The path to motherhood is not always marked by baby showers and birth announcements. For many women, it is defined by fertility investigations; blood tests, transvaginal scans that strip away privacy, and painful procedures done while legs are on cold stirrups as doctors search for answers inside the most intimate parts of their bodies.

Of all these tests, there is one many women never seem to forget. The hysterosalpingogram, commonly known as the HSG. This is a test that fertility specialists routinely recommend to provide critical information about a woman’s fertility.

It takes only a few minutes but some women say it feels like an electric current running through the abdomen before settling in the lower back. Afterwards, there may be bleeding and cramps that stay long after the procedure is over.

At 39, Irene Kiptanui was struggling with fibroids that made it difficult for her to conceive.

She went from one gynaecologist to another, searching for answers about why she could not conceive. It was only when one doctor took the time to carefully review her medical history and previous investigations that the pieces began to fall into place.

She was advised to undergo HSG test, a specialised X-ray used to check whether the fallopian tubes are open.

“When she recommended I do an HSG, I knew little about what the procedure involved.”

She was given a painkiller beforehand to help relax her muscles, but nothing prepared her for the experience itself.

“I was very stubborn about putting my legs apart,” she says with a laugh. “I finally did, the speculum was inserted and they started putting in the dye. My legs were trembling. I was so afraid, but I kept telling myself that if the test gave me a better chance of having a baby, then I would persevere.”

The HSG test was over in minutes, but those minutes felt like an eternity.

Fertility options

The results came back. They showed that one of her fallopian tubes was blocked. The gynaecologist advised her to continue trying to conceive naturally before considering further investigations and other fertility options.

Over time, Irene underwent three more HSG procedures, hoping each one would bring different news.

“My last HSG test was difficult,” she says. “I cried, not because of the severe pain, but because I felt like I was doing it for nothing. The emotional weight of wanting a child seemed to surpass the physical discomfort of taking those tests.”

Today, she still hopes she will conceive naturally.

“I do not want to go through that pain again. I am still hopeful that one day I will conceive. If not, then I may have to consider adoption.”

For Eva Ndichu, seeking fertility treatment was not initially her idea.

Three years into her marriage, questions from relatives about when she would have children became hard to ignore.

“They would ask why I was working so hard yet I had no children,” says the 34-year-old.

Neither she nor her husband had been particularly worried. He already had a child from a previous relationship and they were content to let nature take its course. Still, they eventually decided to seek medical advice.

Routine fertility investigations, including hormone tests and an ultrasound, revealed nothing unusual. Her doctor then recommended an HSG to determine whether her fallopian tubes were open.

“I went early the following morning, beautifully dressed and ready for the test,” she says.

“I was told it would only take a few minutes.”

She undressed, lay on the examination table and waited for the radiologist, who explained the procedure and warned that it might be uncomfortable.

Five minutes later, it was over.

Then the pain began. “It felt like I was using my whole uterus and vagina. I could feel it in my veins. I could not walk properly because of the pain. It was so crazy.”

The pain aside, the results brought welcome news. There was no problem with her reproductive tract and she was advised to continue trying for a pregnancy.

Eva conceived in 2024 and her daughter is almost three years old.

Why an HSG matters

Irene and Eva describe the HSG test as one of the most memorable moments in their fertility journeys. What caught them off guard was not the procedure itself, but the physical pain and emotional weight that came with it.

Dr Kireki Omanwa is a fertility expert.

Photo credit: Pool

According to Dr Kireki Omanwa, a fertility specialist and president of the Kenya Obstetrical and Gynaecological Society, HSG remains one of the most important investigations when a couple is struggling to conceive.

“It is a horrible test,” he says candidly. “But it is an important one.”

The investigation uses contrast dye and X ray imaging to determine whether the fallopian tubes are open and to assess the shape of the uterus.

For natural conception to occur, an egg released during ovulation must travel through an open fallopian tube to meet sperm. If that pathway is blocked, pregnancy becomes difficult or impossible, depending on whether one or both tubes are affected.

Doctors usually recommend fertility investigations when a couple has had regular unprotected intercourse for one year without achieving pregnancy. This applies to both primary infertility, where pregnancy has never occurred, and secondary infertility, where a couple has conceived before but is unable to do so again.

During the procedure, a speculum is inserted into the vagina before a small catheter is passed through the cervix. Contrast dye is then gently introduced into the uterus while X ray images are taken.

Ideally, the dye flows through the uterus, into both fallopian tubes and spills freely into the pelvic cavity. If the dye stops along the way, doctors can identify where the blockage may be.

The test can also reveal abnormalities within the uterus, including fibroids or scar tissue, although Dr Omanwa cautions that it cannot diagnose every condition with certainty. If the images suggest an abnormality, further investigations such as hysteroscopy may be needed.

Hysteroscopy involves passing a small camera through the cervix to view the inside of the uterus directly. It also allows doctors to treat certain conditions during the same procedure.

What if a tube is blocked?

If only one tube is blocked, pregnancy is still possible, although fertility is reduced.

“The timing of ovulation becomes important,” says Dr Omanwa. “If the egg is released from the side with the open tube, conception can still happen.”

When both tubes are blocked, however, natural pregnancy is extremely unlikely. Depending on where the blockage occurs and the condition of the tubes, treatment may involve IVF (in vitro fertilisation).

Sometimes the tubes can be damaged by previous infections, increasing the risk of an ectopic pregnancy even if conception occurs. In other cases, fluid collects inside damaged tubes, prompting doctors to recommend removing them before IVF.

Although blocked tubes can sometimes be surgically opened, Dr Omanwa says this is not always advisable because the delicate structures can sustain further damage.

Can an HSG improve fertility?

The answer, he says, is both yes and no.

Some studies suggest that using oil-based contrast dye during an HSG may improve the chances of pregnancy by flushing minor blockages from the tubes. However, oil-based contrast is also associated with more discomfort and a higher risk of side effects than water-based contrast.

If a tube is completely blocked, however, the procedure alone is unlikely to restore fertility.

Why does it hurt?

Pain during an HSG happens for several reasons.

As contrast dye is introduced, the uterus stretches, stimulating pain sensitive nerves. The cervix also has to be held in place with a surgical instrument known as a tenaculum, which can be uncomfortable. Even inserting the speculum may cause discomfort, especially if the vagina is dry.

Patients are usually advised to take pain medication before the procedure. Depending on individual needs, doctors may recommend paracetamol, diclofenac or injectable pain relief. Some women may also receive antibiotics because, although uncommon, infection is a recognised complication.

“Pain thresholds differ from one person to another,” says Dr Omanwa. “The goal should always be to manage the pain rather than expecting patients simply to endure it.”

Despite its reputation, the HSG remains widely used because it is relatively affordable, readily available and provides valuable information early in the fertility journey.

For women who cannot tolerate the procedure, alternatives such as diagnostic laparoscopy under anaesthesia, HyCoSy or HyFoSy may be considered.

Above all, Dr Omanwa emphasises that fertility is a couple’s issue, not solely a woman’s burden.

“The challenge may lie with the man, the woman or both,” he says. “Partners need to support each other throughout the investigation process.”

He also believes doctors should spend more time explaining what patients can expect before an HSG.

“When women understand why the test is necessary, what it involves and what the results could mean, it becomes less frightening, even if it is still uncomfortable.”

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eintabo@ke.nationmedia.com