Diagnostic accuracy of hysterosalpingo-foam sonography for assessment of fallopian tube patency in infertile women.

RESEARCH QUESTION: What is the diagnostic accuracy of hysterosalpingo-foam sonography (HyFoSy), using two-dimensional ultrasound in tubal patency assessment in infertile women compared with laparoscopy with dye chromotubation? DESIGN: This prospective study was conducted at My Duc Hospital, Vietnam. Infertile women aged 18 years or older, who were scheduled for laparoscopy, were included. Visual Analogue Scale (VAS) score for perception of pain during HyFoSy was used. Laparoscopy was carried out on the same day. Clinicians undertaking laparoscopy were blinded to HyFoSy results. Sensitivity, specificity, negative and positive predictive value, and 95% confidence intervals were calculated. A sample size of 455 women (n = 910 fallopian tubes) was needed to demonstrate a fluctuation hypothesis, not exceeding 6%, for sensitivity and specificity (power 0.80, two-sided alpha 5%, loss to follow-up 5%). RESULTS: Between 2019 and 2022, 455 participants were recruited. Hysterosalpingo-foam sonography was unsuccessfully carried out in six participants. Two withdrew their consent. Data analysis was conducted on the remaining 447 participants (n = 868 fallopian tubes). The sensitivity and specificity of hysterosalpingo-foam sonography compared with laparoscopy were 0.75 (95% CI 0.71 to 0.79) and 0.70 (95% CI 0.65 to 0.74), respectively. Hysterosalpingo-foam sonography gave a positive predictive value of 0.76 (95% CI 0.73 to 0.80) and negative predictive value of 0.68 (95% CI 0.64 to 0.73). A total of 42.8% of women reported a VAS score of no pain. No adverse event was reported. CONCLUSION: Compared with laparoscopy with dye chromotubation, two-dimensional HyFoSy is a well-tolerated, reliable technique for assessing tubal patency.

Iodine and other factors associated with fertility outcome following oil-soluble contrast medium hysterosalpingography: a prospective cohort study.

Objective: To examine factors associated with fertility following hysterosalpingography (HSG) using an oil-soluble contrast medium (OSCM). Design: In a prospective cohort study on 196 women undergoing OSCM HSG, we showed that iodine excess was almost universal (98%) and mild subclinical hypothyroidism was frequent (38%). Here, we report the analyses of secondary outcomes examining factors associated with the likelihood of pregnancy following the HSG. Setting: Auckland, New Zealand (2019-2021). Sample: 196 women with primary or secondary infertility who underwent OSCM HSG. Methods: Baseline and serial urine iodine concentrations (UIC) and thyroid function tests were measured over six months following the HSG. Pregnancy and treatment with levothyroxine during the study period were documented. Results: Following OSCM HSG, pregnancy rates were 49% in women aged <40 years (77/158) but considerably lower (16%) among those ≥40 years (6/38). Similarly, live birth rates were markedly lower in women ≥40 years (17%; 1/6) versus <40 years (73%; 56/77). 29% of participants were iodine deficient at baseline despite advice recommending iodine fortification. Following HSG, the likelihood of pregnancy in women with moderate iodine deficiency was 64% higher than in women with normal iodine levels (p=0.048). Among women aged <40 years who had subclinical hypothyroidism (n=75), levothyroxine treatment was associated with higher pregnancy rates compared to untreated women [63% (26/48) vs 37% (10/27), respectively; p=0.047]. Conclusion: OSCM HSG was associated with higher pregnancy rates in women ≤40 than in those aged >40 years. Iodine deficiency was relatively common in this cohort, and increased iodine levels from OSCM exposure may contribute to the improved fertility observed with this procedure. Trial registration: This study is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR: 12620000738921) https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12620000738921.

The Role of Hysteroscopy in the Assessment of Fallopian Tubal Patency: A Comprehensive Review and Meta-analysis.

