HSG Test (Hysterosalpingogram): Uterine and Tubal Evaluation in Fertility Care

Key takeaways

• The HSG test assesses tubal patency and the shape of the uterine cavity, not overall fertility.
• Free spill of contrast suggests the tube is open; it does not prove the tube functions normally.
• Temporary tubal spasm, technical difficulty and viscous mucus can produce a falsely "blocked" appearance, especially on one side.
• The HSG test involves a small dose of pelvic radiation and is not performed in pregnancy, so timing in the cycle matters.
• Results vary depending on individual clinical circumstances and must be interpreted by the doctor who requested the test.

At a glance

Also known as

• HSG test
• Hysterosalpingography, hysterosalpingogram
• Tube test / tubal patency test
• Uterus aur tube ka X-ray (commonly used description in Indian clinics)
• Dye test (informal; distinct from laparoscopic dye test)

What the HSG test is

The HSG test is a real-time X-ray study of the female reproductive tract. A speculum is placed, the cervix is cleaned, and a thin catheter is passed through the cervical canal. Iodine-based contrast is then instilled slowly. Because contrast blocks X-rays, the fluid outlines the inside of the uterus and, if the tubes are open, travels along them and spills into the peritoneal cavity.

The HSG test therefore images cavities and channels, a "cast" of the inside of the uterus and tubes. The HSG test does not image the uterine wall, ovaries or pelvic structures from outside. Two women with identical HSG pictures can have very different fertility prospects, because tubal patency is only one factor among many.

Why the HSG test is done

• Tubal patency assessment: a core part of the standard infertility work-up, alongside ovulation assessment and semen analysis.
• Uterine cavity outline: may suggest polyps, submucosal fibroids indenting the cavity, intrauterine adhesions or a cavity shape suggesting a congenital anomaly.
• Treatment planning: findings help discuss options such as ovulation induction with timed intercourse, intrauterine insemination, tubal surgery or IVF.
• After tubal surgery or reversal of sterilisation: to check whether contrast now passes.
• Confirming occlusion after certain permanent contraception procedures, where this is protocol.

Who should consider the HSG test

• Couples unable to conceive after about a year of trying, or earlier if the woman is over 35 or there are known risk factors, the HSG test is usually requested as part of a broader work-up, not alone.
• Women with a history of pelvic infection, tuberculosis exposure, ruptured appendix, pelvic surgery or ectopic pregnancy, where tubal damage is more likely.
• Women with recurrent pregnancy loss, mainly to look at cavity shape, though MRI or three-dimensional ultrasound and hysteroscopy define uterine anomalies better.
• Women being assessed after tubal surgery.

The HSG test is generally deferred or avoided in known or possible pregnancy, active pelvic infection or unexplained active heavy bleeding, and needs careful discussion if you have had a serious reaction to iodinated contrast. Your gynaecologist decides suitability case by case.

What the HSG test cannot detect or exclude

This is the part most often misunderstood, so it is worth reading twice.

• Tubal function. A tube can be open on HSG yet not work, the delicate inner lining and muscular movement that carry the egg cannot be assessed by X-ray. "Tubes open" does not mean "tubes healthy".
• Ovarian reserve, egg quality and ovulation. The HSG test tells you nothing about these.
• Sperm factors. Male factor contributes to a large share of infertility and needs semen analysis.
• Endometriosis. The HSG test cannot diagnose or exclude endometriosis. Laparoscopy and, in selected cases, MRI or specialist ultrasound are needed.
• Pelvic adhesions outside the tubes. Peritubal adhesions may be present even when contrast spills freely.
• Fibroids and adenomyosis within the uterine wall. Only lesions distorting the cavity are suggested; the muscle layer itself is not seen. Ultrasound or MRI is required.
• Ovarian cysts or masses. Not assessed.
• Cervical or endometrial cancer. The HSG test is not a cancer screening test and a normal HSG does not exclude malignancy.
• Distinguishing types of uterine anomaly. A cavity that looks divided on HSG cannot be reliably separated into septate, bicornuate or other anomaly without imaging of the outer uterine contour.

A normal HSG report describes what was seen on that day, under those conditions. It does not exclude tubal disease or a cause for infertility. If you are still not conceiving, or symptoms persist despite a normal result, go back to your doctor rather than assuming the question is closed.

Related but different examinations

These tests answer different questions. None is universally superior; which one comes first depends on your clinical problem, prior history and what your team plans to do with the answer.

Many fertility units use HSG or HyCoSy as the initial tubal assessment in women without strong suspicion of pelvic disease, and proceed to laparoscopy when history, symptoms or the HSG findings point that way.

