What to Expect During Sonohysterography

Procedure, Pain, Risks, and Fertility

couple having sonohysterography
Having your partner with you for support during the sonohysterogram can help reduce your anxiety, which will also lessen your physical discomfort. John Fedele / Getty Images

A sonohysterogram is a special kind of ultrasound that evaluates the inside of your uterus. You may have this test done during fertility testing, just before IVF, or when you have symptoms of possible uterine abnormalities.

Sonohysterography may also be referred to as hysterosonography, saline infused sonography (SIS), transvaginal sonography with fluid contrast augmentation, and the abbreviation SHG (sono-hystero-gram).

This same test with special attention to the fallopian tubes may be referred to as sonosalpingography.

What Is a Sonohysterogram?

During sonohysterography, a very thin tube (catheter) is placed inside the cervical opening. Saline solution (a sterilized salt water solution) is slowly introduced via the thin tube. The saline solution gently distends the uterus, so that the uterine walls move slightly away from each other.

Think of your uterus as a deflated balloon. If you would introduce a small amount of water or air, the walls of the balloon would move away from each other. This is what the saline solution does during sonohysterography.

As the saline solution is being introduced into the uterine cavity, a transvaginal ultrasound wand is used to evaluate the uterine shape and walls, and possibly also the fallopian tubes.    

If you haven’t had a transvaginal ultrasound yet, a long, slender wand known as a transducer is used.

The wand is inserted into your vagina by the technician. (For your comfort, some technicians will hand you the wand to place inside yourself. Then, they take the handle back from you for the test.)

The traducer wand emits sound waves that bounce off your body’s tissues. The sound waves that bounce back are echoes, and the transducer records these echoes.

Ultrasound is completely painless.

On the ultrasound screen, your doctor or technician can see a visual representation (created with the sound waves) of your reproductive organs.

Transvaginal ultrasound can be done without the saline solution. However, it’s more difficult to detect some uterine abnormalities and the true uterine shape and structure without the saline solution.

When the saline solution moves the uterine walls away from each other, uterine problems are easier to see.

Why Might Your Doctor Order This Test?

Reasons for ordering a sonohysterogram include:

A sonohysterogram looks for and can detect:

  • uterine shape and congenital uterine abnormalities (like uterine septum, which is when tissue divides the uterus)
  • polyps (non-cancerous growths) on the uterine lining
  • fibroids (especially if they are protruding into the uterine cavity)
  • uterine adhesions (scar tissue)
  • abnormal endometrial tissue growths (which may or may not be cancerous)
  • The overall thickness or thinness of the uterine wall and endometrium

How Does Sonohysterography Fit in With the Other Uterine Fertility Tests?

Sonohysterography is one of a few tests that can be used to evaluate the fallopian tubes, uterine cavity, and endometrium.

The other tests include:

  • HSG (which is specialized X-ray)
  • hysteroscopy (which involves placing an ultra-thin camera through the cervix to visualize the inside of the uterus)
  • transvaginal ultrasound (ultrasound without the saline solution)
  • laparoscopy (which is an invasive surgical procedure, required for endometriosis diagnosis)

You might be wondering why there are so many different tests to evaluate the same thing.

The answer is that each test has its advantages and disadvantages. Depending on the cause of your fertility problems, one test may be better at detecting the issue than another. In some cases, like with hysteroscopy or laparoscopy, the test can also be used for surgical treatment.

Sonohysterography, HSG, and Mock Embryo Transfer

Some doctors prefer sonohysterography over an HSG.

An HSG requires the use of X-ray. While the radiation levels are very low, sonohysterography avoids exposing your reproductive organs to any radiation.

Other doctors may order a sonohysterography at the same time as an HSG. Research has found that the combination of tests may be better at detecting some uterine fertility problems.

The advantage of having an HSG and sonohysterogram at the same time is the catheter needs to be placed only once. (Both tests involve pushing fluid through a catheter that is placed in the cervix.) This may mean less discomfort and anxiety for you.

As always, you should discuss with your doctor the risks and potential benefits of any fertility test or treatment.

If you’re going to have IVF treatment, your doctor may schedule sonohysterography and the same time as a mock embryo transfer (MET/SHG).

Will the Sonohysterogram Hurt?

This is a number one concern and question for many women, understandably so!

A sonohysterogram should not hurt.

