{"paper_id":"0c85ba85-142b-4a18-a8c8-fd54242f47da","body_text":"Submit Manuscript | http://medcraveonline.com\nAbbreviations: HSG, Hysterosalpingography; HyFoSy, \nHysterosalpingo-Foam Sonography; HyCoSy, Hysterosalpingo-\nContrast Sonography; OTB, One Tubal Blocked; BTB, Both Tubes \nBlocked; BTP, Both Tubes Patent\nIntroduction\nSubfertility is a disease of the reproductive system and defined \nas the failure to achieve pregnancy after 12 months of unprotected \nsexual intercourse.1 Subfertility is a distressing condition for couples \nwho are trying to achieve pregnancy and childbirth. Approximately \n15% of couples are affected with subfertility, of which up to 20% \nremain unexplained. Female factors are identified in about 50% of \ncouples.2 The pelvic causes of female subfertility are varied and \nrange from tubal and peri-tubal abnormalities to uterine, cervical, \nand ovarian disorders. 2,3 Tube abnormalities account for up to 40% \nof female subfertility.3,4 Assessment of tubal patency is one of the first \nsteps in infertility workup. 5 Various tests nowadays are available for \nthe purpose of patency test; of these tests are hysterosalpingography \n(HSG), Salpingography, diagnostic laparoscopy with dye \nhydrotubation test and Hysterosalpingo-Contrast Sonography \n(HyCoSy).6 HSG is the most common first-line and widely available \ndiagnostic test. 5-7 Although HSG assesses tubal status and provides \nan image of the outline of the uterine cavity, the intracavitary \nabnormalities are not visualized clearly due to the opacity of the dye \nused for the procedure. 8-10 Besides, the other main disadvantages are \npatients’ exposure to ionizing radiation that is significantly greater \nthan that of a usual chest X-ray, the unpleasant pain experienced \nduring the procedure and the risk of pelvic infection (1-3%). 7 \nMoreover, laparoscopy with a dye test combined with hysteroscopy \nis considered the gold standard in diagnosing uterine abnormalities \nand tubal patency in infertile women. Its use is limited because it is \nexpensive, time-consuming, needs general anesthesia and has risks of \ncomplications.3,11\nHyCoSy was introduced in 2006 to determine tubal patency, \nand different dyes have been tried since then. It offered a quick \nmethod of assessing tubal patency, obviating the need for ionizing \nradiation or general anesthesia.5,6 Though pooled data from literature \nreported acceptable pain tolerance during the HyCoSy examination, \nthe tolerance varies according to the used installation volume \nand contrast material. 12-14 Furthermore, the dyes were declared \nunsafe for gynecological use and could only be used for Doppler \nmicrovasculature. In 2007, HyFoSy was introduced as a safe procedure \nin which an inert material (hydroxymethyl cellulose), which has \nObstet Gynecol Int J. 2017;6(6):156‒160. 156\n©2017 Khan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which \npermits unrestrited use, distribution, and build upon your work non-commercially.\nHysterosalpingo-foam sonography, less painful \nand more instructive as compared with \nhysterosalpingography: a prospective study\nVolume 6 Issue 6 - 2017\nFaryal Khan,1 Mohammed Agdi,2 Dania Al \nJaroudi,1 Isamm Al Fayyad,1 Tahmina Aziz1\n1King Fahad Medical City, Saudi Arabia\n2Bnoon Medical Center, Saudi Arabia\nCorrespondence: Mohammed Agdi, Consultant Reproductive \nEndocrinology & Infertility, Bnoon Medical Center, Riyadh, PO \nBox 7455, Riyadh 13241, Saudi Arabia, T el 966-11-444-8080, Fax \n966-11-444-9090, Email \nReceived: March 29, 2017 | Published: May 02, 2017\nAbstract\nBackground: Hysterosalpingography (HSG) is a vital part of fertility evaluation, and can \nbe painful and cause moderate to severe pain as reported by women. Hysterosalpingo-Foam \nSonography (HyFoSy) is a quick, well-tolerated and less painful procedure than HSG for \ntubal patency testing. Moreover, HyFoSy is safe, non-invasive procedure, economic, and \ntime efficient.