Tubal-factor infertility and tubal surgery — structured oral station (12 minutes)

Opening prompt — "Tell me what this HSG shows and what you will do."

Model response — say it in this order: [3]

• "This HSG shows a right hydrosalpinx with distal occlusion and free left-sided spill. Given her history of chlamydia, this is tubal-factor infertility, and the hydrosalpinx is the finding that changes the plan."[3]
• "My three governing questions are: is the tube patent, is the mucosa healthy, and what is her age and ovarian reserve? At 30 with a normal partner, the answer to the third is favourable, but the hydrosalpinx must be dealt with before any IVF."[2]

Examiner is listening for: recognition of the hydrosalpinx as the key finding, the surgery-versus-IVF framework, and the hydrosalpinx-before-IVF rule. [1]

Probe 1 — "Why does the hydrosalpinx matter for IVF?"

• "A hydrosalpinx actively harms IVF. The Zeyneloglu meta-analysis showed it roughly halves clinical pregnancy and implantation rates and more than doubles miscarriage."[1]
• "The fluid is embryotoxic, it leaks into the uterine cavity and mechanically washes out embryos, and it disrupts the endometrial receptivity cytokines. So a hydrosalpinx is not just a blocked tube — it is an active saboteur of implantation."[1][3]

Probe 2 — "What will you do about it, and what is the evidence?"

• "I would offer laparoscopic right salpingectomy before IVF. The Melo Cochrane review found salpingectomy before IVF probably increases clinical pregnancy versus no surgery (risk ratio 2.02, 95% CI 1.44 to 2.82, moderate-quality evidence), and the Strandell randomised trial confirmed improved cumulative IVF outcomes."[2][4]
• "If salpingectomy were technically difficult — dense adhesions, or ovarian-reserve concerns — proximal tubal occlusion is the supported alternative (RR 3.21, low quality). Aspiration is inferior and temporary, so I reserve it for when no surgery is possible."[2]

Probe 3 — "She asks whether you could 'unblock' the tube with surgery instead."

• "I would explain that for a hydrosalpinx this severe, reconstructive salpingostomy has poor prospects: the lining of the tube is likely damaged, and a patent but non-functional tube carries ectopic risk without restoring fertility. At her age, with a confirmed hydrosalpinx, IVF after salpingectomy gives her the best chance."[3]
• "Reconstructive surgery is something I would consider in a young woman with mild disease and a healthy-looking tube who wanted to try naturally — that is not her situation."[3]

Probe 4 — "Could the HSG itself have helped her conceive?"

• "The Dreyer H2Oil trial found oil-based contrast gave higher ongoing pregnancy (39.7% vs 29.1%) and live birth than water-based within six months. So in unexplained or mild disease, oil-based HSG can be therapeutic."[5]
• "But that benefit applies to women without a major tubal lesion. Her confirmed hydrosalpinx needs salpingectomy, so oil flushing does not substitute for surgery here."[1]

Probe 5 — "What tubal test would you have used first if she had no risk factors?"

• "In a low-risk woman I would offer HyCoSy — hysterosalpingo-contrast-sonography — as a radiation-free first-line test. A meta-analysis reported pooled sensitivity around 86% and specificity around 94% for 2D-HyCoSy against laparoscopic dye, similar to 3D/4D. Laparoscopy with chromopertubation remains the reference standard, and I would go straight to it when risk factors or an abnormal HSG mandate it."[6]

Probe 6 — "She is frightened about losing her tube and her fertility. Speak to her."

This is a scored domain — demonstrate it out loud: [3]

• "I can see this is worrying. Let me explain plainly. The tube on the right is damaged and filled with fluid, and that fluid would actually work against IVF, so we recommend a small operation to remove that tube first — your other tube and both your ovaries stay. Once that is healed, IVF gives you a very good chance, and you are young, which is on your side."
• Acknowledge the fear, avoid jargon, check her understanding, and offer written information and a follow-up.[3]