Beyond tubal patency: A pictorial review of the imaging spectrum of hysterosalpingography.

Abstract

Hysterosalpingography (HSG) remains a widely utilized fluoroscopic examination in the evaluation of female infertility, primarily for assessing fallopian tube patency. Despite the increasing use of ultrasound and magnetic resonance imaging for comprehensive pelvic assessment, HSG continues to serve as a first-line investigation due to its accessibility, cost-effectiveness, and ability to provide real-time functional evaluation of contrast passage through the reproductive tract. However, the diagnostic value of HSG extends beyond the simple determination of tubal patency. A systematic and structured interpretation enables assessment of the uterine cavity, fallopian tube morphology, cervical canal, and peritoneal contrast dynamics, allowing detection of a broad spectrum of abnormalities. These include proximal and distal tubal obstruction, hydrosalpinx, salpingitis isthmica nodosa, intrauterine adhesions, endometrial polyps, congenital uterine anomalies, and peritubal adhesions. Equally important is the recognition of normal variants, technical artifacts, and physiological pitfalls, which may mimic pathology and lead to misinterpretation. This pictorial review illustrates the imaging spectrum of HSG beyond tubal patency, emphasizing pattern-based interpretation, key radiological features, and clinically relevant considerations to optimize diagnostic yield and guide further management in infertility evaluation.