Last month, a 31-year-old patient messaged me at 11 PM with a photograph of her HSG report. She had just picked it up from the imaging centre and the radiologist had left for the day. Her message read: “Cornual block on the right side, contrast spilled freely on the left. What does this mean? Is it serious?”
She had been trying to conceive for eight months. The worry between receiving the report and her clinic appointment was real. She had already read two articles online that told her “cornual block” meant IVF was the only option.
Her result, as I explained that week, meant her left tube was confirmed open. The right-side “block” was most likely tubal spasm during the test, a well-documented phenomenon, not necessarily true structural blockage. We repeated the assessment three months later and both tubes were confirmed open.
This guide is for every woman who has picked up an HSG report, stared at unfamiliar radiological language, and had to wait to find out what it actually means. The report is written for radiologists and referring clinicians, not for patients. But you deserve a plain-language translation before the anxiety sets in.
What you will find here: how the HSG procedure works, how the report is structured, what every major term means clinically, and what to do next based on your specific result.
What an HSG Actually Is
An HSG (hysterosalpingogram) is a 15-minute X-ray procedure done in the radiology department of a hospital or imaging centre. A thin catheter is passed through the cervix into the uterine cavity. A small volume of radio-opaque contrast dye is injected, and its spread through the uterus and tubes is observed under X-ray fluoroscopy in real time.
The test shows two things: the internal shape of the uterine cavity, and whether each fallopian tube is open. If the tubes are open, the dye flows through their entire length and spills into the pelvic cavity on each side, appearing as a “spillage” pattern on the X-ray image. If a tube is blocked, the dye cannot pass and the obstruction point is visible.
Timing matters. HSG is done after your period has fully ended but before ovulation: typically Day 6 to Day 12 of your cycle, counting Day 1 as the first day of full menstrual flow. This window prevents the small possibility of disturbing an early conception.
The diagnostic accuracy is good but not perfect. A meta-analysis by Mol et al. (2009) found HSG has a sensitivity of approximately 65 percent and specificity of 83 percent for tubal occlusion. This means it can occasionally miss a real blockage and, more relevantly for Indian clinical practice, it can flag a blockage that is not structural. That limitation shapes everything in how the results should be interpreted.
This is Layer 7 of the fertility workup covered in The Honest Fertility Workup: An OB-GYN’s Indian Guide. If you have not seen the full workup picture, that post is the right starting point.
The Anatomy of an HSG Report
Indian HSG reports from radiology departments and imaging centres follow a broadly consistent structure. Understanding the layout helps you find the relevant information quickly.
A typical Indian HSG report has four parts:
Patient details and procedure note. Your name, age, cycle day, and a brief sentence confirming the procedure was performed with a specified type of contrast dye (usually a water-soluble contrast such as iohexol or iopromide).
Uterine cavity findings. The first radiological observation: the size, shape, and contour of the uterine cavity, and whether any filling defects are visible inside it.
Fallopian tube findings. Whether each tube filled with contrast and whether the contrast “spilled” at the fimbrial end. Any specific observations about tube calibre, regularity, or appearance.
Impression (or Conclusion). The radiologist’s summary, usually one or two lines of compressed clinical shorthand. This is what most women read first, and it almost always needs unpacking.
Decoding the Uterine Cavity Section
The uterine cavity section tells you about the internal shape of your uterus. Here are the phrases you are most likely to encounter:
“Normal uterine cavity outline” or “uterine cavity appears normal”: The uterus shows the expected triangular shape on X-ray with smooth, regular walls. No further investigation is needed from this finding alone.
“Filling defect”: Something inside the cavity is preventing the dye from filling that region fully. The dye shows the outline of the obstruction. This is a descriptive observation, not a diagnosis. Filling defects most commonly represent submucosal fibroids, endometrial polyps, or intrauterine adhesions. Your next step is a hysteroscopy or saline infusion sonography to characterise exactly what it is and where.
