Hysterosalpingography Research Articles

The feasibility of reduced sutures in 3D laparoscopic tubal sterilization reversal

Study ObjectiveTo show the technique of reduced sutures in 3D laparoscopic tubal reanastomosis. DesignStep-by-step demonstration of the procedure using video. SettingLaparoscopic tubal sterilization reversal demands high precision and requires both skill and experience. Conventionally, 4 to 6 interrupted patterns using 6-0 to 8-0 absorbable sutures are used for laparoscopic tubal reanastomosis. We used fewer and larger sutures under a magnified 3D view to perform the procedure. InterventionsWe presented a case of a 42-year-old woman, gravida 3, para 3, who underwent tubal sterilization during Cesarean section 10 years ago. Preoperative hysterosalpingography (HSG) showed bilateral distal tubal occlusion. The procedure started with the subserosal injection of diluted vasopressin in both proximal and distal ends and in the mesosalpinx to facilitate dissection and hemostasis. After transection of tubal stump and removal of scar tissue, we used a 3 Fr ureteral catheter as the stent to facilitate suturing. Three interrupted 4-0 monocryl sutures were used for suturing both tubal mucosal and muscular layers at 6, 2, and 10 o'clock sites. We performed bilateral ampullo-ampullary reanastomosis. The tubes were successfully reanastomosed, and patency was confirmed by chromotubation performed at the end of the procedure (Figure 1). The operation lasted for 71 minutes. The operative blood loss was less than 50 ml. Patent right fallopian tube was confirmed on postoperative HSG 1 month later. The patient had a successful pregnancy 8 months after the operation. ConclusionOur experience shows the feasibility of 3D laparoscopy for tubal reanastomosis using reduced sutures. The technique alleviates the damage to the fallopian tube. The operative time, hospital stay, and postoperative adhesions were significantly lower than the conventional method with a comparable success rate.

Effect of Intramuscular Hyoscine-N-Butyl Bromide on Tubal Spasm and Pain Perception in Women with Infertility Undergoing Hysterosalpingography: A Randomised Controlled Trial

Background: A tubal patency test is essential in evaluating women with infertility. Hysterosalpingography (HSG) is the investigation of choice for assessing tubal patency. Objective: To evaluate the effect of intramuscular hyoscine-N-butyl bromide on tubal spasms and pain perception during hysterosalpingography. Methods: This randomized, controlled trial was conducted at the Radiology Departments and Infertility Clinics of four health institutions in Bayelsa State, Nigeria, between January 2021 and April 2022. Five hundred and twenty infertile women undergoing hysterosalpingography were randomized into two groups. Women in group I (control) received a placebo, while women in Group II (experimental) received 20 mg of intramuscular hyoscine-N-butyl bromide. Pain scores at different steps of the procedure were recorded. Results: The overall mean pain scores progressively decreased from contrast instillation (4.97 ± 2.08) through 30-minutes post-procedure (3.54 ± 1.54) to 24 hours post-procedure (1.96 ± 1.78). Pain scores at contrast instillation, 30 minutes and 24 hours after HSG were significantly lower in the hyoscine group compared to the placebo group (p = 0.001 each). There were significantly fewer women with tubal blockage in the hyoscine group compared to the placebo group [78 (30.0%) vs 131 (50.4%); p = 0.001]. Conclusion: Intramuscular hyoscine-N-butyl bromide before hysterosalpingography significantly reduces pain and tubal spasm during the procedure.

