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Introduction: Hysterosalpingography (HSG) and hysterosalpingo-foam sonography (HyFoSy) are commonly used tubal patency tests during the fertility work-up. Besides its diagnostic purpose, HSG with oil-based contrast can also be applied for its fertility-enhancing effect, by tubal flushing. HyFoSy is considered as less painful compared with HSG, it lacks exposure to iodinated contrast medium and ionising radiation. The fertility-enhancing effects of HyFoSy are less studied and randomised controlled trials comparing pregnancy rates after HSG and HyFoSy are lacking. This study (FOil study) is initiated to compare the effectiveness of tubal flushing during HSG with oil-based contrast and HyFoSy., Methods and Analysis: The FOil study is a nationwide, multicentre, open label, randomised controlled trial with a superiority design. Infertile women with an indication for tubal patency testing during their fertility work-up will be randomly assigned to HSG with oil-based contrast medium or HyFoSy. The primary outcome is conception within 6 months after randomisation leading to live birth. To demonstrate or refute an 8% difference in conception leading to live birth in favour of HSG with oil-based contrast, 1102 women will be included in the trial. A cost-effectiveness analysis from a societal perspective will be performed alongside the trial., Ethics and Dissemination: The trial is approved by the Medical Ethics Review Committee of the Amsterdam University Medical Centers (Ref. No. 2022.0884, date: 17 March 2023) and by the boards of the participating hospitals. The findings will be disseminated in peer-reviewed journals and participants will be informed through the patient organisation., Trial Registration Number: NCT05882188., Competing Interests: Competing interests: DK reports support from Guerbet. MvW is coordinating editor of the Cochrane Gynaecology and Fertility Group and member of the Cochrane thematic group Reproductive Health. HV is a member of the advisory board of Ferring Ltd, member of the ESHRE unexplained infertility guideline development group, and chairman of the Dutch unexplained infertility guideline development group. FJ is director of the Dutch Menopause Society. BWM received an investigator grant from NHMRC (GNT1176437), and research funding from Merck KGaA. BWM reports consulting fees from Merck KGaA, Organon, and Norgine and travel support from Merck KGaA. BWM reports holding stocks from ObsEva. VM, his department, received research grants from Guerbet, Merck and Ferring and travel and speakers fee from Guerbet. The other authors do not report conflicts of interest. KD, her department, received research grants from ZonMw and Guerbet outside the submitted work., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Study Question: Does hysterosalpingo-foam sonography (HyFoSy) prior to hysterosalpingography (HSG) or HSG prior to HyFoSy affect visible tubal patency when compared HSG or HyFoSy alone?, Summary Answer: Undergoing either HyFoSy or HSG prior to tubal patency testing by the alternative method does not demonstrate a significant difference in visible tubal patency when compared to HyFoSy or HSG alone., What Is Known Already: HyFoSy and HSG are two commonly used visual tubal patency tests with a high and comparable diagnostic accuracy for evaluating tubal patency. These tests may also improve fertility, although the underlying mechanism is still not fully understood. One of the hypotheses points to a dislodgment of mucus plugs that may have disrupted the patency of the Fallopian tubes., Study Design, Size, Duration: This is a secondary analysis of the randomized controlled FOAM study, in which women underwent tubal patency testing by HyFoSy and HSG, randomized for order of the procedure. Participants either had HyFoSy first and then HSG, or vice versa. Here, we evaluate the relative effectiveness of tubal patency testing by HyFoSy or HSG prior to the alternative tubal patency testing method on visible tubal patency, compared to each method alone., Participants/materials, Setting, Methods: Infertile women aged between 18 and 41 years scheduled for tubal patency testing were eligible for participating in the FOAM study. Women with anovulatory cycles, endometriosis, or with a partner with male infertility were excluded. To evaluate the effect HyFoSy on tubal patency, we relied on HSG results by comparing the proportion of women with bilateral tubal patency visible on HSG in those who underwent and who did not undergo HyFoSy prior to their HSG (HyFoSy prior to HSG versus HSG alone). To evaluate the effect of HSG on tubal patency, we relied on HyFoSy results by comparing the proportion of women with bilateral tubal patency visible on HyFoSy in those who underwent and who did not undergo HSG prior to their HyFoSy (HSG prior to HyFoSy versus HyFoSy alone)., Main Results and the Role of Chance: Between May 2015 and January 2019, we randomized 1160 women (576 underwent HyFoSy first followed by HSG, and 584 underwent HSG first followed by HyFoSy). Among the women randomized to HyFoSy prior to HSG, bilateral tubal patency was visible on HSG in 467/537 (87%) women, compared with 472/544 (87%) women who underwent HSG alone (risk difference 0.2%; 95% CI: -3.8% to 4.2%). Among the women randomized to HSG prior to HyFoSy, bilateral tubal patency was visible on HyFoSy in 394/471 (84%) women, compared with 428/486 (88%) women who underwent HyFoSy alone (risk difference -4.4%; 95% CI: -8.8% to 0.0%)., Limitations, Reasons for Caution: The results of this secondary analysis should be interpreted as exploratory and cannot be regarded as definitive evidence. Furthermore, it has to be noted that pregnancy outcomes were not considered in this analysis., Wider Implications of the Findings: Tubal patency testing by either HyFoSy or HSG, prior to the alternative tubal patency testing method does not significantly affect visible tubal patency, when compared to alternative method alone. This suggests that both methods may have comparable abilities to dislodge mucus plugs in the Fallopian tubes., Study Funding/competing Interest(s): The FOAM study was an investigator-initiated study, funded by ZonMw, a Dutch organization for Health Research and Development (project number 837001504). IQ Medical Ventures provided the ExEm®-FOAM kits free of charge. The funders had no role in study design, collection, analysis, or interpretation of the data. H.R.V. reports consultancy fees from Ferring. M.v.W. received a travel grant from Oxford University Press in the role of Deputy Editor for Human Reproduction and participates in a Data Safety and Monitoring Board as an independent methodologist in obstetrics studies in which she has no other role. M.v.W. is coordinating editor of Cochrane Fertility and Gynaecology. B.W.J.M. received an investigator grant from NHMRC (GNT1176437) and research funding from Merck KGaA. B.W.J.M. reports consultancy for Organon and Merck KGaA, and travel support from Merck KGaA. B.W.J.M. reports holding stocks of ObsEva. V.M. received research grants from Guerbet, Merck and Ferring and travel and speaker fees from Guerbet. The other authors do not report conflicts of interest., Trial Registration Number: International Clinical Trials Registry Platform No. NTR4746., (© The Author(s) 2024. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology.)

Introduction: infertility is a significant public health concern in Africa and Hysterosalpingography (HSG) is an affordable option for initial treatment. This study aimed to provide information about the incidence of abnormal pathology and tubal findings in HSG of Sudanese women who experienced infertility., Methods: this prospective cross-sectional study included 100 infertile patients who were requested for HSG, including age, duration of infertility, body mass index (BMI), medical history, and HSG findings collected after performing the radiographic test, which was diagnosed by an experienced radiologist., Results: one hundred infertile women (46% and 54%) experienced primary and secondary infertility, respectively. Mean age was (31.1 ± 5.2, 27.5 ± 6.0) years, and BMI was (25.1 ± 3.3, 25.7 ± 2.9) Kg/cm 2 for primary and secondary infertility respectively. Abnormal findings prevalence was (29/46, 63%) and (30/54, 56%). The incidence of fallopian tube abnormality was (52/100, 52% (25/46, 54.3%), and (27/56, 50%) for primary and secondary infertility, respectively. Forty-one percent of participants had normal hysterosalpingograms. Pelvic surgery was the highest risk factor in 24% of the participants. Age and medical history were significantly associated with the infertility type (P < 0.05)., Conclusion: infertile patients who underwent hysterosalpingography (HSG) were predominantly older, with secondary infertility being slightly more common, underscoring the importance of early diagnostic evaluation and care. Fallopian tube abnormalities were the most common cause of infertility, with tube blockage affecting nearly half of the participants. Additionally, this study revealed that prior pelvic surgery significantly increased the risk of infertility., Competing Interests: The authors declare no competing interests., (Copyright: Eiman Kamal et al.)

Aim: To evaluate the efficiency of last image capture in interpreting a hysterosalpingogram (HSG) when compared to conventional spot views; to confirm its validity in showing pathology; to establish its use as the preferred method; and to decrease the radiation dose to the patient., Materials and Methods: The study population consisted of women aged ≥18 years. A standard technique was performed including additional five last image capture after each spot view. Every patient had two stacks of images, one with the exposure film and one with the last image capture. The images were interpreted separately (high-dose versus low-dose) and blindly by two radiologists with different levels of training assessing for uterine abnormalities, fallopian tube abnormalities, peritoneal spillage, and incidental findings. Inter-reading variability was calculated using Kohen's kappa., Results: Discrepancies between exposure film and last image capture were detected in only a minority of cases for all variables. Except for the presence of strictures, there was at least substantial agreement between the readers and almost perfect agreement regarding peritoneal spillage and fallopian tube patency, both on exposure film and last image capture., Conclusion: Reduction in radiation dose without compromising the diagnostic efficacy of HSG is mandatory. If the study is of sufficient quality and deemed negative on last image capture, conventional spot view can be avoided. If further detail is required, standard spot views can still be obtained. Using last image capture instead of spot films has the potential to reduce the overall radiation dose by up to 78%., (Copyright © 2023. Published by Elsevier Ltd.)