“Septate uterus”: A band of tissue runs down the centre of the uterine cavity, dividing it partly or fully. This is a congenital variation present from development. A complete septum can affect implantation and early pregnancy loss, and a reproductive surgeon can remove it hysteroscopically if indicated.
“Bicornuate uterus”: The uterus has two distinct “horns” rather than a single triangular cavity. This is a structural variation that cannot be corrected surgically. Most women with a bicornuate uterus can conceive; the primary concern is with carrying the pregnancy, not with fertilisation.
“Arcuate uterus”: A mild indentation at the top (fundus) of the uterine cavity. This is a normal variant. It does not require treatment.
“Adhesions” or “Asherman’s syndrome”: Bands of scar tissue inside the uterine cavity, typically following a curettage procedure (D and C), repeated infections, or prior uterine surgery. On HSG these appear as irregular filling defects or a distorted cavity outline. Hysteroscopic adhesiolysis is the treatment.
“Intrauterine polyp” or “submucosal fibroid”: Both create filling defects. A polyp is a soft tissue overgrowth from the endometrium. A submucosal fibroid protrudes into the cavity from the uterine wall. Both can be confirmed and removed hysteroscopically.
| Finding | What it means | Next step |
|---|---|---|
| Normal cavity outline | No uterine structural issue | Proceed to tube findings |
| Filling defect | Something inside the cavity | Hysteroscopy or saline sonography |
| Septate uterus | Congenital midline division | Hysteroscopic resection if indicated |
| Bicornuate uterus | Two-horned uterus | Surveillance in pregnancy |
| Arcuate uterus | Mild fundal dip | No treatment needed |
| Adhesions | Scar tissue inside cavity | Hysteroscopic adhesiolysis |
| Polyp or submucosal fibroid | Growth inside cavity | Hysteroscopic removal |
Decoding the Fallopian Tubes Section
This is the section most women turn to first, and the one with the most consequential language. I will go through every phrase you are likely to see, in order of what they mean clinically.
“Bilateral spillage seen” or “bilateral free spillage”: Both fallopian tubes filled completely with contrast and the dye spilled freely into the pelvic cavity on both sides. This is the result you want. Both tubes are patent (open). No tubal factor concern.
“Unilateral spillage” or “spillage seen on the left only” (or right only): One tube has confirmed free spillage and the other does not. With one open tube, natural conception remains possible. The open tube can pick up eggs from either ovary, because ovulation does not strictly alternate sides every cycle. Many women with confirmed unilateral tubal patency conceive naturally, particularly when the other fertility factors are good. For the full clinical picture of what this diagnosis means, including treatment options, see Blocked Fallopian Tubes: Causes, Signs and Fertility Impact.
“Cornual block”, “proximal block”, or “interstitial block”: The apparent obstruction is at the cornua, the point where the tube enters the uterine wall. This is the most common type of HSG finding that turns out to be a false positive. Tubal spasm at the cornual end is very common during the procedure, especially in anxious patients, and it mimics true blockage on X-ray. A cornual block finding on a single HSG should not be taken as a definitive diagnosis without a confirmatory step. Do not agree to surgery or escalate to IVF on this result alone. (The full explanation of spasm versus structural block is in the next section.)
“Mid-tubal block” or “isthmic block”: A blockage in the middle segment of the tube, between the cornua and the fimbrial end. Mid-tubal blocks are more likely to represent true structural damage than cornual blocks. They are most often caused by prior pelvic infection (PID) or, in India, genital tuberculosis. Surgical options depend on how much healthy tube remains on either side of the blocked segment.
“Distal block” or “fimbrial block”: A blockage at the ovarian end of the tube, where the fimbriae (the finger-like projections that sweep in the released egg) are located. The fimbriae are the most delicate part of the tube and the most easily damaged by infection and endometriosis.
