Hysterosalpingography Research Articles

A randomized controlled trial on the impact of a specialized training program on anxiety and perceived pain in infertile women undergoing hysterosalpingography

Hysterosalpingography (HSG) is a minimally invasive procedure that can be painful. This study aimed to examine the impact of a tailored training program on anxiety and perceived pain intensity in infertile women undergoing HSG. This research was a clinical trial involving 86 infertile women who were candidates for HSG and conducted at the radiology department of the Royan Infertility Center in Tehran, Iran, between November 22, 2021, to March 11, 2023.The participants were divided into two groups:43 women in the intervention group and 43 women in the control group. The randomization of the samples was carried out using a random number table. The women in the intervention group received two face-to-face group training sessions. Data were collected using valid questionnaires. Additionally, the heart rate and blood pressure of the participants were recorded. Data analysis showed the training intervention was significantly associated with reducing anxiety levels, perceived pain, systolic blood pressure, diastolic blood pressure, and heart rate in women undergoing HSG (p < 0.05). These findings support the use of structured training interventions to improve the overall experience and outcomes for patients undergoing HSG.Trial Registration Number: IRCT20150905023897N4.

Practice of Sterilization and Disinfection during Hysterosalpingography in some Hospitals of the Northwest, Southwest and Littoral Regions of Cameroon

Hysterosalpingography (HSG) is a diagnostic imaging procedure used to study the female reproductive system using contrast medium which is injected into the uterus and x-ray images are taken as the dye fills the uterus and fallopian tubes. Proper sterilization and disinfection protocols are essential to minimize the risk of introducing pathogens into the reproductive tract during the procedure. The purpose of this study was to investigate disinfection and sterilization practices of HSG equipment before HSG procedure in some hospitals in Cameroon. At the end of the study, collected data was compiled and analysed, the results showed 0% of proper sterilization was done for the equipment used, all the equipment were poorly disinfected with poorly made chemicals (sodium hypochlorite) solution (100%). Most of the equipment used were either about 80% stained or rusted. Based on the finding of this study, it was concluded that the practice of sterilization and disinfection of HSG equipment in Cameroon is poor, and there is need for improvements of the practice.

7912 Children's Neurodevelopmental Outcomes at School-Age After Conception with Hysterosalpingography Using Iodinated Contrast Media

Abstract Disclosure: S. Keestra: None. C. Kooper: None. N. van Welie: None. K. Dreyer: Grant Recipient; Self; research grants from Guerbet. Speaker; Self; travel and speaker fees Guerbet. R. van Eekelen: None. T. Roseboom: None. J. Oosterlaan: None. B. Mol: Consulting Fee; Self; Organon Laboratories, Norgine, Merck. Grant Recipient; Self; Merck. Stock Owner; Self; ObsEva. M. Finken: None. V. Mijatovic: Grant Recipient; Self; Guerbet, Merck, Ferring Pharmaceuticals. Speaker; Self; Guerbet, Merck, Ferring Pharmaceuticals. M. Königs: None. Thyroid hormone sufficiency in pregnancy is vital for children's neurodevelopment. Exposure to iodine excess can cause transient disruption of thyroid hormone synthesis through the Wolff-Chaikoff effect. Iodinated contrast media are commonly utilized in hysterosalpingography (HSG) as part of female fertility work-up. When conception occurs shortly after HSG with iodinated contrast, a temporary reduction of maternal and/or foetal thyroid hormone synthesis could jeopardize children's neurodevelopment. We compared the neurodevelopmental outcomes of 6-9-year-old children (n=69) conceived &amp;lt;6 months after HSG with 5-10 ml of oil-based contrast (iodine content: 480mg/ml) or water-based contrasts (iodine content: 250mg/ml) in the follow-up of a nationwide randomised controlled trial (H2Oil trial; Netherlands; 2012-2014; NCT05168228). A community sample of naturally-conceived children (n=44) with similar age, sex and parental education was used as a comparison group (NTR9574). Primary outcomes were intelligence (Wechsler’s Intelligence Scale for Children V), behaviour questionnaires for parents and teachers (Strengths and Difficulties Questionnaire (SDQ); Strengths and Weaknesses of ADHD Symptoms And Normal behaviour (SWAN)), and academic performance. Secondary outcomes were neurocognitive domains assessed in computerized tasks focussing on Processing &amp; Control, Verbal Memory, Visual Memory, Verbal Working Memory, Visual Working Memory, and Visuomotor Integration (Emma Toolbox for Neurocognitive Functioning). We adjusted linear regression models for age, sex, and parental education, applying FDR correction for multiple comparisons. Additional analysis looked at children conceived within 4 weeks, 4-12 weeks, or &amp;gt;12 weeks after HSG. Children conceived &amp;lt;6 months after HSG had lower performance on intelligence tests (-6.81; 95%CI -10.97 to -2.65; p=0.02) and the neurocognitive domain Processing &amp; Control (-0.52; 95%CI-0.84 to -0.19; p=0.02), with processing speed and consistency affected. No differences were found for other neurocognitive domains, behaviour or academic performance. In comparison to naturally-conceived children, children conceived &amp;lt;4 weeks after HSG had lower performance on intelligence tests, but there was no difference for children conceived 4-12 weeks and &amp;gt;12 weeks after HSG. Replication studies with higher power are needed to further evaluate the safety of iodinated contrast media use periconception, including their effects on thyroid function and children's neurodevelopment. Closer monitoring and treatment of thyroid dysfunction in the months following HSG may be warranted. Presentation: 6/1/2024

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.