Objective: Nowadays 4D hysterosalpingocontrast sonography (4D-HyCoSy) represents a primary technique in the evaluation of tubal impairment, with a low rate of pain referred and complications related, but its role in increasing the chance of spontaneous clinical pregnancy in women in childbearing age is still debated., Patients and Methods: Retrospective study of 359 women performed 4D-HyCoSy at Reproductive Physiopathology and Andrology Unit, Sandro Pertini Hospital, Rome, during the period 2018-2020., Inclusion Criteria: women attending our IVF (in vitro fertilization) center with at least 1 year of infertility., Exclusion Criteria: female age over 43 years, previously known severe tubal infertility, suspected anovulation, and semen abnormalities., Primary Outcome: evaluation of tubal patency, complications related to technique, and pain perception evaluated thanks to a 10-cm visual analogue scale (VAS) Scale., Secondary Outcomes: clinical pregnancy rate (PR) after the technique confronted between the group of women with bilateral tubal patency (group A) with the group of monolateral tubal patency (group B) within 30 days and between 30-180 days, and 180 days-1 year from the exam. Time to pregnancy (TTP) and other obstetrical outcomes were evaluated too., Results: The average age of the study's population was 33.3 years. Mean duration of infertility was 2.1 years. Complication rate was 6.4%, and in any case the use of ephedrine was required. 182 (50.6%) women reported absence of pain during the exam (VAS scale value 0) and 131 (36.5%), reported mild pain experience (VAS scale value between 1-4). Spontaneous pregnancy rate was of 29.3% in group A and 30.3% in group B; time to pregnancy was 32 ± 14.7 days in group A and 35 ± 13.1 days in group B. The insurgence of a spontaneous pregnancy was significantly lower for both 4D-HyCosy sub-groups after 30 days following technique respect to 30-180 days and 180 days-1 year following the technique (both p-value < 0.001)., Conclusions: We confirm that 4D-HyCoSy is a safe and user-friendly technique, used as first line assessment of tubal patency of women afferent to a reproductive center. We also reported a positive impact on spontaneous pregnancy rate in women performing 4D-HyCoSy, emphasized within the first following month. This mandatory technique for tubal investigation, has not only a function in the diagnostic assessment of female infertility, but also has a therapeutic role, in young women who desire a pregnancy, avoiding, in some cases, the need of IVF treatments and clinical risks linked, while saving medical and monetary resources.

Tubal and peritoneal disease are the main causes of infertility. Tubal pathology can be either congenital malformation or acquired, proximal or distal, unilateral or bilateral and transient or permanent. Several imaging methods such as laparoscopy, fluoroscopy, saline infusion sonography, and hysterosalpingography (HSG) have been used in the assessment of tubal and peritoneal pathology. Although laparoscopy is the modality of choice for investigating tubal patency and pelvic structure in many infertility centers, HSG is usually the initial diagnostic method for infertility workup because of its ease of performance, accuracy, and minimal risk of complications. This method provides useful information about size, contour, and anatomy of the inner surface of the fallopian tubes and is the gold standard for evaluation of tubal lumen. Tubal and peritubal pathology show various imaging manifestations on HSG. This review illustrates the radiographic features of congenital and acquired structural abnormalities of the proximal tubal pathology and along with etiology of proximal obstruction or occlusion will be described.

Background: Evaluation of the fallopian tubes are important for infertile patients. The two most important diagnostic procedures used to evaluate tubal patency are hysterosalpingography and laparoscopy., Objectives: To asses the hysterosalpingography and laparoscopy results of patients diagnosed with infertility and investigate the diagnostic value of hysterosalpingography in patients with tubal factor infertility., Methods: The hysterosalpingography and laparoscopy results of 208 patients who presented to the Obstetrics and Gynecology Clinic at Dicle University, Faculty of Medicine between January 2014- January 2018 were retrospectively evaluated. Hysterosalpingography and laparoscopy results were compared with regard to the investigation of the presence of tubal obstruction and of the pelvic structures that could cause tubal obstruction. The specificity, sensitivity, positive, and negative predictive values of hysterosalpingography were computed., Results: The number of patients evaluated was 208. The ratio of primary infertile patients was 57.2% and 42.8% was secondary infertile. Hysterosalpingography was found to have a specificity of 64.6%, the sensitivity of 81.3%, the positive predictive value of 56.4%, and a negative predictive value of 86% in the determination of tubal obstruction., Conclusion: Patients with suspected tubal infertility can primarily be examined using hysterosalpingography in consideration of the invasive nature and the higher complication rate of laparoscopy., (© 2021 Gündüz R et al.)

Background: Lipiodol tubal flushing is offered to select subfertile women primarily to confirm tubal patency and to increase pregnancy rates., Aims: To investigate the safety of hystero-salpingo contrast sonography (HyCoSy) using Lipiodol flush (through frequency of adverse events and mean recalled pain score) and secondarily to quantify pregnancy rates., Materials and Methods: Retrospective observational Phase 1 study of subfertile women in three centres across Australia between June 2017 and June 2019. Cases were identified from medical records, and women telephoned to assess adverse outcomes, procedure tolerability and confirm pregnancy outcomes within six months from procedure., Results: A total of 325 cases were identified; 14 were excluded due to incomplete or abandoned procedure, 32 were lost to follow-up, leaving 279 for analysis. Fourteen women (5% overall) experienced mild vasovagal reactions, with one case of infection and no reports of anaphylaxis or allergy. There were 141 conceptions reported (51%) within six months after Lipiodol flush, and an ongoing pregnancy in 43% (119) of women. For women with ongoing pregnancies, 55% (78/119) conceived spontaneously, and 45% (63/119) via artificial reproductive technology. Mean recalled pain score was 5.7 (SD 3.2; range 0-10) at a single site., Conclusions: This Phase 1 study has indicated that Lipiodol flush using HyCoSy may be a safe and efficacious alternative to hysterosalpingography in the workup for infertility. The low adverse effect profile observed in this study coupled with a substantial ongoing pregnancy rate indicates that further investigation of Lipiodol under HyCoSy is warranted., (© 2020 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Assessment of tubal patency and therapeutic tubal flushing using Lipiodol, an oil-soluble contrast media (OSCM), has been shown to enhance fertility, resulting in increased interest in the use of Lipiodol. A modified hysterosalpingogram (HSG) technique, including a supplementary ultrasound with the contrast in situ, is recommended when using Lipiodol, taking into account both safety issues and technical challenges specific to Lipiodol., (© 2020 The Royal Australian and New Zealand College of Radiologists.)

Background: Magnetic resonance hysterosalpingography (MR-HSG) is a promising technique in the work-up of female infertility. Few existing MR-HSG studies focus on the comparison between MR-HSG with gold standard examination., Purpose: To compare the diagnostic value of MR-HSG with conventional HSG in patients receiving both exams in one day., Material and Methods: This study included 33 infertile women who completed pelvic MR scanning, HSG, and MR-HSG in that order. A traditional HSG contrast agent (iohexol) and a magnetic resonance imaging (MRI) contrast agent (1 mL gadopentetate dimeglumine (Gd-DTPA) blended with 100 mL iohexol) were used to achieve image enhancement. Inter-observer and inter-modality agreements of HSG and MR-HSG exams were assessed. The results were calculated by using the kappa test. Three radiologists who were blinded to the clinical data independently reviewed the MR images. Extratubal abnormalities were analyzed., Results: A total of 62 fallopian tubes of 33 women were included in the study. MR-HSG imaging findings to depict tubal patency were similar to these of HSG (AUC 0.911, sensitivity 0.821, specificity 1.000, positive predictive values 1.000, and negative predictive values 0.872). Pairwise inter-observer agreement among three observers and inter-modality agreement of the diagnosis were excellent (mean kappa 0.863 and 0.835, respectively). In addition, 29 extratubal abnormalities in 21 patients were found on pelvic MR scanning., Conclusion: MR-HSG and HSG demonstrated similar results in assessing tubal patency. Because it offers the comprehensive assessment of female pelvic structures, and avoids ionizing radiation, MR-HSG may be used as an alternative imaging technique for evaluation of female infertility.

