1. HysterosalpingographyBy
Dr/ Dina Metwaly

2. The Uterus It is the central organ of the female pelvis.
It is a pear-shaped, hollow, muscular organ that is bordered posteriorly by the colon and anteriorly by the urinary bladder
The size and shape of the uterus vary, depending on the patient's age and reproductive history.
The uterus is positioned most commonly in the midline of the pelvis in an anteflexed position supported chiefly by the various ligaments.
The uterus is subdivided into four divisions: (1) the fundus, (2) the corpus (body), (3) the isthmus, and (4) the cervix (neck)
The fundus is the rounded, superior portion of the uterus.
The corpus (body) is the larger central component of the uterine tissue.

3. The narrow, constricted segment, often described as the lower uterine segment that joins the cervix at the internal os, is the isthmus.
The cervix is the distal cylindrical portion that projects into the vagina, ending as the external os.
The uterus is composed of inner, middle, and outer layers. The inner lining is the endometrium, which lines the uterine cavity and undergoes cyclic changes in correspondence to the woman's menstrual cycle.
The middle layer, the myometrium, consists of smooth muscle and constitutes the majority of the uterine tissue.
The outer surface of the uterus, the serosa, is lined with peritoneum and forms a capsule around the uterus.

4. fallopian tubes
They communicate with the uterine cavity from a superior lateral aspect between the body and the fundus.
This region of the uterus is referred to as the cornu.
The uterine tubes are approximately 10 to 12 centimeters in length and 1 to 4 millimeters in diameter.
They are subdivided into four segments.
The proximal portion of the tube, the interstitial segment, communicates with the uterine cavity.

5. The isthmus is the constricted portion of the tube, where it widens into the central segment termed the ampulla, which arches over the bilateral ovaries.
The most distal end, the infundibulum, contains fingerlike extensions termed fimbriae, one of which is attached to each ovary.
The ovum passes through this ovarian fimbria into the uterine tube, where—if it is fertilized—it then passes into the uterus for implantation and development.
The distal infundibulum portion of the uterine tubes containing the fimbriae opens into the peritoneal cavity

7. definition
Hysterosalpingogram (HSG) is a fluoroscopic examination of the uterus and the Fallopian tubes, most commonly used in the investigation of infertility or recurrent spontaneous abortions.

8. Indications Infertility (tubal patency , Ashermans syndrome).
congenital uterine anomalies.
Recurrent miscarriage.
Abnormal uterine bleeding.
Diagnosis of uterine mass (fibroids).
Evaluation following pelvic trauma.

9. Contraindications Pregnancy. Bleeding.
Immediate premenstrual or postmenstrual phase.
Recent untreated pelvic infection.
Tubal or uterine surgery within last 6 weeks.
Contrast medium sensitivity.

10. Patient Preparation
The examination typically is performed 7 to 10 days after the onset of menstruation T(o avoid the possibility that the patient may be pregnant)
proper bowel preparations (to ensure adequate visualization of the reproductive tract unobstructed by bowel gas and/or feces). Preparation may include a mild laxative, suppositories, and/or a cleansing enema before the procedure.

11. mild pain reliever before the examination (to alleviate some of the discomfort associated with cramping).
empty her bladder immediately before the examination (To prevent displacement of the uterus and uterine tubes).
The procedure and possible complications should be explained to the patient and informed consent obtained

12. Major Equipment
The major equipment required for an HSG is a radiographic fluoroscope room.
Ideally, the table should have the capability to tilt the patient to a Trendelenburg position if needed.

13. Instruments of Hysterosalpingography:
Volsellum
Higar dilator
Speculum
Screw cannula
Contrast media

14. Contrast Media
Two categories of radiopaque (positive) iodinated contrast media have been used in HSG.
Water-soluble iodinated contrast media, such as Omnipaque 300, is preferred. It is absorbed easily by the patient, however, cause pain
In the past, oil-based contrast media that allowed for maximal visualization of uterine structures was used. However, it has a very slow absorption rate.
Dose: On average, approximately 5 ml is necessary to fill the uterine cavity, and an additional 5 ml is needed to demonstrate uterine tube patency.

15. Procedure A speculum is inserted into the vagina
A catheter is then inserted into the cervix
Contrast material is injected into the uterine cavity through the catheter
Fluoroscopic images are then taken

16. Technique
The procedure should be performed during the proliferative phase of the patient’s menstrual cycle (days 6-12), when the endometrium is thinnest 
this improves visualization of the uterine cavity, and also minimizes the possibility that the patient may be pregnant 
if there is any uncertainty about the patient’s pregnancy status, a bHCG is warranted prior to commencing.
after an antiseptic clean of the external genital area, a vaginal speculum is inserted with the patient in the lithotomy position ; the cervix is cleaned with an aseptic solution.