“Hydrosalpinx”: A specific finding where a distal blockage has caused fluid to accumulate inside the tube, creating a swollen, fluid-filled segment. This is clinically significant beyond the blockage itself. The accumulated fluid can drain backward into the uterine cavity around the time of embryo transfer in IVF cycles, creating a hostile environment for implantation. If you are planning IVF and your report shows hydrosalpinx, your fertility specialist will recommend surgery (usually salpingectomy or proximal tubal occlusion) before the embryo transfer cycle begins. This is well-established evidence-based guidance from both ASRM and ESHRE.
“Loculated contrast” or “pelvic loculation”: The contrast dye, after spilling from the tube, pooled in pockets rather than spreading freely through the pelvic cavity. This pattern suggests pelvic adhesions, bands of scar tissue that compartmentalise the pelvis. The most common causes are endometriosis and prior pelvic infection. It does not tell us definitively whether the tubes are open, it tells us the pelvic environment has adhesive disease. Laparoscopy is typically recommended to characterise and treat the adhesions directly.
“Beaded appearance” or “irregular tubes with beading”: A pattern where the tube appears segmentally dilated and irregular rather than smooth. This appearance is classically associated with genital tuberculosis. In India, where TB burden is significant, this finding warrants a specific TB workup: Mantoux test, endometrial biopsy for AFB culture, and a chest X-ray. Genital TB is an underdiagnosed cause of tubal infertility in India, and it changes the treatment approach substantially.
“Contrast extravasation”: Contrast leaking outside the expected path, usually into the uterine wall or an unexpected pelvic location. This is typically a procedural finding (too much pressure during injection) rather than a structural pathology. Your OB-GYN will clarify whether it is clinically relevant.
| Report phrase | What it means | What to do next |
|---|---|---|
| Bilateral spillage seen | Both tubes open | No tubal issue to pursue |
| Unilateral spillage | One tube open, one not | Assess other factors; natural conception possible |
| Cornual block | Apparent block at uterus-tube junction | Repeat test or laparoscopy first; may be spasm |
| Mid-tubal block | Block in tube middle segment | Laparoscopy; assess extent of damage |
| Distal block or fimbrial block | Block at ovarian end | Laparoscopy; look for hydrosalpinx |
| Hydrosalpinx | Fluid-filled swollen tube | Surgery before IVF (salpingectomy) |
| Pelvic loculation | Adhesions in pelvis | Laparoscopy to assess and treat |
| Beaded tubes | Pattern suggests tuberculosis | TB workup: Mantoux, biopsy, chest X-ray |
💜 Unsure what your specific HSG result means for your situation? Message Dr. Suganya’s team on WhatsApp and share your findings. We will walk you through it before your next appointment.
What “Spasm vs True Block” Means
The most clinically important scenario in HSG interpretation, and one that comes up almost every week in my clinic, is the cornual block that may be spasm rather than structure.
When the catheter is introduced and dye is injected, the uterus responds. In anxious or sensitive patients, the smooth muscle at the cornual end of the tube contracts involuntarily. On the X-ray image, this contraction looks identical to a true proximal obstruction caused by scarring or prior infection. The dye cannot pass, and the report reads “cornual block.”
The distinction matters enormously for what happens next. A true cornual block caused by infection or tuberculosis scarring is a fixed structural problem with specific treatment pathways. Tubal spasm is temporary and self-resolving.
How to tell the difference: you cannot, definitively, from the HSG alone. What you can do:
One option is to repeat the HSG in a subsequent cycle, with better pre-medication. An NSAID taken 60 minutes before the procedure reduces the uterine contractile response. Some centres also use hyoscine butylbromide (Buscopan) to relax smooth muscle before injection.
Another option is sonosalpingography (SSG), an ultrasound-based test using saline or foam rather than X-ray contrast. SSG tends to produce less cornual spasm and is increasingly available in well-equipped gynaecology clinics across India.
The definitive investigation is diagnostic laparoscopy with chromopertubation: a camera-assisted view of the tubes with dye injected under direct vision. This is the only way to confirm structural versus functional block with certainty.
The key message: a cornual block on a single HSG report is not a diagnosis. It is a finding that requires a confirmatory step before any clinical decision is made. Many women who were advised to proceed directly to IVF after a cornual block finding have had fully open tubes on laparoscopy.
