10 Chapter 1 absorb carbon dioxide), and expected this gas to escape through the Fallopian tubes in case of patency, inducing a pneumoperitoneum. There are several ways to detect this pneumoperitoneum: the gas gives a painful sensation to the shoulder as it irritates the peritoneal cavity, it is often audible by percussion or auscultation of the thorax and it is visible on X-ray. If the gas inflow showed initial high resistance which then decreased, this also confirmed that at least one of the Fallopian tubes was deemed patent (15). This test was not able to differentiate between unilateral or bilateral tubal patency and caused significant discomfort, and therefore other tubal patency tests were developed. At the same time, surgical techniques developed greatly across the 20th century. Initially, laparotomic surgery was the only modality available. Laparotomic surgery comes with a high risk of complications, a long recovery time and it can induce intra-abdominal adhesions at the surgical site. Intra-abdominal adhesions are a known risk factor for tubal infertility and should be prevented where possible. The first laparoscopic surgery in humans was performed in 1910 by the Swedish physician Hans Christian Jacobaeus. The technique has only been used for evaluation of tubal patency since the mid 1980’s when chromopertubation was introduced. During chromopertubation, a methylene blue is inserted into the uterine cavity transvaginally and flow of this dye from the Fallopian tubes into the peritoneal cavity can be visualized directly. Laparoscopy is still considered as the gold standard test for evaluation of tubal patency (16). However, laparoscopy is also invasive and requires full anaesthesia. It is therefore usually reserved for women in whom tubal pathology is suspected by less invasive tubal patency tests, or for women in whom an immediate therapeutic intervention during laparoscopy is desired, for instance in case of endometriosis and/or adhesions. As an outpatient alternative to laparoscopy, transvaginal hydrolaparoscopy, also referred to as fertiloscopy, has been introduced, which consists of a transvaginal hydropelviscopy performed under local anaesthesia (17). This approach allows a complete exploration of the pelvis except for the visualization of the vesico-uterine pouch. Apart from tubal patency testing, it allows direct visualization of the tubal mucosa as salpingoscopy is feasible from the vaginal approach, ovarian drilling and limited adhaesiolysis or electrocoagulation of peritoneal endometriosis. HSG The first visual tubal patency test, hysterosalpingography (HSG), was performed by Rindfleisch in 1910. During HSG, a radiopaque contrast fluid is injected into the uterus transvaginally. Once the uterus and Fallopian tubes fill with contrast, this can be visualized on X-ray images. Using a suspension of bismuth, a non-toxic heavy metal as a contrast medium, his aim was to outline the uterine cavity in order to detect abnormalities of the
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