This post was reviewed for medical accuracy by Rosalie Gunson, a Certified Registered Nurse Practitioner specializing in fertility care.
If you’re getting a full fertility workup, you will likely be sent for a test called a hysterosalpingogram (HSG). This test allows a radiologist to watch contrast dye travel through your pelvis on an X-ray.
It will show if you have any blockages or abnormalities in your reproductive system that would make it harder to get pregnant or maintain a pregnancy.
Does the HSG hurt? It depends. Some women say their HSG wasn’t painful at all. Others report that it was like bad menstrual cramps for about 5-10 minutes.
To help with potential pain, your doctor may suggest taking ibuprofen (or whatever you usually take for menstrual cramps) before your appointment. Many doctors have found that a different version of the test done with saline instead of dye is more comfortable for patients.
You may have heard that women often get pregnant within three months of their HSG. It is believed that the dye can flush out some minor blockages and clear the way for a successful conception. You never know!
But you should consider the HSG a diagnostic test rather than a form of fertility treatment per se.
Getting an HSG
When you get an HSG, you lie down like you’re getting any other kind of gynecological exam. The radiologist inserts a contrast liquid through your cervix using a catheter. The dye in the liquid will look white on the X-ray machine.
Ideally, the dye will flow smoothly through the fallopian tubes and the uterus, indicating that there are no blockages. You might be asked to shift positions a little to allow the doctor to get a different view. The actual procedure should only take a few minutes.
An HSG shows:
- The shape of the uterine cavity
- Any developmental abnormalities of the uterus or tubes
- Any adhesions (scar tissue) inside the uterus, as from a previous pelvic surgery
- Any obstructions in the fallopian tubes
If you do have a blockage, the test is likely to be more uncomfortable. It’s always a good idea to tell your doctor how you’re feeling. Don’t just tough it out! Your doctor needs to know if the procedure is unusually painful for you.
An HSG can rule out certain kinds of issues that would make it difficult to get pregnant “the old-fashioned way.” Knowing that your uterus and fallopian tubes are normal will make it easier to confidently move forward with medicated cycles (Clomid/ letrozole, injections, or combo cycles with both. For more information about combo cycles, check out my post What is a Combo Infertility Cycle?).
On the other hand, if the HSG does show a tubal blockage or some other structural issue, you and your doctor can use that information to develop a treatment plan that is most likely to succeed.
For example, you may be able to have minor surgery to clear the blockage, or your doctor may recommend jumping right to IVF. At least you won’t waste precious time, emotional energy, and money on multiple failed rounds of Clomid!
Keep in mind that radiologists are not as well-versed in fertility issues as reproductive endocrinologists (REs) are. Unfortunately, fertility clinics sometimes see abnormal HSG results that were previously judged to be normal. This can lead to an inaccurate diagnosis of “unexplained infertility,” which might be the most frustrating infertility diagnosis of all!
It’s a good idea to have your fertility specialist interpret the results if possible, rather than just relying on the radiologist’s opinion.
The posts Can Your PCP Prescribe Clomid? and Graduating from an RE to an OB for Prenatal Care provide more detail about the different kinds of providers you may see on your fertility journey.
The Importance of the Shape of the Uterine Cavity
It’s not hard to figure out why you’d want the fallopian tubes to be clear: the egg needs to be able to travel down its path to the uterus if you are going to get pregnant (without IVF, anyway).
But what’s the big deal about the uterine cavity? The uterus needs to be large enough to support a baby, and ideally it would be a normal shape.
A uterus is shaped like an upside-down pear, or a light bulb, but sometimes it develops differently. You probably wouldn’t know if there was anything unusual about your uterus without this kind of testing. After all, it’s an internal organ, and the shape of the uterus may not cause any symptoms that a woman would notice in her everyday life.
Having a uterus with an unusual shape can lead to infertility and higher rates of first-trimester loss. According to a study in the American Journal of Obstetrics and Gynecology, these malformations of the uterus also lead to higher risk of preterm deliveries, breech deliveries, and medically required c-sections. Basically, the pregnancy would be considered high-risk.
Here are some of the uterine variations that an HSG might show:
- Unicornate uterus: A smaller than normal uterus with only one functional fallopian tube. This problem is associated with higher risk of infertility, miscarriage, ectopic pregnancy, fetal growth restriction, and preterm labor.
A unicornate uterus can’t be corrected with surgery, because there’s no way to make the uterus bigger. Luckily, it is very rare to have a unicornate uterus!
- Bicornate uterus: A uterus with two “horns” and a heart shape. This is one of the most common abnormalities of the uterus. It is associated with higher rates of pregnancy loss, fetal growth restriction, and preterm labor.
- Septate uterus: A uterus with a membrane in the middle. This problem is associated with high rates of pregnancy loss. Luckily, it can be corrected by surgically removing the membrane.
Note that these problems are considered congenital, but not genetic. In other words, a woman with a heart-shaped uterus is not likely to have a mother or a daughter with a heart-shaped uterus. It’s just something that can happen as a fetus develops in the womb.
The Best Time To Do an HSG
In terms of the big picture, the HSG should be done early in the fertility workup — around the same time as the semen analysis, if you have a male partner.
