Should hysteroscopy be a part of the basic infertility workup?

The state of the art of the infertility workup, strange as it may appear, has never been accurately defined. A recent survey, that was designed to determine how reproductive endocrinologists practice on a daily basis, demonstrated that the five basic tests that were regarded as the cornerstone of the infertility evaluation were: semen analysis, assessment of ovulation, hysterosalpingogram (HSG), laparoscopy, and the post-coital test (Glatstein et al, 1997a). It would seem that there has been no change during the last 25 years. It was reported that ,50% of the specialists would include a more advanced and more accurate modality of evaluating the uterine cavity, such as hysteroscopy, as part of their routine investigation (Glatstein et al., 1997a). We feel that this finding should be evaluated further. 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 (Kessler and Lancet, 1986; Prevedourakis et al., 1994; Golan et al., 1996; Wang et al., 1996). Kessler and Lancet reported that in about two thirds of the cases hysteroscopy findings were not correlated with those found on HSG (Kessler and Lancet, 1986). 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% (Wang et al., 1996). 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 (Golan et al., 1996) 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,