What Is an HSG (Hysterosalpingography)? How Is It Done, Is It Painful, and When Should It Be Performed?

Short Answer

HSG (hysterosalpingography) is a diagnostic method that shows the shape of the uterine cavity and whether the fallopian tubes are open, using X-ray images taken after a contrast agent is introduced into the uterus. The procedure is usually done right after the end of the menstrual period, takes 5-10 minutes, and cramps similar to menstrual pain may be felt during it.

Key Takeaways

• HSG is the most widely used first-line test showing whether the tubes are open.
• The procedure is performed after the end of the period, between days 6 and 11 of the cycle.
• Mild to moderate cramps similar to menstrual pain may be felt during the procedure; severe pain is not expected.
• The procedure takes about 5-10 minutes, and daily life can be resumed on the same day.
• HSG and hysteroscopy are different procedures: HSG images from the outside with X-rays, while hysteroscopy looks directly inside the uterus with a camera.
• Findings such as tubal blockage, a septum, polyp or adhesions in the uterine cavity can be detected with HSG.
• Mild spotting and cramping may occur for a few days after the procedure; this is normal.

What Is HSG (Hysterosalpingography)?

HSG is a diagnostic method that allows the uterine cavity and fallopian tubes to be imaged with X-rays. During the procedure, a special contrast agent is introduced into the uterus through the cervix with the help of a thin catheter. This fluid fills the uterine cavity and flows through the tubes toward the abdominal cavity; this flow is followed live with X-ray images. The aim is to evaluate the shape of the uterine cavity and whether the tubes are open.

Why Is HSG Performed?

To Evaluate Whether the Tubes Are Open

One of the most common reasons it is requested in an infertility investigation is to see whether the tubes are blocked. For the egg and sperm to meet, at least one tube must be open; HSG provides this information directly.

To See the Shape of the Uterine Cavity

HSG also provides information about whether there is a congenital anomaly, polyp, fibroid or adhesion in the uterine cavity.

Evaluation After Recurrent Miscarriage or IVF Failure

In patients with a history of recurrent miscarriage or whose previous IVF attempts were unsuccessful, the condition of the uterine cavity and tubes can be evaluated with HSG.

Which Tests Are Requested Before HSG?

Some clinics may request simple tests before HSG to rule out urinary tract and genital infections. In addition, because the procedure is not performed when pregnancy is possible, some patients may be asked to rule out this possibility with a pregnancy test before the procedure. The exact requirements may vary from clinic to clinic.

When Should HSG Be Done? On Which Day of the Cycle?

HSG is performed after menstrual bleeding has completely stopped but before ovulation occurs, usually between days 6 and 11 of the cycle. This timing is important for two reasons: if done during bleeding, image quality may be impaired and the risk of infection may increase; if done after ovulation, there is a risk of exposing a not-yet-detected pregnancy to X-rays.

How Is HSG Planned for Women With Irregular Periods?

In patients with irregular menstrual cycles, it can be difficult to predict when ovulation will occur. In this case, the clinic tries to determine the most suitable day for the procedure with the help of hormone monitoring or ultrasound. In some patients, an additional test may be requested to completely rule out the possibility of pregnancy.

Can HSG Be Done During Pregnancy?

No. Because HSG involves X-rays and fluid is introduced into the uterine cavity under pressure, it is never performed during pregnancy. For this reason, the procedure is planned in the safe period before ovulation, and in patients who may be pregnant this possibility is ruled out before the procedure.

How Is HSG Performed?

Preparation

Taking a pain reliever before the procedure is usually recommended. Some clinics may recommend antibiotics before or after the procedure to reduce the risk of infection.

During the Procedure

The patient is positioned on the gynecological examination table, a thin catheter is placed in the cervix, and X-ray images are taken simultaneously while the contrast agent is introduced through it. It is observed whether the contrast agent fills the uterine cavity and passes freely through the tubes into the abdominal cavity.

Duration of the Procedure

The procedure itself usually takes 5-10 minutes; the total time spent at the clinic, including preparation, may be a little longer.

Is HSG Painful?

