What’s the difference between a Hysterosalpingogram (HSG) and a Sono-Hysterogram?
This just happens to be one of my most frequently asked questions, and it’s a good one. Both are can be very important tests. Some women need only one, some both. In this blog you will see pictures and explanations. I enjoyed putting this blog together because I like taking things that are a little complicated and breaking them down into simple pieces to help make the readers understand every day things that were never made clear to them. Despite this I realize that there are some of you that get very intimidated when shown pictures of anything medically related, so I am sorry if some of this compounds your frustration. Give this one a shot and see how it goes.
Hysterosalpingogram, also known as the hysterogram or HSG. Hystero means uterus, salpingo means tube, so it’s a test to evaluate both the uterus and tubes. It’s a dye test that uses an x ray. As far as the patient is concerned, it starts with a speculum, like a pap smear. The doctor, through various techniques mentioned in previous blogs, squirts some dye into the uterus and it then runs out the tubes. The dye is actually as clear as water, but it’s called dye because it is white on an x ray. The dye then shows the shape of the interior of the uterus and the tubes.
Let’s start with the uterus. This is picture of a HSG x ray.
The uterus is perfect. The tubes are abnormal, but I am starting with this one because the view of the uterus is so ideal. You can see that is triangular in shape with the top being relatively straight across.
The hsg only shows us where the dye is, which is inside the uterus and inside the tubes. It does not tell us anything about the middle or outside of the uterus or tubes. The next picture is the same as above except I outlined the outside of the uterus and the approximate location of the ovaries.
You can see that the overall uterine size is greater than what is shown by the hsg, and how the outer uterus and ovaries are invisible using x rays.
The next picture shows what happens to an HSG when there are fibroids on the middle and outside of the uterus. I drew in some hypothetical fibriods in red. Fibriods like these would be invisible on hsg. As you can see, the shape of the inside of the uterus has not changed. So it is possible to have fibroids, and have a normal looking hsg. Fibriods that are closer to the cavity will make the HSG look abnormal. We will later see how certain fibroids can affect the look of the HSG, but in this case many fibroids did not change the HSG picture.
Now we will look an HSG that shows an abnormal uterus.
This hsg is abnormal. There is a black spot in the center, and this could be a number of things, all of which are abnormal. The center is dark because the dye cannot get to the center of whatever is growing in there. It is most likely a polyp, but it could be a small fibroid or even some scar tissue(less likely). The overall triangular shape of the uterus is good. This shows how an HSG can be used for diagnosing uterine problems such as polyps or fibroids that are growing in the cavity.
This is a good time to move over to salinosonohysterograms (sonohysts for short). Commonly called a saline infusion sonohysterogram (SIS). We will come back to HSGs in a bit. The sonohyst does not use an x-ray or x-ray dye. It instead is performed with a regular old ultrasound machine. Prior to performing the ultrasound, the doctor starts with a speculum and then puts a very little plastic tube inside the uterus and squirts some saline (salt water). The saline goes into the uterus and out the tubes.
Here is a normal uterine cavity on ultraound without the saline, its the regular old ultraound.
The next picture is the same, but I added white lines to show you the outline of the entire uterus.
Here is an ultrasound of a uterine polyp (could also be a fibroid). It’s that olive shape in between the arrows. No saline yet.
Here I put a circle around it to make sure you see what I am talking about.
And below is a sonohysterogram of a similar polyp. The doctor put a little saline inside the uterine cavity. Saline or any watery fluid looks black on ultrasound. The black surrounds the polyp and makes it much easier to see. The arrows are not important, they are just pointing out the stalk of the polyp.
Here I would like to end on one very important point. Performing this sonohysterogram was not necessary. We can all see that the polyp is very obviously visible in the picture without the water. There is really no reason to do the sonohysterogram. However time and time again, the doctor will say, "it looks like a polpy, lets do a sonohysterogram to be sure." Yes the picture using the sonohysterogram is prettier, but what he is doing is having you undergo one more unnecessary test, that you may have to pay for, and it’s expensive. So if you are confronted with a sonohysterogram, ask your doctor if he is sure if it really needs to be done. Ask if it will give you any more information than you already have. The sonohysterogram is a great test and I use it all of the time, but not if I know the answer before it’s started.
