Hysterosalpingography

INTRODUCTION — Hysterosalpingography (HSG) is an outpatient fluoroscopy procedure that evaluates the uterine cavity and fallopian tube patency. HSG is commonly performed as part of an infertility evaluation.

This topic will review the indications for HSG, preparation, technique, and test results. Other methods for assessing the uterine cavity and tubal patency are reviewed separately.

●(See "Saline infusion sonohysterography".)

●(See "Overview of hysteroscopy".)

In this topic, when discussing study results, we will use the terms "women" or "patients" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

DEFINITION — HSG is the evaluation of the uterine cavity, fallopian tubes, and adjacent peritoneal cavity following the injection of contrast material through the cervical canal [1,2]. It is performed as a real-time outpatient examination under fluoroscopy with iodinated water-soluble contrast material.

CLINICAL APPLICATIONS

Indications — As HSG assesses fallopian tube patency and intrauterine contour, clinical indications for HSG include evaluation of female infertility or suspected uterine anomalies, preprocedure planning for hysteroscopy, and postprocedure assessment following tubal ligation or tubal reversal procedures.

●Infertility evaluation – HSG is mainly used in the evaluation of female infertility [2]. HSG can identify fallopian tube obstruction, dilation (hydrosalpinx), and surrounding adhesions as well as uterine synechiae, intracavitary lesions, and septa. (See 'Tubes' below and 'Uterus' below.)

●Suspected congenital uterine anomalies – Congenital uterine anomalies (eg, septate, bicornuate, or unicornuate uteri) can be detected with HSG. However, additional imaging, such as three-dimensional ultrasound or magnetic resonance imaging, is typically required to provide information about the external contours of the uterus before the definitive diagnosis can be made. (See 'Other abnormalities' below and "Congenital uterine anomalies: Clinical manifestations and diagnosis", section on 'Diagnostic tools'.)

●Preprocedure planning – Some hysteroscopic procedures, including myomectomy, adhesion resection, and septum resection, benefit from preprocedure HSG to identify the location and size of lesions for resection [3-5]. While hysteroscopy and three-dimensional sonohysterography are performed to assess the uterine cavity only, HSG can be helpful if tubal information is needed or if the other modalities are not available. (See "Uterine fibroids (leiomyomas): Hysteroscopic myomectomy" and "Intrauterine adhesions: Clinical manifestation and diagnosis", section on 'Diagnostic evaluation' and "Congenital uterine anomalies: Surgical repair", section on 'Septate uterus'.)

Contraindications — The major contraindications to HSG are pregnancy, active undiagnosed vaginal bleeding, active pelvic infection (even if the patient is receiving antibiotic therapy), and a history of a moderate or severe reaction to iodinated contrast (table 1) [1,2,5,6]. Active menstruation is a relative contraindication. In our practice, we use an algorithm to screen individuals for contraindications prior to performing the HSG (algorithm 1).

PATIENT PREPARATION

History and consent — Prior to examination, a brief medical history is obtained from the patient to ensure there are no contraindications to the procedure (algorithm 1). Examination indication, the duration of any gynecologic symptoms, history of previous pelvic infections or surgery, obstetric history, contraceptive use, date of the last menstrual period (LMP), and prior contrast reactions are discussed.

The operating clinician explains the procedural steps and answers the patient's questions prior to obtaining written consent. Informed consent includes the possibility of pelvic discomfort, vaginal bleeding, infection, contrast reaction, and irradiation of an unsuspected pregnancy (table 2). Those patients with indwelling fallopian tube micro-inserts or intrauterine devices are advised about the small risk of implant dislodgement that could require a separate procedure for replacement. (See "Informed procedural consent".)

Screening for pregnancy — We perform HSG on days 6 through 11 from the LMP to avoid both pregnancy and menstrual bleeding (algorithm 1). Neither serum nor urine pregnancy tests reliably exclude pregnancy during the first three weeks following the LMP and therefore are not routinely required [7]. As many females presenting for HSG are undergoing fertility evaluation and tracking their periods, reported LMPs are typically accurate and adequate. If the patient cannot recall the date of LMP, we ask her to chart her menstrual cycle and reschedule the test. We also ask patients to reschedule the test if they have had an atypically light menses that could represent implantation bleeding from an early pregnancy. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Types of pregnancy tests'.)