Purpose: To estimate the diagnostic efficacy of saline-air hysterosalpingo-contrast sonography (SA-HyCoSy) compared with the modified hysterosalpingogram (mHSG) for confirmation of both coil location and tubal occlusion following hysteroscopic sterilization., Methods: This study included 19 women who underwent both SA-HyCoSy and mHSG where 1 test was followed by the other. Sensitivity, specificity, and positive and negative predictive values for tubal occlusion against the mHSG were calculated for each fallopian tube by 2 independent interpreters. Interrater reliability was assessed using Cohen κ statistic. Procedure time and pain level by 11-point numeric rating scale of SA-HyCoSy and mHSG were also compared., Results: Thirty-eight fallopian tubes were evaluated. Tubal occlusion was noted in 97.3% of tubes for both interpreters with the mHSG compared with 92.1% and 94.7% with SA-HyCoSy. The positive and negative predictive values for tubal occlusion were 100%/100% and 50%/33%, respectively, with an overall agreement of 97.4% and 95.7%, κ = 0.48, P < 0.01. Saline-air HyCoSy changed interpretation of coil insert location in 50% and 44.7% for each interpreter, being downgraded from optimal to satisfactory in 42.9% (9/21) and 36% (9/25) and upgraded to optimal in 58.8% (10/17) and 61.5% (8/13), respectively. There were no statistically significant differences in procedural time (7.5 vs 9.4 minutes, P > 0.05) or maximum pain scores (2.3 vs 3.1, P > 0.05) for the mHSG compared with SA-HyCoSy., Conclusions: Our findings revealed a high degree of diagnostic accuracy with SA-HyCoSy for tubal occlusion, although coil location changed in nearly half of cases. Avoidance of radiation and patient convenience/compliance with SA-HyCoSy may outweigh the drawbacks.

Purpose: To compare hysterosalpingo-contrast-sonography (HyCoSy) and magnetic resonance-hysterosalpingography (MR-HSG) in the diagnosis of fallopian tubal patency., Materials and Methods: The databases of PubMed, Embase, and the Cochrane Library were searched for records up to November 30, 2019. Studies involved in the diagnostic detection of HyCoSy or MR-HSG for fallopian tubal patency using conventional HSG or laparoscopy as the reference test were included. Data was analyzed by meta-analysis. We compared sensitivity, specificity, positive and negative likelihood ratios (PLR and NLR), diagnostic odds ratio (DOR), and summary receiver operating characteristic (sROC) plots of both HyCoSy and MR-HSG. Quality was assessed using the QUADAS-2 tool., Results: The analysis included 24 articles involving 1340 patients. HyCoSy was studied in 17 studies, and MR-HSG was studied in seven studies. For HyCoSy in diagnosis of fallopian tubal patency, pooled sensitivity was 89 % (95 % confidence interval [CI], 87 %-91 %), and specificity was 93 % (95 % CI, 91 %-94 %). For MR-HSG in diagnosis of fallopian tubal patency, pooled sensitivity was 100 % (95 % CI, 98 %-100 %), and specificity was 82 % (95 % CI, 74 %-89 %). The sROC showed similar diagnostic accuracy for MR-HSG and HyCoSy. 3D/4D HyCoSy with ultrasound microbubbles had equal sensitivity (95 % vs. 100 %, P = 0.186) and significantly higher specificity (94 % vs. 82 %, P = 0.005) compared with MR-HSG., Conclusions: HyCoSy and MR-HSG showed similar overall diagnostic performance for diagnosing fallopian tubal patency. 3D/4D HyCoSy with ultrasound microbubbles could significantly improve the diagnostic specificity of HyCoSy., Competing Interests: Declaration of Competing Interest All authors declare that there are no conflicts of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Infertility, or subfertility, is the inability to achieve a clinical pregnancy after a 1-year period of regular unprotected sexual intercourse in women younger than 35 and after 6 months in women older than 35. Although initial assessment involves a multitude of factors, including a detailed medical history, physical examination, semen analysis, and hormonal evaluation, diagnostic imaging of the female partner often plays an important role in establishing the etiology for infertility. This article provides an overview of the multimodality imaging assessment of female infertility and details the developmental and acquired pelvic abnormalities in which diagnostic imaging aids in evaluation., Competing Interests: Conflict of interest The authors report no conflicts of interests concerning the materials, methods, or results in this article., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: To highlight and compare spectrum of hysterosalpingography (HSG) findings in primary and secondary infertility patients. Methods: This retrospective record-based cross-sectional study was performed in the Radiology Department, King Fahad Military Medical City, Dhahran, Kingdom of Saudi Arabia between August 2016 and 2018. All patients (N=303) who underwent successful HSGs were included, and grouped under primary and secondary infertility cases. Patients with failed, limited or incomplete studies were excluded. Imaging findings were documented as N (Normal) or Ab (Abnormal). Abnormal HSG findings were further categorized as: C=congenital malformation, I=infection or inflammation, S=surgery, T=tumor or tear. Abnormal findings were confirmed on further imaging or intervention. Chi-square test was used to determine any association of HSG findings with type of infertility, and p-value less than 0.05 was considered significant. Results: Of the 303 patients, 166 patients (54.8%) had primary infertility while the rest had secondary infertility. Abnormal studies were found in less than one-third of patients (n=93, 30.7%). Primary infertility patients exhibited more congenital (C) malformations, while surgery (S) was seen more in secondary infertility patients (p=0.01).  Conclusion: Congenital malformations are commonly found abnormalities on HSGs in primary infertility patients, while surgery related findings are seen in secondary infertility cases.

Objectives: We aim to retrospectively analyze the diagnostic image quality of transvaginal 4-dimensional hysterosalpingo-contrast sonography from infertile patients and determine the significant influencing factors., Methods: A total of 445 patients visiting infertility clinics were included in the study, of which 167 were primary infertile and 278 were secondary infertile. The factors were recorded, including age; examination time; infertility type; history of pelvic inflammatory disease, pelvic surgery, intrauterine surgery, and ectopic pregnancy; endometrial thickness; uterine position; ovarian position; 2-dimensional image quality; intravasation quantity, position, and time; balloon volume; and the dosage of contrast agent or the sterile saline solution. All the factors were compared among different diagnostic image quality groups. The method of rank logistic regression analysis was adopted to analyze the risk factors affecting the diagnostic image quality., Results: Among the 445 infertile patients, 124 (27.9%) patients had intravasation occur during transvaginal 4-dimensional hysterosalpingo-contrast sonography. The diagnostic image quality between the 2 sonographers was consistent (Cronbach's alpha, 0.993). Different intravasation quantities, positions, and times; increased of balloon volume; and history of pelvic surgery were substantial risk factors for the diagnostic image quality. The diagnostic image quality diminished with the increase of intravasation. In the patient with cornual intravasation, the diagnostic image quality was substantially worse than that with non-cornual intravasation. Moreover, early onset of intravasation seriously affected the diagnostic image quality., Conclusions: In conclusion, intravasation affected the diagnostic image quality, especially early cornual massive intravasation., (© 2018 by the American Institute of Ultrasound in Medicine.)

Background: Tubal patency testing is an essential part of female subfertility evaluation. Traditionally, hysterosalpingography (HSG) was the first step to evaluate tubal patency. However, during the past decade Hysterosalpingo-Contrast Sonography (HyCoSy) was introduced in order to avoid radiation exposure and Hysterosalpingo-Foam Sonography (HyFoSy) has been developed as a safe and less painful alternative., Objectives and Rationale: The aim of this narrative review is to provide an overview of the currently available HyFoSy literature and related clinical aspects., Search Methods: A literature search was conducted using PubMed and Embase from the introduction of HyFoSy to March 2019. Unfortunately, a meta-analysis was not possible due to a too small number of studies, being mutually incomparable for the various subjects of clinical aspects, even for the reliability as a test for tubal patency., Outcomes: Nine small studies concluded that the accuracy and effectiveness as a test for tubal patency of 2D- and 3D-HyFoSy are comparable or even better than HSG or HyCoSy. With or without using Doppler techniques, 3D-HyFoSy does not seem to offer benefits above real-time 2D-HyFoSy. Five studies reported on pain and discomfort during HyFoSy, concluding that HyFoSy is a well-tolerated, less painful procedure compared to HSG, without a need for the use of analgesics. There are suggestions about an increased pregnancy rate in the first three cycles after the procedure but in no studies pregnancy outcome after HyFoSy was compared with other or no intervention., Wider Implications: HyFoSy is a promising and safe alternative for HSG with regard to accuracy and effectiveness. HyFoSy lacks radiation and iodine exposure and is a well-tolerated and less painful procedure than HSG, without the need for analgesics. However more research is needed to make clear statements regarding a therapeutic effect of HyFoSy.

