Hysterosalpingography (HSG) Hysterosalpingography (HSG) is the radiographic demonstration of the female reproductive tract with a contrast medium. The radiographic procedure best demonstrates the uterine cavity and patency (degree of openness) of the uterine tubes. The uterine cavity is outlined by injection of a contrast medium through the cervix. The shape and contour of the uterine cavity is assessed to detect any uterine pathologic process. As the contrast agent fills the uterine cavity, patency of the uterine tubes can be demonstrated as the contrast flows through the tubes and into the peritoneal cavity.

Indications Infertility Recurrent of miscarriages; investigation of suspected incompetent cervix, suspected congenital anomaly Following tubal surgery, post sterilization to confirm obstruction and prior to reversal sterilization Assessment of the integrity of a caesarean uterine scar (rare) Contraindications During menses Pregnancy A purulent discharge on inspiration of the vulva or cervix, or diagnosed pelvic inflammatory disease in the preceding 6 months Contrast sensitivity

Contrast media Two categories of radiopaque (positive) iodinated contrast media are utilized in HSG. Either an oil-based or water-soluble nonionic contrast media is utilized, based on physician preference. Volume 10-20 ml Major Equipment The major equipment for a hysterosalpingogram is a radiographic fluoroscopic room.

Accessory and Optional Equipment Routinely a sterile, disposable hysterosalpingogram tray is utilized. The general contents of the tray include: a vaginal speculum, basin and cotton balls, medicine cup, sterile gauze, sterile drapes, sponge-holding forceps, 10 cc syringes, 16- and 18-gauge needles, extension tubing, and lubricating jelly. In ad­dition to the HSG tray, sterile gloves, an antiseptic solution, a cannula or balloon catheter, and contrast media are also necessary

Patient Preparation Proper bowel prepara­tions to ensure adequate visualization of the reproductive tract un­obstructed by bowel gas and/or feces Patient may take mild laxative, suppositories, and/or a cleansing enema before the procedure. The patient may be instructed to take a mild pain reliever before the examination to alleviate some of the dis­comfort associated with cramping. To prevent displacement of the uterus and uterine tubes the pa­tient should be instructed to empty her bladder immediately before the examination. The procedure and possible complications should be explained to the patient and informed consent obtained. In some instances the physician may also perform a manual pelvic examination before the radiographic procedure.

Technique Cannula/Catheter Placement and Injection Process To begin the procedure the patient lies supine on the table in the lithotomy position. If gynecologic stirrups are unavailable, the patient bends her knees and places her feet at the end of the table. The pa­tient is draped with sterile towels, and with sterile technique a vagi­nal speculum is inserted into the vagina. The vaginal walls and cervix are cleansed with an antiseptic solution. A cannula or balloon catheter is then inserted into the cervical canal. Dilation with a bal­loon catheter helps to occlude the cervix, preventing contrast medium from flowing out of the uterine cavity during the injection phase.

A tenaculum may be necessary to aid in the insertion and fix­ation of the cannula or catheter. Once cervical placement of the cannula or catheter is obtained, the physician may remove the speculum and place the patient in a slight Trendelenburg position. This position facilitates the flow of con­trast media into the uterine cavity. A syringe filled with contrast is at­tached to the cannula or balloon catheter. Using fluoroscopy, the physician slowly injects the contrast medium into the uterine cavity. If the uterine tubes are patent (open), contrast media will flow from the distal ends of the tubes into the peritoneal cavity

Films Early, mid and full uterine filling As the tube begin to fill: isthmic and ampullary phases When peritoneal spill has occurred and with all the instruments removed If a balloon has been inflated in the cavity then this should be deflated or withdrawn and a further film taken to show the lower uterine cavity

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. Appropriate density and short-scale contrast demonstrate anatomy and contrast medium. The patient ID marker should be clear, and the R or L marker should be visualized without superimposing anatomy

Angiography Angiography refers to the radiographic examination of vessels after injection of a contrast medium. Because the various soft tissues of the body possess similar radiographic densities, contrast medium must be added to study normal and abnormal distribution of the cir­culatory system. Anatomy Divisions or components of the circulatory system The circulatory system consists of The cardiovascular Lym­phatic components 1- The cardiovascular portion includes: The heart, blood, and vessels that transport the blood

2- The lymphatic element of the circulatory system is comprised of: A clear watery fluid called lymph, lymphatic vessels, and lymphatic nodes. The cardiovascular and lymphatic components differ in the function and method of transporting the respective fluids within the vessels Cardiovascular system The heart is the major organ of the cardiovascular system and func­tions as a pump to maintain circulation of blood throughout the body. The vascular component is a network of blood vessels that carry blood from the heart to body tissues and back to the heart again.

Functions of the cardiovascular system include the following: 1. Transportation of oxygen, nutrients, hormones, and chemicals necessary for normal body activity. 2. Removal of waste products through the kidneys and lungs. 3. Maintenance of body temperature and water and electrolyte balance.

Systemic circulatory Arteries Vessels transporting oxygenated blood from the heart to tissues are called arteries. Arteries that originate directly from the heart are large but they subdivide and decrease in size as they extend from the heart to the various parts of the body. The smaller arteries are termed arterioles. As the blood travels through the arterioles, it en­ters the tissues by the smallest subdivision of these vessels, known as capillaries Veins The deoxygenated blood returns to the heart through the venous system. The venous system extends from venous capillaries to venules to veins.