ª Springer Science+Business Media, LLC 2010 Abdom Imaging (2010)

Abdominal DOI: 10.1007/s00261-010-9616-6

Imaging

Virtual hysterosalpingography: experience

with over 1000 consecutive patients
Patricia Carrascosa,1 Carlos Capuñay,1 Javier Vallejos,1 Mariano Baronio,2
Jorge Carrascosa1
1
Department of Computed Tomography, Diagnóstico Maipú, Av. Maipú 1668, Vicente López (B1602ABQ), Buenos Aires,
Argentina
2
CEGYR, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina

Abstract the visualization of the uterine cavity, the external mor-

With the advent of multidetector computed tomography
(MDCT), a whole new spectrum of diagnostic imaging
techniques and procedures appears. Virtual hysterosal-
pingography (VHSG) is a novel non-invasive modality
for assessing the uterus and female reproductive system
that combines hysterosalpingography technique with
MDCT technologies. Nowadays, 64-row VHSG offers
an excellent diagnostic performance, in concordance with
the development of new reproductive interventions and
the need of accurate diagnostic procedures. In this arti-
cle, we review the VHSG technique and describe normal
and pathologic findings.
Key words: Multidetector computed tomography—
Virtual studies—Virtual hysterosalpingography—
Infertility—Uterus—Fallopian tubes
The evaluation of the uterus and fallopian tubes with
diagnostic imaging procedures is classically carried out
using ultrasonography, X-ray hysterosalpingography
(HSG), and magnetic resonance imaging [1]. In the last
10 years, technical developments in computed tomogra-
phy (CT) and the emergence of the multidetector CT
scanners enable the evaluation of anatomic regions with
isotropic spatial and temporal resolution. These advances
allow a whole new spectrum of diagnostic imaging
techniques and procedures [2, 3].
Virtual hysterosalpingography (VHSG) is a novel,
non-invasive diagnostic modality that affords the unique
opportunity to assess the uterus and fallopian tubes
based on volumetric high-resolution CT data, improving
Correspondence to: Patricia Carrascosa; email: investigacion@
diagnosticomaipu.com.ar
phology of the uterus and the morphology and patency
of the tubes, besides the assessment of the other pelvic
structures [4–7]. 64-row CT scanners are considered to-
day the state-of-the-art technology to perform VHSG
studies [4].
The purposes of this pictorial essay are to describe the
CT procedure and image processing techniques and to
characterize the normal and pathologic findings found in
our series of more than 1000 cases.
Materials and methods
Patients
We retrospectively evaluated the CT data of 1500 pa-
tients (mean age 34.7 ± 4.6 years old; age range 22–
43 years) with the diagnosis of infertility. All patients
underwent the VHSG examination during the follicular
phase of the menstrual cycle. The CT image acquisitions
were carried out using a 64-row CT scanner (Brilliance
64; Philips Medical Systems, Highland Heights, OH).
The study protocol was approved by the Institutional
Review Board.
VHSG technique
The CT examination should be carried out between days
7–10 of the menstrual cycle. Patients were instructed to
abstain from sexual relations during the 48 h prior the
day of the CT scan. As a non-invasive technique, no
antibiotic prophylaxis is needed. In the CT room, the
patient is positioned supine on CT table in the lithotomic
position. The perineum is cleansed with povidone–iodine
solution and draped with sterile towels. A sterile specu-
lum is inserted into the vagina and the cervix is cleansed
with povidone–iodine solution. A 10/12-F dedicated
VHSG plastic cannula is positioned at the external
 P. Carrascosa: CT virtual hysterosalpingography

