193 General discussion and future perspectives 9 during fertility work-up can be ascertained including evidence-based advice tailored to the largest subgroups of infertile couples. We strive to provide tailored advice when it comes to fertility treatments as well. The treatment advice can range from expectant management, meaning trying to conceive naturally, up to IVF/ICSI treatment. While for couples with severe male infertility ICSI is often the only option, it can be unclear what the best treatment is for couples with unexplained infertility and especially when to start treatment. The first-line treatment for couples with unexplained infertility is often intra uterine insemination with mild ovarian stimulation (IUI-MOH) (5). It is unclear when to start treatment after expectant management. Previous research showed that the effectiveness of IUI-MOH versus expectant management varies based on the prognosis for natural conception as calculated by the Hunault model (6). It is important to replicate such findings before implementing them into clinical practice. Therefore, we formulated the following research question: III. Can we replicate the finding that the benefit of IUI with mild ovarian stimulation compared to expectant management for couples with unexplained infertility depends on the prognosis of natural conception? Using the H2Oil database, we were able to compare pregnancy chances for couples in expectant management and couples undergoing IUI-MOH treatment in Chapter 4. We did not find a strong correlation between the prognosis of natural conception and the effect of IUI-MOH on pregnancy chances. We did show that IUI increases the chance of conception when compared to expectant management. This treatment effect was dependent on the timing of starting IUI-MOH. In couples with a longer duration of infertility, the benefit of IUI-MOH over expectant management was greater. This leads to our advice to postpone the start of IUI-MOH after the diagnosis of unexplained infertility with several months. With the fertility-enhancing effect of tubal flushing with oil-based contrast, HSG has moved from a purely diagnostic procedure to a therapeutic intervention. Most probably, once the therapeutic effect is included in fertility guidelines, the HSG with oil-based contrast will be performed more often in women with unexplained infertility. For that reason, it is even more important to consider the adverse effects of the procedure. To provide a complete overview of the adverse effects we wanted to answer the following question:
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