We will discuss both again next time. You will learn why the sonohysterogram is not a good test for showing open or closed tubes.
Thanks again for reading and please read disclaimer 5.17.06.
Dr. Licciardi
Hysterosalpingogram, also known as the hysterogram or HSG. Hystero means uterus, salpingo means tube, so it’s a test to evaluate both the uterus and tubes. It’s a dye test that uses an x ray. As far as the patient is concerned, it starts with a speculum, like a pap smear. The doctor, through various techniques mentioned in previous blogs, squirts some dye into the uterus and it then runs out the tubes. The dye is actually as clear as water, but it’s called dye because it is white on an x ray. The dye then shows the shape of the interior of the uterus and the tubes.
Let’s start with the uterus. This is picture of a HSG x ray.
The uterus is perfect. The tubes are abnormal, but I am starting with this one because the view of the uterus is so ideal. You can see that is triangular in shape with the top being relatively straight across.
The hsg only shows us where the dye is, which is inside the uterus and inside the tubes. It does not tell us anything about the middle or outside of the uterus or tubes. The next picture is the same as above except I outlined the outside of the uterus and the approximate location of the ovaries.
You can see that the overall uterine size is greater than what is shown by the hsg, and how the outer uterus and ovaries are invisible using x rays.
The next picture shows what happens to an HSG when there are fibroids on the middle and outside of the uterus. I drew in some hypothetical fibriods in red. Fibriods like these would be invisible on hsg. As you can see, the shape of the inside of the uterus has not changed. So it is possible to have fibroids, and have a normal looking hsg. Fibriods that are closer to the cavity will make the HSG look abnormal. We will later see how certain fibroids can affect the look of the HSG, but in this case many fibroids did not change the HSG picture.
Now we will look an HSG that shows an abnormal uterus.
This hsg is abnormal. There is a black spot in the center, and this could be a number of things, all of which are abnormal. The center is dark because the dye cannot get to the center of whatever is growing in there. It is most likely a polyp, but it could be a small fibroid or even some scar tissue(less likely). The overall triangular shape of the uterus is good. This shows how an HSG can be used for diagnosing uterine problems such as polyps or fibroids that are growing in the cavity.
This is a good time to move over to salinosonohysterograms (sonohysts for short). Commonly called a saline infusion sonohysterogram (SIS). We will come back to HSGs in a bit. The sonohyst does not use an x-ray or x-ray dye. It instead is performed with a regular old ultrasound machine. Prior to performing the ultrasound, the doctor starts with a speculum and then puts a very little plastic tube inside the uterus and squirts some saline (salt water). The saline goes into the uterus and out the tubes.
Here is a normal uterine cavity on ultraound without the saline, its the regular old ultraound.
The next picture is the same, but I added white lines to show you the outline of the entire uterus.
Here is an ultrasound of a uterine polyp (could also be a fibroid). It’s that olive shape in between the arrows. No saline yet.
Here I put a circle around it to make sure you see what I am talking about.
And below is a sonohysterogram of a similar polyp. The doctor put a little saline inside the uterine cavity. Saline or any watery fluid looks black on ultrasound. The black surrounds the polyp and makes it much easier to see. The arrows are not important, they are just pointing out the stalk of the polyp.
Here I would like to end on one very important point. Performing this sonohysterogram was not necessary. We can all see that the polyp is very obviously visible in the picture without the water. There is really no reason to do the sonohysterogram. However time and time again, the doctor will say, "it looks like a polpy, lets do a sonohysterogram to be sure." Yes the picture using the sonohysterogram is prettier, but what he is doing is having you undergo one more unnecessary test, that you may have to pay for, and it’s expensive. So if you are confronted with a sonohysterogram, ask your doctor if he is sure if it really needs to be done. Ask if it will give you any more information than you already have. The sonohysterogram is a great test and I use it all of the time, but not if I know the answer before it’s started.
We will discuss both again next time. You will learn why the sonohysterogram is not a good test for showing open or closed tubes.
Thanks again for reading and please read disclaimer 5.17.06.
Dr. Licciardi
posted by Dr. Licciardi at 7:10 AM
10 Comments:
i, for one, love the more technical posts! this stuff is all so fascinating.