Does preconceptional exposure to oil-based iodinated contrast media during hysterosalpingography (HSG) impact children's neurodevelopment compared with exposure to water-based alternatives? 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. 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. 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). 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. 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. 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. 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. 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. NCT05168228.

Laparoscopy Supports Implementation of Primary Infertility Diagnosis and Treatment: Case Reports

Background: Infertility is defined as conception failure in couples who have had sexual activity without regular contraception for one year and are still not pregnant. Abnormalities in the fallopian tube have the highest percentage of 30-45% as a cause of infertility. Hydrosalping is a condition where one or both fallopian tubes have fluid-containing clots and is the cause of 25–30% of all infertility cases. The condition of the fallopian tube and its patency can be detected with a hysterosalpingogram (HSG). Although a HSG examination can give a picture of the uterine cavity and tubes, other abnormalities such as adhesion and endometriosis are sometimes not detected. So, laparoscopy can be used to solve this problem. Results: We reported that a 27-year-old woman, Para 0, Abortus 0, came to the gynecology department with a major complaint of infertility. At the HSG examination, an unpatented right fallopian tube was found. So, the patient underwent laparoscopy, but both fallopian tubes were found in a patent state, and there was a tubal attachment on the omentum and a paratuba cyst, so adhesionolysis and cystectomy were performed. It can be concluded that tubal abnormalities can be detected more clearly with laparoscopy than with HSG. Conclusions: Laparoscopic is more recommended in cases of primary infertility, but further research to compare or combine these two modalities is still imperative.

The effect of prior hysterosalpingo-foam sonography or hysterosalpingography on tubal patency: a secondary analysis of a randomized controlled trial.

Does hysterosalpingo-foam sonography (HyFoSy) prior to hysterosalpingography (HSG) or HSG prior to HyFoSy affect visible tubal patency when compared HSG or HyFoSy alone? Undergoing either HyFoSy or HSG prior to tubal patency testing by the alternative method does not demonstrate a significant difference in visible tubal patency when compared to HyFoSy or HSG alone. HyFoSy and HSG are two commonly used visual tubal patency tests with a high and comparable diagnostic accuracy for evaluating tubal patency. These tests may also improve fertility, although the underlying mechanism is still not fully understood. One of the hypotheses points to a dislodgment of mucus plugs that may have disrupted the patency of the Fallopian tubes. This is a secondary analysis of the randomized controlled FOAM study, in which women underwent tubal patency testing by HyFoSy and HSG, randomized for order of the procedure. Participants either had HyFoSy first and then HSG, or vice versa. Here, we evaluate the relative effectiveness of tubal patency testing by HyFoSy or HSG prior to the alternative tubal patency testing method on visible tubal patency, compared to each method alone. Infertile women aged between 18 and 41 years scheduled for tubal patency testing were eligible for participating in the FOAM study. Women with anovulatory cycles, endometriosis, or with a partner with male infertility were excluded. To evaluate the effect HyFoSy on tubal patency, we relied on HSG results by comparing the proportion of women with bilateral tubal patency visible on HSG in those who underwent and who did not undergo HyFoSy prior to their HSG (HyFoSy prior to HSG versus HSG alone). To evaluate the effect of HSG on tubal patency, we relied on HyFoSy results by comparing the proportion of women with bilateral tubal patency visible on HyFoSy in those who underwent and who did not undergo HSG prior to their HyFoSy (HSG prior to HyFoSy versus HyFoSy alone). Between May 2015 and January 2019, we randomized 1160 women (576 underwent HyFoSy first followed by HSG, and 584 underwent HSG first followed by HyFoSy). Among the women randomized to HyFoSy prior to HSG, bilateral tubal patency was visible on HSG in 467/537 (87%) women, compared with 472/544 (87%) women who underwent HSG alone (risk difference 0.2%; 95% CI: -3.8% to 4.2%). Among the women randomized to HSG prior to HyFoSy, bilateral tubal patency was visible on HyFoSy in 394/471 (84%) women, compared with 428/486 (88%) women who underwent HyFoSy alone (risk difference -4.4%; 95% CI: -8.8% to 0.0%). The results of this secondary analysis should be interpreted as exploratory and cannot be regarded as definitive evidence. Furthermore, it has to be noted that pregnancy outcomes were not considered in this analysis. Tubal patency testing by either HyFoSy or HSG, prior to the alternative tubal patency testing method does not significantly affect visible tubal patency, when compared to alternative method alone. This suggests that both methods may have comparable abilities to dislodge mucus plugs in the Fallopian tubes. The FOAM study was an investigator-initiated study, funded by ZonMw, a Dutch organization for Health Research and Development (project number 837001504). IQ Medical Ventures provided the ExEm®-FOAM kits free of charge. The funders had no role in study design, collection, analysis, or interpretation of the data. H.R.V. reports consultancy fees from Ferring. M.v.W. received a travel grant from Oxford University Press in the role of Deputy Editor for Human Reproduction and participates in a Data Safety and Monitoring Board as an independent methodologist in obstetrics studies in which she has no other role. M.v.W. is coordinating editor of Cochrane Fertility and Gynaecology. B.W.J.M. received an investigator grant from NHMRC (GNT1176437) and research funding from Merck KGaA. B.W.J.M. reports consultancy for Organon and Merck KGaA, and travel support from Merck KGaA. B.W.J.M. reports holding stocks of ObsEva. V.M. received research grants from Guerbet, Merck and Ferring and travel and speaker fees from Guerbet. The other authors do not report conflicts of interest. International Clinical Trials Registry Platform No. NTR4746.

