Oil-based versus water-based contrast for hysterosalpingography in infertile women: a systematic review and meta-analysis of randomized controlled trials

Hysterosalpingography is a commonly used diagnostic modality utilized in women with infertility and may be considered a possible therapy option for infertility. Our meta- analysis showed that women who previously underwent hysterosalpingography using oil contrast had higher rates of ongoing pregnancy compared to women who under- went this procedure using water contrast. This suggests that using oil-soluble contrast material may increase the chance of pregnancy after hysterosalpingography.

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Volume 110, Issue 1, Pages 153–160.e3

Authors:

Fang Fang, M.D., Yu Bai, M.D., Yu Zhang, M.D., Andrew Faramand, M.D.

Abstract:

Objective

To determine the effect of the using oil-soluble contrast material (OSCM) vs. water-soluble contrast material (WSCM) for hysterosalpingography on pregnancy rates in infertile women.

Design

Systematic review and meta-analysis.

Setting

Not applicable.

Patient(s)

Infertile women.

Intervention(s)

We included randomized controlled trials comparing pregnancy outcomes in women with infertility undergoing hysterosalpingography using OSCM and WSCM. Paired reviewers independently screened citations, assessed risk of bias of included studies, and extracted data. A random-effects model was used to report all outcomes. The Grading of Recommendations Assessment, Development, Evaluation(GRADE) system was used to quantify absolute effects and quality of evidence.

Main Outcome Measure(s)

The primary outcome was ongoing pregnancy per randomized women.

Result(s)

Six trials with a total of 2,562 patients were selected. Our meta-analysis showed OSCM was associated with significantly higher rates of ongoing pregnancy compared with WSCM (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.12–1.93; I2 = 44%, moderate-quality evidence). Three trials reported live birth, but they were not pooled owing to extreme statistical heterogeneity (I2 = 86%). There was no difference in incidence of miscarriage (OR 0.83, 95% CI 0.56–1.24) or ectopic pregnancy (OR 0.65, 95% CI 0.18–2.36) between OSCM and WSCM groups. Three trials were rated as low risk of bias, whereas three were considered unclear.

Conclusion(s)

Women who previously underwent hysterosalpingography using oil contrast had higher rates of ongoing pregnancy compared with women who underwent this procedure using water contrast. There is not enough evidence to either support or oppose the difference between groups concerning miscarriage and ectopic pregnancy.


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Fertility and Sterility

Editorial Office, American Society for Reproductive Medicine

Fertility and Sterility® is an international journal for obstetricians, gynecologists, reproductive endocrinologists, urologists, basic scientists and others who treat and investigate problems of infertility and human reproductive disorders. The journal publishes juried original scientific articles in clinical and laboratory research relevant to reproductive endocrinology, urology, andrology, physiology, immunology, genetics, contraception, and menopause. Fertility and Sterility® encourages and supports meaningful basic and clinical research, and facilitates and promotes excellence in professional education, in the field of reproductive medicine.

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Nienke van Welie over 1 year ago

Letter to the Editor regarding the article “Oil-based versus water-based contrast for hysterosalpingography in infertile women: a systematic review and meta-analysis of randomized controlled trials”

Nienke van Welie1, Rui Wang2, Velja Mijatovic1, Ben Willem Mol3


1. Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands.


2. Robinson Research Institute and Adelaide Medical School, University of Adelaide, North Adelaide


5006, Australia.


3. Department of Obstetrics and Gynaecology, Monash Medical Centre, Monash University and


Monash Health, Clayton 3168, Australia.


 


Dear Editors-in-Chief, Professor Niederberger and Professor Pellicer,


We read with interest the article by Fang et al. (1) entitled “Oil-based versus water-based contrast for hysterosalpingography in infertile women: a systematic review and meta-analysis of randomized controlled trials”. We want to highlight several important issues on methodology and analysis.


The primary outcome of this meta-analysis was ongoing pregnancy, defined as a positive fetal heartbeat on ultrasonographic examination after 12 weeks gestation, and calculated per randomized woman (1). However, five (2-6) of the six included studies did not report ongoing pregnancy, but only clinical pregnancy. Interpreting clinical pregnancy as ongoing pregnancy can be misleading as first trimester pregnancy losses after clinical pregnancy are not accounted for.


Furthermore, the numbers of participants of the two groups in Alper et al. (2) were misplaced in the meta-analysis (Figure 2), i.e. there should be 14 pregnancies in 46 participants (30%) in the oil soluble contrast medium (OSCM) group and 15 pregnancies in 60 participants (25%) in the water soluble contrast medium (WSCM) group instead of 15/46 and 14/60 participants in the OSCM and WSCM group, respectively (1). This directly affects the direction of effect of this study and the summary odds ratio, confidence interval and I2 statistic for heterogeneity. In addition, the group labels in Figure 2 were also misplaced, however they were corrected with a recent erratum.


Based on the above-mentioned issues, it is not possible to perform a meta-analysis on ongoing pregnancy as only Dreyer et al. (7) reported this outcome (1). If we correct the numbers of events and participants, a revised meta-analysis shows that OSCM is associated with increased odds of clinical pregnancy when compared to WSCM (OR 1.43, 95%CI 1.10–1.85; I2 = 40%, see link for the adjusted figure: https://drive.google.com/open?id=1yf3deN6i21OH0MAaP7sc512ZuJ9Yq-1r).


References


1.            Fang F, Bai Y, Zhang Y, Faramand A. Oil-based versus water-based contrast for hysterosalpingography in infertile women: a systematic review and meta-analysis of randomized controlled trials. Fertil Steril 2018;110:153-60 e3.


2.            Alper MM, Garner PR, Spence JE, Quarrington AM. Pregnancy rates after hysterosalpingography with oil- and water-soluble contrast media. Obstet Gynecol 1986;68:6-9.


3.            de Boer AD, Vemer HM, Willemsen WN, Sanders FB. Oil or aqueous contrast media for hysterosalpingography: a prospective, randomized, clinical study. European journal of obstetrics, gynecology, and reproductive biology 1988;28:65-8.


4.            Lindequist S, Rasmussen F, Larsen C. Use of iotrolan versus ethiodized poppy-seed oil in hysterosalpingography. Radiology 1994;191:513-7.


5.            Spring DB, Barkan HE, Pruyn SC. Potential therapeutic effects of contrast materials in hysterosalpingography: a prospective randomized clinical trial. Kaiser Permanente Infertility Work Group. Radiology 2000;214:53-7.


6.            Rasmussen F, Lindequist S, Larsen C, Justesen P. Therapeutic effect of hysterosalpingography: oil- versus water-soluble contrast media--a randomized prospective study. Radiology 1991;179:75-8.


7.            Dreyer K, van Rijswijk J, Mijatovic V, Goddijn M, Verhoeve HR, van Rooij IAJ et al. Oil-Based or Water-Based Contrast for Hysterosalpingography in Infertile Women. In:  NEJM. Vol. 376, 2017:2043-52.