What are the risks associated with lipiodol hysterosalpingography? A literature review.

INTRODUCTION: Hysterosalpingography is widely used as a first-line investigation for infertility, and may also be therapeutic, increasing pregnancy rates. Aqueous and oil-based contrast agents can be used. Some studies suggest Lipiodol hysterosalpingography has a greater therapeutic effect on fertility than aqueous contrast, though this is contentious. There are additionally safety concerns surrounding Lipiodol hysterosalpingography. This review summarises the adverse effects associated with Lipiodol hysterosalpingography, particularly on thyroid function. KEY FINDINGS: 331 articles were identified. Of these, 46 met inclusion criteria. 3 further articles were identified from reference lists. Complications typically cited in the literature include pain, intravasation, life-threatening oil embolism, and lipogranuloma formation. Emerging evidence suggests that Lipiodol hysterosalpingography may also impact maternal and neonatal thyroid function. Women may develop hypo- or hyperthyroidism. Thyroid dysfunction is clinically significant as even subclinical hypothyroidism reduces fertility, increases the risk of pregnancy complications including miscarriage, pre-eclampsia and perinatal mortality, and adversely impacts foetal neurodevelopment. One study suggested a possible link with neonatal congenital hypothyroidism. CONCLUSION: There is emerging evidence to suggest that Lipiodol hysterosalpingography can cause hypo- or hyperthyroidism, in addition to known adverse effects of pain, intravasation, oil embolism, and lipogranuloma formation. IMPLICATIONS FOR PRACTICE: Given the significance of these risks, and contention surrounding whether Lipiodol truly increases pregnancy rates compared to aqueous mediums, careful consideration is required in the selection of contrast agent. In particular, Lipiodol hysterosalpingography may not be suitable for women with pre-existing thyroid dysfunction.

Mother's iodine exposure and infants' hypothyroidism: the Japan Environment and Children's Study (JECS).

In this study, we aimed to determine the association of neonatal/post-neonatal hypothyroidism with mother's iodine exposure, especially povidone iodine disinfection, and hysterosalpingography. Participants were mother-child pairs in a Japanese birth cohort (n = 100,286). Risk factors of hypothyroidism were supplement intake, seaweed intake, other daily iodine intake, povidone iodine disinfection at delivery, and maternal history of hysterosalpingography, thyroid disease (Graves' disease and Hashimoto's thyroiditis), and medication (thiamazole and levothyroxine). Congenital hypothyroidism (CH) at age 1 year was assessed using a questionnaire. Transient hypothyroidism was defined as elevated thyroid stimulating hormone level at birth and absence of CH at age 1 year. The incidence of CH at age 1 year per 100 children was 1.1 for those born at 22-30 weeks' gestation, 0.17 following povidone iodine disinfection, and 0.07, 0.95, 0.81, 1.17, and 1.15 with a maternal history of hysterosalpingography, Graves' disease, Hashimoto's thyroiditis, thiamazole use, and levothyroxine use, respectively. Odds ratios (95% confidence intervals) of CH at age 1 year for povidone iodine disinfection, hysterosalpingography history, maternal Graves' disease, and maternal Hashimoto's thyroiditis were 1.13 (0.71-1.79), 0.47 (0.07-3.36), 7.06 (3.70-13.5), and 5.93 (2.90-12.1), respectively. For transient hypothyroidism for povidone iodine disinfection and hysterosalpingography history, these values were 1.99 (1.51-2.62) and 0.63 (0.20-1.96), respectively. Maternal thyroid disease greatly increased neonatal/post-neonatal hypothyroidism risk. Povidone iodine disinfection may increase transient hypothyroidism risk but not the risk at 1 year of age. Hysterosalpingography does not increase hypothyroidism risk from birth to age 1 year.

Safety of oil-based contrast medium for hysterosalpingography: a systematic review.

