Infertility is defined as the inability of a sexually active couple with no contraception to achieve pregnancy within one year [1]. The most important step in evaluating infertile couples and making treatment plans is to determine the etiology correctly. Tubal factors constitute 20–25% of the causes of infertility in women [2]. The fallopian tubes are serve a highly specialised essential functions in the reproductive process. The first mission, picking up an ovum when it is discharged from the ruptured ovarian follicle and transferring the ovum into the tubal lumen. The second mission of the tubes are, they provide a suitable environment for sperm capacitation and ovum fertilisation to occur, and transfers the fertilised embryo into the uterus [3].

Chromopertubation, in which hysteroscopy (HS) and laparoscopy are combined, is considered the gold standard method in evaluating the tube opening and uterine cavity [4, 5, 6]. However, research is still ongoing on an easy and simple method that can be applied in less invasive and outpatient settings. Today, hysterosalpingography (HSG), which can be used in an out-patient setting, is the most commonly used screening method for evaluation of the fallopian tubes [7]. However, recent studies have shown hysterosalpingography to exhibit a relatively low sensitivity to detect tubal patency and a high inter-observer variation in the interpretation of results [8]. In this context, studies on hysteroscopic methods are concentrated because they can simultaneously provide treatment in case of detection of pathological conditions of the uterine cavity. Undoubtedly, the most important reasons are that they are less invasive and less cost-effective [9, 10, 11]. In this study, we aimed to compare the traditionally applied hysterosalpingography in the evaluation of infertile couples and office hysteroscopy, which we think may be superior in many ways. The first is to evaluate the diagnostic capacity of hysteroscopy to evaluate tube patency compared to hysterosalpingography. Our second aim was to evaluate the uterine cavity simultaneously and to compare the results.

The study was completed with the evaluation of a total of 30 women. In other words, 30 uterine cavities and 60 fallopian tubes were evaluated during the whole study. The women included in the study were women who consecutively applied to the outpatient clinic due to infertility and agreed to participate. In the ultrasonography performed on the third day of menstruation, no pathological sonographic finding was detected in 16 women (53.3%). On the other hand, an appearance compatible with polyp was observed in sonography of two women (6.7%), and an image compatible with uterine septum or arcuate uterus was observed in ultrasonography of five women (16.7%). A clear diagnostic report on the uterine cavity could not be made for seven cases (23.3%). When the uterine cavities of women were evaluated by hysterosalpingography, no uterine pathology was observed in 17 (56.7%) women. On the other hand, filling defects (polyps) were found in the uterine cavity in two (6.7%) women, and uterine septum or arcuate uterus was observed in nine (30%) women. In addition, unfortunately, the uterine cavity could not be evaluated sufficiently in the images of two (6.7%) women. As a result of the hysteroscopic evaluation of the cavities, no uterine pathology was observed in 17 (56.7%) women; on the other hand, uterine septum or arcuate uterus was observed in eight (26.7%) women, and endometrial polyp was found in five (16.7%) women. All the comparative results are presented in Table 1.

Only eleven of the seventeen women in whom the uterine cavity was reported as normal on hysterosalpingography and hysteroscopy had common findings in both, and the uterine cavities were normal. Filling defect was observed on hysteroscopy in four of the remaining six of the seventeen women in whom hysterosalpingography was reported to be normal. The septum or arcuate uterus was observed in two of the women who were reported as normal on hysterosalpingography. Although filling defects were found in two women in hysterosalpingography, none of these women had polypoid formation that could cause filling defect in hysteroscopy. However, polyps were detected in five women on hysteroscopy. And none of these women had polyps detected on hysterosalpingography. The hysterosalpingography of four women who were found to have polyps on hysteroscopy were evaluated as normal. It was evaluated that the remaining one might have a septum defect. In hysterosalpingography, it was thought that nine women might have a uterine septum or an arcuate uterus. However, in the hysteroscopic evaluations of these women, it was observed that two of them were normal and one of them had polyps. The septum was detected in only six of them by both methods. The hysteroscopic evaluation of two women whose hysterosalpingography could not be evaluated clearly was normal. All findings of the uterine cavity are presented in Table 2.

The evaluation of the tubes was performed separately for each woman as right and as a result of the evaluation of the tubes by hysteroscopic bubble (parryscope) and methylene blue methods, it was observed that there was a passage through the inner mouth of both fallopian tubes in twenty-two women. It was observed that three of the remaining eight women had no passage through the right tube and five of them through the left tube. In all cases where bubble transition was observed, the transition of methylene blue was also present. Likewise, in all cases where methylene blue passed, bubble transition occurred. As a result of the hysterosalpingographic evaluation, it was observed that there was passage through the bilateral fallopian tube in twenty-four women. The evaluation of the remaining six women favored that three had no passage through the right tube, and three through the left tube. Findings regarding the comparative evaluation of tubal passages in women are presented in detail in Table 3.