Alternatively, if the patient is measuring urine luteinizing hormone (LH) levels to determine ovulation, the HSG can be performed if there is no evidence of ovulation by the LH test.

PREPROCEDURE CONSIDERATIONS

Infection — The reported rates of pelvic infection following HSG in five series ranged between 0.3 and 3.4 percent [8-12]. Prophylactic antibiotics are not routinely prescribed before the procedure. However, antibiotics are given to those with a history of pelvic inflammatory disease or a finding of dilated tubes or peritubal adhesions at the time of the study because these findings have been associated with increased risk of postprocedure infection [5,10,13,14]. One common regimen for prophylaxis is doxycycline 100 mg by mouth twice a day for five days (table 3) [13]. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Surgical site infection prevention'.)

Analgesia — HSG can be associated with some discomfort, primarily from uterine distention. Pain can be minimized by slowly injecting the contrast medium and using iso-osmolar contrast agents [1]. With counseling, most patients tolerate the uterine cramps, and thus analgesia is not routinely administered (we do not use paracervical block as injection itself is painful). We inform patients that the pain is typically mild and self-limited. We advise patients to use over-the-counter analgesics such as nonsteroidal anti-inflammatory drugs if bothersome uterine cramping occurs on the days following the examination. (See "NSAIDs: Therapeutic use and variability of response in adults", section on 'Dosing and duration'.)

A meta-analysis of trials evaluating pain relief during HSG reported reduced visual analog scale pain scores with administration of intravenous opioid (mean difference -3.5, 95% CI -4.3 to -2.8, one trial, 62 women) or preprocedure topical anesthesia (mean difference -0.6, 95% CI -1.1 to -0.2, seven trials, 613 women) compared with no treatment [15]. However, definitive conclusions were limited by small number of participants and lack of reporting on adverse events in the opioid trial and by study design and limited treatment effect in the topical anesthesia trials.

Severe postprocedure pain is not typical after an HSG; individuals with severe pain are evaluated for possible complication. (See 'Postprocedure follow-up and complications' below.)

Contrast — During an HSG, iodinated contrast is injected retrograde into the uterine cavity, through the fallopian tubes, and into the peritoneal cavity. While the amount varies with uterine size and peritoneal spillage, 10 to 30 mL is a typical dose. Some of this material is cleared intravascularly, and hence the patient is exposed indirectly to small quantities of systemic contrast. Nonionic, water-soluble contrast is used because the rates of allergic reaction are much lower compared with ionic contrast and because oil-based contrast may increase the risk of peritoneal spread of cancer (if present) [6,16]. (See "Patient evaluation prior to oral or iodinated intravenous contrast for computed tomography", section on 'Types of contrast material'.)

In patients with a history of a severe contrast reaction, HSG is contraindicated. In patients with a history of a moderate contrast reaction, the examination is usually contraindicated and but can be performed (with premedication) only if alternative methods for assessing tubal patency (ie, laparoscopy with chromopertubation) are unavailable (table 1). Patients with a history of a mild reaction can undergo HSG safely after receiving prophylactic prednisone and diphenhydramine (table 4) [6]. For patients with a history of any contrast allergy, HSG is performed in settings with the expertise and resources to manage a severe contrast reaction. (See "Diagnosis and treatment of an acute reaction to a radiologic contrast agent".)

