156 Chapter 7 spermatozoa and embryo. Mostly unilateral tubal patency is treated the same as bilateral tubal patency, as unilateral tubal patency does not reduce pregnancy outcomes significantly (10). There are studies reporting on lower odds of pregnancy when unilateral distal tubal occlusion is detected in comparison to proximal tubal occlusion (11). This observed difference between proximal and distal tubal occlusion may result from inherent diagnostic limitations of HSG or may reflect different underlying pathologies that differentially affect pregnancy outcomes. However, proximal or distal occlusion cannot be identified by all index tests, so we will not differentiate between proximal or distal occlusion in this review. 2. Hydrosalpinx: the other condition of interest is hydrosalpinx. It refers to the distension of the Fallopian tube due to distal tubal occlusion and fluid accumulation, and the most common cause is a previous episode of pelvic inflammatory disease (12). A hydrosalpinx has a negative impact on fertility outcomes through different mechanisms. Removal or ligation of the hydrosalpinx has a positive effect on clinical pregnancy rates before assisted reproductive technology (ART) (13). Other conditions that are not the focus of this review, but can be detected during visual tubal patency tests, are endometriosis (which can be visualized during THL), peritoneal/ pelvic adhesions (sono‐HSG and THL) and intrauterine pathology (HSG and sono‐HSG). Endometriosis is seen in about 25% to 40% of women with infertility (14, 15). Pelvic adhesions, caused by previous surgery, pelvic inflammatory disease or endometriosis, may interfere with ovum pickup if they are distorting the anatomy of the ovary and Fallopian tube. Intrauterine pathology as myomas, polyps or intrauterine adhesions, as well as congenital uterine anomalies, can be detected by some of the visual tubal tests. These intracavitary conditions might all have some effect on fertility outcomes (8, 16). Index test(s) We will consider the following four main groups of index tests. 1. Hysterosalpingography (HSG): this uses serial X‐ray or fluoroscopy images during injection of an iodine‐containing contrast medium through the cervical canal into the uterus and subsequently the Fallopian tubes. Different instruments, such as a reusable metal cannula (hysterophore or Jarcho cannula), a 5‐French balloon catheter or a (modified) cervical vacuum cup device, as well as different iodine‐containing contrast media, oil‐based or water‐based, can be used. HSG is contraindicated in women with an allergy to iodine‐containing contrast media. HSG is a safe and widely accepted procedure in the outpatient setting, but it needs to be performed in a radiology department. HSG is well‐tolerated, although more painful
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