(i'm sure this comes as no surprise -- i don't like to mix my real name with my blogging name, but i am your double vagina, double cervix, single uterus patient who got pregnant via IVF this june...i trust that narrows the list down a bit.)
by the way, the pregnancy is going well so far, except for spotting weeks 8-12. probably the cervix, but scary anyway.
thank you for all you help!
What a great post! Thanks!
I'm starting my 1st IVF this month. We're dealing with MFI and, as far as I know, I have no issues.
However, I just learned that my mom had a hysterectomy a few years after I was born b/c of uterine fibroids. (We've both also had issues with fibrous breast tissue.) My HSG was normal. Should I have further testing to evaluate the uterus before IVF?
DR. LICCIARDI
I had a crazy mishap today and was wondering what your opinion of the next step should be. I have PCOS and was able to conceive our first child after 2 IUI cycles. I am so irregular that my infertility specialist prescribed a progesterone injection IM to induce a withdrwal bleed. This is where the problem came in. I came home from the pharmacy with my injection in hand. My husband gave it to me and then we were looking at the box and realized that it was actually HCG! Do I have to wait for the HCG to metabolize before I get a progesterone shot? I have been doing reading online since I had the shot and read that HCG causes progesterone to increase. Will that increase and subsequent decrease induce a bleed? I will be calling my dr. on Monday, but I would sorta like a 2nd opinion.
A 34-year-old friend confided in me that she and her husband want to do an IVF cycle to freeze their embryos for later use (she is starting graduate school and is not ready to have a baby).
She went through her initial testing and found out that her antral follicle count was 6 and her FSH is 15.2. She knows these numbers aren't good...she asked my opinion but I have no success stories to share considering I'm 39 and am undergoing my second donor egg cycle (after 3 failed IVFs and first DE cycle ending with a tragic neural tube defect).
What are the chances that she'll end up with embryos to freeze?
I'm a sonography student and I love all your posts...very helpful!!
Question Dr. Licciardi--
I did IVF shortly after turning 39 and had eleven eggs, eight mature, and six fertilized eggs. On day 5 two blastocysts were transferred and I am now 21 weeks pregnant with a healthy singleton. Also on day 5 two additional embryos were morulas and were "watched". They became blastocysts by day 6, at which point they were frozen. Should I assume they are not as high of quality since they did not grow as quickly as the two transferred on day 5 but instead took until day 6 to reach blast stage? Thank you!
Hello Doctor,
It's a great post.
I had sonohysterogram 2 weeks back(cycle day 10) and it revealed that I have a scar tissue on the fundal endometrium portion, and the endometrium on either walls being 1mm each (no specified or noted scar tissue). My GYN told me I have to undergo hysteroscopy and referred me to an RE. I am 29 yrs old with a 3 year old kid, I am wondering if this scar tissue will pose challenge in conceiving again?
This would be of real help if you can answer me as early as possible.
Karla Rodriguez recently I have done a HSG and the impression was Patent left fallopian tube with spillage. I just hope thi is not a big issue. By the way this site is great lost of important info. I love it! P.R.
A Traditional Chinese Medicine treatment involves a tailor-made herbal formula, which can work better than a general treatment. I bet there are some herbs that can work towards treatment of most infertility problems. Infertility is the inability to conceive a child naturally or the inability to carry a pregnancy to term. There are many reasons why a couple may not be able to conceive, or may not be able to conceive…!
Natural health supplements
I've read your blog all the way through and notice you sometimes answer people's questions...so I thought I'd try. I'm 38, TTC for about 8 months, just did a round of clomid with ovidrel and IUI that did not work. I had an HSG and the RE said it was normal, although the right fallopian tube was in front of the uterus, so that you cannot see it in the scan. He told me not to worry about it. But then I remembered that I was also told that my right ovary is behind my uterus (I always have excruciating ovulation pain, and it's always on the right side, and another RE told me that this might be because of the way my ovary is positioned behind the uterus). Is it possible my ovary and fallopian tube are missing each other? That the egg from the right side (which seems to be the side I almost always ovulate on) is getting lost? Thanks very much for any advice and thanks for the blog.
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