Infertility can have many possible causes, including problems with ovulation, sperm health, the uterus, fallopian tubes, or a combination of factors. One of the important investigations used during female infertility evaluation is Hysterosalpingography (HSG), also known as an HSG test or uterosalpingography.
An HSG is an X-ray-based imaging procedure that examines the inside of the uterus and the openness of the fallopian tubes. It can help doctors identify tubal blockage, certain abnormalities of the uterine cavity, and other structural problems that may interfere with conception or contribute to recurrent pregnancy loss.
What Is an HSG Test?
Hysterosalpingography is a specialized X-ray examination performed using fluoroscopy and contrast material. During the test, a healthcare professional introduces contrast material through the cervix into the uterus. X-ray images are then taken as the contrast moves through the uterine cavity and, if the tubes are open, through the fallopian tubes.
The test primarily answers two important questions:
- Is the uterine cavity structurally normal?
- Are the fallopian tubes open?
This makes HSG particularly useful when evaluating infertility.
Why Is HSG Done for Infertility?
Fallopian tubes play an important role in natural conception. After ovulation, the egg enters a fallopian tube, where fertilization can occur if sperm reaches the egg. The resulting embryo then travels toward the uterus.
If one or both tubes are blocked, this process can be disrupted.
An HSG may therefore be recommended when a doctor is investigating:
- Difficulty becoming pregnant
- Suspected fallopian tube blockage
- Previous pelvic infection
- Previous pelvic or tubal surgery
- Previous ectopic pregnancy
- History of tubal disease
- Recurrent miscarriage when a uterine abnormality is suspected
- Previous sterilization or tubal surgery
- Possible abnormalities inside the uterus
HSG can identify problems such as tubal blockage, uterine fibroids that affect the cavity, polyps, adhesions, and some congenital uterine abnormalities.
What Does HSG Show?
Fallopian Tubes
The main purpose of HSG in infertility evaluation is to determine whether the fallopian tubes are patent, meaning open.
If contrast passes through a tube and spills beyond its end into the pelvic cavity, this generally indicates that the tube is open.
If contrast stops before passing through the tube, a blockage may be suspected.
Uterine Cavity
HSG can also show the shape and contour of the uterine cavity. Certain abnormalities may appear as changes in the normal outline.
Possible findings include:
- Endometrial polyps
- Submucosal fibroids
- Adhesions or scar tissue
- Some congenital uterine abnormalities
- Abnormal uterine cavity shape
However, HSG has limitations and does not provide a complete assessment of every pelvic structure. Additional ultrasound, sonohysterography, hysteroscopy, or other imaging may sometimes be necessary.
When Is an HSG Test Performed?
Timing is important because the test should generally be performed when pregnancy is not possible and before ovulation.
RadiologyInfo recommends scheduling HSG approximately 7–10 days after the first day of the menstrual period and before ovulation. Your doctor or imaging center may provide specific timing instructions based on your menstrual cycle.
Women should tell their doctor if there is any possibility of pregnancy before undergoing the examination.
How to Prepare for an HSG Test
Your healthcare provider will give you specific instructions, but preparation commonly includes the following.
Tell Your Doctor About Pregnancy Possibility
HSG should not be performed if you may be pregnant because the examination uses X-rays.
Inform Your Doctor About Allergies
Tell your doctor if you have previously experienced an allergic reaction to iodinated contrast material or any other medications.
Report Pelvic Infections
Active pelvic infection or an untreated sexually transmitted infection should be addressed before HSG. Performing the procedure in the presence of an active infection may increase the risk of complications.
Discuss Your Medications
Tell your doctor about prescription medicines, over-the-counter medicines, supplements, and any relevant medical conditions.
Pain Relief
Some women experience cramping during the procedure. Your doctor may recommend taking an appropriate pain-relieving medicine before the test. Some doctors may also prescribe an antibiotic before or after the procedure in selected cases. Do not take prescription or over-the-counter medication specifically for the procedure without following your healthcare provider’s instructions.
Clothing
You may be asked to change into a hospital gown. Comfortable clothing can make the appointment easier.
What Happens During an HSG Test?
HSG is usually performed as an outpatient procedure.
The process generally involves these steps:
Step 1: Positioning
You will lie on an examination table in a position similar to that used during a pelvic examination.
Step 2: Speculum Placement
A speculum is gently inserted into the vagina so that the cervix can be visualized.
Step 3: Cleaning the Cervix
The healthcare professional cleans the cervix to reduce the risk of introducing bacteria into the reproductive tract.
Step 4: Catheter Placement
A small catheter is inserted through the cervix into the uterus.
Step 5: Contrast Injection
Contrast material is slowly introduced through the catheter.
