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CONSENT
FORM AND PATIENT
INSTRUCTIONS FOR
HYSTEROSALPINGOGRAM
(HSG or “Dye Test”)
A
hysterosalpingogram
(HSG) is an X-ray procedure
that is performed to
examine the uterine
cavity and to determine
whether the fallopian
tubes are open.
This procedure is commonly
performed to identify
potential causes of
infertility. In
addition, it can be
performed to examine
the uterine cavity in
women who have irregular,
heavy or painful menstrual
periods or history of
fibroids.
This test is performed
in the first half of
the menstrual cycle,
after bleeding has stopped,
but before ovulation.
The timing is designed
to prevent reflux of
menstrual tissue and,
thus, eliminate a potential
source of endometriosis
or damage to an early
conception. Patients
will be scheduled for
this study between days
5-13 of the menstrual
cycle.
SPECIFIC
PATIENT STEPS
| 1). |
Call
office (210)
337-8453 / (210)
FERTILE at the
beginning of
your period
to schedule
your HSG.
The HSG will
be performed
after the bleeding
stops, but before
ovulation. It
can be scheduled
on a Tuesday
and Thursdays. |
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| 2). |
Begin
the antibiotic
(doxycycline
100 mg) with
a light breakfast
the morning
of the procedure.
Continue this
medicine twice
a day until
the prescription
is finished. |
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| 3). |
Take
3-4 (four) tablets
of a painkiller
(200 mg of ibuprofen,
Advil, Motrin)
one hour before
the procedure.
If you are allergic
to NSAIDs (ibuprofen,
Motrin®, naproxen,
etc) or aspirin
you may take
two tablets
of extra strength
acetaminophen
(Tylenol® 500
mg). |
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| 4). |
If
you feel you
will be very
anxious or nervous
during the procedure
please discuss
with our Fertility
Coach, and we
will provide
you a prescription
for 5 mg of
Valium® for
your convenience.
If you choose
this, please
make sure somebody
drives you to
this test as
the Valium®
alters your
ability to drive. |
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| 5). |
The
day of the scheduled
procedure (HSG),
report to the
Radiology office. |
PROCEDURE
This
test is performed with
the assistance of a
radiologist on an X-Ray/fluoroscopy
table.
| 1). |
A
pelvic examination
is performed
with your legs
flexed similar
to the way a
Pap smear is
done. |
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| 2). |
Vagina
is cleansed
with an antiseptic
solution (Betadine).
If you are allergic
to such solutions
or fish, shellfish,
you should call
the office because
you will need
to take some
medications
days before
the procedure
to minimize
the risk of
an allergic
reaction. |
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| 3). |
A
catheter will
be placed into
your cervix
(the entry to
the uterus)
with a special
device; this
will feel like
a “pinch.” At
this point in
time, you will
be ready for
the study to
begin. |
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| 4). |
The
radiologists will
come in the room
and will take
all the necessary
pictures. |
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| 5). |
Dr.
Arredondo will
tell you when
we will start
injecting the
dye and you
will feel pressure
with the injection
of the contrast
as it flows
through your
uterus and fallopian
tubes. |
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| 6). |
You
may be asked
during the study
to hold your
breath or to
move in a particular
position for
our physicians
to take the
proper views
of your uterus
and tubes. |
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| 7). |
Following
this, all the
instruments
from the vagina
will be removed
and subsequently
the radiologist
may keep you
on the table
and move the
table in several
positions to
take a final
view of your
reproductive
organs. |
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| 8). |
After
this, you will
be given a sanitary
pad, which you
should wear
for at least
24 hours since
some of the
contrast material
will be discharged
through the
vagina. |
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At
the end of the study,
we may tell you some
of the findings; however,
a week later our radiologist
will have a more thorough
review of the pictures
taken during this study.
He/she will then write
a report that will be
mailed to the fertility
office, and we will
then notify you if there
is a change in the original
description.
POTENTIAL
COMPLICATIONS
The complication rate
from this procedure
is less than 2%.
Some of the complications
include the following:
| 1). |
Pelvic
infection |
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The
performance
of this test
can result in
an infection
that could produce
lower abdominal
pain and fever
that develop
within a few
days following
completion of
the procedure.
A consequence
of this infection
may be scarred
Fallopian tubes
and infertility.
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.
The infection
rate is significantly
reduced with
the antibiotics
we have given
you. |
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| 2). |
Allergic
reaction |
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The
contrast medium
that is used
contains iodine.
If you have
had an allergic
reaction to
iodine, a reaction
following a
radiological
procedure [i.e.
CAT (CT) scan,
intravenous
pyelogram (IVP)]
or if you have
had a reaction
to fish
or shellfish,
please call
the office,
you will need
to take some
medications
days before
the procedure
to minimize
the risk of
an allergic
reaction. |
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| 3). |
Exposure
of potential pregnancy |
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Despite
your perception
of a normal
menstrual period,
there is always
the possibility
of a potential
pregnancy.
If your last
menstrual period
was abnormal,
either delayed
or lighter,
you should notify
your physician. |
INSTRUCTIONS
FOLLOWING THE TEST
| 1). |
You
can return to
your normal routine
after the completion
of the test |
| 2). |
You
should avoid intercourse
and douching for
the next 2 days. |
| 3). |
If
you develop any
fever, chills,
severe abdominal
pain or heavy
vaginal bleeding,
you should contact
the physician
immediately at
(210) 337-8453.
Small amount of
bleeding (less
than a period)
is not uncommon. |
| 4). |
Remember
to continue taking
the antibiotic
(Doxycycline 100mg)
one tablet twice
a day until all
pills are finished. |
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ACKNOWLEDGEMENT
OF INFORMED CONSENT
AND AUTHORIZATION
I
acknowledge that I have
read and understand
this written material.
I understand the purpose,
risks, benefits and
alternatives of this
procedure. I am
aware that there may
be other risks and complications
not discussed herein
that may occur.
I also understand that
during the course of
the procedure, unforeseen
conditions may be revealed
requiring the performance
of additional procedures.
I also understand that
technical problems with
the instrumentation
may prevent the completion
of the procedure.
I acknowledge that no
guarantees or promises
have been made to me
concerning the results
of this procedure or
any treatment that may
be required as a result
of this procedure.
I have been given the
opportunity to ask questions,
which have been answered
to my satisfaction.
I consent to the performance
of the procedure described
above by my physician.
I
HAVE BEEN GIVEN A COPY
OF THESE INSTRUCTIONS
AND CONSENT FORM ALL
THE QUESTIONS HAVE BEEN
ANSWERED TO MY SATISFACTION
BY THE RMA OF TEXAS
PHYSICIAN.
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Patient Signature |
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Witness Signature |
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