\nObjective: To assess whether HyFoSy is a less painful procedure for tubal patency and \nhighly time efficient compared to HSG.\nMethods:\nDesign: A single-center, prospective, interventional clinical study.\nStudy setting: Reproductive Endocrine and Infertility Medicine Department, Ultrasound \nUnit of Women Specialized Hospital and Radiology Department of King Fahad Medical \nCity Hospital (KFMC) between the period November 2015 and June 2016.\nIntervention: Tubal patency testing by HyFoSy versus HSG.\nOutcome measures: Mean pain scores during tubal patency testing.\nResults: The mean pain score perception during the HyFoSy procedure was 2.44±1.71 \ncompared with 5.03±2.26 during HSG, with a statistically significant difference (p=<0.001). \nNo statistical difference (p=0.597) was found between HyFoSy mean procedure time \n125.01±35.21 compared to HSG mean time 128.15±37.18. Differences in pain perceived \nafter HyFoSy can be explained mainly by the indication (p=0.001), history of ectopic \npregnancy (p=0.002) and OTB (p=0.007).\nConclusion: The HyFoSy procedure is a less painful and less time-consuming tubal \npatency test compared with HSG.\nKeywords: Hysterosalpingography, Hysterosalpingo-Foam Sonography, \nHysterosalpingo-Contrast Sonography, Fallopian tube patency\nObstetrics & Gynecology International Journal\nResearch Article\n Open Access\n\n\nHysterosalpingo-foam sonography, less painful and more instructive as compared with \nhysterosalpingography: a prospective study\n157\nCopyright:\n©2017 Khan et al.\nCitation: Khan F , Mohammed A, Dania AJ, et al. Hysterosalpingo-foam sonography, less painful and more instructive as compared with hysterosalpingography: a \nprospective study. Obstet Gynecol Int J. 2017;6(6):156‒160. DOI: 10.15406/ogij.2017.06.00226\nno reaction with the human body, was used as a contrast agent for \nsonohysterography, offering a more stable filling of the uterine cavity \nand fallopian tubes.15 While HSG is a vital part of fertility evaluation, \nit can be painful and cause moderate to severe pain as reported by \nwomen. Pain and discomfort reach it peaks at the time of contrast \ninstallation. Cervical Instrumentation and uterine distention as well, \nmay release local prostaglandins and thus induce uterine cramps. 16,17 \nOn the other hand, literature has reported many advantages of HyFoSy. \nIt is quick and well tolerated and less painful procedure than HSG \nfor tubal patency testing. Moreover, HyFoSy is safe, non-invasive \nprocedure, economic, and time efficient. 11,18,19 Experienced pain \nduring HSG might have a negative influence on women cooperation, \nthus restraining the utility of the procedure, decrease their satisfaction \nand loss of confidence in clinicians. Therefore, women should have \nrealistic prospects about the procedure.20,21\nOffering less invasive procedures with low cost is recommended \nby clinical guidelines, before going to more invasive with higher cost \nprocedures.22,23 Therefore, the aim of this clinical trial is to assess \nwhether HyFoSy is a less painful procedure for tubal patency and if it \nis time efficient compared to HSG.\nMaterials and methods\nWe conducted a prospective interventional study at the Reproductive \nEndocrinology Infertility Medicine Department and Ultrasound Unit \nof Women Specialized Hospital and Radiology Department of King \nFahad Medical City Hospital (KFMC) between the period November \n2015 and June 2016. 156 consecutive patients who were referred for \ntubal patency evaluation were invited to participate in the study. 75 \npatients out of the 156 were included in the study leaving the response \nat 48%. Excluded patients were those who did not meet the inclusion \ncriteria and those who were unwilling and reluctant to participate \nand give informed consent. Ethical approval was obtained from the \nInstitution Review Board at the study site. Informed consent was \nobtained before patient enrollment in the study.