Diagnostic approaches for tubal factor infertility: a systematic review of HSG, HyCoSy, HyFoSy, and laparoscopy

Introduction Tubal pathology remains a major cause of female infertility, making accurate assessment of tubal patency and morphology important for clinical decision-making. Several diagnostic approaches are available, including hysterosalpingography (HSG), hysterosalpingo-contrast sonography (HyCoSy), hysterosalpingo-foam sonography (HyFoSy), and laparoscopy with chromopertubation. This systematic review aimed to synthesize current evidence on their diagnostic performance, clinical applicability, and role in contemporary diagnostic pathways. Methods PubMed/MEDLINE, Embase, the Cochrane Library, and Web of Science were searched for studies published between January 2015 and March 2026. Studies evaluating methods for tubal patency or morphological assessment in women undergoing infertility investigation were considered. A total of 21 studies were included. Owing to clinical and methodological heterogeneity, particularly differences in study populations, diagnostic thresholds, and reference standards, the findings were synthesized qualitatively. Results HSG generally demonstrated high sensitivity but variable specificity, limiting its reliability for confirming tubal occlusion. HyCoSy showed potentially useful diagnostic performance as a non-invasive screening method, although estimates varied across studies. Several studies reported favorable specificity, predictive values, and agreement measures for HyFoSy, together with improved patient tolerability; however, findings were not uniform and were influenced by methodological heterogeneity and differences in reference standards. Laparoscopy with chromopertubation remained the reference standard for assessing tubal patency and identifying concomitant pelvic pathology, although its invasive nature limits its routine use. Discussion Current evidence supports a stepwise approach to tubal assessment in which less invasive methods may be used initially, with confirmatory or invasive techniques reserved for selected cases. Such an approach may improve diagnostic confidence while reducing unnecessary procedural burden and risks. Further well-designed comparative studies using standardized reference standards and outcome definitions are needed to clarify the relative diagnostic value of available techniques.