Restoring tubal patency with laparoscopic tubocornual anastomosis

ObjectiveTo assess the technical feasibility of laparoscopic tubocornual anastomosis (TCA) at restoring tubal patency in patients with proximal tubal occlusions. Materials and methodsA retrospective analysis of fourteen females with identified proximal tubal occlusions seeking to restore their tubal patency in a university-affiliated tertiary hospital between 2011 and 2018. Tubal patency within one year after the surgery was evaluated. ResultsThe patients had a mean age of 34.0 ± 3.6 years old, median parity of 1 child, and mean BMI of 23.0 ± 5.2 kg/m2. Of the fourteen patients, two (14.3%) received bilateral TCA, eight (57.1%) received only unilateral TCA, and four (28.6%) received TCA on one side and tubal anastomosis on the other. The operative time was 126.4 ± 37.9min for unilateral procedure and 201.0 ± 1.4 min for bilateral anastomoses. Postoperative hysterosalpingogram (HSG) demonstrated a patency rate of 64.2% at the TCA sites. Two ectopic pregnancies were reported thereafter. ConclusionThis preliminary series demonstrates that laparoscopic TCA is technically feasible and provides promising results for patients with proximal tubal occlusions hoping to restore their tubal function in order to conceive naturally. A larger prospective series is mandatory to establish its significance and application in clinical practices. Notably, infertile patients without surgically correctable factors are not suitable for this procedure.

Hysterosalpingography Findings among Women Presenting for Infertility Evaluation

Objective: To determine the pattern of hysterosalpingography (HSG) findings among women presenting with infertility. Methods: From June 2021 to March 2022, this study included 100 women who visited the Nishtar hospital's infertility clinic. All these patients underwent HSG evaluation. The HSG examination was planned to take place between the seventh and twelfth day of the patient's menstrual cycle, and before the patient had any sexual activity. Patients were instructed to take a nonsteroidal anti-inflammatory medication such 400 milligrams of ibuprofen half an hour before their hysterosalpingograms as a preparation for the possibility that they may experience some level of discomfort during the procedure. HSG findings were noted for each patient. Results: The mean of participants was 32.5±1.2 years. Mean infertility duration was 5.5±4.3 years. On hysterosalpingography examination, right fallopian tube occlusion was found in 7% patients, left in 13% and bilateral in 25% patients. Hydrosalpinx was diagnosed in right fallopian tube in 7.0% patients, in left in 5% patients and in both fallopian tubes in 3% patients. Overhanging tubes were diagnosed in 8% patients and beaded tubes in 1.0% patients. Regarding uterine pathologies, fibroids were diagnosed in 21% patients, and synaechiae in 8% patients. Regarding cervical pathologies, irregular pattern was found in 2% patients, patulous in 2% and in stenosis in 1.0% patients. Conclusion: Hysterosalpingogram, an essential instrument in the evaluation of infertility, plays a significant part in identifying illnesses that affect the female reproductive system. According to the findings of this study, tubal diseases are the leading cause of female infertility. Keywords: Infertility, Tubal abnormalities, Hysterosalpingogram

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.

ObjectiveThe 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 methodsInfertile 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.ResultsThe 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.ConclusionThe 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.

Hysteroscopic versus laparoscopic management in patients with communicating hydrosalpinx and planning for IVF: a randomized controlled trial

BackgroundHydrosalpinx is considered one of the obstacles that could hinder the success of IVF techniques due to the toxic effect of the hydrosalpinx fluid pouring into the uterine cavity. Tubal disconnection by either hysteroscopic or laparoscopic approaches is considered the standard in the operative management of hydrosalpinx prior to IVF cycles. The aim of the current study was to compare the success rate of hysteroscopic tubal occlusion using electro-coagulation with laparoscopic tubal disconnection in cases of hydrosalpinx prior to in vitro fertilization (IVF).MethodsA total of 108 women with unilateral or bilateral hydrosalpinx, who were candidates for tubal occlusion before IVF, were equally randomized into two groups. Group A (n = 54) underwent hysteroscopic tubal occlusion using the roller-ball electro-coagulation of the interstitial part of the tube and the uterine cornual area, and group B (n = 54) underwent laparoscopic tubal disconnection using bipolar coagulation and a proximal tubal cut. Operative time, complications, postoperative pain measured by the visual analogue score (VAS score), and postoperative hospital stay were recorded for both groups. The success rate of tubal occlusion was assessed 1 month later using a post-menstrual hysterosalpingogram (HSG).ResultsLaparoscopic tubal disconnection was more successful than the hysteroscopic approach regarding tubal occlusion rate (96.15% vs. 86.67% respectively, p = 0.044). The operative time and postoperative pain VAS scores in the hysteroscopy group (3.65 ± 1.03 min and 1.81 ± 1.35, respectively) were significantly lower than that in the laparoscopy group (17.48 ± 4.70 min and 4.06 ± 1.65, respectively) with p < 0.001.ConclusionAlthough laparoscopic tubal disconnection is more successful, the hysteroscopic approach is an alternative which has its own limitations that can be assessed by hysterosalpingogram, especially when laparoscopy is contraindicated, technically difficult, or refused by the patient.Trial registrationIt was first registered at ClinicalTrials.gov on 30/07/2019 with registration number NCT04037813.