In our practice, we prefer water-soluble contrast rather than oil-based contrast for diagnostic HSGs. Water-soluble contrast provides higher quality images and does not require precautionary measures to avoid the small risk of pulmonary and cerebral embolism that can occur with intravascular injection of oil-based contrast [17]. However, oil-based contrast may be preferred in infertile female patients with low risk of tubal disease because use of oil-based contrast appears to improve live birth rates for the subgroup of individuals who receive oil-based contrast and then proceed with fertility therapy. A multicenter trial that randomly assigned over 1100 women with infertility, but low risk for tubal disease (as indicated by no history of pelvic inflammatory disease, previous chlamydia infection, or known endometriosis), to HSG with either oil-based or water-soluble contrast reported a 37 percent higher rate of ongoing pregnancy and a 38 percent higher rate of live birth in the oil-based contrast group [18]. However, the majority of the difference in ongoing pregnancy rates was attributable to women who then underwent infertility treatment; there were no differences in the ongoing pregnancy rates between the two groups when only the women who conceived spontaneously were evaluated (73.6 percent for oil compared with 72.7 for water). Rates of adverse events were low and equivalent between both contrast types. In contrast, one prior smaller randomized trial and a meta-analysis of this trial plus one other that included infertile women at high risk for tubal disease did not report higher live birth rates with oil-based contrast [19,20]. As noted above, we continue to use water-soluble contrast because our patient population is more similar to the ones in the smaller trials and because the rates of spontaneous conception in the larger trial comparing oil-based and water-soluble contrast were the same.

Radiation — HSG involves ionizing radiation using real-time fluoroscopy during which selected spot radiographs are acquired. Average dose to the female gonads is 2.7 mGy and an effective dose is 1.2 mSv, as measured in a series of 78 consecutive patients undergoing infertility workup [21]. The mean fluoroscopic time is 0.3 minutes and mean number of radiographs is 3.2. To put these numbers into context, the effective dose from annual background radiation is 3.1 mSv and from screening mammography is 0.4 mSv [22]. In terms of biological effects of the radiation conferred by HSG, the risk for anomalies in a future embryo and for fatal cancer induction in an exposed woman ages 20 to 29 years are estimated at 2.7 x 10^-5 and 14.5 x 10^-5, respectively. These risks are over 1000-fold lower than the background rates of birth defects and of spontaneous cancers in the United States [23]. (See "Radiation-related risks of imaging".)

PROCEDURE

Catheter placement — We begin the procedure by placing the patient in the dorsal lithotomy position and performing a bimanual vaginal examination to assess uterine body flexion, cervical location relative to the vaginal introitus, and size of the vaginal canal [24]. Next, the clinician places a speculum into the vagina, visualizes the cervix, and swabs the cervix with antiseptic soap (or saline in the case of allergy). A blunt dilator is placed in the cervical canal for a few moments to facilitate dilation. We use a long forceps to pass a 5-F flexible balloon-tipped catheter through the endocervix into the uterine cavity. The catheter is fixed in place by inflating the balloon with 1.0 to 1.5 cc of sterile water. Before catheter or cannula insertion, contrast is passed through the instrument to expel as many air bubbles as possible. Another option is to use a Jarcho cannula and tenaculum. A small minority of individuals with a steeply antero- or retro-flexed uterus may require straightening of the cervico-uterine angle to allow passage of the catheter. For these patients, if a flexible catheter cannot be passed into the uterine cavity, we place a tenaculum on the anterior cervical lip and then apply gentle downward traction while passing the catheter into the uterine cavity. Once in the uterine body, the catheter is retracted gently to ensure that the balloon creates a tight seal over the internal cervical os. The speculum is then removed so as not to obscure visualization of the cervical canal and lower uterine segment, and the patient is repositioned supine under the fluoroscope.

Image acquisition — Attention to correct fluoroscopic technique is necessary to optimize image quality and reduce radiation dose. To decrease background scatter, the distance from the beam source to the target organs is minimized and images are coned. (See "Radiation-related risks of imaging", section on 'Efforts to reduce the risk of radiation from imaging'.)

The following radiographic images are typically obtained:

●Scout before contrast injection.

●Early filling anteroposterior view of the uterus.

●Anterolateral oblique view of one tube demonstrating spill.

●Anterolateral oblique view of the other tube demonstrating spill.

●En face anteroposterior view of the uterus. To achieve this view, the clinician gently pulls down on the catheter to lay the uterine cavity out in the imaging plane.

The contrast is injected slowly under fluoroscopy (image 1). The early filling anteroposterior view of the uterus is taken after injection of a few mL of contrast because lesions such as polyps, submucous myomas, or synechiae (image 2A-C) could be concealed when the uterus is distended with contrast (image 3). Further incremental injections outline the cornua, isthmic, and ampullary portions of the tubes, which normally demonstrate rugal folds. The contrast then spills from the ends of patent tubes. Peritubal adhesions are suggested by the collection of contrast around the distal end of a tube that persists on delayed imaging following catheter removal. If significant pain occurs during the procedure, the injection is stopped for a few moments followed by slower injection of contrast.

