Background: Women with abnormal hysterosalpingography (HSG) are anxious regarding the presence of tubal pathology. It is important to know the predictive value of HSG and the need for subsequent laparoscopy following an abnormal report. In the era of assisted reproductive technology, the role of invasive testing such as diagnostic laparoscopy is being increasingly questioned due to its invasiveness and associated risks. There is a need to explore the positive predictive value (PPV) of HSG in detecting bilateral tubal block in our population as PPV changes with the prevalence of disease. Aim: The aim of this study was to evaluate the diagnostic accuracy of HSG in identifying tubal blockage in subfertile women. Setting and Design: This was a prospective diagnostic study conducted in the department of reproductive medicine and surgery in a university-level hospital. Materials and Methods: The study included 199 subfertile women who had undergone HSG earlier and were planned for laparoscopy from April 2017 to January 2021. Findings of HSG and laparoscopy were compared with HSG as index test and laparoscopy as reference test, and the outcomes analysed were PPV of HSG for a bilateral tubal block, bilateral hydrosalpinx, abnormal HSG (unilateral or bilateral tubal block) and agreement between HSG and diagnostic laparoscopy in detecting normal and abnormal findings. Statistical Analysis: Kappa statistics, Stuart–Maxwell tests of marginal homogeneity and prevalence-adjusted bias-adjusted kappa (PABAK) statistics were used. Results: The PPV for a bilateral block with HSG was 20.9% (95% CI: 13.7–29.7). The PPV of HSG for bilateral hydrosalpinx was 50.0% (95% CI: 6.8–93.2). PABAK was estimated to be 0.42 (95% CI: 0.30–0.55), suggestive of moderate agreement between the tests. Findings of laparoscopy in women with at least one patent tube in HSG showed that in 12.3% of cases, the management was likely to change due to the operative findings. Conclusion: The current study showed low PPV for bilateral tubal block diagnosed with HSG which translates into a need for further confirmation by laparoscopy. In one out of every eight women with at least one patent tube on HSG, performing laparoscopy changed the management.