While you may experience some discomfort (the same kind you may have during a pap smear), and very slight cramping when they introduce the saline solution, many report no pain at all.

However, pain varies from woman to woman.

Things that may impact whether the test is more uncomfortable for you include:

  • anxiety (The more tenses you are, the more likely you are to experience discomfort. Remember to breathe!)
  • the doctor’s technique
  • if there are blockages or uterine problems (If the fluid can’t spill out from the fallopian tubes as it should, this can be painful)
  • difficulty placing the catheter (if your cervix is narrow or your uterus is unusually tilted)
  • if you experience pain during regular gynecological examinations (if a pap smear is very difficult for you, this may also be difficult)

If you are concerned about pain, talk to your doctor before the test.

It’s natural to search the Internet for other women’s experiences. Keep in mind when reading fertility forums that women with the extra painful stories are more likely to talk about their experiences than those who had no pain or discomfort.

Also, sometimes, women in these forums confuse the different tests.

(I’ve seen women describe hysteroscopy, which is more painful than sonohysterography, when they say they are describing a sonohysterogram. It’s easy to confuse all these similar sounding tests.) 

If you struggle with pain during sexual intercourse, pain during your yearly gynecological check-up, or have vaginismus, talk to your doctor about getting more than just over-the-counter pain relief for the exam.

Your doctor may be able to prescribe something like Valium, which can help you relax and decrease pain.

Most women will not need this extra pain relief.

Many women report that sonohysterography is the least painful fertility test of this sort. Some women report not feeling anything except the placement of the speculum!  

How Should You Prepare for the Test?

As always, talk to your doctor about what you should do before the test.

This test should be done after your period ends but before you ovulate. This is to avoid accidently doing the test in early pregnancy.

You may need to contact your doctor’s office when your period starts, so they can schedule the sonohysterogram appropriately.

If you don’t get your periods, your doctor may prescribe Provera or another medication to bring on menstruation.

You may be asked to take antibiotics prophylactically. This is more likely if you’re at a higher risk for infection.

Many doctors recommend taking over-the-counter pain relief about 30 minutes before the scheduled test.

Typically, 400 mg of ibuprofen is suggested.

If you can’t take ibuprofen, talk to your doctor about your options.

The Sonohysterogram Procedure: What to Expect

First, you will be asked to use the restroom, if you haven’t done so yet. Unlike some other kinds of ultrasounds, you should have an empty bladder for this test.

In the exam room, you’ll remove your clothing from the waist down. You may be given a gown or sheet to put over your legs.

You’ll lie on your back on the exam table.

If there are stirrups, you will put your feet in them and slide forward to the edge of the table.

If there are no stirrups, you’ll be asked to bend your legs at the knees, placing your feet on the table, in a sort of frog leg position. (Don’t worry, the nurse or technician will help you.)

Most likely (but not always), the technician or doctor will do a regular transvaginal ultrasound.

The transvaginal ultrasound wand (or transducer) will have a condom placed over it and some lubricant. They will either gently insert the wand vaginally or hand you the wand and ask you to insert it vaginally as far as it goes.

After you hand the transducer back to the technician, they will move the wand around to get ultrasound pictures. This is slightly uncomfortable but should not at all be painful.

After this, the transducer is removed.

Next, the doctor will take a speculum (usually a metal or plastic device that is used during gynecological exams) and place it into your vagina.

Your doctor will use a cotton swab to disinfect the cervical area. This may feel a lot like a pap smear.

Next, your doctor will take an ultra-thin plastic tube (the catheter) and place it into your cervical opening. You may have slight cramping or you may feel nothing at all.

Now, your doctor will place a tiny balloon next to the catheter and fill it up with either air or water. This balloon holds the catheter in place.

Your doctor will remove the speculum. She will then either hand the transvaginal ultrasound wand to you to place into your vagina or insert it herself.

While the transvaginal ultrasound wand is in place, your doctor will feed saline solution through the catheter. The saline solution will go into your uterus and through your fallopian tubes. You may feel cramping or not feel anything at all.

Ultrasound pictures are taken as the fluid flows through the uterine cavity and fallopian tubes.

Your doctor may also want to take some trans-abdominal ultrasound images. In this case, gel will be squirted on your abdomen and a different shaped transducer will be moved over the gel. Your doctor may press down with slight pressure over on your abdomen. 

