Anatomical & Surgical Female Infertility Testing

Female infertility testing for women at a glance

  • Pelvic adhesions (scar tissue), endometriosis, fibroids, uterine polyps and blocked fallopian tubes can all contribute to infertility.
  • A thorough evaluation includes a pelvic examination and imaging studies.
  • No single imaging study is perfect at detecting all conditions. In some cases, more than one test needs to be performed to thoroughly understand a woman’s anatomy.
  • Surgery may be necessary in some instances to fully investigate anatomical issues that may contribute to infertility.

Anatomical imaging female infertility testing

Hysterosalpingogram (HSG)

A hysterosalpingogram is one of the most common studies performed to assess a woman’s anatomy. Translated it means, picture (gram) of the uterus (hysto) and fallopian tubes (salpingo).

The test is performed in a radiology suite. A speculum is placed into the vagina and a small catheter is introduced through the cervix and into the uterus.

X-ray contrast media is then pushed through the catheter to fill the uterus and tubes. The resulting image shows the inside of the uterus (not the walls) and whether the tubes are open.

X-ray of HSG female infertility testing | Tennessee Reproductive Medicine | Chattanooga, TNIllustration of HSG female infertility testing | Tennessee Reproductive Medicine | Chattanooga, TN

Sometimes an HSG can show whether the tubes are blocked, or if fibroids or polyps are present in the uterine cavity. The HSG is a good screening test for uterine malformations including uterine septum, unicornuate uterus, bicornuate uterus and didelphic uterus.

HSGs can also indicate whether a patient is at increased risk for conditions such as endometriosis. One limitation of the HSG is that it does not show the walls of the uterus or the ovaries directly.

The HSG image is essentially a shadow of the woman’s anatomy, and there are times when these shadows can be incomplete. In these cases, other tests such as saline hysterosonography (ultrasound with water infusion), MRI, or diagnostic surgery may be necessary.

The HSG can cause uterine cramping and, in very rare cases, lead to pelvic infection or tubal scarring. Anti-inflamatory medicine such as ibuprofen is typically recommended prior to the test. Antibiotics are prescribed if a patient is at increased risk for tubal infection.

Other anatomical imaging tests


Ultrasound is the most frequently used test by fertility specialists and gynecologists. It provides an excellent view of the uterus and ovaries and can be instrumental in diagnosing a wide range of conditions including fibroids, polyps, uterine malformations and endometriosis. One limitation of the ultrasound is that it generally does not allow visualization of the fallopian tubes.

Saline hysterosonography

Saline hysterosonography (SHG) is a test that combines ultrasound with the HSG technique. A catheter is inserted through the cervix. The uterus is filled with sterile fluid and the ultrasound is then performed. Aside from looking into the uterus directly with a hysteroscope, saline sonography is the most sensitive test for detecting uterine polyps and fibroids.

Surgical diagnostic female infertility testing

In some cases, surgery may be required to fully evaluate fertility. The most common are a hysteroscopy or laparoscopy, two minimally invasive outpatient surgical procedures for diagnosing abnormalities in female anatomy.

Diagnostic hysteroscopy

Diagnostic hysteroscopy is the most effective procedure for evaluating the inside of a woman’s uterus. This minimally invasive surgical procedure involves placing a very small tube (hysteroscope) into the woman’s uterus. The tube has a video camera attached to it and allows the physician to see inside the uterus with great clarity.

Diagnostic hysteroscopy will verify or rule out any abnormalities suspected on other tests such as HSG, SHG or ultrasound. If abnormalities such as polyps, fibroids or a septate uterus are confirmed, small surgical instruments can be introduced through the hysteroscope to make the uterus normal.

The procedure is accomplished with minimal anesthesia in an outpatient surgical setting. Almost all women require minimal pain medicine after surgery and can return to work the following day.

Diagnostic laparoscopy

Laparoscopy is a surgical procedure in which a camera is placed through the belly button of the female patient to allow for direct visualization of the pelvic anatomy.

Laparoscopy is still considered the gold standard for diagnosing abnormalities in female anatomy. We reserve laparoscopy for very specific cases: for patients who are experiencing pain and need a diagnosis, or if we find abnormalities on ultrasound, HSG or physical examination.

Declining use of laparoscopy for fertility evaluation

If a woman has a normal HSG, no history of pelvic pain and a normal ultrasound, the chance that laparoscopy will change either management or treatment outcome is small. For example, in couples with unexplained infertility (normal sperm, normal HSG and proof of ovulation), there is a 20 percent chance that the woman has endometriosis. Endometriosis can make it more difficult for women to get pregnant.

Studies have shown that removing endometriosis in women with mild to moderate disease does improve pregnancy rates, but unfortunately, the success rates of surgery are actually quite small.

If we had 12 patients with mild to moderate endometriosis and we surgically removed the endometriosis, three of those women would be pregnant within the next 12 months if they were trying to get pregnant. Three out of 12 women conceiving over a 12-month period is not a high pregnancy rate, especially compared wth other therapies.

Furthermore, if instead of operating on these women we had watched them expectantly to see how many conceived, two of the 12 would have conceived in the same 12-month period. This means a doctor have to perform surgery on 12 women to get just one pregnancy we would not otherwise have seen.

To make matters even worse, if there is only a 20 percent chance that a woman has endometriosis, we would have to operate on 60 women to achieve one additional pregnancy.

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