cervical os. No cervical clamping is performed. A total tions are routinely performed during the image inter-
volume of 15 mL of a iodine contrast dilution [2.5 mL of pretation and analysis.
water-soluble iodine contrast (iobitridol; Xenetix 350,
1. Axial images: the first step in the analysis is the
Laboratorios Temis Lostaló, Buenos Aires, Argentina)
evaluation of the original transverse CT images. They
and 12.5 mL of saline solution] is instilled into the
give an integral evaluation of the pelvic structures. An
uterine cavity using an automatic power injector at a
inter-median soft-tissue/bone window setting is re-
flow rate of 0.3 mL/s. CT examination includes an
quired for the assessment of the internal and external
anteroposterior localizer scan of the pelvis followed by
surface of the cervix, uterus, and fallopian tubes.
the volumetric acquisition of the axial images, approxi-
2. Multiplanar reformats: these bi-dimensional images
mately 45 s after initiation of the contrast solution
are displayed in sagittal, coronal, and oblique views.
instillation. The VHSG examinations should be per-
Curved multiplanar reconstructions are used for
formed with at least 64-row multidetector CT equip-
unfolding the uterus in a single plane (Fig. 1). The
ments. Suitable technical scan parameters of data
same window setting described earlier is utilized dur-
acquisition are: 64 9 0.625 mm collimation, 0.6 mm
ing the analysis.
slice thickness, 0.3 mm reconstruction interval, 0.5 s
3. Maximum intensity projections: these three-dimen-
rotation time, pitch 0.64, 120 kV. Tube current modu-
sional reconstructions offer detailed images of the
lation is used to adapt mAs at the patient’s size, ranging
cervix, uterus and particularly the fallopian tubes
from 100 to 250 mAs. Scan time varies between 3 and 4 s
(Fig. 2).
approximately.
4. Volume rendering: these three-dimensional recon-
structions show the entire pelvis anatomy and facili-
tate the identification of pathologic disorders (Fig. 2).
Image post-processing 5. Virtual endoscopy: this advanced three-dimensional
Using available CT image visualization and reprocessing display mode completes the image interpretation se-
tools, two-dimensional and three-dimensional evalua- quence. This algorithm creates endoluminal images

Fig. 1. A Sagittal multiplanar

reconstruction (MPR) used as
reference to depict the curved
MPR along the cervical canal and
uterine cavity. B Curved MPR
that unfolds the uterus in a single
plane.

Fig. 2. Normal uterus, cervix,

and fallopian tubes. A Maximum
intensity projection. B Volume
rendering reconstruction.
P. Carrascosa: CT virtual hysterosalpingography
Fig. 3. Virtual endoscopy views of the cervical canal (A), isthmus (B), and uterine cavity (C).
similar to hysteroscopy, allowing an accurate delin-
eation of the lesion located in the cervical canal,
endometrial cavity, and the fallopian tubes when
dilated (Fig. 3).
Discussion
Indications and contraindications
The principal indication for VHSG is infertility; how-
ever, there are also others including repeated spontane-
ous abortions, preoperative and postsurgical assessment
in patients with history of leiomyomas, and character-
ization of uterine malformations.
Contraindications of the procedure are pregnancy
and active pelvic infection.
Imaging findings
Normal anatomy. The uterus is a muscular organ whose
size varies depending on the patient’s age and parity. The
uterus has an inverted triangular shape, with the base
positioned cranially and the cervix placed in its inferior
side, extending into the vagina. The isthmus is the
Fig. 4. Normal anatomy. The
uterus has an inverted triangular
shape. The isthmus (arrowhead)
is the transition between the
cervix (white asterisk) and the
uterine body (black asterisk). The
fallopian tubes can be divided
into three segments: interstitial
(short arrow), isthmic (long
arrow), and ampullary (curved
arrow). A Maximum intensity
projection. B Volume rendering
reconstruction.
transition between the cervix and the uterine body. The
fallopian tubes are usually 10–12 cm long and arise at the
cornua. Each fallopian tube can be divided into three
segments: interstitial, isthmic, and ampullary (Fig. 4).
Normal variants. In the cervical canal prominent cervical
glands can be found. They consist in tubular or sac-shape
structures protruding to the cervical wall at VHSG. Di-
lated cervical glands often appear as outpouchings
resembling diverticula and they are considered as normal
variation (Fig. 5). On occasion, prominent longitudinal
folds parallel to the cervical canal corresponding to
normal folds can be present at VHSG (Fig. 6). Linear
cornual lucencies separating the cornual lumen from the
uterine cavity are secondary to localized muscular con-
traction and can be seen in some patients (Fig. 7).
Cervical abnormalities
Narrowing. In most cases, narrowing of the cervical canal
is a normal anatomic or menstrual cycle variant. How-
ever, it also can be related to postsurgical or instrumental
trauma, as well as the result of neoplastic stenosis (cervix
 P. Carrascosa: CT virtual hysterosalpingography