If you’re having a sonosalpingography (which checks the fallopian tubes), a very small amount of air may be introduced through the catheter. This is to create bubbles that can be seen on the ultrasound machine.

(The technician hopes to see the bubbles move through the fallopian tubes.)  

After your doctor has gotten all the images they need, the wand will be removed, the catheter and balloon are removed, and you’re done!

When you sit or stand up, expect to feel some of the fluid leak out.

From start to finish, the test should take no more than 15 minutes.

What Are the Risks of Sonohysterogram?

Sonohysterography is a safe fertility test.

There is a very low risk of infection. It’s rare, occurring less than 1 percent of the time.

The test should not be done if you’re pregnant. If you think you might be, tell your doctor.

The test should also not be done if you have an active pelvic or vaginal infection.

What Does the Test Cost?

A sonohysterogram costs between $500 and $700.

If the test is combined with other procedures, the cost will be more.

Your insurance may or may not cover the test. It partially depends on why the test is being done.

For example, if it’s for abnormal menstrual bleeding, your insurance is more likely to cover it. If it’s done in preparation for IVF treatment, it may not be covered.

Be sure to talk to with the financial advisor at your fertility clinic and your insurance provider before the test.

How Will You Feel After the Procedure?

Assuming you only had a sonohysterogram and no other procedures, you should be able to go right back to work after the test.

If you had the exam in the morning, you can resume your normal daily activities that afternoon.

You may experience very mild cramping the day of the test.

Whatever pain medication you take for regular menstrual cramps should relieve your discomfort.

You may find yourself leaking out the saline solution from the exam over the next 24 to 48 hours. You may also have some light spotting.

Be sure to bring some menstrual pads for the leakage.

(Don’t use tampons or anything you put inside your vagina. This is to avoid increasing the risk of infection.)

If you had a sonohysterogram combined with other procedures, your recovery may be slightly different. Talk to your doctor about what to expect.

What Happens the Days After the Test

You should not have sexual intercourse for two to three days following the procedure. This is to avoid infection.

Also, if you experience…

  • fever
  • increased bleeding (more than just light spotting)
  • cramping or pain that continues past the first day
  • sudden severe pain the day of the test
  • anything that feels worrisome to you

Contact your doctor right away.

What the Results Mean/What Happens Next

The doctor or technician who does the sonohysterogram may or may not be able to tell you the results. You should schedule a follow-up with your doctor soon after the exam.

If the test was normal, your doctor may...

  • possibly order additional testing
  • come up with a fertility treatment plan, using the information gained from your entire fertility evaluation
  • approve your upcoming IVF cycle (if this was part of IVF preparation)

If a sonohysterogram finds abnormalities, the next step partially depends on what the doctor found and your goal in testing.

If polyps or fibroids were found, your doctor will discuss with you the pros and cons of removing them. (They may not need to be removed.)

Polyps may be removed via surgical hysteroscopy. This is done under general anesthesia.

Small fibroids may be removed with surgical hysteroscopy as well.

However, larger ones may require laparoscopy (an outpatient procedure) or even abdominal myomectomy (surgery that requires an overnight stay or two in the hospital.)

Uterine septum may be diagnosed with sonohysterography.

Uterine septum is when tissue that should not be there separates the uterus down the middle. This separation may be partial or it may go all the way down to the cervix.

It can cause infertility and repeated pregnancy loss.

This is a rare congenital problem (you are born with it), but it can be corrected with surgery, usually a surgical hysteroscopy.  

After surgical treatment, you may be able to get pregnant on your own or you may still require fertility treatment. This is something you should discuss with your doctor.

 

Sources:

Berridge DL, Winter TC. Saline Infusion Sonohysterography: Technique, Indications, and Imaging Findings. J Ultrasound Med. 2004;23:97–112. 

Lindheim SR1, Sprague C, Winter TC 3rd. Hysterosalpingography and Sonohysterography: Lessons in Technique. AJR Am J Roentgenol. 2006;186(1):24-9. 

Saline infusion sonohysterogram (SHG). Fact Sheet. American Society for Reproductive Medicine. ReproductiveFacts.org. http://www.reproductivefacts.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/SHG.pdf Accessed June 2016.

Sonohysterography. FAQ. The American College of Obstetricians and Gynecologists. https://www.acog.org/-/media/For-Patients/faq175.pdf?dmc=1&ts=20160523T0913216513 Accessed May 25, 2016. 

Continue Reading