HYSTEROSALPINGOGRAPHY

DR. PRADOSH KUMAR SARANGI

UNDER GUIDANCE OF
DR JAYASHREE MOHANTY
DR SASMITA PARIDA
DR B M SWAIN
DR KALYANI PARIDA

1 9/11/17
 HYSTEROSALPINGOGRAPHY

Hysterosalpingography is the radiographic

evaluation of uterus and fallopian tubes under
fluoroscopic guidance.

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 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)
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 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

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 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)
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 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

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 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

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 COMPLICATION
Pain (because of dilatation of uterus , spillage into
peritonium).
Infection (pelvic).
Bleeding.
Vascular or lymphatic Intravasation
Vasovagal episode.
Pregnancy irradiation.
Allergic reaction (to iodinated contrast media).
Uterine perforation
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 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)

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 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
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 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 ?

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 CONTRAST MEDIA
LIPID SOLUBLE CONTRAST WATER SOLUBLE CONTRAST
(iohexol-omnipaque,meglumine
(lipiodol)
diatrizoate-urograffin
Sharp image Ampullary rugae clearly
Minimal pain visualised
Delayed absorption Gets absorbed within hours,
Risk of lipogranuloma does not leave residue
formatation in case of tubal block Granuloma formation rare
or hydrosalpinx

Pain persists after procedure

Intravasation of contrast and
possible risk of oil embolism
Need of delayed film
Pregnancy rate doubled
Less often used
Prompt demonstration of
tubal patency, delayed film
not needed.
Widely used and preferred

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 INSTRUMENTS

Hegar dilator
leech wilkinson tenaculum
cannula

Sponge holder
Speculum

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 Different types of cannula used
1. leech wilkinson cannula
2. acorn tip metallic cannula
3.cervical vaccum cup
4. balloon catheter or pediatric foleys catheter
6F

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 WHICH ONE IS BETTER??
Cervical vacuum cup vs metal cannula:
Shorter length of time
less fluoroscopic time
small amount of contrast needed Cervical
less pain ( no need to grasp cervix) vacuum
Easier for physician to use cup

Uterus cant be easily manipulated

Need to reapply cannula
Superior to metal cannula
Cohen et al (British Journal of Obstetrics and Gynaecology
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October 2001, Vol. 108, pp. 10311035) 15
BALLOON CATHETER VS METAL CANNULA

Less fluoroscopic time

Small amount of contrast
BALLOON CATHETER
Less pain
Easier for physician to use
Good seal at cervix
Single use/disposable(costly)
Superior to metal cannula

Tur-kaspa et al (Human Reproduction vol.13 no.1 pp.7577, 1998)

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 Balloon catheter obscures lower uterine
segment. Need to be deflated to visualise
lower segment
Balloon catheter better tolerated over cervical
cup

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 Cervical vacuum cup cannula
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 Acorn tip metal cannula

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 BALLOON CATHETER

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 The uterine cavity is shown
NORMAL HSG 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
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 NORMAL HSG

At least 4 spot films taken

1.Early filling 2. Uterus fully
phase distended

3.Tubal filling 4.Peritoneal

phase spillage

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 DETECTABLE PATHOLOGY
UTERINE TUBAL
1. Uterine anomaly 1. tubal block
2. Fibroid ( submucosal) 2. Tubal spasm
3. Adenomyosis 3. Tubal polyp
4. Endometrial polyp 4. Hydrosalpinx
5. Intrauterine 5. Salpingitis isthmic
adhesions/synaechiae nodosum (SIN)
6. Endometrial TB 6. Peritubal adhesions
7. Cervical incompetence 7. TB salpingitis

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 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

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 Luminal filling defects
Common finding.
Includes :
Air bubbles
Uterine folds
Synechiae
endometrial polyp
submucosal fibroid

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 AIR BUBBLE

Spot radiograph shows air bubbles (arrow) in the left

side of the uterus.
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 DISAPPEARS

Filling defects on consecutive images at the uterine fundus, that disappear

progressively after the administration of contrast, compatible with air bubbles.

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 UTERINE FOLDS

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.
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 PROMINENT CERVICAL GLANDS

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 CESAREAN SECTION SCAR

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.
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 UTERINE ANOMALIES
AMERICAN SOCIETY OF REPRODUCTIVE MEDICINE
class anomaly
i Partial / complete agenesis
ii Unicornuate
iii Didelphys
iv Bicornuate
V Septate
Vi Arcuate
vii DES-associated anomalies

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 Diagnosis: unicornuate uterus.
Description: one cornua , one tube , one spillage.
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 UNICORNUATE UTERUS
Single right uterine horn with single right fallopian
tube. Right side spillage seen
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 VAGINAL SEPTUM

UTERUS DIDELPHYS
2 Uterine cavities, 2 cervical canals, 2 vagina..
(nonfusion of the two Mllerian ducts.)