Recent meta-analyses have shown that a hysterosalpingography (HSG) with oil-based contrast increases pregnancy rates in subfertile women. However, the frequency of complications during or after an HSG with oil-based contrast in subfertile women and/or their offspring is still unclear. This systematic review and meta-analysis, without restrictions on language, publication date or study design, was performed to fill this knowledge gap. The results show that the most frequently reported complication was intravasation of contrast, which occurred in 2.7% with the use of oil-based contrast (31 cohort studies and randomized controlled trials [RCT], 95% CI 1.7-3.8, absolute event rate 664/19,339), compared with 2.0% with the use of water-based contrast (8 cohort studies and RCT, 95% CI 1.2-3.0, absolute event rate 18/1006). In the cohort studies and RCT there were 18 women with an oil embolism (18/19,339 HSG), all without serious lasting consequences. Four cases with serious consequences of an oil embolism were described (retinal oil embolism [n = 1] and cerebral complaints [n = 3]); these reports did not describe the use of adequate fluoroscopy guidance during HSG. In conclusion, the most frequently reported complication after an HSG with oil-based contrast is intravasation occurring in 2.7%. In total four cases with serious consequences of oil embolisms in subfertile women were published.

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

RESEARCH QUESTION: What are the long-term costs and effects of oil- versus water-based contrast in infertile women undergoing hysterosalpingography (HSG)? DESIGN: This economic evaluation of a long-term follow-up of a multicentre randomized controlled trial involved 1119 infertile women randomized to HSG with oil- (n = 557) or water-based contrast (n = 562) in the Netherlands. RESULTS: In the oil-based contrast group, 39.8% of women needed no other treatment, 34.6% underwent intrauterine insemination (IUI) and 25.6% had IVF/intracytoplasmic sperm injection (ICSI) in the 5 years following HSG. In the water-based contrast group, 35.0% of women had no other treatment, 34.2% had IUI and 30.8% had IVF/ICSI in the 5 years following HSG (P = 0.113). After 5 years of follow-up, HSG using oil-based contrast resulted in equivalent costs (mean cost difference -€144; 95% confidence interval [CI] -€579 to +€290; P = 0.515) for a 5% increase in the cumulative ongoing pregnancy rate compared with HSG using water-based contrast (80% compared with 75%, Relative Risk (RR) 1.07; 95% CI 1.00-1.14). Similarly, HSG with oil-based contrast resulted in equivalent costs (mean cost difference -€50; 95% CI -€576 to +€475; P = 0.850) for a 7.5% increase in the cumulative live birth rate compared with HSG with water-based contrast (74.8% compared with 67.3%, RR 1.11; 95% CI 1.03-1.20), making it the dominant strategy. Scenario analyses suggest that the oil-based contrast medium is the dominant strategy up to a price difference of €300. CONCLUSION: Over a 5-year follow-up, HSG with an oil-based contrast was associated with a 5% increase in ongoing pregnancy rate, a 7.5% increase in live birth rate and similar costs to HSG with water-based contrast.

A prospective self-controlled study on shortening the time before taking delayed radiographs with iodized oil hysterosalpingography.

OBJECTIVES: To verify the feasibility of walking to shorten the time before obtaining delayed radiographs after iodized oil hysterosalpingography (HSG). MATERIAL AND METHODS: One hundred women with infertility were selected for HSG from June 2018 to December 2018 at the Women's Hospital of Nanjing Medical University; the subjects were randomly divided into walking and control groups. The walking group was required to walk more than 12,000 steps within 6 hours after HSG, while the control group was prohibited from performing high-intensity exercise. The degree of pelvic adhesion was diagnosed with delayed radiographs acquired at 6 and 24 hours, and the diagnostic consistency of the radiographs at the two time points was evaluated. RESULTS: No significant difference was observed in the baseline data between groups (p > 0.05). The delayed radiograph results in the walking group showed good agreement (p = 0.255 > 0.05, Kappa value 0.781 > 0.75), while those in the control group showed general agreement (p = 0.002 < 0.05, Kappa value 0.493 > 0.40 < 0.75). CONCLUSIONS: The time for acquiring delayed radiographs can be shortened by instructing patients to walk after HSG. This method improves the diagnostic efficiency of Iodized oil, saves time and costs, and may contribute to the popularization of HSG for female infertility screening, while offering good clinical application prospects.

A randomized pilot study of electro-acupuncture treatment for hysterosalpingography pain relief and related anxiety.

