HSG Test (Hysterosalpingogram): What It Is and What to Expect

✓ This content has been medically reviewed by an obstetrician and gynaecologist
Written & medically reviewed by: Op. Dr. Ayşet Jane Özcan, Obstetrics & Gynaecology Specialist
Istanbul Faculty of Medicine · Medical Park Bahçelievler · TJOD and TSRM member
Last updated: 10 October 2026 · Last medical review: 10 October 2026

If you have been trying to conceive for a while, an HSG test is often one of the first investigations suggested. The full name is hysterosalpingogram: hystero for the uterus, salpingo for the fallopian tubes, gram for a picture. It is a brief X-ray study in which a small amount of liquid contrast (dye) is passed through the cervix into the uterus, so that the shape of the uterine cavity and whether the tubes are open can be watched on a screen. It is done awake, in a radiology room, usually in under ten minutes, and you go home the same day.

Most of the anxiety around this test is about two things: how much it will hurt, and what it would mean to be told a tube is blocked. Both deserve a proper answer rather than reassurance. Below I go through what is actually done step by step, why the timing within your cycle matters, which type of contrast is used and why that is discussed at all, how discomfort is managed, what each pattern of result looks like on the images, what genuinely affects what the test costs, how it compares with HyCoSy and with laparoscopy, and what tends to happen next depending on what is found. None of this replaces your own consultation, where the findings are read alongside your age, your history and your partner's tests.

What Is an HSG Test?

An HSG is an X-ray test that shows the internal shape of the uterus and whether the fallopian tubes are open. A thin catheter is placed through the cervix and a liquid iodinated contrast medium is injected slowly. Contrast absorbs X-rays, so on the screen it appears white and outlines whatever space it fills. The uterine cavity lights up first, then the tubes, as thin curved lines running out to each side.

The inside of a fallopian tube is roughly the width of a pencil lead and is invisible on an ordinary ultrasound scan. Dye makes it visible. If a tube is open along its whole length, contrast travels to the far end and then spills freely into the abdominal cavity, where it looks like a soft smudge spreading around the tube. That free spill is the finding that matters most, because it proves the whole channel is patent rather than just the first part of it.

Water-soluble and oil-soluble contrast

Two types of iodinated contrast are used for this test, and it is worth knowing that the choice exists. Water-soluble agents are the more usual option: they give a sharp outline of the cavity, are absorbed quickly and drain away over a day or so. Oil-soluble contrast is thicker and lingers in the pelvis for longer. Some fertility units choose an oil-soluble agent deliberately, because randomised trials of flushing the tubes with that type of contrast have reported more pregnancies afterwards among couples with unexplained infertility, and some units use both agents in sequence within the same study. The two types also behave differently if contrast enters the small vessels of the uterus, which is covered in the section on risks. None of this changes what the test is for, but it is a fair question to ask when your appointment is booked.

In a single study, an HSG can show:

• whether each tube is open, narrowed or blocked, and roughly where any blockage sits
• the outline and shape of the uterine cavity, including congenital variations
• filling defects inside the cavity, such as polyps, a fibroid pressing inwards, or scar tissue
• a swollen, fluid-filled tube (hydrosalpinx), often from a past infection
• dye that pools in pockets instead of spreading, which suggests adhesions around the tubes

It is just as important to know what an HSG does not show. It says nothing about your ovaries or your egg supply, which is assessed separately with a scan and AMH blood testing. It cannot diagnose endometriosis, and it cannot tell us whether a tube that looks open is actually working. A tube is not a pipe: it has a delicate lining with microscopic hairs that move the egg along. Patent and functional are not the same thing, and this is why an HSG is read as one piece of information rather than a verdict.

Why Your Doctor Might Suggest an HSG

The main reason is that tubal problems are common, completely silent, and change the treatment plan more than almost any other finding. A woman with two blocked tubes can have perfect cycles, normal hormones and no symptoms at all. Nothing in the history or on examination reliably predicts it, so if the tubes matter to the plan, they have to be imaged.

