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7501 Las Colinas Blvd, Ste 200 Irving, TX 75063 Tel 972-506-9986 Fax 972-506-0044 600 W Mayfield Rd Arlington, TX 76014 Tel 817-701-1290 Fax 817-701-1297 Requisition for Hysterosalpingogram
Patient Name: _________________________________________ DOB: _________________________ Patient Phone Number: __________________________________ Procedure performed between cycle day 7-10 Doxycycline or Keflex prior to HSG Valium 5 mg for anxious patients Referring Physician’s Name: ____________________________ Ordering Physician’s Signature: ___________________________ Please fax this order form to (972) 506-0044 and ask your patient to call us to schedule the exam. 7501 Las Colinas Blvd, Ste 200 Irving, TX 75063 Tel 972-506-9986 Fax 972-506-0044 600 W Mayfield Rd Arlington, TX 76014 Tel 817-701-1290 Fax 817-701-1297 INSTRUCTIONS FOR THE HSG
A hysterosalpingogram (HSG) is a procedure in which a special dye is instilled into the uterine cavity while X-
ray images are taken to evaluate the uterus and the fallopian tubes. The HSG is performed during the
investigation for infertility, recurrent miscarriages, abnormal vaginal bleeding and painful periods. The HSG is
performed in the early part of the cycle (day 7-10), after menstruation has stopped.
Special Instructions

1. Please refrain from having intercourse from the time of menses to 2 days after the HSG. 2. Begin the antibiotic (Doxycycline 100 mg) twice daily 2 days before the HSG to minimize the risk of infection from the HSG. Continue this medicine as directed until the prescription is finished. 3. Take 600 – 800 mg of Ibuprofen (Advil, Motrin) one hour before the procedure to prevent cramping. 4. If you are taking Metformin, stop it 2 days prior to the procedure.
The Procedure

A pregnancy test will be done prior to the procedure. The HSG takes only a few minutes. A speculum is
inserted into the vagina and the cervix is swabbed with an antiseptic (Betadine) solution. Local anesthesia will
be used to decrease discomfort. The physician injects dye into your uterus with a special catheter and takes
pictures of your uterus and tubes using an X-ray machine. Mild to moderate cramping may be felt during the
procedure. Vaginal spotting and contrast dye may be noted after the procedure for 1-2 days.
Instructions Following the Test

1. You can return to your normal routine after the completion of the test. 2. If anxiety medication is given, plan for someone to drive you back home. 3. You should avoid intercourse and douching for the next 2 days. 4. If you develop any fever, chills, severe abdominal pain or heavy vaginal bleeding, please contact us. 5. A small amount of bleeding (less than a period) is not uncommon for up to 2 days after the test. 6. Continue taking the antibiotic as directed until all pills are finished.
Potential Complications

The complication rate from this procedure is very low (1%). Some of the complications include the following:
Pelvic Infection - The HSG dye can induce dissemination of an existing infection. Infections are more likely to
occur in women who have already had a previous pelvic infection and/or damaged tubes. If an infection
develops, hospitalization with IV antibiotics, and potentially surgery, may be indicated.
Allergic Reaction - The contrast medium contains iodine. If you have had an allergic reaction to iodine or a
reaction following a radiological procedure (CT scan, IVP) please let us know.
Exposure of Potential Pregnancy - If your last menstrual period was abnormal, either delayed or lighter, you
should notify your physician to evaluate the potential for pregnancy.
Injury or Bleeding - Very rarely instrumentation or injection of the dye may lead to injury to the cervix, tubes or
uterus, which may necessitate an additional procedure to repair it.

Source: http://www.ivfmd.net/wp-content/uploads/2013/07/HSG-Requisition.pdf

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