Is Hysterosalpingography (HSG) mandatory in cases of secondary infertility?

Is HSG Mandatory in Secondary Infertility?

HSG is not mandatory in secondary infertility, but it is highly recommended as a first-line diagnostic test, particularly because tubal pathology is the predominant finding in this population and HSG provides both diagnostic and potential therapeutic benefits.

Clinical Context for Secondary Infertility

Secondary infertility presents a distinct diagnostic pattern compared to primary infertility:

• Tubal pathology is the predominant abnormality in secondary infertility, accounting for 88.4% of detected pathologies in this population 1
• Women with secondary infertility are more likely to benefit from HSG evaluation specifically because tubal factors are most common in this group 1
• In contrast, primary infertility shows uterine pathologies in 62.5% of cases, making the diagnostic yield different between these populations 1

Guideline-Based Recommendations

The American College of Radiology (ACR) Appropriateness Criteria (2020) does not mandate HSG universally but positions it as a first-line option:

• HSG or HyCoSy are recommended as first-line tests for evaluating tubal patency due to their less invasive nature and good diagnostic accuracy 2
• HSG demonstrates 65% sensitivity and 85% specificity for diagnosing tubal patency when compared with laparoscopy 2
• HSG provides structural information about tubal patency, size, irregularity, and peritubal disease 3

Diagnostic Performance

HSG offers specific advantages in secondary infertility evaluation:

• HSG can detect tubal patency, intrauterine adhesions, and peritubal disease with reasonable accuracy 2
• 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 2
• HSG results show statistical significance in predicting conception within 6 months after the procedure 1

Alternative Diagnostic Approaches

While HSG is not absolutely mandatory, alternatives have limitations:

• Transvaginal ultrasound (TVUS) alone is not effective in documenting tubal patency, though it can detect hydrosalpinx with 86% sensitivity 2, 4
• 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 2
• Diagnostic hysterolaparoscopy is more invasive but detects 19.14% more incidental findings than HSG 5
• 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 6, 2

Clinical Decision Algorithm

For secondary infertility workup:

1. Initial imaging should include transvaginal ultrasound to assess ovarian reserve and detect obvious pathology like hydrosalpinx 6

2. HSG or HyCoSy should be performed as the next step to evaluate tubal patency, given the high prevalence of tubal factors in secondary infertility 2, 1

3. Consider antibiotic prophylaxis if there is prior history of pelvic inflammatory disease or if hydrosalpinx is noted 6, 4

4. Reserve diagnostic hysterolaparoscopy for cases where HSG shows abnormalities requiring further characterization or when HSG is contraindicated 5

Important Caveats

• 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 2
• The agreement between HSG and hysteroscopy for uterine cavity evaluation is only 71.3%, representing fair agreement 5
• HSG carries risks including radiation exposure, pain, and rare allergic reactions to contrast material 1
• In secondary infertility specifically, the diagnostic yield justifies the procedure given the predominance of tubal pathology in this population 1