Objective: This prospective study aimed to investigate the use of real-time three-dimensional hysterosalpingo-contrast sonography (4D-HyCoSy), using contrast agent SonoVue, with B mode hysterosalpingo-contrast sonography (B mode-HyCoSy), to evaluate tubal patency and the wall of the Fallopian tubes in infertility patients., Method: In total, we recruited 739 women with fertility requirements from the First Affiliated Hospital of Shantou Medical College between January 2017 and July 2018. All cases received 4D-HyCoSy using contrast agent SonoVue, immediately followed by the B mode-HyCoSy. Of these patients, 145 showed pathological findings in the Fallopian tubes during HyCoSy; 34 of these (62 Fallopian tubes) were verified by laparoscopy and the dye test against routine reference standards. Sonographic findings, along with laparoscopic findings and dye test results, were used to compare the two techniques using the Cohen kappa coefficient. We also investigated the duration of examination and pain score., Results: Compared with laparoscopy and the dye test, the tubal occlusion diagnostic accordance rates for 4D-HyCoSy were 88.7% (32+23)/62, with a kappa coefficient of 0.769 and a 76.9% agreement rate. Distal occlusion diagnostic accordance rates for 4D-HyCoSy were 100% (8/8) with a k coefficient of 1.000 and a 100% agreement rate., Conclusions: The use of 4D-HyCoSy, with B mode-HyCoSy, for the diagnosis of tubal patency is safe, feasible, noninvasive, and highly accurate. B mode-HyCoSy allowed us to observe tubal walls in an intuitive manner.

Background: Prior studies on Hysterosalpingography (HSG) have shown that pelvic inflammatory disease (PID) related tubal adhesions accounted for 30 - 50% of female infertility, with as high as 80% reported in some studies. With improved access to contraceptives, antibiotics and promotion of safe practices, the abnormal findings in HSG may have reduced or altered., Objective: To document the imaging findings in the HSG of participants and to compare current findings with prior studies done nationally and internationally., Method: A retrospective evaluation of 974 HSGs done at the tertiary diagnostic center over a 7-year period was conducted and analyzed using diagnostic accuracy tables., Results: Tubal pathologies were the most common abnormality in this study, (35.1% of the cases), comprising tubal blockage and hydrosalpinges; followed by uterine masses seen in 223 (22.9%) of the clients. Tubal occlusion was higher in clients with multiple abnormal findings; while normal sized and large uterine cavities had a higher percentage of bilateral tubal patency., Conclusion: Tubal factors remain the most common abnormality seen in the HSGs of infertile women in this study, though with lower prevalence compared with prior older studies. Forty seven (47%) of the cases of female factor infertility had normal HSGs with bilateral tubal patency., (© 2019 Omidiji et al.)

Objective: This study sought to examine whether hysterosalpingosonography (sono-HSG) is as effective as hysterosalpingography (HSG) in facilitating conception by comparing pregnancy rates in the 6 months following the procedures., Methods: This retrospective noninferiority study (Canadian Task Force classification II-2) was conducted at a tertiary university centre. The investigators studied 440 consecutive eligible infertile women. Bilateral tubal occlusion, severe male infertility, and having undergone both procedures were exclusion criteria. Tubal testing, as part of the infertility workup, was performed by either sono-HSG or HSG. The primary outcome was pregnancy, defined as a positive fetal heartbeat on ultrasonographic examination, in the 6 months following the procedure., Results: A total of 57 pregnancies (26%) were observed in the HSG group and 33 (15%) in the sono-HSG group. Adjusted and non-adjusted relative risks of pregnancy in the 6 months following sono-HSG compared with HSG were 0.61 (95% CI 0.42-0.89) and 0.58 (95% CI 0.39-0.85). Adverse events were infrequent with both procedures (sono-HSG, 1%; HSG, 4%; P = 0.16)., Conclusion: This study suggests that uterine flushing as performed during sono-HSG is not as effective as when performed during HSG to increase the chances of pregnancy, but further studies will be required because of bias related to the retrospective study design., (Copyright © 2018 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Background: A retrospective study was designed to evaluate the diagnostic value of transvaginal four-dimensional hysterosalpingo-contrast sonography (TVS 4D-HyCoSy) combined with recanalization versus laparoscopy for patients with tubal infertility., Materials and Methods: A total of 195 patients undergoing TVS 4D-HyCoSy were analyzed retrospectively. Of these, 72 patients underwent laparoscopy, which was the gold standard. The endpoints were coincidence rate (defined as a parameter consistent with results arising from TVS 4D-HyCoSy and laparoscopic examination using dye), sensitivity, specificity, positive predictive value, negative predictive value, and Youden index for TVS 4D-HyCoSy., Results: A total of 385 fallopian tubes were assessed by TVS 4D-HyCoSy, of which 147 (38.2%) were tubal patency, 178 (46.2%) as partial tubal obstruction, and 60 (15.6%) as complete tubal obstruction. Of 195 patients, 72 patients with 144 fallopian tubes underwent laparoscopy and a total coincidence rate of 90.97% compared with TVS 4D-HyCoSy. The sensitivity, specificity, positive predictive value, negative predictive value, and Youden index for 4D-HyCoSy versus laparoscopy were 97.7%, 86.7%, 98.4%, 81.3%, and 0.84, respectively., Conclusions: TVS 4D-HyCoSy represents a highly useful method for diagnosing tubal patency. However, further large-scale studies are warranted to investigate our findings in patients with tubal infertility., Competing Interests: There are no conflicts of interest.

Purpose: To compare saline infusion sonohysterography (SIS) versus hysterosalpingogram (HSG) for confirmation of tubal patency., Methods: Secondary analysis of a randomized controlled trial, Pregnancy in Polycystic Ovary Syndrome II (PPCOS II). Seven hundred fifty infertile women (18-40 years old) with polycystic ovary syndrome (PCOS) were randomized to up to 5 cycles of letrozole or clomiphene citrate. Prior to enrollment, tubal patency was determined by HSG, the presence of free fluid in the pelvis on SIS, laparoscopy, or recent intrauterine pregnancy. Logistic regression was conducted in patients who ovulated with clinical pregnancy as the outcome and HSG or SIS as the key independent variable., Results: Among women who ovulated, 414 (66.9%) had tubal patency confirmed by SIS and 187 (30.2%) had at least one tube patent on HSG. Multivariable analysis indicated that choice of HSG versus SIS did not have a significant relationship on likelihood of clinical pregnancy, after adjustment for treatment arm, BMI, duration of infertility, smoking, and education (OR 1.14, 95% CI 0.77, 1.67, P = 0.52). Ectopic pregnancy occurred more often in women who had tubal patency confirmed by HSG compared to SIS (2.8% versus 0.6%, P = 0.02)., Conclusions: In this large cohort of women with PCOS, there was no significant difference in clinical pregnancy rate between women who had tubal patency confirmed by HSG versus SIS. SIS is an acceptable imaging modality for assessment of tubal patency in this population.

This study aimed to ascertain if atropine is useful for suppressing the pain suffered during four-dimensional hysterosalpingo-contrast sonography (4D-HyCoSy) when assessing infertility in women. A total of 252 patients were divided into 2 groups to receive or not receive atropine (0.5 mg) injection 30 minutes before 4D-HyCoSy. Pain was evaluated using a numerical rating scale (NRS): during 4D-HyCoSy; upon 2-dimensional transvaginal sonography; before catheter insertion; upon insertion and fixation of the catheter into the uterine cavity; 30 minutes after 4D-HyCoSy. According to the degree of patency of Fallopian tubes, the 6 patterns observed were integrated further into 3 patient groups: all-negative (both Fallopian tubes were negative), positive-and-negative (one Fallopian tube showed patency and the other showed stenosis or non-patency), and all-positive (both Fallopian tubes showed stenosis or non-patency). We compared the NRS scores and prevalence of side-effects other than pain between the atropine-injection and non-atropine-injection groups within the three groups mentioned above. The NRS score showed no significant differences among the groups at any time point (all P > .05). The different prevalence of side-effects other than pain was significant between the atropine-injection and atropine-non-injection groups (P = .012). These data suggest that atropine does not reduce pain in patients during 4D-HyCoSy. However, atropine may reduce the prevalence of other side-effects during 4D-HyCoSy, which needs a further, large, prospective, multi-cohort study to verify., (© 2018 John Wiley & Sons Australia, Ltd.)

Objectives: To explore the risk factors on contrast agent venous intravasation during transvaginal 4-dimensional hysterosalpingo-contrast sonography (TVS 4D-HyCoSy)., Methods: The TVS 4D-HyCoSy imaging data were collected from 276 female infertile patients. The correlation between endometrial thickness, days after menstruation, intrauterine intervention history, fallopian tubal patency degree, and contrast agent venous intravasation, respectively, was analyzed., Results: In our study, the incidence of contrast agent venous intravasation was 13.04%. Endometrial thickness and days after menstruation were significantly associated with venous intravasation (P < .05). However, there was no significance for intrauterine intervention history and fallopian tube patency degree., Conclusions: Contrast agent intravasation during TVS 4D-HyCoSy is not infrequent. Performing TVS 4D-HyCoSy according to endometrial thickness and menstrual period could reduce intravasation incidence to some extent., (© 2018 by the American Institute of Ultrasound in Medicine.)

