Tubal flushing with oil-based or water-based contrast at hysterosalpingography for infertility: long-term reproductive outcomes of a randomized trial

Risk of adverse pregnancy outcomes after abnormal hysterosalpingography

OBJECTIVE

To investigate the association between an abnormal hysterosalpingogram (HSG) and obstetrical and neonatal outcomes.

DESIGN

A retrospective cohort study comparing outcomes between women with normal versus abnormal tubal patency and uterine cavity on HSG.

RESULTS

Among 2181 women included in the study, 494 (22.6%) had an abnormal HSG. Of these, 207 (42%) presented with uterine abnormalities, 336 (68%) with tubal abnormalities and 49 (10%) with both. The study identified 232 clinical pregnancies in the abnormal HSG group and 814 pregnancies in controls. Women with abnormal HSG showed higher rates of preterm labour (PTL) compared to controls (13.6% vs. 7.7%, p < 0.05, n = 1687). Multivariate analysis revealed that any HSG abnormality was associated with an increased risk of PTL (aOR 2.39, 1.04-5.51). When analysing by type of abnormality, uterine abnormalities increased the risk of preeclampsia (aOR 2.86, 1.06-7.7) and low birthweight (aOR 2.31, 1.0-5.35), while tubal abnormalities were specifically associated with increased risk of PTL (aOR 3.87, 1.63-9.19).

CONCLUSION

An abnormal HSG study was associated with adverse obstetrical outcomes. Specifically, uterine abnormalities increased the risk of preeclampsia and birthweight below 10th percentile, while tubal abnormalities were associated with a heightened risk of PTL.

Comparative analysis of hysterosalpingography and hysterosalpingo-contrast sonography for assessing tubal patency in women with endometriosis-related infertility: a propensity score-matched study

PURPOSE

This study aimed to compare the clinical pregnancy rates of hysterosalpingography (HSG) with water-based contrast and hysterosalpingo-contrast sonography (HyCoSy) to investigate their impact on fertility outcomes in women with endometriosis-related infertility.

METHODS

This retrospective study included 296 women with endometriosis-related infertility, aged 18-39, undergoing HSG or HyCoSy at the First Affiliated Hospital of Guangxi Medical University (January 2020-June 2022). Propensity score matching was applied to balance demographic and clinical variables. Clinical pregnancy outcomes were compared between the groups.

RESULTS

The HSG group showed a higher clinical pregnancy rates compared to the HyCoSy group. Logistic regression demonstrated an odds ratio (OR) of 0.41 (95% CI 0.20-0.82, p < 0.001) for clinical pregnancy in the HyCoSy group compared to HSG. After propensity score matching, the OR was 0.37 (95% CI 0.18-0.75). Similar results were observed across multivariable and IPTW analyses, suggesting that HSG may be associated with better clinical pregnancy outcomes than HyCoSy.

CONCLUSION

Hysterosalpingography (HSG) with water-based contrast appears to be associated with higher clinical pregnancy rates compared to HyCoSy in women with endometriosis-related infertility. This suggests that HSG may be a more favorable diagnostic method for optimizing fertility outcomes, though further research is needed to confirm these findings.

New Insight of Lipiodol Flush on Pregnancy Outcomes in Women with Recurrent Implantation Failure Undergoing IVF/ICSI: a Prospective Study Based on Propensity Score Matching

Pregnancy outcomes in women with recurrent implantation failure (RIF) undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI): does treatment with lipiodol flush matter? In this propensity score-matched study, we recruited 966 RIF patients who underwent IVF/ICSI from two tertiary hospitals. These patients were divided into groups based on whether they received lipiodol flush or not. Further stratification was applied to investigate the effect of lipiodol flush on pregnancy outcomes in RIF patients with different cycle type of embryo transferred. Then, patients subjected to lipiodol flush were categorized into three groups based on the duration of the interval: short interval (≤ 3 months), moderate interval (3-6 months), and long interval (≥ 6 months). The groups were well-matched at baseline. The lipiodol flush group exhibited a significantly lower incidence of biochemical pregnancy (46.27% vs. 56.22%, p = 0.046) and live birth (25.87% vs. 37.31%, p = 0.014). Subgroup analysis for fresh embryo transfer cycles revealed no significant differences in pregnancy outcomes. Among RIF patients underwent frozen-thawed embryo transfer cycle, a statistically significant difference in the live birth rate was observed in the lipiodol flush group when compared to the control group (26.40% vs. 37.21%, p = 0.030). Analysis of different lipiodol flush intervals demonstrated a significantly lower live birth rate in the lipiodol flush group. Our results challenge the value of lipiodol use in clinical practice for the treatment of RIF.Trial registration: Chinese Clinical Trial Registry, ChiCTR1900024273. Registered 4 July 2019.

Neurodevelopmental outcomes of school-age children conceived after hysterosalpingography with oil-based or water-based iodinated contrast: long-term follow-up of a nationwide randomized controlled trial

STUDY QUESTION

Does preconceptional exposure to oil-based iodinated contrast media during hysterosalpingography (HSG) impact children's neurodevelopment compared with exposure to water-based alternatives?

SUMMARY ANSWER

Our study found no large-sized effects for neurodevelopment in children with preconceptional exposure to oil-based iodinated contrast media during HSG compared with water-based alternatives.

WHAT IS KNOWN ALREADY

HSG is widely used as a diagnostic tool in the female fertility work-up. Tubal flushing with oil-based iodinated contrast has been shown to enhance fertility outcomes in couples with unexplained infertility, increasing the chances of pregnancy and live birth compared with water-based alternatives. However, oil-based contrast contains higher doses of iodine and has a longer half-life, and concerns exist that iodinated contrast media can affect women's iodine status and cause temporary (sub)clinical hypothyroidism in mothers and/or foetuses. Considering that thyroid hormones are vital to embryonal and foetal brain development, oil-based contrast media use could increase the risk of impaired neurodevelopment in children conceived shortly after HSG. Here we examine neurodevelopmental outcomes in school-aged children conceived after HSG.