An HSG is commonly offered when conception has not happened after about a year of regular unprotected intercourse, or after about six months if you are 35 or older, since waiting has a cost at that age. It is also considered earlier when something in the history raises suspicion: a past pelvic infection or chlamydia, a previous ectopic pregnancy, previous pelvic or abdominal surgery including a ruptured appendix, a past termination or pregnancy-related infection, or an intrauterine device that was complicated by infection.

There is a second reason, which is the uterus rather than the tubes. If you have had recurrent miscarriage, unusually painful or heavy periods since adolescence, or bleeding between periods, the cavity outline on an HSG can reveal a septum, scar tissue or a polyp that was not obvious on a routine scan.

Finally, an HSG is often done before treatment rather than instead of it. There is little point in stimulating ovulation or arranging insemination if the dye never reaches the abdominal cavity, because both approaches depend on an open tube. In a full infertility assessment the test is therefore usually arranged alongside a semen analysis and an assessment of ovulation, so that the whole picture arrives at the same time instead of in instalments over several months.

When in the Cycle Is an HSG Done, and Why?

An HSG is normally performed in the first half of the cycle, after bleeding has finished and before ovulation, which in practice usually means somewhere between about day five and day twelve, counting day one as the first day of proper bleeding. This window is not arbitrary. Three separate concerns all point to the same few days.

The first is pregnancy. Contrast and X-rays should not be given to a woman who may already have conceived, and in the first half of the cycle that is effectively ruled out. For the same reason you will be asked to avoid unprotected intercourse from the start of your period until the test, or to use a barrier method, even if your dates look reassuring. A urine pregnancy test on the day is standard practice.

The second is image quality. After a period the endometrium is thin, so the dye hugs a clean cavity outline. Later in the cycle the lining is thick and can create shadows and irregularities that imitate polyps or adhesions, which leads to findings that then have to be chased with further tests. Performing the study during bleeding is worse again: clots can mimic filling defects, and pushing menstrual blood upwards is not ideal.

The third is safety and comfort. Infection risk is lowest when the cervix is not actively bleeding, and the cervical canal is generally easier to pass soon after a period.

If your cycles are irregular or long, the timing is worked out from the start of your own bleeding rather than from a textbook 28-day calendar, which is why the clinic asks you to ring on the first day of your period to be given a date. If you have no bleeding at all, the test may be arranged after a negative pregnancy test and a discussion about why the cycles are absent, because that answer matters in its own right.

How to Prepare for an HSG

Preparation is simple, but two parts of it are not optional: confirming you are not pregnant, and making sure there is no untreated genital infection. Passing a catheter through the cervix while an infection is present can carry bacteria upwards, so vaginal swabs and screening for chlamydia are often arranged beforehand, and any infection is treated first. If you have had a previous pelvic infection, or a scan has already suggested a hydrosalpinx, preventive antibiotics may be advised around the procedure.

Tell the person booking the test if you have ever reacted to iodine-containing contrast, if you have severe asthma or significant allergies, if you have kidney disease or a thyroid condition, or if you have had a previous procedure on the cervix. Mention it too if gynaecological examinations are very painful for you, if you have vaginismus, or if you have had a difficult IUD insertion, because that information changes how the test is planned rather than whether it is done.

Practical points for the day itself:

• eat and drink normally; no fasting is needed unless sedation is planned
• take a simple over-the-counter anti-inflammatory painkiller roughly an hour beforehand, unless you have been told not to use that type of medicine; it helps most with the cramping that follows the test
• bring a sanitary pad, since dye and a little blood usually drain afterwards
• do not use tampons, and avoid vaginal creams or douching in the days before
• continue your regular prescribed medicines unless specifically instructed otherwise
• wear clothes that are easy to change out of, and remove piercings in the lower abdomen

You can normally drive yourself home and most women return to work the same day. If sedation has been arranged for you, that changes: you will need someone to accompany you and you should not drive. Bringing a partner or friend is reasonable in any case, mostly because the appointment is easier when you are not sitting in the waiting room alone.

