Pelvic-factor infertility: tubal patency (HyCoSy, HSG, laparoscopy), endometriosis, adhesions, and submucous fibroids

A 34-year-old teacher and her 36-year-old partner arrive in clinic after 14 months of trying. Her cycles are 28 days and regular. She has mild dysmenorrhoea but no dyspareunia. The structured couple workup has been reassuring — normal semen analysis against WHO 6th-edition limits, ovulatory mid-luteal progesterone, AMH and FSH within expected range for her age. The next question is are the tubes open and is the cavity normal? Your job is not to jump to laparoscopy — NICE NG257 orders the assessment: HyCoSy first-line (outpatient transvaginal ultrasound with contrast, no radiation), HSG as alternative (fluoroscopy with iodinated contrast), and laparoscopy with chromopertubation as the gold standard when surgery is indicated. The finding on that first tubal test determines the next move — salpingectomy before IVF for hydrosalpinx, expectant management or ART for normal tubes, or laparoscopy when pelvic disease is suspected. Miss the ordering and you have either over-investigated a low-risk woman or under-treated a hydrosalpinx.^[1][3][8]

Overview and definition

Pelvic-factor infertility encompasses tubal, peritoneal, endometriotic and cavity (uterine) causes, contributing in roughly 20 to 30% of female-factor infertility. NICE NG257 (2026) recognises endometriosis as a dedicated pathway (no longer buried in "unexplained") and frames the tubal assessment as a stepped decision — HyCoSy first-line, HSG as alternative, laparoscopy with chromopertubation when pelvic disease needs surgery.^[1]

The clinical act that earns the mark is the ordered test selection. A low-risk woman with no pelvic symptoms gets HyCoSy; a woman with suspected endometriosis or prior pelvic surgery goes directly to laparoscopy if a surgical decision is needed; a hydrosalpinx on any imaging warrants salpingectomy or proximal tubal occlusion BEFORE IVF, not after. The test you choose is the answer you commit to.^[1][3]

^{[1] [3] [8] [7]}

References12ShowHide

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