92 Chapter 5 treatment is mainly supportive. Corticosteroids are proposed for their possible beneficial effect on the pulmonary capillary membrane, preventing pulmonary oedema (129). The pathogenesis of oil embolisms after the use of oil-based contrast could be similar to that described after a bone marrow fat embolism, however, in the latter case it concerns autologous tissue, while in the case of the use of oil-based contrast it concerns foreign material. In the four cases with severe complications of oil embolisms that are summarized in this review, one case was treated with corticosteroids (30), but in the other cases only supportive measures were reported. In this systematic review of HSGs with oil-based contrast for subfertility, four cases of infection-related mortality were identified. It should be noted that these cases were all in the 1940s, when penicillin had been recently introduced and the treatment for infection was completely different from current practice (131). There are also reports in the literature of infection-related mortality following HSG with the use of waterbased contrast (132). With the increased use and improvements of (prophylactic and therapeutic) antibiotics, the course of these infections has become less severe. The frequency of acute pelvic inflammatory disease after HSG is nowadays 0.5% with antibiotic prophylaxis and 1.4% without prophylaxis (133). There were more than twice the number of reports on oil remnants (n = 85) than lipogranuloma formation (n = 41) after HSG with the use of oil-based contrast. Lipogranuloma is a pathological diagnosis and may be missed if oil remnants are not sent for pathological examination. Lipogranuloma may result in adhesion formation (47). After iodine exposure, there is an excess of iodine transportation into the thyroid gland. Through negative feedback, this causes a transient decrease in the synthesis of thyroid hormone, potentially leading to the development of subclinical hypothyroidism. The level of thyroid hormone production will normally be restored within 24–48 h. However, patients with underlying thyroid abnormalities may be unable to escape from this socalled acute Wolff–Chaikoff effect and therefore acquire an iodine-induced (transient) overt hypothyroidism (13). This is in line with the results of the cohort study by Mekaru et al. (2008), which showed that 35.7% of women with a subclinical hypothyroidism develop overt hypothyroidism after an HSG with oil-based contrast, compared with 0–2.2% of euthyroid women (56, 73). Iodine induced (transient) hyperthyroidism can also occur in susceptible patients due to activation of quiescent nodules (13). This was shown in a case report of a woman with Graves’ disease, who developed hyperthyroidism after an HSG (54). Five out of eight studies included in this review, on maternal thyroid dysfunction after HSG, were performed in Japan. The effect of iodinated contrast on the thyroidal gland
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