Hysteroscopy has been recognized as a reliable method for the evaluation of female infertility for several years. The outpatient setting is particularly convenient, as patients do not require general anesthesia and do not have to stay overnight. In recent years, more and more articles have dealt with the role of diagnostic hysteroscopy in tubal evaluation. Twenty-four articles were included in this comprehensive review and 14 of them were also included in a meta-analysis. This review provides an overview of the different techniques of hysteroscopic tubal evaluation, with a focus on perioperative changes in cul-de-sac volume, the air bubble technique ("Parryscope" technique), the Flow technique and selective hysteroscopic pertubation with methylene blue dye (SHPMBD). In pooled analyses, SHPMBD achieved the highest sensitivity for tubal patency (91.7%, 95% confidence interval, CI: 88.8-94.0), whereas the air bubble technique revealed the highest specificity of all methods (98.4, 95% CI: 95.3-99.6). Furthermore, in a meta-analysis of all methods on the assessment of single tubes, an overall sensitivity of 87.1% and an overall specificity of 79.8% (95% CI: 76.4-82.9) could be shown. In conclusion, the techniques of hysteroscopic tubal evaluation are well-tolerated, clinically relevant, and reliable.

Risk factors for tubal patency and their impact on pregnancy rate after partial salpingectomy and end-to-end anastomosis. / è¾“åµç®¡éƒ¨åˆ†åˆ‡é™¤æœ¯è”åˆç«¯ç«¯å»åˆæœ¯åŽå½±å“æ‚£è€ è¾“åµç®¡é€šç• æ€§å’Œå¦Šå¨ çš„ç›¸å ³å› ç´ åˆ†æž.

OBJECTIVES: To explore the risk factors for tubal patency after partial salpingectomy and end-to-end anastomosis, and their impact on pregnancy outcomes. METHODS: A total of 300 patients with tubal pregnancy who underwent partial salpingectomy and end-to-end anastomosis in Zhengzhou Maternal and Child Health Hospital from January 2020 to April 2023. Hysterosalpingography was performed after surgical treatment to examine the tubal patency. Lasso-Logistic regression was used to analyze the risk factors for postoperative tubal patency, and Spearman's correlation was used to analyze the impact of each risk factor on the pregnancy rate. RESULTS: Hysterosalpingography showed that the fallopian tube was not obstructed in 225 cases (unobstructed group), the tube was not completely patent (n=54) or blocked (n=21) (obstructed group). Univariate analysis showed that age, diameter of the tubal pregnancy sac, location of tubal pregnancy, timing of surgery, pelvic adhesion, anastomotic method, length of remaining tubal, history of pelvic surgery, number of intraoperative electrocoagulation, intraoperative blood loss, and experience of surgeons were factors affecting postoperative tubal patency (all P<0.01). Lasso regression analysis identified location of tubal pregnancy, pelvic adhesion, anastomotic surgical method, length of remaining tubal, history of pelvic surgery, number of intraoperative electrocoagulation, and experience of surgeons as influencing factors. Multivariate Logistic regression analysis showed that tubal isthmus pregnancy, pelvic adhesion, open anastomosis surgery, history of pelvic surgery, and number of intraoperative electrocoagulation were independent risk factors for postoperative tubal patency, while length of remaining tubal and surgeon's work experience were independent protective factors for postoperative tubal patency (all P<0.01). A total of 295 patients were followed up of 1 year, 192 cases (65.08%) were pregnant, including 172 cases of intrauterine pregnancy (89.58%) and 20 cases of ectopic pregnancy (10.42%). Spearman correlation analysis showed that tubal isthmus pregnancy, pelvic adhesion, open abdominal anastomosis surgery, pelvic surgery history, and times of intraoperative electrocoagulation were negatively correlated with postoperative pregnancy, while the remaining tubal length and years of surgeon's working experience were positively correlated with postoperative pregnancy rate (all P<0.01). CONCLUSIONS: For the tubal patency of patients after partial salpingectomy combined with end-to-end anastomosis, the history of tubal isthmus pregnancy, pelvic adhesion, open abdominal anastomosis, pelvic surgery, and the number of intraoperative electrocoagulation are independent risk factors, which are negatively correlated with postoperative pregnancy. The remaining tubal length and the surgeon's work experience are independent protective factors, which are positively correlated with postoperative pregnancy.

Comprehensive exploration unveiling the sonography and histopathology of uterine leiomyoma in a cow.

