87 Safety of HSG with oil-based contrast medium 5 were three women with serious lasting consequences of cerebral complaints after an oil embolism (Table 1) (11, 33, 41). Infection Two RCT and 18 cohort studies reported on the frequency of infection after HSG with the use of oil-based contrast. The overall pooled weighted frequency of infection was 0.90% (95% CI 0.47–1.50, 70/11,287 women). Two RCT and two cohort studies compared HSG with the use of oil-based contrast to HSG using water-based contrast. The frequency of infection with the use of water-based contrast was 1.9% (95% CI 0.27–4.60, 17/564 women). Including only the studies published in or after 1960, the overall pooled frequency of infection was 0.55% (95% CI 0.23–1.00) after HSG with the use of oil-based contrast and 0.35% (95% CI 0.00–7.30) with the use of water-based contrast. The use of antibiotic prophylaxis was not systematically reported. Mortality Five cases of mortality were reported after HSG with the use of oil-based contrast in subfertile women. Four of these cases were infection-related, and they were published in the period between 1942 and 1950 (19, 40, 91). The fifth case described a woman that passed away minutes after a recurrent HSG with 9 ml of lipoiodine under light cyclopropane anaesthesia, possibly due to an allergic reaction to the oil-based contrast or the anaesthesia used (39). Additionally, two cases were reported in 1928 and 1930 where tubal blockage was found on the HSG. These women underwent surgery 1 and 5 days later, and died shortly after, presumably from infectious complications of the surgery (52, 79). Lipogranuloma and oil remnants Eleven studies reported on 41 women with lipogranuloma formation after an HSG with the use of different types of oil-based contrast. These included three cohort studies, one case series and seven case reports. The contrasts used were: Lipiodol not further specified (33 cases), oil-based/iodized contrast not further specified (five cases), Jodipin (two cases), Ethiodol (one case). In nine cases histology examination was mentioned, in 32 cases this was not mentioned. Additionally, there were 85 reports of oil remnants after an HSG with the use of oil-based contrast. These were reported in nine studies; three cohort studies and six case reports. Forty-four cases were discovered within 2 weeks after the procedure, while 41 were discovered up to 27 years after the HSG procedure. Fifty-six cases were diagnosed after laparoscopy; 29 cases were diagnosed after radiology imaging. Histological examination was only reported in one case.
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