Images of fallopian tube micro-inserts (Essure) — HSG is performed three months after contraceptive micro-insert (commercial name Essure) placement (figure 1) to confirm insert location and bilateral tubal occlusion, both of which are required for contraceptive efficacy (image 4) [25-27]. Devices have four radiographic markers (two markers located at each of the proximal and distal ends) (figure 2) [25,28]. Confirmation of satisfactory insert location required visualizing the micro-tip (ie, distal end of inner coil) and coil within the fallopian tube, with less than 50 percent of the outer coil trailing into the uterine cavity, or visualizing the micro-tip and coil up to 30 mm into the tube from the uterine cornua (figure 2). Satisfactory occlusion is defined as occlusion at the cornua or when contrast was visible within the tube but not past any portion of distal end of the coil. Contraceptive micro-inserts are no longer available, but many patients still have them in place. (See "Hysteroscopic female permanent contraception".)

Approach to technical challenges — Technical difficulties can arise during any part of the HSG examination. Some common difficulties and potential solutions include:

●Leaking of contrast media – Use of a balloon catheter reduces the risk of contrast leak. If the study is being done with a cannula, using a larger cannula tip or placing additional traction on the tenaculum can resolve the leak.

●Cervical stenosis – Individuals with cervical stenosis can require a pediatric bladder catheter or cervical dilation. (See "Dilation and curettage", section on 'Cervical stenosis'.)

●Air bubbles – Air bubbles can mimic filling defects in the uterus (image 5) or tubes. Prior to the examination, we expel as many bubbles as possible through the catheter. During fluoroscopy, continued contrast infusion can cause air bubble movement, which helps to distinguish mobile bubbles from fixed structural abnormalities. Lastly, aspirating and refilling the uterine cavity can remove air bubbles.

●Inadequate visualization of the uterine cavity – If the uterine cavity is inadequately visualized, we apply more outward traction on the cervix (with the balloon-tipped catheter or a tenaculum) to bring the fundus into a more axial position (image 6).

●Blocked fallopian tube – Nonfilling of one or both fallopian tubes can be caused by obstruction or cornual spasm. A temporary blockage from a mucous plug or other debris can be dislodged by infusing contrast under constant pressure. On occasion, cornual spasm can be alleviated by pausing the study for a few moments followed by slower injection of contrast. If cornual spasm is still suspected, the test can be rescheduled for a future date. (See 'Cornual spasm' below.)

If unilateral blockage is visualized, we inject 1 to 2 mL of additional contrast material until either the previously nonvisualized tube fills and spills or spillage from the patent side obscures visualization [29].

●Intravasation (image 7) – Early intravasation into uterine and ovarian veins or lymphatics manifests as multiple thin ascending beaded channels on radiography. These channels can be identified by their anatomy and usually demonstrates rapid contrast flow, which distinguishes it from tubal filling. To minimize the risk of intravasation, we avoid inadvertent insertion of the cannula into the myometrium and excessive pressure during injection of contrast material.

●External artifacts – Abdominal structures (eg, air or stool in the colon) superimposed over the uterus can mimic uterine pathology (picture 1). Moving the patient into an oblique position can help distinguish intrauterine from extrauterine structures.

FINDINGS AND RELATED DIAGNOSES

Tubes

Obstruction — Fallopian tube obstruction is confirmed by absence or partial filling of the fallopian tube with contrast (image 8 and image 9). While obstruction can be seen along any part of the tube, the ampulla is the most common site (figure 3). Isthmic obstruction of the fallopian tube is seen following salpingectomy and tubal ligation. Obstruction at the cornua can reflect true obstruction or cornual spasm. (See 'Cornual spasm' below.)

Common nonsurgical causes for tubal obstruction include prior pelvic inflammatory disease, prior ectopic pregnancy, or endometriosis [2,30]. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis" and "Ectopic pregnancy: Clinical manifestations and diagnosis" and "Endometriosis in adults: Pathogenesis, epidemiology, and clinical impact".)

