A 29-year-old woman presents with primary infertility and regular cycles. Her hysterosalpingography reveals bilateral tubal blockage. Which investigation should be prioritized next for management?

1. A

   Serum thyroid function tests for evaluation

2. B

   Endometrial biopsy for luteal phase assessment

3. C

   Transvaginal ultrasound of pelvic organs

4. D

   Diagnostic laparoscopy with chromopertubation

Appeared in: RRB Nsg. Superintendent-2026 (Shift -2nd)

Explanation

• Diagnostic laparoscopy is the gold standard for assessing tubal patency and pelvic pathology like adhesions or endometriosis.
• It is essential to confirm a finding of tubal blockage on Hysterosalpingography (HSG), as HSG has a notable false-positive rate due to factors like cornual spasm.
• Laparoscopy allows for direct visualization of dye spillage from the tubes (chromopertubation), providing a definitive diagnosis.
• This procedure offers a "see and treat" capability, allowing for immediate surgical correction of issues like adhesions, which may restore fertility without needing IVF.

Why Other Options Were Wrong

• Option A: Thyroid function tests evaluate for hormonal causes of ovulatory dysfunction. This patient has regular cycles, making this investigation a lower priority than confirming the known anatomical finding.
• Option B: An endometrial biopsy assesses the uterine lining. It does not provide any information about the fallopian tubes, which is the site of the identified problem.
• Option C: While a standard part of an infertility workup, a transvaginal ultrasound is used to assess the uterus and ovaries. It cannot confirm whether the fallopian tubes are open or blocked.

Related Visual

• Visual 1: Image: Hysterosalpingogram (HSG) showing bilateral hydrosalpinges, where the fallopian tubes are dilated and no dye spills into the pelvic cavity.
• Visual 2: Diagram: Laparoscopy with chromopertubation, illustrating the setup with a laparoscope and uterine manipulator, showing blue dye spilling from the fimbrial end of a patent tube.

Clinical Relevance

• Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Management of tubal factor infertility as background academic context rather than a clinical decision trigger.
• Confirming an HSG finding of tubal blockage with laparoscopy is a critical step before proceeding to IVF. If laparoscopy reveals the tubes are actually open, the couple may be able to conceive naturally or with less invasive treatments.
• The "see and treat" nature of laparoscopy is a key nursing counseling point. Patients should understand that the procedure is both diagnostic and potentially therapeutic, possibly correcting the cause of their infertility in one step.
• What if the patient's HSG was normal, but she still failed to conceive after 6-12 months of trying? In that case, diagnostic laparoscopy would still be a reasonable next step to look for endometriosis or pelvic adhesions, which are not reliably seen on an HSG.

How to Approach the Question

• First, identify the key information in the clinical scenario: a 29-year-old woman with primary infertility, regular cycles, and a specific investigation result (HSG showing bilateral tubal blockage).
• Recognize that 'regular cycles' makes a primary ovulatory problem less likely.
• The core of the question is how to respond to the HSG result. An abnormal finding on a screening test often requires a more definitive, 'gold standard' test for confirmation.
• Evaluate each option's purpose. Ask yourself: 'Does this test address the finding of blocked fallopian tubes?'
• Eliminate options that assess other parts of the reproductive system (thyroid for ovulation, biopsy for endometrium, ultrasound for uterus/ovaries) as they are not the next priority for confirming tubal status.
• Identify that laparoscopy with chromopertubation is the only option that directly visualizes and confirms the patency of the fallopian tubes, making it the correct next step.

Concept Tested & Keywords

• Concept Tested: Management of tubal factor infertility
• Stem keywords: primary infertility, regular cycles, hysterosalpingography, bilateral tubal blockage
• Lead-in keywords: prioritized next
• Clinical cues: HSG showing bilateral tubal blockage is the key finding driving the next step.

Question ID

Q5JfhAe1Aajx4pVbUd-Y4s

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