82 Chapter 5 In spite of this, a recent case report describes a patient falling into a comatose state as a result of an oil embolus after HSG (11). Although this might be a rare complication, it does emphasize the importance of safety and knowledge of the complication rates after HSG with the use of oil-based contrast. As previously mentioned, Lipiodol contains iodine, and the iodine concentration in Lipiodol is higher than in water-based contrast (480 mg iodine/ ml in Lipiodol versus 240–300 mg iodine/ml in water-based contrast). Iodine exposure can cause a transient decrease in the synthesis of thyroid hormone (13). Subclinical hypothyroidism is associated with pregnancy complications (14). Furthermore, the HSG procedure has a risk of infection. The systematic reviews and meta-analyses to date have primarily focused on fertility outcomes and have excluded case reports. This systematic review and meta-analysis included all study types, to provide an overview of the frequency and clinical consequences of all possible complications during or after HSG with the use of oil-based contrast in subfertile women. MATERIALS AND METHODS The protocol of this review was prospectively registered on PROSPERO (https://www.crd. york.ac.uk/prospero/, registration ID: CRD42018102382, registration date: 24 July 2018). The methodology used was as described in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement (15). Information sources and search strategies Electronic databases including MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to June 2020. Textbooks as well as reference lists of identified publications were also manually screened. The key search items included ‘hysterosalpingography’, ‘oil contrast’, ‘ethiodized oil’, ‘ethiodol’, ‘lipiodol’, ‘adverse effect’, ‘side effect’, ‘complication’, ‘thyroid’, ‘intravasation’, ‘embolization’, ‘granuloma’, ‘anaphylaxis’, ‘pelvic inflammatory disease’, and ‘adnexitis’ (Supplementary Tables 1–3). Eligibility criteria All types of studies were included: randomized controlled trials (RCT), prospective and retrospective cohort studies, case series and case reports that report complications occurring during or after HSG with the use of oil-based contrast, with or without comparison to water-based contrast, in women trying to conceive or their offspring. No
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