What is the HSG test?
The HSG is a fertility test used to check for blockages in fallopian tubes and abnormalities in the uterus. It has a reputation in urban legend for being immensely painful. Writing a reassuring report was my original intention, to confirm that the horror stories were written by those with a penchant for hyperbole. But it is with a reluctant heart that I join the ranks of the whiners and wimps. In my experience the HSG can be described in one word: horrendous.
HSG is a bugger to book
After slowly and carefully over pronouncing ‘hysterosalpingogram’ when booking the appointment with the hospital, I have since learnt that anyone who is anyone knows to call it the ‘HSG’. The NHS receptionist said ‘very good, you got it spot on!’, which made me feel like a vaguely competent foreign exchange student. Then with enthusiasm not warranted by the situation, she told me that there weren’t any more slots left for this month. ‘Try again next time!’.
Booking in for this test is a bugger. You have to call on the first day of your period to ensure that the test takes place between days 6 and 10 of your cycle. Day 5 or 11? No sir! The test cannot be undertaken when you are pregnant because it can cause serious damage to an embryo so I think that the strict requirements are based on the assumption that women are likely to have finished their period by day 6, but not yet have ovulated and had an egg fertilised by day 10. It took 4 months for me to get booked in and by the end I had mastered the process.
Top two tips for booking:
Call as soon as the lines open in the morning in order not to get pipped to the post by another (more efficient) infertile woman. This happened to me a couple of times ‘Oh, sorry, our last appointment was snapped up an hour ago. Best of luck next month.’ If my period started during the day I would wait until the following morning to call.
It matters which day of the week your period starts. Because my hospital didn’t perform HSGs at the weekends, if day one of my cycle was a Thursday then there are only 3 days between days 6 and 10 of my cycle on which the HSG could take place. (Wednesday, Thursday and Friday the following week, as days 9 and 10 of the cycle fell on the weekend). Whereas If my period began on a Tuesday then there were 5 days and more chance of getting an appointment. Playing the system was a naughty necessity. My period started on a Monday, but my desperation dictated that a Wednesday morning call was required to maximise my chances. The HSG ended up on day 11 of my cycle. Naughty, but at the time I wasn't ovulating until day 20 onwards, so I made a judgment call.
Is the HSG test painful? Nervous anticipation
My first nervousness was reading the NHS leaflet sent through the post, which described the procedure as causing ‘various degrees of pain from barely any to very painful’. Medical staff always play down the pain caused, with an injection directly into a muscles being ‘a small scratch’ and a SMEAR test involving ‘slight discomfort’. To see the NHS suggest that something may be ‘very painful’ brought me out in a cold sweat. But it was a sliding scale of pain. Surely being a marathon runner and seasoned leg epilator would put me in a good position on the scale of pain thresholds? It would only be those weaklings that had never experienced childbirth or broken a bone who would suffer (oh wait, that’s me too). Either way, the HSG was inevitable, so no point unduly worrying.
HSG test - what to expect. Waiting without pants
I am considering moving in to the Royal Surrey County Hospital. It is much cleaner than my house and has excellent amenities with a substantial M&S and Costa Coffee. After weaving my way through the red trouser clad patients in the reception area being treated for gout and tennis elbow, I made my way to the radiology department. I had to strip naked and put on two gowns, one to be worn backwards to ‘spare my dignity’. Ah bless. Given the number of fertility and SMEAR tests endured since this process began, I had left my dignity back in 2014. Still, it prevented me from striding down a hospital corridor with my gown flapping in the wind and my arse hanging out, so I (and the other patients in the waiting area) should be thankful.
30 minutes passed in the waiting area, clutching the plastic basket containing all my belongings like a refugee whilst my husband read the hospital’s selection of well thumbed gardening magazines. To refer to my gown as ill-fitting would have been a complement. It was gaping. I wasn’t thinking about the procedure, or the potential pain. I was focused on one thought only: I’m sat in public without any pants, made worse only by the disturbing sensation of a fresh breeze.
The HSG - how is it done?
The first action was to sign a declaration that I was not pregnant. The doctor was highly apologetic about this, because it was a personal question or because it was an insensitive query for an infertile lady, I wasn’t sure.
There are two doctors carrying out the test, both absolutely lovely, like all NHS staff that I have encountered so far. One medic was operating the X-ray machine and the other inserting the instruments into my nether regions. The doctor provided a running commentary of her actions, planned and current. Despite being grateful for being kept fully informed, if did feel like being on a unpleasant and painful medical safari.