\nPrimary and secondary outcomes\nThe primary study outcome was the pain experienced by women \nafter both procedures, as assessed by Visual Analogue Scale (V AS) \nwith a scoring value (1-10). The secondary outcome was the procedure \ntime, as measured in seconds.\nInclusion and exclusion criteria\nThe study included women aged between 18 and 40 years who \nwere eligible for fallopian tube patency testing as part of their fertility \nevaluation. Women with chlamydia infection, peritonitis or pelvic \ninflammation were excluded.\nClinical method\nNo premedication pain killers were given prior to both \nprocedures. The procedures were performed after the cessation of \nmenstrual bleeding and before day 14 in the ovulatory cycle. Women \ndemographic and clinical characteristics (age, BMI, primary or \nsecondary infertility, gravidity, parity, abortion, and comorbidity) \nwere collected. Tubal patency was recorded in the data analysis as \nconfirmed by HyFoSy.\nThe patients were sent to the ultrasound department where 2D/3D \nTVS is performed as an initial investigation by an automated sweep \nof a high-resolution transvaginal probe (7-9 MHz). The patients \nwill be scheduled for HSG and subsequently to HyFoSy, after \nmaking sure they are not pregnant. The time difference between the \ntwo procedures was 4-5 days.HSG was performed in the radiology \ndepartment. In lithotomy position, the radio-opaque dye was injected \nthrough the cervix and intermittently X-rays are taken, with the help \nof radiologist, uterine and tubal abnormalities are detected. In our \nhospital, HSG is performed on every sub-fertile woman as a standard \ninitial investigation. The reading of HSG is not operator depended. It \nis easily and correctly reported by the consultant radiologist assigned \nto the radiology department. These radiologists were not aware of the \nongoing study, and thus there was no observer bias on HSG reporting.\nOn the same patients, HyFoSy was performed in the Reproductive \nEndocrinology Infertility Medicine Department. The patient was \nplaced in a lithotomy position; the cervix was visualized with the \nhelp of a speculum. A balloon catheter was introduced into the uterine \ncavity and the balloon filled with 1-1.5 ml of saline solution to fix the \ncatheter and prevent foam backflow. First, 3-5 ml of saline was injected \ngradually into the uterus to distend and outlines the cavity, revealing \nany abnormalities (Mullerian anomaly and endometrial lesions). Then \nthe prepared foam was injected slowly which passed through the \nfallopian tubes, causing their distension and finally spilling into the \npelvis through the fimbrial ends. This foam is easily visible by the \nultrasound and is thus its flow could be traced into the uterine cavity \nand tubes to check for any abnormalities using the ultrasound probe. \nAll cases were performed on the same machine (Philip iU22 3D \nultrasound machine) by only two expert and experienced operator to \nincrease reliability, precision, and accuracy. All the cases of HyFoSy \nwere read and approved at the end of the procedure to prevent any \nobserver bias. The physicians were blinded to the HSG reports when \nperforming and reporting the HyFoSy reports.\nStatistical analysis\nData were analyzed using SPSS version 22.0 (SPSS, Chicago, \nIL, USA). A descriptive analysis (mean, frequency and percentages) \nwas used to describe women characteristics. Paired sample t-test was \nused to assess the significant difference in the mean pain scores for \nboth procedures. Booker’s test was used to determine the level of \nconcordance between HSG and HyFoSy in the levels of pain scores. \nIndependent t-test was used to evaluate difference and compare the \nmean between HyFoSy mean pain score and patients variable. One-\nway ANOV A was used to assess difference and compare the mean \npain score of HyFoSy and the three categories of tubal patency (Both \nTubes Patent (BTP), One Tube Blocked (OTB) and Both Tubes \nBlocked (BTB). A univariate analysis model was established to assess \nwhich of the patients’ characteristics is a predictor for higher pain \nperception.