Objective: Our objective was to explore whether the pregnancy rate (PR) was higher than usual after hysterosalpingo-contrast sonography (HyCoSy)., Methods: We conducted a prospective observational study of 1,008 infertility patients, all of whom were examined by HyCoSy. The expected time for spontaneous pregnancy was at least 180 days after the HyCoSy exams. There were three types of HyCoSy results: type I, defined as both fallopian tubes patent; type II, defined as one fallopian tube patent with obstruction in the other; and type III, defined as both fallopian tubes obstructed. During the HyCoSy examinations, we recorded the mobility of the ovaries, injective resistance, and contrast agent venous intravasation. Before the examinations, we recorded each patient's medical history, including maternal age, infertility type, median duration of menstrual cycle, dysmenorrhea, and parity number., Results: The PR was 19.44% within 180 days after HyCoSy and it was significantly higher in the first 30 days (6.35%) ( P <.01). The PR of type I was highest, with a rate of 32.01%, followed by the PR of type II (25.51%) and type III (15.04%) ( P <.01). Univariate analysis showed that younger age, patency of both fallopian tubes, good ovarian mobility, and absence of injective resistance were positively related to the initiation of pregnancy ( P <.01). Infertility type, median duration of menstrual cycle, dysmenorrhea, parity number, contrast agent venous intravasation, and identity of the sonographer were unrelated to pregnancy ( P >.05). However, multivariate analysis showed that patency of both fallopian tubes and the absence of injective resistance were independently associated with pregnancy., Conclusion: Some infertility patients conceived successfully and naturally not long after HyCoSy, most often in the first month after the examination. Multivariate analysis showed that patency of both fallopian tubes and the absence of injective resistance were independently factors associated with the ability to conceive after HyCoSy examination.

Objectives: Hysterosalpingo-foam sonography (HyFoSy) has been suggested to be a possible less invasive alternative to hysterosalpingography (HSG), which is the reference standard for confirmation of tubal occlusion after Essure (Bayer AG, Leverkusen, Germany) hysteroscopic sterilization. The purpose of our study was to evaluate the accuracy of HyFoSy compared to HSG for confirmation of tubal occlusion after Essure hysteroscopic sterilization., Methods: A prospective study included 90 patients who underwent Essure hysteroscopic sterilization. Twelve weeks after the sterilization, 2-dimensional transvaginal ultrasonography was performed to assess the microinsert position and was followed by HyFoSy and HSG for evaluation of tubal occlusion. Patients with patent fallopian tubes on HSG were scheduled for additional HSG procedures at 3-month intervals until tubal occlusion was documented., Results: Of 90 enrolled patients, 86 patients with 170 fallopian tubes underwent the complete imaging protocol. Tubal occlusion was evaluated by HyFoSy as an index test and HSG as a reference standard. The accuracy of HyFoSy was 97.1% (95% confidence interval [CI], 93%-99%). The sensitivity and specificity were 100% (95% CI, 97%-100%) and 54.6% (95% CI, 23%-83%), whereas the positive and negative predictive values were 97.0% (95% CI, 93%-99%) and 100% (95% CI, 42%-100%), respectively. No long-term complications were reported for HyFoSy or HSG., Conclusions: Given that the concordance rate for tubal occlusion between HyFoSy and HSG was not 100%, an occluded fallopian tube on HyFoSy should be confirmed by HSG, which remains the reference standard for confirmation of tubal occlusion after Essure hysteroscopic sterilization., (© 2018 by the American Institute of Ultrasound in Medicine.)

Study Objective: To assess if follow-up confirmation testing 3 months after hysteroscopic sterilization with the Essure device (Bayer HealthCare Pharmaceuticals, Inc., Whippany, NJ) improved with recommendation for transvaginal ultrasound (TVUS) versus hysterosalpingogram (HSG)., Design: Retrospective, observational case-controlled cohort study (Canadian Task Force classification II-2)., Setting: Two-physician private practice in Evansville, Indiana., Patients: Compliance rates for a TVUS confirmation test on 100 women who underwent hysteroscopic sterilization compared with a previously published cohort of 1004 women who were scheduled to undergo an HSG confirmation test., Intervention: Acquisition of 3-month confirmation testing after Essure hysteroscopic sterilization., Measurement and Main Results: All women who underwent Essure hysteroscopic sterilization with recommendation for TVUS confirmation testing between July 2015 and January 2017 were compared with a previously published cohort of 1004 patients with recommendation for HSG confirmation testing (HSG cohort). In addition, an HSG subgroup cohort (HSG subgroup) similar in size and closest chronology to the TVUS cohort was drawn from the original 1004 patients and analyzed for HSG follow-up. Records for all patients were reviewed for demographic, procedural, and confirmation testing and outcome data. One hundred patients were identified with successful Essure device placement and a recommendation for TVUS confirmation testing. Eighty-eight patients (88.0%) returned for TVUS at 3 months. In the HSG cohort 1004 successful Essure devices were placed, and 778 patients returned for the recommended HSG follow-up (77.5%). There was a significantly higher follow-up rate for TVUS compared with the HSG cohort (88.0% vs 77.5%, p = .008). In the HSG subgroup 184 patients were identified, and 133 patients presented for HSG follow-up (72.3%), indicating a significantly higher follow-up rate in the TVUS cohort (88.0% vs 72.3%, p = .001). No pregnancies after any confirmation testing were noted., Conclusion: Confirmation testing with TVUS rather than HSG 3 months after Essure device placement results in increased patient compliance that may lead to improved patient outcomes with reduction of unintended pregnancy., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Objectives: The purpose of the study was to assess the accuracy of hysterosalpingo-contrast sonography (HyCoSy) for evaluation of the uterine cavity., Methods: Hysterosalpingo-contrast sonography was compared with hysteroscopy for assessment of the uterine cavity. This work was a descriptive prospective study to assess the concordance between pathologic intrauterine findings using the Cohen κ coefficient. Ninety infertile patients from Puerta de Hierro University Hospital were included in the study. They underwent HyCoSy between June 2016 and April 2017. Fifteen of them had pathologic findings in the uterine cavity during HyCoSy and therefore underwent hysteroscopy. Clinical and sonographic findings were compared in those 15 patients by to evaluate the agreement between both techniques., Results: In this study, intrauterine sonographic findings on HyCoSy and hysteroscopic features of the uterine cavity reached 100% concordance, with a κ coefficient of 1.000 and a 100% agreement rate., Conclusions: Hysterosalpingo-contrast sonography permits a very accurate evaluation of the uterine cavity, which could be of interest for infertile patients who might be examined for tubal patency., (© 2017 by the American Institute of Ultrasound in Medicine.)

Background: Tubal pathology is a causative factor in 20% of subfertile couples. Traditionally, tubal testing during fertility work-up is performed by hysterosalpingography (HSG). Hysterosalpingo-foam sonography (HyFoSy) is a new technique that is thought to have comparable accuracy as HSG, while it is less expensive and more patient friendly. HyFoSy would be an acceptable alternative for HSG, provided it has similar effectiveness in terms of patient outcomes., Methods/design: We aim to compare the effectiveness and costs of management guided by HyFoSy or by HSG. Consenting women will undergo tubal testing by both HyFoSy and HSG in a randomized order during fertility work-up. The study group will consist of 1163 subfertile women between 18 and 41 years old who are scheduled for tubal patency testing during their fertility work-up. Women with anovulatory cycles not responding to ovulation induction, endometriosis, severe male subfertility or a known contrast (iodine) allergy will be excluded. We anticipate that 7 % (N = 82) of the participants will have discordant test results for HyFoSy and HSG. These participants will be randomly allocated to either a management strategy based on HyFoSy or a management strategy based on HSG, resulting in either a diagnostic laparoscopy with chromopertubation or a strategy that assumes tubal patency (intrauterine insemination or expectant management). The primary outcome is ongoing pregnancy leading to live birth within 12 months after randomization. Secondary outcomes are patient pain scores, time to pregnancy, clinical pregnancy, miscarriage rate, multiple pregnancy rate, preterm birth rate and number of additional treatments. Costs will be estimated by counting resource use and calculating unit prices., Discussion: This trial will compare the effectiveness and costs of HyFoSy versus HSG in assessing tubal patency in subfertile women., Trial Registration: Dutch Trial Register (NTR 4746, http://www.trialregister.nl ). Date of registration: 19 August 2014.

Background: The aim of this study was to compare 2D and 3D-sonohysterosalpingography (2D-3D-HyFoSy) with previous diagnostic laparoscopy in the diagnosis of tubal patency, and compare each procedure in terms of procedure's time, perceived pain and complication rate., Methods: We prospectively recruited infertile women, previously submitted to laparoscopy and randomly allocated into 2D-HyFoSy (group I) and 3D-HyFoSy (group II). We analyzed the results in term of sensitivity, specificity, positive predictive value and negative predictive value in tubal patency evaluation of both procedures in comparison with laparoscopy., Results: We enrolled 50 women, 25 in group I and 25 in group II. 2D-HyFoSy findings obtained in group I, were concordant with laparoscopy in 81% of cases, with a sensitivity of 80% and a specificity of 92%. In group II, a correspondence was present in 88% of examinations, with a sensitivity and specificity of 98% and 91.4% respectively. 3D-HyFoSy was found to be faster and less painful than 2D (P<0.001)., Conclusions: In the diagnosis of tubal occlusion, in the high-risk population, it seems advisable to us using the 3D-HyFoSy as the first-level examination, while, in low-risk patients, if the tubes appear obstructed in 2D-HyFoSy, the 3D-HyFoSy should be indicated before submitting patients to operative laparoscopy.

