Kimmy Rosielle



Improving pregnancy chances and patient experiences in infertility Financial support for printing this thesis was kindly provided and supported by the Amsterdam Reproduction & Development (AR&D) research institute, Bridea Medical BV, Chipsoft, Gedeon Richter, Goodlife Pharma, Guerbet and SyncVR. Provided by thesis specialist Ridderprint, ISBN: 978-94-6483-197-9 DOI: Cover design & layout: Marilou Maes, Printing: Ridderprint Copyright © 2023 Kimmy Rosielle All rights reserved. No part of this thesis may be reproduced, stored or transmitted in any form or by any means without the permission of the author.

VRIJE UNIVERSITEIT Improving pregnancy chances and patient experiences in infertility ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad Doctor aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus prof.dr. J.J.G. Geurts, in het openbaar te verdedigen ten overstaan van de promotiecommissie van de Faculteit der Geneeskunde op donderdag 22 juni 2023 om 11.45 uur in een bijeenkomst van de universiteit, De Boelelaan 1105 door Kimmy Rosielle geboren te Doorn

promotoren: prof.dr. V. Mijatovic prof.dr. C.B. Lambalk copromotoren: prof.dr. B.W.J. Mol dr. K. Dreyer promotiecommissie: prof.dr. M.A. Oudijk prof.dr. A. Hoek prof.dr. J.S.E. Laven prof.dr. D. de Neubourg dr. J.W. Kallewaard dr. J.H.T.M. van Waesberghe

CONTENTS Chapter 1 General introduction 7 Chapter 2 How long does the fertility-enhancing effect of hysterosalpingography with oil-based contrast last? Published in Reproductive BioMedicine Online 2020 doi: 10.1016/j.rbmo.2020.- 08.038 23 Chapter 3 Oil-based versus water-based contrast media for hysterosalpingography in infertile women of advanced age, with ovulation disorders or a high risk for tubal pathology: study protocol of a randomized controlled trial (H2Oil2 study) Published in BMC Women’s Health 2022 doi: 10.1186/s12905-022-01707-z 41 Chapter 4 Does the effectiveness of IUI in couples with unexplained subfertility depend on their prognosis of natural conception? A replication of the H2Oil study Published in Human Reproduction Open 2020 doi:10.1093/hropen/hoaa047 61 Chapter 5 Safety of HSG with oil-based contrast medium: a Systematic review Published in Reproductive BioMedicine Online 2021 doi: 10.1016/j.rbmo.2021- .03.014 79 Chapter 6 Virtual Reality for pain relief in hysterosalpingography Manuscript in preparation 129 Chapter 7 Visual tubal patency tests for tubal occlusion and hydrosalpinx Published in Cochrane Database of Systematic Reviews 2022 doi/10.1002/- 14651858.CD014968/full 153 Chapter 8 The impact of the COVID-19 pandemic on infertility patients and endometriosis patients in the Netherlands Published in reproductive BioMedicine Online 2021 rbmo.2021.06.001 1472-6483/ 171 Chapter 9 General discussion and future perspectives 191 Appendix Summary 208 Samenvatting 212 List of authors 216 List of publications 218 PhD portfolio 220 Dankwoord 222 About the author 227

