##submission.abstract##
Background: Hysterosalpingography (HSG) remains a widely used first-line test for evaluating tubal patency and uterine cavity contour in the infertility workup, but its diagnostic accuracy relative to laparoscopic chromopertubation, the reference standard, varies across reported series. Methods: We designed a retrospective, single-center study (simulated for this exercise) of women undergoing HSG followed by diagnostic laparoscopy with chromopertubation for infertility evaluation over a one-year period at a hypothetical reproductive medicine center, calculating HSG diagnostic accuracy for tubal patency and describing the distribution of intrauterine and tubal findings. Results: In this simulated dataset (n = 386), HSG had a sensitivity of 79.4%, specificity of 81.2%, positive predictive value of 74.6%, negative predictive value of 85.3%, and overall accuracy of 80.1% for tubal occlusion relative to laparoscopic chromopertubation. Bilateral tubal occlusion was identified on HSG in 14.2% of patients, and an intrauterine abnormality (submucosal fibroid, polyp, or septum) was identified in 11.9%. Conclusion: These illustrative findings are consistent with the published literature (through 2012) in supporting HSG as a reasonably accurate, minimally invasive first-line screening test for tubal factor infertility, while confirming that its imperfect sensitivity and specificity justify laparoscopic confirmation in appropriately selected cases.