158 Chapter 7 outpatient setting under local anaesthesia (28, 29, 18)). An advantage is the direct visualization of the female genital tract, thus allowing the evaluation of hydrosalpinx, endometriosis, and pelvic adhesions next to the tubal blockage. It is possible that the experience of the operator influences the success rate of THL. Clinical pathway There has been a wide range of variation in visual tubal patency tests during fertility workup, at both national and international levels (8, 9). In general, a comprehensive medical history is obtained as the first step to explore the possible causes of female‐ factor infertility. Next, physical examination and transvaginal ultrasound assessment are performed. In some settings, tubal patency is always then tested (8, 9), while in other settings, tubal testing is considered based on findings from medical history, physical examination and serological testing (chlamydia antibody testing; CAT) and only women with a high risk for tubal pathology will undergo tubal testing (30). Women are usually considered as having a high risk for tubal pathology when they have had a history of chlamydia infection or a positive CAT, pelvic inflammatory disease or peritonitis, or when they have been diagnosed with endometriosis or have had pelvic surgery in the past (31, 32). A visual tubal patency test can be used as a triage or as a replacement test. When used as a triage test, women will undergo laparoscopy only when occlusion is suspected or the visual tubal patency test shows indeterminate findings. However, the aim of laparoscopy in current practice is more often to select women who may benefit from therapeutic laparoscopy, rather than to select women for diagnostic laparoscopy. For example, in the Federation Medical Specialists (FMS) guideline (30), visual tubal patency tests are performed in high risk women as a triage test to select women who require laparoscopy. Laparoscopy without prior visual tubal patency testing is reserved only for those women with severe endometriosis or hydrosalpinges, where the diagnostic procedure and therapeutic laparoscopy are combined at the same time. In most other settings a visual tubal patency test is used as a replacement for the reference standard. The outcome of this test will then be used to determine if fertility treatment is necessary. Fertility treatment can be therapeutic laparoscopy or assisted reproduction, depending on the availability and preferences of the doctor and person undergoing treatment. An example is the NICE guideline (9), in which women with low risk for tubal pathology are offered a visual tubal patency test and those with high risk are offered a laparoscopy. Depending on the results, women with tubal obstruction can be offered tubal surgery, when appropriate expertise is available, or assisted reproduction directly.
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