Intrauterine adhesions, peritubal adhesions and tubal occlusion on hysterosalpingography

Pelvic Inflammatory Disease (PID), Dilatation and Curettage (D&amp;C) and other abdominopelvic surgeries are often presumed to cause female infertility. This can occur through adhesions formation that can result in Intrauterine Adhesions (IUA), Peritubal Adhesions (PTA) and Tubal Occlusion (TO). Hysterosalpingography (HSG) can be used to diagnose IUA, PTA, and TO; and the correlations of these findings with the histories of PID, D&amp;C and other abdominopelvic surgeries statistically tested. The available literature shows very few of such correlation tests. The objective of this study was to document HSG diagnosis of IUA, PTA and TO, and test their correlation with histories of previous PID, D&amp;C and abdominopelvic surgeries among women with secondary infertility. This is a prospective descriptive study of 158 subjects, analyzed with SPSS version 21. For correlation test, p≤0.05 is considered significant. There was history of previous PID in 53 subjects (33.5%), D&amp;C in 114 (72.2%), and abdominopelvic surgery in 80 (50.6%). The important findings included: IUA in 20 subjects (12.7%), TO in 53 (33.5%) and PTA in 30 (19.0%). Significant correlation was found between D&amp;C and PTA, but not between PID and IUA, PID and TO, PID and PTA, D&amp;C and IUA, D&amp;C and TO, abdominopelvic surgery and IUA, abdominopelvic surgery and TO, or abdominopelvic surgery and PTA. Tubal occlusion, followed by PTA and by IUA were detected in that order as the possible causes of infertility in our subjects; and these did not correlate well with the history of PID, D&amp;C and other abdominopelvic surgeries.

Can Hysterosalpingo-Foam Sonography Replace Hysterosalpingography as First-Choice Tubal Patency Test? A Randomized Non-inferiority Trial

(Abstracted from Hum Reprod 2022;37:969–979) A main cause of female infertility is tubal pathology, with 11% to 30% of cases resulting from previous surgery, infections (such as sexually transmitted diseases), or endometriosis. Hysterosalpingography (HSG) is considered as the first choice for a tubal patency test during fertility workup, but the more patient-friendly hysterosalpingo-contrast sonography option has also been introduced.

The role of combined diagnostic hysterolaparoscopy in unexplained infertility

Background: The two approaches for evaluating the female reproductive system are hysteroscopy and laparoscopy. Laparoscopy is becoming a standard component of infertility evaluation by virtue of its capability to visualize and manipulate the uterus, the ovaries and fallopian tubes. Hysteroscopy has become an important investigative tool for discovering possible causes of female infertility by examining the uterine cavity. The goal of this study was to examine the role of hystero-laparoscopy in diagnosis women with unexplained infertility.Methods: A total of 202 cases who were 20-35 years old women with 1ry or 2ry unexplained infertility were studied in this cross-sectional observational analytical study. All patients were subjected to: evaluation (physical, abdominal and bimanual), routine laboratory investigations, basic investigations (documentation of sound ovarian factor: hormonal assays and pelvic ultrasonography, normal hysterosalpingography, normal husband semen analysis) and hysterosalpingography (HSG) was reviewed or completed.Results: Abnormal laparoscopic was significantly higher in secondary cases compered to primary infertility (p=0.043). Abnormal combined hystero-laparoscopic was significantly higher in 2ry infertile cases compered to 1ry infertile cases (p=0.006). Pairwise comparison between 1ry and 2ry infertility was statistically significant difference (P=0.004).Conclusions: The percentage of abnormalities found during laparoscopy and hysteroscopy, are difficult to be visualized by the use of other noninvasive methods. While a thorough history, thorough examination, and early studies such as pelvic ultrasonography can all lead to the suspicion of numerous abnormalities, a considerable percentage of abnormalities may go undetected.