17. Catheterisation of the cervix is then performed the catheter should be primed with contrast prior to commencing to avoid the introduction of gas bubbles which may provide a false positive appearance of a filling defect.
water soluble iodinated contrast is subsequently injected slowly under fluoroscopic guidance.
Some radiologists use iodinated oil (Lipiodol) as contrast when the indication is for lack of fertility. Some authors report increased fertility after its use. This remain controversial however .
a typical fluoroscopic examination includes preliminary frontal view of the pelvis, as well as subsequent spot images that demonstrate uterine endometrial contour, filled fallopian tubes and bilateral intraperitoneal spill of contrast, to ESTABLISH tubal patency.

18. Filming
An overhead AP scout image may be obtained on a 24 × 30-centimeter (10 × 12-inch) IR.
The central ray and IR are centered to a point 2 inches (5 cm) superior to the symphysis pubis.
If fluoroscopy is unavailable, fractional injection of contrast medium is implemented, with a radiograph performed after each fraction to document filling of the uterine cavity, the uterine tubes, and contrast medium within the peritoneum.
Additional images as determined by the radiologist may include LPO or RPO positions.

19. RADIOGRAPHIC CRITERIA
• The pelvic ring as seen on an AP projection should be centered within the collimation field.
• The cannula or balloon catheter should be demonstrated within the cervix.
• An opacified uterine cavity and uterine tubes are demonstrated centered to the IR.
• Contrast medium is seen within the peritoneum if one or both uterine tubes are patent.
• The patient ID marker should be clear, and the R or L marker should be visualized without superimposition of anatomy

20. Scout

23. Complications Common but self limiting abdominal cramping PV spotting
Rare but serious
pelvic infection
contrast reaction

24. Diagnosis: normal film. Description: small uterus (nulliparous)
Case 1
1-Long thin tubal outline.
2-ill defined peritoneal spillage.
3-Anteverted triangular uterus,
Normal size : 2.5 – 5 cm. 1 2 3
Diagnosis: normal film.
Description: small uterus (nulliparous)

25. Diagnosis: normal film. Description: large uterus (multiparous)
Case 2
1-Long thin tubal outline.
2-ill defined peritoneal spillage.
3-Anteverted triangular uterus. 1 2 3
Diagnosis: normal film.
Description: large uterus (multiparous)

26. Diagnosis: amenorrhoea due to adhesion.
Case 3
Diagnosis: amenorrhoea due to adhesion.
Description: uterus is smaller than normal

27. Diagnosis: infantile uterus.
Case 4
Diagnosis: infantile uterus.
Description: uterus is smaller than normal.

28. Diagnosis: normal film. Description: very large uterus.
Case 5
Diagnosis: normal film.
Description: very large uterus.

29. Diagnosis: retroverted uterus. Description: deviation from medline.
Case 6
Diagnosis: retroverted uterus.
Description: deviation from medline.

30. Diagnosis: retroverted uterus. Description: deviation from medline.
Case 7
Diagnosis: retroverted uterus.
Description: deviation from medline.

31. Diagnosis: arcuate uterus.
Case 8
Diagnosis: arcuate uterus.
Description: partial separation (forming right angle).

32. Diagnosis: arcuate uterus.
Case 9
Diagnosis: arcuate uterus.
Description: partial separation (forming right angle).

33. Diagnosis: unicornuate uterus.
Case 10
Diagnosis: unicornuate uterus.
Description: one cornua , one tube , one spillage.

34. Diagnosis: unicornuate uterus.
Case 11
Uterus Unicornis
1 tube
1 uterus
Diagnosis: unicornuate uterus.
Description: one cornua , one tube , one spillage.

35. Diagnosis: bicornuate uterus.
Case 12
Diagnosis: bicornuate uterus.
Description: complete separation (forming open angle).

36. Diagnosis: bicornuate uterus.
Case 13
Diagnosis: bicornuate uterus.
Description: complete separation (forming open angle).

37. Diagnosis: bicornuate uterus.
Case 14
Diagnosis: bicornuate uterus.
Description: complete separation (forming open angle).

38. Diagnosis: bicornuate uterus.
Case 15
Diagnosis: bicornuate uterus.
Description: large right side containing fetus (miscarriage).

39. Diagnosis: complete didelphys uterus.
Case 16
Diagnosis: complete didelphys uterus.
Description: two cervix , two uterus (look for two cannula!)