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 UTERUS DIDELPHYS

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 1 CERVIX

BICORNUATE UNICOLLIS
2 uterine cavities, 1 cervical canal
Incomplete fusion of the cephalad extent of the uterovaginal horns with
resorption of the uterovaginal septum.
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 BICORNUATE UNICOLLIS UTERUS

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 BICORNUATE BICOLLIS

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 BICORNUATE UTERUS
Spot radiograph shows two markedly splayed uterine horns.
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 BICORNUATE UNICOLLIS

> 100
degree

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 UTERUS DIDELPHYS UTERUS BICORNIS BICOLLIS
2 uterus 2 uterus
2 cervix 2 cervix
2 vagina 1 vagina

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DES-related uterine anomaly. Hysterosalpingogram
demonstrates a hypoplastic T-shaped uterus. The
patient had been exposed to DES while in utero.
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 ARCUATE UTERUS
Depression of uterine fundus

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SEPTATE UTERUS: PARTIAL AND COMPLETE

SEPTUM

PARTIAL COMPLETE

There is incomplete resorption of the final fibrous

septum between the two uterine horns.
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 SEPTATE UTERUS

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 SEPTATE UTERUS
slight separation (forming acute angle).

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 Bicornuate and Septate Uteri
Bicornuate: Septate:
Fundus indented Normal external surface
Cavities widely Cavities are close
separated( > 100 degree) together
Partial fusion of Defect in canalization or
mullerian ducts
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
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 ADENOMYOSIS
Irregular outline, multiple diverticulum
(arrows)
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 FIBROID UTERUS

Multiple filling defects

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 RIGHT SUBMUCOSAL MYOMA

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 SALPINGITIS ISTHMICA NODOSA

Out pouchings of isthmus

Unilateral or bilateral
Unknown cause
Associated with infertility, PID and ectopic
pregnancy

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 SALPINGITIS ISTHMIC NODOSUM (SIN)
small outpouchings or diverticula from the isthmic
portion of the fallopian tubes. SIN can be either
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unilateral or (as in this case) bilateral. 53
 LEFT SALPINGITIS ISTHIMICA NODOSUM
Multiple outpouchings from isthmus ( arrow)

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 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
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 BILATERAL HYDROSALPINX

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 TUBAL POLYP
small filling defect (arrow) in the proximal left
fallopian tube, a finding that typically represents a
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tubal polyp 57
 TUBAL POLYP . (FILLING DEFECT)

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 LEFT HYDROSALPINX ,RIGHT TUBAL LIGATION
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.
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 TUBAL LIGATION
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).
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 LEFT PERITUBAL ADHESION
A round collection of contrast material adjacent to the left
fallopian tube, a finding that suggests peritubal adhesions. Note
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free contrast material spillage on the right side. 61
 SYNECHIAE

Intra uterine adhesions

Post curettage and infection
Linear filling defect
Arising from one of the uterine walls
Multiple+infertility= Asherman syndrome

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 SYNECHIAE
Central oval filling defect within the uterus

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 SYNECHIAE
Multiple irregular filling defects in uterine
cavity
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 CORNUAL SPASM
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 9/11/17 65
 LEFT CORNUAL SPASM

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 B/L FALLOPIAN TUBE LIGATION
No peritoneal spillage of contrast

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 VASCULAR INTRAVASATION
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 SCOUT FILM
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
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fallopian tube.
 Radiograph obtained after instillation shows no contrast
material filling of the fallopian tube beyond the microinsert, a
finding that helps document tubal occlusion.
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 HSG FINDINDS IN GENITAL
TUBERCULOSIS

FALLOPIAN TUBES UTERUS

SPECIFIC SPECIFIC
Beaded tube T shaped uterus
Golf club tube
Pseudounicornuate uterus
Pipestem tube
Trifoliate uterus
Cobblestone tube
NONSPECIFIC
Leopard skin tube
NON SPECIFIC endometritis
Hydrosalpinx Syneciae
Mucosal thickening distortion of uterine
Peritubal adhesion contour
Venous, lymphatic
intravasation
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 TUFTED TUBE
Multiple small diverticular like appearance surrounding
the ampulla produced by caseous ulceration gives the
tubal outline a Rosette-like appearance
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 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).
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 cotton-wool plug appearance
Distribution of contrast medium in a reticular pattern
producing a " cotton-wool plug" appearance [arrow]
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 BEADED TUBE

Multiple constrictions along the fallopian tube giving rise to

a " beaded" appearance [arrows]
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 GOLF CLUB TUBE

Sacculation of both tubes in distal portion with an

associated hydrosalpinx giving a Golf club-like appearance
(arrows).
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 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.
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 FLORAL APPEARANCE

Twisted hydrosalpinx resembles a floral

appearance of left side tube (arrow).
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 LEOPARD SKIN APPEARANCE
Multiple rounded filling defects following intraluminal granuloma
formations within the hydrosalpinx, resembling a " leopard skin"
appearance [arrows]
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 COBBLE STONE APPEARANCE

Intraluminal scarring of the tube gives rises a cobblestone

like appearance which is an effective radiographic sign of
intraluminal adhesions
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 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]
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 PERITUBAL HALO

Thickening of the tubal walls due to peritubal adhesions

(arrows) represents a cloudy sign on hysterosalpingograms.
This
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finding is a non-specific feature of tubal tuberculosis. 82
 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.
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 INTRAUTERINE ADHESION AND DISTORTION

A B

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.

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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.
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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
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normal.
 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
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 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
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 Thank
You
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