De plaats van het hysterosalpingogram en de diagnostische laparoscopie bij subfertiliteit

Tubal pathology is a significant cause of subfertility. The status of the tubes can be assessed with hysterosalpingography (HSG) or diagnostic laparoscopy, whereas measurement of Chlamydia antibody titers (CAT) can be used to select patients at increased risk for tubal pathology. The discriminative capacity of HSG and CAT is comparable, when laparoscopy is used as reference test. Unilateral tubal pathology at HSG implicates a slight reduction of fertility prospects, whereas bilateral tubal pathology implicates a strong reduction of fertility prospects. Unilateral tubal pathology at laparoscopy implicates a strong reduction of fertility prospects, whereas bilateral tubal pathology virtually eliminates the chance of pregnancy, although 'spontaneous' pregnancy still cannot be ruled out. Decision analysis modelling shows that work-up to detect tubal pathology in subfertile couples should start with CAT in couples with relatively good fertility prospects, whereas couples with relatively poor fertility prospects benefit from a strategy starting with immediate HSG. Laparoscopy should be performed immediately in the event that the probability for tubal pathology exceeds 15%, whereas laparoscopy can be postponed for a year in the event that the probability of tubal pathology is below 15%.