Board Review

A 26-year-old woman is evaluated because she and her husband have been trying to conceive for 14 months without success. Her husband fathered a child in a previous marriage. Her medical history is notable for pelvic inflammatory disease, which was diagnosed and successfully treated at age 18 years. Her only medication is a prenatal vitamin.

Physical examination findings are unremarkable.

Which of the following studies is most likely to be diagnostic?

A) Diagnostic laparoscopy

B) Hysterosalpingogram

C) Peripheral karyotype of the patient

D) Semen analysis of the patient's husband

E) Transvaginal ultrasound assessment of follicle count

Answer: B - Hysterosalpingogram

Objective: Evaluate primary infertility with a hysterosalpingogram.

Key Point

Primary infertility due to a tubal abnormality is common, particularly in women with a history of pelvic inflammatory disease, and is best evaluated with a hysterosalpingogram.

The test most likely to be diagnostic is a hysterosalpingogram (HSG) to evaluate tubal patency. Primary infertility due to a tubal abnormality is common and is best evaluated with dynamic testing of the female reproductive tract under fluoroscopy with an HSG. This patient, owing to her history of pelvic inflammatory disease, is likely to have a distal tubal occlusion and resultant hydrosalpinx. Many women with hydrosalpinx have no symptoms; however, symptoms may include pelvic pain (both unilaterally and bilaterally) and chronic vaginal discharge. Confirmatory evaluation should include diagnostic laparoscopy, but this is not typically performed as first-line evaluation given the need for general anesthesia, intubation, and recovery. Repair of the fallopian tubes may be possible with microsurgical techniques; however, reocclusion is possible and the risk of subsequent ectopic pregnancy is high. Many women elect to proceed with in vitro fertilization in lieu of tubal surgery.

Ovarian reserve assessment and semen analysis are essential when evaluating a couple with infertility. Ovarian reserve assessment can be accomplished with early follicular phase testing of follicle-stimulating hormone (FSH) or anti-müllerian hormone (AMH). Transvaginal ultrasound in the early follicular phase allows for counting of antral follicles in each ovary, which if present at greater than eight bilaterally support normal ovarian reserve. However, given this patient's history of pelvic inflammatory disease and her husband's history of fathering a child in a previous marriage, HSG is the diagnostic test that is most likely to reveal an abnormality.

Semen analysis can be performed after a short window of abstinence on an ejaculated sperm specimen. However, it is unlikely to be helpful in this patient's husband.

Karyotyping is usually not indicated as part of the initial evaluation of unexplained female infertility because of the low incidence of discovered abnormalities.

Specialized laboratories with andrology services evaluate sperm concentration, sperm motility, and sperm morphology. Ovarian reserve may be evaluated by serum testing (day 3 follicle-stimulating hormone level, AMH level) or by transvaginal ultrasound assessment of antral follicle count.

Maheux-Lacroix S, Boutin A, Moore L, et al. Hysterosalpingosonography for diagnosing tubal occlusion in subfertile women: a systematic review with meta-analysis. Hum Reprod. 2014 May;29(5):953-63. Link Out