When the reference method was taken as hysterosalpingography, the specificity of hysteroscopy was determined as 85.71% (95% CI: 42.13%–99.64%) and sensitivity was 94.74% (95% CI: 85.38%–98.9%), since only the inner mouths of the fallopian tubes can be evaluated in hysteroscopy in the evaluation of the tubal passage. The positive predictive value of hysteroscopy was calculated as 98.18% (95% CI: 89.78%–99.7%) and the negative predictive value as 66.67% (95% CI: 38.96%–86.24%). The test can give an accurate result with a probability of 93.75% (95% CI: 84.76%–98.27%). When the reference method is taken as hysterosalpingography, the evaluation of the fallopian tubes with office hysteroscopy is statistically significant in terms of the results obtained (p 0.01). And it appears to be a viable method. Table 4 presents the general evaluation of tubal passages obtained by two different evaluation methods.

There are many methods for evaluating tubes. These methods also have many advantages and disadvantages. HSG is the most widely used method in the evaluation of the fallopian tubes and uterine cavity because of its low cost and the fact that it is a procedure that does not require hospitalization. However, of course, the gold standard method is to observe the transition laparoscopically [13].

The swirl created by the water flowing from the sink shows us that the sink drain is open. In some of the women we performed hysteroscopy we noticed that spontaneous bubbles are directed from the inner mouths of the fallopian tubes into the abdomen. Likewise, we observed that the liquid mixed with blood also formed a whirlpool at the same points and directed towards the inside of the abdomen. Inspired by this events, we formed the basis of our work.

Duraker et al. [14] compared laparoscopic chromopertubation and hysterosalpingography in terms of tubal patency. According to their results, while no tubal pathology was observed with L/S in 61.2% of patients who were diagnosed as unilateral tubal occlusion in HSG, this ratio was 51.2% in patients with bilateral tubal factor.

A meta-analysis compared hysterosalpingography with laparoscopic chromopertubation, which is the gold standard method for the evaluation of fallopian tubes, and reported the sensitivity of hysterosalpingography to show tubal passage as 65% and specificity as 83% [15, 16]. While this is the case, although the power to evaluate the passage through the fallopian tubes is not as much as laparoscopic chromopertubation, it is considered that it does not change the planned treatment methods by 95% [17]. And therefore the reference test for evaluating the fallopian tubes in our study was accepted as hysterosalpingography and the statistical evaluation was performed. This situation of course creates a limitation for our study and affects the generalizability of the results we obtain. Another limiting factor may be the sample size of the study. On the other hand, although the power analyzes required for the number of samples were performed and the lowest number of cases required to be evaluated was determined as twenty, thirty cases (sixty tube) were included in the study, but this number may also be insufficient in terms of generalizing the results. Alternative methods to HSG have been tried to be developed for years. However, studies on the evaluation of tubal patency by hysteroscopy are very limited in the literature [18, 19]. It is a known fact that hysteroscopy is the gold standard method for detecting lesions related to the uterine cavity [20]. Therefore, in our study, we did not evaluate the power of hysteroscopy to detect lesions in the uterine cavity. We presented the results we obtained on this subject as a table in order to make comparisons only and to better understand the superiority of the method by providing subject integrity. In our study, just like the others, the superiority of hysteroscopy was once again emphasized because it also enables the treatment of detected pathologies [20, 21]. Parry et al. [22] measured the ability of office hysteroscopy to evaluate the tubal patency using the Parryscope technique. They reported that with the use of small-caliber (3 mm) flexible hysteroscopes, it is possible to obtain very high accuracy results by avoiding excessive distension and preventing the occurrence of spasm. They found that office hysteroscopy has 98.3%–100% sensitivity and 83.7% specificity for tube occlusion when applied according to the procedure. They suggested that office hysteroscopy can evaluate the patency of the tube accurately and quickly with this method. And they reported that it is a promising technique for evaluating fertility rather than HSG [22]. Although we could not compare hysteroscopy with laparoscopic chromopertubation, which is the gold standard method [23], our results show that hysteroscopy provides similar and even better results with hysterosalpingography in the evaluation of tubes. On top of that, considering the obvious advantage of hysteroscopy over hysterosalpingography, as shown in previous studies, in the evaluation of the uterine cavity, its benefit is further increased.

Considering the results we obtained, it is seen that hysteroscopy has advantages and disadvantages compared to hysterosalpingography in the evaluation of infertile women. We still think that more research should be done on which method will be more useful in the evaluation of infertile women.

BAY: Materials, Data Collection and/or Processing. EP, Literature Review, Writer, Critical Review. MAU, Conception, Design, Supervision. All authors participated in data interpretation, statement and approved the final version of the manuscript.

All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Canakkale 18 Mart University Scientific Research Ethics Committee: 15.11.2017 / 2017-18 (2011-KAEK-27/2017-E.98469).

Thanks to all the peer reviewers for their opinions and suggestions.

This research received no external funding.

The authors declare no conflict of interest.