Should a hysterosalpingogram be a first-line investigation to diagnose female tubal subfertitlity in the modern subfertility workup?

Tubal assessment is an integral part of female fertility evaluation. While diagnostic laparoscopy is gold standard, it is not
suitable to be used as a screening test. Hysterosalpingogram (HSG) has been advocated as first-line investigation historically. With advances
in diagnostics, more tests are available, such as hysterosalpingo contrast sonography (HyCoSy) and Chlamydia antibody titre (CAT) are available.
The CAT test is much cheaper, less invasive and can be performed at any time during the cycle. The CAT test can also be used as a
means of identifying which patients need further evaluation. HyCoSy has same diagnostic accuracy as HSG, without exposing women to
radiation. We argue that HSG is out of date and has no place in a modern infertility evaluation. We also suggest a pathway (based on
history, clinical and ultrasound evaluation) for investigations to screen for and diagnose tubal pathology.