Hysterosalpingogram

by

Molly Jonna, MS4 and Jennifer Lim-Dunham, M.D.

What is Hysterosalpingogram?

• A hysterosalpingogram is a radiographic evaluation of the uterine cavity and fallopian tubes. It is performed by injecting radio-opaque material (contrast) into the cervical canal, and then fluoroscopy is performed.
• In general, radiographs are taken at the beginning of uterine cavity filling, when the cavity is filled, during tubal filling to evaluate tubal mucosa, and later to document whether there is spillage of contrast into the peritoneal cavity.
• Hysterosalpingography also has therapeutic effects and can increase fertility in the months following the procedure.

What are the indications for hysterosapingography?

• Hysterosalpingography is most commonly used in the evaluation of infertility. Uterine abnormalities are thought to be a contributing factor in approximately 10% of infertile women and 50% of women with recurrent early pregnancy loss, while the prevalence of tubal abnormalities in infertility is approximately 20%. Therefore, assessment of the uterine cavity and fallopian tubes is a standard practice in the baseline infertility workup.
• It is also performed in recurrent early pregnancy loss and pre-term delivery.
• Evaluation of tubal patency in surgical sterilization or reversal of sterilization, although this is more rare.
• Detection of uterine anomalies, endometrial polyps, submucous myoma, and synechiae.
• It will detect several tubal abnormalities, including cornual occlusion, salpingitis isthmica nodosa, and hydrosalpinx.
• HSG should not be performed if active infection is suspected anywhere in the pelvis or in the cervix/vagina, or if there is active bleeding.
• Pregnancy is an absolute contraindication and the study should be performed in the follicular phase (days 1-10) of the menstrual cycle to minimize the chance of interfering with a possible early pregnancy.

What are the possible imaging abnormalities?

• The radiographs are examined to determine the size and shape of the uterus, whether there are filling defects, whether the endometrial surfaces are irregular or smooth, and whether there is normal spillage of contrast into the peritoneal cavity of the pelvis.
• Extravasation or spillage of contrast into the pelvis indicates patency of the fallopian tubes. For fertility studies only one tube needs to be patent.
• Possilbe uterine abnormalities include:
• Uterine congenital anomalies
• Submucosal uterine fibroids
• Uterine malignancy
• Adenomyosis
• Intrauterine adhesions
• Uterine polyps
• Possible tubal abnormalities include:
• Obstruction of fallopian tubes, usually secondary to previous inflammation
• Tubal polyps
• Tubal malignancy
• Hydrosalpinx
• Salpingitis isthmica nodosa (SIN)

What are the complications?

• Common complications are abdominal cramping and light spotting.
• Uncommon and more serious complications include the risk of infection, contrast reaction, hemorrhage, and uterine perforation.

Take Home Points:

• Hysterosalpingography (HSG) is used both for diagnosis of uterine and tubal defects and for treatment of unexplained infertility.
• The major indications for HSG are infertility and recurrent pregnancy loss. The major contraindications are active pelvic infection, active bleeding, and pregnancy
• HSG should be done during the follicular phase of menstrual cycle, when pregnancy is unlikely.
• Spillage of contrast into the pelvis is normal and indicates patency of fallopian tubes. Only one tube needs to be patent for fertility.

Imaging

	Image 1 This image shows an early radiograph from a normal HSG. The white arrowhead is pointing towards the uterus, which is filled with contrast (the dark, radiopaque material), and is normal in shape. The white arrows are pointing towards the right and left fallopian tubes which are both beginning to fill with contrast.
	Image 2 This normal HSG shows normal spillage of contrast material in to the peritoneal cavity of the pelvis, indicating that the fallopian tubes are normal and patent. The white arrows indicate the dark areas of contrast material which form a triangular shape as it flows around bowel loops.
	Image 3 Abnormal HSG showing obstructed left fallopian tube. The white arrowhead is pointing towards the uterus, which has filled with contrast and is normal in shape. The white arrow is pointing towards the right fallopian tube, which has begun to fill with contrast. Note that the left fallopian tube does not fill with contrast, indicating that it is obstructed.
/td>	Image 4 At a later point in time, this image shows contrast spilling from the right fallopian tube into the peritoneum (white arrow). Again, note that the left fallopian tube did not fill with contrast and that there is no spillage on the left side which indicates that the tube is obstructed and is not patent.

Helpful Links with Additional Imaging:

1. http://radiopaedia.org/articles/hysterosalpingogram case images can be found on the right side of the page
2.  http://pubs.rsna.org/doi/pdf/10.1148/radiographics.8.6.3060910 case images are found throughout the article
3.  http://www.ajronline.org/doi/full/10.2214/ajr.177.1.1770131 case images are found throughout the article

References:

1. Baramki, T. A. (2013). Hysterosalpingography. In S. Falk & R. Barbieri (Eds.), UpToDate. Retrieved from http://www.uptodate.com/contents/hysterosalpingography?detectedLanguage=en&source=search_result&search=hysterosalpingogram&selectedTitle=1~42&provider=noProvider
2. Wolf, D. M., & Spataro, R. F. (1988). The current state of hysterosalpingography. RadioGraphics, 8(6), 1041-1058. Retrieved from http://pubs.rsna.org/doi/pdf/10.1148/radiographics.8.6.3060910
3. Steward, R. G. (2012). Hysterosalpingogram. In R. Rucidi (Ed.), Medscape. Retrieved from http://emedicine.medscape.com/article/2111999-overview

12.09.13