How the HSG Procedure Is Done, Step by Step

The whole appointment usually lasts half an hour or so, and the part involving X-rays lasts only a few minutes. It is done in a radiology room on a table under a fluoroscopy unit, which is an X-ray camera that produces a live image rather than single snapshots, so the dye can be watched as it moves. Normally a gynaecologist and a radiologist, or a radiologist alone, carry out and report the study.

In sequence, what happens is this:

• you empty your bladder, undress from the waist down and lie on your back with your knees bent and apart, as for a smear test
• a speculum is passed and the cervix and upper vagina are cleaned with antiseptic
• a thin catheter is passed a short way through the cervical canal; most units use a soft catheter with a tiny balloon that is inflated inside the cervix or lower cavity to hold it in place and stop dye leaking back out, while some use a narrow metal cannula held against the cervix
• the speculum is often removed at this point, which is more comfortable than leaving it in
• the contrast is injected slowly by hand while the images are watched live; the operator can feel the resistance and stops if it is high
• images are recorded as the cavity fills, as each tube fills, and as dye spills out at the far end
• you may be asked to roll a little to one side or the other so overlapping structures separate and a tube that was hidden behind the uterus can be seen
• the balloon is deflated, the catheter is removed, and you rest for a few minutes before getting up

If a tube does not fill at first, the operator may wait a short while and inject again, because the muscular wall of the tube can clamp shut temporarily and then relax. A delayed image is sometimes taken after a few minutes to see whether contrast has arrived late. These small manoeuvres are the difference between a reliable report and a false alarm.

Afterwards you will usually be told informally what was seen, since the images are visible as they are taken, with the formal written report following. It is worth asking for a copy of the report and, if possible, the images themselves, because any clinician you see later will want to look at them rather than take the conclusion on trust.

Does an HSG Hurt, and How Is the Pain Managed?

Most women describe an HSG as strong period-like cramping that lasts a short time, peaks while the dye is being injected, and settles within minutes of the catheter coming out. A minority find it genuinely painful, and some are surprised by how little they feel. I would rather you expect something in the middle than be told it is nothing.

Understanding where the pain comes from makes it easier to handle. There are two sources. Touching and passing the cervix produces a deep, dull cramp of the kind many women recognise from a smear or an IUD insertion. Filling the cavity with fluid stretches the uterus, and the uterus responds to stretch the way it responds to a period: it contracts. If a tube is narrowed or blocked, pressure builds against that obstruction and the cramp can be felt more sharply on that side. None of this means damage is being done.

What reduces the discomfort

Several things help, and they are mostly decided before the test rather than during it. Doing the study in the first half of the cycle, when the cervix passes more easily, helps. An anti-inflammatory painkiller taken about an hour beforehand is a reasonable step, and it most reliably helps the cramping afterwards; trials of taking one before the test have given mixed results for the few minutes of the injection itself, so do not be surprised if you still feel a strong cramp despite having taken it. Injecting slowly rather than quickly makes a real difference, as does using a soft balloon catheter instead of instruments that grasp the cervix. Slow breathing out through the mouth genuinely reduces the cramp, mainly by stopping you from tensing the pelvic floor and bracing against the catheter.

For women in whom a difficult or very painful examination is expected, local anaesthetic injected around the cervix, a paracervical block, has the better evidence behind it for the part of the pain that comes from instrumenting the cervix, and sedation can be arranged instead or in addition. This is a planning decision: it is much easier to organise beforehand than halfway through. Say so at the booking stage if examinations are hard for you.

During the test, tell the team when something hurts. The injection can be paused, which usually allows the cramp to pass in a few seconds. Afterwards, feeling light-headed or sweaty is common and harmless; it is a reflex response to cervical stimulation and improves quickly if you lie flat with your legs raised. Cramping over the rest of the day responds to simple painkillers and a warm pack on the lower abdomen.