Impact of Hysteroscopic Polypectomy on IVF Outcomes in Women with Unexplained Infertility.

Objective: To assess the effect of hysteroscopic polypectomy on the in vitro fertilization (IVF) results in infertile women with at least one prior negative IVF outcome. Methods: This retrospective cohort study included women who had attended the "2nd Department of Obstetrics and Gynecology of the National and Kapodistrian University of Athens" and "Iaso" Maternity Hospital from October 2019 to January 2023 for infertility treatment. The medical records of 345 women aged 18-45 years old without abnormal findings in hysterosalpingography (HSG) and with at least one previous failed IVF procedure were analyzed. The male factor was excluded, as well as a prior hysteroscopic removal of polyps. In 67 women, polyps were suspected during initial two-dimensional ultrasound (2D-US) examination. The final sample of the study comprised 40 patients, in which endometrial polyps were removed by hysteroscopy with the use of resectoscope. All patients underwent ovarian stimulation and IVF in the consecutive cycle using a short GnRh antagonist protocol. Main Results: After hysteroscopic polypectomy, 29 (72.5%) out of 40 patients had a positive pregnancy result: 26 (65%) clinical and 3 (7.5%) biochemical pregnancies were documented. There was a statistically significant difference between the number of clinical pregnancies before and after polypectomy (p < 0.001), as well as between the total number of pregnancies (p < 0.001). Secondary Results: Women with positive outcome were significantly younger and had significantly lower FSH levels (p < 0.007). They also had significantly higher AMH (p < 0.009) and peak estradiol levels (p < 0.013) and yielded more M II oocytes (p < 0.009) and embryos (p < 0.002). Conclusions: Hysteroscopic polypectomy in women with a suspected endometrial polyp using 2D ultrasound and a history of prior failed IVF attempt improves IVF outcomes in terms of the clinical and total number of pregnancies.

P-756 Neurodevelopmental outcomes at school-age after conception with hysterosalpingography using iodinated contrast media - follow-up of the nationwide multicentre H2Oil trial

Abstract Study question How does conception &amp;lt;6 months after hysterosalpingography (HSG) with iodinated contrast media affect the neurodevelopment of the offspring compared to naturally-conceived peers at a school-age? Summary answer Children conceived &amp;lt;6 months after HSG with iodinated contrast media perform lower on intelligence tests and information processing and attention control compared to naturally-conceived peers. What is known already Tubal patency in subfertile women is commonly assessed using hysterosalpingography (HSG), but the potential risks of exposure to high iodine content in contrast media used remains unknown. Exposure to iodine excess can cause transient reduction in thyroid hormone synthesis due to the Wolff-Chaikoff effect. Thyroid hormone sufficiency in early pregnancy is vital for children’s neurodevelopment. When conception occurs shortly after HSG with iodinated contrast, a temporary reduction of maternal and/or foetal thyroid hormone supply could jeopardize children’s neurodevelopment. Study design, size, duration We evaluated neurodevelopmental outcomes of 6–9-year-old children conceived &amp;lt;6 months after HSG with oil-based (iodine content: 480mg/ml) or water-based contrast (iodine content: 240-300mg/ml) in a nationwide randomised controlled trial (H2Oil trial; Netherlands; 2012-2014; NCT05168228). Naturally-conceived children (n = 44) with similar age, sex and parental education were used as a comparison group (NTR9574). We also compared children conceived &amp;lt;4w, 4-12w, &amp;gt;12w after HSG with those conceived naturally. The study took place January 2022 until November 2023. Participants/materials, setting, methods We contacted 140 mothers from the H2Oil trial, 69 children conceived &amp;lt;6m after HSG participated, and parallelly we recruited 44 naturally-conceived children. Primary outcomes were intelligence (Wechsler’s Intelligence Scale for Children V), behavioural functioning (SDQ and SWAN, administered to parents and teachers), and academic performance. Secondary outcomes were neurocognitive function assessed by a battery of computerized tests. We used linear regression adjusted for age, sex, and parental education and applied FDR correction. Main results and the role of chance Compared to naturally conceived children, children conceived &amp;lt;6m after HSG had lower performance on intelligence tests (-6.81; 95%CI-10.97 to -2.65; p = 0.02) and the neurocognitive domain Processing &amp; Control (-0.52; 95%CI-0.84 to -0.19; p = 0.02), with functions relating to information processing speed and consistency affected. No differences were found for other neurocognitive domains, behaviour or academic performance. Considering time between HSG and conception, intelligence scores were lower for children conceived &amp;lt;4w after HSG compared to naturally-conceived peers (-11.47; 95%CI-17.98 to -4.95; p = 0.03), while no significant differences were found for the groups of children conceived 4-12 weeks after HSG (-7.17; 95%CI -12.28 to -2.06; p = 0.10) or &amp;gt; 12 weeks after HSG (-4.20; 95%CI -9.33 to 0.94; p = 0.52). The findings of this study warrant replication in larger independent samples in order to evaluate the long-term neurodevelopment of children conceived after HSG with iodinated contrast media. Limitations, reasons for caution We aimed to recruit 64 children for each group, but our study was not sufficiently powered for small- and medium-sized differences. We did not collect information on the thyroid or iodine status of the mothers following HSG, and there is limited knowledge about pharmacokinetics of iodinated contrast media in humans. Wider implications of the findings Replication studies with are needed to further evaluate the safety of iodinated contrast media use periconception, including their effects on thyroid function and children’s neurodevelopment. Closer monitoring and treatment of thyroid dysfunction in the months following HSG may be warranted. Trial registration number NCT05168228

