INFORMED CONSENT DOCUMENT
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PROCEDURE: Hysterosalpingography
The procedure that you are to undergo consists of channelling the external cervical
orifice through a special catheter in aseptic conditions, so as introduce through it a
radiological iodine contrast, in order to study the uterine cavity and fallopian tubes.
This procedure is usually harmless and does not cause significant discomfort.
The patient may feel a slight discomfort during the introduction of the contrast and can
also feel a slight abdominal discomfort in the hours following the completion of the test.
If the the patient presents abnormal symptomatology, such as severe abdominal pain,
fever, etc., she should consult this clinic, her gynaecologist or a hospital.
Occasionally (less than 3% of cases) it has been reported that the
Hysterosalpingography performed can disseminate an infectious genital process that
may have gone unnoticed. If the patient, prior to the exploration presents fever,
discomfort in the genital area or any type of flow or vaginal secretion, is should be
reported.
Similarly, if during the exploration prior to the Hysterosalpingography the doctor
detects any suspicious sign of a genital infection or other pathology that may involve a
risk to the patient, the test shall be suspended, which may be realised after receiving
appropriate treatment.
As it is a diagnostic procedure that uses ionizing radiation, if the patient believes she is
pregnant, it should be reported.
An ionized contrast is used for this diagnostic test., which normally does not produce
any discomfort to the patient. However, there is the possibility that in sensitised patients
an allergic reaction is developed. The likelihood of that occurring is very low (less
likely to happen when using iodine intravenous contrast) and generally the reaction is
mild (burning sensation, bitter taste in the mouth, nausea, vomit, itching or nettle rash).
The appearance of severe allergic reaction is rare.
No previous test exists that allows us to know which persons can produce a reaction.
Let us know before performing the exploration if you have been subjected previously
to any other test using iodized contrast, if your allergic to iodine contrast, iodine or any
other medication of substance.
Malaga on ………of …………….. 20........
Signature of the Patient
(or Legal Guardian)
Signature of the Doctor
Signature of the Witness.