Fig. 5. Dilated cervical gland (arrow head). A Maximum intensity projection. B Volume rendering reconstruction. C Virtual
endoscopy view.

Fig. 6. Prominent longitudinal folds parallel to the cervical canal corresponding to normal thickened folds (arrowheads). A Axial
CT image. B, C Virtual endoscopy views.

Fig. 7. Linear cornual lucencies (arrow heads). Symmetrical linear defects in the cornual-tubal junction. A Maximum intensity
projection. B Coronal multiplanar reconstruction. C The linear corneal lucencies are not visible on the virtual endoscopy view.

leiomyoma). Narrowing of the cervix may be focal or
diffuse. It can be seen clearly with VHSG in different
angles without any cervical traction (Fig. 8).
Elevated lesions. Cervical polyps are rare. VHSG can de-
tect them easily by axial images and virtual endoscopy
views (Fig. 9). Other causes of elevated lesions include
synechiae, congenital remnants, and submucosal myo-
mas. Synechiae can generate irregular elevated lesions and
also stenosis of the canal (Fig. 10). In X-ray HSG as well
as in VHSG endoscopy views, air bubbles can be mistaken
with other filling defects such as polyps or blood clots. The
visualization of the bi-dimensional VHSG images can
identify them with high accuracy and avoid misdiagnosis.
P. Carrascosa: CT virtual hysterosalpingography
Uterine abnormalities
Size anomalies. The size of the uterus has many varia-
tions and depends on the patient’s age and parity. A
small uterus can be found in young patients, nulliparous
women or in cases of extensive synechiae. A larger uterus
has also several etiologies but it is most frequently related
to multiparity and large leiomyomas.
Shape anomalies. Abnormalities of the uterine shape
have diverse causes. They include normal variants, con-
genital malformations and several acquired abnormali-
ties like myomas and previous surgeries.
Uterine malformations are due to abnormal fusion of
the Müllerian ducts during the early gestational period
[8]. Infertility is usually not associated with these
abnormalities; nevertheless, an accurate diagnosis is
important to decide a treatment. The most frequent
anomaly is arcuate uterus (Fig. 11). Other anomalies
include unicornuate uterus (Fig. 12), bicornuate uterus
(Fig. 13), septate uterus (Figs. 14, 15), and uterus didel-
phys (Fig. 16), being the septate uterus related to recur-
rent abortions [9]. In contrast to X-ray HSG, one of the
most important benefits of VHSG is the possibility to
visualize the external contour of the uterus [4, 10].
This facilitates the differentiation between a bicornuate
from a septate uterus, because a bicornuate uterus has a
bilobed, concave fundal appearance, whereas a septate
Fig. 8. Narrowing of the
cervical canal (arrow head). A, B
Coronal and sagittal maximum
intensity projections. C Volume
rendering reconstruction. D
Virtual endoscopy view.
uterus has a normal, convex morphology. The angles
between the uterine horns can be also easily determined.
Elevated lesions. Endometrial polyps are focal over-
growths of the endometrium. On VHSG they consist in
elevated soft tissue density formations, variable in size,
sessile, or pedunculated (Fig. 17). High detailed, isotro-
pic images on VHSG permit the visualization of small
lesions on multiplanar reconstructions and virtual
endoscopic images. VHSG provides a complete charac-
terization of elevated lesions (morphology, density,
and size) [6]. As mentioned earlier, air bubbles can be
mistaken with other filling defects such as polyps, blood
clots, or submucosal myomas on VHSG endoscopy
views (Fig. 18).
Submucosal myomas are benign neoplasms of the
smooth muscle of the uterus. They appear as round
masses with discrete lesser or higher density than normal
myometrium on VHSG and they are easily differentiated
from other elevated lesions [7, 11] (Figs. 19, 20).
Intrauterine synechiae refer to adhesions within
uterine cavity. They can be secondary to infection and
trauma, such as maneuvers of dilatation and curettage.
The infertility is attributed to an unfavorable endome-
trium for sperm migration and embryo implantation.
Adhesions manifest as linear, irregular, or serpinginous
filling defects within the uterine cavity (Figs. 21, 22).