What the Results Show: Blocked Tubes, Open Tubes and Uterine Shape

A normal HSG shows a smooth, triangular uterine cavity, both tubes filling along their length, and contrast spilling freely into the abdominal cavity on both sides. Everything else is a variation on that, and the report usually describes the uterus and each tube separately.

Tubal findings

Where a blockage sits matters more than the fact that it exists. A block at the point where the tube leaves the uterus is called proximal or cornual. This is the least reliable finding on an HSG, because muscular spasm, a mucus plug or debris can imitate a true blockage, and it is often the finding that is revised when the test is repeated or a different method is used. A block at the far end is distal, and is more likely to be real. When the outer end is sealed, dye accumulates inside and the tube balloons into a sausage-shaped hydrosalpinx, usually the legacy of a past infection, endometriosis or previous surgery. Dye that reaches the end but then collects in pockets instead of dispersing suggests adhesions wrapped around the tube and ovary. A tube may also show multiple tiny outpouchings near the uterus, a pattern associated with a chronic inflammatory change in the tube wall. Importantly, one blocked tube and one open tube is a very different situation from two blocked tubes.

Uterine findings

Anything occupying space inside the cavity shows up as a filling defect: a rounded shadow where dye should be. The usual causes are endometrial polyps, a fibroid growing into the cavity, or bands of scar tissue following previous uterine surgery or infection. The outline itself can also reveal a shape present since birth, such as a dip in the roof of the cavity, a dividing wall creating two horns, a single-sided cavity, or a narrow T-shaped cavity.

Here an HSG has a real limitation worth knowing in advance. Because the test only shows the inside outline, it cannot distinguish a uterus with a septum from one with two separate horns, and that distinction changes management completely. Making it needs an assessment of the outer contour, usually with three-dimensional ultrasound or MRI. So a shape finding on an HSG is a reason for one more imaging test, not a reason to proceed to surgery.

Two caveats apply to the whole report. False blockages are commoner than false openings, so a single unexpected block deserves scepticism rather than resignation. And a tube reported as open may still work poorly, particularly after infection, which is why the report is read in the context of your age, how long you have been trying and the rest of the results rather than on its own.

Risks, Side Effects and Aftercare

An HSG is a low-risk outpatient test, and the great majority of women have nothing worse than cramping and a day or two of discharge. The side effects worth expecting are cramping that fades over a few hours, light spotting, a watery or sticky discharge as the contrast drains out over a day or so, and sometimes a brief feeling of faintness just after the catheter is removed.

The complication that matters most is pelvic infection. It is uncommon, but it is the reason for the swabs beforehand and the reason the cervix is cleaned with antiseptic. Risk is higher in women with a hydrosalpinx or a history of pelvic inflammatory disease, and those are the women most likely to be offered preventive antibiotics. An allergic reaction to iodinated contrast is rare, and because you are awake and monitored it would be recognised immediately. Injury to the uterus from the catheter is very rare.

Contrast occasionally passes into the small veins or lymphatic channels of the uterus, which is called intravasation. It looks dramatic on the screen, and with the water-soluble agents used in most units it is generally harmless: the contrast is simply absorbed and cleared. Where an oil-soluble agent is used the same event matters more, because oil entering the circulation carries a small risk of embolism. This is part of why the injection is given slowly under live imaging and stopped as soon as intravasation is seen, and part of why the choice of contrast is a decision made by the team performing the test rather than a detail of no consequence.

On radiation: the dose from an HSG is low, the fluoroscopy is kept as brief as the images allow, and the test is deliberately scheduled before ovulation so that no pregnancy is exposed. This is not a reason to avoid the test, but it is a reason not to repeat it casually.

