HSG Test — What to Expect, Costs & Results Explained

If you've been referred for an HSG, you may have found a wide range of descriptions online — from "barely noticeable" to "the worst pain of my life." The reality, for most women, falls somewhere in between, and preparation makes a significant difference in how the experience goes.

Hysterosalpingography (HSG) is an X-ray procedure that evaluates two things: whether your fallopian tubes are open (patent), and whether the inside of your uterus looks normal. It is one of the most commonly ordered tests in the initial fertility workup and provides information that cannot be obtained from blood tests or standard ultrasound.

This guide covers everything you need to know about the HSG — before, during, and after.

What Is an HSG?

HSG stands for hysterosalpingogram — "hystero" (uterus) + "salpingo" (fallopian tubes) + "gram" (image). It is a fluoroscopic X-ray procedure in which contrast dye is injected through the cervix into the uterine cavity. If the tubes are open, the dye flows through them and spills into the peritoneal (abdominal) cavity, which shows up clearly on X-ray images.

What HSG can detect:

• Tubal blockage (proximal, mid-tube, or distal)
• Hydrosalpinx (dilated fluid-filled tube from distal blockage)
• Uterine cavity abnormalities — submucosal fibroids, polyps, congenital anomalies (septate or bicornuate uterus), intrauterine adhesions (Asherman's)
• Unicornuate or other Müllerian anomalies visible as abnormal uterine shape

What HSG cannot reliably detect:

• Peritoneal adhesions (scar tissue around the tubes and ovaries that may prevent egg pickup even when tubes are patent)
• Endometriosis implants
• Ovarian reserve or egg quality
• Small intrauterine polyps or fibroids (saline infusion sonography is more sensitive for these)

When Is an HSG Ordered?

An HSG is typically ordered as part of the initial fertility evaluation when:

• Infertility evaluation begins (especially after 12 months of unsuccessful trying, or 6 months for women over 35)
• There is history of pelvic infection (chlamydia, gonorrhea, PID)
• There is history of prior pelvic or abdominal surgery
• There is history of ectopic pregnancy
• Irregular uterine bleeding may suggest a uterine cavity abnormality
• Recurrent pregnancy loss (to evaluate uterine cavity shape)
• After tubal surgery (to confirm patency post-procedure)

In many fertility workups, HSG is ordered alongside semen analysis, ovarian reserve testing (AMH, AFC, FSH), and hormonal evaluation as a baseline assessment before initiating any treatment.

The Procedure: Step by Step

Scheduling. HSG is scheduled in the first half of the menstrual cycle — typically days 7–12, after menstruation ends but before ovulation. This ensures the procedure is not performed on a potential early pregnancy and that the endometrium is thin, allowing better visualization of the cavity.

Pre-procedure instructions. Most physicians recommend:

• Taking 600–800 mg ibuprofen 30–60 minutes before the procedure to reduce cramping
• A urine pregnancy test on the day of the procedure (or on the morning of)
• Some practices prescribe a prophylactic antibiotic (doxycycline 100 mg twice daily for 5 days) for women with history of pelvic infection or when HSG reveals dilated tubes (to reduce risk of pelvic infection from introducing bacteria into a dilated tube)

Setting. HSG is performed in a radiology suite or, in some practices, a procedure room equipped with fluoroscopic X-ray. It takes approximately 10–30 minutes from start to finish.

The procedure:

1. You lie on a table with your legs in stirrups, similar to a pelvic exam.
2. A speculum is inserted to visualize the cervix.
3. The cervix is cleaned with antiseptic solution.
4. A thin catheter is passed through the cervical opening into the uterine cavity. The catheter typically has a small balloon at the tip that is inflated with saline to hold it in place (balloon catheter) — or a metal cannula is used with a tenaculum (a small clamp) on the cervix. The tenaculum placement causes a brief sharp sensation for some women; the balloon inflation causes less discomfort.
5. Contrast dye is slowly injected through the catheter while X-ray images are taken in real time.
6. The dye fills the uterine cavity, outlining its shape, and then flows into the fallopian tubes. Patent tubes show dye flowing freely into the peritoneal cavity (seen as spilling around the ovaries on X-ray). Blocked tubes show dye stopping at the point of obstruction.
7. Images are captured and reviewed by the radiologist and/or gynecologist.
8. The catheter is removed and you rest briefly before discharge.

What It Feels Like: Pain and Discomfort

Pain during HSG is highly variable. The most commonly reported sensations:

• Speculum insertion: Mild discomfort, similar to a pap smear.
• Tenaculum placement (if used): A brief, sharp pinch. Not all procedures use a tenaculum.
• Dye injection: This is the most uncomfortable part for most women — a cramping, pressure sensation as the dye fills the uterus and tubes. Severity ranges from mild to severe. Women with tubal blockage (where dye cannot flow freely) may experience more intense cramping due to pressure buildup.
• Dye spilling into the peritoneum: Some women experience referred shoulder tip pain briefly, caused by diaphragmatic irritation from intraperitoneal dye.