Genital tumours are rare among cattle, largely due to their relatively short lifespans. Leio-myoma, a smooth muscle tumour being more prevalent in dogs, appears only at a rate of 1.00 - 2.00% in cattle, affecting reproductive efficiency in cases of complete uterine obstruction. This case report involves an 8-year-old cow with repeated insemination attempts unveiled 5.00 cm intra-luminal uterine mass, obstructing the right uterine horn. Transrectal sonography (TRUS) revealed a highly vascularized mass with normal ovarian function. Confirmation of clinical condition, i.e., uterine leiomyoma, via uterine biopsy concluded the presence of neoplastic smooth muscle cells arranged in interlacing bundles showing mild pleomorphism, and special staining using Masson's trichrome revealed an unappreciable amount of connective tissue; subsequently right flank celiotomy was performed to remove the benign tumour. Forty-five days after celiotomy, TRUS examination confirmed an unobstructed uterine horn, and bilateral oviduct patency was adjudged with 2.50% methylene blue. Following treatment for chronic endometritis, artificial insemination led to conception nearly 90 days post-procedure. The TRUS aids preliminary diagnosis, while definitive identification demands necropsy and surgical methods. This case underscores the diagnostic significance of TRUS, histopathology and celiotomy for identifying and managing uterine leiomyoma in cattle.

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

STUDY QUESTION: 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? SUMMARY ANSWER: 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. WHAT IS KNOWN ALREADY: 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. STUDY DESIGN, SIZE, DURATION: 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. PARTICIPANTS/MATERIALS, SETTING, METHODS: 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. MAIN RESULTS AND THE ROLE OF CHANCE: 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. LIMITATIONS, REASONS FOR CAUTION: 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. WIDER IMPLICATION OF THE FINDINGS: 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. STUDY FUNDING/COMPETING INTEREST(S): 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. TRIAL REGISTRATION NUMBER: International Clinical Trials Registry Platform No. NTR4746.

Enhancing Fertility in the Same Cycle: A Case Report on Effects of Hysterosalpingo-Foam Sonography (HyFoSy) for a Couple With Mild Infertility.

Fertility issues are becoming increasingly prevalent, leading many couples to seek fertility treatment at specialized centers. Infertility is a diverse clinical condition, with multiple potential etiologic factors and variable severity in its manifestation. Regardless of the underlying factors and severity, routine fertility assessment rarely differs between cases, with an essential step being fallopian tube patency assessment. Hysterosalpingo-foam sonography (HyFoSy) is the latest available diagnostic technique to assess this parameter, offering robust results, with reduced intra-procedural pain and equipment requirements, in the convenience of the office setting. However, apart from its diagnostic value, HyFoSy has also demonstrated a therapeutic tubal flushing effect, that may be the decisive factor for couples with mild infertility to spontaneously conceive. In this report, we present the case of a couple with mild infertility, who managed to spontaneously conceive after a HyFoSy examination, and in fact within the same cycle.

Sequential-contingent strategy for fallopian tube evaluation using hysterosalpingo foam sonography: a cost analysis.

Background: Tubal pathology is the etiological factor in 20% of couples with female infertility. Historically, diagnostic evaluation of the fallopian tubes has been performed by means of hysterosalpingography (HSG). Hysterosonosalpingography with EXEM® foam is a recent technique with supposedly comparable effectiveness to HSG, but with better tolerability for patients. Methods: Tubal patency was assessed in patients who were candidates for intrauterine insemination (IUI) between January 2020 and July 2021. (I) Hysterosonosalpingography with EXEM® foam. (II) If the patient had both tubes patent, IUI was proposed. In case of inconclusive or pathological results, HSG was performed. (III) If the HSG concludes tubal patency, IUI is proposed. On the other hand, if it results in tubal obstruction, in vitro fertilization (IVF) is proposed. Results: Assessment of tubal patency by HSG showed concordance with previous Hysterosonosalpingography with EXEM® foam results in 45.5% (n=15) of cases of unilateral obstruction and 66.7% (n=6) of cases of bilateral obstruction. When we compare the total cost of HSG (€54,899.46) with the sum of patients who only required Hysterosonosalpingography with EXEM® foam together with those who underwent both tests (€45,575.96), it shows that the latter represents a cost benefit strategy (cost difference €9,323.50). Conclusions: Our results suggest a benefit of €9,323.50 when performing the contingent sequential strategy, in case of pathological or inconclusive results, compared to performing a systematic HSG in all patients. Patients with an obstructive hysterosalpingogram with EXEM® and a patent hysterosalpingogram will be the subgroup that will benefit the most, as IUI can be proposed instead of IVF. In addition, there is a benefit in terms of optimizing the medical procedure, hospital visits and speeding up the time to start assisted reproductive technology (ART).

