A Review of the Use of Lipiodol Flushing for Unexplained Infertility

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.

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.

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.

Treatment effect of oil-based contrast is related to experienced pain at HSG: a post-hoc analysis of the randomised H2Oil study

STUDY QUESTION

Does pain or volume of used contrast medium impact the effectiveness of oil-based contrast during hysterosalpingography (HSG)?

SUMMARY ANSWER

In women who report moderate to severe pain during HSG, the use of oil-based contrast resulted in more ongoing pregnancies compared to the use of water-based contrast, whereas in women who reported mild or no pain, no difference in ongoing pregnancies was found.

WHAT IS KNOWN ALREADY

We recently showed that in infertile women undergoing HSG, the use of oil-based contrast results in more ongoing pregnancies within 6 months as compared to the use of water-based contrast. However, the underlying mechanism of this fertility-enhancing effect remains unclear.

STUDY DESIGN, SIZE, DURATION

We performed a post-hoc analysis of the H2Oil study, a multicentre randomised controlled trial (RCT) evaluating the therapeutic effect of oil- and water-based contrast at HSG. Here, we evaluated the impact of pain experienced at HSG and volume of used contrast media during HSG on ongoing pregnancy.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In a subset of 400 participating women, pain during HSG by means of the Visual Analogue Scale (VAS) (range: 0.0–10.0 cm) was reported, while in 512 women, we registered the volume of used contrast (in millilitres). We used logistic regression analyses to assess whether pain and volume of used contrast media modified the effect of oil-based contrast on ongoing pregnancy rates. Data were analysed according to intention-to-treat principle.

MAIN RESULTS AND THE ROLE OF CHANCE

In 400 women in whom pain scores were reported, the overall median pain score was 5.0 (Interquartile range (IQR) 3.0–6.8) (oil group (n = 199) 4.8 (IQR 3.0–6.4); water group (n = 201) 5.0 (IQR 3.0–6.7); P-value 0.28). There was a significant interaction between pain (VAS ≤5 versus VAS ≥6) and the primary outcome ongoing pregnancy (P-value 0.047). In women experiencing pain (VAS ≥6), HSG with oil-based contrast resulted in better 6-month ongoing pregnancy rates compared to HSG with water-based contrast (49.4% versus 29.6%; RR 1.7; 95% CI, 1.1–2.5), while in women with a pain score ≤5, 6-month ongoing pregnancy rates were not significantly different between the use of oil- (28.8%) versus water-based contrast (29.2%) (RR 0.99; 95% CI, 0.66–1.5). In the 512 women in whom we recorded contrast, median volume was 9.0 ml (IQR 5.7–15.0) in the oil group versus 8.0 ml (IQR 5.9–13.0) in the water group, respectively (P-value 0.72). Volume of used contrast was not found to modify the effect of oil-based contrast on ongoing pregnancy (P-value for interaction 0.23).

LIMITATIONS, REASONS FOR CAUTION

This was a post-hoc analysis that should be considered as hypothesis generating. The RCT was restricted to infertile ovulatory women, younger than 39 years of age and with a low risk for tubal pathology. Therefore, our results should not be generalised to infertile women who do not share these features.

WIDER IMPLICATIONS OF THE FINDINGS

The underlying mechanism of the fertility-enhancing effect induced by HSG with the use of oil-based contrast remains unclear. However, these findings suggest a possible mechanistic pathway, that is increasing intrauterine pressure occurring prior to dislodging pregnancy hindering debris or mucus plugs from the proximal part of otherwise normal fallopian tubes. This information might help in the search of the underlying fertility-enhancing mechanism found by using oil-based contrast during HSG.

STUDY FUNDING/COMPETING INTEREST(S)

The original H2Oil RCT was an investigator-initiated study that was funded by the two academic institutions (AMC and VUmc) of the Amsterdam UMC. The funders had no role in study design, collection, analysis and interpretation of the data. K.D. reports consultancy for Guerbet. H.V. reports consultancy fees from Ferring. C.B.L. reports speakers’ fees from Ferring and research grants from Ferring, Merck and Guerbet. V.M. reports receiving travel and speakers fees as well as research grants from Guerbet. B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck KGaA and Guerbet and travel and research grants from Merck KGaA and Guerbet. The other authors do not report conflict of interests.

