15 General introduction 1 During HyFoSy, a foamy contrast liquid is inserted into the uterus transvaginally while at the same time a transvaginal ultrasound is made. The contrast contains air bubbles that give an echogenic reflection on the ultrasound monitor. As the contrast enters the genital tract, the shape of the uterine cavity and Fallopian tubes will be delineated and tubal patency can be established. This diagnostic procedure can be conducted by a gynaecologist, fertility doctor, nurse or sonographist and does not require radiation or the use of iodinated contrast A recent large multicentre RCT, the FOAM study, compared management based on the results of HyFoSy with management based on the results of HSG (42). The study concluded that management based on the results of the HyFoSy result in an equal number of pregnancies as management based on the results of HSG (difference -1.2%; 95% CI: -3.4% to 1.5%). Due to the design of the study, the therapeutic effect of the individually used tests could not be evaluated as all participants underwent both HyFoSy and HSG in a randomized order. The mean pain score, a secondary outcome of this study, was significantly lower for HyFoSy than for HSG (3.1 standard deviation 2.2) for HyFoSy and 5.4 (standard deviation 2.5) for HSG (p<0.001) which is in line with previous research reporting low pain scores during HyFoSy (43). TREATMENT OF INFERTILITY Depending on the results of the fertility work-up, and taking into account prognostic factors for conception, a treatment plan will be determined as can be seen in Figure 1 on the right hand side. There is a large variability in treatment options and strategies between different countries and regions. While in some countries a prognostic model such as the Hunault model is used (44), other countries rely on female age or duration of infertility alone in the decision to go for expectant management or start fertility treatment. Prognostic models have been developed to guide physicians in determining the best treatment strategy for the individual couple aiming to prevent overtreatment. The prognostic model of Hunault (44) takes into account female age, duration of infertility, referral status, whether the woman is facing primary or secondary infertility and the motility of the male partners semen. The algorithm then calculates the chance of natural conception within 12 months based on the given parameters. A prognosis of ≥30% chance of natural conception within 12 months will guide physicians to counsel patients for expectant management for a period of 6-12 months (45).
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