Evaluation of tubal patency by hysterosalpingo-contrast Sonography (HyCoSy): Controversies, dilemmas and considerations.

Evaluation of tubal patency is one of the vital steps in the process of female infertility management. Hysterosalpingo-contrast Sonography (HyCoSy) has become the first-line recommendation for evaluating tubal patency. However, there remain some controversies and dilemmas relevant to the evaluation of tubal patency by HyCosy, with no effective solution has been proposed or no consensus has been reached. Herein, combined with previous research and clinical experience, we conclude and analyze these controversies and dilemmas, aiming at offering our perspective on the opportunities and challenges which are faced by HyCosy.

Tubal Pathologies and Fertility Outcomes: A Review.

Anomalies of the fallopian tubes represent one of the most significant elements that might contribute to reproductive issues. They can be inherited or acquired; they are among the most important problems of the profession. Although there is much discussion regarding which therapies for each tubal disease are the most effective and result in the best long-term reproductive outcomes. During the evaluation of an infertile couple, certain anomalies of the fallopian tubes are frequently discovered. These abnormalities were thought, for a long time, to not have an influence on fertility; however, in recent years, researchers have discovered that they seem to play a crucial role in fertility problems. Couples in industrialized countries are postponing childbearing, which raises the risk of women developing tubal diseases before they are ready to become pregnant. These disorders may have a negative impact on a woman's ability to get pregnant. The goals of this study are to conduct research to gain a deeper understanding of the recent advancements that have been made in the field of tubal diseases and to carry out an evaluation of the medical conducts that have the best fertility outcomes. We searched both Medline and PubMed, paying special attention to the most relevant articles that have been added to either database over the course of the last six years.

Comparative Study Between Hysterosalpingo-Contrast Sonography and Hysterosalpingography in Evaluating Tubal Patency at Aminu Kano Teaching Hospital, Kano.

Background: Tubal diseases contribute significantly to secondary infertility, affecting 25-35% of couples seeking infertility treatment. Traditional methods for assessing tubal patency, such as laparoscopy and dye tests, are invasive, costly, and require specialized expertise. Hysterosalpingography (HSG) is an alternative, but it involves pain and radiation exposure. This study aimed to compare the effectiveness of Hysterosalpingo-contrast Sonography (HyCoSy) using a saline and air mixture to HSG in assessing tubal patency in infertility patients at Aminu Kano Teaching Hospital. Methodology: A cross-sectional study involved 50 consenting patients seeking fertility evaluation. The researchers used a semi-structured questionnaire to gather demographic information. HyCoSy with the saline and air mixture was performed between the 5th and 10th day of the menstrual cycle, followed by HSG within the next five days. The patency of each fallopian tube was assessed, and pain levels experienced during both procedures were recorded using a numerical rating scale. Results: The results indicated that 68.8% of patients had bilateral patent tubes according to HyCoSy, while 60.4% were found to have patent tubes with HSG. A comparison of findings for individual tubes showed an 89.6% concordance rate between the two tests, with a Kappa index of 0.73, indicating substantial agreement. Importantly, patients reported significantly less pain during the HyCoSy procedure (mean NRS score of 4.1) compared to HSG (mean NRS score of 7.1). Conclusion: This study demonstrated that HyCoSy using a saline and air mixture is highly comparable to HSG in assessing tubal patency. Notably, HyCoSy was preferred by patients due to its reduced pain and better tolerance, with minimal adverse effects. This suggests that HyCoSy may be a more patient-friendly and cost-effective alternative for tubal assessment in cases of infertility.