40. Bicornuate Uterus (double uterus)
Uterus bicornic bicollis
2 uterus
1 cervix
1 vagina
Uterus didelphys
2 uterus
2 cervix
2 vagina

41. Diagnosis: septate uterus.
Case 17
Diagnosis: septate uterus.
Description: slight separation (forming acute angle).

42. Diagnosis: septate uterus.
Case 18
Diagnosis: septate uterus.
Description: slight separation (forming acute angle).

43. Diagnosis: septate uterus.
Case 19
Diagnosis: septate uterus.
Description: slight separation (forming acute angle).

44. Diagnosis: bicornuate uterus with filling defects.
Case 20
Diagnosis: bicornuate uterus with filling defects.
Description: differential diagnosis: fibroids , air bubbles , bowel gas.

45. Diagnosis: bicornuate uterus with filling defects.
Case 21
Diagnosis: bicornuate uterus with filling defects.
Description: differential diagnosis: fibroids , air bubbles , bowel gas.

46. Diagnosis: bilateral hydrosalpinges with patent fallopian tube.
Case 22
Diagnosis: bilateral hydrosalpinges with patent fallopian tube.
Description: dilatation of tubes.

47. Diagnosis: bilateral hydrosalpinges with patent fallopian tube.
Case 23
Diagnosis: bilateral hydrosalpinges with patent fallopian tube.
Description: saccular dilatation of tubes.

48. Diagnosis: uterine fibroid.
Case 24
Diagnosis: uterine fibroid.
Description: large, Irregular outline uterus with filling defect.

49. Diagnosis: uterine fibroid.
Case 25
Diagnosis: uterine fibroid.
Description: large, Irregular outline uterus with multiple filling defects.

50. Diagnosis: Hydrosalpinx.
Case 26
Diagnosis: Hydrosalpinx.
Description: take different size and shape of dilatation (sacculation).

51. Diagnosis: uterine fibroids.
Case 27
Diagnosis: uterine fibroids.
Description: constant filling defect (immobile).

52. Diagnosis: uterine fibroids.
Case 28
Diagnosis: uterine fibroids.
Description: constant filling defect (immobile).

53. Diagnosis: uterine fibroids.
Case 29
Diagnosis: uterine fibroids.
Description: constant filling defects (immobile).

54. Diagnosis: adenomyosis.
Case 30
Diagnosis: adenomyosis.
Description: irregular outline, multiple diverticulum..

55. Diagnosis: small narrow uterus.
Case 31
Diagnosis: small narrow uterus.
Description: differential diagnosis : Asherman ,DC, TB uterus.

56. Diagnosis: small narrow uterus.
Case 32
Diagnosis: small narrow uterus.
Description: differential diagnosis : Asherman ,DC, TB uterus.

57. Diagnosis: small narrow uterus.
Case 33
Diagnosis: small narrow uterus.
Description: differential diagnosis : Asherman , DC,TB uterus.

58. Diagnosis: fallopian tube ligation.
Case 34
Diagnosis: fallopian tube ligation.
Description: absent uterine tube at both sides.

59. Diagnosis: intravasation of contrast.
Case 35
Diagnosis: intravasation of contrast.
Description: contrast intered ureter.

60. Diagnosis: intravasation of contrast.
Case 36
Diagnosis: intravasation of contrast.
Description: contrast intered ureter.

61. Diagnosis: intravasation of contrast.
Case 37
Diagnosis: intravasation of contrast.
Description: contrast intered ureter.

62. Plain X-Ray

63. Diagnosis: cephalic presentation.
Case 38
Body
Head
Diagnosis: cephalic presentation.
Description: plain x-ray taken for pregnant lady( for lie , presentation)

64. Diagnosis: breech presentation.
Case 39
Head
Body
Diagnosis: breech presentation.
Description: plain x-ray taken for pregnant lady( for lie , presentation)

65. Description: tooth inside uterus.
Case 40
Diagnosis: Dermoid.
Description: tooth inside uterus.

66. Description: copper IUCD inside uterus.
Case 41
Diagnosis: IUCD.
Description: copper IUCD inside uterus.

67. Description: copper IUCD outside uterus (missed).
Case 42
Diagnosis: IUCD.
Description: copper IUCD outside uterus (missed).

68. Diagnosis: uterine fibroid. Description: calcification inside uterus.
Case 43
Diagnosis: uterine fibroid.
Description: calcification inside uterus.

69. Diagnosis: uterine fibroid. Description: calcification inside uterus.
Case 44
Diagnosis: uterine fibroid.
Description: calcification inside uterus.

70. الحمد
لله