P-334 Hysterosalpingo-Contrast-Sonography: a key step in the female infertility workup?

Abstract Study question The main objective of this study is to estimate the possibility of offering Hystero-Salpingo-Contrast-Sonography (HyCoSy) as a first-line diagnosis test in the female infertility exploration Summary answer HyCoSy represents a key step in decision-making regarding subsequent steps in infertility diagnosis and treatment What is known already In this age of rising rates of infertility; the evaluation of the fallopian tubes and the endometrial cavity in an essential part of the infertility investigation. Traditionally hysterosalpingography has been used to evaluate tubal patency; but it has many disadvantages; laparoscopy and hysteroscopy are at present considered as the gold standard techniques for tubal and endometrial cavity assessment, respectively. Hysterosalpingo- Contrast –Sonography or HyCoSy was introduced over 20 years ago since 1981; it allows to gynecologist to evaluate the fallopian tubes the uterus and the ovaries with only one ultrasound in the office. Study design, size, duration During two years, one hundred and sixty-seven patients with a context of female infertility with normal spermogram were included in our prospective and descriptive study, Participants/materials, setting, methods Our patients underwent: a Hysterosalpingography (HSG), a Hysteroscopy, a Laparoscopy and as part of our study: a Hystero-Salpingo-Contrast-Sonography (HyCoSy), a comparison was made between the tubal and uterine parameters found by the HyCoSy with those of the HSG after comparison with the data shown by the Gold Standard techniques: Laparoscopy and Hysteroscopy, also we evaluated the failure rate, its duration, its tolerability, its cost, its complications, its limitations and the rate of post-HyCoSy pregnancies. Main results and the role of chance The technique was impossible in 4 patients, so a failure rate of 2.4%, the average duration of the procedure was 17+/-1 min (10-30 min), generally well tolerated, pain assessment found an average of 3 on the VAS (2-4), the rate of all minor complications was 8.85% at 5 min and 3.06% at 15 min, no case of allergy to the contrast product was noted. Following the 4 cases of failures the comparison was only possible in 163 patients, after comparing the data with the GOLD STANDARDS For the tubal permeability we noted almost perfect concordances between the three techniques HyCoSy, HSG and laparoscopy, with a concordance of 0.87 between HyCoSy versus laparoscopy (p value at 0.34) and 0.85 between HSG versus laparoscopy (p value at 0.18), For the uterine cavity evaluation the comparison of hydrosonography(step one of our technique) to hysteroscopy finds an almost perfect agreement at 0.88 (p value at 0.71) in contrast to a low agreement at 0.27 between the HSG and the gold standard (p value &amp;lt;0.02). Our technique also allows us to carry out a morphological and functional assessment of the ovaries as well as a study of the peritoneal cavity. Limitations, reasons for caution A disadvantage of this technique is the rate of false results, regardless of the contrast product used. However, it is important to note that these errors also occur when using an HSG, or during a Laparoscopy.A review of the literature allows us to identify the causes and identify solutions. Wider implications of the findings It is important to work more on improving exploration techniques by working to ensure that they are as precise, tolerable, of certain safety and as economical as possible and why not with a therapeutic effect. Trial registration number not applicable

O-023 Does flushing with oil-based contrast during hysterosalpingography (HSG) increase the live birth rate as compared to water-based contrast: a prospective cohort study