\nResults and discussion\nUtilizing a consecutive sampling method, 75 patients were involved \nin the study and underwent HSG procedure and subsequent HyFoSy. \nThe mean age score of the participants was 30.53±5.34 (range; 19-\n40 year), and the Body Mass Index (BMI) was 28.41±5.61(range; \n18-49) (Table 1). Merely 48 (64%) of the patients they have primary \ninfertility impending 27 (36%) with secondary infertility. The majority \nwere nulliparous 63 (84%) and nulligravida 62 (62.7%). Among the \npatients, 11 (14.7%) they have a history of one abortion and 7 (9.3%) \nhave a history of more than one abortion. The majority of patients \nhad no comorbidity (84%); however, 7 (9.3%) had hypothyroidism, \n4 (5.3%) had diabetes and only 1 (1.3%) had hyperthyroidism. With \nregards to tubal patency, 10 (13.3%) were found to have unilateral \ntubal blockage, and 3 (4%) had bilateral tubal blockage (Table 1).\n\nHysterosalpingo-foam sonography, less painful and more instructive as compared with \nhysterosalpingography: a prospective study\n158\nCopyright:\n©2017 Khan et al.\nCitation: Khan F , Mohammed A, Dania AJ, et al. Hysterosalpingo-foam sonography, less painful and more instructive as compared with hysterosalpingography: a \nprospective study. Obstet Gynecol Int J. 2017;6(6):156‒160. DOI: 10.15406/ogij.2017.06.00226\nT able 1 Patients characteristics\nPatients characteristics\nAge 30.53±5.34\nBody Mass Index 28.41± 5.61\nSubfertility type n (n%)\nPrimary infertility \nSecondary infertility\n48 (64%) \n27 (36%)\nGravidity n (n%)\nNulligravida \nPrimigravida \nMultigravida\n47 (62.7%) \n9 (12%) \n19 (25.3%)\nParity n (n%)\nNulliparous \nPrimiparous \nMultiparous\n63 (84%) \n6 (8%) \n6 (8%)\nAbortion n (n%)\nNo abortion \n1 \n≥2\n57 (76%) \n11 (14.7%) \n7 (9.3%)\nComorbidity n (n%)\nNO \nDiabetes Mellitus \nHyperparathyroidism \nHypothyroidism\n63 (84%) \n4 (5.3%) \n1 (1.3%) \n7 (9.3%)\nT ubal patency n (n%)\nBoth T ubes patent \nOne T ube Blocked \nBoth T ubes blocked\n62 (82.7%) \n10 (13.3%) \n3 (4%)\nTable 2 shows the primary and secondary outcomes, the pain score \nand procedure time. A statistically significant difference (p<0.001) in \nthe mean pain score was found between HSG procedure (5.03±2.26); \nwith pain score range (V AS: 0-6), and HyFoSy (2.44±1.71) with \npain score range (V AS: 1-10). With regards to procedure time (sec), \nno significant difference (p<0.697) was observed between HSG \n(128.15±37.18) and HyFoSy (125.01±35.21).\nT able 2 Primary and Secondary outcomes\nHyFoSy1 \n(n=75)\nHSG2 \n(n=75) p-value\nPrimary outcome\nVAS Pain score (cm) 2.44±1.71 5.03±2.26 <0.001*\nSecondary outcome\nProcedure time (seconds) 125.01±35.21 128.15±37.18 0.597\n1HyFoSy: Hysterosalpingo-Foam Sonography\n2HSG: Hysterosalpingography\nThe pain perception (mild, moderate and severe) for both \nprocedures was compared using Booker’s test to assess the level \nof concordance between HSG and HyFoSy in the levels of pain \nscores. Interestingly, severe pain was not reported among women \nafter HyFoSy. 14 patients (18.7%) who did not report pain after \nHyFoSy had mild (8 patients) and moderate (6 patients) pain after \nHSG. Moreover, 23 patients (60.5%) who reported mild pain after \nHyfosy had moderate pain after HSG. Besides, 18 patients (24%) \nwho reported severe pain after HSG, 9 of them reported mild pain \nand 9 reported moderate pain after HyFoSy. Collectively, 18 (24%) \nof the patients reported the same level of pain after both procedures. \nA significant statistical difference was observed in pain levels scores \nbetween HSG and HyFoSy procedure (P=0.002) (Table 3).