Hysterosalpingogram (HSG): what is it, what to expect, cost

Struggling with infertility is one of the most painful experiences a person can have. It comes with tremendous uncertainty, dashed hopes, and a physical, financial, and emotional burden many people can’t understand. One essential part of this journey is for your fertility specialist to do a full work-up to determine what’s causing these struggles. A hysterosalpingogram or HSG is often one of the first tests done early in this process. It’s a minimally invasive surgical procedure that allows healthcare providers to assess the inside of the uterus and fallopian tubes. 

Here’s what you need to know about having a hysterosalpingogram, including what it is, what to expect, the risks, and the associated costs.

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A hysterosalpingogram procedure allows your gynecologist to assess your uterine cavity (the inside of your uterus) and fallopian tubes. Your fallopian tubes are the structures that carry your eggs (oocytes) to your uterus after they are released from your ovaries. If these become blocked, you may experience infertility (Mayer, 2021).

During an HSG, your provider fills your uterus with a special contrast dye that can be seen on an x-ray. Multiple x-rays of your pelvis are taken during the procedure to follow the contrast as it flows from your uterus through your fallopian tubes, eventually reaching your ovaries (Mayer, 2021).

Your provider can assess your reproductive system to see if there are any abnormalities, polyps, fibroids, or blockages. Development abnormalities show up in about 5% of all hysterosalpingograms. Your provider might also find blocked fallopian tubes. These are a common cause of female infertility (Mayer, 2021).

A hysterosalpingogram is typically performed as one of the steps in an evaluation for infertility for females. Up to one third of women experiencing infertility have a blockage in one or both of their fallopian tubes (called a tubal obstruction) (Mayer, 2021).

An exploratory surgery called a laparoscopy using a special dye is the gold-standard procedure for evaluating your fallopian tubes. This is an invasive procedure, so many providers choose to use a hysterosalpingogram first for women with no clear risk of tubal obstruction since it is less invasive (Lindsay, 2015; Walker, 2021).

Women with risk factors for tubal obstruction, such as endometriosis, pelvic infections, known adhesions, or ectopic pregnancy, should instead have a laparoscopy. This allows the surgeon to possibly treat any condition that might be found (such as endometriosis) at the same time (Lindsay, 2015).

The primary purpose of an HSG is to assess whether your fallopian tubes are capable of having an egg journey down them from the ovary at one end, become fertilized, and then exit the fallopian tube at the other end to implant in the uterus (Mayer, 2021). 

Your provider will assess you for any possible contraindications or risk factors for the side effects of an HSG before performing the test. These might include (Mayer, 2021):

• An allergy to the contrast materials

• A history of thyroid disease

• Pelvic inflammatory disease (PID)

You will be asked to schedule your outpatient HSG during the follicular phase of your menstrual cycle. This is the early part of your cycle, after your monthly menstrual period, when the lining of your uterus is at its thinnest. This can make it easier for your provider to evaluate your reproductive system (Mayer, 2021).

These are the most common steps that take place before, during, and after a hysterosalpingogram (Mayer, 2021; Balasubramanya, 2020):

1. You may need to have a negative pregnancy test before the procedure.

2. In some cases, you may be put under light sedation by an anesthesiologist, though sedation is not always necessary. 

3. Your legs will be placed up in stirrups.

4. Your vagina and cervix will be prepared with an antiseptic.

5. Various instruments, such as a speculum or a tenaculum, might be used to hold your cervix open.

6. Depending on your provider’s preference, lidocaine with epinephrine might be used to prevent pain and bleeding.

7. A water-soluble contrast medium that shows up on x-rays is then instilled through a catheter.

8. A radiologist will take multiple x-rays during the procedure while your uterus and fallopian tubes fill.

9. Your provider will assess the shape of the uterus and fallopian tubes to see if there are any defects, polyps, fibroids, or blockages.

10. Once the procedure is done, you will then recover from the anesthesia. If you are feeling okay, you can go home the same day.

Your provider might also talk about a procedure called a uterosalpingography. This is actually the exact same procedure as a hysterosalpingogram. The term “uterosalpingography” is just an older term that some medical providers still use.

All medical procedures have some chance of complications, but your healthcare provider can help you minimize these risks. A hysterosalpingogram is considered a relatively safe and easy procedure. The most common risks of an HSG include (Bhoil, 2016; Mayer, 2021): 

• Infection

• Vaginal bleeding

• Radiation exposure (a tiny amount from the x-rays used)

• Injury to the uterus

• Abdominal cramping

• Allergic reaction to the contrast material

An HSG can be uncomfortable, but it isn’t typically painful. Still, researchers have looked at ways to make it more comfortable for the woman involved. While topical anesthetics and intravenous opioids might have some benefit during the procedure, they don’t appear to help with discomfort afterward. There isn’t enough evidence that shows that any one type of pain relief is preferred. Some providers may recommend over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) before and after a hysterosalpingogram (Hindocha, 2015).

Another possible risk of an HSG is something called intravasation. This means that the contrast dye used leaks into the blood vessels in your pelvis. This is a rare side effect, but it can be serious. There are ways that your healthcare provider can identify if you are at increased risk of intravasation, and they can then take steps to minimize these risks (Bhoil, 2016).

Antibiotics aren’t typically needed before or after an HSG. However, if you have other risk factors for infection or a history of pelvic infection, your provider might have you take a preventative course of medicine (Mayer, 2021).

It can be difficult to estimate the costs of various medical procedures ahead of time. The final costs are dependent on your location, your health insurance coverage, and whether or not your insurance covers procedures related to infertility (not all plans do).

If you and your provider are considering a hysterosalpingogram as part of your treatment, make sure to let your provider know that cost is a concern. It might also help to contact your health insurance company and speak to a benefits specialist.

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Every article on Health Guide goes through rigorous fact-checking by our team of medical reviewers. Our reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the writer.

Current version

December 17, 2021

Written by

Ellyn Vohnoutka, BSN, RN

Fact checked by

Steve Silvestro, MD

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About the medical reviewer

Steve Silvestro, MD, Ro

Dr. Steve Silvestro is a board-certified pediatrician and Associate Director, Clinical Content & Education at Ro.