Estimation of patient doses from selected fluoroscopy guided examinations based on Monte Carlo calculations (PCXMC)

The aim of this work is to estimate organ and effective dose of patients during some selected fluoroscopy guided examinations using monte carlo based code PCXMC and propose conversion factors for dose estimation at the facility. Screening time, number of radiographs were recorded from the fluoroscopy console and the kerma area product (KAP) from a KAP meter for a total of one hundred and seventy-one (171) patients in two different facilities (A and B). Incident air kerma at reference point, organ and effective doses were estimated with PCXMC software. The mean KAP value was 11.0, 10.4 and 81.0 mGycm2 for hysterosalpingography (HSG), retrograde (RUG) and barium swallow (BaS) respectively. The estimated effective dose was 0.8, 1.1, 22.8 mSv for HSG, RUG and BaS respectively. The mean fluoroscopy screening time was 0.89, 1.26, 2.92 minutes for HSG, RUG and BaS respectively. The mean number of radiographs taken was 4.5, 7.0, 13.0 for HSG, RUG and BaS respectively. Bladder (7.96 mGy), testicles (21.89 mGy) and breast (76,77 mGy) received the highest dose for HSG, RUG and BaS respectively. The recorded mean KAP values of this study for BaS was high than that of HSG and RUG by a factor of 7.4 and 7.8 respectively. This was attributed to high number of radiographs taken and fluoroscopy screening time. The mean KAP of this study was more than that of other studies by a maximum factor of 22.0, 7.8 and 23.5 for HSG, RUG and BaS respectively. The fluoroscopy screening of this study was more than that of other studies by a maximum factor of 3.3, 4.7 and 10.3 for HSG, RUG and BaS respectively. Also, the mean number of radiographs taken for this study was more than that of other studies by a maximum factor of 2.0, 2.6 and 1.7 for HSG, RUG and BaS respectively. It was suggested that there are other contributing factors to patient doses in addition to the screening time and radiographs taken during fluoroscopy procedures. A dose conversion factor from measurable quantities to effective dose estimation has been proposed to aid patient dose optimization. Further studies aiming at reporting patient organ doses in fluoroscopy examination and investigate into other patient dose contributing factors has been recommended to strengthen patient dose optimization.

Management of tubal blockage through Ayurvedic interventions

INTRODUCTION: Fallopian tube blockage is among the most notorious factors for female infertility, which is responsible for 25%–30% of total female infertility. Tubal blockages can be correlated to Sanga Srotodushti of Artavavaha Srotasa in Ayurveda, involving Vata and Kapha Doshas. Normalizing the vitiated Vata–Kapha Dosha leads to restoration of tubal function and easy conception. The case report presented here highlights the role of Ayurvedic medicines and therapies in successfully managing tubal blockage. MATERIALS AND METHODS: In the present case report, a 27-year-old married female diagnosed with infertility due to bilateral fallopian tube blockage presented with chief complaints of inability to conceive for 3 years and was treated with Ayurveda medications and therapeutic procedures. Oral medicines such as decoctions, herbal powder, medicated ghee, and tablets were administered along with therapeutic procedures, which included Virechana (therapeutic purgation), Basti (therapeutic enema), and Uttarbasti (intrauterine medication). Pre- and post-assessments were done by hysterosalpingography (HSG). RESULT AND CONCLUSION: At the end of the treatment, there was a normal spillage of dye in both tubes noted in HSG. In this study, a comprehensive therapeutic intervention using Ayurveda medications and therapeutic procedures such as Virechana, Basti, and Uttarbasti was found to effectively clear the blockage of tubes.

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

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). To asses if additional tubal flushing with oil-based contrast during THL is feasible. 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. 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. 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. 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.

