Pelvic-factor infertility — structured SAQ (15 marks)

(a) NICE NG257 ordering of tubal patency tests (4 marks)

One mark per test with rationale, plus one for the ordering. ^[1][2]

• First-line — HyCoSy (hysterosalpingo-contrast-sonography) — outpatient transvaginal ultrasound with contrast; sensitivity ~93%, specificity ~88% vs laparoscopy in the Xydias 2025 meta-analysis; no ionising radiation; no iodinated contrast; assesses the uterine cavity and ovaries at the same visit; preferred in low-risk women.^[1][2]
• Alternative — HSG (hysterosalpingography) — fluoroscopy with iodinated water-soluble or oil-based contrast; sensitivity ~94%, specificity ~92% in older meta-analyses; useful when HyCoSy is unavailable or inconclusive; carries radiation and contrast exposure; oil-based contrast may have a mild therapeutic effect (tubal flushing).^[2]
• Gold standard — laparoscopy with chromopertubation — direct visualisation of pelvic anatomy and dye spill from fimbrial ends; permits surgical treatment of endometriosis, adhesions, hydrosalpinx; required when pelvic disease is suspected on history or imaging; higher cost, anaesthetic risk, and recovery time.^[1]
• Chlamydia and gonorrhoea screen BEFORE any intrauterine tubal assessment — re-activation of subclinical PID can compromise the very tubes being assessed.^[1]

(b) Hydrosalpinx management before IVF (4 marks)

One mark per point, maximum four. ^[3][6]

• The finding — a visible hydrosalpinx on ultrasound; embryotoxic fluid that halves IVF live birth rates if left in situ.^[3]
• The intervention — salpingectomy (laparoscopic removal of the affected tube) or proximal tubal occlusion (when salpingectomy is surgically risky or the surgical access is poor).^[6]
• The evidence base — the Cochrane review (Johnson et al 2010) confirms that salpingectomy for hydrosalpinx before IVF improves implantation, pregnancy and live birth rates compared with no surgery or simple drainage. The Turok 2021 study confirms salpingectomy and proximal tubal occlusion are both effective.^[3][6]
• The trade-off — loss of the tube for natural conception; counsel the couple on the irreversible nature and the IVF success rate with the intervention (which approaches that of couples without tubal disease after age adjustment).^[6]

(c) Hysteroscopic myomectomy for the FIGO 1 fibroid (4 marks)

One mark per point, maximum four. ^[5]

• The lesion — a FIGO 1 submucosal fibroid, 2 cm, distorting the cavity; submucosal fibroids (FIGO 0-2) are the highest-yield lesion for cavity-resective surgery before ART.^[5]
• The intervention — hysteroscopic myomectomy (resectoscope or morcellator) to restore normal cavity shape and remove the cavity-distorting component.^[5]
• The evidence base — the Cochrane review (Metwally 2015) and the ASRM committee opinion support hysteroscopic resection of submucosal fibroids before IVF; cavity restoration improves conception, implantation, and live birth rates. The cavity matters more than the myometrium.^[5]
• The comparator — for intramural fibroids without cavity distortion, the evidence is more equivocal and the decision is individualised; for FIGO 5-7 subserosal lesions, fertility is rarely affected.^[5]

(d) Three specific pitfalls in pelvic-factor infertility (3 marks)

One mark per pitfall with rationale. ^{[1][3][4][3][2]}

• Pitfall 1 — performing HSG or HyCoSy without a recent chlamydia screen; the procedure can re-activate subclinical PID and compromise the very tubes being assessed.^[1]
• Pitfall 2 — treating endometriosis medically (GnRH analogues, COC, progestins) before ART in a woman trying to conceive; these suppress ovulation and are CONTRACEPTIVE — refer for surgery or ART, do not use hormonal suppression as a fertility treatment.^[1][4]
• Pitfall 3 — performing repeated endometrioma cystectomy and depleting the ovarian reserve; AMH falls after each cystectomy and the third cystectomy is rarely in the patient's interest. Consider ART with the cyst in situ for large lesions or in women over 35 with low reserve.^[3][2]
• (Acceptable alternative pitfall) — missing a septum versus bicornuate distinction; resecting a bicornuate uterus creates a unified but deficient uterus. Use 3D ultrasound or MRI before any septum surgery.^[5]