TRIAL REGISTRATION NUMBER

The H2Oil study was registered at the Netherlands Trial Registry (NTR 3270).

TRIAL REGISTRATION DATE

1 February 2012.

DATE OF FIRST PATIENT’S ENROLMENT

3 February 2012.

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

OBJECTIVE

To determine the impact of oil-based versus water-based contrast on pregnancy and live birth rates ≤5 years after hysterosalpingography (HSG) in infertile women.

DESIGN

A 5-year follow-up study of a multicenter randomized trial.

SETTING

Hospitals.

PATIENT(S)

Infertile women with an ovulatory cycle, 18-39 years of age, and having a low risk of tubal pathology.

INTERVENTION(S)

Use of oil-based versus water-based contrast during HSG.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy, live births, time to ongoing pregnancy, second ongoing pregnancy.

RESULT(S)

A total of 1,119 women were randomly assigned to HSG with oil-based contrast (n = 557) or water-based contrast (n = 562). After 5 years, 444 of 555 women in the oil group (80.0%) and 419 of 559 women in the water group (75.0%) had an ongoing pregnancy (relative risk [RR] 1.07; 95% confidence interval [CI] 1.00-1.14), and 415 of 555 women in the oil group (74.8%) and 376 of 559 women in the water group (67.3%) had live births (RR 1.11; 95% CI 1.03-1.20). In the oil group, 228 pregnancies (41.1%) were conceived naturally versus 194 (34.7%) pregnancies in the water group (RR 1.18; 95% CI 1.02-1.38). The time to ongoing pregnancy was significantly shorter in the oil group versus the water group (10.0 vs. 13.7 months; hazard ratio, 1.25; 95% CI 1.09-1.43). No difference was found in the occurrence of a second ongoing pregnancy.

CONCLUSION(S)

During a 5-year time frame, ongoing pregnancy and live birth rates are higher after tubal flushing with oil-based contrast during HSG compared with water-based contrast. More pregnancies are naturally conceived and time to ongoing pregnancy is shorter after HSG with oil-based contrast.

CLINICAL TRIAL REGISTRATION NUMBER

Netherlands Trial Register (NTR) 3270 and NTR6577(www.trialregister.nl).

Impact of genital Chlamydia trachomatis infection on reproductive outcomes among infertile women undergoing tubal flushing: a retrospective cohort at a fertility centre in Uganda

BACKGROUND

The impact of current C. trachomatis on clinical pregnancy and live birth rates among women undergoing tubal flushing is largely unknown. This study aimed to investigate whether current female genital C. trachomatis infection affects the chance of achieving a clinical pregnancy and a live birth, among infertile women undergoing tubal flushing, at a fertility centre in Uganda.

METHODS

A retrospective Cohort study at a peri-urban fertility centre. A total of 253 eligible women with tubal factor infertility, who underwent tubal flushing, were enrolled and categorised according to their exposure to current genital C. trachomatis infection. These women were followed up for a period of 12 months, with the primary outcome measure being clinical pregnancy and live birth. Secondary outcome measures included pregnancy loss and procedural related adverse events.

RESULTS

Exposure to current genital C. trachomatis infection reduced chance of clinical pregnancy (adjusted relative risk 0.42; 95% confidence interval, 0.18-0.96) and a live birth (adjusted relative risk 0.37; 95% confidence interval, 0.14-0.95) after tubal flushing. Women with current C. trachomatis infection had an increased risk of adverse events (adjusted relative risk, 1.20; 95% confidence interval, 1.08-1.34). However, current C. trachomatis infection did not affect the risk of spontaneous abortion and ectopic pregnancy.

CONCLUSION

Current genital C. trachomatis infection in women with tubal factor infertility, undergoing tubal flushing, lowers their chance of pregnancy and live birth.

Tubal flushing with oil- or water-based contrast medium: can we identify markers that indicate treatment benefit?