How to prepare for the HSG test

Preparation, timing, escort requirements and consent processes are operational matters that differ between hospitals and radiology units. The written instructions given by the unit performing your HSG test take precedence over anything here.

• Cycle timing: commonly scheduled in the first half of the cycle, after bleeding has stopped and before ovulation, to reduce the chance of an unrecognised early pregnancy. Report the first day of your last period when booking.
• Contraception and intercourse: many units advise avoiding unprotected intercourse from the start of the cycle until the test. Follow your unit's advice.
• Pain relief: a simple analgesic about an hour before the test is common practice. Do not take a new medicine without checking with your doctor, especially if you have gastritis, asthma, kidney disease or a bleeding disorder.
• Antibiotics: prescribed selectively, often where there is a history of pelvic infection or hydrosalpinx. Take only what is prescribed for you.
• Allergy and medical history: tell the team about any previous reaction to iodinated contrast, asthma, thyroid disease, kidney disease, diabetes and all medicines including AYUSH and herbal products.
• Practical points: wear or bring comfortable clothing and a sanitary pad; you may be asked to empty your bladder before the procedure.

If you may be pregnant

Tell the team before the test. The HSG test uses X-rays and is not performed when pregnancy is known or suspected. Many units confirm with a pregnancy test on the day.

If you have diabetes on glucose-lowering therapy

The HSG test does not usually require fasting. If your unit asks you to fast, ask specifically how to handle insulin or tablets such as sulfonylureas that can cause low blood sugar, and carry a sugar source. Speak to your prescriber before changing any dose.

If you have kidney disease

Contrast is instilled into the uterine cavity rather than injected into a vein, so systemic absorption is limited. Even so, tell the team about advanced CKD or dialysis so they can review the plan.

If you have thyroid disease

Iodinated contrast can affect thyroid function tests and thyroid activity in susceptible people. Mention any thyroid disorder or planned radioiodine treatment.

Older adults and adolescents

The HSG test is used almost entirely in reproductive-age women. In adolescents, assessment of suspected congenital anomalies is generally led by ultrasound and MRI rather than HSG.

What happens during the HSG test, and how long it takes

Expect to be in the department for about an hour in total, with roughly 15-30 minutes in the procedure room and only a few minutes of actual X-ray imaging.

• Positioning: you lie on the X-ray table with knees bent, as for a pelvic examination.
• Speculum and cleaning: a speculum is inserted and the cervix is cleaned with antiseptic.
• Catheter placement: a thin catheter, sometimes with a small balloon or a cannula held against the cervix, is placed. This step can cause a cramping sensation.
• Contrast instillation: contrast is instilled slowly. Most women feel period-like cramps, occasionally moderate. Tell the team if pain is severe, the rate can be slowed.
• Imaging: images are taken as contrast fills the cavity and moves along the tubes. You may be asked to turn to one side for oblique views.
• Afterwards: the catheter and speculum are removed. Some contrast and a little blood-stained fluid leak out over the next few hours; use a pad, not a tampon. Cramping usually settles within a day.

Most women drive or travel home the same day. If sedation was used, arrange someone to accompany you.

Understanding your HSG report

An HSG report is descriptive. It comments on the cervical canal, the shape and outline of the uterine cavity, the appearance of each tube and whether contrast spilled freely into the peritoneal cavity on each side. There is no numerical reference range for an HSG test.

• "Normal cavity with bilateral free spill": the cavity outline appeared normal and contrast passed out of both tubes. This is a reassuring finding about patency. It does not confirm the tubes work, and does not explain or exclude other causes of infertility.
• "Unilateral non-visualisation" or "unilateral block": contrast did not pass on one side. This is frequently due to spasm, catheter position or preferential flow down the easier tube, rather than true disease. Many units re-evaluate before concluding anything.
• "Bilateral block": no spill on either side. The level matters, a block close to the uterus behaves differently from a block at the outer end. Further assessment, often laparoscopy, is usually discussed.
• "Hydrosalpinx": a dilated, fluid-filled tube with delayed or absent spill. This has specific implications for fertility treatment that your specialist will explain.
• "Filling defect": an area where contrast does not fill, which may suggest a polyp, submucosal fibroid or adhesion. Hysteroscopy or ultrasound usually follows to characterise it.
• "Abnormal cavity contour": may suggest a congenital anomaly or intrauterine adhesions. Further imaging is needed before labelling the anomaly type.
• "Venous or lymphatic intravasation": contrast entering small vessels, sometimes seen with high pressure or with tubal tuberculosis; it may limit interpretation.

Preliminary impressions are often shared on the same day, with the formal report following. Do not act on an HSG report by itself, the findings mean different things depending on your age, duration of infertility, semen analysis, ovarian assessment and history.