\nT able 3 Comparing reported pain levels scores between HyFoSy and HSG\nHyFoSy1\nT otal\nHSG2\n no pain Mild pain Moderate pain Severe pain\nNo pain 0 0 0 0 0\nMild pain 8 (57.1%) 6 (15.8%) 2 (8.7%) 0 16 (21.3%)\nModerate pain 6 (42.9%) 23 (60.5%) 12 (52.2%) 0 41 (54.7%)\n Severe pain 0 9 (23.7%) 9 (39.1%) 0 18 (24%)\nT otal 14 (18.7%) 38 (50.7%) 23 (30.6%) 0 75\n1HyFoSy: Hysterosalpingo-Foam Sonography\n2HSG: Hysterosalpingography\nThis study found that patients with primary infertility had a \nstatistically significant (p-0.002) lower mean pain scores (1.98±1.56) \nafter HyFoSy procedure compared to patients with secondary \ninfertility. Patients with a history of ectopic pregnancy had a \nstatistically significant difference (p=0.013) higher mean pain score \n(5±1.160) compared with those without previous experience of \nectopic pregnancy (2.3±1.63).\nThere was a significant difference (P=0.023; One-way ANOV A \ntest) in patients’ pain perception according to tubal patency after \nHyFoSy. Our finding revealed that patients after HyFoSy with \nOTB (3.8±1.99) and BTP (2.24±1.58) had a higher mean pain score \ncompared to patients with BTB (2±2). On the other hand, among \nthese subgroups, no significant difference was found in the mean pain \nscore after HSG. Looking at the mean pain scores for all independent \npatients’ variables, we found that the mean pain scores were higher \namong patients after HSG compared to those after HyFoSy (Table \n4). Nevertheless, no statistical difference (p<0.597) was observed \nin the procedure time for HyFoSy and HSG (125.01 and 128.15 \nrespectively) (Table 1).\nT able 4 T -test and One-way ANOVA analysis of patient mean pain after \nHyFoSy and HSG\n \nHyfosy1 \n(n=75)\nHsg2 \n(n=75)\nMean ± sd P-value Mean ± sd P-value\nIndicationa     \nPrimary infertility \nsecondary infertility\n1.98±1.56 \n3.26±1.68 0.002* 4.75±2.11 \n5.52±2.47 0.18\nParitya     \nNulliparous \nparous\n2.38±1.80 \n2.75±1.14 0.365 4.97±2.23 \n5.33±2.50 0.644\nGraviditya     \nNulligravida \nmultigravida\n2.23±1.67 \n2.79±1.75 0.185 4.91±2.10 \n5.21±2.53 0.601\nHistory of ectopic \npregnancya     \nNo \nyes\n2.3±1.63 \n5±1.160 0.013* 4.89±2.21 \n7.5±1.73 0.051\nT ubal patencyb     \nBoth tubes patent \none tube blocked \nboth tubes blocked\n2.24±1.58 \n3.8±1.99 \n2±2\n0.023*\n4.85±2.17 \n5.9±2.73 \n5.67±\n0.356\n*a: Independent T -test analysis, b: One-way ANOVA analysis\n1HyFoSy - Hysterosalpingo-Foam Sonography\n2HSG – Hysterosalpingography\n\nHysterosalpingo-foam sonography, less painful and more instructive as compared with \nhysterosalpingography: a prospective study\n159\nCopyright:\n©2017 Khan et al.\nCitation: Khan F , Mohammed A, Dania AJ, et al. Hysterosalpingo-foam sonography, less painful and more instructive as compared with hysterosalpingography: a \nprospective study. Obstet Gynecol Int J. 2017;6(6):156‒160. DOI: 10.15406/ogij.2017.06.00226\nUnivariate linear regression analysis showed that differences \nin pain perceived after HyFoSy could be explained mainly by the \nindication (p=0.001), history of ectopic pregnancy (p=0.002) and \nOTB (p=0.007) (Table 5).\nT able 5 Univariate linear regression model: Predictors of the patients’ characteristics one reported pain score after Hyfosy1\nVariables Un-standardized coefficients Standardized coefficients T P-valueB Std. Error Beta\nIndication 1.280 0.386 0.362 3.314 0.001*\nParous 0.369 0.541 0.080 0.683 0.497\nGravidity 0.552 0.406 0.157 1.359 0.178\nEctopic pregnancy 2.704 0.826 0.358 3.272 0.002*\nOne tube blocked (otb) 1.558 0.561 0.312 2.778 0.007*\nBoth tubes blocked (btb) -0.242 0.973 -0.028 0.028 0.804\na. Dependent Variable: HyFoSy Pain Score\n1HyFoSy: Hysterosalpingo-Foam Sonography\nIn our study, we evaluated the experienced pain after HSG and \nHyFoSy procedure and the duration of the procedure. HyFoSy is a \nsafe, nontoxic and a