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Purpose and principlesIndications, selection and cautionsMethod and interpretationClinical next stepsRisks, monitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Tubal patency and uterine-cavity assessment

Obstetrics and gynaecology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Exclude pregnancy and active infection before instrumentation

Introducing contrast or instruments into the uterus in an unrecognised pregnancy or active pelvic infection can cause harm, and severe post-procedure pain, fever, offensive discharge, heavy bleeding or collapse may signal a complication.

Action: Confirm appropriate cycle timing and pregnancy exclusion, screen for chlamydia, defer elective instrumentation during active infection, and arrange urgent assessment for systemic illness, peritonism, major bleeding or haemodynamic change.

Purpose and principles

Select the least invasive reliable test for tubal patency, reserve laparoscopy and hysteroscopy for appropriate indications, prevent procedure-related infection, and connect structural findings to management.

Fertilisation normally occurs within a patent fallopian tube, followed by embryo transport to the uterine cavity. Tubal assessment asks whether contrast can traverse the tubes; uterine assessment asks whether a clinically important cavity or endometrial abnormality is present. No single test assesses ovulation, tubal function, pelvic disease and implantation, so investigation must be selected from the history rather than ordered as an indiscriminate panel.

Estimate pelvic risk first. Previous pelvic inflammatory disease, chlamydia, ectopic pregnancy, endometriosis, pelvic or tubal surgery and substantial pelvic pain increase the probability of tubal or peritoneal disease. In their absence, NICE recommends hysterosalpingography because it reliably rules out occlusion, is less invasive and uses fewer resources than laparoscopy. Where appropriate expertise exists, hysterosalpingo-contrast-ultrasonography is an effective alternative without ionising radiation.

HSG introduces radiographic contrast through the cervix and images uterine filling and spill from each tube. It supplies a cavity outline and tubal map but not direct visualisation of external pelvic adhesions or endometriosis. Ensure pregnancy is excluded and follow local timing and allergy procedures. Explain transient cramping and infection risk. Proximal muscular spasm, mucus or technical factors can mimic occlusion, so an apparent block is a finding to interpret, not always a final anatomical diagnosis.

Indications, selection and cautions

Low-risk tubal assessment

No history suggesting PID, ectopic pregnancy or endometriosis supports HSG or expert HyCoSy rather than diagnostic laparoscopy.

High-risk pelvic phenotype

Previous ectopic pregnancy, PID, endometriosis, pelvic surgery or significant pelvic pain raises the value of laparoscopy and dye because other pelvic disease can be assessed.

Proximal occlusion pattern

Failure of contrast to enter the proximal tube may be true obstruction or transient cornual spasm and requires technical review before definitive treatment.

Hydrosalpinx

A distended fluid-filled damaged tube may be seen on ultrasound or contrast imaging and has particular importance before embryo transfer.

Suspected cavity disease

Abnormal bleeding or ultrasound evidence of a polyp, submucosal fibroid, adhesion or endometrial lesion creates a genuine indication for targeted cavity assessment.

Red flags requiring action

  • Possible pregnancy, especially with pain or bleeding, must be assessed before HSG, HyCoSy or hysteroscopy.
  • Fever, purulent discharge, cervical excitation or acute pelvic pain suggests active pelvic infection and elective instrumentation should be deferred.
  • Severe or worsening pain, fever, offensive discharge, heavy bleeding, syncope or peritoneal signs after a procedure needs urgent review for infection, perforation, bleeding or another acute cause.

Method and interpretation

  1. 01
    HysterosalpingographyFirst step
    Why
    Screen uterine contour and tubal occlusion in people without suspected pelvic comorbidity.
    Interpretation and limitations
    Free spill supports patency; absent spill may reflect true distal or proximal disease, spasm or technique. HSG does not exclude peritoneal endometriosis or all adhesions.
  2. 02
    Hysterosalpingo-contrast ultrasonography
    Why
    Provide an ultrasound-based alternative patency test where trained staff and validated technique are available.
    Interpretation and limitations
    Observed contrast passage supports patency; equivocal or abnormal results require specialist correlation, and test performance is operator dependent.
  3. 03
    Laparoscopy and dye
    Why
    Assess tubal passage together with endometriosis, adhesions and external pelvic anatomy in higher-risk presentations.
    Interpretation and limitations
    Direct pelvic findings guide surgical or IVF planning, but the anaesthetic and operative burden makes it inappropriate as routine low-risk screening.
  4. 04
    Transvaginal pelvic ultrasound
    Why
    Assess uterine structure, endometrium, ovaries and adnexa and identify hydrosalpinx or suspected cavity lesions.
    Interpretation and limitations
    A normal scan does not prove tubal patency; focal intracavitary abnormalities may need saline sonography or hysteroscopy.

