202 Chapter 9 C. Alternatives to HSG Our group has recently published the results from the large multicentre randomized controlled trial ‘FOAM’. In this study, all 1026 participants are subjected to both an HSG and a HyFoSy with ExEm Foam® in a randomized order. The study compares the results in terms of ongoing pregnancies leading to live births after management after a fertility work-up based on HSG versus management based on HyFoSy. The results of this noninferiority study show that the procedures result in comparable pregnancy outcomes. Pain scores during HSG were found to be significantly higher in comparison to HyFoSy. Since all participants underwent both procedures, a direct comparison between both tests in terms of their fertility enhancing effect could not be made. For that reason a new study is initiated, that will directly compare HSG with oil contrast versus HyFoSy with ExEm Foam® in terms of live birth within six months after the test. This study is funded by ZonMw (grant number 10390012110083) and is expected to start recruiting in the beginning of 2023 within the Dutch Consortium. Several groups are working on ways to incorporate tubal flushing with oil-based contrast during or after an alternative tubal patency test such as HyFoSy (30) and THL (31), to combine the advantages of the alternative tubal patency tests with the pregnancy enhancing effect of oil-based contrast. The results of the diagnostic accuracy review that will be executed, of which the protocol is described in chapter 7, should be taken together with results of therapeutic effects of the various tubal patency tests when deciding on the right test in any given situation. Ideally, patient preference should also be investigated as a factor in deciding what test to advice women in each situation. D. COVID-19 and infertility Patients facing infertility experience more psychological distress and feel less able to cope with this distress than patients with endometriosis in our study. A study conducted in America showed that infertility remained the top stressor for infertility patients over other common life stressors as their job, money, health and family. This remained constant before, at the start and amidst the first lockdown (32). In a UK-based study, conducted while gynaecology services and elective surgeries had already restarted after the lockdown, still 55.2% of the 1089 endometriosis patients noticed an increase in their overall pelvic pain and 69.2% reported worsening of associated mental health issues compared to pre-pandemic (33). An international survey study revealed that patients confronted with cancellation or postponement of their medical appointments, fertility treatments or surgery, were more likely to report a deterioration of their mental state (34). This emphasizes the need for a more holistic approach for endometriosis
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