3. INDICATION
1. Infertility (main role)
2. Recurrent spontaneous abortions
3. Congenital anomalies of uterus
4. Postoperative evaluation following (a)tubal
ligation (b) reversal of tubal ligation
5. Suspected case of genital tuberculosis
6. To prove tubal occlusion after insertion of
transcervival sterilization microinsert (essure)
HSG also has a potential therapeutic role in increasing the probability of
pregnancy ( especially if oil soluble contrast –lipiodol is used)3-Jan-16 3
4. CONTRAINDICATION
• Suspected pregnancy
• Acute pelvic infection
• Active vaginal bleeding
• Recent dilation and curettage
• Immediate pre and post menstrual phase
• Tubal or uterine surgery within last 6 wks
• Contrast sensitivity
3-Jan-16 4
5. PATIENT PREPARATION
• Done in first half of menstrual cycle in
proliferative phase between 8th to 12th day
• Patient to avoid unprotected sexual intercourse
from the date of her period until investigation is
over to avoid possible risk of pregnancy
• If periods are irregular , do urine b- hcg test to
rule out pregnancy
• Exclude active pelvic infection
• Prophylactic antibiotics not routinely
recommended (considered in case of bacterial
endocarditis)
3-Jan-16 5
6. PROCEDURE
• Informed consent is taken
• Antispasmodic (im drotin) given before procedure.
• Patient is asked to empty bladder immediately before
procedure
• Scot film may be taken.
• Patint is placed in lithotomy position
• The perineum is cleaned with antiseptic solution
(Betadine)and draped with sterile towel. The cervix is
localized and cleansed with povidone-iodine solution.
A speculum is inserted into the vagina. Cervix is
cannulated with any of available cannulas which is
made air free before administration of contrast
3-Jan-16 6
7. PROCEDURE ....
• Tenaculm is used to hold anterior lip of cervix .
• Speculum is removed & Patient is placed in slight
trendelenburg position and contrast is slowly given
• 3 ml contrast to fill uterine cavity and another 3 ml to
fill tube. ( up to 10 ml)
• 4 spot films are taken
• 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
3-Jan-16 7
9. HISTORY OF HSG
• First report on HSG using oil soluble contrast
(collargel) published by Carey in 1914.
• Collargel – significant tissue damage and
painful
• Because of these serious adverse events, its
use was abandoned and a tubal insufflation
test was introduced by Rubin in 1920 (Rubin,
1920)
3-Jan-16 9
10. HISTORY....
• Rubin insufflated oxygen (later carbon dioxide)
under pressure through the cervical canal into
the uterine cavity. Tubal patency was determined
by presence of air under the diaphragm on X-ray,
by auscultation of air flow into the abdomen or a
drop in pressure during insufflation
• Heuser was the first to report on the use of
lipiodol in HSGs (Heuser, 1925)
• Lipiodol- oil soluble, low viscosity, less toxic,
became widely accepted
3-Jan-16 10
11. • Lipiodol was gradually replaced by water
soluble contrast media for several reasons
LIPIODOL is 40% iodine in poppy seed oil
Manufactured by guerbert ,france
WHY WATER SOLUBLE CONTRAST MEDIA ARE PREFERRED ?
3-Jan-16 11
12. CONTRAST MEDIA
LIPID SOLUBLE CONTRAST
(lipiodol)
• Sharp image
• Minimal pain
• Delayed absorption
• Risk of lipogranuloma
formatation in case of tubal
block or hydrosalpinx
• Intravasation of contrast and
possible risk of oil embolism
• Need of delayed film
• Pregnancy rate doubled
• Less often used
WATER SOLUBLE CONTRAST
(iohexol-omnipaque,meglumine
diatrizoate-urograffin
• Ampullary rugae clearly
visualised
• Gets absorbed within hours,
does not leave residue
• Granuloma formation rare
• Pain persists after procedure
• Prompt demonstration of
tubal patency, delayed film not
needed.
• Widely used and preferred
3-Jan-16 12
14. Different types of cannula used
1. leech wilkinson cannula
2. acorn tip metallic cannula
3.cervical vaccum cup
4. balloon catheter or pediatric foley’s catheter
6F
3-Jan-16 14
15. WHICH ONE IS BETTER??
• Cervical vacuum cup vs metal cannula:
Shorter length of time
less fluoroscopic time
small amount of contrast needed
less pain ( no need to grasp cervix)
Easier for physician to use
Uterus cant be easily manipulated
Need to reapply cannula
Superior to metal cannula
Cervical
vacuum
cup
3-Jan-16 15
Cohen et al (British Journal of Obstetrics and Gynaecology
October 2001, Vol. 108, pp. 1031–1035)
16. BALLOON CATHETER VS METAL
CANNULA
Less fluoroscopic time
Small amount of contrast
Less pain
Easier for physician to use
Good seal at cervix
Single use/disposable(costly)
Superior to metal cannula
3-Jan-16 16
BALLOON CATHETER
Tur-kaspa et al (Human Reproduction vol.13 no.1 pp.75–77, 1998)
17. • Balloon catheter obscures lower uterine
segment. Need to be deflated to visualise
lower segment
• Balloon catheter better tolerated over cervical
cup
3-Jan-16 17
21. NORMAL HSG
• The uterine cavity is shown
during HSG as a triangular
contrast-filled structure,
with its base on top and
the apex caudally (inverted
triangle) and the uterine
fundus on top, which can
be flattened, concave or
slightly convex .