As the contrast agent is introduced into the uterus during the procedure, it is common to feel mild to moderate cramping similar to menstrual pain. If one of the tubes is blocked or the uterus contracts, this cramping may be more noticeable. Severe, unbearable pain is not expected; most patients describe the procedure as a temporary discomfort lasting a few minutes.

What Can Be Done to Reduce the Pain?

Taking a pain reliever recommended by the doctor on time before the procedure can significantly reduce discomfort. Breathing deeply and regularly and trying to keep the abdominal muscles relaxed during the procedure can also help the cramping be tolerated more comfortably. Communicating with the team performing the procedure in advance and sharing concerns also makes the process easier.

What Does the HSG Result Mean?

If the Tubes Are Open

The contrast agent spreading freely into the abdominal cavity from both tubes shows that the tubes are open.

If There Is a Blockage in the Tubes

The contrast agent failing to pass through one or both tubes suggests that there may be a partial or complete blockage in that tube. With a one-sided blockage, natural pregnancy may still be possible if the other tube is open; with a blockage on both sides, IVF treatment is usually considered.

If There Is a Finding in the Uterine Cavity

If findings such as a septum, polyp, fibroid or adhesions are detected, the effect of these findings on fertility and, if necessary, treatment options are evaluated separately.

Is It True That HSG Has a Therapeutic Effect?

Some studies have reported that, owing to the mild "flushing" effect of the contrast agent given during HSG on the tubes, a small increase in natural pregnancy rates may be seen in the few months after the procedure. This does not mean that HSG is a treatment method; the procedure is primarily diagnostic, but the fact that an additional benefit can be observed in some patients is an interesting finding.

What Is the Difference Between HSG and Hysteroscopy?

These two procedures are often confused, but they serve different purposes:

• HSG images the shape of the uterine cavity and the patency of the tubes from the outside using X-rays and a contrast agent; it is diagnostic and no treatment can be performed.
• Hysteroscopy allows the uterine cavity to be viewed directly from the inside by entering through the cervix with a thin camera; it offers both diagnosis and the possibility of treatment in the same session, such as removing a polyp or releasing adhesions, but it does not provide information about the patency of the tubes.

You can find detailed information about hysteroscopy in our article what is hysteroscopy?.

What Is the Difference Between HSG and Laparoscopy?

Another procedure HSG is often confused with is laparoscopy. Laparoscopy is a surgical procedure performed by entering the abdomen through small incisions and examining the uterus and tubes directly by eye from the outside; it requires general anesthesia. HSG, on the other hand, is an X-ray-based diagnostic method performed on an outpatient basis without anesthesia. When a suspicious finding is detected on HSG, laparoscopy may sometimes be considered for detailed evaluation.

Why Is HSG Important for Patients Planning Treatment Abroad?

For patients planning to travel for treatment as part of health tourism, having basic evaluations such as HSG completed in their own country before travel, if possible, saves time. This way, the time spent at the clinic can be devoted directly to treatment planning and implementation. Bringing the results as an organized report, and if possible with the images, speeds up the evaluation.

Does HSG Have Risks?

HSG is generally considered a safe procedure, but it rarely carries some risks:

• The risk of infection is rare; to reduce this risk, preventive antibiotics may be recommended for some patients.
• An allergic reaction to the contrast agent is very rare; a history of allergy is asked about before the procedure.
• The radiation dose used is low, but the procedure is still not performed when pregnancy is possible.

How Do I Know Whether I Am Allergic to the Contrast Agent?

Before the procedure, your doctor will ask whether you have a known allergy to iodine-containing substances or X-ray contrast agents. If you have had a reaction during a similar procedure or during imaging with intravenous contrast before, you must mention it; this information allows precautions to be taken before the procedure.

How Many Times Can HSG Be Repeated?

There is no strict limit on repetition. If a finding remained unclear on the first HSG or a new evaluation is needed over time, the procedure can be repeated. However, because it involves X-rays, unnecessary repetitions are avoided, and each decision to repeat is made on clinical grounds.

At Which Stage of an Infertility Investigation Is HSG Done?