Objective: To evaluate, in patients who underwent Fallopian-tube sterilization by hysteroscopic insertion of an Essure® device, the feasibility and accuracy of three-dimensional (3D) transvaginal sonography (TVS) to check the position of the device and 3D hysterosalpingo-foam sonography (3D-HyFoSy) using contrast-enhanced gel foam to assess consequent tubal occlusion., Methods: This was a prospective multicenter study conducted from June 2012 to July 2014 in four Italian centers, which included 50 women who underwent hysteroscopic Essure microinsert placement in a total of 95 Fallopian tubes. Placement of the microinserts was performed in an outpatient setting following standard procedure recommendations. All patients underwent transvaginal 3D-HyFoSy and hysterosalpingography (HSG) approximately 12-14 weeks after the procedure. The position of the devices was first checked on 3D-TVS and classified according to specific criteria (Positions A, B, C and D). Then, 3D-HyFoSy with ExEm® gel foam as the ultrasound contrast agent was performed to confirm tubal occlusion by the absence of contrast agent within the tubes and/or around the ovaries. To evaluate the feasibility of 3D-HyFoSy, consecutive volume acquisitions were performed while injecting the gel foam. After sonographic evaluation, women underwent HSG to assess the success of sterilization, as standard methodology. Side effects and pain evoked during and after 3D-HyFoSy and HSG were evaluated using a numeric pain rating scale., Results: On 3D-TVS, 10 devices (10.5%) were in Position A, two (2.1%) in Position B, 59 (62.1%) in Position C and 24 (25.3%) in Position D. During 3D-HyFoSy, tubal occlusion was observed in 89 of 95 tubes (93.7%). In the six cases in which the passage of the contrast was observed, one device (16.7%) was in Position B, one device (16.7%) in Position D and four devices (66.7%) were found to lie in Position C. Tubal patency was confirmed at HSG with a concordance rate of 100%. The mean pain score associated with 3D-HyFoSy was significantly lower than that on HSG., Conclusions: 3D-TVS with HyFoSy allows accurate assessment of the position of Essure microinserts and tubal occlusion. It can be considered a safe, reliable, non-invasive alternative to HSG. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.)

Study Objective: To evaluate the algorithm of transvaginal ultrasound (TVU) and/or modified hysterosalpingogram (HSG) confirmation testing 3 months after Essure placement to determine if women can rely on the device for permanent birth control., Design: Interim analysis of an ongoing 10-year, prospective, multicenter, nonrandomized, single-arm, international trial (Canadian Task Force classification II-2)., Setting: Twenty study centers in the United States (n = 12), Canada (n = 1), The Netherlands (n = 6), and Spain (n = 1)., Patients: Women undergoing the Essure procedure for permanent birth control., Interventions: Based on the algorithm for confirmation testing, women with an uncomplicated Essure procedure underwent TVU as the confirmation test; modified HSG was used for women ineligible for TVU, when TVU findings were abnormal or inconclusive, or based on the physician's discretion., Measurements and Main Results: Co-primary endpoints (intention-to-treat [ITT] population) were the reliance rate and the 1-year pregnancy rate. Safety evaluation was based on adverse events. Bilateral insert placement was attempted in 597 women (ITT population) and achieved in 582 of 597 (97.5%). A total of 547 women were told to rely on Essure for permanent birth control. Both co-primary endpoints met prespecified limits: based on Bayesian statistics, the reliance rate was 91.6% (547/597; 95% credible interval, 89.2%-93.6%) and the 1-year pregnancy rate .67% (95% credible interval, .16%-1.53%). Using the algorithm for confirmation testing, of 547 subjects told to rely on Essure, 470 (86%) underwent TVU alone, 30 (6%) had modified HSG alone, and 47 (9%) had TVU followed by modified HSG. Four women became pregnant after being told to rely on Essure. They all had confirmation testing with TVU alone, and each initially read incorrectly as optimal insert locations. In each case postpregnancy follow-up and root cause analysis revealed unsatisfactory insert locations, 2 of which were perforations. Most adverse events were mild and unrelated to Essure., Conclusion: The algorithm of TVU and/or modified HSG confirmation testing 3 months after Essure placement can determine that a woman can rely on the device for permanent birth control. The adverse events observed are consistent with the known safety profile of Essure. (clinicaltrials.gov: NCT01327105.)., (Copyright © 2017 American Association of Gynecologic Laparoscopists. All rights reserved.)

Objectives: The purpose of this study was to evaluate the performance of 4-dimensional (4D) hysterosalpingo-contrast sonography (HyCoSy) for assessing fallopian tube fimbria patency in infertile women., Methods: Seventy-seven infertile female patients with obstruction at the tubal fimbria or partial obstruction with pelvic adhesions were included. All of the patients underwent 4D HyCoSy enhanced by dynamic observation after a flush of normal saline and were followed with laparoscopic chromopertubation using methylene blue within 6 months., Results: The overall accordance between 4D HyCoSy and laparoscopic chromopertubation was 92.9%. The sensitivity and specificity of 4D HyCoSy with laparoscopic chromopertubation as a reference standard were 93.8% and 92.2%, respectively., Conclusions: Four-dimensional HyCoSy can be the preferred method for assessment of tubal fimbria patency and pelvic adhesions surrounding the ovaries, with its advantages of accuracy, noninvasiveness, and a good safety profile., (© 2017 by the American Institute of Ultrasound in Medicine.)

Rationale: Hysterosalpingography is still the main method to begin with when studying the causes of female impossibility to conceive a baby., Objective: The aim of this study is to correlate and evaluate the wide range of tubal pathology discovered by routine hysterosalpingography in a university hospital in Romania with the successful pregnancy rate., Methods and Results: A total of 95 consecutive patients explored by routine hysterosalpingography in a university hospital during 2015 and 2016 were included. Out of 173 fallopian tubes studied, 28.9% were occluded, 13.29% were almost occluded, and only 57.8% were patent. Of these patients, 11 successful pregnancies occurred in 95 women (11.57%) until September 2017. A number of 7 patients delivered a normal baby in our hospital (7.36%). One patient was admitted at 36 weeks of gestation, and another one at 26 weeks of gestation, for risk of premature delivery. None of these two patients delivered in our hospital. Two patients were admitted for miscarriage at 8 weeks and 5 weeks of pregnancy. In all the 7 patients who delivered a normal baby, the fallopian tubes were entirely visible (100%), whether they were patent or not., Discussion: To our knowledge, this is the largest study about hysterosalpingography and the successful pregnancy rate in Romania so far., Abbreviations: ART= Assisted reproductive technologies.

Background Hysterosalpingram (HSG) evaluation of tubal patency is typically performed in the follicular phase, but data to support this timing are lacking. Purpose To determine whether menstrual cycle phase or hormonal treatments affect observation of tubal patency during HSG. Material and Methods Ten participants underwent repeated HSG examinations: during the follicular and luteal phase of a natural menstrual cycle; 30 days following continuous administration of a combined oral contraceptive (COC); and 30 days after an intramuscular injection of depo medroxyprogesterone (DMPA) acetate. Participants with tubal blockade following DMPA had a fifth HSG 30 days following a second course of COCs. The primary outcome was tubal patency. Results All 10 participants demonstrated bilateral tubal patency (BTP) on at least one HSG examination during the study. One participant showed bilateral functional occlusion (FO) during the follicular phase examination, but BTP with the luteal phase, COC cycle, and DMPA exams. One participant with BTP discontinued participation and nine completed the COC HSG exam with BTP in seven, and one each with bilateral or unilateral FO. Seven participants completed the DMPA HSG with BTP in six and unilateral FO in one; BTP was seen in the final HSG after restarting the COC. Conclusion This pilot study supports the luteal phase of natural cycles as the optimum time for evaluation of tubal patency. The occurrence of functional occlusion of the fallopian tube on HSG examination performed during the follicular phase and following contraceptive steroid treatment supports a role of hormonal action on the utero-tubal junction.