-free spillage of the
contrast to the peritoneum
noted
3-Jan-16 21
22. At least 4 spot films taken
4.Peritoneal
spillage
2. Uterus fully
distended
1.Early filling
phase
3.Tubal filling
phase
NORMAL HSG
3-Jan-16 22
24. NON PATHOLOGIC FINDINGS
• Air bubble- round, often multiple, welldefined
mobile filling defect ,usually displaced to
fallopian tubes if additional contrasts given
• Normal myometrial folds-longitudinal folds
with parallel orientation to uterine cavity
• Prominent cervical glands-tubular structure
with their origin in both cervical walls
• Previous caeserean section scar
3-Jan-16 24
25. Luminal filling defects
• Common finding.
• Includes :
Air bubbles
Uterine folds
Synechiae
endometrial polyp
submucosal fibroid
3-Jan-16 25
26. Spot radiograph shows air bubbles (arrow) in the left
side of the uterus.
AIR BUBBLE
3-Jan-16 26
27. Filling defects on consecutive images at the uterine fundus, that disappear
progressively after the administration of contrast, compatible with air bubbles.
3-Jan-16 27
DISAPPEARS
28. 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.
UTERINE FOLDS
3-Jan-16 28
30. Spot radiograph shows the uterine incision from a cesarean section (arrows) in the
typical location (i.e., oriented transverse in the lower uterine segment in the region of
the isthmus). At HSG, a cesarean section scar can have a linear appearance (as in this
case) or can occasionally manifest as a wedge-shaped outpouching or diverticulum.
CESAREAN SECTION SCAR
3-Jan-16 30
31. UTERINE ANOMALIES
class anomaly
i Partial / complete agenesis
ii Unicornuate
iii Didelphys
iv Bicornuate
V Septate
Vi Arcuate
vii DES-associated anomalies
3-Jan-16 31
AMERICAN SOCIETY OF REPRODUCTIVE MEDICINE
37. BICORNUATE UNICOLLIS
2 uterine cavities, 1 cervical canal
Incomplete fusion of the cephalad extent of the uterovaginal horns
with resorption of the uterovaginal septum.
3-Jan-16 37
1 CERVIX
43. DES-related uterine anomaly. Hysterosalpingogram
demonstrates a hypoplastic T-shaped uterus. The
patient had been exposed to DES while in utero.3-Jan-16 43
45. SEPTATE UTERUS: PARTIAL AND
COMPLETE
There is incomplete resorption of the final fibrous
septum between the two uterine horns.
SEPTUM
PARTIAL COMPLETE
3-Jan-16 45
48. Bicornuate and Septate Uteri
• Bicornuate:
– Fundus indented
– Cavities widely
separated( > 100 degree)
– Partial fusion of
mullerian ducts
• Septate:
– Normal external surface
– Cavities are close
together
– Defect in canalization or
resorption of midline
septum between
mullerian ducts.
HSG cant differentiate these two. Definite diagnosis by MRI
Intervening cleft > 1 cm & intercornual distance > 5cm in
bicornuate uterus
3-Jan-16 48
52. SALPINGITIS ISTHMICA NODOSA
• Out pouchings of isthmus
• Unilateral or bilateral
• Unknown cause
• Associated with infertility, PID and ectopic
pregnancy
3-Jan-16 52
53. SALPINGITIS ISTHMIC NODOSUM (SIN)
small outpouchings or diverticula from the isthmic
portion of the fallopian tubes. SIN can be either
unilateral or (as in this case) bilateral.
3-Jan-16 53
55. RIGHT HYDROSALPINX
Steep right oblique spot radiograph shows dilatation of the ampullary portion of
the right fallopian tube (arrow). The left fallopian tube is normal in caliber.
Mucosal folds are visible in the ampullary portions of both fallopian tubes, a
finding that helps confirm the presence of contrast material within the tubes
3-Jan-16 55
59. Dilatation of the ampullary portion of the left fallopian tube, a finding that is consistent with a
hydrosalpinx. No contrast material spillage is seen on the left side. The right fallopian tube is
abruptly cut off, a finding that is consistent with previous tubal ligation.
LEFT HYDROSALPINX ,RIGHT TUBAL LIGATION
3-Jan-16 59
60. Cutoff of contrast material in the isthmic portions of both fallopian tubes, with
bulbous dilatation of the distal aspects of the opacified portions. These findings can
be seen with postsurgical occlusion (eg, following tubal ligation).
TUBAL LIGATION
3-Jan-16 60
61. A round collection of contrast material adjacent to the left
fallopian tube, a finding that suggests peritubal adhesions. Note
the free contrast material spillage on the right side.