A model established for predicting natural pregnancy possibility based on the imaging characteristics of 4-dimensional hysterosalpingo-contrast sonography. / åŸºäºŽå››ç»´è¶ å£°å­å®«è¾“åµç®¡é€ å½±çš„å½±åƒå­¦ç‰¹å¾å»ºç«‹è‡ªç„¶å¦Šå¨ é¢„æµ‹æ¨¡åž‹.

OBJECTIVES: The incidence of infertility is increasing, more than 30% of them having related abnormal tubal patency. Four-dimensional (4D) hysterosalpingo-contrast sonography (HyCoSy) overcomes the shortcomings of 3D HyCoSy in the diagnosis of tubal patency, showing high specificity and accuracy. In addition, 4D HyCoSy discards iodine allergy and X-ray radiation and possesses easy-operating, contributing to good acceptance in clinical practice. However, there is no research to explore the imaging standards related to the possibility of natural pregnancy after 4D HyCoSy. If a predictive model of postoperative natural pregnancy was established using the analysis of clinical data combined with imaging characteristics of 4D HyCoSy of patients with tubal factor infertility, clinical decision-making can be wisely guided in the future. This study aims to establish a predictive model of natural pregnancy after 4D HyCoSy based on clinical data and imaging characteristics of patients with tubal factor in fertility. METHODS: A retrospective study was conducted for patients who were diagnosed with tubal factor infertility in Hunan Guangxiu Hospital from February 2017 to May 2018. The patients ought to possess complete 4D HyCoSy imaging data and at least one-side-unobstructed fallopian tube. General clinical data and imaging data were collected. Pregnancy outcome was followed up till 3 months after 4D HyCoSy. According to pregnancy outcome, patients were divided into a pregnancy group and a non-pregnancy group. Binary logistic regression was used to analyze the correlation between various variables and natural pregnancy after 4D HyCoSy. The variables with significant difference (P<0.05) in single-factor logistic regression were included in the natural pregnancy probability prediction model. The classification accuracy was further verified with 10-fold cross-validation. RESULTS: A total of 1 085 patients with clinically suspected tubal factor infertility who met the requirements and followed the doctors' prescription were collected. Clinical characteristics (age and duration of infertility) and 4D HyCoSy imaging characteristics (thickness of endometrium from the 3rd to the 7th day after the end of menstruation, visualization of the left fallopian tube, the diffusion of contrast agent around the left ovary, and the diffusion of contrast agent around the right ovary) were independent predictors for natural pregnancy 3 months after 4D HyCoSy. A natural pregnancy probability prediction model was established with the area under the curve (AUC) verified by the 10-fold cross-validation all greater than 0.75, and the best AUC was 0.868. The Q value obtained by the prediction model was the probability of natural pregnancy, and the cutoff value was 0.5. When the Q value was greater than 0.5, it was recommended to attempt natural pregnancy for 3 months, and when the Q value was less than 0.5, in vitro fertilization was adviced. CONCLUSIONS: A predictive model for the evaluating probability of natural pregnancy in women with tubal factor infertility after 4D HyCoSy is successfully established based on the analysis for clinical data and imaging characteristics. This model shows a great potential in assisting clinical decision making.

A Review of Tubal Factors Affecting Fertility and its Management.

Infertility is a problem that affects both developed and developing countries today. Many couples choose to have financial stability before conception, irrespective of age. Tubal blockage accounts for 30%-40% of a woman's fertility. Congenital abnormalities, acute and persistent inflammatory diseases, endometriosis, and different pathologies are associated with infertility and cause partial or complete obstruction of the fallopian tubes. Approximately 30% of women experience infertility due to fallopian tube illness, with 10%-25% of these women experiencing proximal fallopian tube obstruction. The fallopian tube is an integral part of the union of sperm, and its normal function is a prerequisite for natural conception. Tubal obstruction is a common cause of infertility. These patients are keen to unblock their blocked fallopian tubes and restore reproductive function. Accurate diagnosis and optimal treatment options are essential for treating infertility.

Fertility Improvement of Hysteroscopy with Chromopertubation in the Management of Infertile Women with Hysterosalpingography Evidence of Abnormal Tubal Patency: A Prospective Comparative Study.