In terms of a particular cycle, fertility specialists typically want you to schedule the test between CD 5 and CD 12. It is important to do the HSG after your period but before you ovulate.
You may wonder if you can do an HSG and an IUI in the same cycle. You can, as long as you do the test well before ovulation.
But your provider may recommend waiting at least one cycle before doing the IUI. That’s because most women will have started their stimulation medications by the time they get the results of their HSG.
If the test shows a problem that needs to be corrected, it is better to find that out before you’ve invested in medications (especially if you’re taking injectables, which can be expensive).
You shouldn’t do an HSG if you are already pregnant. That’s partly because it involves X-ray radiation, and partly because you don’t want to risk damaging a growing embryo.
If there’s a chance you could be pregnant, or you don’t know where you are in your cycle, you will probably be asked to take a pregnancy test before the procedure.
By the time you’re considering an HSG you’ve probably had a transvaginal ultrasound… but if you haven’t, check out the sister post to this one, Do Transvaginal Ultrasounds Hurt?
HSG vs. SIS
As I said above, a traditional HSG is a type of 2D X-ray done with contrast dye. A saline infusion sonogram (SIS) is a similar test with saline instead of dye, and an ultrasound machine instead of an X-ray machine. It’s a newer test that is becoming more popular with infertility specialists. (You may also see this called an SHG, or sonohysterogram. It’s the same thing.)
I had the SIS rather than the HSG, because my doctor said most people find it less painful.
It was also more convenient, since I could do it right in my doctor’s office. Any time I can avoid a trip to the hospital, I’m all for it! (I had all my fertility treatment done at an ob/gyn practice rather than a fertility clinic. Big fertility clinics may have the equipment to do an HSG in-house.)
So how did it go? Not gonna lie, I was surprised at how uncomfortable it was! I remember grabbing the nurse’s hand and thinking, “How am I going to handle labor if stupid saline hurts this much?!” So I am very glad I didn’t do the dye version.
But it was over quickly, and the results were great. My uterine cavity and tubes looked healthy, and there were no blockages anywhere. Whew!
I should add that these tests have other uses too, such as investigating the cause of heavy bleeding or recurrent pregnancy loss.
Depending on the concerns in your specific case, you might be sent for one test or the other. For example, the SIS is considered better at detecting uterine fibroids, but the HSG is better for assessing the health of the fallopian tubes.
What do healthy fallopian tubes look like? Healthy fallopian tubes are open, but not dilated. Dilated fallopian tubes can allow fluid to build up, leading to potential infection. Dilated tubes can also backflow into the uterus, making it slippery and not ideal for implantation.
Because IVF bypasses the fallopian tubes entirely, IVF patients often do a SIS rather than an HSG.
The Cost of an HSG (or SIS)
The HSG and SIS are both outpatient diagnostic tests, and diagnostic tests are more likely to be covered by insurance than other aspects of fertility treatment. Even if your health insurance plan doesn’t cover IUIs or IVF, it may cover this.
If you don’t have coverage, you can expect the test to cost somewhere in the ballpark of $500 to $1,000 in the United States… but as we all know, prices for medical treatment vary a lot in this messed-up system of ours.
If you’re self-paying, be sure to let the billing office know, along with any other information that could help them code the visit in a better way. The reason you are getting the HSG/ SIS could affect whether it’s covered.
For more information about navigating the health insurance minefield, check out my posts How Much Does an IUI Cost Without Insurance? and Insurance Coverage for Fertility Treatment: 8 Things to Know.
The good news is that this is a one-time thing in most cases. Assuming everything looks healthy and there’s no reason to suspect anything has changed, you won’t have to do another HSG.
When a Follow-Up Hysteroscopy is Needed
Sometimes an HSG/ SIS shows a potential problem that you need a hysteroscopy to further diagnose.
In a hysteroscopy, your doctor would look inside your uterus with a very small, flexible telescope that is attached to a camera. This device is called a hysteroscope.
Believe it or not, there are even smaller tools that can fit through the hysteroscope for performing minor surgery. For example, these tools can collect tissue for a biopsy.
A purely diagnostic hysteroscopy can be done while you are awake. But if your doctor suspects a problem that can be corrected using the hysteroscopy and those little tools, you may be put under general anesthesia.
That way, you won’t have to go back for a second hysteroscopy to fix whatever they discovered on the first one (for example, fibroids or polyps). A hysteroscopy done as part of a surgical procedure will be more expensive than one that is done for diagnostic purposes.
A friend who had several of these procedures said that the diagnostic hysteroscopy was less painful than the HSG! So that’s good news. She went on to have two surgeries under anesthesia to remove fibroids (hysteroscopic myomectomies), and then two rounds of IVF before getting pregnant with beautiful twin boys.
Conclusion
An HSG may be a bit uncomfortable, but it shouldn’t be agonizingly painful. The SIS, which is a form of ultrasound rather than an X-ray, is more comfortable for many women.
Either way, the test is over quickly, and it provides valuable information about your reproductive health.
Resources for Further Reading:
Hysterosalpingography FAQ from the American College of Obstetricians and Gynecologists (ACOG)
This post was last updated in March 2021.
I’m Jenn! Here I am with my beautiful twin boys. My pregnancy was possible thanks to fertility treatment for PCOS.