It started in exactly the same way as a regular SMEAR test, with a speculum. But at the point when the SMEAR test would be over, the HSG test began. A quick canter through the procedure: A small tube is passed through the cervix into the uterus. A small balloon on the end of the tube is then inflated in order to anchor it in place. The x-ray dye is injected into the uterus, which (hopefully) passes through the fallopian tubes, whilst the radiologist takes x-rays to examine whether there are any blockages preventing the dye’s travel.
And so it began.
‘If I see any lesions then I’ll pop them as I go. Totally normal’.
‘Oh great! Thanks.’
I had no idea what lesions were and to pop them sounded like no big deal, the way that you ‘pop to the shops’ or ‘pop a cork’. It turns out that lesions are scar tissues that bind between two surfaces and ‘popping’ involves ramming through them with the small tube. I had 3 or 4 of these and it felt like a big deal.
The ballon being inflated at the end of the small tube was not ‘pressure’, as the doctor suggested, but intense steady pain. Then it happened, the dye. I wasn’t expecting it to be painful. My uterus doesn’t go in for the old cramping routine and I luckily never experience period pain. Blocked tubes, which can also cause the HSG to be more painful, were not an issue for me either. But when the dye was injected the pain rushed in. It was a burning sensation, like someone was injecting hot oil into my organs. After only 30 (very long) seconds I was teetering along the edge of my pain threshold. From being a normally quiet and gentle women I turned into a foul mouthed troll. Is pain induced tourettes a thing? I pretended it was In my subsequent polite apologies to the doctors for my terrible language.
Is the HSG pain like an early contraction in labour?
God I hope so, because if contractions are worse than that then I can declare, hands up, right now, that I cannot cope. In theory it makes sense that it should be similar to an early contraction. The cervix is slightly dilated, due to the inserted tube, and the uterus is repeatedly contracting, due to the dye. But from an extensive internet search I have not been able to find an account from anyone who has had a painful HSG and been through labour to clarify whether the 'discomfort' (a classic NHS word) is similar. Later contractions must be more intense than an HSG, surely? But then during the early stages of labour you don’t have to remain completely still with no pain relief, so maybe it is swings and roundabouts.
The whole test, from start to finish, could not have taken more than 2 minutes. But I could not have endured a second more. Taking account of the NHS’ warning that the test could be ‘very painful’ for some, I should have anticipated being one of the unlucky few and taken over the counter pain relief before the test, just in case.
Post procedure shell shock
I lay on the bed after the procedure in my shell shocked state with the doctor rubbing my legs to comfort me (thank goodness I had epilated). I was told not to move until the colour returned to my face (worrying), that ‘that was a bad one wasn’t it’ (yep) and that most people either have pain when the ballon inflates, or pain during the dye, but not both (lucky them).
With the NHS sanitary pad the size of a nappy between my legs (orange coloured dye leaks from between the legs for a day or so) I hugged my basket of belongings to my chest and waddled out into the corridor. My husband, who was part way through an article on hydrangeas, took one look at my wide eyed and glazed stare, before quickly wrapping his arm around me and leading me out to safety. As advised by the doctors, I took the rest of the day off work, although honestly I would have been fine to go in with the only post op symptom was a slightly tender muff which prevented romantic activity for a couple of days.
Pregnancy after HSG test - Increase in fertility for 3 months
One of the positive aspects of having the HSG, other than it establishing whether you have issues with your uterus and fallopian tubes, is that you have statistically increased chance of conceiving in the three months following the procedure. Research suggests that among subfertile women with a 17% chance of ongoing pregnancy if they have no intervention, the rate will increase to between 29% and 55% if they have tubal flushing with oil-based contrast media (basically the same as an HSG), although the researchers say that their confidence in the studies is low. Doctors are not sure why HSG increases fertility case but one theory is that the injection of the dye, which is a bit like being blast cleaned with a hose pipe, flushes away some debris and potential minor blockages in the fallopian tubes, leaving a clearer path for the egg to pass. My crazy theories, which are based on nothing other than mere speculation and no science, include that the antibiotics proscribed prior to the procedure would help with fertility if you have unknown digestive issues and painting the patient with iodine could also help ovarian health if they are deficient.
HSG test preparation. What I learnt from my HSG
The HSG was a life experience that I hope never to repeat. The sort that my mother would refer to as ‘character building’. In the office they love to undertake Lessons Learnt exercises and from the HSG I learnt a number of important life lessons:
That my tubes are not blocked
That the preemptive taking of pain relief is to be encouraged, always
That if I am ever lucky enough to get pregnant, I am not going to cope well in labour
That I have pain related tourettes and if I ever go through labour I should take with me an ‘apology hamper’ to present to the hospital staff on leaving
That the NHS massively scrimp on the quality of their sanitary towels and have opted to buy a cheap job lot of adult nappies, and finally
That going commando is not all it's cracked up to be.
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