Infertility evaluation usually progresses starting from simple, low-risk tests. Together with semen analysis and basic hormone tests, HSG is one of the first steps of the evaluation in most clinics, because it provides quick and clear information about whether the tubes are open. If no problem is detected on HSG and pregnancy still does not occur, the process continues with ovulation monitoring and, if necessary, more advanced treatment options.

Can a False Blockage (Spasm) Occur on HSG?

Sometimes, even though the tube is not actually blocked, the passage of the contrast agent may be hindered because the uterine and tubal muscles show a temporary spasm due to the stress of the procedure. This can mistakenly look like a blockage. With a suspicious result, additional imaging or confirmation with a different method may sometimes be requested to rule out the possibility of spasm.

What Are Clinics Doing to Make HSG Less Uncomfortable?

Some clinics try to reduce discomfort by using thinner, flexible-tipped catheters during catheter placement. In addition, keeping the patient informed throughout the procedure and explaining each step in advance to reduce anxiety is a common practice. In some centers, guiding the patient through breathing and relaxation techniques during the procedure is also a simple but effective approach that increases comfort.

Who Is HSG Not Suitable For?

The procedure is postponed in patients with an active pelvic infection, unexplained heavy vaginal bleeding or suspected pregnancy. In patients with a known serious allergy to the contrast agent, alternative approaches are considered. These conditions are evaluated by the doctor before the procedure.

Does the Experience of the Doctor Performing HSG Affect the Result?

Yes. The experience of the physician performing the procedure makes a difference both in the patient's comfort and in the correct interpretation of the images. An experienced practitioner can place the catheter more comfortably, reduce cramping by avoiding unnecessary pressure and be more accurate in distinguishing a suspicious finding from a spasm. For this reason, it is recommended that the procedure be performed by a team experienced in the field of infertility.

Should Sexual Intercourse Be Avoided Before HSG?

It is usually recommended to avoid unprotected intercourse for a few days before the procedure so that the possibility of pregnancy is clear. This is a safety measure intended to prevent the procedure from being performed accidentally during pregnancy. The exact recommendation may vary from clinic to clinic.

What Can Be Expected After the Procedure?

Mild spotting, cramping or a mild discharge related to the contrast agent may occur for a few days after the procedure. These findings are usually normal and resolve on their own. Most patients can return to their daily activities on the same day.

What Should You Wear on HSG Day, and What Should You Pay Attention To?

Comfortable, easily removable clothing is recommended; the procedure is performed in the gynecological examination position. Having a thin pad with you may be helpful in case of mild discharge after the procedure. There is usually no harm in driving after the procedure because sedation is not given; still, if cramping is noticeable, it is more comfortable to rest for a while before leaving.

How Is the Contrast Agent Eliminated From the Body After HSG?

The contrast agent used is water-based and is eliminated from the body quickly, largely by draining through the vagina; some of it is also removed from the body in the urine via the kidneys. A mild, watery discharge lasting a few days after the procedure is a normal part of this elimination process and is not a cause for concern.

Is the Menstrual Cycle Affected After HSG?

Because HSG is a short procedure involving a low dose of radiation, it is not expected to affect the menstrual cycle directly. In some patients, the period may come a few days earlier or later after the procedure, but this is usually related to hormonal fluctuations in that cycle rather than to the procedure itself. If a marked irregularity continues, it is recommended to share it with the clinic.

Is There an Alternative to HSG?

In addition to HSG, some centers may also use an ultrasound-based method that does not involve radiation to evaluate whether the tubes are open. This method may not be available at every center and is not as widely used as HSG, but it can be considered an option for some patients who want to avoid radiation. Which method is suitable is determined according to the clinic's facilities and the patient's condition.

When Should You See a Doctor?

After the procedure, contact the clinic in the following situations:

• High fever
• Severe, steadily increasing abdominal pain
• Foul-smelling, heavy discharge
• Bleeding lasting longer than 2-3 days

How Is the Shape of the Uterine Cavity Evaluated During HSG?