OBJECTIVE: To investigate the effect of acupuncture on reducing pain and anxiety related to hysterosalpingography (HSG). MATERIALS AND METHODS: A total of 107 patients planned to undergo HSG were randomly separated into 3 groups; the acupuncture group (n=36), intramuscular diclofenac sodium group (n=35), and control group (n=37). In the acupuncture group, electro-acupuncture was applied to specified points for 20 mins before the procedure. In the intramuscular diclofenac sodium group, an intramuscular injection of 75 mg diclofenac sodium was applied 30 mins before the procedure. No analgesics were administered to the patients in the control group before intervention. Pain was evaluated with a Visual Analog scale (VAS) and anxiety with the State-trait Anxiety inventory -state (STAI-S), preoperatively and at specified times postoperatively. RESULTS: The VAS scores at 1 and 5 minutes after HSG were similar in acupuncture group and intramuscular diclofenac sodium group, and significantly lower than in the control group. At 30 mins postoperatively, there was no significant difference between the 3 groups in respect of the VAS scores. The STAI-S scores at 1 hour preoperatively were similar in all the groups (p=0.563). In the comparisons of the STAI-S values at preoperative 5 mins, following acupuncture in acupuncture group and the diclofenac injection in intramuscular diclofenac sodium group, and at postoperative 30 mins, the acupuncture group values were determined to be statistically significantly lower than those of the other groups (p<0.001, p<0.001). CONCLUSION: Acupuncture has similar effects on the reduction of pain as other analgesics and reduces anxiety. It can therefore be used in HSG in suitable clinics.

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

STUDY QUESTION: Does pain or volume of used contrast medium impact the effectiveness of oil-based contrast during hysterosalpingography (HSG)? SUMMARY ANSWER: In women who report moderate to severe pain during HSG, the use of oil-based contrast resulted in more ongoing pregnancies compared to the use of water-based contrast, whereas in women who reported mild or no pain, no difference in ongoing pregnancies was found. WHAT IS KNOWN ALREADY: We recently showed that in infertile women undergoing HSG, the use of oil-based contrast results in more ongoing pregnancies within 6 months as compared to the use of water-based contrast. However, the underlying mechanism of this fertility-enhancing effect remains unclear. STUDY DESIGN, SIZE, DURATION: We performed a post-hoc analysis of the H2Oil study, a multicentre randomised controlled trial (RCT) evaluating the therapeutic effect of oil- and water-based contrast at HSG. Here, we evaluated the impact of pain experienced at HSG and volume of used contrast media during HSG on ongoing pregnancy. PARTICIPANTS/MATERIALS, SETTING, METHODS: In a subset of 400 participating women, pain during HSG by means of the Visual Analogue Scale (VAS) (range: 0.0-10.0 cm) was reported, while in 512 women, we registered the volume of used contrast (in millilitres). We used logistic regression analyses to assess whether pain and volume of used contrast media modified the effect of oil-based contrast on ongoing pregnancy rates. Data were analysed according to intention-to-treat principle. MAIN RESULTS AND THE ROLE OF CHANCE: In 400 women in whom pain scores were reported, the overall median pain score was 5.0 (Interquartile range (IQR) 3.0-6.8) (oil group (n = 199) 4.8 (IQR 3.0-6.4); water group (n = 201) 5.0 (IQR 3.0-6.7); P-value 0.28). There was a significant interaction between pain (VAS ≤5 versus VAS ≥6) and the primary outcome ongoing pregnancy (P-value 0.047). In women experiencing pain (VAS ≥6), HSG with oil-based contrast resulted in better 6-month ongoing pregnancy rates compared to HSG with water-based contrast (49.4% versus 29.6%; RR 1.7; 95% CI, 1.1-2.5), while in women with a pain score ≤5, 6-month ongoing pregnancy rates were not significantly different between the use of oil- (28.8%) versus water-based contrast (29.2%) (RR 0.99; 95% CI, 0.66-1.5). In the 512 women in whom we recorded contrast, median volume was 9.0 ml (IQR 5.7-15.0) in the oil group versus 8.0 ml (IQR 5.9-13.0) in the water group, respectively (P-value 0.72). Volume of used contrast was not found to modify the effect of oil-based contrast on ongoing pregnancy (P-value for interaction 0.23). LIMITATIONS, REASONS FOR CAUTION: This was a post-hoc analysis that should be considered as hypothesis generating. The RCT was restricted to infertile ovulatory women, younger than 39 years of age and with a low risk for tubal pathology. Therefore, our results should not be generalised to infertile women who do not share these features. WIDER IMPLICATIONS OF THE FINDINGS: The underlying mechanism of the fertility-enhancing effect induced by HSG with the use of oil-based contrast remains unclear. However, these findings suggest a possible mechanistic pathway, that is increasing intrauterine pressure occurring prior to dislodging pregnancy hindering debris or mucus plugs from the proximal part of otherwise normal fallopian tubes. This information might help in the search of the underlying fertility-enhancing mechanism found by using oil-based contrast during HSG. STUDY FUNDING/COMPETING INTEREST(S): The original H2Oil RCT was an investigator-initiated study that was funded by the two academic institutions (AMC and VUmc) of the Amsterdam UMC. The funders had no role in study design, collection, analysis and interpretation of the data. K.D. reports consultancy for Guerbet. H.V. reports consultancy fees from Ferring. C.B.L. reports speakers' fees from Ferring and research grants from Ferring, Merck and Guerbet. V.M. reports receiving travel and speakers fees as well as research grants from Guerbet. B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck KGaA and Guerbet and travel and research grants from Merck KGaA and Guerbet. The other authors do not report conflict of interests. TRIAL REGISTRATION NUMBER: The H2Oil study was registered at the Netherlands Trial Registry (NTR 3270). TRIAL REGISTRATION DATE: 1 February 2012. DATE OF FIRST PATIENT'S ENROLMENT: 3 February 2012.