For the day or two afterwards:

• use pads rather than tampons until the discharge stops
• expect to resume normal activity and work the same day if you feel up to it
• simple painkillers and a warm pack are enough for residual cramping
• follow the advice you are given about intercourse, swimming and baths, which is usually to wait a day or two, longer if antibiotics were prescribed
• keep a note of the date, as it may be relevant if your next period is unusual

Your next period may come slightly early or late, or be a little heavier, and that settles without any action. Occasional spotting for a day after the test is also expected. What is not expected is fever, worsening pain, or an unpleasant-smelling discharge, and those are covered in the final section.

What Affects the Cost of an HSG Test

I am not able to discuss prices here, but I can explain what actually sits inside the cost of an HSG, which is usually more useful when you are comparing two quotations. The test is not a single item; it is a room, a machine, consumables, two professional roles and a set of pre-tests, and clinics bundle those differently.

The main variables are:

• Setting. A public or university hospital radiology department, a private hospital and a standalone imaging centre have different overheads, and the fluoroscopy room itself is an expensive piece of equipment occupied for your appointment.
• Who performs and who reports. Some units bill a single procedure; in others the gynaecologist performing the test and the radiologist producing the written report are charged separately.
• Consumables. A soft balloon catheter costs more than a simple metal cannula, and the volume and type of contrast used varies, including whether a water-soluble or an oil-soluble agent is chosen.
• Anaesthesia. Sedation adds an anaesthetist, monitoring and recovery time, which is typically the single largest change to the total.
• Pre-procedure tests. A pregnancy test, vaginal swabs and chlamydia screening may be included or billed separately.
• Bundling. When the HSG forms part of a wider fertility assessment with consultations, ultrasound and a semen analysis, the figure quoted may cover much more than the imaging.
• Funding and referral rules. Whether the test is publicly funded, reimbursed by insurance, or self-funded, and whether a referral or a prior diagnosis is required, changes what you personally pay regardless of the underlying cost.
• Follow-on imaging. If the cavity outline is unclear, the additional three-dimensional ultrasound or MRI needed to clarify it is a separate study.

When you ask about cost, ask what is included rather than what the test costs: whether the report fee is separate, whether the pregnancy test and swabs are counted in, whether a follow-up consultation to discuss the images is part of the price, and whether you will be given a copy of the images. A cheaper study that produces no usable report, or that has to be repeated because of poor timing in the cycle, is the most expensive version of this test.

One more thing is worth weighing. An ultrasound-based alternative is discussed in the next section, and because it uses different equipment and consumables its cost structure is not the same. Which test is right for you should be decided on clinical grounds, with cost as a practical consideration rather than the deciding one.

HSG vs HyCoSy vs Laparoscopy: Which Test, and When

HSG and HyCoSy are both reasonable first-line ways of checking whether the tubes are open in a woman with no other pelvic problems; laparoscopy is a surgical test kept for when the pelvis itself needs to be inspected or treated. They are not competing versions of the same thing.

HyCoSy and HyFoSy

These are ultrasound versions of the same idea. A catheter is placed in the same way, but instead of X-ray contrast a saline and air mixture, or a foam gel, is injected while the tubes are watched on ultrasound. The advantages are that there is no ionising radiation and no iodinated contrast, and that the ovaries, the follicle count and any fibroids can be assessed in the same sitting, which is efficient in a fertility workup. The disadvantages are that it depends heavily on the operator's experience and on the equipment available, and that it does not leave the same permanent map of the tube outline that an X-ray study does. Where both are available and expertise is good, the choice is often a matter of local practice and of your own preferences about radiation and contrast.

Laparoscopy with dye

This is keyhole surgery under general anaesthesia, in which the pelvis is inspected directly through a camera while dye is injected through the cervix and watched emerging from the tubes. It answers questions that neither imaging test can: whether there is endometriosis, how extensive adhesions are, and what the ovaries and the outside of the tubes actually look like. It also allows treatment in the same operation, which is why it is the route chosen when there is pelvic pain, suspected endometriosis, a history of pelvic infection or previous surgery, or when imaging has given an answer that does not fit the story. Being an operation, it carries the risks of anaesthesia and surgery and needs recovery time, so it is not a screening test. If you would like to understand what that operation involves, our page on laparoscopic surgery goes through it.

