Postcoital test: This is the test to detect sperm survival in the cervical mucus. However, it has no predictive value on pregnancy rate. Hence this test is no longer recommended [Ref]
Diagnostic Laparoscopy: Women with unexplained subfertility with tubal patency confirmed by normal HSG findings, can still have peri-tubal adhesions and/or endometriosis, which can lower the chances of their spontaneous conception[Ref]. However, it is difficult to predict who is going to benefit most from the surgery and the concerns are increased cost along with surgical risks and patient’s anxiety. Both ASRM (American Society for Reproductive Medicine) and NICE (National Institute for Health and Care Excellence) suggests laparoscopy only in women with symptoms of comorbidities [Ref], [Ref]. In 2010, Badawy et al, showed in a prospective randomised controlled trial that diagnostic laparoscopy could be postponed until 3-6 failed cycles of ovarian stimulation and timed sexual intercourse[Ref]. While it is reasonable to postpone laparoscopy in asymptomatic women with normal HSG and no previous history of pelvic infection or surgery, it might be of value in selected patients with multiple failed ovarian stimulation with or without intrauterine insemination[Ref], [Ref].
Hysteroscopy: Hysteroscopy is a reliable way to diagnose and treat uterine cavity anomalies like fibroids, polyps, septum and adhesions [Ref]. Women with unexplained subfertility might benefit from hysteroscopic removal of submucous fibroid and polyps to improve their chances of conceiving[Ref]. Where facilities are available, saline infusion sonography along with 3-D ultrasound can offer a less invasive outpatient method to assess the uterine cavity with an accuracy similar to hysteroscopy [Ref].