Fig. 10. Cervical synechiae. There is an irregular, linear filling defect in the cervical canal (arrow). A Axial CT image. B
Maximum intensity projection. C Virtual endoscopy view.
Wall abnormalities. VHSG has the ability of evaluating
the uterine wall for the presence of uterine enlargement,
contour abnormalities, and focal masses.
Leiomyomas have a wide spectrum of shape, size, and
location and they can generate distortion of the uterus.
At VHSG, subserosal leimyomas appear as focal masses
deforming the external contour of uterus (Fig. 23), while
P. Carrascosa: CT virtual hysterosalpingography
Fig. 9. Cervical polyp. There is
a small filling defect in the
cervical canal (arrow). A Axial
image. B Maximum intensity
projection. C Volume rendering
reconstruction. D Virtual
endoscopy view.
intramural myomas show as focal soft-tissue masses
within the normal myometrium.
Adenomyosis is characterized by the extension of the
endometrial glands into the myometrium. Adenomyosis
can be demonstrated on VHSG if there is a connection
between the endometrial glands extending deep into the
myometrium and the uterine cavity. VHSG of a focal
P. Carrascosa: CT virtual hysterosalpingography

Fig. 11. Arcuate uterus. There is a small, symmetric indentation in the fundus of the uterine cavity (arrow head). The external
configuration of the uterus is normal. A Maximum intensity projection. B Volume rendering reconstruction.
C Virtual endoscopy view.

Fig. 12. Unicornate uterus. A single uterine horn and a single fallopian tube are visualized. A Maximum intensity projection.
B Volume rendering reconstruction. C Virtual endoscopy view.

Fig. 13. Bicornuate uterus. The uterine horns are widely depicted (arrow head). B Volume rendering reconstruction.
separated by myometrium. A Maximum intensity projection. C Virtual endoscopy view. Two polyps are present in the
The heart-shape external appearance of the uterus is clearly endometrial cavity (asterisks).

adenomyosis is nonspecific. It appears as small, isolated
diverticula projecting into the myometrium. Diffuse
adenomyosis manifest as irregular branching outpouch-
ings that are continuous with the uterine cavity (Fig. 24).
Hyperplasia of the myometrium and uterine wall
enlargement is almost always present around the
abnormal implants.
Postsurgical changes secondary to cesarean section
or myomectomy are frequently seen on VHSG exams.
C-section scar is usually seen at VHSG as a wedge-
shaped indentation near to the internal os (Fig. 25).
A small diverticulum-like outpouching can be seen
at the site of a submucosal myoma after surgical
resection.
 P. Carrascosa: CT virtual hysterosalpingography

Fig. 14. Incomplete septate uterus. A Maximum intensity acute angle between the two uterine horns. C Virtual endos-
projection. A normal external appearance of the uterus is copy view. The indentation of the septum in the uterine fundus
depicted (arrow heads). An incomplete septum is present is visualized (asterisk).
(asterisk). B Volume rendering reconstruction. There is an

Fig. 15. Complete septate uterus. A Maximum intensity projection. A normal external appearance of the uterus is depicted. The
uterine septum extends into the cervical canal (arrow heads). B Volume rendering reconstruction. C Virtual endoscopy view.