Objectives: To investigate the feasibility of hysterosalpingo foam sonography (HyFoSy) with automated 3-dimensional (3D) software in the evaluation of tubal patency and visualization of the tubal course by obtaining a 3D volume acquisition of tubes., Design: Prospective observational study (Canadian Task Force classification III)., Setting: University hospital., Patients: A total of 132 infertile females evaluated between October 2013 and February 2015., Interventions: All patients underwent HyFoSy with the new automated 3D coded contrast imaging (CCI) followed by 2-dimensional (2D) real-time HyFoSy. To evaluate the feasibility of 3D visualization of the tubal course, consecutive volume acquisitions were performed during gel foam contrast agent injection. Conventional 2D real-time hysterosalpingo contrast sonography (HyCoSy) by detection of gel foam moving through the tubes and around the ovaries was finally performed and considered to indicate the final results of tubal status., Measurements and Main Results: All the patients underwent 3D CCI HyFoSy, followed by 2D real-time HyFoSy. After both procedures, we observed 108 patients (81.8%) with bilateral tubal patency, 22 patients (16.6%) with unilateral tubal patency, and 2 patients (1.5%) with bilateral tubal occlusion. The concordance rate for tubal status between the first and second 3D volume acquisitions and the final 2D real-time evaluation was 84.8% and 97.0%, respectively., Conclusions: Transvaginal ultrasound HyFoSy with 3D volume reconstruction of the uterus and tubes is an accurate and safe technique that allows complete visualization of tubal shape and patency with high patient compliance., (Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To determine the pain intensity and incidence of mild to severe pain during the ultrasound assessment of the uterine cavity and tubal patency using saline, air and saline, and foam as contrasts with and without painkiller., Design: Prospective observational study (Canadian Task Force classification II-1)., Setting: Private clinic., Patients: Three hundred infertile women who were consecutively submitted to uterine cavity and tubal patency assessment by ultrasound using saline, air, and foam in single exam between October 2012 and November 2013., Interventions: No painkillers were used until March 2013 when we started offering an effervescent codeine tablet containing paracetamol 500 mg and codeine phosphate 30 mg approximately 1 hour before the procedure., Measurements and Main Results: Pain intensity measured with an 11-point (0-10) numerical rating scale and incidence of moderate/severe levels of pain (numerical rating scale > 3) during the main components of the procedure (speculum insertion, catheter insertion, saline infusion, air and saline infusion, foam infusion, and after the procedure [0 minutes, 15 minutes, 30 minutes, and 24 hours]) were assessed. The incidence of moderatesevere pain was significantly lower in women using painkillers considering any moment of the procedure: 49 of 175 (28%) versus 65 of 125 (52%); relative risk, .54; 95% confidence interval, .40-.72; p < .001; number needed to treat, 4. Less women presented with moderate/severe pain during air and saline compared with foam infusion: 31 of 300 (10%) versus 75 of 300 (25%); p < .001; relative risk, .41, 95% confidence interval, .28-.61., Conclusion: The incidence of moderate/severe pain during the ultrasound assessment of the uterine cavity and tubal patency is common. Our results suggest that using paracetamol + codeine before the procedure reduces the pain level, but randomized controlled trials are required., (Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.)

Objectives: To apply the three-dimensional (3D) hysterosalpingo-contrast sonography (HyCoSy) with perfluoropropane-albumin microspheres as contrast agents and normal saline injections into the pelvic cavity for assessment of the tubal patency and adhesions of fimbrial parts., Methods: Fifty-five infertile female patients were recruited to undergo 3D HyCoSy with normal saline injected into the pelvic cavity, in which the tubal patency was observed by visualizing the spillage of contrast agents from the fimbriae, and the fimbrial adhesion was confirmed by the finger-like projections of the fimbriae and their floating and moving status., Results: Of the 55 patients, bilateral tubal patency was observed in 44 (80.0%), unilateral tubal patency and the other partial occlusion in 7 (12.7%), unilateral partial occlusion and the other complete occlusion in 3 (5.4%), and bilateral complete occlusion in 1 (1.8%). The fimbrial parts were observed in 105 fallopian tubes, among which 101 were seen with the finger-like fimbriae floated and moved in the pelvic cavity, whereas 4 tubes were not because of adhesion to the pelvic cavity (n = 3) or the ovary and intestine (n = 1). More than three visible, quite long, and distributed evenly finger-like projections were present for the patent fimbrial parts; however, fewer, flat, and not evenly distributed finger-like projections were present for the adhesive tubes. No serious complications occurred during or after this procedure., Conclusions: Combination of 3D HyCoSy with normal saline injected into the pelvic cavity may be a feasible and safe procedure to assess tubal patency and adhesions of the fimbrial parts., (© 2017 by the American Institute of Ultrasound in Medicine.)

Study Question: What is the diagnostic accuracy of 2D/3D hysterosalpingo-foam sonography (HyFoSy) and 2D/3D-high-definition flow Doppler (HDF)-HyFoSy in comparison to laparoscopy with dye chromotubation (as the reference method) and 2D air/saline-enhanced hysterosalpingo-contrast sonography (HyCoSy) (as the initial index test)?, Summary Answer: 2D/3D-HDF-HyFoSy had the best diagnostic accuracy and was the only method that did not significantly differ from the reference method, while both 2D/3D-HyFoSy and 2D/3D-HDF-HyFoSy had significantly higher accuracy than 2D-air/saline-HyCoSy., What Is Known Already: Previous studies on X-ray hysterosalpingography and laparoscopy and dye as the reference standard have undermined the impact of older commercial contrast agents on the accuracy of ultrasound tubal patency tests. Recently, HyFoSy was reported to have very high accuracy in a small pilot study in comparison to laparoscopy and dye, and had a very high positive predictive value (PPV) for medical tubal occlusion. A new Doppler sonographic technique, known as HDF imaging with better axial resolution, fewer blooming artifacts and higher sensitivity than color and power Doppler imaging, has been introduced., Study Design, Size, Duration: A prospective observational study was performed on 132 women (259 Fallopian tubes) consecutively enrolled between 2013 and 2015., Participants/materials, Setting, Methods: This study included infertile women of reproductive age who previously had not been examined for tubal patency and who presented for the evaluation to the university hospital, private hospital and clinic at which this study was conducted. 2D-Air/saline-HyCoSy, 2D/3D-HyFoSy and 2D/3D-HDF-HyFoSy and laparoscopy were performed independently by experienced readers. During HyFoSy, the 3D mode was used for standardization of pelvic scanning and observations of contrast flow without diagnosis after volume acquisition. Sensitivity, specificity, negative and positive predictive value (NPV and PPV), negative and positive-likelihood ratio (LR- and LR+) and 95% CI were calculated. McNemar's test and relative predictive values (a comparison of NPV and PPV) were used to compare all the index tests., Main Results and the Role of Chance: 2D-Air/saline-HyCoSy, 2D/3D-HyFoSy and 2D/3D-HDF-HyFoSy indicated that 46 (17.8%), 27 (10.4%) and 24 (9.2%) of the 259 tubes were occluded, respectively; additionally, inconclusive results were obtained for 8 (3%), 5 (1.9%) and 3 (1.2%) tubes, respectively. The reference method revealed 18 (6.9%) occluded Fallopian tubes. 2D-Air/saline-HyCoSy had a high NPV (99.5%) that was similar to that of 2D/3D-HyFoSy (99%) and 2D/3D-HDF-HyFoSy (99.6%) (P > 0.05), but had a very low PPV (30.4%). The use of 2D/3D-HyFoSy, especially 2D/3D-HDF-HyFoSy, which had a significantly higher PPV (48% and 71%, P < 0.05 and P < 0.01; respectively), resulted in fewer false positive and inconclusive findings than the use of 2D-air/saline-HyCoSy. The LR- and LR+ was 0.14 and 14.8, respectively, for 2D/3D-HyFoSy, 0.06 and 32.1, respectively, for 2D/3D-HDF-HyFoSy, and 0.08 and 6.9, respectively, for 2D-air/saline-HyCoSy. The number of inconclusive or positive results per patient was significantly fewer with 2D/3D-HyFoSy (odds ratio, OR = 0.5, CI = 0.3-0.95, P < 0.05) and 2D/3D-HDF-HyFoSy (OR = 0.4, 95% CI = 0.2-0.8, P < 0.01) than with 2D-air/saline-HyCoSy., Limitations, Reasons for Caution: An unselected infertile population with a low prevalence of tubal occlusion is suitable for estimating the diagnostic accuracy of imaging tests only as a screening tool., Wider Implications of the Findings: These findings can be used to establish a diagnostic strategy with high accuracy but minimum invasiveness and limited use of contrast agents and sophisticated technology. 2D-Air/saline-HyCoSy, which has a high NPV, is suitable as an initial test and basic screening method, but 2D/3D-HDF-HyFoSy, which has a significantly higher PPV, can be used as a standard to verify any questionable or positive results obtained with 2D HyCoSy. This strategy may signficantly reduce the need for laparoscopy as a reference standard., Study Funding/competing Interest(s): There was no external funding for this study, and the authors have no conflicts of interest to declare., Trial Registration Number: N/A., (© The Author 2017. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Objective: Determination of the diagnostic capabilities of magnetic resonance imaging of the uterus and its appendages (MRHSG) on devices with the induction of the magnetic field 3 Tesla (T) as an alternative to the classic X-ray hysterosalpingography, accompanied by a significant radiation dose to the patient., Material and Methods: During the period from April 2015 to February 2016 12 MRHSG was conducted using magnetic resonance imaging apparatus Verio Magnetom 3T, Siemens company (Diagnostic Center "BarsMed", Kazan, Russia). We used neutral and not giving adverse reactions contrast agent – carbon dioxide. The pelvic organs – the uterus and fallopian tubes – represent the zone of interest., Results: Analysis of the data showed that MRHSG on the apparatus with the induction of the magnetic field of 3 T is a highly informative method in the diagnosis of tubal patency, allowing fully assess the state of the pelvic organs on the whole and identify pathology. The absence of radiation exposure and contraindications associated with intolerance to iodinated contrast agents and other side effects differs MRHSG from the traditional X-ray method and makes MRHSG to be an alternative secure method of diagnosis, which has a number of advantages described in the article., Conclusions: MRHSG on the apparatus with the induction of the magnetic field of 3 T in diagnosis of obstruction of the fallopian tubes and the visualization of the uterus and appendages diseases can be optimal and safe alternative to the X-ray hysterosalpingography, which accompanied with radiation exposure and is a number of side effects.

