15.3 Reproductive System Studies: Hysterosalpingography, Pelvimetry & Male Reproductive Procedures
Key Takeaways
- Hysterosalpingography is scheduled 7 to 10 days after the onset of menstruation — after bleeding has stopped and before ovulation — so that pregnancy is excluded and the endometrium is thin.
- The absolute contraindications to hysterosalpingography are pregnancy, active pelvic inflammatory disease and active uterine bleeding; the study is performed under aseptic technique in the lithotomy position with a cannula or balloon catheter in the cervical canal.
- Water-soluble iodinated contrast is the modern standard for hysterosalpingography because it is rapidly absorbed and avoids the granuloma and oil-embolism risk of the older oil-based agents.
- Free spill of contrast from the fimbrial ends into the peritoneal cavity is the radiographic sign of tubal patency and the primary endpoint of the examination in an infertility workup.
- Radiographic pelvimetry and fetography are historic procedures now superseded by ultrasound and magnetic resonance imaging, while male reproductive contrast studies comprise vasography and seminal vesiculography for obstructive azoospermia.
15.3 Reproductive System Studies: Hysterosalpingography, Pelvimetry & Male Reproductive Procedures
Special Radiologic Examinations carries 24 items in the Radiographic Positioning and Radiologic Procedures subject, and the TOS names five procedure groups explicitly: gastrointestinal tract, urological studies, reproductive system, nasopharyngography, and fistulogram/sinus tract visualization. Sections 15.1 and 15.2 covered the first two. This section covers the reproductive group, where the competencies are to explain the preparation and types of examinations and to distinguish and perform the preparation and procedures for positioning the patient to demonstrate specific structures.
1. Hysterosalpingography (HSG)
Definition. Radiographic demonstration of the uterine cavity and the fallopian tubes after retrograde injection of contrast medium through the cervical canal, performed under fluoroscopic control.
Indications
| Indication | What is being sought |
|---|---|
| Infertility workup (the dominant indication) | Tubal patency or occlusion; also a possible therapeutic flushing effect |
| Recurrent pregnancy loss | Uterine anomaly, cervical incompetence |
| Suspected congenital uterine anomaly | Septate, bicornuate, unicornuate or didelphys uterus |
| Suspected Asherman syndrome | Intrauterine synechiae (adhesions) |
| Suspected submucosal fibroid or endometrial polyp | Filling defect within the cavity |
| Post-tubal-ligation or post-reversal assessment | Confirmation of occlusion or of restored patency |
| Post-hysteroscopic-sterilisation confirmation | Device position and tubal occlusion |
Timing — the single most examined fact
Schedule the examination 7 to 10 days after the first day of the last menstrual period — that is, in the proliferative phase, after bleeding has ceased and before ovulation.
Three reasons, all of which you should be able to state:
- Pregnancy is reliably excluded, because conception has not yet occurred in that cycle.
- The endometrium is thin, so small filling defects are not obscured by a thick secretory lining.
- Menstrual blood is absent, so clot does not mimic a filling defect and retrograde flow of menstrual debris into the peritoneum is avoided.
Contraindications
| Absolute | Relative |
|---|---|
| Pregnancy | Known severe iodinated contrast allergy |
| Active pelvic inflammatory disease | Recent uterine surgery |
| Active uterine bleeding | Severe cardiopulmonary disease limiting lithotomy positioning |
Patient preparation
- Confirm the menstrual history and the date of the last menstrual period; document it.
- A bowel preparation (laxative the night before and/or a cleansing enema) improves visualisation by clearing overlying gas and faeces.
- The bladder should be emptied immediately before the study, since a full bladder displaces the uterus.
- Explain that cramping is expected during injection and usually settles within minutes. Analgesia may be prescribed.
- Prophylactic antibiotics are given in selected patients, particularly with a history of pelvic inflammatory disease.
- Obtain informed consent, and include the small risk of infection, of contrast reaction, and of vasovagal reaction.
Technique
- The patient is placed supine in the modified lithotomy position on a fluoroscopic table.
- Under strict aseptic technique, a speculum is inserted, the cervix is cleansed, and a cannula, acorn tip or balloon catheter is seated in the cervical canal.
- A scout image of the pelvis is taken before contrast.
- Water-soluble iodinated contrast is injected slowly under fluoroscopic observation while spot images are recorded.