O-188 Tubal testing with Hysterosalpingo-foam sonography (HyFoSy) versus hysterosalpingography (HSG) during the fertility work-up: a cost-effectiveness analysis alongside a randomised controlled trial

Abstract Study question What are the costs and effects of management based on tubal patency testing by HyFoSy compared to HSG in infertile women during fertility work-up? Summary answer Management based on the results of either HyFoSy or HSG leads to similar pregnancy rates with lower costs for management based on HyFoSy. What is known already Traditionally, tubal patency testing during the fertility work-up is performed by HSG. We recently showed in a randomised controlled trial (RCT) that in infertile women scheduled for tubal patency testing, management based on the results of either HyFoSy or HSG leads to comparable diagnostic accuracy (FOAM trial, van Welie et al, 2022 conditionally accepted). Also, HyFoSy is associated with significantly less pain, it lacks ionizing radiation and exposure to iodinated contrast medium. Moreover, it can be performed by a gynaecologist during a one-stop fertility work-up. Here, we compare the costs and effects of both tubal patency strategies. Study design, size, duration We performed an economic evaluation alongside the FOAM trial, a multi-center cohort study with embedded RCT in the Netherlands. The FOAM trial included 1,160 infertile women (18-41 years) scheduled for tubal patency testing. Women underwent, in a randomised order, both HyFoSy and HSG. The results of both tests were compared and in case of discordant results for HyFoSy or HSG women were randomly allocated to management based on the results of either HyFoSy or HSG. Participants/materials, setting, methods The economic evaluation compared costs of management based on either test within 12 months in the entire study population and in women with discordant results. For the entire study population, we compared two strategies: one that follows the management based on HyFoSy and one based on HSG. We calculated incremental cost-effectiveness ratios (ICERs): the difference in total costs and in chance of live birth. Data were analyzed using the intention to treat principle. Main results and the role of chance Between May 2015 and January 2019, we studied 1,160 women, of which 1026 (88%) women underwent both tubal tests and had data available. They were divided in three groups: women with concordant (n = 747, 48% live births), inconclusive (n = 136, 40% live births) or discordant (n = 143, 41% had a live birth after management based on HyFoSy and 49% had a live birth after management based on HSG) results. When these data were integrated in the two strategies, one based on HyFoSy and one based on HSG, the estimated chance of live birth per management strategy was 47% after HSG and 46% after HyFoSy (difference 1.2% (95%CI: -1.5% to 3.4%)). For the procedures itself, HSG costed €266 and HyFoSy €132. When costs of additional fertility treatments were incorporated, the mean total costs per couple were €1,366 for the HSG strategy and €1,250 for the HyFoSy strategy (mean difference €152 (95%CI: €149 to €155). Taking into account the 1.2% increase in live birth rate after the HSG stratey, this leads to an ICER of €10,014 for one additional live birth after HSG compared to HyFoSy. Limitations, reasons for caution The number of inconclusive results for HyFoSy was higher than anticipated. This might be explained by the learning-curve of performing HyFoSy although training was mandatory. Women underwent both tests, therefore the immediate fertility enhancing effect e.g. by using oil-based contrast, could not be determined and is therefore not incorporated. Wider implications of the findings The diagnostic accuracy of HSG and HyFoSy are comparable, while HyFoSy leads to lower costs, is associated with less pain and no ionizing radiation without exposure to iodinated contrast. HyFoSy could replace HSG as first-line tubal patency test, although the direct fertility enhancing effect of both tests should be incorporated. Trial registration number NTR 4746

P-750 The cost-effectiveness of transvaginal hydrolaparoscopy versus hysterosalpingography in the work-up for subfertility