STUDY QUESTION

Can we identify patient characteristics that distinguish which ovulatory infertile women undergoing hysterosalpingography (HSG) benefit more or less from flushing with oil-based contrast medium compared to water-based contrast medium?

SUMMARY ANSWER

In ovulatory infertile women, HSG with oil-based contrast medium resulted in higher 6-month ongoing pregnancy and live birth rates as compared to HSG with water-based contrast medium and this treatment effect was independent of characteristics of the couple.

WHAT IS KNOWN ALREADY

We recently showed that in infertile women undergoing HSG, flushing with oil-based contrast medium resulted in more ongoing pregnancies than flushing with water-based contrast medium.

STUDY DESIGN, SIZE, DURATION

We used data from our randomized clinical trial (RCT) in which 1,119 ovulatory infertile women undergoing HSG during fertility work-up were randomized for use of oil-based (N = 557) or water-based (N = 562) contrast medium.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We built logistic regression models to predict ongoing pregnancy and live birth (secondary outcome) as a function of the specific contrast, the specific marker, and marker-by-contrast-interaction. Markers considered were female age, maternal ethnicity, female smoking, body mass index (BMI), duration of infertility, infertility being primary or secondary, sperm quality, and previous appendectomy.

MAIN RESULTS AND THE ROLE OF CHANCE

The 6-month ongoing pregnancy rates in the overall population were 39.7% after use of oil-based contrast versus 29.1% after use of water-based contrast medium [relative risk (RR), 1.37; 95% confidence interval (CI), 1.16–1.61; P < 0.001]. Among the studied baseline characteristics, BMI (P = 0.002) and semen volume (P = 0.02) were statistically significant prognosticators. The treatment effect of oil-based contrast was stronger in women with a BMI ≤30 kg/m² [RR, 1.54; 95% CI, 1.23–1.92; P = 0.002], and in women whose partner had a semen volume >3 ml [RR, 1.77; 95% CI, 1.28–2.46; P = 0.02]. Also, in women who smoked, the treatment effect of flushing with oil was stronger, but this interaction did not reach statistical significance (P = 0.066). We found no positive effect of oil-based contrast in obese women. We found similar but weaker associations for live birth, which was probably due to lower number of events resulting in less power.

LIMITATIONS, REASONS FOR CAUTION

The RCT was restricted to infertile ovulatory women younger than 39 years of age without endocrinological disorders and at low risk for tubal pathology. Our results should not be generalized to infertile women who do not share these features.

WIDER IMPLICATIONS OF THE FINDINGS

All infertile, ovulatory women younger than 39 years with a low risk for tubal pathology will benefit from an HSG with oil-based contrast; therefore, this should be offered to them after fertility work-up.

STUDY FUNDING/COMPETING INTEREST(S)

The original H2Oil RCT was an investigator-initiated study that was funded by the two academic institutions (AMC and VUmc) of the Amsterdam UMC. The study displayed in this paper was funded by an unconditional research grant from Guerbet. B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548). K.D. reports consultancy for Guerbet, during the conduct of the study, and also reports research grants from Guerbet. C.B.L. reports grants from Guerbet, during the conduct of the study, and grants from Ferring, grants from Merck, and personal fees from Ferring, outside the submitted work. P.H. reports grants from Guerbet, during the conduct of the study, and grants from Ferring and Merck, outside the submitted work. V.M. reports receiving travel and speakers fee as well as research grants from Guerbet. B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA, and Guerbet, and research grants from Guerbet and Merck. The other authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

NTR 3270 www.trialregister.nl

TRIAL REGISTRATION DATE

1 February 2012.

DATE OF FIRST PATIENT’S ENROLMENT

3 February 2012.

Randomised Trial of Lipiodol Uterine Bathing Effect (LUBE) in Women with Endometriosis-Related Infertility

BACKGROUND: We aimed to assess whether lipiodol alters endometrial gene expression through a uterine bathing effect that might enhance receptivity to embryo implantation.

