Synopsis
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.
- 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.
Key red flags
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.
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.
Investigation priorities
Screen uterine contour and tubal occlusion in people without suspected pelvic comorbidity.
Management branches
Tubal patency must be assessed during fertility investigation.
- Ask about PID and chlamydia, ectopic pregnancy, endometriosis, pelvic surgery, pain, bleeding and previous imaging.
- Use HSG or expert HyCoSy when no pelvic comorbidity is known; choose laparoscopy and dye when simultaneous pelvic assessment is clinically valuable.
- Explain what the chosen test can and cannot show, including spasm, operator dependence or failure to visualise endometriosis.