Abstract Study question Is transvaginal hydrolaparoscopy (THL) cost-effective compared to hysterosalpingography (HSG) in the work-up for subfertility in a population at low-risk for tubal pathology? Summary answer THL is cost-effective compared to HSG in a preselected group of women at low-risk of tubal pathology. What is known already Tubal pathology is a common cause of subfertility and tubal patency testing plays an important part in the work-up of the subfertile couple and the subsequent counseling for fertility treatment. THL is an out-patient procedure. After access through the pouch of Douglas, the tubes and pelvic cavity are directly observed using hydroflotation, whereas HSG is a radiographic evaluation of the uterine cavity and patency of the tubes with injection of contrast medium in the uterine cavity. Both methods are safe and feasible for subfertile women at low-risk of tubal pathology. Study design, size, duration We performed an economic analysis as part of a randomized controlled trial comparing THL and HSG in the work-up for subfertility. Women were eligible if they had an indication for evaluation of tubal patency. Primary outcome was a conception leading to live birth in 24 months. We randomly assigned 300 subfertile women to THL or HSG between May 2013 and October 2016. Participants/materials, setting, methods This study was performed in four Dutch teaching hospitals. The economic evaluation was performed from a health care perspective. Costs were either derived from literature or calculated. The mean costs and outcomes for each treatment group were compared. Costs were combined with effectiveness by calculating ICER, and bootstrap resampling was performed. We generated a cost-effectiveness plane and cost-effectiveness acceptability curves. Main results and the role of chance After 24 months of follow-up there was a 3% difference in live birth rate in favour of the THL group (58.5% in the THL group versus 55.4% in the HSG group (83/142 versus 82/148 difference 3.0% (95% CI: -8.3 – 14.4)). Multiple pregnancy and miscarriage rate were low and did not differ between groups. Ectopic pregnancy occurred in two women in the HSG group and not in the THL group. The mean cost was lower in the THL group, compared to the HSG group (THL group 4,927 EUR versus 5,197 EUR in the HSG group, difference -270 EUR). Although the costs of the diagnostic procedure itself were higher in the THL group (425 EUR versus 289 EUR, difference 136 EUR), the costs for fertility treatments are higher in the HSG group. The base case outcome is that THL costs less and is more effective than HSG, making THL the dominant strategy. The spread of the bootstrap indicates that there is uncertainty regarding the effectiveness of THL over HSG but less uncertainty regarding the cost difference between THL and HSG. Limitations, reasons for caution This trial was conducted in the Netherlands, using price calculations of the Dutch healthcare system in Euro’s. Since prices of fertility treatments and especially ART or fertility enhancing surgery can vary widely worldwide, it is possible that the outcomes of our study are not generalizable to other countries. Wider implications of the findings The findings of our trial suggest that in a preselected group of women with low risk for tubal pathology, a diagnostic strategy starting with THL is cost-effective compared to a diagnostic strategy starting with HSG in the workup for subfertility. Trial registration number NTR3462

P-732 Definitions and diagnostic criteria for unexplained infertility (UI) – a systematic review