Fig. 16. Uterus didelphys.

Presence of two separate uterine
and cervical cavities. The clinical
examination showed two vaginal
cavities separated by a septum.
A Maximum intensity projection.
B Volume rendering
reconstruction.

Fallopian tubes pathology. Conventional X-ray HSG is 64-row MDCT allows an accurate tubal lumen and
suggested as the best appropriate examination for eval- tubal wall visualization, and it is possible a virtual
uating the fallopian tubes and determining tubal patency. endoscopic intratubal navigation in dilated tubes [4]. At
With recent advances in CT technologies, VHSG using VHSG, normal fallopian tubes are thin, smooth tubular
P. Carrascosa: CT virtual hysterosalpingography
structures that widen in the ampullary portion. In ab-
sence of pathology, there should be free spillage of
contrast material into peritoneal cavity.
Tubal occlusion secondary to inflammation or pre-
vious surgery manifests as non-opacification or abrupt
interruption of the fallopian tube with no intra-perito-
neal contrast spillage. Occlusion can be unilateral
(Fig. 26) or bilateral, and can affect the proximal,
Fig. 17. Endometrial polyp.
There is a filling defect at the left
lateral wall of uterine cavity
(arrow head). A Maximum
intensity projection. B Volume
rendering reconstruction. C, D
Virtual endoscopy views.
Fig. 18. Air bubble. A Virtual
endoscopy view. There is a small
filling defect at the fundus of the
uterine cavity (arrow). B Coronal
thin slab maximum intensity
projection showing a small, round
shape, low attenuated structure
that corresponds to air (arrow).
middle, and distal segment of the tube. If blockage is
distal, a hydrosalpinx can be developed.
Hydrosalpinx defines the dilatation of the ampullary
portion of the tube (Fig. 27). It is commonly secondary
to post-infection scarring, endometriosis, and surgery.
Although ultrasound provides a non-invasive view of the
dilated tube, VHSG offers a better view of the inside of
the dilated tube with a direct visualization by virtual

falloscopy (Fig. 28). Intratubal adhesions can be seen in
those cases.
Grade of discomfort
Based in our experience and data analysis, VHSG is a
well-tolerated examination, with the majority of the
patients (86%) referring absence or only mild discom-
P. Carrascosa: CT virtual hysterosalpingography
Fig. 19. Submucosal myoma.
A, B Coronal and axial maximum
intensity projections. Presence of
a large filling defect in the right
antero-lateral wall of the uterus
(asterisks). C Volume rendering
reconstruction. D Virtual
endoscopy view.
Fig. 20. Submucosal myomas.
There are two large filling defects
that protrude into the uterine
cavity. A Coronal multiplanar
reconstruction. B Virtual
endoscopy view.
fort during the procedure. The use of a plastic cannula
positioned in the external cervical os without cervical
clamping reduces pain. The instillation of a dilution of
water soluble contrast media using an automatic
power injector at a slow rate assures less peritoneal
irritation. Besides, it is not necessary to turn or change
the patient’s position on the CT table during the
exam.
P. Carrascosa: CT virtual hysterosalpingography

Fig. 21. Uterine synechiae. There is a large, irregular linear filling defect in the uterine cavity (arrow). A Maximum intensity
projection. B Volume rendering reconstruction. C Virtual endoscopy view.

Fig. 22. Asherman Syndrome. Large uterine synechiae. The uterus is small and irregular in shape. A Maximum intensity
projection. B Volume rendering reconstruction. C Virtual endoscopy view.

