Welcome to the new, fresh blog about Sono HSG with FemVue. Through this blog, you will be able to receive helpful imaging hints and tips, learn about interesting cases and follow the growth of Sono HSG with FemVue! There is so much enthusiasm shown for the procedure with FemVue from all levels. I am so excited to be sharing with you what I have learned through talking with physicians, sonographers and patients while covering procedures.
Whenever we see pathology, we are taught to describe, not diagnose.
During a Sono HSG, we are determining patency. Here is a round about way we can describe what we have observed in order for the physician to make the patent or non patent call.
Please note that this is only to give you an idea of how to come up with an approved form for your practice.
(This is just an example of a way you can document observations)
Distended cavity? Yes / No
Right Side:
(Circle whether or not you made the following observations)
| Cornual distention | Yes / No |
| Zone 1 | Yes / No |
| Zone 2 | Yes / No |
| Zone 3 | Yes / No |
Left Side:
(Circle whether or not you made the following observations)
| Cornual distention | Yes / No |
| Zone 1 | Yes / No |
| Zone 2 | Yes / No |
| Zone 3 | Yes / No |
Cul-de-Sac
Contrast/Increased Fluid in the Cul-de-sac? Yes / No
If there ever is a case to not wish for, it is this one! Many issues arise in this case. Where to start? Here is a list:
1. Full bladder – enhancement and patient discomfort
2. Bowel loops everywhere – difficult to visualize fallopian tube course
3. Mid plane uterus – makes getting a true transverse image difficult
4. Too much scanning around – slowly and steadily scan laterally when looking for the tube
Right tube:
Zone 1 is not visualized. You immediately see flow in zone 2 and 3. It’s not until the left side is being evaluated that we see zone 1.
Leftt tube:
Flow is seen in distal zone 2 and exiting zone 3 slowly right before the video is done.
Simultaneous flow means that the air bubbles are visualized in both the right and left sides at the same time. This can happen. It does not always happen, but when it does you will need to evaluate each side separately. I would suggest still trying to see flow in Zones 1-3.
If you do not see simultaneous flow, choose a side to evaluate first. Once you have established flow, evaluate the contralateral tube.
Tip: If you choose to start with a side that is not demonstrating flow, evaluate the opposite side and come back to the original side. It might take some time for the tube to fill up!
We can see on this video that we have great cornual distention.
Left tube:
The bubbles are seen lining up in the cavity to start the exit through Zone 1. There is great delineation of Zone 1 in this case. Zone 2 flow is seen right away. The probe is then moved around in order to visualize the left ovary. Some more flow is seen in Zone 2. Finally, we find the ovary and Zone 3 flow is noted. Notice that when we see the bubbles exiting, they are moving nice and fast.
This is a fantastic view because the sonographer really focused on that end flow.
Talk about shadowing from a fibroid! It’s amazing how those can really affect the image quality. Don’t get discouraged when you see or find out the patient has fibroids before you do the procedure. They can get in the way, but it is possible to still see saline and air flow in multiple zones! My advice is to just start in the transverse view and really work at trying to find the uterine tubal junction. This will allow you to trace the tube slowly and laterally trying to connect the dots.
Hint: the flow will appear as quick “flashes.”
Left tube:
The bubbles are seen entering Zone 1 and diving posteriorly. Some flashing is seen adjacent to the uterus in Zone 2. The probe was moved around trying to find the bubbles exiting, but the fibroid was in the way. So, the uterine cornual interface was then imaged and flow through Zones 1 & 2 was documented for 5-10 seconds.
Great example of bilateral patency! Also, this is a good case to show that you need to remember to have the patient empty their bladder. An empty bladder will avoid patient discomfort and artifacts. The air in this video appears extremely hyperechoic due to the enhancement coming from the bladder.
Left tube:
Flow is seen very clearly in all 3 Zones. The probe was held still while watching the bubbles move through the tube. The ovary was then focused on to see the bubbles exiting in Zone 3.
Right tube:
Flow is seen in all 3 zones as well.
We always recommend using a balloon catheter for a Sono HSG. Let me just say that a balloon catheter is not necessary, but it is recommended. The reason is because you want to avoid cervical retrograde flow. The balloon, when inflated, will help block the exit to keep the saline and air bubbles within the cavity and moving forward to the Fallopian tubes.
However, just using a balloon catheter does not prevent cervical retrograde flow, but the correct placement does. The optimal placement for the balloon is in the lower uterine segment against the internal os. I have been in a lot of cases where we have had to reposition the balloon after wondering why the cavity wasn’t staying distended and we weren’t seeing flow through the tubes.
So here are some tips in trying to avoid this happening:
The goal is for balloon placement to become routine at the beginning of the procedure and not to use it as a troubleshooting technique! We all want the same thing with this procedure…a successful case!
This case is really a good example of how bowel can be a distraction during the procedure, but not get in the way of visualizing flow. The depth was set to not image deep. This setting was okay for this case because the tubes followed an anterior course. If the tubes were seen diving posterior, I would suggest increasing the depth to view them in their entirety. There is no set depth for this procedure. My advice is to try and find a happy medium. This will ensure that you won’t miss the flow due to location of the tube. Adjust when you can see the tube well.
Left tube:
Flow is seen through Zone 1 moving rapidly through Zone 2. Zone 3 wasn’t evaluated.
Right tube:
The air bubbles are seen entering Zone 1 and moving rapidly through Zone 2. Again, Zone 3 was not evaluated.
Good quality of flow and demonstration of 5-10 seconds was enough to support the physician’s call of patency.
We do not have any set recommendations on bowel prep for this procedure. Whether or not you want a patient to prep is up to your office and what the doctor prefers.
I will say that I have seen many cases where the patient had a lot of bowel moving around and it didn’t affect the outcome. It might be a little more challenging due to the distraction of the bowel moving.
You can tell a difference between air bubbles and bowel. The bowel moves by means of peristalsis and the air bubbles will be seen as more of a flash.
On this video, the ovaries are situated very close to the uterus. This means that we are able to visualize the ovaries and uterus on the screen at the same time. We first see a distended cavity.
Left tube :
Notice that the sonographer angled the probe to include the left ovary on the screen. Flow is noted entering zone 1 at a fast pace. Zone 2 flow appears as flashing on the screen. The air bubbles are visualized exiting in zone 3 around the left ovary.
Right tube:
There are bubbles in the cavity moving towards the right uterine tubal junction. The probe is moved slightly trying to catch the angle of zone 1. After about 34-35 seconds, air is seen moving through zone 2 and zone 3. The probe is tweaked slightly and zone 1 flow is then documented.
At the end of the video, the left side is viewed again with flow seen beautifully through all zones! Great case and great scanning!