A hysterosalpingogram (HSG) is an x-ray procedure used to evaluate the inside of the uterus and the fallopian tubes. It begins just like a pa smear examination. A speculum is inserted into the vagina and the cervix is swabbed with an antiseptic solution. A special tube is then placed into the uterus and the radiologist gently fills the uterus with a contrast dye. While the dye is being introduced into the uterus, x-ray pictures are taken. The radiologist is then able to determine the shape of the uterine cavity and whether the fallopian tubes are open. Mild to moderate cramping may be felt during the procedure.

Common risks and complications:

• Bleeding from vagina. This usually resolves after a few days

Less common risks and complications:

• Infection, requiring antibiotics and further treatment
• Damage to Fallopian tubes, requiring corrective surgery

Rare risks and complications:

• Allergic reaction to the contrast dye. This could result in a rash, itching, nausea, fainting or shortness of breath. You can be given medication to relieve this.
• It is possible to be pregnant at the time of HSG without you knowing and for the pregnancy test to be negative. If you are pregnant and have HSG done, there is a higher chance of miscarriage or abnormalities developing in the unborn baby.
• In extremely rare cases, literature has indicated fatality.

Your consent:

• I understand the risks and complications, including the risks that are specific to me.
• I have been able to ask questions and raise concerns with the radiologist/technologist about the proposed procedure and its risks. My questions and concerns have been discussed and answered to my satisfaction.
• I understand I have the right to change my mind at any time, including after I have signed this form but preferably following a discussion with my radiologist /technologist.
• I understand that if after the procedure, I have a fever, abdominal pain, heavy vaginal bleeding or any other problems I believe are related to the procedure I should contact my nearest physician and/ or medical center.

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