Radiation in the scan length and tube current (mA), allow us to

Concern for radiation exposure is particularly important
when relatively young patients and the gonadal region
are involved. One of the most important subjects of
discussion regarding multidetector CT is the association
with potentially high radiation dose risks. Knowledge
about multidetector technology principles, the modifi-
cation of the acquisition parameters according to the
weight and size of the patient, the correct election of the
best pitch and rotation time and implementation of dose
modulation techniques, ensure to scan with the minimum
radiation dose while maintaining a diagnostic image
quality, using a dose as low as reasonably achievable
(ALARA).
Radiation dose reported for a routinely X-ray HSG
by committees from the American College of Radiology
(ACR) and the Radiological Society of North America
(RSNA) is about 1 mSv [12]. In our daily practice, the
radiation dose of this examination ranges between 1 and
4 mSv. Radiation dose estimations for VHSG are low. In
our initial series of 1000 cases, the mean effective radi-
ation dose was 2.58 ± 0.75 mSv [6]. Modifications and
readjustments in the acquisitions parameters, especially
significantly reduce the mean radiation dose. In our last
500 cases, the mean effective radiation dose was
0.93 ± 0.08 mSv, resulting in a mean difference of 1.65
P < 0.0001 (95% CI 1.60–1.70).
Complications
Complications are extremely rare. The non-invasive and
painless nature of the procedure significantly reduced the
risk of bleeding, infection, and vasovagal reactions.
Allergic-like reactions to the contrast media are also
infrequent due to the use of a diluted low osmolar non-
ionic iodinated agent. Alternatively, a gadolinium dilu-
tion can be used in patients with documented iodine
allergy history [13].
Advantages
Advantages of the procedure are: (i) the non-invasive,
painless, well-tolerated nature of the procedure; (ii)
the extremely low risk of complications; (iii) the
 P. Carrascosa: CT virtual hysterosalpingography

Fig. 23. Large subserosal

myoma. A, B Coronal and
sagittal maximum intensity
projections. There is enlargement
of the uterus secondary to the
presence of a large leiomyoma in
the posterior wall (asterisks).
C Virtual endoscopy view of the
inside of the uterus. The
endometrial cavity is normal.
D Virtual endoscopy view of the
external surface of the uterus.
There is a large subserosal
myoma (asterisk).

Fig. 24. Diffuse adenomyosis. Multiple variable-sized outpouchings projecting off the uterine fundus wall (arrow heads).
A Maximum intensity projection. B Volume rendering reconstruction. C Virtual endoscopy view.

high-resolution isotropic images that provide detailed Disadvantages

information of the uterus and fallopian tubes; (iv) the
possibility to have a non-invasive endoluminal view of the
cervical canal and endometrial cavity; (v) the evaluation of
extra uterine pathology (adnexal pathology, bowel
abnormalities, pelvic processes, and skeletal abnormali-
ties); and (vi) a low radiation dose.
Relative disadvantages of the procedure include: (i) the
cost, twofolds the cost of X-ray HSG; (ii) the availability
of the examination; and (iii) the inability to perform an
immediate tubal cannulation in case of proximal tubal
occlusion.
P. Carrascosa: CT virtual hysterosalpingography
Fig. 25. C-section scar. Diverticulum-like deformity of the isthmic region due to C-section (arrow head). A, B Coronal and
sagittal maximum intensity projections. C Virtual endoscopy view.
Conclusions
Sixty-four-row VHSG is a new high-resolution modality
that provides a reliable, non-invasive diagnostic proce-
dure useful in the evaluation of the female reproductive
system. Uterine and tubal anatomy and pathology can be
accurately evaluated with this examination. The combi-
Fig. 26. Unilateral right fallopian tube
occlusion. A Maximum intensity
projection. B Volume rendering
reconstruction.
Fig. 27. Slight right tube
ampullary dilation (arrow head)
with large left tube hydrosalpinx
(asterisk) without peritoneal
spillage. A Maximum intensity
projection. B Volume rendering
reconstruction.
nation of bi-dimensional, three-dimensional, and endo-
luminal views give well-appointed anatomic information
and a detailed characterization of the different patho-
logic processes. It provides a more precise information in
comparison with X-ray HSG. Based on all the concepts
exposed, we conclude that 64-row VHSG may play a
valuable role in the infertility diagnosis.

Acknowledgment. We would like to thank Dr. Graciela Fernandez
Alonso for her assistance in editing this manuscript.
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