81 Safety of HSG with oil-based contrast medium 5 INTRODUCTION Hysterosalpingography (HSG) to assess tubal patency is an essential part of the workup for subfertile couples (1). The first HSG was performed in 1910 by Rindfleisch (2). From 1914 iodized oils were used as an alternative to the water-based contrasts, which were irritative to the peritoneum (3, 4, 5).Different iodized oils were introduced, such as Lipiodol®, Iodochlorol, Ethiodol, Jodipin, Jodumbrin and Lipiodol® Ultra Fluid. The oilbased contrasts available today are Lipiodol® Ultra Fluid (Guerbet, Villepinte, France) and Ethiodized Poppyseed Oil (Heng Rui Pharmaceuticals, Jiangsu, China), the latter being currently only available in Asia. Lipiodol was developed in 1901 as a solution containing iodine, and was used for a wide range of indications, including the reduction of struma and infection prevention. After the discovery of its radiological qualities, it was used for visualization of the uterine cavity and Fallopian tubes, but also in myelography, bronchography and later in lymphography. In 1960 a transesterified version of Lipiodol was developed, Lipiodol Ultra Fluid, which had a lower viscosity (6, 7). For nearly seven decades, the therapeutic effect of oil-based contrast during HSG in the fertility work-up has been debated. Recently two meta-analyses have shown a favourable effect of oil-based contrast on fertility outcomes, with an OR of 1.47 (95% CI 1.12–1.93) for ongoing pregnancy and 2.18 (95% CI 1.30–3.65) for live birth when comparing HSG with oil-based contrast to water-based contrast (8, 9). This generated a worldwide renewed interest in the use of oil-based contrast for fertility enhancement. However, some clinicians are still hesitant about its use because of complications that have been reported in the past. In 1929 the first report of intravasation of oil-based contrast during HSG was published (10). Intravasation is the inflow of contrast in the venous or lymphatic system, and is visualized by radiography, ideally with the use of fluoroscopy screening. Even though water-based contrast can also intravasate, only oil-based contrast is known to enter the circulation as droplets because of its hydrophobic qualities. These oil droplets can reach organs such as the lungs or brain as oil emboli and cause inflammation and/or occlusion of the vasculature (11). After this first case, more reports of intravasation followed, but most patients had only minor symptoms and recovered after observation. Intravasation was therefore regarded as innocuous (5). Currently, intravasation with the use of oilbased contrast is estimated to occur in around 5% of the HSG in the Netherlands (12).
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