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New to Infertility

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Hello Everyone,

As the years have gone by, I have very much enjoyed explaining the fertility treatment in a way that is a little more detailed and hopefully more clear than what you might be getting at your doctors office or from other infertility web sites.

The first blogs were more of a “basic training” in infertility, and with time the posts have become more focused on more complex elements of diagnosis and treatment.

The next few blogs will go back to more basic information for those who are new to the infertility world and need a starting point.  Certainly, all of the posts are available for reference.  Here you are with todays entry.


Infertility: The Basics

Infertility is a disease, and as with most diseases, nearly all suffers never thought they would be the ones afflicted.  Becoming pregnant is natural, necessary for us all to continue, and it doesn’t make much sense that barriers to conception could exist.  Unfortunately, some if us are indeed sub-fertile or even infertile.  In some cases there have been indications along the way that a woman or man may have trouble conceiving, maybe due to treatment of other medical or surgical conditions, but for most people, finding out that pregnancy has become evasive is troubling news.  The bright side is that significant advances in infertility care have rendered more people fertile than ever before.

I will first establish a few definitions.  I don’t like to spend too much time categorizing patients because it can lead to depersonalization, but you may encounter some of these terms, so here are a few.

 Infertility: the inability to conceive after one year of actively trying. This should be modified in women over the age of 35 to 6 months of trying.  Age is a very sensitive subject: no one wants to be told they are older or not be enthusiastically treated due to age, but age matters, as we will discus in a later blog.

Primary infertility: infertile and never pregnant.

Secondary Infertility: infertile after being pregnant in the past.

So if you have been trying for 6-12 months with no pregnancy, what is your next step?  It’s time to see a doctor. The workup is very simple, and who knows, there may be something discovered that is very easy to remedy that can quickly fix the problem.  Some people are worried about seeing a doctor because they have heard or read misinformation about the diagnosis and treatment options, but you owe it to yourself to at least find out what the problem may be.  Plus a good infertility doctor will explain many things to you about natural and assisted conception; this is valuable information that you should get from an expert.  Alternative educational sources can be excellent (like this website), but having a single experienced resource put everything together will help you make the best decisions.

What does the doctor do to determine what the problem may be?  The testing phase is not very complicated.  There are 3 initial tests.

1)   The hysterogram (the long word is the hysterosalpingogram, also abbreviated HSG). This is an x-ray test to confirm that the fallopian tubes are open. In order for pregnancy to occur, the egg has to make it from the ovary in to the tube, and then pass through the tube into the uterus.  And, the sperm needs to swim up from the uterus into the tube.  Thus, blockage of the tube does not allow for pregnancy to initiate.  The HSG also confirms that the shape of the uterus is normal. Previous uterine surgery can alter the shape. Also, some women are born with an abnormal shape to their uterus, which at times can be corrected.  Some doctors perform alternatives to the HSG, but others believe it is the best test to confirm normal anatomy.

2)   The Semen Analysis.  This is where the sperm is counted and checked for motility (movement) and morphology (sperm shape). If the counts or motility are low, the male partner may be referred to a urologist who can develop a treatment strategy.

3)   Analysis of ovarian reserve. All women lose eggs as they age, and unfortunately, even some very young women are left with a low or absent egg number.  The lower the egg reserve, the more difficult pregnancy becomes. To test for a diminished ovarian reserve you may be asked to have a blood test in day 2 or day 3 of your cycle for the hormones FSH, Estradiol and AMH (more on this in the next blog).

Once all of these tests are performed, your doctor can help you formulate a plan. There are many options available, your doctor will work with you to develop a course of action that is best for you.

Thank you for reading and I look forward to writing again soon,

Dr. Licciardi

New Updated Video: Uterine Septum

award winning fertility doctor new york city


Dear Readers,

Yes, it has been quite a while since I’ve written. I hope you all have been well and I am excited to return to the blog sphere. It’s not that I have been slacking; I have been writing extensively in other areas, but I do miss the blog so it’s good to be back.
The attached link is to a patient education piece that I produced on uterine septums, which was accepted and presented at the latest meeting of the American Society of Reproductive Medicine. I am very pleased with this final version and I hope some of you find it helpful.

Patient Education: Uterine Septum Video

More to come!