Step 6: Fluoroscopy
As the contrast moves through the uterus and fallopian tubes, the radiologist uses fluoroscopy to capture images.
Step 7: Completion
Once adequate images have been obtained, the catheter is removed and you can generally return home after a short observation period.
The examination itself commonly takes around 30 minutes, although the total appointment time can vary.
Is HSG Test Painful?
HSG may cause some discomfort, but the experience varies between women.
You may experience:
- Mild to moderate menstrual-like cramps
- Pressure in the lower abdomen
- Brief discomfort when contrast is injected
- Mild pelvic discomfort after the procedure
Some women experience little discomfort, while others may find the cramping more noticeable.
Mild spotting for a few days after the procedure can occur.
If you experience severe or worsening pain, heavy bleeding, fever, chills, or other concerning symptoms after HSG, contact your healthcare provider promptly.
HSG Test Results: What Do They Mean?
The radiologist examines the X-ray images and prepares a report for the doctor who requested the examination. Your gynecologist can then interpret the findings in the context of your fertility history and other test results.
Normal HSG Result
A normal result generally means:
- The uterine cavity has an expected appearance.
- Contrast passes through the fallopian tubes.
- Contrast spills beyond the ends of the tubes, suggesting that the tubes are open.
A normal HSG is reassuring, but it does not guarantee pregnancy because fertility depends on several other factors.
Blocked Fallopian Tube
If contrast does not pass through part or all of a fallopian tube, blockage may be suspected.
Blockage can occur because of:
- Previous infection
- Pelvic inflammatory disease
- Scar tissue
- Previous surgery
- Endometriosis-related damage
- Previous tubal procedures
The location and appearance of the suspected blockage are important when deciding what should happen next.
Bilateral Tubal Blockage
If both tubes appear blocked, natural conception may be significantly affected. Your gynecologist or fertility specialist may recommend additional evaluation and discuss appropriate fertility treatment options.
Importantly, an HSG result should not automatically be interpreted as proof of permanent infertility. Sometimes further evaluation is needed to confirm an apparent blockage.
Can HSG Open Blocked Fallopian Tubes?
In some cases, the passage of contrast during HSG may help open a mildly blocked tube, particularly when the obstruction is related to mucus or minor debris.
However, HSG should primarily be considered a diagnostic test, not a guaranteed treatment for blocked tubes. The RadiologyInfo patient resource notes that HSG can potentially open some blocked fallopian tubes, but whether this occurs depends on the nature and location of the blockage.
HSG and Fertility: Can It Improve Pregnancy Chances?
Some women may conceive after an HSG, but this does not mean that HSG itself is a fertility treatment.
If a minor obstruction is cleared during the procedure, improved tubal passage may potentially contribute to conception. However, pregnancy depends on many factors, including:
- Age
- Ovulation
- Egg quality
- Sperm health
- Tubal function
- Uterine health
- Endometriosis
- Overall reproductive health
Therefore, an HSG result should always be considered as one part of a complete infertility assessment.
Other Tests Related to Infertility
HSG evaluates the uterus and fallopian tubes, but infertility can have many causes. Doctors may therefore recommend additional laboratory tests and investigations.
Pregnancy Test
A pregnancy test is important when menstrual periods are delayed or absent before certain infertility investigations.
FSH Test
Follicle-stimulating hormone (FSH) may be measured when evaluating ovarian function, particularly in women with irregular periods or suspected diminished ovarian function.
LH Test
Luteinizing hormone (LH) may be assessed as part of an evaluation of ovulation and reproductive hormone function.
Estradiol Test
Estradiol levels can provide information about ovarian hormone activity and may be ordered alongside other reproductive hormones.
AMH Test
The Anti-Müllerian Hormone (AMH) test is commonly used as a marker related to ovarian reserve. It may help doctors assess ovarian reserve, but it does not by itself determine whether a woman can become pregnant.
TSH Test
Thyroid dysfunction can affect menstrual cycles and fertility. A thyroid-stimulating hormone (TSH) test may therefore be included in an infertility evaluation when clinically appropriate.
Prolactin Test
Abnormally high prolactin levels can interfere with reproductive hormone signaling and ovulation. A prolactin test may be recommended when menstrual irregularities or other relevant symptoms are present.
Semen Analysis
Infertility evaluation should not focus only on the woman. A semen analysis evaluates male reproductive factors such as sperm concentration, movement, and morphology.
Because infertility can involve male, female, or combined factors, evaluation of both partners is important. ACOG describes basic infertility evaluation as an assessment of the couple to identify possible causes and guide appropriate treatment.
Pelvic Ultrasound
A pelvic or transvaginal ultrasound can assess the uterus, ovaries, endometrium, and other pelvic structures. It may help identify fibroids, ovarian cysts, endometrial abnormalities, and other findings.