Cornual spasm — The cornual portion of the fallopian tube is encased in smooth muscle; muscle spasm can cause transient tubal occlusion and prevent contrast from filling an otherwise patent tube. Spasm is characterized by a rounded smooth cornual margin, whereas cornual occlusion is characterized by pointed or irregular cornual margin, although these changes can be difficult to distinguish definitively (image 10) [31].

If corneal spasm is suspected, we pause the study for several minutes to allow the spasm to resolve and then proceed with the study. If the spasm does not resolve, the patient is rescheduled. Repeat examination at a future date typically allows differentiation of the tube in spasm from one that is permanently obstructed. Of note, a historical report described administering 1 mg of glucagon intravenously to cause muscle relaxation and thus enable contrast flow and tube opacification [32], but this approach is not common practice.

Hydrosalpinx — Hydrosalpinx is defined as fluid-filled dilation of the fallopian tube [33] and is most commonly caused by peritubal adhesions [34]. On HSG, hydrosalpinx appears as a contrast filled and dilated fallopian tube, often without free spill of contrast into the peritoneum (image 11 and image 12). Information on hydrosalpinx is presented separately. (See "Pelvic inflammatory disease: Long-term complications", section on 'Hydrosalpinx'.)

Other abnormalities

●Peritubal adhesions – On a normal HSG, contrast spills freely from the fallopian tubes into the peritoneal cavity (image 13). In patients with peritubal adhesions, the spill appears contained as contrast loculi in amorphous collections adjacent to the ampullary ends of the tube, which are the most commonly involved sites (image 14) [2,35].

●Salpingitis isthmica nodosa – Salpingitis isthmica nodosa is an acquired condition in which mucosal glands penetrate the myosalpinx with resultant hyperplasia and hypertrophy. The characteristic appearance on HSG is that of multiple, small diverticula extending from the isthmic lumen into the wall, which is sometimes described as tubal diverticulosis (image 15) [30]. It affects both tubes in 80 percent of cases [36] and is frequently associated with ampullary dilatation or obstruction proximally. The condition is strongly associated with infertility and ectopic pregnancy. (See "Female infertility: Causes", section on 'Fallopian tube abnormalities/pelvic adhesions'.)

●Genital tract tuberculosis – The genital tract is affected in 1 to 2 percent of females with tuberculosis [37]. When pelvic tuberculosis occurs, fallopian tube involvement occurs in approximately one-third of these females. While no radiographic features are pathognomonic for genital tract tuberculosis, typical HSG findings include a shriveled and deformed uterus and fallopian tubes with ragged outlines and multiple strictures, which are caused by caseous ulceration of the tubal mucosa (image 16) [38,39]. Tubal occlusion is the most common HSG finding and occurs most frequently in the isthmic and ampullary portions of the tube [38]. Multiple strictures along the fallopian tube create a "beaded" appearance and scarring leads to a "rigid pipe stem" appearance. (See "Tuberculosis: Natural history, microbiology, and pathogenesis" and "Clinical manifestations, diagnosis, and treatment of miliary tuberculosis", section on 'Clinical manifestations'.)

Uterus

Uterine filling defects

●Leiomyomas – On HSG, submucosal leiomyomas (fibroids) appear as intracavitary filling defects that can also enlarge the uterine cavity (figure 4 and image 2B and image 17). Small lesions may not be seen [1]. Rarely, submucosal fibroids cause cornual obstruction and prevent opacification of the ipsilateral fallopian tube (image 9) [40]. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history".)

●Endometrial polyps – Endometrial polyps typically appear as well-defined filling defects and are best seen during the early filling phase (image 2A) [1]. Small polyps can be obscured when contrast completely distends the uterine cavity. Additionally, polyps can be indistinguishable from leiomyomas on HSG and further study with sonohysterography or hysteroscopy can be required. (See "Endometrial polyps".)

●Uterine synechiae – Uterine synechiae or adhesions are often due to a previous trauma to the endometrial cavity, such as dilatation and curettage or infection [40]. Typically, the HSG demonstrates a distorted uterine contour with irregular filling defects [40]. In females with Asherman syndrome (intrauterine adhesions accompanied by amenorrhea or infertility), the uterine cavity can be partially or completely obliterated by adhesions (image 18 and image 2C) [41]. (See "Intrauterine adhesions: Clinical manifestation and diagnosis".)