When HSG results can be misleading

Findings that can falsely suggest blockage

• Tubal spasm triggered by the procedure, most often affecting the segment nearest the uterus, a leading cause of a false "blocked tube".
• Preferential flow down one tube, so the other simply does not fill.
• Catheter or balloon malposition, or a balloon inflated within the cavity obscuring part of it.
• Thick mucus or debris temporarily plugging the tubal opening.
• Insufficient contrast volume or too-short imaging sequence.
• Severe pain limiting the study before the tubes fill.

Findings that can falsely appear normal or reassuring

• Peritubal adhesions or endometriosis with open tubes: free spill looks normal while pelvic disease remains undetected.
• Damaged tubal lining with preserved patency, which X-ray cannot show.
• Small cavity lesions masked by dense contrast, a balloon, or overlapping structures.
• Adenomyosis or intramural fibroids not touching the cavity, which are invisible on HSG.

Other sources of error

• Air bubbles introduced with contrast can mimic a polyp or filling defect.
• Overlapping bowel gas or previous surgical clips can obscure detail.
• Operator and technique differences affect how much is seen, HSG interpretation is partly subjective, and reports from two units may read differently for the same anatomy.

Risks and safety of the HSG test

Most women have an uncomplicated HSG test, but the procedure is invasive and carries genuine, if uncommon, risks. Risk is not the same for everyone, a history of hydrosalpinx, pelvic infection, prior pelvic tuberculosis or previous contrast reaction changes the picture. No procedure of this type is free of risk.

Pain and cramping

Period-like cramping during instillation is expected and usually brief. A minority experience moderate to severe pain, and some feel faint shortly after the cervix is manipulated. Both usually settle with rest and simple analgesia.

Bleeding and spotting

Light spotting for a day or two is common. Bleeding heavier than a period is not expected and should be reported.

Pelvic infection

Uncommon but important, and more likely where there is pre-existing tubal disease or previous pelvic infection. Fever, worsening pelvic pain or foul-smelling discharge in the days afterwards needs prompt medical review.

Radiation

The HSG test uses a low dose of pelvic X-ray, kept as low as reasonably achievable by limiting screening time. Because the ovaries and a potential early pregnancy are in the field, timing within the cycle and confirming you are not pregnant matter.

Contrast reactions

Reactions to iodinated contrast are uncommon with intrauterine instillation, but can occur, including rash or, rarely, a more serious allergic reaction. Declare previous contrast reactions beforehand.

Uterine or tubal injury

Perforation with the catheter is rare. Rarely, a tube already containing infected fluid can be disturbed by instillation.

A note on the "therapeutic" effect

Some studies of tubal flushing, particularly with oil-based contrast, have reported higher pregnancy rates in the months afterwards. The size of the effect and who benefits remain debated, contrast type matters, and the HSG test should not be requested as a fertility treatment. Results vary depending on individual clinical circumstances.

Special situations

Pregnancy

The HSG test is not performed in known or suspected pregnancy. If you later discover you were pregnant at the time, tell your obstetrician so the exposure can be discussed in context rather than assumed harmful.

Breastfeeding

Intrauterine iodinated contrast reaches the bloodstream in very small amounts. Most guidance does not require interrupting breastfeeding after such procedures, but confirm with the team performing your test.

Known or previous pelvic tuberculosis

Genital tuberculosis is a relevant cause of tubal disease in India and can produce characteristic HSG appearances, including a rigid, beaded or distorted tube and cavity adhesions. These appearances are suggestive, not diagnostic, and require correlation with clinical findings and specific tests.

Diabetes on glucose-lowering therapy

No routine change to medication is needed for an HSG test. If fasting is requested by your unit, ask your prescriber how to adjust timing safely; do not skip or alter doses on your own.

Chronic kidney disease, heart failure or fluid restriction

The HSG test does not involve fluid loading or large intravenous contrast volumes, so it is usually straightforward. Declare these conditions anyway so any pre-procedure instructions can be individualised.

Thyroid disorders

Mention thyroid disease, and especially any planned radioiodine scan or therapy, as iodinated contrast may need to be timed around it.