The way the contrast agent fills the uterine cavity shows whether the cavity has a normal triangular form or carries a congenital difference (for example, a septum in the middle). This information is especially important in patients with a history of recurrent miscarriage, because a structural difference in the uterine cavity may be associated with some pregnancy losses. When a suspicious appearance is detected, additional imaging or hysteroscopy may be recommended for clarity.

What Happens If Both Tubes Are Blocked on HSG?

A result showing that both tubes are blocked indicates that the chance of natural pregnancy is seriously reduced, because the egg and sperm cannot meet naturally. In this case, IVF treatment is usually considered the most effective option, because in IVF fertilization takes place in the laboratory and open tubes are not needed. In some special cases, surgical options aimed at opening the tubes may also be considered, but success rates vary according to the cause and degree of the blockage.

Can the HSG Result Differ From the Physical Examination Result?

Yes, sometimes a tube that appears blocked on HSG may actually turn out to be open on further evaluation (for example, during laparoscopy); the reason may be a temporary muscle spasm during the procedure. For this reason, a borderline or unexpected HSG result alone may not be considered sufficient for a definitive decision, and a complementary evaluation is requested when necessary.

What Questions Should You Ask the Doctor Before HSG?

Among the topics patients most want to know about before the procedure are the level of pain, when the pain reliever should be taken, how long to rest after the procedure and when and how the results will be shared. Clarifying these questions before the procedure both reduces anxiety and helps the process go more comfortably.

Should HSG Films Be Kept?

Yes, it is recommended that the patient keep a copy of the images obtained during HSG. Especially if treatment continues at a different clinic, previous HSG results can save time in the new evaluation and prevent an unnecessary repeat.

Common Mistakes

"HSG and hysteroscopy are the same procedure."

They are different: HSG images from the outside with X-rays, while hysteroscopy looks directly from the inside with a camera and offers the possibility of treatment.

"HSG is always a very painful procedure."

Mild to moderate cramping is felt; severe, unbearable pain is not expected, and most patients tolerate the procedure.

"If HSG shows a blockage, natural pregnancy will never happen."

With a one-sided blockage, natural pregnancy may still be possible if the other tube is open; the evaluation is individual.

"HSG can be done on any day you like."

The timing of the procedure is important; it should be done after menstrual bleeding ends and before ovulation.

"HSG provides both diagnosis and treatment."

HSG is diagnostic only; if a problem is detected in the uterine cavity, a separate procedure such as hysteroscopy may be needed for treatment.

Assoc. Prof. Dr. Nurettin Türktekin's Assessment

HSG is one of the most basic and informative tests of an infertility investigation; however, what my patients worry about most is usually how painful the procedure is. In my experience, most patients tolerate the procedure more comfortably than they expected, and the cramping is temporary. What really matters is obtaining the result with the right timing and the right technique; a film taken at the wrong time can both give a misleading result and require an unnecessary repeat. When a tubal blockage is detected, I also make a point of explaining to my patients in detail whether it is one-sided or two-sided and how this affects the chance of natural pregnancy, because this result directly determines the patient's treatment path.

Is HSG Routinely Requested Before IVF Treatment?

Some clinics may request HSG or similar imaging before starting IVF treatment to confirm that the uterine cavity is healthy. However, this is not a mandatory step for every patient; the decision varies according to the patient's history, previously performed tests and the clinic's protocol. If there is no suspicion regarding the uterine cavity, this evaluation can also be done directly with hysteroscopy.

How Is the HSG Result Sent to the Clinic?

The images and report are usually ready shortly after the procedure; in some centers the result is delivered to the patient or the treating physician on the same day, in others within a few days. The results must be interpreted by a physician experienced in the field of infertility, evaluated together with the patient's entire clinical picture; the technical expressions in the report can be open to misunderstanding when read on their own.

Conclusion

HSG (hysterosalpingography) is a diagnostic method frequently used in infertility investigations that images the shape of the uterine cavity and the patency of the tubes with X-rays. The procedure is performed in the period after menstrual bleeding ends, takes 5-10 minutes, and mild to moderate cramping may be felt during it. HSG, hysteroscopy and laparoscopy are separate procedures serving different purposes. The results should be interpreted together with the patient's overall evaluation.