Purpose: To investigate the clinical value of hysteroscopy with chromopertubation (HSC) in infertile patients with hysterosalpingography (HSG) evidence of abnormal tubal patency. Methods: The study consisted of 296 patients. HSG was performed as a preliminary test for the evaluation of fallopian tube status. Patients who desired to conceive naturally were treated with HSC in the next month or followed-up without additional treatment. The primary outcome was natural clinical pregnancy within 12 months after the procedure. Results: In total, the number of clinical pregnancies was estimated to be 70 of 143 (48.95%) clinical pregnancies with management by HSC and 65 of 153 (42.48%) pregnancies with management comprising follow-up without additional treatment, and this was not significantly different (Log rank test, P = 0.516). Subgroup analysis showed that among women with bilateral abnormalities by HSG, patients receiving management with HSC tended to have a higher probability of pregnancy throughout the follow-up period than women without HSG (Log rank test, P = 0.005). No corresponding significant difference was found for women with a unilateral abnormality (P = 0.674). Conclusion: HSC shows potential fertility improvement value for infertile patients with tubal factors. HSC may be complementary to HSG and could be incorporated as a modality of the fertility work-up.

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

STUDY QUESTION: Is a strategy starting with transvaginal hydrolaparoscopy (THL) cost-effective compared to a strategy starting with hysterosalpingography (HSG) in the work-up for subfertility? SUMMARY ANSWER: A strategy starting with THL is cost-effective compared to a strategy starting with HSG in the work-up for subfertile women. WHAT IS KNOWN ALREADY: Tubal pathology is a common cause of subfertility and tubal patency testing is one of the cornerstones of the fertility work-up. Both THL and HSG are safe procedures and can be used as a first-line tubal patency test. STUDY DESIGN, SIZE, DURATION: This economic evaluation was performed alongside a randomized clinical trial comparing THL and HSG in 300 subfertile women, between May 2013 and October 2016. For comparisons of THL and HSG, the unit costs were split into three main categories: costs of the diagnostic procedure, costs of fertility treatments and the costs for pregnancy outcomes. PARTICIPANTS/MATERIALS, SETTING, METHODS: Subfertile women scheduled for tubal patency testing were eligible. Women were randomized to a strategy starting with THL or a strategy starting with HSG. The primary outcome of the study was conception leading to a live birth within 24 months after randomization. The mean costs and outcomes for each treatment group were compared. We used a non-parametric bootstrap resampling of 1000 re-samples to investigate the effect of uncertainty and we created a cost-effectiveness plane and cost-effectiveness acceptability curves. MAIN RESULTS AND THE ROLE OF CHANCE: We allocated 149 women to THL and 151 to HSG, and we were able to achieve complete follow-up of 142 versus 148 women, respectively. After the fertility work-up women were treated according to the Dutch guidelines and based on a previously published prognostic model. In the THL group, 83 women (58.4%) conceived a live born child within 24 months after randomization compared to 82 women (55.4%) in the HSG group (difference 3.0% (95% CI: -8.3 to 14.4)). The mean total costs per woman were lower in the THL group compared to the HSG group (THL group €4991 versus €5262 in the HSG group, mean cost difference = -€271 (95% CI -€273 to -€269)). Although the costs of only the diagnostic procedure were higher in the THL group, in the HSG group more women underwent diagnostic and therapeutic laparoscopies and also had higher costs for fertility treatments. LIMITATIONS, REASONS FOR CAUTION: Our trial was conducted in women with a low risk of tubal pathology; therefore, the results of our study are not generalizable to women with high risk of tubal pathology. Furthermore, this economic analysis was based on the Dutch healthcare system, and possibly our results are not generalizable to countries with different strategies or costs for fertility treatments. WIDER IMPLICATIONS OF THE FINDINGS: After 2 years of follow-up, we found a live birth rate of 58.4% in the THL group versus 55.4% in the HSG group and a lower mean cost per woman in the THL group, with a cost difference of -€271. The findings of our trial suggest that a strategy starting with THL is cost-effective compared to a strategy starting with HSG in the workup for subfertile women. However, the cost difference between the two diagnostic strategies is limited compared to the total cost per woman in our study and before implementing THL as a first-line strategy for tubal patency testing, more research in other fields, such as patient preference and acceptance, is necessary. STUDY FUNDING/COMPETING INTEREST(S): The authors received no external financial support for the research. B.W.J.M. is supported by an NHMRC Investigator Grant (GNT1176437). B.W.J.M. reports consultancy for ObsEva, Merck KGaA, Guerbet. B.W.J.M. reports receiving travel support from Merck KGaA. C.T.P. reports consultancy for Guerbet, outside of this manuscript. All other authors have no conflicts to declare. TRIAL REGISTRATION NUMBER: NTR3462.

