HSG is one of the basic tool for infertility diagnosis and was performed in all of our cases. Fertility rates were found to be significantly higher particularly at secondary infertility cases whom liposoluble contrast media were used. Our findings were consistent with the literature
8-11. Since removal of speculum is needed in order to evaluate the dimensions of cervix at the time of x-ray exposure, we preferred Collins speculum which provides enough information about the cervix measurements (length, width). Cervical insufficiency, constriction and tuberculosis that is still important in developing countries, are the situations in which length of cervix should be known. In our cases right after the end of menses, Doxycycline 2x100 mg/day was administered before HSG and used for 5 days
14. No infection was noted. In a standard HSG set, parasympatholytic, anticonvulsant, antihistaminic drugs are mandatory. Because all interventions via the cervical canal (D/C, HSG, RIA implantation etc) might lead to life-threatening complications as vasovagal reflex, or convulsion
15. Because the highest conception rate is observed within the first four months after HSG procedure so we prefer to wait for 3 months after HSG and before any ovulation induction and insemination
16. Despite the use of antispasmolitic agent, it was of note that one case in whom bilateral tubal passage was absent and therefore excluded from the study, presented with pregnancy one month later; no corresponding publishment was available in the literature. Rasmussen et al
11 found out the most unsuccessful cases as being the bilateral occlusion cases, as opposed to the single tubal disease cases in which the fertility rates were similar. We had no complication before and after HSG procedure. Particularly the emboli result from liposoluble contrast media may be life-threatening, So, careful evaluations must be done for diabetes mellitus, hydrosalpynx, intrauterine adhesion or endometrial damage
17. During HSG with Lipiodol, the initial dose should be administered and monitored under fluoroscopy, if intravasation, hydrosalpynx, and Asherman.
Syndrome suspected procedure should be stopped in order to prevent the emboli risk. Furthermore De Cherney et al 9 reported that fertility was accounted 30% of the primary and 56% of the secondary infertile cases, with a total of 40% who underwent HSG investigation with liposoluble agents whereas these ratios were noted 5%, 0%, and 2.6% with water soluble agents. Schawabe et al 8 found 78% fertility in Lipiodol administered cases and 10% in Urovizyon group these findings were consistent with ours. Watson et al declared in their meta analysis that in randomized clinical studies, particularly with unexplained infertilities, liposoluble contrast agents increased the fertility rates as obtained in our study 18. Many speculations have taken place about the causative factors responsible of the increase in fertility. The concentration of macrophages and lymphocytes in peritoneal fluid have found to be increased in unexplained infertility and endometriosis cases 19,20. Boyer et al 21 was the first who claimed that peritoneal macrophages were inhibited in vitro by use of ethiodol. Johnson et al 22 found 1/100 sinographine ineffective on inhibiting the fagocytosis function of macrophages as opposed to ethiodol at the same doses. The decrease in the number and function of peritoneal macrophages/lymphocytes decreases the concentration of reproductive toxic cytokines in peritoneal environment, which in turn contributes to the favorable circumstances for conception and fertility 23. Mechanical effects are accounted as removal of the mucous plaques (11) and adhesions 11,23, promoting the tubal ciliary activity 11,23, and anti infectious effect 11. On the other hand, Alper et al 12 found similar effects of oil and aqueous agents on fertility. However it is of note that he performed this investigation over the entire infertile cases. Referring to Schwabe et al’s study 8, similar pregnancy rates were encountered in the rest of infertility cases sparing the unexplained group. The similar results were also valid in the De Cherney et al’s study 9 but the lipiodol, which was also efficacious in the male factors. Spring et al 13 also found similar rates for male factors. We believe that De Cherney et al’s report was more reliable hypothetically. Because liposoluble media decrease the amount of oxygen radicals, macrophages and lymphocytes in peritoneal fluid which also decrease sperm fagocytosis and contribute to a better environment for conception. Liposoluble media stay in place much longer in the obstructed fallopian tubes or peritoneal cavity 24. In our one case Lipiodol visualised seven days after HSG in Douglas pouche. All of our findings were consistent with the literature. Spring et al 13 reported no differences between the effects of liposoluble and water soluble media on fertility. This is not like our results we think that this difference resulted from study group that is composed of all infertility types. We study only the unexplained infertility cases.
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