian tubes that should be open. This is to allow the egg to pass through, and lastly, the uterus needs to be in good shape. 

Infertility affects around 15% of couples and is characterized as the failure to conceive after 12 months of frequent unprotected sexual intercourse. Male factor (45%), ovulation abnormalities (37%), and tubal injury are the most common causes of infertility (18 percent ).

Approximately 20% of all couples have a mix of many characteristics. Tubal injury can be caused by either intrinsic (ascending salpingitis, including salpingitis isthmica nodosa) or external factors (peritonitis, endometriosis and pelvic surgery).

In 10% of women, uterine cavity anomalies can be a contributing cause of infertility. Abnormal uterine findings have been documented in up to 50% of women with recurrent implantation failure. Endometrial polyps or fibroids, which are detected as filling defects or uterine wall abnormalities utilizing hysterosalpingography, are among these results (HSG). HSG can also reveal intrauterine adhesions and congenital defects.

What is a hysterosalpingogram test?

Imaging is crucial in determining the cause of female infertility. Transvaginal ultrasonography (TVUS) is a common, first-line technique. Saline or contrast hysterosalpingo sonography can be used to further examine abnormal results. Hysterosalpingo contrast sonography (HyCoSy) has been shown to be extremely sensitive, specific, and accurate in detecting uterine abnormalities such as polyps.

It is, however, of little use in assessing tubal anomalies. MRI can be used to examine congenital Müllerian duct abnormalities and to identify adenomyosis, leiomyoma, and endometriosis; however, its function in tubal evaluation is still restricted. 

Benefits of Hysterosalpingogram 

HSG's major function is to assess the morphology and patency of the fallopian tubes. The fallopian tubes should be seen as thin, smooth lines that broaden in the ampullary region.

HSG is typically an essential procedure to help every woman who has trouble getting pregnant. It can also be helpful to a woman who has suffered pregnancy issues, including multiple miscarriages. Furthermore, HSG can help diagnose the actual cause of infertility and come up with an effective treatment plan. Some of the common causes of infertility include fallopian tube blockage, uterine fibroids, uterine polyps, uterine structural abnormalities, etc. 

Tubal occlusion can be unilateral or bilateral, manifesting as an abrupt stoppage of contrast material with non-opacification of the distal fallopian tube. Peritubal adhesions keep contrast material from flowing into the abdominal cavity and freely disseminating.

HSG can also be used to assess uterine cavity abnormalities. It is thought to have a high sensitivity (60–98%) but low specificity (15–80%) in detecting uterine anomalies, and hysteroscopy is still the preferred approach for the final assessment.

Polyps, endometrial hyperplasia, submucosal fibroids, intrauterine adhesions, and septa are included in the differential diagnosis of intrauterine filling abnormalities by HSG. These results demand further hysteroscopy research to confirm and perhaps treat the pathology.

In case you have undergone tubal surgery, then the doctor can recommend HSG to check whether the procedure was successful. Sometimes, the doctor can perform HSG for patients who have had a tubal ligation to ensure that tubes are closed appropriately. Tubal ligation is a procedure to close both the fallopian tubes as a way of preventing pregnancy. HSG can also help check if tubal ligation reversal was successful and the closed fallopian tubes have been reopened.

Other benefits of hysterosalpingogram procedure include; 

• Less to no complications since HSG is a minimally invasive type of procedure
• Provides helpful information regarding the problems associated with pregnancy issues 
• It helps open blocked fallopian tubes, hence enabling you to get pregnant in the future.
• Radiation doesn’t remain in the body after conducting an x-ray examination.
• X-rays are not associated with any side effects in the typical diagnostic range for HSG test procedure.

How to Prepare for Hysterosalpingogram Test?

To guarantee that the patient is not pregnant and to avoid false-positive intrauterine filling abnormalities and proximal tubal blockage owing to endometrial thickness, the treatment should be conducted in the late follicular phase of the menstrual cycle. Some hospitals do routine pregnancy testing prior to the treatment; however, this technique has an unfavorable cost-benefit ratio.

Sometimes, the HSG test procedure is associated with pain and discomfort. In such a case, the doctor can administer some pain-relieving medication or recommend an over-the-counter pain drug. You should take these pain medicines about one hour before undergoing the procedure. 

Pain from HSG is commonly linked with cervical manipulation, uterine cavity distention from contrast media instillation, and peritoneal irritation from dye spilled into the pelvis. Discomfort often peaks at the moment of dye injection and then begins to diminish rapidly, with most patients reporting considerable alleviation 30 minutes following the treatment. 

If necessary, the doctor can also administer a sedative. This helps you relax and feel at ease, especially if you are anxious about the process. An antibiotic can also be helpful; hence you can take it before or after the procedure to prevent infection.