Technical Tips and Tricks after 10 Years of HyFoSy for Tubal Patency Testing.

BACKGROUND: Hysterosalpingo-foam sonography (HyFoSy) has gained popularity in the last decades, as it represents a feasible, well-tolerated, and minimally invasive method of evaluation of tubal patency in cases of infertility. The purpose of this study was to communicate the technical tips and tricks based on our experience in performing HyFoSy, with the aim to improve the feasibility, to reduce the pain, and to evaluate pregnancy-obtaining rate after procedure. METHODS: Our observational study includes 672 patients from infertile couples who underwent HyFoSy for tubal patency evaluation. During HyFoSy, tubal pathway and patency as well as the level of pain were evaluated. A telephonic questionnaire was conducted in order to assess the pregnancy obtaining rate in the first 3 months and more than 3 months after the procedure. RESULTS: The median age in our group was 33.5 years. Most of our patients (61.16%) underwent HyFoSy in the 8-10 days of the menstrual cycle. Tubal patency was present bilaterally in 86% cases, unilaterally in 11% of patients, and was absent in 3% of cases; 75% of patients related absent or tolerable pain, 17% described HyFoSy as a painful procedure, and 8% experienced extreme pain. After HyFoSy, pregnancy was naturally obtained in 10.86% of cases within the first 3 months after HyFoSy. CONCLUSIONS: HyFoSy represents a useful, easy to use, and painless tool in female infertility evaluation and should be considered as a complementary method of the transvaginal ultrasonography, completing the genital tract imaging with information about the hidden part of the standard examination: tubal patency. HyFoSy provides information about patency, caliber regularity, pathway, and occlusion location of the fallopian tubes; therefore, it should be introduced along with transvaginal ultrasound as a first-line infertility exploration method.

Hysterosalpingography is obsolete: hysterosalpingo-contrast foam sonography should be the alternative.

Current evidence suggests that the hysterosalpingo-foam sonography test (HyFoSy) has emerged as a new option to make Fallopian tube assessment easier. Several published studies have compared the different types of tubal patency test available with the accepted gold standard, laparoscopy and dye, endorsing the advantages of HyFoSy over the other techniques. However, the authors wonder why professionals nowadays do not indicate HyFoSy as a first-choice diagnostic tool, with X-ray hysterosalpingography as still the most recommended procedure in outpatients. The aim of this article is to highlight the latest updates on this topic in order to raise awareness of the benefits of hysterosalpingo-contrast sonography as well as provide some tips for performing HyFoSy to obtain the maximum information in a single consultation.

Fertility-related quality of life in subfertile women undergoing tubal testing with transvaginal hydrolaparoscopy or hysterosalpingography.

OBJECTIVE: Both subfertility and its management can have significant impact on quality of life (QoL). Tubal patency testing as part of the fertility work-up, is considered to cause more physical complaints and stress than other tests. Pain scores for HSG are higher than for THL, but acceptability of the procedures was found to be comparable. Fertility-related QoL has not yet been studied in women undergoing tubal patency testing. STUDY DESIGN: We performed a standardized questionnaire study alongside a previously reported randomized controlled trial comparing THL and HSG in subfertile women, in which 24-month live birth rates occurred in 58.5% versus 55.4%, respectively. We randomly assigned 300 subfertile women to THL or HSG between May 2013 and October 2016. Women were eligible if they were undergoing a fertility work-up with an indication for evaluation of tubal patency. Fertility-related QoL was measured six weeks after the procedure with the validated FertiQoL questionnaire. The scores for the Core scale and subscales between THL and HSG were compared using Mann-Whitney-U test and multiple linear regression analysis. RESULTS: The questionnaire was completed by 84 women in the THL group (56%) and 96 women in the HSG group (64%). Core scores were 74.6 ± 12.8 for THL and 73.4 ± 12.4 for HSG (p = 0.39). Scores for the Emotional domain were 64.5 ± 19.0 for THL versus 66.0 ± 16.3 (p = 0.67) for HSG. Scores for the 'Mind-body' domain for THL were 76.9 ± 15.6 versus 74.1 ± 18.0 for HSG (p = 0.42), while scores for the Relational domain were 79.2 ± 12.9 for THL and 76.9 ± 15.6 for HSG (p = 0.21). Scores for the Social domain for THL were 77.9 ± 15.1 versus 76.7 ± 14.1, (p = 0.42). The multiple linear regression analysis showed only a statistical significant positive effect of older age on the score for the Emotional domain (p = 0.015). CONCLUSION: In a preselected group of women with low risk for tubal pathology we did not find differences in fertility-related QoL between tubal patency testing with THL versus HSG.