STUDY DESIGN, SIZE, DURATION

This is a long-term follow-up of the H2Oil trial in which oil-based or water-based contrast was used during HSG (Netherlands; 2012-2014; NTR3270). Of 369 children born <6 months after HSG in the study, we contacted the mothers of 140 children who gave consent to be contacted for follow-up. The follow-up study took place from January to July 2022 (NCT05168228).

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

The study included 69 children aged 6-9 years who were conceived after HSG with oil-based (n = 42) or water-based contrast (n = 27). The assessments targeted intelligence (Wechsler Intelligence Scale for Children), neurocognitive outcomes (computerized neurocognitive tests), behavioural functioning (parent and teacher questionnaires), and academic performance. Linear regression models, adjusted for age, sex, and parental educational attainment were employed to compare groups.

MAIN RESULTS AND THE ROLE OF CHANCE

School-aged children born to mothers after oil-based contrast HSG did not significantly differ from children born to mothers after water-based contrast HSG, in regards to intelligence, neurocognitive functioning, behavioural functioning, or academic performance, with the exception of better performance for visuomotor integration functions in children exposed to oil-based contrast preconception. After exploratory correction for multiple comparisons, none of the group differences was statistically significant.

LIMITATIONS, REASONS FOR CAUTION

The small sample size of this follow-up study limited statistical power. This study provides evidence for the absence of large-sized differences between preconceptional exposure to the two contrast media types but does not rule out more subtle effects on neurodevelopment compared to naturally conceived children without preconceptional exposure to HSG.

WIDER IMPLICATIONS OF THE FINDINGS

This study contributes to our knowledge about the long-term effects of different types of iodinated contrast media used in fertility work-up, indicating that choosing oil-based over water-based iodinated contrast media is unlikely to have major effect on the long-term neurodevelopmental outcomes of children conceived shortly after HSG. However, further research should focus on the overall safety of iodine exposure during HSG, comparing children conceived after HSG to those conceived naturally as both types of contrast contain high amounts of iodine.

STUDY FUNDING/COMPETING INTEREST(S)

The original H2Oil randomized controlled trial was an investigator-initiated study that was funded by the two academic hospitals now merged into the Amsterdam University Medical Centre. The current follow-up study (Neuro-H2Oil) is funded through a research grant awarded to the authors by the Amsterdam Reproduction & Development (AR&D) research institute. S.K. is funded by a AMC MD/PhD Scholarship from the Amsterdam UMC. S.K. reports holding voluntary roles in the civil society organizations Universities Allied for Essential Medicines and People's Health Movement. V.M. reports receiving travel and speaker fees as well as research grants from Guerbet, Merck and Ferring. K.D. reports receiving travel and speaker fees as well as research grants from Guerbet. BWM is supported by a NHMRC Investigator grant (GNT1176437) and reports consultancy, travel support and research funding from Merck, consultancy for Organon and Norgine, and holding stock from ObsEva. The other authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

NCT05168228.

Contrast media for hysterosalpingography: systematic search and review providing new guidelines by the Contrast Media Safety Committee of the European Society of Urogenital Radiology

OBJECTIVES

Hysterosalpingography (HSG) is widely used for evaluating the fallopian tubes; however, controversies regarding the use of water- or oil-based iodine-based contrast media (CM) remain. The aim of this work was (1) to discuss reported pregnancy rates related to the CM type used, (2) to validate the used CM in published literature, (3) to discuss possible complications and side effects of CM in HSG, and (4) to develop guidelines on the use of oil-based CM in HSG.

METHODS

A systematic literature search was conducted for original RCT studies or review/meta-analyses on using water-based and oil-based CM in HSG with fertility outcomes and complications. Nine randomized controlled trials (RCTs) and 10 reviews/meta-analyses were analyzed. Grading of the literature was performed based on the Oxford Centre for Evidence-Based Medicine (OCEBM) 2011 classification.

RESULTS

An approximately 10% higher pregnancy rate is reported for oil-based CM. Side effects are rare, but oil-based CM have potentially more side effects on the maternal thyroid function and the peritoneum.

CONCLUSIONS

1. HSG with oil-based CM gives approximately 10% higher pregnancy rates. 2. External validity is limited, as in five of nine RCTs, the CM used is no longer on the market. 3. Oil-based CM have potentially more side effects on the maternal thyroid function and on the peritoneum. 4. Guideline: Maternal thyroid function should be tested before HSG with oil-based CM and monitored for 6 months after.

CLINICAL RELEVANCE STATEMENT

Oil-based CM is associated with an approximately 10% higher chance of pregnancy compared to water-based CM after HSG. Although side effects are rare, higher iodine concentration and slower clearance of oil-based CM may induce maternal thyroid function disturbance and peritoneal inflammation and granuloma formation.

KEY POINTS

• It is unknown which type of contrast medium, oil-based or water-based, is the optimal for HSG. • Oil-based contrast media give a 10% higher chance of pregnancy after HSG, compared to water-based contrast media. • From the safety perspective, oil-based CM can cause thyroid dysfunction and an intra-abdominal inflammatory response in the patient.

No pain relief by virtual reality during hysterosalpingography (HSG): results from a randomized controlled trial

STUDY QUESTION

Is virtual reality (VR) an effective non-pharmacological tool to reduce procedural pain during hysterosalpingography (HSG)?