A fourth test often comes up in the same conversation. Hysteroscopy looks inside the uterine cavity with a camera and says nothing about the tubes, but it is the way a polyp, a septum or scar tissue first seen on an HSG is confirmed and treated. In practice the sequence is usually: image the tubes first with HSG or HyCoSy, and reserve hysteroscopy or laparoscopy for the specific question that imaging has raised.

What Happens Next, Depending on the Result

The value of an HSG is that each result leads to a different plan, so it is worth knowing in advance which door each finding opens. What follows is how these decisions are usually framed; your own plan depends on your age, how long you have been trying, your ovarian reserve and your partner's semen analysis as much as on the images.

Both tubes open and a normal cavity. This closes the tubal question and moves attention elsewhere: whether you are ovulating, the semen analysis, the timing of intercourse, your age and how long you have been trying. Depending on those, the next step may be continuing to try with support, medication to induce ovulation, intrauterine insemination, or IVF. If you are weighing up the last two, our comparison of IUI and IVF sets out how that decision is made.

One tube open, one blocked. Conception through the open side remains possible, and treatment is not automatically escalated. Whether to continue trying, to use medication, or to move to IVF is decided on your age, your ovarian reserve and how long you have already been trying, because those factors determine how much time it is reasonable to spend.

Both tubes blocked. If the blockage is at the point where the tubes leave the uterus, the first question is whether it is genuine, since spasm can imitate it; the test may be repeated, a different method used, or the tube opened under X-ray guidance with a fine wire in selected cases. If the blockage is confirmed and at the far end, the usual route is IVF, which bypasses the tubes altogether. Surgery to open a blocked tube is still appropriate for some women, typically when the damage is limited and age is on their side, and it is a decision made with the images in front of you.

A hydrosalpinx. A swollen, fluid-filled tube is generally dealt with before IVF rather than left alone, usually by removing or clipping the affected tube, because the fluid itself is unfavourable for implantation. This is one of the findings that most clearly changes the order of treatment.

A filling defect or an unusual cavity shape. A polyp, a fibroid indenting the cavity or scar tissue is confirmed and treated at hysteroscopy. A suspected septum needs its outer contour assessed by three-dimensional ultrasound or MRI before anyone operates, because the surgical decision depends on what the outside of the uterus looks like, not only the inside.

When to Call Your Doctor After an HSG

Cramping that improves over a few hours and a watery or slightly bloodstained discharge for a day or two are expected; fever, escalating pain and offensive discharge are not. The reason to be clear about this is that the one complication that needs prompt treatment, pelvic infection, declares itself in the first days and is straightforward to treat early.

Contact your doctor or an emergency department the same day if you have:

• a temperature of 38°C or above, or shivering and chills
• pelvic pain that is getting worse rather than better after the first day, or that is not helped by simple painkillers
• vaginal discharge that smells unpleasant, or that becomes thick and discoloured
• bleeding heavy enough to soak a pad within an hour, or clots
• fainting, persistent vomiting, or feeling generally very unwell
• a rash, facial swelling, wheeze or difficulty breathing in the hours after the test
• chest pain, breathlessness or coughing that starts in the hours after the test

There is one further situation to keep in mind over the following weeks. If your period is late after an HSG and a pregnancy test is positive, that is good news, but tell your doctor promptly and arrange an early scan, particularly if there is any pain on one side or unusual bleeding. Women having tubal investigations are, by definition, often women with some tubal risk, and the early symptoms of an ectopic pregnancy are worth recognising. Severe one-sided pain, shoulder-tip pain or faintness with a positive test needs same-day assessment.

Beyond that, the most useful thing you can do after the test is to book the follow-up appointment while the images are fresh, and to come to it with the report, a copy of the images and your partner's semen analysis if it has been done. An HSG answers a narrow question very well. Its value appears when that answer is placed next to everything else, and a plan with a timeframe is agreed rather than one more test ordered.