Hysterosalpingo-contrast-sonography (usually shortened to HyCoSy) is a simple and well-tolerated outpatient ultrasound procedure used to assess the patency of the fallopian tubes, as well as detect abnormalities of the uterus and endometrium.

The test requires the use of a contrast agent to visualise the patency of the fallopian tubes. Many women will be able to have the test performed simply using an agitated saline / air mixture. Some women will require the use of a non-iodinated contrast agent called ExEm Foam (the HyCoSy procedure previously used a contrast agent called Levovist, however this product is no longer available). If ExEm Foam is used, the test is then referred to as a HyFoSy procedure.

The HyCoSy procedure is a safe and reliable alternative to the conventional hysterosalpingogram (HSG) which uses X-rays. No radiation or iodinated contrast material is used for a HyCoSy test.

Investigation of infertility is the main reason for a woman to be referred for a HyCoSy procedure.

Occluded (blocked) fallopian tubes are a common cause of infertility. Tubal occlusion can occur with a number of conditions including previous pelvic infection, severe endometriosis, previous appendicitis and pelvic adhesions. Many women will be unaware that these conditions are present and that tubal blockage has occurred.

A normal fallopian tube is not seen with regular ultrasound.

Even if the fallopian tube is blocked, it may still be difficult to see on regular ultrasound unless it is also filled with fluid (forming what is known as a hydrosalpinx). This is why a special test using a contrast agent such as ExEm Foam is useful, as it helps the doctor to visualise the fallopian tubes and assess whether they are patent (working).

The HyCoSy procedure allows integrated assessment of the fallopian tubes, the uterus and endometrial cavity, and the pelvis.

The initial part of the HyCoSy procedure uses saline (like a saline sonohysterogram) to assess the endometrial cavity for pathology. The doctor will be looking for problems such as endometrial polyps, submucous fibroids and congenital uterine abnormalities (such as uterine septum).

The HyCoSy procedure also allows concurrent ultrasound review of the remaining pelvis, such as ovaries. We will not usually perform a detailed scan of the remaining pelvis at the time of the HyCoSy (a detailed pelvic scan requires additional time for a thorough assessment) but we will perform a basic pelvic assessment to ensure no obvious problems exist. If other conditions become apparent at the time of the HyCoSy, it may be suggested to your doctor that you return for a detailed pelvic ultrasound at another appointment.

It is important that you are not pregnant when you have this test, as the procedure can disturb the implantation of the embryo. If there is a possibility that you are pregnant, the procedure will need to be postponed until your next menstrual cycle. 

The best time to perform a HyCoSy is just after your period has finished, approximately day 7 to day 10 of a regular 28-day (monthly) menstrual cycle (the first day of your period is counted as day 1).

If your menstrual cycle is shorter than 28 days (for example, you usually only have 21 days between periods), you will need to have the test earlier in the cycle.

If your menstrual cycle is longer than 28 days, but still regular (for example, you usually have 35 days between periods), you may be able to have the test later in the cycle if that is more convenient.

If your periods are infrequent or irregular, please discuss the optimal time for this test with your doctor or our reception staff.

The level of pain experienced during the HyCoSy is variable, but most women experience only mild to moderate cramping period-type discomfort during the test.

We suggest that you take 2 naprogesic tablets 30-60 minutes before the procedure, to minimise your discomfort. No anaesthetic is required for this procedure.

You do not need a full bladder for this test, unless you are also booked for a pelvic ultrasound on the same day. We will ask you to completely empty your bladder before the test begins.

If you are booked for both a pelvic scan and HyCoSy, the pelvic scan will be performed first, followed by the HyCoSy procedure.

You can eat and drink normally before and after the test.

The first part of the HyCoSy is like the first part of a pap smear, with a vaginal speculum gently inserted into the vagina to visualise the cervix. The cervix is then cleansed with antiseptic solution to decrease the risk of infection. A thin flexible balloon catheter is inserted through the opening of the cervix, so that the catheter lies within the endometrial cavity. Inserting this intrauterine catheter does not usually cause discomfort. A tiny balloon at the tip of the catheter is slowly inflated with saline – this is necessary to stop fluid leaking back out through the cervix during the test. Inflating this tiny balloon can cause some discomfort. The vaginal speculum is then removed, with the catheter remaining inside the uterus. Next, the transvaginal ultrasound (internal scan through the vagina) is used to image the uterus.