SUMMARY ANSWER

An HSG with VR does not reduce procedural pain scores compared to an HSG without VR.

WHAT IS KNOWN ALREADY

An HSG is often experienced as painful and uncomfortable. VR has been proven successful to reduce acute procedural pain during a variety of medical procedures and interventions.

STUDY DESIGN, SIZE, DURATION

We performed a two-centre open-label randomized controlled trial between January 2021 and October 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women scheduled for HSG as part of their infertility work-up were screened for participation. After informed consent, women were randomized between HSG with or without VR. Due to the nature of the intervention, the study was not blinded. VR was administered by a head-mounted device displaying nature movies and/or relaxation exercises. The primary endpoint was procedural pain measured using VAS (scale 0.0-10.0 cm). Procedural pain was divided into overall pain score and peak pain score during the procedure. It was measured immediately after HSG. Secondary endpoints included patient satisfaction, VR preferences, and adverse effects of VR.

MAIN RESULTS AND THE ROLE OF CHANCE

We included a total of 134 women, 69 to the intervention group (HSG with VR) and 65 to the control group (HSG without VR). The mean VAS for peak pain was 6.80 cm (SD 2.25) in the intervention group versus 6.60 cm (SD 2.40) in the control group (mean difference 0.28 (95% CI -0.57, 1.12), P = 0.52). The mean VAS for overall pain was 5.00 cm (SD 2.10) in the intervention group versus 4.90 cm (SD 2.13) in the control group (mean difference 0.06 (95% CI -0.71, 0.84), P = 0.88). The expectation that VR would be a good distraction from pain during HSG was correlated with both overall and peak pain scores. When correcting for this expectation, we found that women in the intervention group reported significantly higher scores, both in peak (adjusted MD 0.58 (95% CI -0.81, 1.97), P = 0.021) and overall (adjusted MD 0.43 (95% CI -0.84, 1.71), P = 0.013) pain, compared to the control group. There were no differences in the prevalence of symptoms that were considered as adverse effects of VR.

LIMITATIONS, REASONS FOR CAUTION

The study was not blinded. Reasons for declining participation in the study were anxiety or wanting full control during HSG, which might have created selection bias. The distraction score possibly indicates that the level of VR immersiveness was not optimal due to the lack of sound and/or the type of VR applications. Future studies should investigate whether more immersive or interactive VR applications could decrease procedural pain scores during HSG.

WIDER IMPLICATIONS OF THE FINDINGS

Since VR does not reduce procedural pain, this additional tool should not be used during HSG.

STUDY FUNDING/COMPETING INTEREST(S)

There was no external funding for this study. KR and AvH report receiving a travel grant from Merck outside the scope of this study. BM is supported by a National Health and Medical Research Council (NHMRC) investigator grant (GNT1176437) and BM reports consultancy for Merck, Organon, and Norgine and travel and research funding from Merck. BM holds stock for ObsEva. CL reports receiving research grants from Merck, and Ferring. KD and VM report receiving travel and speaker's fees from Guerbet and research grants from Guerbet. VM also reports research grants from Merck and Ferring. The remaining authors have nothing to declare.

TRIAL REGISTRATION NUMBER

The trial is registered prospectively in the Netherlands Trial Register (trialregister.nl registration number NL9203, currently accessible on trialsearch.who.int).

TRIAL REGISTRATION DATE

16-01-2021.

DATE OF FIRST PATIENT’S ENROLMENT

The first participant was enrolled on 19 January 2021.

Impact of oil-based contrast agents in hysterosalpingography on fertility outcomes in endometriosis: a retrospective cohort study

BACKGROUND

Previous studies have suggested that oil-based contrast agents used during hysterosalpingography (HSG) in infertile patients can enhance fertility. However, limited research has investigated the effect of oil-based contrast medium specifically in individuals with endometriosis-related infertility.

OBJECTIVE

This study aims to explore the impact of oil-based contrast medium on fertility outcomes in women with endometriosis-related infertility.

METHODS

Conducted at the First Affiliated Hospital of Guangxi Medical University (January 2020 to June 2022), the study included 512 patients undergoing HSG. Patients were categorized into oil-based and non-oil-based groups, and after propensity score matching, demographic characteristics were compared. Main outcomes included clinical pregnancy rates, live birth rates, early miscarriage rates, and ectopic pregnancy rates.

RESULTS

In our analysis, the Oil-based group showed significantly better outcomes compared to the Non-oil-based group. Specifically, the Oil-based group had higher clinical pregnancy rates (51.39% vs. 27.36%) and increased live birth rates (31.48% vs. 19.93%). This trend held true for expectant treatment, IUI, and IVF/ICSI, except for surgical treatment where no significant difference was observed. After adjusting for various factors using propensity score matching, the Non-oil-based group consistently exhibited lower clinical pregnancy rates compared to the Oil-based group. The Odds Ratio (OR) was 0.38 (95%CI: 0.27-0.55) without adjustment, 0.34 (0.22-0.51) in multivariable analysis, 0.39 (0.27-0.57) using inverse probability of treatment weighting (IPTW), and 0.22 (0.14-0.35) in propensity score matching.

CONCLUSION

Oil-based contrast medium used in HSG for women with endometriosis-related infertility is associated with higher clinical pregnancy rates and live birth rates compared to Non-oil-based contrast medium.

Effect of interval time between hysterosalpingography and intrauterine insemination on the pregnancy outcome of infertile patients

Background

Hysterosalpingography (HSG) is the most commonly applied tubal patency test in clinical practice. Although some studies have found an increased pregnancy rate after HSG, no studies to date have specifically characterized the effect of interval time between HSG and IUI on pregnancy outcome.

Objectives

To investigate the effect of interval time between HSG and intrauterine insemination (IUI) on live birth rates of infertile patients.

