157 Cochrane study protocol: Accuracy of tubal patency tests 7 than sono‐HSG (17) or THL (18). In addition to its advantage of evaluating the uterine cavity and tubal patency, it has a potential therapeutic effect when an oil‐soluble contrast medium is used, with a higher chance of clinical pregnancy and live birth rates (19). Choice of contrast medium, operator skill and the observer interpreting the HSG are likely to be potential sources of heterogeneity (20). 2. Sono‐hysterosalpingography (sono‐HSG): this includes both hysterosalpingo‐foam sonography (HyFoSy) and hysterosalpingo‐contrast sonography (HyCoSy). Overall, this test is based on ultrasound, in which an echogenic medium is used to assess the uterine cavity and tubal patency. Many different sono‐HSG techniques are performed, with differences in two‐ or three‐dimensional ultrasound modality; vaginal or abdominal ultrasound; contrast type (commercially available foam as well as normal saline, saline and air or galactose, or combinations of these); or the usage of colour doppler sonography (21). The advantages of these tests are that they can be performed in an outpatient setting without a radiology department (offering the possibility of a one‐stop fertility evaluation), and are generally well tolerated (17). Furthermore, when compared to HSG, the procedure does not require exposure to radiation or iodine‐containing contrast media (22). In addition to tubal patency, the uterine cavity and myometrium, as well as both ovaries, can be assessed during the procedure (23). It is likely that choice of contrast, operator skill and test technology influence the diagnostic quality. 3. Magnetic resonance hysterosalpingography (MR‐HSG): this is similar to HSG. It uses MR‐imaging instead of X‐ray or fluoroscopy, and the contrast medium is a gadolinium‐based solution, available from different manufactures and prepared in different ways (24). Similar to HSG, the procedure can be performed in an outpatient setting when a radiology department is available, and it is well tolerated (25, 26). It also avoids exposure to radiation and iodine‐containing contrast media, and can be used to diagnose (deeply infiltrating) endometriosis, uterine and ovarian anomalies. In comparison to sono‐HSG, the advantage of MR‐HSG is that is not operator dependent, with a better reproducibility (24, 26). 4. Transvaginal hydrolaparoscopy (THL): also known as transvaginal endoscopy or fertiloscopy, this technique uses hydroflotation for exploration of the pelvic cavity. A small diameter optic is inserted transvaginally through an incision in the vaginal posterior fornix, after the pelvis is filled with warm normal saline for pelvic cavity distention. By using a dye, mostly methylene blue, tubal patency can be tested (27). Different instruments, disposable or reusable, can be used for THL (28). THL is a known, safe and well‐tolerated procedure, which can be performed in an
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