METHODS: An open-label randomised controlled trial design in a single-centre tertiary infertility service. Twelve women with endometriosis (n [Formula: see text] 11) or previous successful lipiodol procedure (n [Formula: see text] 1) were randomised to receive immediate or delayed lipiodol hysterosalpingography, followed by endometrial biopsy. Endometrial samples were assessed for gene expression, using Affymetrix microarrays and validation studies using reverse transcriptase quantitative polymerase chain reaction analysis. Subsequent endometrial gene expression responses to treatment and clinical fertility outcomes were assessed.

RESULTS: Eleven of 12 women had successful endometrial sampling procedures. Nine women had successful pregnancies within the 9-month follow-up phase. Following lipiodol bathing we identified 20 down-regulated and 13 up-regulated genes with p [Formula: see text] 0.05 and with magnitude of change [Formula: see text]1.5-fold in at least three of the four women, with osteopontin being the only gene down-regulated in all four women.

CONCLUSIONS: This study supports the concept of a uterine bathing effect of lipiodol altering endometrial biology and gene expression. Whether regulation of inflammation and immune response pathways by lipiodol might contribute to an increase in endometrial receptivity to embryo implantation merits further investigation.

The IVF-LUBE trial - a randomized trial to assess Lipiodol® uterine bathing effect in women with endometriosis or repeat implantation failure undergoing IVF

RESEARCH QUESTION

Does pre-IVF Lipiodol^® increase the success of IVF treatment in women with endometriosis or repeat implantation failure (RIF) compared with IVF alone?

DESIGN

Lipiodol is known to enhance natural fertility, especially amongst women with endometriosis. The effect of Lipiodol may accrue through an impact on the endometrium that enhances receptivity to implantation. A randomized controlled trial (RCT) was carried out on 70 women due to undergo IVF. Women with endometriosis or RIF in previous IVF treatments, recruited from IVF clinics in New Zealand and in Pune, India, received either Lipiodol by hysterosalpingogram or no intervention prior to IVF treatment.

RESULTS

Between May 2009 and January 2014, 33 women were randomized to Lipiodol plus IVF and 37 to IVF alone. When pregnancies resulting from fresh embryo transfer from the IVF cycle under study were considered, live birth rates were 8/33 (24%) in the pre-IVF Lipiodol group and 11/37 (30%) in the IVF only group (relative risk [RR] 0.81; 95% confidence interval [CI] 0.37 to 1.8). Live birth rates from pregnancies within 6 months were 11/33 (33%) and 12/37 (32%) in these respective groups (RR 1.03; 95% CI, 0.53 to 2.0). The trial was underpowered to detect smaller differences between treatment and control groups.

CONCLUSIONS

No evidence was found of benefit of Lipiodol prior to fresh embryo transfer in women with endometriosis or RIF. It is suggested that this treatment should not be undertaken purely as an adjuvant in IVF other than in the context of a further well-designed RCT.

Use of Lipiodol as a drug-delivery system for transcatheter arterial chemoembolization of hepatocellular carcinoma: a review

Hepatocellular carcinoma (HCC) remains a major public health problem. Transarterial chemoembolization (TACE) is recognized as the standard of care for patients with unresectable, asymptomatic, noninvasive and multinodular HCC. This procedure is based on percutaneous administration of a cytotoxic drug emulsified with Lipiodol followed by embolization of the tumour-feeding arteries. The standard procedure involves Lipiodol, an oily contrast medium which consists of a mixture of long-chain di-iodinated ethyl esters of poppy seed fatty acids. The aim of this review is to discuss the physical properties, tumour uptake behaviour and drug delivery effects of Lipiodol, the parameters influencing tumour uptake and future prospects. Lipiodol has a unique place in TACE as it combines three specific characteristics: drug delivery, transient and plastic embolization and radiopacity properties. Substantial heterogeneity in the physicochemical characteristics of Lipiodol/cytotoxic agent emulsions might reduce the efficacy of this procedure and justifies the current interest in Lipiodol for drug delivery.

Endometrial scratching to improve pregnancy rate in couples with unexplained subfertility: a randomized controlled trial

AIM

The aim of this study was to examine the effect of endometrial scratching in women with unexplained infertility.