Methods

Retrospective cohort study. The reproductive medical record system was used to identify patients who completed ≥1 IUI cycle between January 2017 and October 2021. According to the interval time between HSG and IUI, patients were divided into three groups: <6months interval group,6-12 months interval group and >12 months interval group. The generalized estimating equation with Poisson distribution was used to estimate the risk ratios (RRs) and 95% confidence intervals (CIs) of different groups.

Results

A total of 413 patients completed 701 IUI cycles during the study period, <6months interval group, 415 cycles; 6-12 months interval group, 138 cycles; >12 months interval group, 148 cycles. The live birth rate of <6 months group was higher than other two groups (17.35% vs. 12.32% vs. 8.11%, P=0.017); Similarly, the clinical pregnancy rate of <6 months group was also higher than other two groups (19.76% vs. 14.49% vs.11.49%, P=0.049). When adjusted separately for FSH, AMH, infertility type, duration of infertility, infertility diagnosis, total motile count (TMC) of sperm, medications, endometrium size and dominant follicle size, the live birth rate of >12 months group severally significantly decreased by 60% (adjusted RR = 0.40, 95% CI [0.19-1.40]). The cumulative clinical pregnancy and live birth rates of <6 months group were higher than other two groups (P<0.05), but the cumulative pregnancy rate among three groups were not statistically different (log rank test: P=0.06).

Conclusion

The interval time between hysterosalpingography and IUI is related to pregnancy outcome. The clinical pregnancy and live birth rates were the highest when the time interval was less than 6 months. Therefore, IUI should be recommend as soon as possible after HSG if the patient couple meets the IUI indication.

Comparison of fertility outcomes between oil‑based and water‑based contrast media during hysterosalpingography: A meta‑analysis

Water-based and oil-based contrast media are both widely used in clinical practice for patients receiving hysterosalpingography (HSG). However, minor controversy exists about whether the oil-based contrast medium has a superior fertility-enhancing effect during HSG. The present meta-analysis intended to comprehensively compare the fertility outcomes of patients receiving either an oil-based or a water-based contrast medium during HSG. Web of Science, PubMed, Excerpta Medica Database, Cochrane, China National Knowledge Infrastructure, Wanfang Data and China Science and Technology Journal Database were examined for literature comparing the fertility enhancement between oil-based and water-based contrast media during HSG up to November 10, 2022 and there was no cut off for studies published earlier than any given year. Data for clinical pregnancy, ongoing pregnancy, live birth, miscarriage and ectopic pregnancy were extracted and analyzed. A total of 11 studies with 2,462 patients receiving oil-based contrast medium and 2,830 patients receiving water-based contrast medium during HSG were included. Relative risks (RRs) and 95% confidence intervals (CIs) were presented for outcome assessment, and the random effects model was utilized for all analyses. Publication bias was analyzed using Egger's and Begg's tests. The results indicated that the rate of clinical pregnancy was increased using oil-based contrast medium compared with water-based contrast medium [relative risk (RR) (95% CI), 1.29 (1.07, 1.54); P=0.006]. In addition, the rate of ongoing pregnancy [RR (95% CI), 1.39 (1.22, 1.59); P#x003C;0.001] and live birth [RR (95% CI), 1.41 (1.07, 1.87); P=0.016] were also increased using oil-based contrast medium compared with water-based contrast medium. However, miscarriage [RR (95% CI), 1.06 (0.61, 1.86); P=0.833] and ectopic pregnancy [RR (95% CI), 0.66 (0.18, 2.36); P=0.518] were not affected by using oil-based or water-based contrast medium. Begg's test and Egger's test suggested that no publication bias of clinical pregnancy, ongoing pregnancy, live birth, miscarriage and ectopic pregnancy existed (all P>0.05), which indicated the stability of the present meta-analysis. In conclusion, the oil-based contrast medium enhances fertility outcomes compared with the water-based contrast medium in patients receiving HSG.

Alternatives to in vitro fertilization

There have been concerns on the potential overuse of in vitro fertilization (IVF) in view of the lack of evidence on effectiveness in certain populations, potential short and long-term safety risks, and economic considerations. On the other hand, the use of alternatives to IVF seems to be underappreciated in clinical practice as well as research. In this review, we summarized the up-to-date evidence on the effectiveness, safety as well as cost-effectiveness of different alternatives to IVF, including expectant management, intrauterine insemination, tubal flushing, in vitro maturation as well as intravaginal culture. We also discussed the trend of IVF use over the last decade and the available tiers of service because of intravaginal culture, and revisited the roles of different alternatives to IVF in modern reproductive medicine from both clinical and research perspectives.

A meta-analysis of fertility and adverse outcomes in oil- and water-based contrast for hysterosalpingography

Infertility is the inability to conceive after one year of regular unprotected intercourse. There is a debate about the therapeutic effect of hysterosalpingography (HSG) and whether the selection of contrast materials makes a difference in the chance of subsequent conception. In this study, we aimed to compare the fertility-enhancing outcomes and adverse effects of oil and water-based contrasts in patients who underwent HSG. This systematic review and meta-analysis was conducted following the PRISMA guidelines. We searched the Web of Science, PubMed, and Scopus until September 2022. We included all primary randomized controlled trials evaluating the fertility-enhancing benefits of HSG in oil-based versus water-based contrast media in women of childbearing age with infertility. Eleven studies with 4,739 patients were selected. The pregnancy rate in the oil group was significantly higher than that in the water group [odds ratio (OR)=1.51 (1.23, 1.86), p<0.0001]. Our meta-analysis favored the oil group in abdominal pain and vaginal bleeding with the odd ratios of 0.73 (0.58, 0.91), (p=0.006) and 0.91 (0.46, 1.81), (p=0.79), respectively. Water-based contrast was associated with less intravasation [OR=2.09 (1.09-4.02), p=0.03]. There were no differences between the contrasts for miscarriage [OR=1.02 (0.71, 1.46), p=0.92], and ectopic pregnancy [OR=0.84 (0.27, 2.63), p=0.77]. HSG with oil-based contrast was related to a higher pregnancy rate, live birth rate, and intravasation rate. While HSG using a water-based contrast medium was associated with increased abdominal discomfort, vaginal bleeding, and the visual-analogue scale pain score.