Sonohysterography
Sonohysterography, also called saline infusion sonography, uses ultrasound and sterile saline to examine the uterine cavity. It can help investigate infertility and recurrent miscarriage and can detect certain uterine abnormalities. Unlike HSG, ultrasound does not use ionizing radiation.
HSG vs. Ultrasound
HSG and pelvic ultrasound provide different types of information.
HSG:
Uses X-rays and contrast to evaluate the uterine cavity and particularly the openness of the fallopian tubes.
Transvaginal ultrasound:
Uses sound waves to evaluate the uterus, ovaries, endometrium, and other pelvic structures.
These tests may complement each other rather than replace one another.
Risks and Possible Complications of HSG
HSG is generally considered a minimally invasive procedure, and serious complications are uncommon.
Possible risks include:
- Pelvic cramping
- Vaginal spotting
- Infection
- Allergic reaction to contrast material
- Rare injury or other complications
- Exposure to a small amount of ionizing radiation
Inform your doctor about pregnancy possibility, active pelvic infection, untreated sexually transmitted infection, and previous contrast reactions before the test.
What Happens After an HSG?
Most women can return home after the procedure. Mild cramps and spotting may occur.
Your doctor may advise you about:
- When you can resume normal activities
- Whether you should avoid intercourse temporarily
- Whether medication is needed
- When and how you will receive the report
- Whether additional fertility tests are necessary
Your next step depends on the HSG findings and your overall fertility evaluation.
What If the HSG Is Normal but Pregnancy Does Not Occur?
A normal HSG does not rule out every cause of infertility.
For example, HSG cannot diagnose:
- Problems with sperm count or sperm quality
- Every ovulation disorder
- Egg-quality problems
- All forms of endometriosis
- Certain problems with implantation
- Some ovarian disorders
RadiologyInfo specifically notes that HSG cannot evaluate infertility caused by abnormal sperm or problems with implantation and has limitations in evaluating the ovaries and other pelvic structures.
If the HSG is normal but conception remains difficult, your gynecologist or fertility specialist may recommend additional hormonal tests, semen analysis, ultrasound, ovulation assessment, or other investigations.
When Should You See a Gynecologist for Infertility?
Consider consulting a gynecologist or fertility specialist if you have:
- Been trying to conceive without success
- Irregular or absent periods
- A history of pelvic infection
- Previous ectopic pregnancy
- Previous pelvic or tubal surgery
- Suspected endometriosis
- Recurrent miscarriages
- A history of conditions that may affect fertility
- Concerns about ovarian reserve or ovulation
The appropriate timing for infertility evaluation depends on age and individual circumstances, so discussing your reproductive history with a healthcare professional is important.
Frequently Asked Questions About HSG
- Is HSG test done for infertility?
Yes. HSG is commonly used during infertility evaluation to examine the uterine cavity and determine whether the fallopian tubes are open.
- How long does an HSG test take?
The examination itself commonly takes about 30 minutes, although the total time at the facility can vary.
- Is HSG painful?
Some women experience mild to moderate cramping or pressure during contrast injection. The intensity of discomfort varies from person to person.
- Can I get pregnant after an HSG?
Pregnancy may occur after HSG, but the procedure does not guarantee pregnancy. In some cases, minor tubal blockage may be relieved during the procedure. Fertility depends on multiple factors.
- Can HSG detect blocked fallopian tubes?
Yes. HSG is particularly useful for assessing whether contrast can pass through the fallopian tubes, helping identify suspected blockages.
- When is the best time to have an HSG?
It is generally scheduled after menstruation but before ovulation. RadiologyInfo recommends approximately 7–10 days after the first day of the menstrual period. Your doctor will provide individualized timing instructions.
- What tests may be done with HSG?
Depending on your situation, your doctor may recommend tests such as AMH, FSH, LH, estradiol, TSH, prolactin, pregnancy testing, pelvic ultrasound, and semen analysis. Not every patient needs all of these tests.
Book an Online Consultation With a Gynecologist
HSG is an important investigation when doctors need to assess the fallopian tubes and uterine cavity during an infertility evaluation. However, it is only one part of the fertility assessment. Your age, menstrual cycle, ovulation, ovarian reserve, uterine health, and your partner’s sperm health may also need to be evaluated.
If you are having difficulty conceiving, have irregular periods, or have been advised to undergo an HSG test, book an online consultation with the best gynecologist via InstaCare. A qualified gynecologist can review your medical history, recommend appropriate laboratory tests and imaging, explain your HSG results, and guide you toward the next steps.
Medical Disclaimer: This article is intended for general educational purposes and does not replace professional medical diagnosis or treatment. HSG should be performed only when recommended by an appropriate healthcare professional, and individual preparation and follow-up instructions may vary.
