FemVue Sono HSG Procedure
Conduct a standard ultrasound evaluation per your practice guidelines.
In a transverse view locate and landmark:
Endometrial Stripe and Uterotubal Junctions (Fig A)
This will help visualize the proper plane for scanning Zone 1. It may be helpful to visualize the endometrial stripe transitioning into each uterotubal junction separately.
Zone1 and Zone 3 :
Ovary Position Relative to Uterus (Fig B)
The area between the ovary and uterus is, Zone2 where contrast flow can be anticipated.
Take note of the probe position when obtaining these views, as they will be used when visualizing saline and air flow.
Place catheter and conduct the SIS first, if performing.
Using a balloon may prevent retrograde flow.
Inflating the balloon slowly may minimize tubal spasm.
Fill, Prime, and then attach FemVue to the Catheter
To Fill, Submerge device tip into a saline-filled bowl.
Fully pull back the plunger handle and hold until the saline chamber completely fills.
To prime, submerge the tip in the saline bowl and depress the plunger handle until bubbles are visible. Only a few bubbles need to be seen for the device to be primed.
Prime FemVue just before attaching it to the catheter.
FemVue fills with a delay, so keep the tip in the saline for a few seconds after the handle has reached its stop point.
Saline should fill between 9 and 10 mL.
Avoid over tightening when connecting FemVue to the catheter. This prevents catheter kinking and ensures easy device disconnection for refilling, if necessary.
Video: FemVue Saline- Air Device - Filling & Priming
Contrast Delivery and ruling out retrograde flow
In a sagittal view:
Begin slowly and steadily instilling contrast. Confirm there is no retrograde flow of contrast around the balloon and into the cervix.
It may be helpful to have the endometrial stripe, balloon and cervix visualized in a single view.
Holding the probe until the contrast reaches the fundus and distends the cavitiy may confirm proper balloon placement, if no retrograde flow is observed.
Confirm in the sagittal view there is no retrograde flow through the cervix. If retrograde flow is observed, adjust the balloon's placement or use a balloon to block the flow.
FemVue Retrograge for more information on ruling out retrograde flow.
Starting in a transverse view evaluate each tube:
To evaluate Zone 1
Focus and hold the probe at Zone1 and evaluate contrast flowing into the tube.
To evaluate Zone 2
Slowly and methodically scan from Zone 1 to Zone 3 (the ovary) looking for contrast flowing through the tubal course.
To evaluate Zone 3
Focus the probe at the ovary and look for contrast exiting the distal part of the tube, fimbrial turbulence, and/or bubbles in the cul-de-sac.
Sono HSG: Demonstrating Tubal Patency
Patency guidelines from literature using saline and air contrast:
- Zone 1 - Flow in the interstitial part of the tube
(8-10 seconds of contrast flow throuhg the uterotubal junction).1,2
- Zone 2 - Flow throughout course of tube
(flow may not be seen).1
- Zone 3 - Flow exiting tube
(fimbrial turbulence, bubbles seen around ovary or in
Overcoming Assessment Challenges:
No contrast is seen exiting catheter
- Make certain that catheter clamp is open.
- Replace catheter if kinking is suspected.
No contrast flow is visible in Zone 1
- Retrograde flow: Check balloon is placed over the internal cervical os.
- Tubal spasm: If suspected, hold probe steady at Zone 1, stop instilling contrast, and wait for possible resolution of tubal spasm.
- Preferential flow (i.e. contrast seen in only one tube): Instill more contrast, slightly faster, to increase the uterine pressure.
No contrast flow visible in Zone 2
- Adjust the probe depth and angle while tracing laterally from Zone 3 to Zone 1.
- Adjust the patient's position to reorient the anatomy closer to the probe, possibly improving visualization.
- Flow may not be seen in Zone 2.1
No contrast flow visible in Zone 3
- Re-evaluate Zone 1 and/or Zone 2 looking for 8-10 seconds of flow without observed hydrosalpinx. 1,2,3
Additional Assessment Videos
1 Volpi, Ultrasound Obstetrics Gynecology. 1996;7:43-48.
2 Exacoustos, The Journal of the American Association of Gynecologic Laparoscopists. 2003;10(3):367-372.
3 Allahbadia, Fertility and Sterility. 1992;58(5):901-907.