The cost-effectiveness of transvaginal hydrolaparoscopy versus hysterosalpingography in the work-up for subfertility

STUDY QUESTION

Is a strategy starting with transvaginal hydrolaparoscopy (THL) cost-effective compared to a strategy starting with hysterosalpingography (HSG) in the work-up for subfertility?

SUMMARY ANSWER

A strategy starting with THL is cost-effective compared to a strategy starting with HSG in the work-up for subfertile women.

WHAT IS KNOWN ALREADY

Tubal pathology is a common cause of subfertility and tubal patency testing is one of the cornerstones of the fertility work-up. Both THL and HSG are safe procedures and can be used as a first-line tubal patency test.

STUDY DESIGN, SIZE, DURATION

This economic evaluation was performed alongside a randomized clinical trial comparing THL and HSG in 300 subfertile women, between May 2013 and October 2016. For comparisons of THL and HSG, the unit costs were split into three main categories: costs of the diagnostic procedure, costs of fertility treatments and the costs for pregnancy outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Subfertile women scheduled for tubal patency testing were eligible. Women were randomized to a strategy starting with THL or a strategy starting with HSG. The primary outcome of the study was conception leading to a live birth within 24 months after randomization. The mean costs and outcomes for each treatment group were compared. We used a non-parametric bootstrap resampling of 1000 re-samples to investigate the effect of uncertainty and we created a cost-effectiveness plane and cost-effectiveness acceptability curves.

MAIN RESULTS AND THE ROLE OF CHANCE

We allocated 149 women to THL and 151 to HSG, and we were able to achieve complete follow-up of 142 versus 148 women, respectively. After the fertility work-up women were treated according to the Dutch guidelines and based on a previously published prognostic model. In the THL group, 83 women (58.4%) conceived a live born child within 24 months after randomization compared to 82 women (55.4%) in the HSG group (difference 3.0% (95% CI: -8.3 to 14.4)). The mean total costs per woman were lower in the THL group compared to the HSG group (THL group €4991 versus €5262 in the HSG group, mean cost difference = -€271 (95% CI -€273 to -€269)). Although the costs of only the diagnostic procedure were higher in the THL group, in the HSG group more women underwent diagnostic and therapeutic laparoscopies and also had higher costs for fertility treatments.

LIMITATIONS, REASONS FOR CAUTION

Our trial was conducted in women with a low risk of tubal pathology; therefore, the results of our study are not generalizable to women with high risk of tubal pathology. Furthermore, this economic analysis was based on the Dutch healthcare system, and possibly our results are not generalizable to countries with different strategies or costs for fertility treatments.

WIDER IMPLICATIONS OF THE FINDINGS

After 2 years of follow-up, we found a live birth rate of 58.4% in the THL group versus 55.4% in the HSG group and a lower mean cost per woman in the THL group, with a cost difference of -€271. The findings of our trial suggest that a strategy starting with THL is cost-effective compared to a strategy starting with HSG in the workup for subfertile women. However, the cost difference between the two diagnostic strategies is limited compared to the total cost per woman in our study and before implementing THL as a first-line strategy for tubal patency testing, more research in other fields, such as patient preference and acceptance, is necessary.

STUDY FUNDING/COMPETING INTEREST(S)

The authors received no external financial support for the research. B.W.J.M. is supported by an NHMRC Investigator Grant (GNT1176437). B.W.J.M. reports consultancy for ObsEva, Merck KGaA, Guerbet. B.W.J.M. reports receiving travel support from Merck KGaA. C.T.P. reports consultancy for Guerbet, outside of this manuscript. All other authors have no conflicts to declare.

TRIAL REGISTRATION NUMBER

NTR3462.

Fertility-enhancing effect of oil-based contrast agents during hysterosalpingography and the variation of this effect within a 3-year follow-up period in infertile patients

Objective

The previous study has indicated the fertility-enhancing effect of oil-based contrast agents during hysterosalpingography (HSG) in infertile patients. However, the variation of this effect with the time frame is seldom reported. The current study aimed to explore fertility improvement using oil-based contrast agents and the change of this improvement during the 3-year follow-up period in infertile patients.

Materials and methods

Infertile women who underwent HSG with oil-based contrast agents (N = 500) or water-based contrast agents (N = 500) were enrolled. Spontaneous pregnancy rate and time to pregnancy were assessed at months (M)1, M2, M3, M6, M12, M24, and M36 after HSG.

Results

The spontaneous pregnancy rate was 79% in the oil-based group and 70.2% in the water-based group. The cumulative spontaneous pregnancy rate was increased in the oil-based group when compared with the water-based group (p = 0.015). Fertility-enhancing effect of HSG was increased in the oil-based group when compared with the water-based group at all time points {M1 [odds ratio (OR)]: 1.536}; M2 (OR: 1.455); M3 (OR: 1.494); M6 (OR: 1.356); M9 (OR: 1.288); M12 (OR: 1.249); M24 (OR: 1.131); and M36 (OR: 1.125). While this superiority of the fertility-enhancing effect of HSG in the oil-based group (vs. the water-based group) was decreased with the time frame. Similar findings were also observed based on the physiological cycles.