An investigation into the effect of evening primrose in dilatation of cervix and pain during and after hysterosalpingography.

Hysterosalpingography is one of the essential diagnostic methods for examining women who have difficulty becoming pregnant. This procedure is somehow invasive and is associated with numerous complications such as allergic sensitivity, pain, abdominal cramps and shock. Therefore, this study aimed to investigate the effect of evening primrose on cervical length and pain during and after hysterosalpingography. In this double-blind clinical trial, 66 candidates for hysterosalpingography were randomly divided into two groups. A group received 1000 mg of evening primrose orally for two days prior to hysterosalpingography, while the control group received a placebo drug similar in size to evening primrose three days prior to hysterosalpingography. The pain level was recorded based on the Visual Analogue Scale (VAS), during tenaculum placement but also immediately and four hours after hysterosalpingography. Finally, the data were analyzed using SPSS (version 20). There was a significant difference between the two groups in terms of pain during insertion of speculum and injection of the contrast medium (p <0.05). Less pain was reported in the evening primrose group compared to placebo. There was no significant difference between the two groups in terms of the length and diameter of the cervix (p <0.05). Given the fact that it is a medicinal plant with no complications and can reduce pain during speculum insertion and during contrast medium injection, evening primrose seems to be a good drug for managing pain during hysterosalpingography.

Ethiodized poppyseed oil versus ioversol for image quality and adverse events in hysterosalpingography: a prospective cohort study.

BACKGROUND: This study aimed to investigate the image quality and adverse events (AEs) of ethiodized poppyseed oil (EPO) compared with ioversol as contrast agents in hysterosalpingography (HSG). METHODS: Two hundred twenty-eight patients underwent HSG were consecutively recruited in this prospective cohort study, and were accordingly divided into EPO group (N = 165) and ioversol group (N = 63). The quality of image was assessed according to the European Guidelines on quality criteria for diagnostic radiographic images. AEs during, within 2 h and at 1-month post-HSG were recorded. RESULTS: EPO displayed elevated image quality compared with ioversol including the total image quality score (P < 0.001), the cervical canal display score (P < 0.001), shape and outline of uterus score (P < 0.01), cervical mucosa or folds score (P < 0.001), oviduct isthmus score (P < 0.001), ampulla and fimbriae of oviduct score (P < 0.001) and celiac diffuse image score (P < 0.001). Multivariate linear regression displayed that EPO (P < 0.001) was an independent predictive factor for increased total image quality score. AEs were similar between EPO group and ioversol group during and within 2 h post-HSG (all P > 0.05). However, at 1-month post-HSG, the number of patients had unchanged and faded menstrual blood color decreased but the proportion of patients with deepened menstrual color increased in EPO group compared with ioversol group (P = 0.007). In addition, the number of patients had iodine residue in uterine cavity was elevated in EPO group compared with ioversol group (P < 0.001). CONCLUSION: EPO is more efficient in image quality and equally tolerant compared to ioversol as contrast agents in HSG.

