How does your doctor interpret your HSG ?

An HSG ( hysterosalpingogram, X-ray of the uterus and tubes,  is one of the commonest tests performed for infertile women , to confirm their uterine cavity is normal and their fallopian tubes are open.

How does the doctor interpret your HSG films ?

Sometimes, the films are of such poor quality , that we cannot make any sense of them. This maybe because the procedure was not done properly; or because the film was overexposed or under-exposed. Sometimes, the patient moves during the procedure, as a result of which the images may be blurred or out of focus.

When this happens, this is a major shame, because we are then forced to repeat the study. I hate doing this, because I know the HSG can be quite painful !

This is why it’s best to do the HSG in a clinic which has a lot of experience doing HSGs; and which uses an image intensifier , to make sure they get good quality images.

A good HSG study should take multiple images, including a delayed film, to ensure that the doctor can track the spread of dye from the fallopian tubes into the abdominal cavity. Sadly, sometimes some X-ray clinics take shortcuts ( to save money ?) and do not take a delayed film. This can be very frustrating, because then we cannot reliably answer the key question the HSG is designed for – are the tubes open or closed ?

If the plates are technically of good quality, then we look at the medical information they provide. The dye first fills the uterine cavity, which appears as a triangle. It’s important to carefully look at the cervical canal also, because sometimes a long and narrow cervical canal suggests cervical stenosis, which may make an embryo transfer technically difficult.

The uterine cavity may have filling defects within them. Often, these are air bubbles ( which appears as spherical lucencies which move as more dye is injected) , and can be safely ignored. Sometimes, the defects allow the doctor to make a diagnosis of polyps; submucous fibroids; or intrauterine adhesions.

Uterine cavities come in many shapes and sizes and many fertile women have small uterine cavities ; or cavities with curved walls . However, when some doctors see a small uterine cavity, or one which has a curved shape in an infertile woman, they diagnose this to be the cause of the infertility , and advise a “ hysteroscopic metroplasty, to “increase the size of the cavity” , claiming that this procedure increases the chances of the embryo implanting. This is unnecessary meddlesome surgery, which can actually create adhesions and reduce your fertility, so please do not do this. An embryo is microscopic, and can implant in any healthy uterine cavity , no matter how small it is !

The doctor then checks if the dye has entered the tubes are not. The tubes appear as 2 fine lines arising from the upper and outer ends of the triangle ( the cornu of the uterus) . In a normal woman, both the tubes will fill with the dye which will then spill out of the outer ( fimbrial) end of the tubes into the peritoneal cavity, where they will appear as a smudge. Normal tubes are said to show normal fill and spill.

If the tubes are blocked, they will not allow the dye to pass through them. This block should be at the cornual end of the tube; in its isthmic or mid-tubal segment; or its terminal end ( when it is called a hydrosalpinx)

Remember that the dye injected during the HSG only outlines the inside of the cavity and tubes – we cannot see the ovaries or endometriosis or peritubal adhesions with a HSG.

If the tube shows normal fill and spill, this just means that it is anatomically normal – this does not mean that the tubes function properly. Sadly, there is still not test for tubal function; but for someone with normal patent tubes, it’s quite reasonable to assume that the tubes work properly . Sometimes the radiologist describes the tubes as being “beaded”. If it’s open, it’s still best to assume that this is an anatomic variant and that the tube works properly.

If one tube is blocked and the other is open, this is usually not a cause for concern, as one normal fallopian tube is enough for making a baby ( though the time taken to conceive may be increased in these women).

If both the tubes are blocked, then further management will depend upon where the block is. If it’s a fimbrial block, then there is no way of repairing damaged fallopian tubes, as they cannot function normally even after surgery, since their inner lining ( the cilia) has been damaged. IVF would be the best option.

Some doctors remove the hydrosalpinx prior to IVF because they believe the hydrosaplpinx fluid is embryotoxic. We do not recommend this and you can read why at www.drmalpani.com/hydrosalpinx.htm

If it’s a cornual block, this could be because of a spasm; or because of a mucus plug. A simple treatment option is called FTR and you can read more about this at http://www.drmalpani.com/ftr_fallopian_tubal_recanalisation.htm

Some doctors advise that patients have a laparoscopy if their tubes are blocked, so they can find out more about the block and what has caused it. We do not advise this, as this does not change your treatment options at all ! Read more at http://www.drmalpani.com/laparoscopy-and-infertility.htm

Need help making sense of your treatment options if your tubes are blocked ? I’ll be happy to provide a free second opinion if you send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm !