Brachytherapy for cervix cancer has evolved rapidly over the last few years through the introduction of image-guided brachytherapy. This has enabled the transition from Manchester-based orthogonal radiograph planning to more conformal treatments, incorporating the concepts of patients' anatomy, tumor characteristics and tumor response with time. The purpose of this article is to outline the evolution of cervix cancer brachytherapy, discuss guidelines and recommendations on image-guided brachytherapy and describe our single-institution conformal image-based brachytherapy experience.