less expensive alternative procedure to HyCoSy.6 \nOur findings are in concordance with the results of other studies in \nsupporting the evidence of the lower pain experienced after HyFoSy \ncompared to HSG. 11,24 The study showed about 50% difference in \nfavor of HyFoSy in the mean pain score in comparison to HSG. \nRemarkably, the difference (0.98:1; HyFoSy and HSG, respectively) \nin the procedure time between HyFoSy and HSG was not significant, \nabout 2 minutes for each, which is contrasting previous published data \nin the literature.11,24 However, the average time for HyFoSy is in other \nstudies was about 5 minutes.\nOur results added new value to the current knowledge of pain \nwith HyFoSy in evaluating the effect of the clinical characteristics \non pain perception among patients. Among these variables is the type \nof patients’ infertility (Primary vs. Secondary). The results indicated \na significant difference in patients’ perception of pain (nearly 40% \nlower) after HyFoSy between the two types of infertility in favor of \nprimary infertility. We found that the history of ectopic pregnancy had \nits effect in the perception of pain; patients with history of one or \nmore ectopic pregnancy experienced higher pain perception (about \n50% more) after HyFoSy. Regarding tubal patency, our results are in \nline with a previous study, in which the mean pain score after HyFoSy \nfor patients with BTP was less than the mean of patients with OTB.21\nVan Schoubroeck et al. 21 reported parity as a predictor for \nexplaining the difference in the perception of pain; 21 however, our \nfinding revealed that parity was not a predictor for pain perception. Our \nobservation showed that the patients’ type of infertility (indication), \nhistory of ectopic pregnancy and tubal patency (OTB) variables that \na have an association with pain perception. The main limitation of \nthis study is we did not assess the mean pain score according to the \ninstalled volume of contrast medium.\nConclusion\nThe experienced pain after HyFoSy procedure is well-tolerated. \nPatients’ clinical characteristics could predict the anticipated pain; \nhence, considering these characteristics help in physicians’ decision to \ngive pain killer before HyFoSy procedure. Future research is required \nfor large number of patients and should focus on assessing the pain \nduring the stages of HyFoSy procedure.\nAcknowledgments\nThe authors gratefully acknowledge and extend their gratitude’s \nto the research center, King Fahad Medaical City, for the Fund award \n(Number: 015-015). Special thanks to the Intramural fund committee \nfor the guidance and support.\nConflicts of interest\nNone.\nReferences\n1. Zegers–Hochschild F, Adamson GD, De Mouzon J, et al. International \nCommittee For Monitoring Assisted Reproductive Technology \n(ICMART) And The World Health Organization (WHO) Revised \nGlossary Of ART Terminology, 2009. Fertil Steril . 2009;92(5):1520–\n1524.\n2. Steinkeler JA, Woodfield CA, Lazarus E, et al. Female Infertility: \nA Systematic Approach to Radiologic Imaging and Diagnosis. \nRadiographics. 2009;29(5):1353–1370.\n3. Pundir J, El Toukhy T. Uterine Cavity Assessment Prior To IVF. Womens \nHealth (Lond). 2010;6(6):841–847.\n4. Snick HK, Snick TS, Evers JL, et al. The Spontaneous Pregnancy \nPrognosis in Untreated Sub Fertile Couples: The Walcheren Primary \nCare Study. Hum Reprod. 1997;12(7):1582–1588.\n5. Lim CP, Hasafa Z, Bhattacharya S, et al. Should a Hysterosalpingogram \nBe a First–Line Investigation to Diagnose Female Tubal Subfertility in \nthe Modern Subfertility Workup? Hum Reprod. 2011;26(5):967–971.\n6. Emanuel MH, Van Vliet M, Weber M, et al. First Experiences with \nHysterosalpingo–Foam Sonography (Hyfosy) For Office Tubal Patency \nTesting. Hum Reprod. 2011;27(1):114–117.\n7. Suresh YN, Narvekar NN. The Role of Tubal Patency Tests and \nTubal Surgery In The Era Of Assisted Reproductive Techniques. The \nObstetrician & Gynaecologist. 