90 Chapter 5 Other complications One case of a tubal rupture, without ill effects, was described. The diagnostic method was not reported (114). Additionally, one case report described abdominal pain, like Fitz- Hugh–Curtis syndrome, possibly due to the chemical stimulation of the iodized oil (not further specified) used during an HSG (75). HSG performed for non-subfertility indications The primary intention of this study was to take into account HSGs performed for subfertility. However, in a non-systematic way, the study also identified one case of a massive oil embolism leading to death, published in 1931. A 60-year-old received an HSG with 8 ml Jodipin for postmenopausal blood loss which was suspected for malignancy. A massive oil embolism occurred in the cerebrum, pituitary gland, liver, spleen, kidney and heart, and the patient died within 5 h after the procedure. The use of fluoroscopy screening was not reported. It is likely that no adequate fluoroscopy was performed at the time (122). Furthermore, a case report of a woman falling into a comatose state after an HSG was reported. This woman had had two unsuccessful curettage attempts for termination of pregnancy, after which she received an HSG with Lipiodol Ultra Fluid. The endometrium was injured after the several curettages, and so the contrast could flow directly into the bloodstream, leading to a massive intravasation with oil embolisms. After 81 days she was discharged with slight mental deficit (123). This study also identified case reports of pulmonary oil embolisms after HSG performed in patients with: tubal ligation (n = 2) (124) , suspected endometrium carcinoma (n = 1) (125), abdominal pain (n = 1) (126), uterus myomatosus (n = 2) (127) and missed abortion (n = 1) (128). DISCUSSION In this review of articles published from 1928 onwards, including a total of 23,536 HSG with the use of oil-based contrast, the most frequently reported complication of HSG performed for subfertility was intravasation of contrast. This occurred in 2.7% of the HSG with the use of oil-based contrast (31 studies, 95% CI 1.7–3.8), compared with 2.0% with the use of water-based contrast (8 studies, 95% CI 1.2–3.0) derived from cohort studies and RCT. Oil embolisms occurred in 0.1% of the HSG performed in cohort studies and RCT. In all studies, including the case reports, the percentage of symptomatic oil embolisms was strikingly lower in the group with fluoroscopy guidance during HSG compared with
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