Oil-based or water-based contrast for hysterosalpingography in infertile women: a cost-effectiveness analysis of a randomized controlled trial.

OBJECTIVE: To determine the cost effectiveness of the use of oil-based versus water-based contrast in infertile women undergoing hysterosalpingography (HSG). DESIGN: Economic evaluation alongside a multicenter randomized trial. SETTING: Hospitals. PATIENT(S): Infertile women with an ovulatory cycle, 18-39 years of age, low risk of tubal pathology. INTERVENTION(S): Use of oil-based versus water-based contrast during HSG. MAIN OUTCOME MEASURE(S): Costs per additional ongoing pregnancy and per live birth within 6 months of randomization, incremental cost-effective ratios (ICERs). RESULT(S): A total of 1,119 women were randomized to HSG (oil-based contrast, n = 557; water-based contrast, n = 562). After HSG, most women had no additional treatment; a minority had IUI or IVF. In the oil group, 39.7% women had an ongoing pregnancy within 6 months of randomization versus 29.1% women in the water group. There was a 10.7% increase in the live birth rate in the oil group. For ongoing pregnancy, the mean costs per couple were US$2,014 in the oil group and US$1,144 in the water group, with a corresponding ICER of US$8,198 per additional ongoing pregnancy. For live birth, the mean costs per couple were US$11,532 in the oil group and US$8,310 in the water group, with a corresponding ICER of US$30,112 per additional live birth. CONCLUSION(S): Hysterosalpingography with oil-based contrast results in higher 6-month ongoing pregnancy and live birth rate. If society is willing to pay US$8,198 for an additional ongoing pregnancy, HSG with oil-based contrast is a cost-effective strategy compared with HSG with water-based contrast for infertile, ovulatory women at low risk for tubal pathology. CLINICAL TRIAL REGISTRATION NUMBER: Dutch Trial Register, NTR 6577 (www.trialregister.nl).

Examination of the antioxidant effects of pre-HSG melatonin use on ovarian surface epithelium in rats: An experimental study.

BACKGROUND: There is no study of whether the dysplastic changes in the ovarian surface epithelium of X-ray-exposed rats during hysterosalpingography (HSG) decrease or not with the use of Lipiodol and melatonin given both intraperitoneally (i.p.) and into the suspensorium ovarii. OBJECTIVES: We investigated the restorative effects of melatonin and Lipiodol administration during the HSG procedure on the dysplastic changes in the ovarian surface epithelium of X-ray-exposed rats. MATERIAL AND METHODS: A total of 50 Wistar rats with regular estrous cycles were randomly divided into 5 groups. Group 1 was the control group. In other groups, X-ray was applied (group 2), 0.1 mL Lipiodol was applied to each uterine horn (group 3), 20 mg/kg intraperitoneal melatonin application was followed by 0.1 mL Lipiodol administration to each uterine horn after 15 min (group 4), and 20 mg/kg melatonin was administered to the ligamentum suspensorium ovarii, followed by 0.1 mL Lipiodol application to each uterine horn after 15 min (group 5). The rats in groups 2-5 were exposed to whole body radiation 3 times. After 3 h, the abdomens of all rats were reopened and left oophorectomy was performed. RESULTS: The presence of nucleoli and mitosis values were found similar among the groups. All other parameters were significantly higher in group 2 compared to other groups, except for the presence of nucleoli and mitosis values (p < 0.05). The presence of hyperchromasia and the total score were found to be the highest in group 2, followed by group 3, when compared to other groups (p < 0.05). It was detected that the detrimental effects of X-ray exposure diminished with Lipiodol use, and were further reduced by the use of melatonin in combination. CONCLUSIONS: We suggest that the use of melatonin and Lipiodol during HSG may prevent the carcinogenic changes exerted by radiation on the ovarian surface epithelium.

