A comprehensive understanding of female pelvic anatomy is fundamental for gynecologists, reproductive specialists, and surgeons. It underpins the diagnosis and management of infertility, gynecological disorders, and pelvic surgeries. Among the essential assessments in infertility workup, the tubal patency test plays a pivotal role in evaluating the fallopian tubes, which are critical for natural conception.

Female Pelvic Anatomy

The female pelvis houses the reproductive organs, urinary bladder, rectum, and supporting structures. Its anatomy is complex, and knowledge of spatial relationships is essential for surgical interventions and diagnostic procedures.

Bony Pelvis

The pelvic girdle consists of the ilium, ischium, pubis, and sacrum.

It provides structural support, protects pelvic organs, and forms the birth canal in women.

Pelvic Cavity and Compartments

The pelvic cavity is divided into three compartments:

Anterior compartment: Contains the urinary bladder and urethra.

Middle compartment: Houses the uterus, fallopian tubes, and ovaries.

Posterior compartment: Includes the rectum, rectouterine pouch (pouch of Douglas), and supporting ligaments.

Uterus

Pear-shaped, muscular organ located between the bladder and rectum.

Divided into fundus, body, isthmus, and cervix.

The endometrium lining undergoes cyclical changes during the menstrual cycle.

Fallopian Tubes

Bilateral, narrow muscular tubes connecting the uterine cavity to the peritoneal cavity near the ovaries.

Divided into four segments:

Interstitial (intramural) segment – Passes through the uterine wall.

Isthmus – Narrow part adjacent to the uterus.

Ampulla – Wider, serpentine segment where fertilization typically occurs.

Infundibulum – Distal funnel-shaped end with fimbriae that capture the ovulated oocyte.

Ovaries

Almond-shaped glands located on either side of the uterus.

Produce oocytes and secrete hormones (estrogen and progesterone).

Supporting Structures

Ligaments: Broad ligament, round ligament, ovarian ligament, uterosacral ligament.

Mesosalpinx: Part of the broad ligament supporting the fallopian tubes.

Peritoneal Pouches: Pouch of Douglas (rectouterine pouch) is clinically important for fluid collection and endometriosis evaluation.

Tubal Patency Test

Tubal patency assessment evaluates whether the fallopian tubes are open and functional, a critical factor in infertility. Tubal obstruction can result from pelvic inflammatory disease, endometriosis, adhesions, or congenital anomalies.

Indications

Infertility lasting more than 12 months

History of pelvic infections, pelvic inflammatory disease, or surgery

Suspected endometriosis

Recurrent pregnancy loss

Methods of Tubal Patency Testing
Hysterosalpingography (HSG)

Radiographic procedure using contrast dye injected into the uterine cavity.

X-ray images reveal the uterine cavity and fallopian tube patency.

Advantages: Outpatient, relatively quick.

Limitations: Discomfort, radiation exposure, and less sensitivity in distal tubal blockages.

Sonohysterography with Saline Infusion (Sonohysterography)

Involves instilling sterile saline and air bubbles or contrast into the uterine cavity.

Transvaginal ultrasound detects fluid movement through the tubes.

Less invasive, no radiation exposure.

Hysterosalpingo-Contrast Sonography (HyCoSy)

Uses microbubble contrast agents under ultrasound guidance.

Provides higher sensitivity and accuracy for detecting tubal patency and uterine abnormalities.

Hysteroscopy with Chromopertubation (Laparoscopic Tubal Test)

Considered the gold standard.

During laparoscopy, dye (methylene blue or indigo carmine) is introduced into the uterine cavity.

Patency is confirmed by observing dye spillage into the peritoneal cavity near the fimbrial ends.

Advantage: Simultaneous evaluation of pelvic pathology such as adhesions, endometriosis, or fibroids.

Preparation and Procedure

Pre-procedure evaluation: Medical history, pelvic exam, imaging studies, and infection screening.

Timing: Usually performed in the follicular phase of the menstrual cycle to avoid disrupting early pregnancy.

Anesthesia: Local, sedation, or general anesthesia may be used depending on the technique (e.g., laparoscopy).

Post-procedure care: Mild cramping or spotting is common; patients are advised to monitor for fever, severe pain, or abnormal discharge.

Significance

Identifies tubal obstruction, guiding further infertility management.

Helps in planning assisted reproductive techniques (ART) such as IVF if tubes are blocked.

Allows simultaneous diagnosis and treatment of pelvic pathologies when performed laparoscopically.

Conclusion

A thorough understanding of female pelvic anatomy is essential for gynecologists and reproductive specialists. The fallopian tubes’ role in fertilization makes tubal patency testing a critical component of infertility evaluation. Techniques such as HSG, HyCoSy, and laparoscopic chromopertubation enable accurate assessment, guiding treatment decisions and improving reproductive outcomes. Knowledge of pelvic anatomy combined with appropriate tubal evaluation allows clinicians to provide targeted, safe, and effective care, optimizing fertility and overall gynecological health.