Conclusion

The HSG procedure with oil-based contrast agents shows a fertility-enhancing effect when compared to water-based contrast agents. This improvement could last at least 1 year while dropping to the normal level within the subsequent 2 years.

Modern assessment of the uterine cavity and fallopian tubes in the era of high-efficacy assisted reproductive technology

The high efficacy of modern assisted reproductive technology (ART) and increase in the number of noninfertile patients who are using ART for family building in the United States call into question the relevance of the standard, one-size-fits-all infertility evaluation. Here, we explore whether all patients presenting for ART need uterine cavity and tubal assessment and what tests are most appropriate, efficient, and cost-effective in current times.

Tubal flushing with oil-based contrast during transvaginal hydro laparoscopy, a case report

Background: Oil-based contrast has been shown to have a fertility-enhancing effect during hysterosalpingography (HSG) but is not yet used during transvaginal hydro laparoscopy (THL). Objective: To asses if additional tubal flushing with oil-based contrast during THL is feasible. Materials and methods: Case report with video assessment. A healthy 29-year-old woman with primary unexplained subfertility, underwent a THL under local anaesthesia. First, chromopertubation was performed by methylene blue. Afterwards, tubal flushing with 3mL oil-based contrast (Lipiodol® UltraFluid, Guerbet) was performed. Main outcome measures: In this case report we evaluated the feasibility of additional tubal flushing with oil- based contrast during THL, in terms of; the visibility of the oil-based contrast at the tubal fimbriae, the pain and acceptability scores. Results: Both fallopian tubes were patent to methylene-blue as well as to oil-based contrast. Interestingly, the oil-based contrast came out of the fallopian tube in the form of free droplets with strong internal bonding. Furthermore, some residue of the droplets was visible on the surface of the peritoneal wall in the form of oily micro-droplets. Conclusions: We present the first sub-fertile woman, in which additional tubal flushing with oil-based contrast during THL was performed. It is likely, that the residue of oily micro-droplets is also present inside the fallopian tube, where it may enhance the cilia movement by introducing lubrication. These lubricating characteristics of the oil-based contrast may be important for its fertility-enhancing effect. More research is necessary to confirm this hypothesis and the feasibility of tubal flushing with oil-based contrast during THL in more women.

Lipiodol flushing under ultrasound guidance at time of hystero-salpingo contrast sonography (HyCoSy): A retrospective observational study

BACKGROUND

Up to 30% of female infertility can be attributed to tubal abnormalities. Assessment of fallopian tube patency forms a component of the basic assessment of infertility. Tubal patency can be checked through hysterosalpingogram (HSG) under radiologic guidance with oil- or water-based contrast medium (OBCM or WBCM), or hystero-salpingo contrast sonography (HyCoSy) under ultrasound guidance with WBCM. Tubal flushing with OBCM has been shown to improve fertility rates.

OBJECTIVES

To study the feasibility and tolerability of performing Lipiodol (ethiodised oil) flush concurrently with HyCoSy. To examine the in vivo sonographic visibility of Lipiodol vs normal saline.

MATERIALS AND METHODS

Retrospective observational study of patients with subfertility referred for Lipiodol flushing under ultrasound guidance between August 2017-September 2020 at six private ultrasound practices in Sydney, Australia.

RESULTS

There were 412 patients who were referred for Lipiodol flushing. Of these, 86 patients did not have concurrent Lipiodol flush at HyCoSy performed due to strict exclusion criteria. Of the 326 patients who proceeded with Lipiodol flushing at HyCoSy, all cases were successful, with no cases of extravasation. There were no major complications. In vivo sonographic visualisation of Lipiodol was similar to that of the commonly used agitated 0.9% saline (n = 20; mean visibility score 4.3 ± 0.9 vs 4.0 ± 1.2).

CONCLUSION

Our study has shown that Lipiodol flushing at time of HyCoSy as a single procedure is feasible and tolerable to patients. Flushing with Lipioidol during HyCoSy is likely as sonographically visible as 0.9% saline.

Incidental detection of retained oil-based hysterosalpingography contrast medium on postoperative postpartum radiography: A case report

Hysterosalpingography is widely performed in assisted reproductive technology. We present a rare case of contrast medium retention which was incidentally found and mimicked a retained surgical instrument. A medical history of treatment for infertility can facilitate the differential diagnosis of abnormal findings on post-caesarean section radiography.

Oil-based versus water-based contrast media for hysterosalpingography in infertile women of advanced age, with ovulation disorders or a high risk for tubal pathology: study protocol of a randomized controlled trial (H2Oil2 study)

BACKGROUND

In women with unexplained infertility, tubal flushing with oil-based contrast during hysterosalpingography (HSG) increases ongoing pregnancy and subsequent live birth rates when compared to tubal flushing with water-based contrast. It is currently unclear whether an HSG with oil-based contrast also results in more ongoing pregnancies and live births in women of advanced age, women with ovulation disorders, and women with potential tubal pathology when compared to an HSG with water-based contrast.

METHODS

We plan an international, multicentre, open-label, randomized controlled trial (RCT) studying three groups of infertile women who have an indication for tubal patency testing according to their treating physician and additionally; (1) are 39 years of age or older, (2) have an ovulation disorder or (3) have a high risk for tubal pathology based on their medical history. Women with an allergy for iodinated contrast medium are excluded, as are women with diabetes, hyperprolactinemia or untreated hyper- or hypothyroidism, and women with a partner with severe male infertility. After informed consent, women will be randomly allocated to the intervention, tubal flushing with the use of oil-based contrast during HSG or the control group, tubal flushing with the use of water-based contrast during HSG in a 1:1 ratio by the web-based system Castor. The primary endpoint will be ongoing pregnancy leading to live birth with conception within six months after randomization. Secondary outcomes are other pregnancy outcomes, used fertility treatments, adverse events and cost-effectiveness. Based on the expected ongoing pregnancy rate of 17% in the control group and 27% in the intervention group, the sample size will be 930 women (465 per group). Study inclusion is expected to be complete in four years.

