Normal human functioning relies upon normal functioning (physiology) and normal anatomy. Abnormalities in anatomy can reduce or eliminate a person’s chance of conceiving.

The most common anatomical causes of infertility include pelvic scarring and endometriosis. There are other less frequent causes such as intrauterine scarring (Asherman’s syndrome), congenital anomalies, and, uncommonly, fibroids.

The diagnostics tests used to assess anatomy has changed dramatically over the course of the last 20- 25 years. The advent of IVF has also altered the diagnostic approach to anatomy. Traditionally, an X-ray based test called a hysterosalpingogram, a surgical procedure termed a diagnostic laparoscopy were the basis for diagnostic testing for anatomical abnormalities. Ultrasound, particularly vaginal ultrasound, has revolutionized the anatomic evaluation.

  • Diagnostic laparoscopy

    A laparoscopy is a surgical procedure done with the person under general anesthesia. A small incision in made under the belly button and a telescopic device is introduced into the abdomen. Usually, a small incision is made above the pelvic bone and a second instrument for manipulating the structures within the abdomen is introduced. Blue water can be flushed through the cervix and uterus can determine if the fallopian tubes are open. Prior to the use of IVF, the diagnostic laparoscopy was a commonly performed procedure. Currently, diagnostic laparoscopies are seldom performed.

  • Hysterosalpingogram (HSG)

    The HSG is an X-ray based procedure. This is usually done in the department of radiology by a radiologist. The person is placed on an X-ray table. The cervix is visualized by placing a speculum. Th cervix is cleansed and grasped. A metal tube is place in the cervix and radio-opaque fluid is flushed through the uterus and fallopian tubes. If the tubes are open, the dye will spill into the abdomen. The test can be painful and there is a slight chance of either infection or an allergic reaction to the dye. The value of the test lies in the ability of the test to determine abnormal pathology. If there are abnormal structures in the cavity of the uterus they will show on the X-ray. The test is accurate in determining if the fallopian tubes are open. However, the test is far less accurate if it says the tubes are blocked. If the test says the tubes are blocked, the accuracy is only 40-50 %, meaning half the time the test suggested the tubes are abnormal when in fact the anatomy is normal. Furthermore, commonly the test will say one tube is blocked just as the tube leaves the uterus, called a proximal, unilateral obstruction. Unless there is other evidence for an anatomic problem, this finding does not suggest a reduction in fertility rates. Before the introduction if ultrasonography, the course of action was to do a HSG and if normal follow that with a diagnostic laparoscopy. Today, that course has been replaced with the use of ultrasonography.

  • Ultrasonography (US)

    Pelvic US can be done with or without infusing the uterus and tubes with water or a substance that shows up on US. The advantage of the US is that is gives information about soft tissues like the uterus and ovaries that an X-ray does not provide.

    Further, US evaluates the entire organ and not just the surface as seen by laparoscopy. Thus, the US can detect fibroids, adenomyosis, and ovarian structures such as cysts or the antral follicle count. Water or a fluid which reflects on the US can be infused, similar to the HSG.

    This is highly accurate in determining structures within the uterine cavity such as polyps and fibroids. It can also detect scarring which cannot be seen if the water is not infused. Finally, water infused sonography (SIS for saline infused sonogram) can determine if the fallopian tubes are open. The SIS is as accurate as the HSG but give considerably more information than the HSG. Furthermore, it can be done in a physician’s office and is less painful the HSG. There does remain the potential risk of infection.