84 Chapter 5 RESULTS Characteristics of included studies The search identified 492 records. A total of 8 RCT, 41 cohort studies (4 prospective cohorts, 24 retrospective cohorts, 13 cohort studies which were not further specified) and 59 case reports/case series were included within the review. In these studies, a total of 23,536 HSG procedures were performed with the use of oil-based contrast (23,298 HSG in cohort studies/RCT). Sixteen of the included studies reported on HSG with water-based contrast as well, with a total of 1,975 HSG with water-based contrast (1,973 HSG in cohort studies/RCT) (for flow chart see Supplementary Figure 1). The included studies were published between 1928 and 2020 (see Supplementary Table 5 for the characteristics of the included studies) (10, 11, 17-121). Quality of evidence of the studies Of the 49 cohort studies and RCT, 16 studies were classified as low risk, 31 studies as moderate risk and two studies as high risk of study bias. In 18 studies, there was no clear definition of the reported complications. Mainly, there was no predefined definition of intravasation or oil embolism. There is no reliable or valid classification method for intravasation, therefore 44 of the 48 studies were classified as high risk of bias for the reliability and validity of the study instrument that measured the parameter of interest (see Supplementary Table 6 for the classification of all studies). Intravasation and oil embolisms Eight studies (three RCT and five cohort studies) compared the frequency of intravasation between HSG with the use of oil-based and water-based contrast (Figure 1). Rates of intravasation were 2.8% (38/1353) after HSG with oil-based contrast and 1.8% (18/1006) after HSG with water-based contrast (OR 5.05; 95% CI 2.27–11.22; P < 0.0001) based on the RCT and 1.23 (95% CI 0.50–3.07; P = 0.65) based on the cohort studies), showing that intravasation occurs more frequently with the use of oil-based contrast. Twenty-three additional cohort studies reported on the prevalence of intravasation with the use of oil-based contrast alone. The overall pooled weighted frequency of intravasation in the 31 RCT and cohort studies with the use of oil-based contrast was 2.7% (95% CI 1.7–3.8, absolute event rate 664/19,339), compared with 2.0% (95% CI 1.2–3.0, absolute event rate 18/1,006) in the eight studies with the use of water based contrast. When including only studies published from 2000 onwards, the pooled frequency of intravasation with the use of oil-based contrast was 2.8% (95% CI 1.2–5.1, absolute event rate 12/471), compared with 1.8% (95% CI 0.0–5.9, absolute event rate 8/403) with the use of water-based contrast.
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