HSG in Nulliparous Women with Infertility
Yes, hysterosalpingography (HSG) is warranted in nulliparous women experiencing fertility issues as a first-line diagnostic test for evaluating tubal patency and uterine cavity abnormalities. 1, 2
Primary Recommendation
The American College of Radiology recommends HSG (or HyCoSy as an alternative) as a first-line test for evaluating tubal patency in infertility workup due to its less invasive nature and good diagnostic accuracy. 1, 2 This applies equally to nulliparous women, as tubal and peritoneal disease are among the main causes of infertility regardless of parity status. 3
Diagnostic Performance
HSG demonstrates 65% sensitivity and 85% specificity for diagnosing tubal patency when compared with laparoscopy, making it an appropriate initial test before considering more invasive procedures. 1, 2
Key diagnostic capabilities include:
- Tubal patency assessment: Detects tubal occlusion, size, irregularity, and peritubal disease 1, 2
- Intrauterine pathology: Identifies adhesions, polyps, submucous fibroids, and uterine septa 1, 4
- Structural abnormalities: Evaluates uterine cavity morphology and fallopian tube lumina 5, 3
Therapeutic Benefit
HSG offers a therapeutic advantage beyond diagnosis: tubal flushing during the procedure increases pregnancy rates up to 38% compared to 21% in women who did not undergo HSG. 1, 2 This therapeutic effect makes HSG particularly valuable in nulliparous women seeking their first pregnancy.
Clinical Algorithm
Initial assessment: Perform transvaginal ultrasound to assess ovarian reserve and detect obvious pathology like hydrosalpinx 1
HSG timing: Proceed with HSG as the next diagnostic step to evaluate tubal patency, given the high prevalence of tubal factors in infertility 1
Antibiotic prophylaxis: Consider prophylactic antibiotics if there is prior history of pelvic inflammatory disease or if hydrosalpinx is noted on initial imaging 1, 2
Further evaluation if needed: If congenital uterine anomalies are suspected, proceed to MRI rather than relying on HSG, as HSG has only 16.7% accuracy for categorizing Müllerian duct anomalies compared to MRI's 100% accuracy 1, 2
Important Caveats
HSG has limited accuracy (52.6%) for detecting fibroids compared to sonohysterography (75% accuracy), so if intrauterine lesions are strongly suspected based on clinical presentation, consider sonohysterography as an alternative or complementary test 6
Transvaginal ultrasound alone is inadequate for documenting tubal patency (though it can detect hydrosalpinx with 86% sensitivity), so HSG or HyCoSy remains necessary for complete tubal evaluation 1, 2
Hysteroscopy may reveal additional pathology: In nulliparous women with unexplained infertility after HSG, hysteroscopy detected endocavitary lesions (polyps, septa, submucous myomas) that led to an 85% pregnancy rate after treatment 7
Alternative Considerations
HyCoSy (hysterosalpingo-contrast sonography) can be offered as an alternative to HSG with similar diagnostic accuracy (91% in women with endometriosis) and can be performed in one comprehensive session with transvaginal ultrasound. 1, 2 However, HSG remains more widely available and provides superior structural detail of the tubal lumen. 3