HSG Cost in India and What to Expect on the Day
The cost of an HSG in India ranges from approximately ₹2,500 to ₹6,000 depending on the type of centre and the city.
For more on this, read our guide on HSG Test Cost India 2026. At the lower end: imaging centres and radiology departments in government and semi-government hospitals. Apollo Diagnostics, Aarthi Scans, and comparable diagnostic chains in South India typically fall in the ₹2,500 to ₹3,500 range. At the higher end: private hospitals with dedicated fluoroscopy suites in metro cities, where the cost includes the radiologist’s interpretation fee and the nursing support.
The test is done in the radiology department, not the operation theatre. It does not require anaesthesia. Most women are home within an hour.
What to do before and on the day:
Take an NSAID (ibuprofen 400 mg or naproxen 500 mg) 45 to 60 minutes before the procedure. This significantly reduces the cramping during dye injection and is the single most effective comfort measure you can take.
Empty your bladder just before the procedure. Bring a support person if possible. You can drive yourself home but having someone with you makes it easier.
The cramping during contrast injection is the main discomfort. Most women describe it as moderate menstrual-level cramping that lasts 30 to 60 seconds during the injection phase, then settles quickly. Some women feel completely fine within minutes; others prefer to rest for the afternoon. Plan accordingly.
You may have some light spotting for a day or two after the test. This is normal. Avoid intercourse for 48 hours afterward, and contact your doctor if you develop fever, severe pelvic pain, or unusual discharge.
When to Repeat an HSG
There are four situations where repeating the HSG, or choosing a different confirmatory test, is worth discussing with your OB-GYN:
Cornual block on first HSG: As described above, this is the most common reason. A repeat in a subsequent cycle, with better pre-medication, or an SSG, often clarifies the picture before laparoscopy is needed.
Technically inadequate study: The contrast volume was suboptimal, the patient could not tolerate the full procedure, or the images are inconclusive. A repeat or alternative investigation is warranted.
After tubal surgery: If adhesiolysis or salpingostomy was performed, an HSG at 3 to 6 months post-surgery confirms whether patency was restored.
Unexplained difficulty conceiving with a previously normal HSG: This is where the limitations of HSG matter most. HSG shows only the interior of the tube. It cannot see endometriosis implants on the tube surface, adhesions binding the tube to the ovary or pelvic wall, or any peritubal disease. A tube can appear open on HSG while being functionally compromised by surrounding adhesions that prevent it from picking up the egg at ovulation. If you have symptoms that suggest endometriosis (cyclical pelvic pain, painful periods, painful intercourse, pain with bowel movements around menstruation) and your HSG is normal, that is not a complete picture of tubal health. Laparoscopy is the only investigation that sees the exterior environment around the tubes.
If your fertility workup is complete and you are weighing the next clinical step, Do You Need IVF? An OB-GYN’s Honest Decision Framework walks through that decision with the same evidence-based approach.
Reading an HSG report at 11 PM on your own is not the right context for drawing conclusions. The terms are written for clinical communication between radiologists and physicians. What I hope this guide does is give you enough to hold the report without panic, understand what each phrase is pointing to, and walk into your next clinic appointment with clear and specific questions.
When you sit with your OB-GYN after an HSG, here are the questions worth asking: if there is a cornual block, ask whether a repeat test is recommended before any decisions are made. If hydrosalpinx is present, ask what the surgical plan is before IVF. If the result is normal, ask what the rest of the workup picture tells you about why conception has not happened.
Most HSG results, even the ones that sound alarming on first reading, have a clear next step. A cornual block gets a repeat assessment. A hydrosalpinx gets a surgical plan before the IVF cycle. One open tube gets a structured timed conception plan. Even a genuinely difficult result is the beginning of a clinical plan, not the end of options.
For the full fertility workup context, including how HSG fits alongside AMH, AFC, hormone panels, and progesterone testing, start with The Honest Fertility Workup: An OB-GYN’s Indian Guide. For couples working on natural conception alongside their investigations, How to Conceive Naturally: A Couple’s Complete Guide is a practical companion.