MATERIAL AND METHODS

A randomized controlled trial was conducted in Mansoura University Teaching Hospital and a private practice setting. A total of 105 couples with unexplained infertility were randomly allocated into two groups: group A comprised 54 women who underwent endometrial scratching in the luteal phase of a spontaneous menstrual cycle; and group B included 51 women who underwent a placebo procedure. The main outcome measured was cumulative clinical pregnancy rate after 6 months and miscarriage rate.

RESULTS

Clinical pregnancy rate was significantly higher in the women experiencing endometrial biopsy than in the control group (25.9% and 9.8%, respectively, P = 0.04). There was no significant difference in miscarriage rate between pregnant women in the endometrial injury group and pregnant women in the control group (12.5% and 16.5%, respectively, P = 0.79).

CONCLUSIONS

Endometrial scratching may improve clinical pregnancy rates in couples with unexplained infertility. Adequately powered studies are mandated to confirm or refute the findings.

After the FLUSH trial: A prospective observational study of lipiodol flushing as an innovative treatment for unexplained and endometriosis-related infertility

OBJECTIVES

To assess the demographics, efficacy and safety of lipiodol flushing fertility treatment.

DESIGN

Prospective observational study.

SETTING

Secondary level care infertility clinic and radiology centre based in Auckland, New Zealand.

POPULATION

The first cohort of 100 New Zealand women with infertility to undergo lipiodol flushing as an innovative fertility treatment.

METHODS

Women received lipiodol flushing performed by a hysterosalpingogram technique and were followed up at 6 months.

MAIN OUTCOME MEASURES

Clinical pregnancy at 6 months post-treatment; and live birth or ongoing pregnancy.

RESULTS

The overall pregnancy rate was 30% and the live birth or ongoing pregnancy rate 27%. For women under 40 years old, a 32% pregnancy rate and a 25% live birth or ongoing pregnancy rate were seen in women with unexplained infertility, and a 50% pregnancy rate and a 47% live birth or ongoing pregnancy rate were seen in women with endometriosis. Of women aged 40 years and older, the pregnancy rate was 13% and the live birth or ongoing pregnancy rate was 13%. The pregnancy rates included those occurring after additional interventions, such as intrauterine insemination and in vitro fertilisation, accounting for 12 of the 30 pregnancies. There were no treatment complications.

CONCLUSION

This study provides further evidence of the efficacy and safety of lipiodol flushing fertility treatment.

Survey of Australasian clinicians' prior beliefs concerning lipiodol flushing as a treatment for infertility: A Bayesian study

OBJECTIVE

To evaluate clinicians' beliefs concerning the effectiveness of lipiodol flushing as a treatment for unexplained infertility, and to integrate these prior beliefs with evidence from randomised trials.

DESIGN

Survey.

SETTING

Specialists in Australasian in vitro fertilisation (IVF) clinics in 2001.

METHODS

One of two types of structured survey was used to gather information from fertility specialists in Australasian IVF clinics. Prior beliefs were captured graphically and textually from responses.

RESULTS

Nineteen specialists returned questionnaires. Eighteen of the 19 specialists believed that lipiodol flushing was more likely to be beneficial than harmful. The most widely held prior belief, reflected in both textual and numerical responses, was that lipiodol was likely to produce a small beneficial response. The credible limits of this belief were compatible with a reasonable fertility benefit, as more than 50% believed that a 1.5-fold increase in pregnancy rate was plausible. The two surveys found that a 1.2-fold or 1.4-fold increase in pregnancy rate was the median expected level of benefit at which clinicians would have been inclined to recommend lipiodol flushing to their patients (combined range 1.1- to 2.3-fold) - new evidence suggests that for women with endometriosis but otherwise unexplained infertility, these levels of benefit are exceeded.

CONCLUSIONS

Among Australasian fertility specialists there is variation in prior beliefs concerning the effectiveness of lipiodol flushing as a treatment for unexplained infertility and in the expected level of benefit at which clinicians are inclined to recommend this treatment. Generalisability of these beliefs remains uncertain owing to a low study response rate.