- Standard images: AP for the uterine cavity and both tubes, RPO and LPO obliques (about 30-35 degrees) to open out the cornua and separate overlapping tubes, and a delayed image to show peritoneal spill.
- Free intraperitoneal spill of contrast from the fimbrial ends confirms tubal patency. Contrast that halts at the cornu or dilates the tube into a sausage-shaped hydrosalpinx indicates occlusion.
Contrast medium selection
| Agent | Behaviour | Status |
|---|---|---|
| Water-soluble iodinated | Rapidly absorbed from the peritoneum; good mucosal detail; causes more transient cramping | Standard of care |
| Oil-based iodinated | Slow absorption; risk of oil embolism and granuloma formation; requires a delayed 24-hour image | Historic; used selectively in some fertility protocols |
Radiation protection
The uterus is directly in the beam and the patient is of reproductive age, so: confirm the cycle timing, use pulsed fluoroscopy at the lowest frame rate, keep fluoroscopy time to the minimum, collimate tightly to the pelvis, use last-image-hold instead of extra exposures, and record the dose-area product in the report.
2. Radiographic Pelvimetry and Fetography — Historic Procedures
The Board still expects awareness of these, and the correct examination answer is that they are obsolete in routine practice.
- Radiographic pelvimetry measured the maternal bony pelvic inlet, midpelvis and outlet against the fetal head to predict cephalopelvic disproportion. Named techniques include Colcher-Sussman (AP and lateral with a radiopaque ruler at the level of the ischial tuberosities) and Thoms. It has been replaced by clinical assessment, ultrasound and MRI, because it irradiates the fetus for information of limited predictive value.
- Fetography was direct radiography of the fetus in utero to assess position, number and gross skeletal anomaly. It has been entirely replaced by obstetric ultrasound, which is non-ionising, real-time and far more informative.
- Amniography — intra-amniotic contrast to outline the fetal soft tissues — is likewise historic.
If an item asks for the imaging modality of choice for the gravid uterus, the answer is ultrasound first, MRI second, ionising radiation only when clinically unavoidable.
3. Male Reproductive Contrast Studies
| Procedure | What is opacified | Indication |
|---|---|---|
| Vasography (vasoseminal vesiculography) | Vas deferens, seminal vesicles and ejaculatory ducts, via direct puncture or cannulation of the vas at scrotal exploration | Obstructive azoospermia; confirmation of vasectomy or of vasovasostomy patency |
| Seminal vesiculography | Seminal vesicles specifically | Suspected obstruction, cyst or inflammatory disease |
| Retrograde urethrography (male) | Anterior and posterior urethra | Stricture, trauma, fistula — covered in Section 15.2 with the urological studies |
These are performed under aseptic technique with water-soluble iodinated contrast, usually in the operating theatre with a urologist, and have themselves been substantially displaced by scrotal ultrasound and transrectal ultrasound.
4. Cross-Modality Perspective
| Clinical question | First-line modality today |
|---|---|
| Tubal patency in infertility | Hysterosalpingography (or hysterosalpingo-contrast sonography where available) |
| Uterine anomaly characterisation | MRI or three-dimensional ultrasound |
| Adnexal mass | Ultrasound, then MRI |
| Fetal assessment | Ultrasound, then MRI |
| Cephalopelvic disproportion | Clinical assessment and ultrasound; MRI pelvimetry if truly needed |
| Obstructive azoospermia | Transrectal ultrasound, then vasography if intervention is planned |
The radiologic technologist's contribution is the same across all of them: confirm the indication and the pregnancy status, verify the cycle timing where relevant, maintain aseptic technique, control fluoroscopy dose, and produce images in which the cornua, both tubes and any peritoneal spill are unambiguously demonstrated.
A 29-year-old woman is referred for hysterosalpingography as part of an infertility workup. Her last menstrual period began on the 3rd of the month. When should the examination ideally be scheduled?
During a hysterosalpingogram, contrast fills the uterine cavity and both tubes, and delayed images show contrast dispersed freely throughout the pelvis outside the tubal outlines. What does this finding indicate?
Which combination represents absolute contraindications to hysterosalpingography?
A student asks why water-soluble iodinated contrast has replaced oil-based contrast for routine hysterosalpingography. What is the principal reason?