Blocked fallopian tubes is the cause of infertility in 25%-35% of people with ovaries. If you're experiencing conception challenges, a hysterosalpingogram (HSG) may be one of the first tools a reproductive endocrinologist (REI) will use to better understand the cause of infertility in people with ovaries. This nifty five-minute X-ray exam helps doctors pinpoint if the fallopian tubes are blocked.
We’ll break down everything you need to know below, but before we dive into the details, here are some of the key takeaways:
- The goal of an HSG test is to observe the shape of the uterus and fallopian tubes to identify any abnormalities in shape or tubal blockages. If insurance doesn't cover the test, it might cost you anywhere from a couple hundred dollars to over $1,000.
- Fallopian tubes may be blocked because of untreated sexually transmitted infections (STIs), endometriosis, prior pelvic or abdominal surgery, or even a ruptured appendix.
- If the HSG test indicates that your fallopian tubes are blocked or the results aren't clear enough, a second HSG test may be recommended to confirm the results. If both tests show blockage, you have options that include further exploration of your reproductive system or assisted reproductive technology (ART).
- Some studies have found that an HSG may slightly increase fertility after the procedure.
Keep reading for everything you need to know about HSG testing, from how it works to what the results look like to how to prepare for the test.
First things first: What causes blocked fallopian tubes?
25%-35% of people with ovaries experience infertility because of tubal blockage. When the tubes are open, mature eggs can travel to the uterus after the ovulatory phase of the menstrual cycle in preparation for possible fertilization. If they're blocked? That's a barrier to sperm meeting up with an egg.
According to Dr. Eduardo Hariton, MD, MBA, an OB-GYN and reproductive endocrinology and infertility fellow at the University of California in San Francisco, fallopian tubes may be blocked in the following situations:
- A prior history of sexually transmitted infections (STIs): If an STI is left untreated, people with ovaries can develop pelvic inflammatory disease (PID) — an infection of the uterus, fallopian tubes, ovaries, and cervix. PID can result in tubal blockage and infertility.
- Endometriosis: Endometriosis, which is a condition where tissue similar to the uterus lining grows in other parts of the body, can block off the fallopian tubes if tissue is growing there.
- Pelvic surgery: Tubal blockage can also happen after surgery of the pelvis or abdomen.
- Ruptured appendix: If your appendix bursts, that can also lead to damage and blockage in the fallopian tubes.
How can you find out if your tubes are blocked? Enter the hysterosalpingogram (HSG).
What is a hysterosalpingogram (HSG)?
A hysterosalpingogram (HSG) is an X-ray reproductive endocrinologists can use to look at the inside of your uterus and fallopian tubes. The resulting images resemble a black-and-white photograph: The white areas, made by dye injected into the cervix at the beginning of the procedure, will show the shape of your uterus and fallopian tubes. This helps identify if blockages or abnormalities are present in these organs.
An HSG test is typically performed after a period but before ovulation.
When is an HSG test recommended?
An HSG will be recommended for one of two reasons:
- You're experiencing challenges with getting pregnant or infertility.
- Your doctor is worried that you may have a hydrosalpinx, which is a buildup of fluid or dilation of the tube because of blockage or damage.
- You had a tubal ligation procedure (aka getting your "tubes tied”) and want to make sure it was successful.
What can you learn from an HSG test?
For those using an HSG to better understand why they're having challenges conceiving, the results can show two things:
- The shape of the uterus and fallopian tubes: If there are abnormalities inside either organ, the test may detect that.
- Whether the fallopian tubes are open or blocked: If the test indicates that the tubes are open, then the doctor can usually rule out the fallopian tubes as a possible cause of conception problems.
What can't you learn from an HSG test?
While an HSG test can provide insight into possible causes of fertility troubles, there are some limitations to the test. An HSG can't:
- Identify endometriosis.
- Determine whether or not the ovaries are functioning as expected.
- Highlight fibroids that are outside of the uterine cavity (i.e., inside the uterine muscle).
What can you expect during an HSG test?
You can expect the test to be administered by a gynecologist or radiologist and it will take place either in your OB-GYN’s office, a hospital, or a health clinic. The procedure usually takes about five minutes and will include the following steps:
- The beginning of an HSG procedure will feel similar to an annual gynecological wellness exam. You'll lie on your back and place your feet into stirrups.
