The Dreaded HSG

a blog by Serena H. Chen, M.D., IRMS Reproductive Medicine at Saint Barnabas, January 18, 2012

HSG — the hysterosalpingogram. This is the infertility test that women dread the most.

Hystero means uterus, salpingo means fallopian tubes and gram means image. This is a test that allows us to see what is going on with your uterus and your tubes. Is your uterus normal? Does it have a funny shape? Are there any polyps or fibroids or scar tissue inside the uterine cavity that could increase your risk for miscarriage? Are your tubes open? If the tubes are blocked, the sperm and egg cannot get together.

The HSG is dreaded because it is a test that causes a lot of intense pelvic cramping. It is the most invasive test that most infertile women will undergo these days. The other tests are a pelvic exam and sonogram, and blood tests. Of course the guy might have a few blood tests, and then he has to masturbate into a cup to produce the sperm sample for analysis. The guys will complain bitterly about this, but they would never be able to tolerate the HSG.

On the other hand, the HSG is much easier than childbirth. Basically, the test is usually done in a radiologic facility. It is done at a specific time in your menstrual cycle — after you finish bleeding and before you ovulate. For many women this will be between days 7 and 10 of their cycle, with day 1 being the first day of bleeding. Scheduling can be tricky if you are irregular, so definitely discuss that with your doctor or nurse if you are confused.

Before the HSG

Some doctors are nice (like me) and give their patients pain medications ahead of time. I usually give some antibiotics (not absolutely necessary, but a nice touch I think), a medicine for cramps such as Advil or Aleve (I give a prescription dose of Aleve), and I like to give a small dose of valium to help you relax a little. The worst part of the HSG is the anticipation of pain — the discomfort is usually not so bad but is definitely made worse by being anxious about the test. There are all kinds of reasons to feel anxious — all your girlfriends’ horror stories (were they trying to be helpful?); just the generalized anxiety of not being able to conceive; and concern about what abnormalities might be found and fear of the unknown. So a little bit of valium or something like that can really make things go much more smoothly. Not every doctor gives valium, but many will be OK with it if you ask. So talk with your doctor about it if you think it may be helpful. If you take the valium, you cannot drive, so you will need a ride, and then afterwards you will just want to go home and nap.

OK, so now you have your appointment, you have taken your premedications and you are sitting on the table in a gown in radiology. The doctor will place a speculum in the vagina, and then clean off the cervix with some antiseptic such as betadine. The key here is to RELAX. I know, how can you relax with a big metal clamp in your vagina? Not exactly a relaxing situation. However, if you can fight the urge to tense up and really keep all the muscles in your pelvis and hips relaxed (deep breath), the test will be significantly easier — faster and less uncomfortable. If you are really tense, just let the doctor know. S/he can often talk you through the procedure and help remind you to relax.

If you are allergic to iodine, then the doctor will use something other than betadine. Also, if you are allergic to iodine, you may be allergic to the HSG dye as well. Some people with relatively mild allergies can still have the test done, but may need medications prior to the test to prevent an allergic reaction. Usually this is an antihistamine and a corticosteroid like prednisone — both are taken orally. For severe allergies, it may be better to skip this test and do something else. Please ask your doctor about this. For women on Glucophage or metformin, this drug can interact with the dye and should be stopped prior to the HSG or any dye study. The risks with the HSG are low, since the dye is not injected directly into your veins, but we usually stop the metformin just to be safe. We stop the metformin for two days prior to the HSG and then restart it one day after the test is done. Please discuss the details with your doctor since each person’s situation is a little different.

Now the speculum is in, the cervix is clean, and the doctor will put a small clamp on the cervix. Actually, I usually give a paracervical block before I do this (again, this is not routine, but is a numbing injection that I like to do because I feel like it makes the procedure easier to tolerate. The downside is that it requires an injection of medication into the cervix, which can cause some mild discomfort — the nerves in the cervix are different than your skin or your mouth, so the discomfort is much less than an injection in those areas). The injection also causes more bleeding and there is a very small chance that you could have a reaction to the medication. I feel like the upsides outweigh the downsides, but not all doctors agree, so not everyone does this. Again, if you want to have this done, talk with your doctor.

During the HSG

So, having done the cervical cleansing, the paracervical block and the clamp on the cervix, I put the cannula (tube) into the cervix. Now the radiology tech will position the fluoroscope over the pelvis so we have a nice clear picture of the pelvis. While the fluoroscope is on, I inject the dye into the cervix, the uterus and out the tubes. We take pictures periodically, so we can show the dye going in. We cannot see your uterus or tubes on the X-ray, but can see the dye, so the dye will show us the inside of the uterus and the tubes. We can tell whether or not the tubes are open by the pattern of the dye. During the dye injection, many women may experience cramping. This is the reason for the Advil or Aleve ahead of time (one to two tablets an hour prior — clear it with your doctor first) and for the paracervical block. The injection and the pictures take only about one minute – really – only about one minute. Labor can last hours, so you can do this!

After the Test

Once the injection is done, the doctor takes out all the instruments and checks the cervix for any excessive bleeding. Remember the small amount of blood will be mixed with the clear dye, so it will seem like you have a watery bloody flow for a day or so. This is normal. The cramping should stop very quickly once the injection is done. One last picture is taken with the instruments out, and then you can get dressed. Remember to wear a pad. Usually we recommend nothing in the vagina or “pelvic rest” for 24 hours — no tampons, intercourse, swimming or baths (showers are OK). This prevents things going into the cervix and potentially causing an infection while the cervix may be a little open.

If your gynecologist or your reproductive endocrinologist is doing the HSG, then s/he may discuss the results with you right there in the room. If the doctor is a radiologist, s/he may just wish you a good day and send the ordering physician a report.

Whew! You are done — you did great.