Abstract Study question What are the various inclusion criteria for the definition of unexplained infertility used for recruitment to clinical trials, and is there homogeneity of these definitions? Summary answer There is a need to standardise the definition of unexplained infertility when recruiting for clinical trials to optimise interpretation of results and allow appropriate meta-analysis. What is known already Unexplained infertility (UI) is a diagnosis of exclusion. The pathology underlying this diagnosis is likely to include different subtle contributing factors. Unfortunately there is no universally accepted definition of unexplained infertility. NICE in the UK, and ACOG/ASRM both have lists of recommended investigations but no specific minimum standards to define UI. Even the ICMART definition is ambiguous, describing ‘apparently normal’ ovarian function and ejaculate. This may lead to heterogeneity between inclusion criteria in relevant research studies. This introduces selection bias and renders meta-analysis of trial results less meaningful. A single definition would improve the quality of research for this important diagnosis. Study design, size, duration A systematic review of primary research investigating definitions of unexplained infertility in humans. A thorough search of online databases Medline and Embase was performed from inception to November 2021. A bespoke Excel spreadsheet was used to collect data for baseline study characteristics and outcome data. Results are reported as percentages. Participants/materials, setting, methods The search strategy included all primary research on heterosexual couple unexplained infertility in human participants. Papers with specified inclusion criteria were included and no date or language restrictions were applied. From 663 results, title and abstract screening identified 83 duplicates and 6 studies unsuitable for the review. A further 275 papers were excluded after full-text screening. 241 papers remained and their inclusion criteria recorded and analysed. Main results and the role of chance Only 35.7% of papers specified duration of infertility. Timescales varied from 1 year (46.5%), 2 years (39.5%) or 3 years (14%). 85% papers specified that semen analysis should be ‘normal’. Of these, 40% used the most recent WHO criteria. No other national or international criteria for grading semen analysis was identified. 90% studies required fallopian tube patency as an inclusion criteria. Of these, 65.4% specified bilateral patency. Methods for demonstrating patency included hysterosalpingogram (HSG) (15.7%), laparoscopy (18.4%), a combination of either (29.5%) or both (24.4%) of these or hystero-contrast-salpingography (0.9%). 11.5% papers did not specify an imaging modality. 48.5% included studies mentioned uterine cavity assessment, 65% of these using HSG to assess the cavity, other methods mentioned include ultrasound (26.5%) or hysteroscopy (15.4%). Only 5.4% papers required either exclusion of or evidence of only minimal endometriosis 80.5% of included papers required evidence of regular ovulation. 58.7% used luteal serum progesterone levels, 41.2% required regular cycles (patient-reported) and 17.5% used basal body temperature pattern assessment. Other methods mentioned by a minority of papers include endometrial biopsy, ultrasound follicular tracking, serum and urinary luteinising hormone levels. 44% studies required normal endocrine profiles of which 66% measured prolactin and FSH and 50% measured thyroid function. Limitations, reasons for caution The strength of this study is that we included all primary research papers studying unexplained infertility with no time limitations. Included studies originated from across the world. This is a thorough representation of criteria used across all clinical trials for unexplained infertility. Wider implications of the findings Only 63/241 (26%) studies included duration of infertility, tubal patency, proof of ovulation and semen analysis in their inclusion criteria. This demonstrates the need for standardisation of the definition of unexplained infertility. If future research can apply the same inclusion criteria this will reduce selection bias and allow appropriate meta-analysis. Trial registration number NA

Is hysteroscopy justified in infertile women?

This retrospective study aimed to assess the value of Hysteroscopy (HS) in studying the rate and types of abnormalities found in uterine cavity during evaluation of infertile patients in comparison to hysterosalpingography (HSG). Subject and Methods: this study included 149 infertile women underwent HS for primary &amp; secondary infertility, recurrent abortions and failed IVF cycles at Department of Obstetrics &amp; Gynecology at Zliten teaching Hospital, Misurata center for Diagnosis and treatment of Infertility . Preoperative assessment: history, pelvis evaluation with necessary investigations including ultrasound and HSG. Data were analysed in terms of type &amp; rate of abnormality found, their relation with age and type of infertility including correlation between HSG and HS findings. Results: Abnormalities of uterine cavity were detected in more than half of the patients studied (59%), significantly more at ages of 31-42 years (58.3%) when compared with ages of 20-30 years (34.6%),(P&lt;0.05). Endometrial polyps (20.4%), septate and subseptate uterus (17.2%). Submucous myomas, cornual polyps and intrauterine adhesions were seen at same rate (6%),. Most of the pathologies were seen in primary infertility patients except the intrauterine adhesions which exclusively found in those with secondary infertility.

The effect of hysteroscopic metroplasty on fertility in T-shaped and Y-shaped dysmorphic uterus

Objective T/Y-shaped dysmorphic uterus is frequently associated with subfertility, abortion, preterm delivery, and recurrent implantation failure. In this study, the impact of hysteroscopic metroplasty for a T/Y-shaped uterus on obstetric outcomes was investigated in patients with infertility and recurrent pregnancy loss (RPL) and compared the uterine anomaly subgroups. Method Cases with infertility and/or RPL diagnosed with T/Y-shaped uterus by hysterosalpingography (HSG) and 3D transvaginal ultrasonography (3D TVUSG) with no other male or female pathology have recruited the study. Medical history and the obstetric outcome after two years of follow-up were recorded. Results Out of the 92 cases recruited, T-shaped uteri (Group-1) were observed in 30, while 62 (67.3%) patients had Y-shaped uteri. Pregnancy was achieved in 50 (54.3%) of the cases, 28 (56%) of the pregnancies occurred spontaneously, and in 22 (44%) pregnancy was achieved through assisted reproductive techniques (ART). Term delivery occurred in 29 (76.3%) of the pregnancies while 9 (23.6%) had preterm deliveries and a total of 38 (76%) resulted in a live birth. Out of the 31 patients with previous RPL history, 13 (41.9%) achieved pregnancy and 11 out of 13 (84.6%) had a term pregnancy followed by live birth. Conclusion Spontaneous pregnancy, and term pregnancy rates after surgery were found to be promising in these uterine anomalies. The pregnancy outcome of the primary infertile patients was found the same in two groups (50%–46.1%), but the results of the RPL patients were found to be better in the T-shaped group than in the Y-shaped group (70%–28.5%).

