Understanding Hysterosalpingography (HSG)

By Constance McGraw, MPH

What is the HSG test?

A hysterosalpingogram, or HSG test, is a minor X-ray procedure used to view the inside of the uterus and fallopian tubes and can also indicate if the uterus is of normal shape and size. It is often used as a routine part of an infertility workup to see if the fallopian tubes are partly or fully blocked.

HSG Test for Infertility 

HSGs are often a routine part of infertility workups. An HSG test uses X-rays and a special dye to find issues like scar tissue, polyps, fibroids, or growths that might block your tubes or stop a fertilized egg from implanting in your uterus. Blocked tubes or growths can make it harder to get pregnant. If your tubes are blocked, sperm can't reach the egg. HSG may also be used following some tubal sterilization procedures to make sure that the fallopian tubes have been completely blocked or to examine reasons for recurring early pregnancy loss.

Benefits of HSG

The HSG test not only identifies blockages and growths but also has been suggested to improve fertility within 3-6 months through "tubal flushing." Tubal flushing involves injecting dye into the uterus and fallopian tubes without an X-ray. Research indicates higher pregnancy and live birth rates when using an oil-based dye compared to water-based solutions. However, a Cochrane review on the efficacy of tubal flushing and fertility found that the studies identified were of poor quality and more robust research is needed to better understand comparing oil‐soluble versus water‐soluble media or no treatment on improving pregnancy rates post HSG test.

SHG vs. HSG

The Sonohysterography, SHG, and the Hysterosalpingogram, HSG, are distinct procedures for fertility testing despite their similar acronyms. HSG uses X-ray imaging to examine the uterus and fallopian tubes, while SHG, or saline infusion sonography, uses ultrasound and saline solution to detect uterine issues. Both tests offer insights into fertility health, with HSG focusing on tubal evaluation and SHG detailing uterine cavity conditions. HSG involves low radiation and is usually performed early in the menstrual cycle to avoid potential pregnancy, while SHG is scheduled after your period has stopped but before ovulation. While HSG is the standard for tubal infertility diagnosis and has high accuracy for detecting blocked fallopian tubes, studies show SHG is more accurate in evaluating the uterine cavity. Consult your healthcare provider to decide the best test for your fertility concerns. Find fertility specialists near you.

‍Is HSG painful?

The most commonly reported side effect of the HSG procedure is pain, reported by 72%-80% of patients across studies. Pain is often reported with cramping during dye insertion, particularly with fallopian tube blockages, and is frequently cited as the more painful aspect of the procedure. Various methods like oral, intrauterine (within the uterus), and topical analgesics (pain killers) have been suggested to manage pain with HSG. Among these, applying lidocaine cream and a paracervical (located or administered next to the uterine cervix) lidocaine injection seem to be effective in relieving pain during and after HSG. If you have concerns about your pain during or following an HSG procedure, you should talk to your medical provider immediately about what pain medication may work best for you.

HSG cost

The cost of an HSG varies widely depending on insurance coverage and location, typically ranging from $500 to $3,000 for uninsured individuals. Insurance policies may not cover HSGs, considering them infertility treatments. Review your insurance beforehand to understand costs and avoid unexpected bills.

References:

1. The American College of Obstetricians and Gynecologists (ACOG) 2021. Hysterosalpingography (HSG). Retrieved December 2023 from: https://www.acog.org/womens-health/faqs/laparoscopyhttps://www.acog.org/womens-health/faqs/hysterosalpingography#:~:text=Hysterosalpingography%20(HSG)%20is%20an%20X,a%20normal%20size%20and%20shape.
2. Dreyer K, van Rijswijk J, Mijatovic V, et al. Oil-Based or Water-Based Contrast for Hysterosalpingography in Infertile Women. N Engl J Med. 2017;376(21):2043-2052. doi:10.1056/NEJMoa1612337
3. Unlu BS, Yilmazer M, Koken G, et al. Comparison of four different pain relief methods during hysterosalpingography: a randomized controlled study. Pain Res Manag. 2015;20(2):107-111. doi:10.1155/2015/306248
4. Babandi RM, Agboghoroma OC, Durojaiye KW, Jimoh KO, Essiet EA. Pain Relief for Hysterosalpingography: A Randomized Controlled, Double Blinded Trial Comparing Suppository Diclofenac, Prilocaine/Lignocaine (EMLA) Cream And Placebo. West Afr J Med. 2021;38(12):1174-1182.
5. Hindocha A, Beere L, O'Flynn H, Watson A, Ahmad G. Pain relief in hysterosalpingography. Cochrane Database Syst Rev. 2015;2015(9):CD006106. Published 2015 Sep 20. doi:10.1002/14651858.CD006106.pub3
6. The American College of Obstetricians and Gynecologists (ACOG) 2021. Sonohysterography. Retrieved December 2023 from: https://www.acog.org/womens-health/faqs/sonohysterography
7. Acholonu UC, Silberzweig J, Stein DE, Keltz M. Hysterosalpingography versus sonohysterography for intrauterine abnormalities. JSLS. 2011;15(4):471-474. doi:10.4293/108680811X13176785203923