💜 Want to go through your HSG report with Dr. Suganya before your next appointment? Send your report details via WhatsApp and we will give you a clear explanation of what each finding means for your specific situation.
You can also download Dr. Suganya’s free Guide to Getting Pregnant, which covers the full fertility workup and what to do at each stage, or read about the Fertilia Fertility Program for women who want a structured 90-day plan alongside their investigations.
Frequently Asked Questions
What does “bilateral spillage seen” mean on an HSG report? It means both your fallopian tubes are open. The contrast dye passed through the full length of both tubes and spilled freely into the pelvic cavity on both sides. This is the result you want from an HSG. There is no tubal blockage on either side, and this finding clears the tubal factor from your fertility picture. If you are not conceiving despite bilateral spillage, the issue lies elsewhere in the workup: ovulation, egg reserve, hormonal factors, or the partner’s semen analysis.
Is a cornual block on HSG the same as a permanently blocked tube? Not necessarily. Cornual (proximal) blocks are the most common false positives in HSG because the smooth muscle at the uterus-tube junction can contract during the procedure (called tubal spasm), which looks identical to a true structural block on X-ray. A single HSG showing a cornual block is not sufficient grounds to diagnose permanent tubal blockage or to recommend IVF. A repeat HSG with better pre-medication, a sonosalpingography, or a laparoscopy with chromopertubation is needed to confirm the finding before any major treatment decision.
What should I do if my HSG report shows hydrosalpinx? See your OB-GYN promptly. Hydrosalpinx, a fluid-filled blocked tube, reduces IVF success rates because the accumulated fluid can drain back into the uterus at the time of embryo transfer and impair implantation. Current ASRM and ESHRE guidelines recommend surgical management of the hydrosalpinx (salpingectomy or proximal tubal occlusion) before the embryo transfer cycle begins. This is standard evidence-based practice, not an overly cautious recommendation.
How painful is an HSG test? Most women experience cramping similar to moderate menstrual pain during the dye injection phase. The injection itself takes about 60 to 90 seconds and the cramping settles quickly afterward. Taking ibuprofen 400 mg or naproxen 500 mg 45 to 60 minutes before the test significantly reduces the discomfort. A small proportion of women find the test quite painful; a small proportion barely notice it. The majority manage it without difficulty and are home within the hour.
What does “pelvic loculation” mean in my HSG report? Pelvic loculation means the contrast dye pooled in pockets after spilling from the tube rather than spreading freely through the pelvic cavity. This suggests pelvic adhesions, bands of scar tissue that divide the pelvis into compartments. The most common causes are endometriosis and prior pelvic infection (PID). A laparoscopy is usually recommended to visualise and treat the adhesions directly. Loculated contrast does not tell us definitively whether the tubes themselves are open, it tells us the pelvic environment has adhesive disease.
Can I conceive naturally if only one tube is open? Yes. The open tube can pick up eggs from either ovary, because ovulation does not alternate sides in a strict pattern every cycle. Many women with one confirmed open tube conceive naturally, particularly when ovulation is regular, the open tube is structurally healthy, and the partner’s semen analysis is normal. Your OB-GYN may recommend a few cycles of timed intercourse before considering intrauterine insemination (IUI). The full decision depends on your age, how long you have been trying, and the rest of your fertility workup picture.
What is the difference between HSG and sonosalpingography (SSG)? Both tests confirm whether the fallopian tubes are open. HSG uses X-ray and a radio-opaque contrast dye injected through the cervix. Sonosalpingography uses ultrasound and saline or foam. SSG avoids radiation, is often better tolerated (less cornual spasm), and is increasingly available in gynaecology clinics across India. HSG provides clearer visualisation of the uterine cavity shape and remains more widely available at most hospital radiology departments. If your HSG shows a suspicious cornual block, SSG is a reasonable next confirmatory step before proceeding to laparoscopy.
