HSG in the evaluation of infertility, Is there any purpose?

The Use of HSG (hysterosalpiingogram) in the evlaution of infertility in my opinion should be essentially relegated to the history books. This is the test wherein dye is injected into the uterus and x-rays are taken to see if it spills out of the tubes into the abdominal cavity. The problems with this test (as many of you will attest) are virtually legendary:

1) Pain. It is painful and unpleasant. I think many women would put up with it if it provided good information that is helpful to the couple. That is the problem...it really does not.

2) False Negative tests are common. If the test is totally normal it is true that HSG tells accurately if the tubes are open. However, there are many false negatives. that is patients are told the tubes are open, and this means the tubes are just fine. They then proceed with clomid, IUI, etc. Later they ahve a laparoscopy to find out the tubes are damaged or distorted by adhesions (but open...) and/or there are other problems like endometriosis, etc. that can prodoundly affect fertility. Also these conditions significantly lower the probability of success of those prior treatemnts...Personally I feel that this would have been nice to know prior to embarking on those treatments.

3) False Postive tests are common. During the process of injecting the dye with HSG, air bubbles often are introduced. These can produce the appearance of blockage at the proximal part of the tube, the part where the tube meets the uterus. Additonally when the dye is introduced rapidly by the person doing the injection, the uterus expand quickly and its natural reaction is to contract (i.e. spasm). This is why it is so painful often times as well. The spasm also can falsely produce the appearance of blockage. What happens next is often the patients are told they need IVF or worse, told they need another HSG or tubal catheterization procedure to determine if this is truly a blockage or not...

4) The HSG does not evaluate the pelvis. Along the same vein as #2, a normal HSG does not tell you if there is tubal damage not resulting in blockage. Nor does it tell you if there are other factors in the pelvis that profoundly can affect fertility (namely endometirosis and adhesions). The majority of patients I see that have tubal damage in fact do not have blockage, i.e. they ahve a 'normal' HSG.

So I believe the better way to go about the fertility evaluation in the most efficient and cost effective manner is to skip the HSG all together. One can evaluate tubal patency just as reliably with in office ultrasound in most cases and without nearly the level of discomfort for the patient seen with HSG. The laparoscopy should replace the HSG in selected cases where the answer for fertility is not found with the simple male and female evaluation (blood test, US, male tests). Not all patients need laparoscopy, so be clear on that. Do it where it will help the couple make decisions on future fertility treaments, i.e. in cases where the findings with laparoscopy will affect future fertility treatment outcome, thus help decide beforehand what treatments you will do in the first place. After all, it is a basic tenet of medicine to try and have a diagnosis BEFORE you treat...same with fertility treaments. The HSG serves only to delay the efficient evaluation, beget delays in treatment and lead to unnecessary tests. Not too mention all this burdens the system with increased costs and burdens patients with painful exams that do not meaningfully help them. It is a rare case indeed where I feel that the HSG helps the couple by providing useful information that helps them make decisions.