Checking Tubes: The HSG is better than the Saline Sonogram

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Hello again everyone.
Today we are going to finish discussing the difference between the HSG and saline sonogram. Last time we highlighted the differences as they relate to studying uterine problems. Today I will point out the differences as they relate to the tubes. We will see how the biggest mistake doctors make with the saline sonogram is when they see no fluid from the tubes and stubbornly say that the tubes must be blocked, therefore you need IVF. Let me explain.

The saline sonogram is not the best test to check the tubes. It gives a hint as to the tubal status, but the results are not definitive enough.

Last blog we discussed one of the basic concepts of the saline sonogram: water looks black on ultrasound, polyps and fibroids look white. We put water inside the uterus and the white polyps or fibroids float in the black fluid making them easy to see.
During a saline sonogram, the saline, after it fills up the uterus, will wander through the tubes and out into the pelvis. So it makes sense that if we can see some black fluid outside the uterus, around the ovaries and intestines, the tubes must be open.

Here is a picture of an ultrasound showing some free fluid in the pelvis. The arrow points to the free fluid. Presumably this fluid stated in the uterus and got squeezed through the tubes and ended up in the pelvis.

However seeing water outside the tubes does not necessarily mean the tubes are in good shape. First of all, one can’t see much detail of the patterns of water flow; the flow can’t be seen as clearly as the dye on an x-ray. We may be able to see if there is water present but we can’t see how it got there. Let’s say, for example, that only one tube is open. This is easy to see on HSG, but on saline sonogram, you cannot tell if one or two tubes are open because you usually can’t see the water flowing from each tube.

Here is an HSG showing open tubes. In the second picture I places lines to show you the approximate place there the tubes ends and there the free flow of dye out the tubes starts. This is much better visualized on the HSG; you can see each tube and the flow of dye directly.

In the case of a hydrosalpinx, the end of the tube can fill with fluid, and although the doctor should be able to tell the difference between and hydrosalpinx and an open tube, sometimes the distinction is difficult.

Here is an HSG of a hydrosalpinx. The arrow points to the blocked tube. You probably noticed that some HSGs show the dye in white and some in black. It just depends on the preference of the physician, they can be printed with either way.

A hydrosalpinx is usually very easy to see on HSG, possible but more difficult to see on saline sonogram.
The point is that this hydro, using a saline sonogram, may have shown up as a little free fluid, and someone may have been told her tubes were indeed open. Severe tubal disease like this may be present even though there is some “free fluid” seen in the pelvis.

At the start of this blog I spoke of the biggest mistake docotrs make when interpreting the sonohysterogram. No fluid in the pelvis does not necessarily mean the tubes are blocked, and IVF may not be the next step after “failing” a saline sonogram. Do not use saline-sono tube tests to make decisions about IVF. A saline sonogram is not an adequate test to proclaim the openness of your tubes. If you want important information about your tubes, a hystersalpingogram is the only way, with very few exceptions, as in the case of a very obvious hydro. Sometimes there is no free fluid seen outside the uterus, but maybe this is because the catheter was not positioned properly, maybe the fluid just backed out the cervix instead of going upward, or maybe there was tubal spasm. In any event, if you were told no free fluid means IVF, talk to your doctor about having an HSG.

That’s it for now, thanks for reading, and don’t forget to read disclaimer 5/17/06.

Dr. Licciardi



  • Papaioanou S, Bourdrez P, Varma R, Afnan M, Mol BW, Coomaraswamy A. Tubal evaluation in the investigation of subfertility: a structured comparison of tests. BJOG 2004; 111(12):1313-21.
  • Swart P, Mol BW, van der Veen F, van Beurden M, Redekop WK, Bossuyt PM. The accuracy of hysterosalpingography in the diagnosis of tubal pathology: a meta-analysis. Fertil Steril. 1995 Sep;64(3):486-91.
  • Saunders RD, Shwayder JM, Nakajima ST. Current methods of tubal patency assessment. Fertil Steril. 2011 Jun;95(7):2171-9

11 responses to “Checking Tubes: The HSG is better than the Saline Sonogram”

  1. Anonymous says:

    Following HSG, I was told to have one tube blocked (the other seems perfectly normal) and after 2 years of trying to conceive we ended up getting IVF, which worked the first time. Now we’d like to have another child, my logic was if only one tube is blocked there is always a chance one will work, so i’m delaying getting in touch with the IVF clinic, am I in denial or is my logic right? Thanks
    (I’m 35 and we have one embryo frozen)

  2. Anonymous says:

    I also have a tube blocked and for seven years have been unsuccessful with becoming pregnant. I have tried chlomid but that is the extent of the assistance I have received. I am wondering if I should have my partners sperm checked or if I should go straight to the IVF clinic. How costly is that?

  3. Anonymous says:

    I conceived naturally after failed femara cycle in 2007. Now I’m 34 still rarely ovulate and have tried femara 5mg which induced ovulation once but not the second time. I have low-normal BMI and eat well. RE said injectibles are my only hope. Insurance won’t cover IUI. What are my chances of conception with injectibles and no IUI? How many cycles should I attempt? And is there any way to reduce the odds of multiples. I really do not want twins.

  4. Anonymous says:

    34 years old. PCOS diagnosis. Management through diet and exercise. BMI: 25. (Difficult to keep it lower.) Two years trying to conceive naturally.

    Long menses.
    Ovulate on my own around day 18-20.
    Start spotting IMMEDIATELY after ovulation and get full flow after 5-6 days.

    Will progesterone supplementation help? Or should we focus on improving a weak ovulation?


  5. Amy says:

    I don’t know much about the Saline Sonogram, but it seems like my septum wouldn’t have been detected. Even I could easily see the septum from the pictures. I still haven’t been able to get pregnant and supposedly the septum was just a miscarriage risk, but I am glad that I got the HSG and was able to get it fixed.

    Also, what do you think about the anecdote that an HSG can help encourage pregnancy by cleaning out the tubes?


  6. plasidway says:

    This comment has been removed by a blog administrator.

  7. Anonymous says:

    I had an hsg done and both tubes are blocked my doctor said there are 2 options surgery to open them up or ivf. He recommends doing the ivf I’m just wondering if anyone has done the surgery and has been succesful? I don’t know why I wouldn’t just try the surgery first before jumping straight into the ivf…anyone?

  8. As a sappy mom would I have tears in my eyes because I remember my 3D sono of my second one and it was amazing.. thanks for the flashbacks this was too precious.

  9. I was just collecting some information about my upcoming Baby i found the new one thing in the shape of 3d ultrasounds it’s amazing and really awesome now i can see a preview of my upcoming new born in clarity it’s a miracle and have a really New experience for me……..

  10. these pics are 4 4d ultrasounds?

  11. Agata B says:

    Not sure if you will be able to respond to this.. I HOPE SO! ..I had an HSG two weeks ago and discovered a fibroid right in the center of my uterus. About 3 to 3.5 inches large. The doctor said to remove it but I didnt like the doc since he was rude, i went to another one. New doctor confirmed i should remove it and did an ultrasound today (follicle count)where he said it looks like its in the wall which means myomectomy through stomach wall. He saw a ‘dent’ (black like space in the fibroid) which he said indicated its where its inside the wall. Next week im having a Sono hsg to figure out where exactly its located so that the doctor will know which way to remove it for certain… Any idea if Sono is needed or should i go straight for Myomectomy and if so what kind? I am terrified. We have been trying for 6 months and i just found this out…also-can you have a regular vaginal birth after myomectomy through incisions of uterus???? PLEASE HELP!

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