- A speculum is then inserted into your vagina so the medical professional can clearly see your cervix. If the use of anesthesia was agreed upon before the procedure, the cervix will be injected with anesthesia to help keep you comfortable during the procedure.
- A small tube called a cannula that looks like a straw is inserted into the uterus and a balloon is inflated to keep the dye, also known as a contrast medium, from leaking out. The dye will be injected through the cannula. After the speculum is removed, dye is fed through the cannula.
- When enough dye has been inserted into your cervix, the X-ray portion of the procedure can begin. The X-ray images will show the progress of the dye (which shows up as white on the X-ray image) through the uterus and fallopian tubes. Once the dye has filled the uterus and fallopian tubes, abnormalities will show up if they're present.
- Once the medical professional has finished capturing the X-ray images, the cannula is removed and the procedure is complete.
During an HSG, you may feel cramping due to the stretching of the fallopian tubes, uterine distention (when it's enlarged from internal pressure), or pressure from the balloon. This cramping usually lasts for about 5-10 minutes after the procedure but can sometimes be felt for several hours afterwards.
What are the possible side effects of an HSG test?
Cramping is a common possible side effect of the exam. But there are a few other symptoms you may experience after the procedure:
- Feeling faint
- Vaginal discharge
If you experience any of the following side effects, it's a good idea to check in with your fertility specialist:
- Fever or chills
- Heavy vaginal bleeding
- Foul-smelling vaginal discharge
- Severe abdominal pain
- Increasing pain or fever within the first two days after having an HSG (which can be a sign of a pelvic infection)
What are the next steps after getting an HSG test?
If your fallopian tubes appear to be open and you’re trying to conceive, your doctor may recommend waiting 2-3 days after the procedure before starting to try, says Dr. Hariton. But have a conversation with your doctor first so they can give you a personalized answer depending on your unique circumstances. They will also be able to recommend other tests that can be performed next if you are still experiencing challenges conceiving.
If an HSG shows your tubes are blocked, your doctor may (but won't always) recommend that you do a second HSG test to confirm the results. If the tubes are blocked, depending on the situation, that may be reversed through surgery: a laparoscopy (a tiny incision through the belly button) or a laparotomy (open surgery through a larger incision). Providers may recommend pursuing in vitro fertilization (IVF) to conceive so you can avoid your fallopian tubes altogether.
Can an HSG test really improve your fertility?
While most medical professionals use an HSG test strictly as a diagnostic tool, a handful of studies have shown that it may slightly increase fertility for a few months after the procedure. This can happen when the injectable dye “flushes” out temporary blockages caused by mucus or adhesions. That said, tubal flushing has been found to be successful only when an oil-based dye (rather than a water-based one) is used.
How can you prepare for an HSG test?
There are a few things you can do before an HSG test to prepare yourself:
- Ask a friend or family member to take you there and back: Because it’s likely that you will experience cramping, consider coordinating with a friend or family member to have them drive you home.
- Consider over-the-counter pain medications: Your doctor may recommend taking over-the-counter pain meds (like tylenol or ibuprofen) prior to the procedure to reduce cramping.
- Check with your insurance company to see if they'll cover the procedure: An HSG is a diagnostic test, so there's a chance that it will be covered by your insurance company as part of a standard infertility workup. But if your insurance company considers the procedure a fertility treatment rather than a diagnostic test, they may not cover it. Out of pocket, says Dr. Hariton, HSG tests can range anywhere from a couple of hundred dollars to over $1,000.
Wrapping it all up
Fallopian tube blockage is a common cause of infertility. If you're having trouble conceiving, one of the first things you can do is get a better understanding of why. The five-minute HSG test can help you help identify if a blockage in the fallopian tubes is causing infertility, and possibly “flush” out temporary blockages from substances like mucus.
If you’d like to learn about other people’s experiences with HSG or other fertility testing, join the Modern Community. It’s a free online community and a safe space for people with ovaries to learn and connect with one another.
This article was reviewed by Dr. Eduardo Hariton, an OB-GYN and reproductive endocrinology and infertility fellow at the University of California in San Francisco.