What is the fertility-enhancing effect of tubal flushing? A hypothesis article.

Hysterosalpingographies (HSGs) have formed an essential part of the fertility workup for more than a century. More recently, tubal flushing, especially with oil-based contrast, has been shown to significantly improve the natural conception rates. Critically, the mechanism of this fertility-enhancing effect during tubal flushing is still unclear. This article postulates hypotheses, based on published and own research, on the potential mechanisms and root cause of tubal flushing fertility enhancement. Possible explanations for the increased fertility rates, especially with oil-based contrast, are divided into the biochemical and interfacial effects derived from the contrast properties. The biochemical effects may include the immunological response of the endometrium or peritoneum, the impact on the endometrial opioid receptors or the iodine content. The interfacial effects may include improvement of interfacial factors due to the lubricant effect or dislodgement of mucus debris within the Fallopian tubes. Impact StatementWhat is already known on this subject? Tubal flushing during hysterosalpingographies (HSGs) increases natural conception rates, and using oil-based over water-based contrast increases that effect even further. However, the underlying mechanism of the observed fertility-enhancing effect is still poorly understood.What do the results of this study add? This article postulates different hypotheses on the potential mechanisms and root cause of the fertility enhancement from tubal flushing.What are the implications of these findings for clinical practice and/or further research? We suggest additional research on the different hypotheses, intending to determine which subfertile women will benefit most from tubal flushing using oil-based contrast and at which stage of their subfertility. Furthermore, we suggest research on administering tubal flushing with oil-based contrast, besides in HSG.

Development of a Nomogram for Predicting Intravasation Before Transvaginal 4-Dimensional Hysterosalpingo-Contrast Sonography.

Background: Intravasation during transvaginal 4-dimensional hysterosalpingo-contrast sonography (TVS 4D-HyCoSy) may lead to false-negative results in tubal patency evaluation. Although the influencing factors associated with intravasation have been investigated, some factors are only identified during 4D-HyCoSy, thus currently no studies on preventing intravasation. However, several preprocedural features can be collected in advance, which may be valuable in predicting intravasation. Objective: The purpose of this study is to establish a nomogram incorporating the preprocedural features to predict the risk of intravasation before TVS 4D-HyCoSy. Methods: The data of 276 infertile women with patent fallopian tubes were analyzed retrospectively. They were assigned to the study group (n = 62) and the control group (n = 214) according to the development of intravasation. The preprocedural characteristics were collected to investigate the predictors independently associated with intravasation, which were then served as the construction of a nomogram. The performance of the nomogram was verified internally. Results: History of uterine curettage (OR = 2.341, P = 0.009), endometrial thickness (OR = 0.587, P < 0.001), and examination schedule (OR = 0.790, P = 0.024) were found to be the independent influencing factors associated with intravasation. The established nomogram incorporating these preprocedural features was useful for predicting the risk of intravasation prior to 4D-HyCoSy. It yielded net benefits when the predicted probability was less than 50%. Conclusion: The nomogram incorporating the preprocedural characteristics achieved a net benefit for clinical decision-making when the estimated risk was less than 50%. It is recommended to change the examination schedule for patients with an estimated risk greater than 50% and perform 4D-HyCoSy when the risk is less than 50%.