Female Infertility Diagnosis and Management

Indications and Evaluation

The American College of Radiology recommends hysterosalpingography (HSG) for evaluating female infertility, particularly to assess tubal patency and uterine cavity abnormalities, with a sensitivity and specificity of 65% and 85% compared to laparoscopy with chromopertubation 1
HSG allows detection of tubal patency, tubal size, tubal irregularity, and peritubal disease 1
Transvaginal ultrasound has a sensitivity of 86% for detecting hydrosalpinx, according to the American College of Radiology 1
Hysterosalpingo-contrast sonography (HyCoSy) is an alternative to HSG, with an accuracy of 91% compared to laparoscopy, as reported by the American College of Radiology 1
MRI is useful when ultrasound findings are inconclusive, with an accuracy of 75.6%, as noted by the American College of Radiology 1
Laparoscopy with chromopertubation is the definitive diagnostic method, according to the American College of Radiology 1

Pelvic inflammatory disease (PID) is the primary cause of blocked fallopian tubes, most commonly resulting from sexually transmitted infections like Chlamydia trachomatis and Neisseria gonorrhoeae, as reported by the Centers for Disease Control and Prevention (CDC) 2, 3
Sexually transmitted infections (STIs), such as Chlamydia trachomatis, are the most common infectious cause of fallopian tube blockage, according to the CDC 3
Endometriosis can cause peritoneal adhesions and tubal damage, as noted by the American College of Radiology 1
A history of previous PID, STIs, pelvic surgery, or endometriosis should raise suspicion of fallopian tube blockage, according to the American College of Radiology 1

Early and appropriate treatment of STIs and PID is crucial to prevent long-term sequelae, such as tubal infertility, as stated by the CDC 2, 3
Regular STI screening for sexually active individuals is recommended, as reported by the CDC 3
Prompt treatment of partners of infected individuals is essential, according to the CDC 2
Antibiotic prophylaxis during certain gynecological procedures may be necessary, as noted by the American College of Radiology 1
The American College of Radiology recommends salpingectomy (surgical removal of the affected tube) as the preferred approach before IVF treatment, which improves IVF outcomes by eliminating toxic fluid reflux, and laparoscopic approach is recommended when feasible 1
Early and appropriate treatment of pelvic inflammatory disease, complete removal of fallopian tubes during hysterectomy, and consideration of prophylactic salpingectomy during pelvic surgery in women who have completed childbearing are recommended to prevent hydrosalpinx, according to the American College of Radiology 1

Typical ultrasound findings for hydrosalpinx include a tubular anechoic or hypoechoic structure adjacent to ovary, incomplete septa ("beads-on-a-string" sign) in chronic cases, and thin wall in chronic cases (97% of chronic cases), as described by the American College of Radiology 4
The differential diagnosis for hydrosalpinx includes paraovarian cyst, ovarian cyst, tubo-ovarian abscess (TOA), ectopic pregnancy (in reproductive-age women), and peritoneal inclusion cyst 1

Tubal flushing during HSG has been shown to increase pregnancy rates up to 38% compared to 21% in women who did not undergo HSG, with highest rates seen when oil-soluble contrast is used 1
HSG has limitations, including inability to provide complete information about external uterine contour, limiting accurate distinction between septate and bicornuate uterus, and only 16.7% accurate in characterizing Müllerian duct anomalies compared to MRI (100% accurate) and 2D TVUS (92% accurate) 1
Hydrosalpinx significantly reduces IVF success rates by creating a hostile environment for embryo implantation, according to the American College of Radiology 1
The prognosis for fertility is significantly impacted by the presence of hydrosalpinx, with bilateral hydrosalpinx having a worse prognosis, as stated by the American College of Radiology 1