Clinical next steps

01Select the testLet pelvic risk determine invasivenessFirst stepTubal patency must be assessed during fertility investigation.+
  1. 1Ask about PID and chlamydia, ectopic pregnancy, endometriosis, pelvic surgery, pain, bleeding and previous imaging.
  2. 2Use HSG or expert HyCoSy when no pelvic comorbidity is known; choose laparoscopy and dye when simultaneous pelvic assessment is clinically valuable.
  3. 3Explain what the chosen test can and cannot show, including spasm, operator dependence or failure to visualise endometriosis.
02Procedure safetyPrevent pregnancy and infection harmUterine contrast or instrumentation is planned.+
  1. 1Follow local cycle timing, establish that pregnancy is not present and check for symptoms of active pelvic infection.
  2. 2Offer sensitive chlamydia screening; treat positive results and partners, or consider prophylactic antibiotics if screening has not occurred.

Risks, monitoring and follow-up

  • Before instrumentation, document pregnancy exclusion, chlamydia screening or prophylaxis decision, allergies and symptoms of active infection.
  • After HSG, HyCoSy or hysteroscopy, provide a route for urgent review of fever, increasing pain, offensive discharge, heavy bleeding, syncope or systemic illness.
  • Record whether each tube was patent, occluded or equivocal and whether the apparent level could reflect spasm or technical limitation.
  • After tubal surgery, reassess the time allowed for spontaneous conception against age, reserve, semen and any ectopic-pregnancy risk.
  • Before IVF, confirm that a hydrosalpinx management plan is complete and that any cavity procedure had a defined clinical indication and result.

Special situations

Ultrasound is not a patency test

Routine transvaginal ultrasound may identify a hydrosalpinx but cannot demonstrate that an otherwise normal-looking tube is open.

Spasm can imitate obstruction

A proximal block on contrast imaging may be transient; image pattern and technical context matter before labelling bilateral irreversible disease.

Laparoscopy answers more at a cost

It visualises endometriosis and adhesions as well as dye passage, but its anaesthetic and operative risks justify selection by pelvic history.

Hysteroscopy needs a reason

NG257 amended the recommendation in 2026: do not offer hysteroscopy unless a uterine or endometrial abnormality is clinically suspected.

Hydrosalpinx changes IVF preparation

Treating the affected tube before embryo transfer improves the treatment pathway; aspiration is a fallback when laparoscopy presents high complication risk.

Common pitfalls

  1. 01

    Assuming a normal transvaginal ultrasound proves that both tubes are patent.

  2. 02

    Sending every patient directly to laparoscopy rather than using HSG or expert HyCoSy in low-risk assessment.

  3. 03

    Calling apparent proximal occlusion permanent without considering cornual spasm or technical quality.

  4. 04

    Instrumenting the uterus without pregnancy exclusion and chlamydia screening or a documented prophylaxis decision.

  5. 05

    Offering routine hysteroscopy, endometrial scratch or receptivity testing before IVF in the absence of suspected pathology.

  6. 06

    Planning IVF without addressing a hydrosalpinx or integrating age, reserve and male factors into the surgery-versus-IVF decision.

Practice

Two practice questions

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Question 1 of 2
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Obstetrics and gynaecologyOriginal SBA

First-line test without pelvic comorbidity

A 30-year-old with ovulatory cycles has no history of PID, ectopic pregnancy, endometriosis or pelvic surgery. Tubal patency requires assessment. Which test does NICE recommend as first-line screening?

Choose one answer, then submit
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG257 tubal and uterine investigation
  • NICE NG257 female-factor management
  • NICE NG257 IVF procedures and add-ons
  • RCOG outpatient hysteroscopy information
  • NICE NG257 recommendations PDF

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom

HyCoSy uses ultrasound-visible contrast to evaluate spill and can be combined with pelvic ultrasound. Its diagnostic value depends on equipment and operator expertise. It avoids X-ray exposure but does not remove the need for pregnancy exclusion or infection precautions. When either HSG or HyCoSy shows abnormal or equivocal findings, specialist review decides whether repeat imaging, tubal catheterisation, laparoscopy or IVF is the useful next step.

Laparoscopy and chromopertubation directly assess dye passage while visualising the pelvis. Offer it when comorbidity is suspected because endometriosis, adhesions and tubal distortion can be assessed together. It requires anaesthesia and carries surgical risks, so it is not first-line merely to prove patency in a low-risk person. Consent should cover the planned extent of any treatment, including whether endometriosis or adhesions might be addressed at the same procedure.