Abstract Study question What is the effectiveness of oil-based contrast during HSG compared to water-based contrast? Summary answer HSG with oil-based contrast increased the live birth rate as compared to water-based contrast. What is known already Tubal flushing has long been thought to increase live birth rate in infertile couples. A large randomised clinical trial (RCT) in The Netherlands confirmed the long-term hypothesis that HSG with oil-based contrast (Lipiodolâ) increased the live birth rate as compared to HSG with water-based contrast. We assessed whether this treatment effect was also achieved with oil-based contrast in Chinese women. Study design, size, duration We performed a prospective cohort study between May 4, 2020 and March 30, 2022. A total of 1187 women were included in the analysis.These women were categorized into two groups based on the contrast they used: the Oil-Soluble Contrast Media (OSCM) group, which employed poppy seed oil, consisting of 569 cases, and the Water-Soluble Contrast Media (WSCM) group, which used iodixanol, comprising 618 cases. Participants/materials, setting, methods This study was conducted at Shanghai Jiao Tong University International Peace Maternity and Child Health Hospital .The primary outcome was ongoing pregnancy rate within 6 months after the examination.Secondary outcomes included clinical pregnancies, miscarriage, ectopic pregnancy and thyroid Stimulating Hormone. Main results and the role of chance The ongoing pregnancy rate of the oil group is significantly higher than that of the water group (24.1% versus 17.2%, rate ratio [RR], 1.53; 95% confidence interval [CI], 1.14 to 2.06; P = 0.004). Women in the oil group also achieved higher clinical pregnancy rate (32.2% versus 22.2%, RR, 1.67; 95% CI, 1.27 to 2.18, P &amp;lt; 0.001), higher live birth rate (23.9% versus 16.8%, RR, 1.56; 95% CI, 1.16 to 2.09, P = 0.003), and bore higher risk of miscarriage (8.0% versus 5.0%, RR, 1.67; 95% CI, 1.02 to 2.72, P = 0.04) than water group. Limitations, reasons for caution The sample size along with the data was obtained from a cohort study in a single center. Wider implications of the findings Tubal flushing with oil-based contrast medium is an effective treatment to improve the pregnancy outcomes of infertile women that should be part of every infertility work-up. Trial registration number not applicable

P-313 Additional tubal flushing with ethiodized oil during transvaginal hydrolaparoscopy; feasibility and live birth rate, a pilot study in subfertile women

Abstract Study question Is tubal flushing with ethiodized oil during transvaginal hydrolaparoscopy (THL) feasible and what is the live birth rate within 6 months after THL? Summary answer Additional flushing with ethiodized oil during THL is feasible and safe with a live birth rate of 32.0% compared to 23.4% using solely water-based-contrast (p = 0.25). What is known already The use of ethiodized oil during hysterosalpingography (HSG), an alternative method to test tubal patency, has shown to have a positive effect on the live birth rate, compared to the use of water-based contrast (methylene blue). The benefit of THL over HSG as a tubal testing method is the possibility to also explore tubo-ovarian structures and the pouch of Douglas. Currently, only water-based media are used for tubal flushing during THL. Study design, size, duration A single-center cohort study at Máxima MC, the Netherlands, including 50 subfertile women who underwent THL and in whom there was at least unilateral tubal patency for methylene blue. Outcomes of interest included feasibility, safety and 6- months live birth rate. Our data were compared with a historical cohort of 111 subfertile women who underwent THL using solely water-based contrast (van Kessel MA. et al., 2021). Univariate – and multivariate logistic regression analysis were performed. Participants/materials, setting, methods Women with an iodine allergy and/or manifest thyroid dysfunction were excluded. Participants received additional tubal flushing with ethiodized oil (Lipiodol® Ultra Fluid). Main outcomes were appearance of oil and cell/mucus debris at the tubal fimbriae, pain scores (Visual Analogue Scale, VAS) and acceptability scores (0-10, completely unacceptable-acceptable). Secondary outcomes included; amount of ethiodized oil used, thyroid function four weeks afterwards, adverse events and live birth rate within 6 months after THL. Main results and the role of chance In 48 of the 50 THL procedures there was bilateral patency to methylene blue, ethiodized oil appeared from the tubal fimbriae bilateral in 77% (37/48), unilateral in 17% (8/48), while it did not appear in 6% (3/48). In two procedures there was unilateral patency to methylene blue. Ethiodized oil appeared unilateral in one and did not appear during the other THL. The amount of ethiodized oil used was 5 mL [3.4–6.3). The median reported pain scores on the VAS were 2.9 [IQR 1.0–5.0] after flushing with methylene blue and 3.0 [IQR 1.0–5.0] after ethiodized oil. The acceptability of the procedure was rated as 10 out of 10 [IQR 8–10]. Four weeks after the procedure 14% (6/42) had developed subclinical hypothyroidism, one woman had overt hypothyroidism (FT4 slightly decreased to 11.0 pmol/L, TSH 5.60 mU/L) and one woman had isolated hypothyroxinemia (FT4 11.0 pmol/L, TSH 3.40 mU/L). One adverse event, persistent bleeding at the trocar insertion site was reported, for which a diagnostic laparoscopy was performed. The live birth rate within 6 months after a THL was 32% (16/50), compared to 23% (26/111) in our historical cohort using solely water-based contrast (OR = 1.54, 95% CI 0.74–3.22, P = 0.25). Limitations, reasons for caution As this is a pilot study without a power analysis, the study is presumably underpowered to show an effect on the live birth rate. Also, the control group was historical. Wider implications of the findings By proving feasibility of using ethiodized oil during THL we encourage further research on its effect on pregnancy rates. Furthermore, the direct observation of tubal flushing with ethiodized oil during THL enables further investigation of the contrast characteristics, which are presumably responsible for its positive effect on live birth rate. Trial registration number NL8696