Pain management tips:

• Take ibuprofen 30–60 minutes before (confirm this with your doctor)
• Bring a heating pad or hot water bottle for afterward
• Ask about anxiolytic or additional pain medication in advance if you have a low pain tolerance or significant anxiety
• Some practices now offer paracervical blocks (local anesthesia at the cervix) — ask whether this is available
• Arrange for someone to drive you home; while most women drive themselves, the cramping can be distracting

Most women describe the total procedure time as feeling manageable, with the worst discomfort lasting only 1–3 minutes during dye injection.

Exploring Conception Options?

The HSG test evaluates whether your fallopian tubes are open — but if you're exploring all paths to conception, including options that use the tubes differently or bypass them, it's worth knowing what's available.

MakeAMom makes reusable at-home insemination kits for couples and individuals trying to conceive at home: the CryoBaby for frozen or low-volume sperm, the Impregnator for low-motility sperm, and the BabyMaker for those with sensitivities. Kits ship discreetly and are designed for use without a clinic visit.

Explore home insemination kits at MakeAMom →

Oil vs. Water Contrast: The TRIUMPH Trial

One of the most clinically significant advances in HSG practice in recent years came from the TRIUMPH trial (N Engl J Med, 2017), a large randomized controlled trial conducted in the Netherlands.

The trial compared oil-based contrast (lipiodol) versus water-soluble contrast for HSG in women with unexplained infertility. The result was striking: women who had their HSG with oil-based contrast had significantly higher ongoing pregnancy rates than those receiving water-based contrast (39.7% vs. 28.6% in the 6 months after HSG). This was not a new observation — small studies had suggested a therapeutic effect of oil contrast for decades — but the TRIUMPH trial provided robust prospective RCT confirmation.

Why might oil contrast improve pregnancy rates? Proposed mechanisms include:

• Mechanical flushing and clearance of mucus plugs or debris from the tubes
• Anti-inflammatory effects of the oil
• Improved tubal motility after the flush
• Immunomodulatory effects on the peritoneal environment

Oil contrast is not appropriate for all patients — it carries a small risk of oil embolism if injected intravascularly, and it is more viscous and slightly more uncomfortable to inject. It is also more expensive and not universally available.

Based on TRIUMPH, oil-based contrast HSG is now a reasonable first-line option for women with unexplained infertility whose tubes are patent. It effectively converts the diagnostic HSG into a potential therapeutic intervention. Many fertility centers in Europe have adopted lipiodol; US adoption is growing but not yet universal. Ask your provider whether oil contrast is available and appropriate for your situation.

Understanding Your HSG Results

Your HSG results will typically be communicated either immediately after the procedure by the performing physician or within 1–3 days after radiologist review. Here is how to interpret the key findings:

Normal HSG

• Uterine cavity appears smooth, pear-shaped, with no filling defects
• Both fallopian tubes fill symmetrically with dye
• Dye spills freely from both tubes into the peritoneal cavity
• Next steps: No tubal or uterine factor identified; continue with other elements of fertility workup

Unilateral Tube Blockage

• Dye fills one tube and spills freely; the other tube does not fill or does not spill
• Implications: Reduces fertility (one functioning tube is not the same as two), but natural conception remains possible through the patent tube. IVF bypasses this concern entirely.
• Next steps: Confirm with repeat HSG or laparoscopy; consider evaluation for the contralateral tube's anatomy

Bilateral Tube Blockage

• Neither tube fills or spills
• Caution: Proximal bilateral non-fill has a false-positive rate of approximately 20–40% due to tubal spasm. This finding should not immediately prompt IVF without further evaluation.
• Next steps: Repeat HSG or selective tubal cannulation before concluding bilateral blockage exists; if confirmed, IVF is typically recommended

Hydrosalpinx

• One or both tubes fill but do not spill; the tube appears dilated and fluid-filled
• Implications: Hydrosalpinx significantly reduces IVF implantation rates (by approximately 50% per Strandell et al.) and should be treated before IVF — see our blocked fallopian tubes guide
• Next steps: Laparoscopic evaluation; salpingectomy or proximal tubal occlusion before IVF

Uterine Filling Defect

• The cavity outline shows an indentation or "hole" in the dye pattern
• Possibilities: Submucosal fibroid, endometrial polyp, intrauterine adhesion, air bubble (artifact)
• Next steps: Saline infusion sonography (SIS) or hysteroscopy to characterize and treat

Uterine Anomaly

• Cavity shape appears abnormal — heart-shaped, divided by a septum, or smaller than expected
• Next steps: MRI for definitive characterization of Müllerian anomaly; surgical consultation if septum is identified

What Happens After the HSG

Immediately after: Some cramping and spotting are normal for 24–48 hours. Light spotting may continue up to a week if the cervix was instrumented with a tenaculum.