The best time to perform the HSG test is a few days after your menstruation and just before ovulation. This is to ensure that you are not pregnant and minimize the risks of infection. In case you are already pregnant, then it’s essential to notify your doctor. This is because the procedure might be dangerous to the fetus. Also, avoid undergoing an HSG test if you are suffering from pelvic inflammatory disease and abnormal vaginal bleeding.

HSG x-ray test involves the use of a contrast dye. This is a substance that can be injected into the body or swallowed. It helps highlight some tissues and organs from those that surround them. This substance does not, however, dye the organs. Instead, it can either dissolve or get out of the body through urination. In case you have an adverse allergic reaction to contrast dye, it’s vital to inform your doctor to avoid complications.

If you are wearing any metal like jewelry on your body, the doctor can ask you to remove them. This is because metal can highly alter the x-ray machine and the outcome.

How Hysterosalpingogram is done?

Once you are ready to undergo the procedure, the doctor will lead you to the examination room. You will then be positioned beneath the fluoroscope on the operation table. A fluoroscope refers to the x-ray imaging device that captures images during the test. 

Either a gynecologist or a radiologist can perform the HSG test. They can examine your uterus by inserting a speculum into the vagina. A speculum refers to a medical tool used when examining the uterus to dilate the orifice. 

The specialist will clean the cervix and insert an instrument known as the cannula at the cervix's mouth. Once it is clean, they proceed and fill the uterus with a certain liquid containing iodine via the cannula. The purpose of the liquid is to make the inner organ visible through the x-ray machine. 

The procedure is usually completed in about 3-5 minutes, The doctor will view the contrast as white content on the images displayed on the computer screen. It also displays the uterus contour as the content flows from the cannula into the uterus and the fallopian tubes. Once the liquid reaches the fallopian tube, it highlights the actual length and shows the tube ends if open. 

This generally makes it easier for the doctor to detect any abnormality in the uterine cavity. This is done by observing and studying the pictures of the fluid movement and any disruption that can indicate an abnormality. 

During the procedure, the doctor can obtain both side views of the uterus and fallopian tubes. This is by asking you to change her position on the table. You can experience mild pain and cramping as the dye flows down through the fallopian tubes. 

However, you should note that the HSG test is not suitable for evaluating ovaries and diagnosing endometriosis. Also, it can’t detect fibroids located outside the endometrial or uterine cavity or the muscular section of the uterus. 

Once the HSG test is complete, the gynecologist will remove the cannula. He or she will then prescribe some medication to help ease pain and prevent infection before being discharged. Straight away, you can go back to your usual activities. However, some doctors can ask you to avoid intercourse for at least a few days.

What to Expect After the Procedure? 

You may continue experiencing cramps like those of the menstrual period after the procedure. Some women might also experience minor vaginal bleeding or vaginal discharge. In case of bleeding, doctors recommend using a pad rather than a tampon to prevent infections during this period. However, not every woman who undergoes HSG will experience such issues. 

Depending on the overall health state, some patients can experience nausea and dizziness after the procedure. However, these side effects are usually normal and can disappear with time. In case you experience infection-related symptoms, then you should immediately consult your doctor. These symptoms can include; 

• High fever
• Chronic and persistent pain or cramping
• Vaginal discharge with a foul smell 
• Sudden fainting
• Heavy vaginal bleeding
• Nausea and vomiting

The HSG procedure is not attempting to explore the ovaries or diagnose endometriosis, nor is it capable of detecting fibroids that are outside of the endometrial cavity, either in the muscular section of the uterus or on the exterior of the uterus. Side views of the uterus and tubes are frequently obtained by having the lady change positions on the table. After the HSG, a woman can resume regular activities right once, however, some doctors advise her to avoid sexual activity for a few days.

After a successful procedure, the radiologist or gynecologist will send the results to your doctor. He or she will check out the HSG test results with you to determine the underlying problem. Based on the outcome, the doctor may recommend some follow-up examinations or inquire for more tests.

Results of your HSG test

Your HSG test findings might help your doctor identify if you have a blockage in your fallopian tube or uterus, which could make it difficult for sperm to reach and fertilize an egg.

It also allows your gynecologist to examine the shape of your uterus, which affects fertility.

Here's what the various test results mean:

Normal HSG test results

If the liquid dye passes through your fallopian tubes and leaks out, your HSG test findings are normal, suggesting that there are no obstructions. (The spilled dye enters your stomach and is absorbed by your body.)