The HSG test in the Indian context

• Terminology: patients and clinics commonly say "tube test", "dye test" or "uterus ka X-ray". Ultrasound-based alternatives may be described as sono-salpingography or SSG. Clarify which test has actually been advised, since the preparation and information obtained differ.
• Genital tuberculosis is a recognised contributor to tubal infertility in India and influences both the interpretation of HSG findings and the choice of next steps.
• Pelvic infection and post-abortal or post-partum infection also contribute to tubal damage, making a careful history essential before the HSG test.
• Regulatory context: the Pre-Conception and Pre-Natal Diagnostic Techniques (PC-PNDT) Act, 1994 governs the use of diagnostic techniques capable of sex determination and applies to registered ultrasound facilities. An HSG test is not a prenatal diagnostic test and is not performed in pregnancy, but any imaging facility you attend should display its registration details. Advertising claims about pregnancy outcomes are also restricted under the Drugs and Magic Remedies (Objectionable Advertisements) Act, 1954, be cautious of clinics promising results.
• Data privacy: reports, images and any online booking forms involve personal health data protected under the Digital Personal Data Protection Act, 2023. You may ask how your records are stored and shared.
• Anaemia and general health: iron-deficiency anaemia is common among Indian women of reproductive age; heavy menstrual bleeding alongside infertility deserves evaluation in its own right.

Cost and insurance in India

Charges for an HSG test vary widely between cities, between government and private facilities, and between standalone imaging centres and hospital-based fertility units. Any figure quoted online should be treated as indicative only; ask the performing unit for a written estimate before booking.

Factors that affect the cost:

• City and type of facility (government, trust, standalone imaging centre, corporate hospital)
• Whether a radiologist, gynaecologist or both are involved
• Type and volume of contrast used, and the catheter or balloon system
• Use of analgesia or sedation, and whether monitoring is required
• Additional consultations, pregnancy test, infection screening or prescribed antibiotics
• Whether the HSG test is part of a bundled infertility evaluation package

Insurance: in India, investigations and treatment for infertility are excluded from many standard health insurance policies, and outpatient diagnostics are often not covered even when infertility is included. Coverage depends on your specific policy wording, waiting periods and whether the test is linked to an admitted procedure. Check with your insurer or the hospital's insurance desk in writing before the test rather than assuming reimbursement.

Myths and facts

Frequently asked questions

What is the HSG test used for?

The HSG test is used mainly to check whether the fallopian tubes are open and to outline the shape of the uterine cavity. Gynaecologists request it during infertility evaluation, after tubal surgery, and sometimes in recurrent pregnancy loss. It forms one part of a wider assessment, never the whole answer.

How painful is the HSG test?

Most women feel cramping similar to period pain for a few minutes while contrast is instilled, with some pressure during catheter placement. A minority find it moderately painful. Analgesia taken shortly before the test, as advised by your doctor, and slow instillation both help considerably.

How long does the HSG test take?

Plan for roughly an hour in the department. The procedure itself usually takes about 15 to 30 minutes, of which actual X-ray imaging accounts for only a few minutes. Additional time goes to consent, positioning, changing and a short rest afterwards before you leave.

Can I try to conceive in the same cycle as the HSG test?

Many doctors permit intercourse from a day or two after the HSG test, once any bleeding has settled and there are no signs of infection. Some units advise waiting longer. Follow the specific advice given by the team who performed your test.

Is HSG or sono-salpingography better?

Neither is universally better. The HSG test gives a detailed X-ray road-map of the tubes but uses radiation. Ultrasound-based tube tests avoid radiation and also show the uterus and ovaries, but depend more on operator expertise and equipment availability. Your gynaecologist selects based on your history.

What happens if my HSG report says the tubes are blocked?

Your gynaecologist interprets the level and side of the block alongside your age, semen analysis and ovarian assessment. Options discussed may include repeating or confirming the finding, laparoscopy with dye testing, tubal surgery in selected cases, or assisted reproduction. Outcomes vary depending on individual circumstances.

Does the HSG test improve chances of pregnancy?

Research on tubal flushing suggests some women conceive in the months following the procedure, with debate about the contrast type and which groups benefit. The evidence is not strong enough to use the HSG test as a treatment. It remains a diagnostic test performed for information.

Can the HSG test be done during periods?

The HSG test is not usually performed during menstrual bleeding, because blood and debris obscure the images and may be pushed along the tubes. Most units schedule it after bleeding has stopped and before ovulation, though exact scheduling policy differs between hospitals.

Do I need someone to accompany me?

Many women attend alone and travel home unaided. If your unit plans sedation, or if you have fainted during pelvic procedures before, bring someone with you. Ask the unit when you book, since escort policies differ from one facility to another.

Sources

• National Institute for Health and Care Excellence, Fertility problems: assessment and treatment (CG156) [Confirm current edition, TO BE VERIFIED]
• American College of Obstetricians and Gynecologists, patient and practice resources on infertility evaluation
• American Society for Reproductive Medicine, committee opinions on the diagnostic evaluation of the infertile female
• Royal College of Radiologists / ACR-SPR practice parameters on hysterosalpingography and radiation in women of reproductive age
• Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Act, 1994; Drugs and Magic Remedies (Objectionable Advertisements) Act, 1954; Digital Personal Data Protection Act, 2023, Government of India