Background Fallopian tube and uterine abnormalities are the most common cause of female infertility, accounting for 30% of cases. Hysterosalpingography is the safe, minimal invasive radiographic technique for evaluation of uterine cavity and fallopian tubes defects. The purpose of the study was to assess the various uterine and tubal abnormalities leading to infertility Objective To assess the abnormalities in uterus and fallopian tubes detected on Hysterosalpingography (as causative factors of infertility in a tertiary care centre for proper decision making in treatment. Method This is the prospective cross sectional study done in department of radiology Dhulikhel hospital, Kathmandu University Hospital between January 2015 to January 2016 with complain of infertility. Hysterosalpingography was performed using ionic contrast medium (10-20 ml of 76% urograffin) under digital fluoroscopy. Radiographic films were obtained and analyzed. Demographic data and radiological findings were reviewed and the obtained data analyzed with SPSS version 16. Result Out of the total 100 patient, 75 had primary infertility while 25 had secondary infertility. The age ranged from 19 to 43 years with mean age of 27.75 years. Normal Hysterosalpingography findings were seen in 37% cases. Tubal abnormalities were seen in 34%, uterine abnormalities in 23% and both tubal and uterine abnormalities in 6% patients. The most common tubal abnormality detected on Hysterosalpingography was tubal block 75%. Out of the 30 patients who had tubal block, unilateral block was noted in 76.7% patients whereas bilateral block was noted in 23.3%. Hydrosalphinx was seen in 25% cases with tubal abnormality. Among the 29 cases with various uterine abnormalities, bicornuate uterus 9% was the most common abnormality Conclusion Hysterosalpingography is an easily available radiographic procedure that can demonstrate a wide variety of uterine and tubal abnormalities for the initial assessment of infertility which can avoid unnecessary and sometimes more aggressive procedures.

Aim: The aim of this study was to assess the diagnostic accuracy of hysterosalpingography (HSG) on tubal patency (TP) and to determine whether performing laparoscopy (LS) can change the original management strategy based on HSG findings., Material and Methods: Records of all infertile couples (n = 1298) treated at a university-based infertility clinic between January 2002 and June 2010 were reviewed. All patients who had both HSG and LS testing (n = 264) were included in the study. HSG was performed in an attempt to rule out tubal and/or uterine pathologies. All patients included in the study were evaluated with LS not more than 12 months after HSG., Results: The validity of HSG screening for TP was calculated as 84.1%. The positive and negative predictive values of HSG were 54.6% and 98.3%, respectively. The sensitivity of HSG was higher in patients with distal tubal occlusion than in patients with proximal tubal occlusion (69.8% [44/63] vs 46.7% [28/60], respectively; P = 0.011). The rates of management plan change in patients with bilateral TP, unilateral tubal occlusion and bilateral tubal occlusion were 2.8%, 12.2% and 32.4%, respectively (P = 0.000)., Conclusions: Patients with both unilateral tubal occlusion and bilateral tubal occlusion on HSG should be reevaluated with LS to determine the appropriate management strategy., (© 2015 Japan Society of Obstetrics and Gynecology.)

Purpose: To retrospectively compare three-dimensional ultrasonography (3D-US) and pelvic X-rays to assess the position of tubal sterilization microinserts., Material and Methods: Forty-four patients who underwent tubal sterilization with Essure(®) microinserts in our institution were included. The microinserts'position was evaluated three months after the procedure using 3D-US and pelvic X-rays. Placement on 3D-US was binary categorized as correct or incorrect and the distance between the two devices was reported. The orientation and symmetric deployment of the microinserts and the distance between the proximal parts of the two devices was assessed on pelvic X-rays. Performance of 3D-US and pelvic X-ray were compared using Mac Nemar test. Comparison of the distance between the two devices measured on pelvic X-rays and 3D-US was made with the paired Student t test., Results: 3D-US images showed microinserts in 93% (41/44). Eighty-six percent (38/44) were correctly positioned on 3D-US and 82% (36/44) on pelvic X-rays. No significant differences between the performances of the two imaging techniques were found. No significant differences for the distance between the two devices measured on pelvic X-ray and 3D-US was found., Conclusion: 3D-US is a simple, non-ionizing technique, which appears as a promising alternate technique to pelvic X-rays to assess the correct position of Essure(®) microinserts., (Copyright © 2015 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.)

Aim: Evaluation of tubal status is critical in the diagnostic work-up of infertile women. The purpose of this study was to explore the diagnostic efficacy of three-dimensional hysterosalpingo-contrast sonography (3-D HyCoSy) for tubal occlusion., Methods: MedLine, Embase, Cochrane Library, ScienceDirect, CNKI, Chinese VIP Database, Chinese Wanfang Database and Chinese Biomedicine Database were searched for relevant trials published from June 1994 to August 2013. Meta-DiSc (version 1.4) was used for the meta-analysis. Diagnostic accuracy was determined by pooled estimates of sensitivity and specificity, as well as area under the curve (AUC) and the pooled diagnostic accuracy (Q*) derived from a summary receiver operating characteristic analysis. The heterogeneity test was done using the Cochran Q statistic and the I(2) statistic. Significant difference was defined as P < 0.10 (Q-statistic) or I(2) > 50% (I(2) -statistic) and a random effect model was used to pool data, otherwise the fixed effects model was used., Results: A total of 11 studies (1037 Fallopian tubes) were included in this meta-analysis. The pooled estimates for diagnostic efficacy of 3-D HyCoSy had a sensitivity of 0.92 (95%CI: 0.89-0.94) and specificity of 0.95 (95%CI: 0.93-0.96). AUC and Q* were 0.976 and 0.929, respectively, but there was significant heterogeneity in sensitivity across the included studies., Conclusions: 3-D HyCoSy had good diagnostic performance in the detection of tubal occlusion., (© 2015 Japan Society of Obstetrics and Gynecology.)

Objective: To investigate diagnostic efficacy of transvaginal three-dimensional hysterosalpingo-contrast sonography (3D-HyCoSy) in assessing tubal patency with chromolaporoscopy., Methods: A total of 157 infertile women underwent 3D-HyCoSy to evaluate tubal patency. Among these patients, 39 patients were also examined by chromolaporoscopy. The concordance of the two clinical assessment methods was analyzed by the Kappa coefficient test., Results: Among the 306 oviducts examined by 3D-HyCoSy, 99 (32.4%) were patent, 126 (41.2%) partially obstructed, and 81 (26.5%) completely obstructed. Diagnostic results with 3D-HyCoSy were not statistically different from those obtained in the 39 women (78 oviducts) who also underwent chromolaporoscopy, and the two methods showed a high concordance (k=0.747, P=0.000). The 3D-HyCoSy procedure had a sensitivity of 84.8% (28/33), a specificity of 96.2% (25/26), and positive and negative predictive values of 93.3% (28/30) and 86.2% (25/29) respectively., Conclusion: Transvaginal 3D-HyCoSy can accurately reveal the spatial path and morphology of the oviduct and is a safe and effective method to evaluate tubal patency.

Rationale: The development of IVF techniques has diminished the importance of tubal infertility but recent discoveries shed a new light on reproductive tubal surgery prior to any IVF cycle., Objective: To adapt current state of the art recommendations concerning tubal factor infertility to actual possibilities in Romanian healthcare system and to grow the awareness of fellow fertility specialists and general practitioners to the improved outcomes of novel management and treatment modalities., Methods and Results: 67 free full text articles centered on the subject of management in tubal infertility were identified in international databases. Four articles described general diagnosis using data from medical history, 21 works approached the diagnosis through hysterosalpingography, 14 papers introduced the use of different sonographic procedures, 8 files analyzed the importance of exploratory laparoscopy and 20 articles reviewed different treatment modalities., Discussions: Current data show that active implementation of the large scale use of tubal surgery prior to any IVF cycle will reduce up to 30% the costs associated with obtaining a viable pregnancy in cases with tubal factor sterility.