Adverse Reactions and Management of Real-time Three-dimensional Hysterosalpingo-contrast Sonography / 中国医学影像学杂志

Purpose To investigate the adverse reactions and management in the process of transvaginal real-time three-dimensional hysterosalpingo-contrast sonography (3D-HyCoSy).Materials and Methods A total of 976 patients with infertility accepting 3D-HyCoSy in Jiangsu Provincial Hospital of Traditional Chinese Medicine,Affiliated Hospital of Nanjing University of Traditional Chinese Medicine,from December 2014 to August 2016 were retrospectively analyzed.The pain degree was evaluated using visual analog scale (VAS).Adverse reactions,including contrast countercurrent,vomiting,syncope and allergies,were recorded.The relationship between adverse reactions and ultrasound imaging signs was explored.Results There were 66 cases (6.76％) of VAS grade 0,346 cases of mild pain (35.45％),374 cases of moderate pain (38.32％) and 190 cases (19.47％) of severe pain.With the increase in the degree of tubal obstruction,the degree of pain gradually increased.Pain was the most common adverse reaction among patients,followed by vomiting (15 cases,1.54％),syncope (1 case,0.10％),and allergies (1 case,0.10％).The incidence of contrast countercurrent was 12.30％ (120 cases).The adverse reaction incidence of patients with abnormal ultrasound imaging signs was significantly higher than that of patients with normal signs (x2=29.02,P＜0.01).Conclusion With the extensive use of 3D-HyCoSy examination,its clinical application value has attracted a lot of attention,meanwhile,the understanding of its safety and related adverse reactions should also be improved.The state of patients should be closely observed before,during and after 3D-HyCoSy.Medical personnel should watch out for syncope and allergic reactions,and prepare for emergency management.

Subsequent Cancer Risk of Women Receiving Hysterosalpingography: A Nationwide Population-Based Retrospective Cohort Study.

The objective of this study was to estimate the subsequent cancer risk of women after receiving hysterosalpingography (HSG) by conducting a nationwide retrospective cohort study. We identified a study cohort of 4,371 patients who had had a HSG examination and a comparison cohort of 17,484 women without HSG examination between 1998 and 2005. Both cohorts were followed up with until the end of 2010 to measure the incidence of cancer. The risk of developing cancer for patients with HSG was assessed using the Cox proportional hazard model. In the multivariate analyses, the HSG cohort did not have a significantly greater risk of cancer (Hazard Ratio [HR] = 1.02, 95% CI = 0.79-1.31) than the non-HSG cohort. The HR was highest for genital cancer (HR = 1.32, 95% CI = 0.77-2.25), followed by urinary system cancer (HR = 1.11, 95% CI = 0.23-5.40), and abdominal cancer not involving the GU system (HR = 1.04, 95% CI = 0.53-2.03), all of which were non-significant elevations. The cancer incidence rates, especially that for urinary system cancer, were increased in the HSG cohort, but the increase in cancer incidence was small and not statistically significant.

Efficacy of Yavakshara Taila Uttarabasti in the management of fallopian tube blockage.

INTRODUCTION: Tubal blockage is one of the most common causative factors for female barrenness. It accounts for about 25-35% of female infertility. It is very difficult to manage, as the treatment choices for it are only tubal re-constructive surgery and in vitro fertilization (IVF). On the other hand, there is not established any reliable Ayurvedic treatment for the tubal blockage. It is the need of the time to establish an efficient and cost-effective therapy for this problem. AIM: To evaluate the efficacy of Yavakshara Taila Uttarabasti in fallopian tubal blockage. MATERIALS AND METHODS: Patients of childbearing age with active marital life of 1 year or more, having complaint of failure to conceive with at least one fallopian tube blockage were selected. Total 19 patients were registered with 42.11% unilateral and 57.89% bilateral tubal blockage. Yavakshara Taila (5 ml) Intrauterine Uttarabasti was given for 6 days (with interval of 3 days in between), after completion of menstrual cycle for two consecutive cycles. RESULTS: The tubal patency was found in 68.75% of patients and conception was achieved in 6.25% of patients. CONCLUSION: Yavakshara Taila Uttarabasti an effective procedure for treating tubal blockage with no apparent evidence of complication.