Watch for signs of infection: Fever above 38°C (100.4°F), increasing rather than decreasing pelvic pain, or purulent vaginal discharge in the days following are warning signs of pelvic infection and require prompt medical attention. The risk is approximately 1–3% and is higher when dilated tubes (hydrosalpinx) were present.

Radiation exposure: The radiation dose from HSG is low — approximately equivalent to a few months of background radiation. It does not meaningfully increase lifetime cancer risk.

When to try to conceive after HSG: In the absence of pathology, there is no need to wait — if your tubes are open and the cavity is normal, conception attempts can resume in the same cycle.

HSG Cost

HSG costs vary substantially by geographic region, facility type, and insurance coverage:

If your state has mandated infertility coverage, HSG is typically included. Check with your insurer before the procedure — pre-authorization is sometimes required.

HSG vs. Other Tubal Patency Tests

HSG is the standard first-line test. Laparoscopy is more comprehensive but involves general anesthesia and surgical recovery, making it inappropriate as a first-line screening tool in most situations.

Frequently Asked Questions

Q: What does it feel like to have an HSG test? A: Pain during HSG is highly variable. The most uncomfortable part for most women is the dye injection — a cramping, pressure sensation as dye fills the uterus and tubes, typically lasting 1–3 minutes. Women with tubal blockage may experience more intense cramping due to pressure buildup. Taking 600–800 mg of ibuprofen 30–60 minutes before the procedure significantly reduces discomfort. Some practices also offer paracervical blocks (local anesthesia at the cervix) — it is worth asking in advance if this is available.

Q: What did the TRIUMPH trial find about oil vs. water contrast for HSG? A: The TRIUMPH trial (N Engl J Med, 2017), a large randomized controlled trial in the Netherlands, found that women with unexplained infertility who had HSG with oil-based contrast (lipiodol) had significantly higher ongoing pregnancy rates in the 6 months following the procedure compared to those receiving water-soluble contrast — 39.7% vs. 28.6%. This means oil-based contrast HSG may function as both a diagnostic and therapeutic intervention for women with unexplained infertility whose tubes are patent.

Q: Should bilateral tube blockage seen on HSG be taken as a definitive diagnosis? A: Not without further evaluation. Proximal bilateral non-fill on HSG has a false-positive rate of approximately 20–40% due to tubal spasm — the tubes may appear blocked when they are actually open. This finding should prompt a repeat HSG or selective tubal cannulation before concluding that true bilateral blockage exists and recommending IVF. Immediate redirection to IVF based on a single HSG showing proximal non-fill is premature.

Q: What is a hydrosalpinx and why does it matter before IVF? A: A hydrosalpinx is a dilated, fluid-filled fallopian tube resulting from distal blockage. It significantly reduces IVF implantation rates — by approximately 50% per Strandell et al. (1999) — because fluid from the hydrosalpinx may flow back into the uterus, creating a hostile environment for implantation. A hydrosalpinx found on HSG should be treated (typically by laparoscopic salpingectomy or proximal tubal occlusion) before proceeding with IVF embryo transfer.

Q: When can I try to conceive after a normal HSG result? A: In the absence of pathology, there is no need to wait — if both tubes are open and the uterine cavity appears normal, conception attempts (whether through intercourse, home insemination, or IUI) can resume in the same cycle. Some women with unexplained infertility who had oil-based contrast HSG have conceived in the weeks immediately following the procedure, which is consistent with the TRIUMPH trial findings on the therapeutic effect of lipiodol.

Key Takeaways

• HSG is an X-ray procedure that evaluates tubal patency and uterine cavity shape; it is typically ordered early in the fertility workup.
• The procedure takes 10–30 minutes; cramping during dye injection is the most uncomfortable part.
• Ibuprofen pre-medication, patient education, and cervical anesthesia (when available) reduce discomfort.
• The TRIUMPH trial (NEJM 2017) showed oil-based contrast HSG improves 6-month pregnancy rates in unexplained infertility — ask your provider if lipiodol is available.
• Proximal bilateral non-fill should not be assumed to represent true blockage without further evaluation due to a high false-positive rate.
• Hydrosalpinx found on HSG requires treatment before IVF; normal HSG means no tubal or uterine barrier to attempting natural conception or IUI.

References

1. Dreyer K, et al. (TRIUMPH Study Group). Oil-based or water-based contrast for hysterosalpingography in infertile women. N Engl J Med. 2017;376(21):2043–2052.
2. American Society for Reproductive Medicine. Role of tubal surgery in the era of assisted reproductive technology: a committee opinion. Fertil Steril. 2015;103(6):e37–e43.
3. Strandell A, et al. Hydrosalpinx and IVF outcome: a prospective, randomized multicentre trial. Hum Reprod. 1999;14(11):2762–2769.
4. Swart P, et al. The accuracy of hysterosalpingography in the diagnosis of tubal pathology. Fertil Steril. 1995;64(3):486–491.
5. Mol BWJ, et al. The accuracy of serum chlamydial antibodies in the diagnosis of tubal pathology. Fertil Steril. 1997;67(6):1031–1037.