Surgical management of an ectopic pregnancy in the setting of an unexpected Müllerian anomaly: intraoperative and postoperative implications

ObjectiveTo describe the intraoperative and postoperative implications arising from the unexpected diagnosis of a Müllerian anomaly during the surgical management of an ectopic pregnancy. DesignVideo article. SettingAcademic Center. Subject(s)A 39-year-old nulligravid woman with anovulation and irregular menstrual cycles presented to the office. Her urine pregnancy test was incidentally positive; serum β-human chorionic gonadotropin (β-hCG) level was 5,644 mIU/mL. Outpatient transvaginal ultrasonography (TVUS) demonstrated a 2.1 x 1.7 x 2.2-cm thick-walled structure in the left adnexa without an intrauterine pregnancy. These findings were highly suspicious for a left tubal ectopic pregnancy. The patient was consented for laparoscopy with planned left salpingectomy. The patient included in this video gave consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.) and other applicable sites. InterventionDiagnostic laparoscopy did not show an obvious left tubal ectopic pregnancy. Instead, a right unicornuate uterus with a dilated rudimentary left uterine horn was seen. Both fallopian tubes and ovaries appeared normal. These laparoscopic findings were consistent with an ectopic pregnancy in the rudimentary horn. However, in the absence of informed consent for a hemi-hysterectomy and no evidence of ectopic rupture or bleeding within the pelvis, we decided to proceed with excision of the ectopic pregnancy from the uterine horn. An incision was made over the anterior surface of the uterine horn, and the pregnancy sac was dissected from the underlying myometrium and excised in its entirety. Left salpingectomy was also performed. The patient was discharged home the same day, and her β-hCG levels decreased to <5 mIU/mL within 28 days of surgery. Main Outcome MeasuresComplete resolution of a left rudimentary uterine horn ectopic pregnancy through surgical excision of the pregnancy sac without hemi-hysterectomy. ResultsPostoperative hysterosalpingography (HSG) demonstrated a right unicornuate uterus with normal fill and spill of the right fallopian tube. Magnetic resonance imaging (MRI) of the pelvis confirmed the findings of a right unicornuate uterus with a non-communicating left rudimentary uterine horn that did not contain any endometrial tissue. Thus, the patient did not require an interval hemihysterectomy. She underwent letrozole and intrauterine insemination treatment 5 months after the initial surgery, which resulted in a clinical intrauterine pregnancy. However, this pregnancy was terminated in the early second trimester due to findings of trisomy 18. She conceived naturally one year later, and this pregnancy resulted in a full-term vaginal birth at 39 weeks gestation. ConclusionUndiagnosed or unexpected Müllerian anomalies can impact the standard intraoperative and postoperative management of ectopic pregnancies.

Hystero-Salphingography in current clinical practice-old flames, die hard!

Hysterosalpingography (HSG) remains a valuable diagnostic tool in current clinical practice, offering crucial insights into endometrial cavity, fallopian tubes and the adjoining part of the pelvic peritoneal cavity. Despite the emergence of alternative imaging and non-imaging options, HSG continues to be widely utilized due to its diagnostic accuracy, cost-effectiveness, and easy accessibility. Due attention to the correct technique and optimal image interpretation will further enhance its diagnostic accuracy and precision in the work-up of patients with fertility problems.

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

Is virtual reality (VR) an effective non-pharmacological tool to reduce procedural pain during hysterosalpingography (HSG)? An HSG with VR does not reduce procedural pain scores compared to an HSG without VR. 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. We performed a two-centre open-label randomized controlled trial between January 2021 and October 2022. 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. 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. 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. Since VR does not reduce procedural pain, this additional tool should not be used during HSG. 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. The trial is registered prospectively in the Netherlands Trial Register (trialregister.nl registration number NL9203, currently accessible on trialsearch.who.int). 16-01-2021. The first participant was enrolled on 19 January 2021.

Pattern of hysterosalpingographic findings among women with infertility in Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Hysterosalpingography (HSG) is a radiological procedure that is routinely done for female fertility workup in most clinical settings. Hysterosalpingography (HSG) is primarily done to assess tubal patency, but it can detect cervical, uterine, and peritoneal diseases. As such, it remains a valuable tool in the evaluation of female infertility in our environment, where the high prevalence of infertility has been largely attributed to tubo-peritoneal factors. It was a retrospective cross-sectional descriptive study. A total of 215 HSG reports of women with infertility at the Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, were reviewed retrospectively. Data on sociodemographic profile, reproductive profile, infertility profile, and HSG reports were obtained from the case records and archives of the Department of Radiology on a proforma. The obtained data was analyzed using SPSS version 20. Most of the clients were within the age range of 35 to 44 years. Secondary infertility accounted for 58.6% of cases of infertility. Abnormal HSG was reported in 70.2% of cases. Tuboperitoneal pathology was the most common abnormality, detected in 46% of cases. Uterine and cervical pathologies were seen in 38.1 and 15.3% of cases, respectively. A total of 116 (53.9%) of the cases had a combination of abnormalities. Abnormal HSG was significantly associated with secondary infertility and a history of induced abortion (p=0.006 and ˂0.001, respectively). Tuboperitoneal pathologies are still a common cause of infertility in our environment. HSG remains a valid tool for female infertility workup.

