17 General introduction 1 whether the fertility enhancing effect is also present in other subgroups of infertile women. Furthermore we want to compare the diagnostic quality of the HSG with more contemporary tubal patency tests and examine an innovative method for pain reduction during HSG. As the recent COVID-19 pandemic had an profound global effect on elective health care, we wanted to investigate the psychological impact of the COVID-19 pandemic on women facing infertility. OUTLINE In Chapter 2, we start with an investigation into the duration of the fertility enhancing effect of tubal flushing with oil-based contrast in women with idiopathic infertility. With this secondary analysis of the H2Oil study and it’s follow-up study, we aim to gain more insight in the mechanism of action of the fertility enhancing effect of oil-based contrast. In this chapter, we will answer the question: Does the fertility-enhancing effect of tubal flushing during HSG change over time? The H2Oil study excluded three important subgroups of women: women of advanced age (39 years of age or over), women with an increased risk for tubal pathology based on their medical history and women with ovulation disorders. In chapter 3 we present the H2Oil2 study, an ongoing international randomized controlled trial in which we study these three groups that were excluded from the H2Oil study. The research question is: What is the effectiveness and cost-effectiveness of the use of oil-based versus waterbased contrast medium during HSG in terms of live birth in women who are 39 years or older, women wo have a high risk for tubal pathology or who have an ovulation disorder? The results of this study together with its cost-effectiveness analysis will help clinicians and policy-makers to determine what the most appropriate use of contrast is for each patient group. In Chapter 4 we also look into the most appropriate use of resources for specific patient groups. Using the H2Oil-study database, we tested the previously studied hypothesis that IUI has a greater beneficial effect on pregnancy chances than expectant management in couples with a low prognosis for natural conception compared to couples with a good prognosis. The research question was: Can we replicate the finding that the benefit of IUI-ovarian stimulation compared to expectant management for couples with unexplained infertility depends on the prognosis of natural conception? Aside from the beneficial effect of HSG with oil-based contrast, we also look at potential downsides in this thesis. Chapter 5 gives an overview of all literature reports on
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