Frederick Licciardi, M.D.
Professor OGBYN
NYU Langone Medical Center

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What’s the difference between a Hysterosalpingogram (HSG) and a Sono-Hysterogram?

award winning fertility doctor new york city


This just happens to be one of my most frequently asked questions, and it’s a good one. Both are can be very important tests. Some women need only one, some both. In this blog you will see pictures and explanations. I enjoyed putting this blog together because I like taking things that are a little complicated and breaking them down into simple pieces to help make the readers understand every day things that were never made clear to them. Despite this I realize that there are some of you that get very intimidated when shown pictures of anything medically related, so I am sorry if some of this compounds your frustration. Give this one a shot and see how it goes.

Hysterosalpingogram, also known as the hysterogram or HSG. Hystero means uterus, salpingo means tube, so it’s a test to evaluate both the uterus and tubes. It’s a dye test that uses an x ray. As far as the patient is concerned, it starts with a speculum, like a pap smear. The doctor, through various techniques mentioned in previous blogs, squirts some dye into the uterus and it then runs out the tubes. The dye is actually as clear as water, but it’s called dye because it is white on an x ray. The dye then shows the shape of the interior of the uterus and the tubes.

Let’s start with the uterus. This is picture of a HSG x ray.

The uterus is perfect. The tubes are abnormal, but I am starting with this one because the view of the uterus is so ideal. You can see that is triangular in shape with the top being relatively straight across.
The hsg only shows us where the dye is, which is inside the uterus and inside the tubes. It does not tell us anything about the middle or outside of the uterus or tubes. The next picture is the same as above except I outlined the outside of the uterus and the approximate location of the ovaries.

You can see that the overall uterine size is greater than what is shown by the hsg, and how the outer uterus and ovaries are invisible using x rays.

The next picture shows what happens to an HSG when there are fibroids on the middle and outside of the uterus. I drew in some hypothetical fibriods in red. Fibriods like these would be invisible on hsg. As you can see, the shape of the inside of the uterus has not changed. So it is possible to have fibroids, and have a normal looking hsg. Fibriods that are closer to the cavity will make the HSG look abnormal. We will later see how certain fibroids can affect the look of the HSG, but in this case many fibroids did not change the HSG picture.

Now we will look an HSG that shows an abnormal uterus.

This hsg is abnormal. There is a black spot in the center, and this could be a number of things, all of which are abnormal. The center is dark because the dye cannot get to the center of whatever is growing in there. It is most likely a polyp, but it could be a small fibroid or even some scar tissue(less likely). The overall triangular shape of the uterus is good. This shows how an HSG can be used for diagnosing uterine problems such as polyps or fibroids that are growing in the cavity.

This is a good time to move over to salinosonohysterograms (sonohysts for short). Commonly called a saline infusion sonohysterogram (SIS). We will come back to HSGs in a bit. The sonohyst does not use an x-ray or x-ray dye. It instead is performed with a regular old ultrasound machine. Prior to performing the ultrasound, the doctor starts with a speculum and then puts a very little plastic tube inside the uterus and squirts some saline (salt water). The saline goes into the uterus and out the tubes.

Here is a normal uterine cavity on ultraound without the saline, its the regular old ultraound.

The next picture is the same, but I added white lines to show you the outline of the entire uterus.

Here is an ultrasound of a uterine polyp (could also be a fibroid). It’s that olive shape in between the arrows. No saline yet.

Here I put a circle around it to make sure you see what I am talking about.

And below is a sonohysterogram of a similar polyp. The doctor put a little saline inside the uterine cavity. Saline or any watery fluid looks black on ultrasound. The black surrounds the polyp and makes it much easier to see. The arrows are not important, they are just pointing out the stalk of the polyp.

Here I would like to end on one very important point. Performing this sonohysterogram was not necessary. We can all see that the polyp is very obviously visible in the picture without the water. There is really no reason to do the sonohysterogram. However time and time again, the doctor will say, “it looks like a polpy, lets do a sonohysterogram to be sure.” Yes the picture using the sonohysterogram is prettier, but what he is doing is having you undergo one more unnecessary test, that you may have to pay for, and it’s expensive. So if you are confronted with a sonohysterogram, ask your doctor if he is sure if it really needs to be done. Ask if it will give you any more information than you already have. The sonohysterogram is a great test and I use it all of the time, but not if I know the answer before it’s started.