In vitro effect of hyoscine-N-butyl bromide and diclofenac sodium in human tuba uterina.

To investigate the in vitro effect of diclofenac on tubal smooth muscle as an alternative to hyoscine-N-butyl bromide, which is used for premedication before hysterosalpingography (HSG). Fallopian tubes were retrieved from seven healthy women after bilateral tubal ligation and in vitro contractility and histological studies were conducted using tissue bath and immunohistochemistry. Diclofenac sodium and hyoscine-N-butyl bromide did not significantly change the basal mean tension; however, they decreased the contractions induced by potassium chloride (KCl). The relaxant effect of diclofenac sodium and hyoscine-N-butyl bromide was not statistically significantly different. The presence of cyclooxygenase (COX)-2 enzyme in the fallopian tube was demonstrated by immunohistochemical studies. The in vitro relaxant effect of diclofenac sodium on the fallopian tube is similar to hyoscine-N-butyl bromide. Diclofenac may have the potential to be used as an alternative to hyoscine-N-butyl bromide in premedication in HSG.

Determining The Frequency of Tubal Blockage in Infertility Patients Undergoing X-Rays Hysterosalpingography

Background: Infertility is a complex global health issue, affecting millions of couples and necessitating detailed diagnostic evaluations. Among the various diagnostic procedures, X-ray hysterosalpingography (HSG) is pivotal for assessing tubal patency and identifying underlying causes of infertility. Objective: To determine the frequency of tubal blockages, particularly hydrosalpinx, in patients undergoing HSG at a tertiary care facility. Methods: This retrospective study was conducted at Allama Iqbal Teaching Hospital DG Khan from July 2022 to February 2024. A total of 210 female patients with consecutive infertility were included, excluding those with prior tubal surgeries. Data were extracted from medical records, focusing on demographics, clinical history, and HSG results. Results: The mean age of the participants was 32.35 ± 3.56 years, and the mean duration of infertility was 3.5 ± 2.1 years. Among the patients, 65% were nulliparous, and 35% were parous. Prior fertility treatments were reported in 75% of cases. Tubal blockage was identified in 45 patients (21.4%), with 25 (11.9%) exhibiting unilateral blockage and 20 (9.5%) bilateral blockage. Hydrosalpinx was the most common abnormality, occurring in 30 patients (66.7%). Conclusion: Tubal blockage, particularly hydrosalpinx, is a significant contributor to infertility, found in 21.4% of the study population. These findings emphasize the need for thorough tubal evaluations in infertility assessments.

The categorization of opaque pathologies outside of contrast media in hysterosalpingography which facilitate interpretation: A pictorial review.

Hysterosalpingography (HSG) is a practical and reliable imaging method to evaluate the cervical canal, uterine isthmus, uterine cavity, and fallopian tubes. Using HSG, opaque pathologies outside of contrast media can be detected as well as pathologies of uterus and fallopian tubes. We aim to present and categorize some uncommon and interesting abnormal findings that are located outside of the contrast areas in HSG. This is a pictorial review that depicts various types of HSG images that include opaque pathologies outside of the contrast areas. Images have been extracted from valuable archives collected over 50 yr by professor Shahrzad. A plain pelvic film contains soft tissues of the pelvis, bony structures, artifacts, or foreign bodies. Categorization might easily help the radiologist to interpret the HSG cliché. Opaque pathologies outside of contrast area in HSG can be categorized into 2 groups: "Pelvic Tissue Related" and "Foreign Bodies". Pelvic tissue abnormalities might have a gynecologic or non-gynecologic source. Foreign bodies can be located in the pelvis or outside of the body. HSG is a reliable and inexpensive procedure. Familiarity with the pathologies of pelvic tissues and the accurate interpretation of HSG images are important.

Hysterosalpingography Investigation Versus Patients’ Radiation Dose Risk

Background: Hysterosalpingography (HSG) is a useful radiographic investigation involving the use of contrast medium for the management of infertility in females. It is however, not only a costly procedure but it is also a semi-invasive procedure and carries some radiation risks. One principle of radiation protection is justification of practice which means that the overall benefit of the procedure should outweigh the radiation risks. The aim of this study was to determine justification of HSG procedure by assessing the rate and pattern of pregnancy success among infertile women who underwent HSG procedures at a tertiary hospital in South Eastern Nigeria between 2016 and 2020. Methods: a retrospective cross-sectional study of a sample of 222 women, aged 20-46years (mean 32,55 ±8,16years) who underwent HSG examination at the hospital between 2016 and 2020 was made. The data of eligible subjects were collected from the archives of radiology department of the hospital. Results: The result showed that 121 (54,5 %) out of 222 of the patients achieved pregnancy with proper follow up infertility management. Of the 121, 48(39,67 %) were in the 25-29 years age group and 35(28,93 %) in the 30-34years age group. The commonest pathology found was uterine fibroid 71(32,0 %), followed by tubal blockage, 42(18,92 %) while the least occurring pathology was salpingitis isthmica nodosa 1(0,45 %). Conclusion: there was a strong positive correlation between the age of patient, the HSG findings and the rate of pregnancy success. The procedure is justified in all the age groups except for the &gt;45years group

Hysterosalpingo-foam sonography versus hysterosalpingography during fertility work-up: an economic evaluation alongside a randomized controlled trial.