LEFT PERITUBAL ADHESION
3-Jan-16 61
62. SYNECHIAE
• Intra uterine adhesions
• Post curettage and infection
• Linear filling defect
• Arising from one of the uterine walls
• Multiple+infertility= Asherman syndrome
3-Jan-16 62
65. Right fallopian tube does not opacify beyond the cornual portion (arrow), whereas the left
fallopian tube opacifies to the ampullary portion. Arrowheads indicate amorphous
calcifications on the right side of the pelvis. These calcifications were also present on the scout
image
CORNUAL SPASM
3-Jan-16 65
69. Irreversible tubal occlusion with a microinsert. Scout radiograph
obtained prior to the instillation of contrast material shows a
microinsert that has been placed hysteroscopically into the proximal
fallopian tube.
SCOUT FILM
3-Jan-16 69
70. Radiograph obtained after instillation shows no contrast
material filling of the fallopian tube beyond the microinsert, a
finding that helps document tubal occlusion.
3-Jan-16 70
71. HSG FINDINDS IN GENITAL
TUBERCULOSIS
FALLOPIAN TUBES UTERUS
SPECIFIC
Beaded tube
Golf club tube
Pipestem tube
Cobblestone tube
Leopard skin tube
NON SPECIFIC
Hydrosalpinx
Mucosal thickening
Peritubal adhesion
SPECIFIC
T shaped uterus
Pseudounicornuate
uterus
Trifoliate uterus
NONSPECIFIC
endometritis
Syneciae
distortion of uterine
contour
Venous, lymphatic
intravasation
3-Jan-1671
72. TUFTED TUBE
Multiple small diverticular like appearance surrounding
the ampulla produced by caseous ulceration gives the
tubal outline a Rosette-like appearance
3-Jan-16 72
73. TB SIN-like
Penetration of contrast medium between the mucosal folds
produces small diverticular-like outpouchings with a bizarre
pattern. Entire of both tube involved (arrows).
3-Jan-16 73
76. GOLF CLUB TUBE
Sacculation of both tubes in distal portion with an
associated hydrosalpinx giving a Golf club-like appearance
(arrows).
3-Jan-16 76
77. PIPE STEM APPEARANCE
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.
3-Jan-16 77
79. LEOPARD SKIN APPEARANCE
Multiple rounded filling defects following intraluminal granuloma
formations within the hydrosalpinx, resembling a " leopard skin"
appearance [arrows]
3-Jan-16 79
80. COBBLE STONE APPEARANCE
Intraluminal scarring of the tube gives rises a cobblestone
like appearance which is an effective radiographic sign of
intraluminal adhesions
3-Jan-16 80
81. CORK SCREW APPREANCE
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]3-Jan-16 81
82. PERITUBAL HALO
Thickening of the tubal walls due to peritubal adhesions
(arrows) represents a cloudy sign on hysterosalpingograms.
This finding is a non-specific feature of tubal tuberculosis.3-Jan-16 82
83. 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.
3-Jan-16 83
84. 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.
A B
3-Jan-16 84
INTRAUTERINE ADHESION AND DISTORTION
85. 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.
3-Jan-16 85
86. T –SHAPED TB UTERUS DES RELATED T SHAPED UTERUS
T-shaped configuration in two different patients. A. " T-shaped"
tuberculosis uterus. Irregular contour of the uterine cavity with diminished
capacity resembling a T-shaped uterus. Both tubes are obstructed from
isthmic portion.B. T-shaped uterus due to DES exposure. Narrow
endocervical canal and small uterine cavity. Note both tubes are normal.3-Jan-16 86
87. 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
3-Jan-16 87
88. DIAGNOSTIC ACCURACY
(Hsg vs laparoscopy)
• Hsg-minimally invasive
-superior to laparoscopy for detecting
intrinsic tubal and uterine pathology.
- false negative rate due to undected
peritubal adhesion,incomplete filling of a dilated
hydrosalpinx
- false positive rate due to tubal spasm,
inadequate contrast injection
both are complementary methods in evaluation
of infertility
3-Jan-16 88
Dying-art of investigation . Being replaced by sonohysterography,ct, mri, laparoscopy. gold standard in the evaluation of infertilty
If menstrual cycles are irregular do urine b hcg test to ruleout pregnancy.reasons for containdications above 1. radiation exposure to embryo.2 exacerbation of infection 3.risk of flushing clots into peritoneal cavity thereby increasing risk of infection and endometriosis 4 &5 increased risk of intravasation of contrast
Procedure is avoided in secretory phase because of thick endometrium- increased risk of venous intravasation, false positive diagnosis of cornual occlusion
Uterine sound sponge holder,
Comparison of cervical vacuum cup cannula with metal cannula
for hysterosalpingography --Shlomo B. Cohen, Arnaud Wattiez, Daniel S. Seidman, Arie L. Lidor, Israel Hendler,
Jaron Rabinovichi, Mordechai Goldenberg (British Journal of Obstetrics and Gynaecology
October 2001, Vol. 108, pp. 1031–1035)
Hysterosalpingography with a balloon catheter versus a metal cannula: a prospective, randomized, blinded
comparative study. -----Tur-Kaspa, D.S.Seidman, D.Soriano, Greenberg, J.Dor and D.Bider(Human Reproduction vol.13 no.1 pp.75–77, 1998)