2014;16(1):37–45.\n8. Crosignani PG, Rubin BL. Optimal Use of Infertility Diagnostic Tests \nand Treatments. The ESHRE Capri Workshop Group. Hum Reprod . \n200015(3):723–732.\n9. National Institute for Health and Clinical Excellence, Guidance. Fertility \nProblem Assessment and Treatment. London, UK. 2016;p.14.\n10. Lanzani C, Savasi V , Leone FP, et al. Two–Dimensional Hycosy \nWith Contrast Tuned Imaging Technology And A Second–Generation \nContrast Media For The Assessment Of Tubal Patency In An Infertility \nProgram. Fertil Steril. 2009;92(3):1158–1161.\n11. Dreyer K, Out R, Hompes PG, et al. Hysterosalpingo–Foam Sonography, \nA Less Painful Procedure For Tubal Patency Testing During Fertility \nWorkup Compared With (Serial) Hysterosalpingography: A Randomized \nControlled Trial. Fertil Steril. 2014;102(3):821–825. ‏\n12. Savelli L, Pollastri P, Guerrini M, et al. Tolerability, Side Effects, And \nComplications Of Hysterosalpingo–contrast Sonography (Hycosy). \nFertil Steril. 2009;92(4):1481–1486.\n\nHysterosalpingo-foam sonography, less painful and more instructive as compared with \nhysterosalpingography: a prospective study\n160\nCopyright:\n©2017 Khan et al.\nCitation: Khan F , Mohammed A, Dania AJ, et al. Hysterosalpingo-foam sonography, less painful and more instructive as compared with hysterosalpingography: a \nprospective study. Obstet Gynecol Int J. 2017;6(6):156‒160. DOI: 10.15406/ogij.2017.06.00226\n13. Marci R, Marcucci I, Marcucci AA, et al. Hysterosalpingo–contrast \nSonography (Hycosy): Evaluation Ofthe Pain Perception, Side Effects \nAnd Complications. BMC Med Imaging. 2013;13:28.\n14. Socolov D, Iuliana Boian, Lucian Boiculese, et al. Comparison Of The \nPain Experienced By Infertile Women Undergoing Hysterosalpingo \nContrast Sonography or radiographic Hysterosalpingography. Int J \nGynaecol Obstet. 2010;111(3):256–259.\n15. Rajesh H, Lim SL, Yu SL. Hysterosalpingo–foam sonography: patient \nselection and perspectives. Int J Womens Health. 2017;9:23–32.\n16. Hindocha A, Beere L, O’Flynn H, et al. Pain Relief in \nHysterosalpingography. Cochrane Database of Systemic Reviews  No. \n9. 2015;p.1–5.\n17. Szymusik Iwona, Grzechocinska, Marianowski, et al. Factors \nInfluencing the Severity of Pain during Hysterosalpingography. Int J \nGynaecol Obstet. 2015;129(2):118–122. ‏\n18. Roxana B, Stan A, Steriu M, et al. Fallopian‐Tube Patency Testing By \nHysterosalpingo‐Foam Sonography in Infertility Exploration. Ultrasound \nin Obstetrics & Gynecology. 2015;46:228–228. ‏\n19. Smetanova D, Hynek M, Brezinova S, et al. Hysterosalpingo‐Foam \nSonography: A Technique To Evaluate Uterine Anomalies And Visualise \nTubal Patency. Ultrasound in Obstetrics & Gynecology . 2014;44:355–\n355. ‏\n20. Galaal KA, Deane K, Sangal S, et al. Interventions For reducing Anxiety \nin Women Undergoing Colposcopy. Cochrane database Systemic Rev . \n2007;(3):CD006013.\n21. Van Schoubroeck Dominique, Van den Bosch T, Ameye L, et al. Pain \nduring Fallopian‐Tube Patency Testing By Hysterosalpingo‐Foam \nSonography. Ultrasound Obstet Gynecol. 2015;45(3):346–350. ‏\n22. Chambers GM, Sullivan EA, Shanahan M, et al. Is In Vitro Fertilisation \nMore Effective Than Stimulated Intrauterine Insemination as A First‐\nLine Therapy for Subfertility? A Cohort Analysis. Aust N Z J Obstet \nGynaecol. 201050(3):280–288.\n23. The Practice Committee of the American Society for Reproductive \nMedicine. Effectiveness and Treatment for Unexplained Infertility. \nFertil Steril. 2006;86(5Suppl 1):S111–S114.\n24. Dreyer K, Mijatovic V , Emanuel MH, Hompes PGA. Hysterosalpingo–\nfoam sonography (HyFoSy), a new technique to confirm proximal tubal \nocclusion after treatment of a hydrosalpinx by an Essure device prior \nto in vitro fertilization (IVF). Fertil Steril. 2012;98(3):S224.","source_license":"CC0","license_restricted":false}