What are the costs and effects of tubal patency testing by hysterosalpingo-foam sonography (HyFoSy) compared to hysterosalpingography (HSG) in infertile women during the fertility work-up? During the fertility work-up, clinical management based on the test results of HyFoSy leads to slightly lower, though not statistically significant, live birth rates, at lower costs, compared to management based on HSG results. Traditionally, tubal patency testing during the fertility work-up is performed by HSG. The FOAM trial, formally a non-inferiority study, showed that management decisions based on the results of HyFoSy resulted in a comparable live birth rate at 12 months compared to HSG (46% versus 47%; difference -1.2%, 95% CI: -3.4% to 1.5%; P = 0.27). Compared to HSG, HyFoSy is associated with significantly less pain, it lacks ionizing radiation and exposure to iodinated contrast medium. Moreover, HyFoSy can be performed by a gynaecologist during a one-stop fertility work-up. To our knowledge, the costs of both strategies have never been compared. We performed an economic evaluation alongside the FOAM trial, a randomized multicenter study conducted in the Netherlands. Participating infertile women underwent, both HyFoSy and HSG, in a randomized order. The results of both tests were compared and women with discordant test results were randomly allocated to management based on the results of one of the tests. The follow-up period was twelve months. We studied 1160 infertile women (18-41 years) scheduled for tubal patency testing. The primary outcome was ongoing pregnancy leading to live birth. The economic evaluation compared costs and effects of management based on either test within 12 months. We calculated incremental cost-effectiveness ratios (ICERs): the difference in total costs and chance of live birth. Data were analyzed using the intention to treat principle. Between May 2015 and January 2019, 1026 of the 1160 women underwent both tubal tests and had data available: 747 women with concordant results (48% live births), 136 with inconclusive results (40% live births), and 143 with discordant results (41% had a live birth after management based on HyFoSy results versus 49% with live birth after management based on HSG results). When comparing the two strategies-management based on HyfoSy results versus HSG results-the estimated chance of live birth was 46% after HyFoSy versus 47% after HSG (difference -1.2%; 95% CI: -3.4% to 1.5%). For the procedures itself, HyFoSy cost €136 and HSG €280. When costs of additional fertility treatments were incorporated, the mean total costs per couple were €3307 for the HyFoSy strategy and €3427 for the HSG strategy (mean difference €-119; 95% CI: €-125 to €-114). So, while HyFoSy led to lower costs per couple, live birth rates were also slightly lower. The ICER was €10 042, meaning that by using HyFoSy instead of HSG we would save €10 042 per each additional live birth lost. When interpreting the results of this study, it needs to be considered that there was a considerable uncertainty around the ICER, and that the direct fertility enhancing effect of both tubal patency tests was not incorporated as women underwent both tubal patency tests in this study. Compared to clinical management based on HSG results, management guided by HyFoSy leads to slightly lower live birth rates (though not statistically significant) at lower costs, less pain, without ionizing radiation and iodinated contrast exposure. Further research on the comparison of the direct fertility-enhancing effect of both tubal patency tests is needed. FOAM trial was an investigator-initiated study, funded by ZonMw, a Dutch organization for Health Research and Development (project number 837001504). IQ Medical Ventures provided the ExEm®-FOAM kits free of charge. The funders had no role in study design, collection, analysis, and interpretation of the data. K.D. reports travel-and speakers fees from Guerbet and her department received research grants from Guerbet outside the submitted work. H.R.V. received consulting-and travel fee from Ferring. A.M.v.P. reports received consulting fee from DEKRA and fee for an expert meeting from Ferring, both outside the submitted work. C.H.d.K. received travel fee from Merck. F.J.M.B. received a grant from Merck and speakers fee from Besins Healthcare. F.J.M.B. is a member of the advisory board of Merck and Ferring. J.v.D. reported speakers fee from Ferring. J.S. reports a research agreement with Takeda and consultancy for Sanofi on MR of motility outside the submitted work. M.v.W. received a travel grant from Oxford Press in the role of deputy editor for Human Reproduction and participates in a DSMB as independent methodologist in obstetrics studies in which she has no other role. B.W.M. received an investigator grant from NHMRC GNT1176437. B.W.M. reports consultancy for ObsEva, Merck, Guerbet, iGenomix, and Merck KGaA and travel support from Merck KGaA. V.M. received research grants from Guerbet, Merck, and Ferring and travel and speakers fees from Guerbet. The other authors do not report conflicts of interest. International Clinical Trials Registry Platform No. NTR4746.