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  » Infertility  »  Hysterosalpingogram (HSG)

Normal hysterosalpingogram
A smooth triangular uterine cavity and spill from the ends of both tubes

What is a hysterosalpingogram?

A hysterosalpingogram is an important test that is part of the basic infertility evaluation .

The test is usually done in the radiology department of a hospital in which radiographic contrast (dye) is injected into the uterine cavity through the vagina and cervix. The uterine cavity fills with dye and if the fallopian tubes are open the dye will then fill the tubes and spill out into the abdominal cavity. In this way it can be determined whether the fallopian tubes are open or blocked and whether the blockage is located at the junction of the tube and the uterus (proximal) or whether it is at the end of the fallopian tube (distal). These two areas where the tube is most commonly blocked have different causes. Effective treatment for tubal factor infertility is available.

There are other things that potentially can be seen on a hysterosalpingogram other that whether the tubes are open or blocked. The uterine cavity is evaluated for the presence of polyps or fibroid tumors or scar tissue. The fallopian tubes are also examined for any defects within the tube or suggestion of a partial blockage.

What to expect during a hysterosalpingogram

The hysterosalpingogram study only takes about 5 minutes to actually perform. However as the test is usually done in the radiology department of a hospital there is additional time for the woman to register at the facility and fill out a questionnaire and answer some questions regarding allergies to medication etc. The way the test is done is the following:

The woman lies on the table on her back and brings her feet up into a "frog leg" position.

The doctor places a speculum in the vagina and visualizes the cervix.

Either a soft, thin catheter is placed through the cervical opening into the uterine cavity or an instrument called a tenaculum is placed on the cervix and then a narrow metal cannula is inserted through the cervical opening.

Contrast is slowly injected through the cannula or catheter into the uterine cavity. An x-ray picture is taken as the uterine cavity is filling and then additional contrast is injected so that the tubes should fill and begin to spill into the abdominal cavity. Additional x-rays are taken as this "fill and spill" occurs.

When both tubes are demonstrated to be patent (or blocked), the woman is usually asked to roll to one side or the other slightly to give a slightly oblique x-ray image which may help to further delineate her anatomy.

The procedure is now complete. The instruments are removed from the cervix and vagina. The woman usually remains on the table for several minutes to recover from the cramping which usually accompanies injection of the contrast.

After several minutes the woman can get dressed and leave the hospital.

The results of the test are immediately available. The x-ray pictures can be reviewed with the woman several minutes after the procedure has been completed if both she and the physician prefer to do this.

Pregnancy rates in several studies have been reported to be slightly increased in the first months following a hysterosalpingogram. This may be due to the fact that the flushing of the tubes with the contrast could open a minor blockage or clean out some debris that may be a factor that is preventing the couple from conceiving. Some of these studies suggest that using oil based contrast provides a greater increase in pregnancy rates after a hysterosalpingogram than does the use of water based contrast.


Complications associated with a hysterosalpingogram include the possibility of an allergic reaction to the dye, which is uncommon. This usually manifests as a rash, but can rarely be more serious.

Pelvic infection or uterine perforation are also possible complications. Both of these are very uncommon.

If a woman has multiple sexual partners or is otherwise at risk for sexually transmitted diseases, she should be screened with cervical cultures before doing an HSG. Some physicians prescribe several days of antibiotics for their patients to attempt to reduce the risk of infection after HSG.

HSG showing multiple "filling defects" in uterine cavity
These represent numerous endometrial polyps
The polyps were then removed by hysteroscopic resection

HSG showing a normal uterus and blocked tubes
No "spill" of dye is seen at the ends of the tubes
This woman then had successful in vitro fertilization

Abnormal study with a collection of dye in a "pocket" at the end of the left tube
Scar tissue (adhesions) are holding the dye in the pocket
Right tube was previously removed at surgery for a tubal pregnancy

Hysterosalpingogram showing a uterus with a myoma that is pushing in to the cavity
Another myoma on the outside of the uterus is circumscribed by dye along the red line
The myoma inside the cavity might cause reproductive problems

Egg images, page

Oocytes (eggs), sperm and embryos

Fertilized human egg
This is what we see the morning after an IVF aspiration (retrieval) when we check the eggs
Male and female genetic material (DNA) is contained in the 2 pronuclei seen in the center

A high quality day 3 human embryo at the 8-cell stage
6 cells are visible in this plane of focus

This is a high quality blastocyst on day 5

Blastocyst transfer
after culture for 5 days in sequential culture media
is a relatively new technique that can result in high pregnancy rates with lower multiple pregnancy rates

Eggs and sperm

Human eggs (oocytes)
Examples of normal and abnormal eggs are shown, including low quality eggs, high qualitymature eggs, abnormal eggs, very immature eggs, degenerative eggs

Human sperm
In the end, us men are just DNA donors. And, some women would (? falsely) claim that's all we're good for! If cloning is ever perfected and applied to humans, the women won't even need us for our DNA. 
Let's hold off on the cloning research, please...

Day one embryos
Fertilized human eggs, one-cell embryos, also called zygotes
This is what we want to see the morning after the egg aspiration in IVF cycles

Abnormally fertilized egg (triploid)
Embryos such as this must be discarded

Day two embryos

4-cell embryos
This is what we want to see at about 48 hours after the egg aspiration

2-cell embryos: Multinucleation
Two embryos are shown, one is multinucleated and very abnormal, the other appears normal

2-cell embryos: Fragmentation
Two embryos are shown, one has some fragmentation, the other does not

Day three embryos

8-cell embryo at high magnification
This is what we want to see at about 72 hours after egg retrieval
Embryos that look like this generally have a high rate of implantation after being transferred to the uterus

Normal and abnormal day 3 embryos
One embryo has a very unusual shape. Is it to become a football star?
An example of a very fragmented and low quality embryo is also shown.

Day four embryos

Embryos at the morula stage
This is the last stage of embryo development before it (hopefully) becomes a blastocyst

Day five to six embryos

Blastocysts - day 5-6 embryos
The blastocyst stage is the last stage of embryo development before the embryo hatches and implants into the lining of the uterus. Blastocyst transfer can reduce multiple pregnancy risks, with high pregnancy rates.

Other embryo related images

Intracytoplasmic sperm injection for severe sperm deficiency (ICSI)
A series of images that demonstrates ICSI

Embryos undergoing assisted hatching
Assisted hatching can improve a couple's chances for pregnancy
Assisted hatching can improve a couple's chances for pregnancy
A series of 5 images demonstrates the hatching procedure

Embryo quality and embryo grading issues
Embryos of different grades are shown to demonstrate differences in morphologic quality (basically, how pretty they are)

Abnormalities of the embryo's shell (zona pellucida)
Three embryos are shown:
One has a thick shell, another has an irregular shell, and the third is normal

Abnormalities of the embryo's inner cells (blastomeres)
Two embryos are shown
One has granular cells, the other has normal cells

A 3-cell embryo cleaving
A 4 cell "wannabee"

Multinucleated embryos
Two embryos are shown
A zygote with many pronuclei and a multinucleated 2 cell
These are significant chromosomal abnormalities