Initially, a small amount of sterile saline is introduced into the endometrial cavity through the catheter, as occurs with a saline sonohysterogram. This saline distends the endometrial cavity, allowing assessment of the contour and shape of the cavity. The doctor will be looking for such problems as endometrial polyps, submucous fibroids and congenital uterine abnormalities (such as uterine septum).

Next, a small amount of a contrast agent (either agitated saline /air mixture, or ExEm Foam) will be introduced through the catheter. The doctor will be looking at both fallopian tubes, to see if the tubes are patent. If the contrast can be seen flowing through each tube, and spilling out the end of the tube into the area around the ovaries, the tubes are patent.

The transvaginal ultrasound and catheter are removed at the end of the test.

For more information about transvaginal ultrasound, please go to:

HyCoSy is a safe and well-tolerated procedure for the assessment of tubal patency.

Infection of the uterus/pelvis is not common following this procedure, but it may rarely occur.

You should contact either your referring doctor or our practice immediately if you have the following symptoms:

  • Persistent or foul-smelling vaginal discharge
  • Increasing lower abdominal pain
  • Unexplained fever
  • Generally unwell

Such symptoms may indicate an infection requiring antibiotics.

If you have a history of pelvic infection or in other special circumstances, the doctor may give you antibiotics to prevent pelvic infection.

Please tell the doctor before your procedure begins if you have a history of pelvic infection, or another reason for antibiotic prophylaxis. Antibiotics are otherwise not routinely given during this test.

You should wear a sanitary pad after the procedure. There may be some persistent vaginal discharge for a few hours, as the fluid used in the test will leak out the vagina. This discharge is sometimes blood stained so do not be alarmed if this occurs.

Our practice will give you a sanitary pad to use following the procedure.

Most women do not find the test too uncomfortable. Most women experience only mild to moderate cramping period-type pain during the test, but this usually subsides once the test is completed. You should be able to drive and resume normal daily activities after the test. Occasionally women have more severe pain, and do not feel up to driving or returning to work. If you are concerned about how you will feel after the test, you may consider having a friend drive you home, or having the day off work.

You can eat and drink normally after the procedure.

The ultrasound doctor will discuss your results once the procedure has been completed (for example, whether the fallopian tubes appear patent).

Both the catheters used for this test, and the contrast agent ExEm Foam, are expensive, making the cost of a HyCoSy test more than a regular pelvic ultrasound.

A hysterosalpingogram (HSG) is performed using iodine contrast and X-ray. It is the traditional method used to assess tubal patency.

Studies have shown that the HyCoSy procedure is as reliable as the more traditional HSG in assessing tubal patency.

Advantages of HyCoSy compared to HSG include:

  • HyCoSy does not use radiation or ionising contrast material.
  • Many women find HyCoSy less painful than HSG.
  • Small lesions in the endometrial cavity such as polyps may be better demonstrated with HyCoSy.
  • HyCoSy can assess submucous fibroids protruding into the endometrial cavity for intramural components thus assisting plans for surgical removal.
  • Congenital uterine abnormalities may be better assessed with HyCoSy as the external contour of the uterus is viewed on ultrasound but not on X-ray. This can help define the exact type of congenital uterine abnormality.

Your doctor will discuss which test is better suited for you.

Sometimes the fallopian tubes (either one or both tubes) are not seen during the HyCoSy procedure. This may be due to:

  • Spasm of the uterus at the opening of the fallopian tubes, which temporarily prevents the flow of contrast from the uterus into the tube
  • Permanent tubal occlusion, secondary to an underlying problem such as pelvic adhesions
  • Technical factors may hinder visibility during the ultrasound, such as uterine fibroids, size of the patient abdomen, and bowel in the pelvis.

It is important to remember that HyCoSy is simply one test used to investigate infertility. Neither HyCoSy nor the traditional HSG provide definitive answers in all women, making other investigations sometimes necessary.

Your referring doctor will decide if you need to have further investigations or procedures such as laparoscopy.