We will discuss both again next time. You will learn why the sonohysterogram is not a good test for showing open or closed tubes.

Thanks again for reading and please read disclaimer 5.17.06.

Dr. Licciardi


  • Steinkeler JA, Woodfield CA, Lazarus E, Hillstrom MM. Female infertility: a systematic approach to radiologic imaging and diagnosis. Radiographics. 2009 Sep-Oct;29(5):1353-70.
  • Bingol B, Gunenc Z, Gedikbasi A, Guner H, Tasdemir S, Tiras B. Comparison of diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography and hysteroscopy. J Obstet Gynaecol. 2011;31(1):54-8.
  • Ayida G, Chamberlain P, Barlow D, Kennedy S. Uterine cavity assessment prior to in vitro fertilization: comparison of transvaginal scanning, saline contrast hysterosonography and hysteroscopy. Ultrasound Obstet Gynecol. 1997 Jul;10(1):59-62.

Hysterograms: Let’s Not Forget the Uterus

Hysterosalpingogram: it means an x-ray of the Hyster(uterus) and Salpinges(tubes). Both are very important. Again and again I see films that are reported as normal, yet the uterus is not in proper view. If it’s not in proper view, it can’t be seen well and we can’t say its normal. We may be missing hidden abnormalities.
One common problem is the placement of a balloon inside the uterus during the test. The balloon is helpful because it acts as a plug, preventing the dye from spilling back out through the cervix, so that the dye can go up and out the tubes. The problem is that the balloon fills up the uterus so one can’t get a good view of what is inside the uterus.
Another problem is the angle of the uterus. The uterus is in a slightly different position in all women. In some women it’s tilted way forward, some way back and for most people its somewhere in between. If the uterus is pointing towards the camera, the picture will be through the top edge of the uterus, and the inside cannot be seen well. Imagine trying to tell the date on a coin if you only could look at the coin from its edge. The uterus needs to be straightened out during the procedure so that we can see it from a side view, not a top view.
A patient this week had both issues. Her HSG was read as normal. Yes her tubes were open, but the uterus could not bee seen well because it was on edge and a balloon was used. I strongly recommended repeating the test the proper way. She was reluctant, but after the repeat we found the uterus was not normal: there was a septum (subject for another day). Thanks for reading and please see post 5/17/06.


  • Steinkeler JA, Woodfield CA, Lazarus E, Hillstrom MM. Female infertility: a systematic approach to radiologic imaging and diagnosis. Radiographics. 2009 Sep-Oct; 29(5):1353-70.
  • Ayida G, Chamberlain P, Barlow D, Kennedy S. Uterine cavity assessment prior to in vitro fertilization: comparison of transvaginal scanning, saline contrast hysterosonography and hysteroscopy. Ultrasound Obstet Gynecol. 1997 Jul; 10(1):59-62.
  • 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.

A woman who thought her Hysterogram was normal

Each holiday season I receive many wonderful cards from patients, most accompanied by photos of their new families. There are usually some from people I have not heard from in years, and its great to see these photos because they are not of babies, but of pre-teen, on their way to adulthood, beautiful boys and girls. This year was no exception. When I get time, I try to call as many of these card-givers as I can, but a card from a memorable patient from years ago elicits an immediate response. After receiving a card with a picture of 4 kids, I picked up the phone and called the sender. I had had a very comforting conversation about her overcoming her fertility problems, and she reminded me of how our relationship started with a hysterogram.
She was seeing me for a second opinion. As with all of my patients, I asked for the films of the hysterogram another doctor had performed(if it has not been done I do it myself). I did not want the report, just the films. In her case, the report and her first doctor said the tubes were open. When I looked at the films, I had to tell her that her tubes were not open, they were blocked, and this was the reason she could not get pregnant. The reason my diagnosis was different was that one tube did have dye coming out, but it was through a tiny hole on the side, and not through the larger opening at the end. So the radiologist read it wrong, and her doctor didn’t look at the film, he just went with the report. Over the next few years she was treated with a combination of surgery and IVF, the result being 4 healthy kids.
So the bottom line is your doctor needs to carefully look at the films, not the report. If you ever go for a second opinion, bring the films so the new doctor can read them too. This story is a very common scenario. I am sure there will be later postings about hysterograms and the wrong diagnosis.