Objectives <p>X-ray hysterosalpingography (HSG) and hysterosalpingo-contrast sonography (HyCoSy) are both commonly utilized for fallopian tube examination and can improve pregnancy. This study compared the effects of X-ray HSG and HyCoSy on pregnancy and adverse events in infertile patients.</p> Methods <p>This prospective, multicenter, cohort study enrolled 96 infertile patients who received X-ray HSG (n = 64) or HyCoSy (n = 32). The clinical pregnancy rate, cumulative clinical pregnancy rate, and adverse events were evaluated in the X-ray HSG and HyCoSy cohorts.</p> Results <p>The baseline pregnancy duration was longer in the X-ray HSG cohort than in the HyCoSy cohort [median (interquartile range (IQR)]: 18.0 (12.0–25.0) months vs. 12.0 (12.0–22.0) months, <i>P</i> = 0.039). The clinical pregnancy rate was greater in the X-ray HSG cohort than in the HyCoSy cohort (37.5% vs. 15.6%, <i>P</i> = 0.028). The cumulative clinical pregnancy rate was also greater in the X-ray HSG cohort than in the HyCoSy cohort (<i>P</i> = 0.040). After adjustment by Cox proportional hazard regression models, examination (X-ray HSG vs. HyCoSy) (hazard ratio: 3.441, <i>P</i> = 0.032) was independently associated with increased clinical pregnancy in infertile patients. In terms of adverse events, although the incidence of intraoperative abdominal pain was not different between the X-ray HSG and HyCoSy cohorts (90.6% vs. 100.0%, <i>P</i> = 0.174), the intraoperative pain visual analog scale score was lower in the X-ray HSG cohort than in the HyCoSy cohort (median (IQR): 2.0 (1.0–6.0) vs. 4.0 (2.3–6.0), <i>P</i> = 0.024). No difference was found in other intraoperative or postoperative adverse events between the two cohorts (all <i>P</i> &gt; 0.050).</p> Conclusions <p>Compared with those receiving HyCoSy, infertile patients receiving X-ray HSG are more likely to become pregnant and have less intraoperative pain.</p>