Abnormal HSG test results

If the liquid dye hits a blockage in one of your fallopian tubes or in your uterus, your HSG test findings will be abnormal. Surgery may help remove the obstruction and boost your chances of conceiving in some circumstances. In some circumstances, particularly if a blockage has caused damage or scarring to the fallopian tubes, your doctor may advise you to attempt in vitro fertilization (IVF). 

Whether to have surgery or attempt IVF is a personal choice. Your doctor can assist you in weighing the benefits and drawbacks of each choice to determine which one will give you the best chance of becoming pregnant.

Risks and complications of HSG

HSG is one of the safest and reliable procedures. But regardless, it’s sometimes associated with a few risks and complications where complex issues are rare. They include; 

Pelvic infection: 

This is the most common and serious issue associated with HSG procedure. It can occur if the patient has initially suffered tubal disease, including a previous infection of chlamydia. Though rare, the infection can advance and cause damages to the fallopian tubes. In such a case, removing the tubes might be necessary to prevent more complications. Therefore, if you experience increasing and persistent fever or pain within the first two days of HSG, you should seek immediate medical attention. 

See more information about: "What you need to know about Chlamydia"            

Fainting

The most common adverse event is a vasovagal reaction with bradycardia and hypotension, potentially resulting in syncope. This may occur anytime during the procedure. Most cases resolve with simple maneuvers including termination of the procedure and placement of the patient in a The most prevalent side effect is a vasovagal response with bradycardia and hypotension, which can lead to syncope. This might happen at any point during the operation. Most situations are resolved with simple actions such as stopping the treatment and, if feasible, placing the patient in a Trendelenburg position.

Radiation Exposure: 

During the HSG procedure, there is extremely low and less exposure to radiation as compared to a kidney or bowel study. Such exposure does not always cause any harm, even if you get pregnant later during the same month. However, if pregnancy is suspected, then the HSG procedure should not be done. 

Iodine Allergy:

In rare cases, a woman can be allergic to the iodine contrast used when performing an HSG test. Thus, it’s essential to inform the doctor if you are allergic to iodine, seafood, or intravenous contrast dye. To prevent allergic reactions to iodine, the doctor can perform the procedure without using an iodine-containing dye substance. In case you develop a rash, swelling, or itchiness after the test, you should immediately see your doctor.

Contrast dye allergies are significantly less prevalent than with intravenous delivery, however, they have been documented. The majority of patients exhibit urticaria. In a patient with asthma, one episode of angioedema with bronchospasm following extravasation was described, necessitating systemic administration of epinephrine and Benadryl.

Spotting:

Sometimes, spotting can occur for one to two days following the HSG test. Thus, it's essential to inform your doctor if you experience heavy bleeding after the procedure unless instructed otherwise. 

Extravasation:

Extravasation of dye is also a reason to stop the treatment. Extravasation that continues unabated may raise the danger of a systemic response to the contrast, increase the risk of infection, and result in embolism with an oil contrast agent.

Hysterosalpingogram cost

How much does an HSG test cost without insurance? You might expect to pay between $500 and $3,000 for this service. The precise amount is determined by your practitioner and where you reside.

Alternatives to HSG

Other procedures that can offer your doctor some of the same information as HSG include:

• Laparoscopy: This surgical procedure requires general anesthesia 
• Hysteroscopy: This treatment can provide a detailed view of the uterus's inside. It cannot, however, determine whether the fallopian tubes are obstructed.
• Sonohysterography: Ultrasound is used in this procedure to visualize the interior of the uterus. It, like hysteroscopy, does not reveal anything concerning the fallopian tubes.

Conclusion 

Hysterosalpingogram (HSG) is a type of x-ray technique that doctors use to view a woman’s womb or uterus and fallopian tubes. Fallopian tubes are the structures that carry the eggs from the ovaries towards the uterus. This method uses contrast substances to make the uterus and fallopian tubes visible through x-ray. This also allows the doctor to analyze and determine the underlying problem and develop an effective treatment plan. 

HSG remains the most often used first-line diagnostic test for uterine cavity and tubal patency. HSG is a simple technique that may be conducted as an outpatient procedure. Patients tolerate the surgery well when a suitable anesthetic strategy is used in conjunction with propofol sedation.

A dye is passed through a narrow tube during the test. This tube is inserted into the vaginal canal and into the uterus. The dye will flow into the fallopian tubes since the uterus and fallopian tubes are connected. A constant beam of X-ray (fluoroscopy) is used to obtain pictures while the dye moves through the uterus and fallopian tubes.

The pictures may reveal issues such as an injury or an irregular structure of the uterus or fallopian tubes. They can also reveal an obstruction that prevents an egg from passing through a fallopian tube and into the uterus. A clog may also prevent sperm from entering a fallopian tube and uniting (fertilizing) an egg. The test may also detect issues on the interior of the uterus that impair fertility.