9 common questions about sonohysterograms

Understanding the sonohysterogram and its role in fertility

At Markham Fertility Centre (MFC) we offer many testing options, one of which is a sonohysterogram (SHG), also known as a saline infusion sonogram (SIS) or sono for short. The sonohysterogram is a test that we do as part of the initial workup for somebody who is looking to get pregnant. If somebody is thinking about freezing their eggs, or is looking at becoming an egg donor, we don’t typically order this test. But, in a situation where somebody is trying to get pregnant or wants to be pregnant, then it’s a commonly ordered test. Now let’s answer a few of the common questions about sonohysterograms:

  1. What is a sonohysterogram or sono?
  2. Is a sono painful?
  3. What do you look for in a sono?
  4. What are the risks of a sono?
  5. What to expect after a sono
  6. When to schedule a sono
  7. How long should you wait after a sono to have intercourse?
  8. How often is a sono done?
  9. How long after an ectopic can you do a sono?

What is a sonohysterogram or sono?

A sono is done on-site at MFC, at Care Imaging by one of the gynecologists, and the ultrasound department. We use a little catheter that is inserted in through the cervix with a speculum. A speculum is a medical instrument that goes in the vagina to allow us to see the cervix; it can be metal or plastic in composition. At MFC, we use metal, which is actually more comfortable and allows us to see the cervix when we put the little catheter through the cervix.

Is a sono painful?

We find that women who have never had a sonohysterogram done before tend to find it a little bit more painful. And women who have come to us after having had a child tend to find it less painful. Experiences can range from zero pain, where patients tell us, “I didn’t even know you were there!”, to more pain, like bad menstrual cramps. We recommend that patients take 1-2 Advils before their appointment. There are some patients who, for other reasons, have a lot of difficulty with vaginal exams. This could be due to vaginismus, or a history of trauma, and in these cases we can consider using anesthesia or using a medication like Ativan to help them get through the sono. 

What do you look for in a sono?

What we’re looking for in a sono is two things: 

  1. We want to look inside the cavity of the uterus and 
  2. We also want to look at the fallopian tubes and assess whether they’re open or not 

Now, we aren’t always looking at the fallopian tubes. For instance, let’s say we’re doing a sono prior to an embryo transfer, then we don’t need to see the fallopian tubes because the fallopian tubes are not part of the embryo transfer procedure.

If we’re seeing somebody with primary infertility or secondary infertility and we’re looking at the big picture and we’re considering IUI or IVF , then that’s an opportunity to look at the fallopian tubes. 

As described earlier, we put a catheter through the cervix, add some fluid in and this opens up or separates the walls of the uterus so we can have a really good look at what’s inside the cavity of the uterus.

During the test, we look for:  

  • polyps (which are common)
  • possible submucosal fibroids
  • abnormal shape of the uterus which could be due to a septum or a congenital anomaly
  • if we’re looking at the fallopian tubes, we also push contrast through the fallopian tubes to see if they’re open

What are the risks of a sono?

Overall, the risks are very minimal. We do many of them and the complication rate is very low. But, some patients are at higher risk for infection.  These would be patients who have a large endometrioma, which is a type of ovarian cyst. When we see this, we give patients prophylactic antibiotics, which means prescribing an antibiotic before you actually have an infection to prevent the infection. But, there is still a risk of infection for any patient, so we advise all patients if they have increasing pain or fever after the procedure to contact our office.

What to expect after a sono

It is also important to talk about what is normal after a sono, and what’s not necessarily a sign of a bad outcome or a sign that something went wrong. After a sono, it’s very normal to have a lot of watery discharge and oftentimes there will be a little bit of blood mixed in it because we’re basically putting a lot of fluid (sterile saline or the contrast) into the uterus.  In doing so a person will lose a little bit of endometrial tissue, similar to the discharge that comes out during menstruation. And when you have a drop of blood mixed in with water, it can look like a lot more blood than it actually is; therefore watery discharge, pinkish discharge, and a little bit of bleeding is very normal. Some small blood clots can be very normal as well or similar types of mucousy, stringy tissue are also very normal. 

When the test begins often people will have the most painful cramps. As the test progresses, the cramping tends to get a bit better. You can take Advil and Tylenol, for instance, if you’re finding that the cramping is impacting your day-to-day routine.

When to schedule a sono

A sonohysterogram is normally done between day five and day nine of the cycle. This date range is chosen for a number of reasons: 

  1. First of all, usually by that time there’s no more menstrual bleeding. We don’t want loose menstrual blood inside the uterus because it can make the uterus cavity difficult to see.
  2. Second, we want to do this test prior to ovulation. If we were to do it in the later part of the cycle, ovulation would have happened, and a pregnancy could potentially be implanting, so we don’t want to be disrupting that. We avoid interfering with couples who would want to conceive during the cycle of the sono. It is possible to do a sono in the same cycle that you’re trying to conceive, and sometimes we even do a sono in the same cycle as an IUI , as long as you’re doing the test early on in the cycle. As a matter of fact, there are some studies that suggest that a sonohysterogram causes a small increase in pregnancy rate over the next three cycles. As a result, we do encourage everybody to try the same cycle as their sonohysterogram and the subsequent cycles after that. 

How long should you wait after a sono to have intercourse?

Typically waiting 24 to 48 hours is ideal. It’s probably uncomfortable to have intercourse on the same day as a sono. If a sono is done on day five to day nine, the ovulation window is not going to start until day 10 to day 16 for most people with ovaries.

How often is a sono done?

If there is no change from your previous sono test, meaning that there were no pregnancies or miscarriages or changes in the menstrual cycle, we normally want the sonohysterogram to be done within one year’s time. 

These are some of the scenarios that would lead us to recommend a sono: 

  • You’re planning an embryo transfer and you haven’t had a sono in two to three years
  • In the case of a miscarriage and there is a concern for retained products
  • After a C-section or retained placenta or complications during delivery
  • Anytime there is irregular bleeding or mid-cycle spotting
  • Anytime you see something abnormal on an ultrasound

How long after an ectopic can you do a sono?

An ectopic is a really good reason to do a sono, prior to restarting fertility treatment. 

Firstly, we want to ensure the pregnancy test AKA the beta HCG level is back to zero. 

Secondly, we ideally wait until one menstrual cycle has taken place and then a sonohysterogram would be performed to look inside the cavity of the uterus, but specifically to look at the fallopian tubes. 

If we see that there is flow going through that fallopian tube, then we say the tube is open and that’s reassuring that the fallopian tube is back to working normally. However, if there is no flow going through the fallopian tube, then it could mean that it’s blocked or scarred from the ectopic pregnancy. The sonohysterogram is one of the best tests we have today for assessing tube function.

Learn more about the sonohysterogram at Markham Fertility Centre and if you are interested in scheduling a sono, contact the clinic today.