Indications, Contraindications, and Patient Preparation

Indications

• Infertility evaluation (assessment of fallopian tube patency).
• Evaluation of uterine abnormalities (polyps, fibroids, adhesions, congenital anomalies).
• Investigation of recurrent miscarriage.
• Post-surgical assessment (tubal ligation reversal, uterine reconstruction).
• Assessment of intrauterine device (IUD) placement.

Contraindications

• Pregnancy.
• Active pelvic infection.
• Recent uterine or tubal surgery (risk of perforation).
• Severe contrast sensitivity.

Patient Preparation

• Exam scheduled 7–12 days after the onset of menstruation (endometrium least congested, avoids early pregnancy).
• Patient should empty bladder before exam.
• Cleansing enemas may be given if bowel preparation is needed.
• Vaginal irrigation and perineal cleansing immediately prior.
• Outpatient exam; patient may rest briefly after procedure due to cramping.

Contrast Media

• Preferred: Low-viscosity, water-soluble iodinated contrast (absorbed quickly if intraperitoneal spill occurs).
• Injection: Via uterine cannula with acorn tip or balloon to prevent reflux.
• Method: Fractional doses under fluoro or overhead imaging, with peritoneal spill confirming tubal patency

Projections

AP Pelvis (Primary Projection)

CR Location & Positioning

• SID: 40 inches.
• Patient Position: Lithotomy position, supine, knees flexed over leg supports.
• Adjustments: Center midsagittal plane to IR; support pelvis for stability.
• CR: Perpendicular to IR, centered 2 in. above pubic symphysis.
• Pt. Instructions: Suspend respiration; remain still during injection and imaging.

Evaluation Criteria

• Anatomy demonstrated: Entire uterine cavity, fallopian tubes, and any peritoneal contrast spill included.
• Positioning: No rotation, as evidenced by symmetrical iliac wings and spine aligned in midline.
• Technical factors: Adequate exposure shows uterine outline, fallopian tube lumina, and soft tissue contrast; contrast-filled structures well visualized without overexposure.

Oblique Projections (As Indicated)

CR Location & Positioning

• SID: 40 inches.
• Patient Position: Supine, rotated 30–45° RPO or LPO.
• Adjustments: Elevate and abduct upper thigh to avoid superimposition.
• CR: Perpendicular to IR, centered 2 in. above pubic symphysis and 2 in. medial to ASIS.
• Pt. Instructions: Suspend respiration; remain still during exposure.

Evaluation Criteria

• Anatomy demonstrated: Uterine cavity and fallopian tubes free from superimposition; contrast spill into peritoneum if tubes patent.
• Positioning: Correct obliquity evident by reduced overlap of pelvic bones with uterus/tubes; elevated thigh not obscuring pelvic structures.
• Technical factors: Soft tissue detail visible, with contrast outlining lumen of tubes and uterus; uniform brightness/contrast without motion.

Lateral Pelvis (Optional)

CR Location & Positioning

• SID: 40 inches.
• Patient Position: Lateral recumbent, knees flexed slightly, arms forward.
• Adjustments: Midcoronal plane centered to IR.
• CR: Perpendicular to IR, centered 2 in. above pubic symphysis at MCP.
• Pt. Instructions: Suspend respiration.

Evaluation Criteria

• Anatomy demonstrated: Uterus and fallopian tubes in lateral profile; may demonstrate fistulae, uterine wall anomalies, or abnormal orientation.
• Positioning: True lateral confirmed by superimposed femoral heads and symmetric iliac crests.
• Technical factors: Appropriate exposure shows uterine and tubal outlines with contrast clearly visualized against soft tissues; no motion blurring.

IUD Imaging (AP, Lateral, or Obliques as Needed)

• Timing: HSG often performed ~3 months after permanent IUD insertion to confirm function.
• Projection: AP and lateral abdomen/pelvis; obliques if displacement suspected.
• Findings: IUDs are usually radiopaque (metallic composition).
• Note: Radiography alone may not confirm extrauterine placement—correlation with ultrasound often required.

Evaluation Criteria

• Anatomy demonstrated: Uterus fully visualized with IUD in situ; device located within endometrial cavity.
• Positioning: No pelvic rotation (iliac wings symmetrical, spine midline on AP).
• Technical factors: IUD radiopaque and sharply defined; exposure allows visualization of device relative to uterine margins and endometrial cavity.

Procedure Adaptation

• Use fluoroscopy when available for real-time observation of uterine filling and tubal spill.
• Consider patient comfort: warm contrast, explain cramping as normal.
• Use smallest volume necessary to reduce discomfort and minimize spillage.
• Oblique or lateral projections may be added for better delineation of uterine anomalies or tube course.

Exposure Factors & Technical Considerations

• kVp: 70–80 (for optimal visualization of contrast-filled soft tissue).
• mAs: Low to medium (short exposure time to reduce motion).
• SID: 40 inches.
• Collimation: To pelvic region (from iliac crests to pubic symphysis).
• Radiation protection: Tight collimation, ALARA principles, minimal fluoro time.