208 Appendix SUMMARY Infertility affects approximately one in six couples trying to conceive. Patients facing infertility can be referred for fertility work-up, a series of diagnostic tests, to diagnose and treat or rule out any causes for infertility. If all known cases of infertility are ruled out, this is called unexplained infertility. One of the tests often performed in the fertility work-up is the hysterosalpingogram (HSG). A contrast fluid is infused into the uterine cavity to delineate the uterine cavity and Fallopian tubes. Once the contrast enters the abdominal cavity through the open ends of the Fallopian tubes, tubal patency is established. Various types of contrast can be used, they can be divided in two groups: oil-based contrast and water-based contrast. Previous research (the H2Oil study) has ascertained that in couples with unexplained infertility and a low risk for tubal pathology, an HSG with use of oil-based contrast results in 10% more ongoing pregnancies than an HSG with use of water-based contrast. It is unclear what the mechanism of action of oil-based contrast is. Improving pregnancy chances and patient experiences in infertility In this thesis, we wanted to further investigate the specifics of the fertility-enhancing effect of oil-based contrast during HSG, the safety and accuracy of HSG and test a novel method to reduce discomfort. An additional chapter focusses on the most notable event that took place during the course of this thesis; the Coronavirus-19 pandemic. Couples with unexplained infertility benefit from an HSG with oil-based contrast, both on the short term and the long term as was shown by a follow-up study using data on pregnancies and fertility treatments up until 5 years after HSG. In Chapter 2 we conducted a secondary analysis using the database of this long term follow-up study to determine how long the fertility enhancing effect is noticeable. We discovered that the fertility enhancing effect is greatest immediately after HSG, and disappears after around 2 years. Three important groups of women were excluded from the H2Oil study: women of advanced age, women with ovulation disorders and women with a high risk for tubal pathology based on their medical history. Factors leading to a high risk for tubal pathology are related to having had an pelvic infection, ectopic pregnancy, surgery to the reproductive organs and/or endometriosis. We are repeating the H2Oil study but this time including exactly these groups of women. The protocol of this ongoing study, called ‘H2Oil2’, is presented in Chapter 3. We expect to use the results of this study to
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