All About Hysterosalpingogram (HSG)

Hysterosalpingogram (HSG) is a specialized type of X-ray used to assess female fertility. It is an outpatient procedure that typically lasts no longer than 30 minutes. During the HSG test, an iodine-based dye is inserted through the cervix, and X-rays are taken to evaluate the shape of the uterus and determine if the fallopian tubes are blocked.

If you have experienced difficulties conceiving or have had recurrent miscarriages or secondary infertility, an HSG may be recommended as one of the initial fertility tests.

The level of discomfort experienced during the test varies from person to person. Some individuals report mild to moderate cramping, while others feel no unpleasant sensations. Severe cramping is rare, and many patients find that their fear of pain is worse than any discomfort they actually feel. Pain medications can be administered as needed to enhance comfort during the procedure.

Before the HSG Test

Before undergoing an HSG test, it is generally advised to schedule the test after your menstrual period but before ovulation to minimize the risk of performing the test while pregnant. Your fertility clinic or doctor will provide instructions to contact the radiology facility on the first day of your period to schedule the test. It is common for doctors to prescribe antibiotics to reduce the chance of infection.

HSG Test Step-by-Step

During the HSG procedure, you will be positioned on a table, typically with stirrups. In the event that stirrups are not available, an alternative position may be required. In this case, you would lie on the table, bend your knees, and place your feet (somewhat) flat on the table, while keeping your legs apart.

Pelvic exam

  • A pelvic exam is performed, involving the insertion of a speculum into the vagina, similar to a regular gynecological exam. This step may cause discomfort, especially for individuals who experience pain during pelvic exams or suffer from sexual pain.

X-Ray Prep

  • The healthcare provider positions an X-ray machine over your abdomen, which may cause a slight feeling of awkwardness, especially when the speculum is inserted and your knees are raised. The cervix is swabbed to clean it before a plastic catheter called a cannula is inserted into the cervical opening. This may cause slight discomfort resembling a Pap smear or may be entirely painless.

Dye Injection

  • The subsequent step involves injecting an iodine-based dye through the catheter. When the dye is injected, you may experience a warming sensation. The dye travels through the uterus and fallopian tubes (if unobstructed) and spills into the pelvic cavity. If the tubes are blocked, you may feel discomfort during the dye injection, which should be promptly communicated to your doctor.

X-Rays Taken

  • X-rays are taken after the dye injection, and you will be asked to hold your breath briefly for each picture. Your position might be adjusted during the process, such as lying on your side. It is natural to feel discomfort with the speculum and X-ray equipment in place, but you can request assistance if needed. Once the doctor is satisfied with the images, the X-ray machine is removed, and the speculum is taken out. You are free to go home.

Managing Discomfort During HSG Test

To alleviate discomfort during the HSG test, some doctors recommend taking a painkiller like ibuprofen one hour before the procedure. This can help reduce mild cramping. It is important to note that anxiety and fear can amplify the perception of pain, so managing stress levels can contribute to a more comfortable experience.

After the HSG Test

You may experience mild cramps and notice light spotting after the test. Over-the-counter pain relievers can help alleviate cramping. Normal activities can be resumed after the procedure, although some doctors may advise refraining from sexual intercourse for a few days. If discomfort intensifies after the test or if you develop a fever, it is advisable to contact your doctor, as there is a rare risk of infection following an HSG.

What HSG Test Results Mean

The HSG test results provide valuable information to your healthcare provider regarding two crucial factors.
Let’s analyze and understand the implications of these results:

Are the Fallopian Tubes Open? 

  • If the HSG shows that the fallopian tubes are blocked, it means that the egg cannot meet the sperm, which hinders conception. Various causes can lead to fallopian tube blockage, and corresponding treatments are available to address this issue.

Are There Any Uterine Abnormalities?

In cases of recurrent pregnancy loss, an abnormally shaped uterus may be the underlying cause. The HSG test can also detect the presence of fibroids or polyps that might interfere with embryo implantation and growth. Some uterine abnormalities can be treated through surgical intervention.
Now, let’s consider different scenarios based on the HSG test results:

Normal Results:

Normal findings are indicated when the x-ray reveals a normal uterine shape and the dye freely flows from the ends of the fallopian tubes. However, it’s important to note that normal HSG results do not necessarily indicate normal fertility. Some causes of infertility related to hormone imbalances cannot be visualized through an HSG. Additionally, not all uterine-based fertility problems can be detected with this test.

It’s worth mentioning that a small study reported a 35% occurrence of false negatives in HSG results. This means that the HSG might show a normal uterine shape, but abnormalities are later discovered through hysteroscopy (a procedure involving a thin camera inserted through the cervix to examine the uterus).

An HSG cannot diagnose endometriosis; only an exploratory laparoscopy can confirm or rule out this condition.

Abnormal Results:

  • If the dye injection during the HSG reveals an abnormally shaped uterus or restricted flow from the fallopian tubes, it indicates a potential problem.
  • It’s important to be aware that 15% of women may experience a “false positive” result, where the dye fails to pass from the uterus into the tubes. This blockage appears at the junction of the fallopian tube and the uterus. If this occurs, the doctor may recommend repeating the test or ordering a different test for confirmation.
  • While an HSG can identify blockages in the fallopian tubes, it cannot determine the underlying cause. Further testing, such as exploratory laparoscopy or hysteroscopy, may be recommended by your doctor. These procedures can provide a more comprehensive investigation of the issue and potentially offer corrective measures.

Understanding the results of your HSG test is crucial for determining appropriate fertility interventions and potential treatment options. Your healthcare provider will guide you through the interpretation of these results and help you make informed decisions regarding your fertility journey.

HSG Test Risks and Safety Concerns

Here is a description of the risks and safety concerns associated with an HSG :


  • Infection: Occurs in less than 1% of cases, more common if there’s a history of infection or risk of pelvic inflammatory disease (PID).
  • Fainting: Possible during or after the test; lying down until stable is recommended.
  • Iodine Allergy: Rare but potentially serious; inform the doctor if allergic to iodine or shellfish.

Safety Concerns:

  • Radiation: Low amount used in HSG; no known adverse effects, even if pregnancy occurs later.
  • Pregnancy: HSG should not be done if pregnant, inform the doctor if there’s a possibility of pregnancy.

Overall, the HSG procedure is usually quick and painless for most individuals. If any pain occurs, it is typically brief and mild. If you experience intense or prolonged pain, promptly inform your doctor, who will take appropriate steps to alleviate the discomfort. It is recommended to consult with your doctor regarding the use of painkillers before the exam.

FAQ About HSG test

1. Does an HSG test hurt?

Some women may experience mild discomfort or cramping during an HSG procedure, similar to menstrual cramps. However, pain levels can vary, and pain medication or a local anesthetic may be provided to alleviate discomfort.

2. Can an HSG help with infertility?

Yes, an HSG can help identify potential causes of infertility. It can reveal blockages in the fallopian tubes, abnormalities in the uterine shape, or other issues that may impact fertility. Identifying these factors can guide appropriate treatment options.

3. Are there any limitations to what an HSG can detect?

An HSG can provide valuable information about the anatomy of the uterus and fallopian tubes. However, it cannot identify all causes of infertility. Some conditions, such as hormonal imbalances or endometriosis, cannot be visualized through an HSG and may require additional tests for diagnosis.

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