Uterine contour abnormalities

●Adenomyosis – Adenomyosis represents ectopic endometrial glands within the myometrium that result in smooth muscle hypertrophy and hyperplasia. On HSG, adenomyosis appears as an enlarged cavity with multiple saccular contrast collections that extend beyond the expected endometrial contour into the myometrium (image 19) [42]. Adenomyosis can be diffuse or focal. (See "Uterine adenomyosis".)

●Congenital müllerian anomalies – Uterine anomalies arise from abnormal junction of the müllerian ducts or defective resorption of the tissue between the fused ducts [43]. HSG can be useful in identifying a uterine cavity with a single horn (eg, unicornuate or didelphys uterus) or in delineating a vertical intracavitary septum (eg, bicornuate (image 20), septate (image 21), or arcuate uterus (image 22)). However, definitive diagnosis of these anomalies also requires visualization of the external uterine contour, which is better seen on magnetic resonance imaging or ultrasound with three-dimensional reconstruction. (See "Congenital uterine anomalies: Clinical manifestations and diagnosis".)

●Diethylstilbestrol exposure – On HSG, a diethylstilbestrol-exposed uterus appears as a classic "T-shaped configuration" in 31 percent of cases (image 23) [44,45]. The T-shaped appearance is due to a shortened upper uterine segment (figure 5) [46]. Other abnormalities affecting the uterus include a small, hypoplastic uterus; constriction bands; a widened lower uterine segment; a narrowed fundal segment of the endometrial canal; irregular endometrial margins; and intraluminal filling defects [44,45]. The fallopian tubes can be foreshortened, with sacculations and fimbrial deformities and/or fimbrial stenosis [47]. (See "Outcome and follow-up of diethylstilbestrol (DES) exposed individuals".)

DIAGNOSTIC PERFORMANCE — HSG test performance is affected by factors such as underlying pathology, the training and experience of the clinician(s) performing the procedure and interpreting the images, and the standard used to validate the HSG results. HSG is most useful for predicting tubal occlusion.

●Tubal occlusion – In a meta-analysis of nine studies comparing HSG or sonohysterosalpingography with laparoscopy as the standard, the pooled estimates of sensitivity and specificity for HSG in identifying tubal occlusion were 0.94 (95% CI 0.47-0.99) and 0.92 (95% CI 0.87-0.95), respectively [48].

●Uterine pathology – In a prospective study of 336 women undergoing both HSG and diagnostic hysteroscopy (reference standard), the ability of HSG to detect intrauterine pathology reported [49]:

•Sensitivity: 98 percent

•Specificity: 35 percent

•Positive predictive value: 70 percent

•Negative predictive value: 92 percent

•Accuracy: 73 percent

•False-positive and false-negative rates: 30 and 8 percent, respectively

The common incorrect diagnoses of HSG were identifying cervical stenosis as severe intrauterine adhesions (24 women), endometrial polyps as submucous myoma (22 of 50 women), and submucous myoma as endometrial polyps (12 out of 72 women).

POSTPROCEDURE FOLLOW-UP AND COMPLICATIONS — Mild pain is common during the procedure and can last for a few hours afterwards. Treatment with nonsteroidal anti-inflammatory drugs usually relieves this discomfort. We inform patients that leaking of contrast and a small amount of bleeding from the vagina are common for a day or two after an HSG. Usual activities can be resumed immediately, including vaginal intercourse. Heavy bleeding, fever, or increasing pain are not normal and require evaluation for possible complication.

Complications of HSG are very uncommon and include infection, allergic reaction, and syncope [1]. The rate of infection of the upper genital tract is typically approximately 1 percent, but has been reported in up to 3 percent of patients after HSG [9]. There are rare case reports of shock and pulmonary and cerebral embolus with oil-soluble contrast media [50].