Lidocaine-prilocaine cream as analgesia for hysterosalpingography: a randomized, double blinded, controlled study.

OBJECTIVE: The efficacy of lidocaine-prilocaine cream (EMLA(®)) analgesia in the practice of hysterosalpingography is controversial. This study provides new drill results and a new method of application in terms of mode, time and place. The aim of the paper is to investigate the efficacy of 5% lidocaine 25 mg-prilocaine 25 mg/g cream applied to the uterine cervix for reducing pain during hysterosalpingography. STUDY DESIGN: A randomized, double blinded, controlled study set in the general gynaecology clinic of a university teaching hospital between September 2012 and June 2013. One hundred successive patients programmed to undergo hysterosalpingography were randomized to either 3 ml of EMLA (50) cream or 3 ml of placebo (50), placed endocervically and exocervically, 10 min before hysterosalpingography. Patients' intensity of pain was assessed in four steps: at baseline (speculum application), after application of Pozzi tenaculum and cannula on the uterine cervix, during cervical traction and after contrast medium injection, using a 10-cm Visual Analogue Scale (VAS) immediately after the procedure. The most painful step was also identified. VAS was administered again at one-month follow-up visit. TRIAL REGISTRATION: NCT01303614. RESULTS: The contrast medium injection was the most painful step of hysterosalpingography in both groups (EMLA 3.96, placebo 4.54, 95%CI: -0.481 to 1.641). No differences were found between the two groups (P=0.281) during this step. When comparing the VAS scale after the application of Pozzi tenaculum and cannula (EMLA 1.06, placebo 3.34, 95%CI: 1.495-3.065) and after cervical traction (EMLA 2.54, placebo 3.46, 95%CI: 0.034-1.806), significantly less pain was experienced by the EMLA group than the placebo group: P=0.000 and P=0.042, respectively. CONCLUSION: Endocervical and exocervical topical application of EMLA 10 min before performing hysterosalpingography significantly reduced pain during cervical manipulation with tenaculum and cannula and during cervical traction, but did not reduce pain during injection of contrast that was the most painful step.

Pregnancy following hysterosalpingography with oil and water soluble dye.

PIP: To determine whether hysterosalpingography (HSG) increases the conception rate and to compare the therapeutic effectiveness of oil and water soluble contrast media, the histories of 744 women who attended the Yale Infertility Clinic in 1965-69 were reviewed. Exclusion of women who had been infertile less than 1 year before coming to the clinic, in whom a HSG was done outside the clinic, and in whom there was no follow-up resulted in a study population of 460. The pregnancy rate for the study group (49%) was identical to that for the larger population. The study group was divided into women who became pregnant during their clinic attendance or within 1 year of terminating clinic care and women who did not become pregnant in this period. These 2 categories were then subdivided according to whether a HSG was done. To determine the relative effectiveness of different media, the conception rate following HSG in the Yale Clinic, where the iodized oil Ethiodol was used, was compared with that among 63 women who had HSG done by a private practitioner with the water soluble dye Salpix. 221 women were in the Ethiodol HSG group, 121 (55%) of whom conceived. Of the 239 Yale Clinic patients who did not have HSG, 103 (43%) became pregnant. Exclusion of couples with organic factors that could account for infertility resulted in a pregnancy rate of 58% for the HSG group and 47% for the non-HSG group. 25 (40%) of the 63 women in the Salpix group conceived, but exclusion of couples with organic factors lowered the pregnancy rate to 38% in this group. The average length of infertility was 0.5 years longer in the non-HSG group than in the Ethiodol HSG group, but shorter in the Salpix HSG group compared to the Ethiodol group. These results suggest that Ethiodol HSG may enhance fertility. Although the oil media has been criticized on the basis that it may cause granuloma formation or embolization, documented complications in the Yale series were rare. In contrast to earlier studies, unilateral nonpatency on x-ray was not found to affect eventual conception (58% pregnancy rate among women in the Ethiodol HSG group with normal tubes compared with 50% in those with filling of only 1 tube).^ieng