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What is Hysterosalpingography test?

Hysterosalpingography (HSG) or an HSG test is an internal examination of the uterus and fallopian tubes. This technique uses a special type of X-ray called fluoroscopy and a contrast medium to obtain images of the uterine cavity and fallopian tubes. An HSG test is most commonly used to examine the morphology of uterus and cervix and assess the level of obstruction (patency), if any, in fallopian tubes. Imaging is most useful in finding abnormalities that can be an underlying cause of infertility. It is a cost-effective and simple technique that can help detect blockages, polyps and salpingitis isthmica nodosa (SIN).

SIN is characterised by nodular thickening of fallopian tube due to inflammation. It is often recommended after the reports of transvaginal ultrasound imaging are obtained and when further investigation is needed.

  1. Why is HSG test performed?
  2. How do you prepare for an HSG test?
  3. How is an HSG test performed?
  4. What do HSG test results indicate?

An HSG test is commonly used to check infertility and diagnose uterine problems. It gives detailed images about the abnormal size of uterus, partial or total blockage in fallopian tubes and abnormality in the mucosal lining of these tubes. In India, the prevalence of tubular damage is more due to pelvic inflammation and tuberculosis. Repeated abortions can also cause injury to the tubes. Following are the conditions for which HSG may be recommended by a gynaecologist:

  • Fertility testing: Infertility in women is mainly attributed to tubular damage or blockage. Damaged or blocked fallopian tubes are unable to transport eggs and early embryos, affecting the normal reproductive process. Sometimes, only one tube is affected, but both tubes may be nonfunctional. The severity of the damage of fallopian tubes is one of the deciding factors for fertility. An HSG test helps in a thorough examination of fallopian tubes to detect any damage. Artificial reproduction technology clinics regularly advise an HSG test to study the patency of fallopian tubes and examine the uterine cavity for any abnormal findings.
  • This procedure is often advised after a few months of a hysteroscopic tubular occlusion procedure, which is done to prevent pregnancy.

An HSG test is a simple, inexpensive and noninvasive method with high specificity. The test is avoided in the following scenarios[4,9]:

In case am HSG test is scheduled, a gynaecologist advises to refrain from sexual intercourse from the onset of menstrual cycle to the day of HSG test. Prior to the test, a nonsteroidal anti-inflammatory drug is given to manage uterine cramps experienced during the test. Antibiotics, such as doxycycline may be prescribed a few days prior to the test to rule out any infection. It is better to carry out this test in the first half of the menstrual cycle.

HSG test is performed by an experienced radiologist who also interprets the findings of this test. The patient is asked to empty the bladder before lying down on the X-ray table. It is a completely sterile technique in which a water-soluble X-ray contrast dye is introduced into the uterine cavity using a thin tube that is inserted through the cervix. As the test dye travels along the uterine cavity and fallopian tubes, X-ray images are captured. The total duration of the test is approximately 45 minutes. There are chances of vaginal spotting or bleeding, and hence a sanitary pad is provided. Some people may be allergic to the dye. 

Normal results: No abnormalities are seen in the uterine cavity and walls. No blockage is seen in fallopian tubes. These results indicate that uterus is normal, and the patency of fallopian tubes is maintained, with no visible defects. Hence, further investigations need to be done to find the underlying causes of infertility.

Abnormal results: Abnormal findings in uterus include the presence of polyps, cysts or fibroids. Echotexture of the uterine wall may not be smooth. Either one or both fallopian tubes may show structural abnormalities, such as blockages, changes in the wall of the tubes, inflammation and infection of tubes. Distal blockages may signify hydrosalpinx (a condition where the fallopian tube is blocked, distorted and filled with clear fluid with distortion). These abnormalities suggest the reason for not being able to conceive or conditions, such as pelvic infection, the likelihood of ectopic pregnancy and loss of patency of the tubes.

Conclusively, an HSG test is used as a common diagnostic tool by in vitro fertilisation centres and gynaecologists to determine the exact underlying cause of infertility. The process is simple and inexpensive and provides detailed images of the uterus and fallopian tubes. The test is easily carried out at a hospital or diagnostic centres.

Disclaimer: All results must be clinically correlated with the patient’s complaints to make a complete and accurate diagnosis. The above information is provided from a purely educational perspective and is in no way a substitute for medical advice from a qualified doctor. 

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References

  1. Drew P. Oxford Handbook of clinical and laboratory investigation, 4th Ed 2018. Oxford University Press. Chapter 13 Radiology p 818.
  2. UCSF Department of Radiology and Biomedical Imaging: University of California [internet]; Prepare for a Hysterosalpingogram (HSG) Exam
  3. UCSF health: University of California [internet]; Hysterosalpingography
  4. Birmingham Women's and Children's National Health Service Foundation Trust. Information leaflet; Hysterosalpingogram (HSG)
  5. American College of Obstetricians and Gynecologists. [internet], FAQ, Special Procedures, Bethesda (MD); Hysterosalpingography
  6. Al-Jaroudi D, Abdullah AA, Alshamry WS, Alrashidi AS, and Bahnassy AA. Hysterosalpingogram findings among subfertile women undergoing assisted reproductive technology. International Journal of Women’s Health. 2018;10:432-438.
  7. Grau EG, Vizcaíno MCA, Oliveira M, Juanós JL, Collado RC, and Estevez YC. The Value of Hysterosalpingography following Medical Treatment with Methotrexate for Ectopic Pregnancy. Obstetrics and Gynecology International Volume 2011, Article ID 547946, 5 pages
  8. Onwuchekwa CR, Oriji VK. Hysterosalpingographic (HSG) Pattern of Infertility in Women of Reproductive Age.. J Hum Reprod Sci. 2017 Jul-Sep;10(3):178-184. doi: 10.4103/jhrs.JHRS_121_16. PMID: 29142446
  9. H Burks. Management of unilateral tubal block at hysterosalpingogram. International Journal of Obstetrics and Gynecology. Published Online 5 November 2018.