HSG does not appear to increase the risk of subsequent cancer [51]. In individuals who have occult endometrial cancer, HSG could disseminate tumor cells into the peritoneal cavity. Positive peritoneal washings would increase the surgical stage to at least IIIA. However, the clinical significance of this finding is not known as transport of these cells does not necessarily result in implantation and persistence. (See "Endometrial carcinoma: Epidemiology, risk factors, and prevention".)

RESOURCES FOR CLINICIANS — Practice guidelines regarding the personnel qualifications and maintenance of radiographic equipment are published separately [5].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Female infertility".)

SUMMARY AND RECOMMENDATIONS

●Test description – Hysterosalpingography (HSG) is a fluoroscopic evaluation of the inner contour of the uterus and fallopian tubes. Information obtained by HSG includes the width/length of the cervix, shape of the uterine cavity, outline of the cornua and lumen for each fallopian tube, contrast spill (or absence) from the tubes, and, in some cases, information about peritoneal adhesions around the tubes. (See 'Clinical applications' above.)

•Indications – Indications for HSG include evaluation of female infertility, suspected uterine anomalies, preprocedure planning for hysteroscopy, and postprocedure assessment following tubal ligation or tubal reversal procedures. (See 'Indications' above.)

•Contraindications – Contraindications to HSG include pregnancy, active undiagnosed uterine bleeding, active pelvic infection, and a history of a moderate or severe reaction to iodinated contrast. Active menstruation is a relative contraindication. In our practice, we use an algorithm to exclude female patients with contraindications prior to performing the HSG (algorithm 1). (See 'Contraindications' above.)

●Preparation – Prior to an HSG examination, a brief medical history is obtained, any contrast reactions are discussed, and pregnancy is excluded by either the last menstrual period or the luteinizing hormone test. To avoid pregnancy, HSG is performed following peak menses but before cycle day 12 (ie, cycle days 6 through 11). Pain medication is not required prior to the procedure. (See 'Patient preparation' above and 'Contrast' above and 'Analgesia' above.)

●Limited role of antibiotics – Prophylactic antibiotics are not indicated unless the patient has a history of pelvic inflammatory disease (PID) or if the study demonstrates dilated tubes or contained spill into the peritoneal cavity (ie, evidence of adhesive disease). For individuals with a history of PID or dilated tubes, antibiotic therapy consisting of doxycycline 100 mg by mouth twice a day for five days is started at the time of examination (table 3). (See 'Infection' above.)

●Radiation dose – During HSG, the average radiation dose to the female gonads is 2.7 mGy and an effective dose is 1.2 mSv. For comparison, the effective dose from annual background radiation is 3.1 mSv and from screening mammography is 0.4 mSv. (See 'Radiation' above.)

Correct fluoroscopic technique optimizes image quality and reduces radiation dose. To decrease background scatter, the distance from the beam source to the target organs is minimized and images are coned. Contrast is injected slowly to minimize pain and potential cornual spasm. (See 'Image acquisition' above.)

●Tubal evaluation – Tubal processes visualized with HSG includes obstruction, hydrosalpinx, and contraceptive micro-insert placement and resultant obstruction. Cornual spasm can mimic tubal occlusion by preventing contrast from filling an otherwise patent tube. Less commonly, the HSG will identify peritoneal adhesions, salpingitis isthmica nodosa, or genital tract tuberculosis. (See 'Tubes' above.)

●Uterus evaluation – Uterine pathology visible by HSG includes uterine filling defects and endometrial contour abnormalities. Filling defects can be caused by leiomyomas, endometrial polyps, and synechiae. Contour abnormalities can represent adenomyosis, congenital müllerian anomalies, and in-utero diethylstilbestrol exposure. (See 'Uterus' above.)

●Diagnostic performance – HSG test performance is affected by factors such as underlying pathology, the training and experience of the clinician(s) performing the procedure and interpreting the images, and the standard used to validate the HSG results. HSG is most useful for predicting tubal occlusion. (See 'Diagnostic performance' above.)

●Postprocedure – After HSG, mild cramps, leaking of contrast, and a small amount of bleeding from the vagina are common for a day or two. Usual activities can be resumed immediately. Heavy bleeding, fever, or severe pain are not normal and require evaluation for possible complication. (See 'Postprocedure follow-up and complications' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Theodore A Baramki, MD, who contributed to an earlier version of this topic review.