Tubal flushing

Infertility is a significant global health issue, affecting approximately 17% of couples at some point in their lives. Couples facing infertility report poorer mental health outcomes, including increased feelings of depression and diminished self-confidence, compared to those who have fulfilled their desire to have children. This underscores the importance of effective diagnostic and therapeutic approaches in fertility care. This thesis focused on tubal patency testing as a diagnostic tool and explored its potential therapeutic effects. In chapter 2, we provided an overview of the available visible tubal patency tests and their diagnostic accuracy for diagnosing tubal occlusion compared with diagnostic laparoscopy with chromopertubation as the reference standard. We performed a systematic review and meta-analysis within the Cochrane network and included diagnostic accuracy studies in which at least one of the index tests (sono-hysterosalpingography (sono-HSG), hysterosalpingography (HSG), transvaginal hydrolaparoscopy (THL), or magnetic resonance hysterosalpingography (MR-HSG)) was compared with the reference standard. We found that sono-HSG, HSG, and THL are all reliable for diagnosing bilateral tubal occlusion. For MR-HSG no studies were included. In chapter 3, we aimed to evaluate what the optimal timing is to HSG with oil-based contrast related to the fertility work-up in women with unexplained infertility and a favourable prognosis for natural conception. Participating women were randomly allocated to immediate HSG with oil-based contrast as part of their fertility work-up or delaying this procedure by six months. We found that time to pregnancy leading to live birth was comparable for the immediate and delayed HSG group after 6 and 12 months, so were the cumulative pregnancy rates leading to live birth. Based on these findings, HSG should not be offered early during the fertility work-up in women with unexplained infertility and a favourable prognosis for natural conception. In chapter 4, we evaluated the impact of oil-based contrast during HSG on thyroid function in a subset of women in the H2Oil-timing study. We found that thyroid dysfunction after HSG occurs in 10 out of 41 (24%) of infertile women that were euthyroid before the procedure. These abnormalities resolved in 70% of the women without intervention. These findings emphasize the risk of (transient) thyroid dysfunction after HSG with oil-based contrast. In chapter 5, we presented the study protocol for the H2Oil2 study. In this study, we aim to evaluate the fertility-enhancing effects of HSG with oil-based contrast in subgroups of infertility beyond unexplained by randomizing women of advanced age, at risk for tubal pathology, and/or known with ovulation disorders to either HSG with oil-based or water-based contrast. In chapter 6, we presented an economic evaluation performed alongside the FOAM study. We compared the effects and costs related to management strategies based on either hysterosalingo-foam sonography (HyFoSy) or HSG test results. We found that HyFoSy led to lower costs per couple, and live birth rates were also slightly lower (although not statistically significant). This resulted in an ICER of €10 042, meaning that using HyFoSy instead of HSG would save €10 042 per each additional live birth lost. In chapter 7, we evaluated the effect of performing HyFoSy prior to HSG on visible tubal patency compared to HSG alone and vice versa. We found that tubal patency testing by either HyFoSy or HSG, prior to the alternative tubal patency testing method does not significantly affect visible tubal patency, when compared to alternative method alone. This suggests that both methods may have comparable abilities to dislodge mucus plugs in the Fallopian. In chapter 8, we described the study protocol of the FOil study. This study aims to directly compare the therapeutic effects of HSG with oil-based contrast and HyFoSy with ExEm® Foam.