Uterine-cavity assessment is symptom and imaging led. Transvaginal ultrasound evaluates uterine shape, fibroids, endometrium, adnexa and ovarian morphology but can miss small intracavitary lesions. Saline-infusion sonography can delineate a suspected polyp or submucosal fibroid. Hysteroscopy provides direct visualisation and possible biopsy or treatment; under NG257 it should not be offered unless uterine or endometrial abnormality is clinically suspected.

The same restraint applies before IVF. NICE advises against pre-treatment hysteroscopy solely to improve IVF outcome and against endometrial scratch or receptivity testing. Findings must have a plausible management consequence. Intrauterine adhesions associated with amenorrhoea are a specific exception: hysteroscopic adhesiolysis can restore menstruation and improve pregnancy chance. Persistent abnormal bleeding follows the appropriate endometrial-risk pathway rather than being dismissed as a fertility issue.

Structural results lead to individualised management. Mild tubal disease may be considered for surgery in an expert centre; proximal obstruction may be treated by radiological or hysteroscopic tubal catheterisation after comparing risks and benefits with IVF. Hydrosalpinges should be treated with laparoscopic salpingectomy or tubal occlusion before IVF. Always integrate age, ovarian reserve, semen factors, duration, bilateral versus unilateral disease and patient preference before choosing surgery or assisted conception.

Key points

  • Choose tubal testing from pre-test probability: HSG is first-line when there is no known pelvic comorbidity, while expert HyCoSy is an effective alternative.
  • Offer laparoscopy and dye when PID, previous ectopic pregnancy, endometriosis or another pelvic comorbidity makes simultaneous inspection and treatment planning valuable.
  • A normal pelvic ultrasound does not demonstrate tubal patency; most normal fallopian tubes are not visible on routine ultrasound.
  • Screen for Chlamydia trachomatis with a sensitive test before uterine instrumentation; treat a positive person and partners with contact tracing.
  • If chlamydia screening has not been performed, NICE says to consider prophylactic antibiotics before instrumentation.
  • Do not offer hysteroscopy unless a uterine or endometrial abnormality is clinically suspected, and do not use screening hysteroscopy simply to improve IVF outcome.
  • Apparent proximal occlusion on contrast testing may reflect tubal spasm; interpret images, technical quality and bilateral patterns before concluding permanent blockage.
  • Before IVF, offer laparoscopic salpingectomy or tubal occlusion for hydrosalpinges; consider aspiration near oocyte retrieval only when laparoscopy carries high complication risk.
  • Postmenopausal bleeding, persistent intermenstrual bleeding or suspicious uterine imaging requires a diagnostic pathway for endometrial disease rather than fertility screening alone.
  • A hydrosalpinx before IVF requires specialist management because untreated hydrosalpingeal fluid reduces implantation and pregnancy outcomes.
    • 05
    Saline-infusion sonography or hysteroscopy
    Why
    Characterise a clinically suspected intracavitary or endometrial abnormality.
    Interpretation and limitations
    Use when symptoms or imaging justify it; hysteroscopy directly visualises and can biopsy or treat but is not routine fertility screening.
  • 06
    Chlamydia nucleic-acid amplification test
    Why
    Reduce ascending infection risk before introducing instruments or contrast through the cervix.
    Interpretation and limitations
    Treat a positive person and sexual partners with contact tracing before elective instrumentation; consider prophylaxis if screening was not performed.
  • 3Give analgesia advice and clear post-procedure safety-netting for severe pain, fever, offensive discharge, heavy bleeding or collapse.
    • 03Abnormal patency resultConfirm consequence before interventionHSG or HyCoSy suggests unilateral, bilateral, proximal or distal tubal disease.+
    1. 1Review image quality, contrast pattern and possibility of proximal spasm, integrating the history and the other tube.
    2. 2Discuss expert laparoscopy, proximal catheterisation, mild-disease surgery or IVF according to site, severity, age and other fertility factors.
    3. 3Treat hydrosalpinges before IVF with salpingectomy or occlusion, reserving aspiration for selected people at high surgical risk.
    04Cavity concernInvestigate a suspected lesion, not everyoneSymptoms or imaging suggest a uterine or endometrial abnormality.+
    1. 1Characterise bleeding, prior uterine procedures and ultrasound findings, and assess endometrial malignancy risk separately where appropriate.
    2. 2Use targeted saline sonography or hysteroscopy with biopsy or treatment planning; obtain specific consent for possible intervention.
    3. 3Do not offer screening hysteroscopy, endometrial scratch or receptivity testing solely to improve IVF success when no abnormality is suspected.