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

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. 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. 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. 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). 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.

Effects of Oocyte Cytoplasmic Central Granulation on Embryonic Development, Blastocyst Formation, and Pregnancy Outcome in Assisted Reproductive Technology and Its Mechanism.

To investigate whether oocyte centrally located cytoplasmic granulation (CLCG) affects embryonic development, blastocyst formation, and pregnancy outcomes in assisted reproductive technology, fifty patients with CLCG in all oocytes were selected as the CLCG group. Then, 150 patients with no abnormal oocyte morphology were randomly recruited as the control group. Both groups underwent laparoscopy, hysterosalpingography (HSG), vaginal ultrasound, and male semen examination. The down-regulation regimen was selected regarding the patient's ovarian reserve. The egg maturation rate, normal fertilization rate, cleavage rate, available embryo rate, and high-quality embryo rate in the CLCG group were greatly inferior to those in the control group, with remarkable differences (P< 0.05). CLCG grading of oocytes after 30 cycles in the CLCG group indicated that there were 36 cases in the mild group and 14 cases in the severe group. The egg maturation rate in the mild group was lower than that in the severe group, with a notable difference (P< 0.05). The fertilization rate, cleavage rate, available embryo rate, and high-quality embryo rate in the mild group were higher than those in the severe group, with a notable difference (P< 0.05). Compared with the control group, there was no considerable difference in the implantation rate, clinical pregnancy rate, and abortion rate between the CLCG group (P> 0.05). In summary, oocyte CLCG may affect fertilization, embryonic development, and blastocyst formation, but not pregnancy outcomes.

Diagnostic hysterolaparoscopy: An important tool in evaluation of female infertility, in beneficiaries of ESI scheme in Eastern India

Background: The WHO estimates that 60–80 million couples worldwide suffer from infertility and the overall prevalence of the primary infertility in India is 3.9–16.8%. As usual tests and examinations are unable to appreciate majority of pelvic pathology in infertile women, diagnostic laparoscopy has become an essential part of infertility evaluation. Diagnostic laparohysteroscopy (DHL) gives the opportunity to directly visualize and manipulate pelvic organs which allow accurate diagnosis and give an option to treat at the samesitting. Aims and Objectives: The aims of this study were to detect pelvic organ abnormalities by diagnostic hysteroscopy and laparoscopy in the evaluation of female infertility in a tertiary care hospital. Materials and Methods: This cross-sectional observational study recruited 50 patients who attended the infertility clinic during 1 year period as per inclusion and exclusion criteria. Those with male factor and endocrine abnormality were excluded from the study. The patients having abnormal hystero-salpingography (HSG) findings and those who in spite of having normal HSG finding, did not conceive even after three cycles of ovulation induction, underwent DHL. Results: Out of the 50 patients, 35 (70%) suffering from the primary and 15 (30%) suffering from the secondary infertility. The mean age of the study population was 29.5±5.3 years. Most of the cases presented with 3–6 years of infertility. The most common reported laparoscopic abnormality was ovarian in 58% cases, followed by 56% of pelvic and peritoneal abnormalities, 44% tubal factor abnormality, 36% having endometriosis at different stages, and 30% having uterine abnormality. Conclusions: Hystero -laparoscopy has good diagnostic accuracy in evaluating pelvic pathologies. The combination of hysteroscopy with laparoscopy done in a single setting improves the detection rate of abnormalities of uterus, fallopian tubes, ovaries, and pelvic peritoneum.