Diagnostic Evaluation of Secondary Infertility

Guideline-Based Recommendations

The American College of Radiology recommends HSG or HyCoSy as first-line tests for evaluating tubal patency due to their less invasive nature and good diagnostic accuracy 1
HSG demonstrates 65% sensitivity and 85% specificity for diagnosing tubal patency when compared with laparoscopy 1
HSG provides structural information about tubal patency, size, irregularity, and peritubal disease 2

HSG can detect tubal patency, intrauterine adhesions, and peritubal disease with reasonable accuracy 1
The procedure has therapeutic potential: tubal flushing during HSG increases pregnancy rates up to 38% compared to 21% in women who did not undergo HSG 1

Transvaginal ultrasound (TVUS) alone is not effective in documenting tubal patency, though it can detect hydrosalpinx with 86% sensitivity 1, 3
HyCoSy (hysterosalpingo-contrast sonography) has similar accuracy to HSG (91% accuracy in women with endometriosis) and can be performed as part of a comprehensive examination 1
Sonohysterography (SIS) demonstrates 75% accuracy in detecting fibroids compared to HSG's 52.6% accuracy, but regular SIS without contrast is not supported for tubal occlusion assessment 1, 4

Initial imaging should include transvaginal ultrasound to assess ovarian reserve and detect obvious pathology like hydrosalpinx 5
HSG or HyCoSy should be performed as the next step to evaluate tubal patency, given the high prevalence of tubal factors in secondary infertility 1
Consider antibiotic prophylaxis if there is prior history of pelvic inflammatory disease or if hydrosalpinx is noted 3, 4

HSG has limited value (16.7% accuracy) in categorizing Müllerian duct anomalies compared to MRI (100% accuracy), so if congenital anomalies are suspected, MRI should be considered 1