It is widely accepted that a complete infertility workup should include an evaluation of the uterine cavity. ... Today, hysteroscopy is considered the gold standard for evaluating the uterine cavity, and due to improved endoscopic developments, can be performed reliably and safely as an office procedure.
One of the basic steps of the infertility workup is to assess the shape and regularity of the uterine cavity. Historically, and still today as it turns out, the HSG has been the most commonly used test for this purpose. During the last two decades, however, several studies have demonstrated that when the uterine cavity has to be investigated within the infertility workup, hysteroscopy is much more accurate than HSG. It was shown that 54.3% of intrauterine adhesions diagnosed on HSG were not found on direct hysteroscopic examination. Another recent study comparing the diagnostic value of HSG and hysteroscopy in female infertility showed that among 79 women with normal HSG, 28 had abnormal findings on hysteroscopy, for a false negative rate of 35.4%. Of the 135 women with an abnormal HSG, hysteroscopy demonstrated a normal uterine cavity in 21, a false positive rate of 15.6%. The sensitivity of HSG was 80.3% in revealing intrauterine abnormality and its specificity was 70.1%. Other investigators have reported similar results. Therefore, it appears that in more than one third of the cases where the HSG is interpreted as normal, it may supply a false reassurance. These women, wrongly treated as women with a normal uterine cavity, would probably undergo other `unjustified' tests within the infertility workup, while the cause of their infertility might be the missed intrauterine lesion. Furthermore, hysteroscopy allows exact location of intrauterine lesions, and provides a better way than the blunt curettage to ensure excision of such lesions .