DISCUSSION

This multicentre RCT will establish whether, for women of advanced age, women with ovulatory disease, and women who have a high risk for tubal pathology, there is a fertility enhancing effect of tubal flushing with oil-based contrast during HSG and whether the use of this contrast medium is cost-effective. Trial Registration The study was prospectively registered in the Netherlands Trial Register on August 1st 2019 as 'H2Oil2' (reference number NL7925, https://www.trialregister.nl/trial/7925 ).

Fertility Outcome and Safety of Ethiodized Poppy Seed Oil for Hysterosalpingography in 1,053 Infertile Patients: A Real-World Study

Objective

Ethiodized poppy seed oil for hysterosalpingography (HSG) is reported to display some therapeutic effect on infertility, but big a sample-size study under real clinical settings is still lacking to verify the speculation. Thus, this real-world study enrolled 1,053 infertile patients who underwent ethiodized poppy seed oil-based HSG to explore its fertility enhancement value.

Method

A total of 1,053 infertile patients who underwent HSG using ethiodized poppy seed oil as the contrast medium were retrospectively analyzed. The live birth rate and 3-, 6-, 12-month and total pregnancy rate were retrieved. Besides, adverse events during and after HSG were recorded.

Results

The 3-, 6-, 12-month and total pregnancy rate was 22, 36.8, 50, and 53.8%, respectively. The total live birth rate was 42.7%. Sub-group analyses showed that pregnancy rate was 53.7, 53.8, 54.1, and 62.4% in subgroups of primary infertility patients, secondary infertility patients, infertility patients with fallopian tube disease, and infertility patients with unknown cause, respectively. Meanwhile the live birth rate was 44.3, 41.3, 41.5, and 59.2% in these subgroups, separately. Multivariate logistic regression analysis disclosed that BMI ≥ 24 kg/m², history of dysmenorrhea, and abnormity of sperm count or motility-related infertility were independently correlated with reduced pregnancy rate and livebirth rate (All Ps < 0.05). Adverse events mainly included pain (20.6%) and interstitial reflux (7.9%), which were mild and tolerable.

Conclusion

Ethiodized poppy seed oil for HSG discloses a satisfying fertility outcome with a tolerable safety profile in infertile patients; meanwhile, this effect might be influenced by BMI, history of dysmenorrhea, and paternal abnormity of sperm.

Tubal Flushing Treatment for Unexplained Infertility

Tubal patency testing was initially introduced as a diagnostic test. However, it has been observed that some tubal patency tests also have a therapeutic effect. This therapeutic effect can be influenced by the contrast medium used during tubal flushing. In this review, we discuss current evidence associated with different methods for tubal flushing and their potential impact on reproductive outcomes in women with unexplained infertility. Furthermore, we discuss their diagnostic accuracy, safety, and cost-effectiveness.

Does the effectiveness of IUI in couples with unexplained subfertility depend on their prognosis of natural conception? A replication of the H2Oil study

STUDY QUESTION

Can we replicate the finding that the benefit of IUI-ovarian stimulation (IUI-OS) compared to expectant management for couples with unexplained subfertility depends on the prognosis of natural conception?

SUMMARY ANSWER

The estimated benefit of IUI-OS did not depend on the prognosis of natural conception but did depend on when treatment was started after diagnosis, with starting IUI-OS later yielding a larger absolute and relative benefit of treatment.

WHAT IS KNOWN ALREADY

IUI-OS is often the first-line treatment for couples with unexplained subfertility. Two randomized controlled trials (RCTs) compared IUI-OS to expectant management using different thresholds for the prognosis of natural conception as inclusion criteria and found different results. In a previous study (a Dutch national cohort), it was found that the benefit of IUI-OS compared to expectant management seemed dependent on the prognosis of natural conception, but this finding warrants replication.

STUDY DESIGN SIZE DURATION

We conducted a secondary analysis of the H2Oil study (n = 1119), a multicentre RCT that evaluated the effect of oil-based contrast versus water-based contrast during hysterosalpingography (HSG). Couples were randomized before HSG and followed up for 3-5 years. We selected couples with unexplained subfertility who received HSG and had follow-up or pregnancy data available. Follow-up was censored at the start of IVF, after the last IUI cycle or at last contact and was truncated at a maximum of 18 months after the fertility workup.

PARTICIPANTS/MATERIALS SETTING METHODS

The endpoint was time to conception leading to an ongoing pregnancy. We used the sequential Cox approach comparing in each month the ongoing pregnancy rates over the next 6 months of couples who started IUI-OS to couples who did not. We calculated the prognosis of natural conception for individual couples, updated this over consecutive failed cycles and evaluated whether prognosis modified the effect of starting IUI-OS. We corrected for known predictors of conception using inverse probability weighting.

MAIN RESULTS AND THE ROLE OF CHANCE

Data from 975 couples were available. There were 587 couples who received at least one IUI-OS cycle within 18 months after HSG of whom 221 conceived leading to an ongoing pregnancy (rate: 0.74 per couple per year over a median follow-up for IUI of 5 months). The median period between HSG and starting IUI-OS was 4 months. Out of 388 untreated couples, 299 conceived naturally (rate: 0.56 per couple per year over a median follow-up of 4 months). After creating our mimicked trial datasets, starting IUI-OS was associated with a higher chance of ongoing pregnancy by a pooled, overall hazard ratio of 1.50 (95% CI: 1.19-1.89) compared to expectant management. We did not find strong evidence that the effect of treatment was modified by a couple's prognosis of achieving natural conception (Akaike's Information Criterion (AIC) decreased by 1 point). The effect of treatment was dependent on when couples started IUI-OS (AIC decreased by more than 2 points). The patterns of estimated absolute chances over time for couples with increasingly better prognoses were different from the previous study but the finding that starting later yields a larger benefit of treatment was similar. We found IUI-OS increased the absolute chance of pregnancy by at least 5% compared to expectant management. The absolute chance of pregnancy after IUI-OS seems less variable between couples and starting times of treatment than the absolute chance after expectant management.

LIMITATIONS REASONS FOR CAUTION

This is a secondary analysis, as the H2Oil trial was not designed with this research question in mind. Owing to sample size restrictions, it remained difficult to distinguish between the ranges of prognoses in which true benefit was found.

WIDER IMPLICATIONS OF THE FINDINGS

We replicated the finding that starting IUI-OS later after diagnosis yields a larger absolute and relative benefit of treatment. We did not replicate the dependency of the effect of IUI-OS on the prognosis of natural conception and could not identify clear thresholds for the prognosis of natural conception when IUI-OS was and/or was not effective. Because many of these couples still have good chances of natural conception at the time of diagnosis, we suggest clinicians should advise couples to delay the start of IUI-OS for several months to avoid unnecessary treatment.

STUDY FUNDING/COMPETING INTERESTS

The H2Oil study (NTR 3270) was an investigator-initiated study that was funded by the two academic institutions (AMC and VUmc) of the Amsterdam UMC. The follow-up study (NTR 6577) was also an investigator-initiated study with funding by Guerbet, France. The funders had no role in study design, collection, analysis and interpretation of the data. B.W.M. is supported by an Investigator grant (GNT1176437) from the Australian National Health and Medical Research Council (NHMRC). K.D. reports receiving travel and speaker fees from Guerbet. B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA, iGenomix and Guerbet. V.M. reports receiving travel- and speaker fees as well as research grants from Guerbet.

The long-term costs and effects of tubal flushing with oil-based versus water-based contrast during hysterosalpingography

RESEARCH QUESTION

What are the long-term costs and effects of oil- versus water-based contrast in infertile women undergoing hysterosalpingography (HSG)?

DESIGN

This economic evaluation of a long-term follow-up of a multicentre randomized controlled trial involved 1119 infertile women randomized to HSG with oil- (n = 557) or water-based contrast (n = 562) in the Netherlands.

RESULTS

In the oil-based contrast group, 39.8% of women needed no other treatment, 34.6% underwent intrauterine insemination (IUI) and 25.6% had IVF/intracytoplasmic sperm injection (ICSI) in the 5 years following HSG. In the water-based contrast group, 35.0% of women had no other treatment, 34.2% had IUI and 30.8% had IVF/ICSI in the 5 years following HSG (P = 0.113). After 5 years of follow-up, HSG using oil-based contrast resulted in equivalent costs (mean cost difference -€144; 95% confidence interval [CI] -€579 to +€290; P = 0.515) for a 5% increase in the cumulative ongoing pregnancy rate compared with HSG using water-based contrast (80% compared with 75%, Relative Risk (RR) 1.07; 95% CI 1.00-1.14). Similarly, HSG with oil-based contrast resulted in equivalent costs (mean cost difference -€50; 95% CI -€576 to +€475; P = 0.850) for a 7.5% increase in the cumulative live birth rate compared with HSG with water-based contrast (74.8% compared with 67.3%, RR 1.11; 95% CI 1.03-1.20), making it the dominant strategy. Scenario analyses suggest that the oil-based contrast medium is the dominant strategy up to a price difference of €300.

CONCLUSION

Over a 5-year follow-up, HSG with an oil-based contrast was associated with a 5% increase in ongoing pregnancy rate, a 7.5% increase in live birth rate and similar costs to HSG with water-based contrast.

How long does the fertility-enhancing effect of hysterosalpingography with oil-based contrast last?

RESEARCH QUESTION

Does the fertility-enhancing effect of tubal flushing during hysterosalpingography (HSG) with oil-based contrast change over time?

DESIGN

This was a secondary analysis of the H2Oil (long-term follow-up) study, a multicentre randomized controlled trial evaluating the effectiveness of oil-based and water-based contrast during HSG. The main outcome was ongoing pregnancy. Cox proportional hazards models for time to ongoing pregnancy were fitted over 3 years of follow-up.

RESULTS

Data on 1107 couples were available; 550 couples had oil-based contrast and 557 water-based contrast at HSG. Ongoing pregnancy rates after 3 years were 77% and 71%, respectively. Median follow-up was 9-10 months (5th-95th percentile: <1 to 36). The hazard ratio for ongoing pregnancy for oil versus water over 3 years of follow-up was 1.26 (95% confidence interval [CI] 1.10-1.45). The scaled Schoenfeld residual plots showed a decrease in hazard ratio that was linear with log-transformed time. After including an interaction with log-transformed time, the hazard ratio immediately after HSG was 1.71 (95% CI 1.27-2.31) and reduced to no effect (hazard ratio of 1) at approximately 2 years. There was no evidence for a change in hazard ratio over time in a subgroup of women who experienced pain during HSG.

CONCLUSIONS

The hazard ratio for ongoing pregnancy of oil-based versus water-based contrast was 1.71 immediately after HSG, gradually decreasing and plateauing towards a hazard ratio of 1 (indicating no effect) after approximately 2 years. This supports the hypothesis that oil-based contrast might dislodge debris or mucus plugs from the Fallopian tubes, but this has yet to be definitively proved.