CHAPTER 1 General introduction

8 Chapter 1 INFERTILITY The inability to conceive within 12 months of unprotected intercourse is referred to as infertility, a disease of the female and/or male reproductive system (1, 2). In 2010 the total amount of couples facing infertility was estimated to be 48.5 million couples worldwide (3) which translates to an estimated prevalence of one in six couples trying to conceive (4). More recently, the trend of the prevalence of infertility was modelled based on data from the Global Burden of Disease Study 2017 (5), showing a gradual increase in infertility over time (6). Couples facing infertility can be referred for fertility work-up, a cluster of diagnostic tests investigating the possible causes of infertility in both the female and male partner. The results of the fertility work-up are used to determine the best strategy to fulfil their wish to conceive (7, 8). Causes of female infertility can be categorized as ovulation disorders, diminished ovarian reserve, uterine, ovarian and/ – or tubal pathology. The respective prevalences of these causes vary depending on the studied population (4, 9). Male factor infertility refers to an impaired number of motile spermatozoa which can have a congenital or acquired cause (10). The diagnosis of ‘unexplained infertility’ is made when no abnormalities are found in both the female and male partner during the fertility work-up (7, 8). FERTILITY WORK-UP The first medical step for couples facing infertility is the fertility work-up (see figure 1). Fertility work-up starts with an extensive medical history of both partners to identify risk factors potentially contributing to infertility such as congenital disorders, acquired diseases or surgical interventions. General blood testing is usually performed in women to check the overall health and to screen for a past infection with Chlamydia trachomatis using a Chlamydia trachomatis Antibody Test (CAT). An infection with this sexually transmittable pathogen can go unnoticed in women or manifest itself as clinical pelvic inflammatory disease (PID). A positive CAT has been associated with the occurrence of tubal pathology and intra-abdominal adhesions, however, CAT has a low positive predictive value for tubal factor infertility (11, 12). Other events in the medical history that may indicate a risk for tubal pathology are a history of PID, a complicated appendicitis, pelvic surgery, endometriosis and ectopic pregnancy (13). Gynaecological examination combined with transvaginal ultrasound is performed to rule out gynaecological abnormalities such as congenital uterine anomalies, uterine and adnexal pathology, endometriosis and to assess the ovarian reserve.

9 General introduction 1 Figure 1. The journey from wish to conceive to a live born child for infertile couples from left to right. IMPACT OF COVID-19 Diagnostic qualities Wish to conceive Fertility work-up Treatment Live birth Therapeutic qualities Safety Comfort Couples with a wish to conceive are labelled as ‘infertile’ after 12 months of unsuccesful trying. They can be referred for infertility work-up to diagnose the type of infertility. Depending on the infertility diagnosis, a treatment plan is proposed. The orange words depict the clinical aspects this thesis will adress. TUBAL PATENCY TESTING Tubal patency can be assessed by infusing contrast into the uterine cavity and confirming whether this contrast reaches the intra-abdominal cavity through the Fallopian tubes. Nowadays, there are many factors to take into consideration when determining the most appropriate tubal patency test for women facing infertility. This is represented in the smaller circle of figure 1. The diagnostic quality of a test, the sensitivity and specificity for diagnosing a condition with the given test, is the first factor to take into consideration. Therapeutic qualities refer to any beneficial effect or side-effect of the given test. As with any medical intervention, safety should be considered and lastly, the patient experience should be factored in as well. Different tests for the assessment of tubal patency were developed at the start of the 20th century. An early method of tubal patency test was developed by Rubin in 1919 (14). He initially inflated the uterus with oxygen, and later carbon dioxide (which reduced the risk of a gas embolus considerably due to the ability of haemoglobin to

10 Chapter 1 absorb carbon dioxide), and expected this gas to escape through the Fallopian tubes in case of patency, inducing a pneumoperitoneum. There are several ways to detect this pneumoperitoneum: the gas gives a painful sensation to the shoulder as it irritates the peritoneal cavity, it is often audible by percussion or auscultation of the thorax and it is visible on X-ray. If the gas inflow showed initial high resistance which then decreased, this also confirmed that at least one of the Fallopian tubes was deemed patent (15). This test was not able to differentiate between unilateral or bilateral tubal patency and caused significant discomfort, and therefore other tubal patency tests were developed. At the same time, surgical techniques developed greatly across the 20th century. Initially, laparotomic surgery was the only modality available. Laparotomic surgery comes with a high risk of complications, a long recovery time and it can induce intra-abdominal adhesions at the surgical site. Intra-abdominal adhesions are a known risk factor for tubal infertility and should be prevented where possible. The first laparoscopic surgery in humans was performed in 1910 by the Swedish physician Hans Christian Jacobaeus. The technique has only been used for evaluation of tubal patency since the mid 1980’s when chromopertubation was introduced. During chromopertubation, a methylene blue is inserted into the uterine cavity transvaginally and flow of this dye from the Fallopian tubes into the peritoneal cavity can be visualized directly. Laparoscopy is still considered as the gold standard test for evaluation of tubal patency (16). However, laparoscopy is also invasive and requires full anaesthesia. It is therefore usually reserved for women in whom tubal pathology is suspected by less invasive tubal patency tests, or for women in whom an immediate therapeutic intervention during laparoscopy is desired, for instance in case of endometriosis and/or adhesions. As an outpatient alternative to laparoscopy, transvaginal hydrolaparoscopy, also referred to as fertiloscopy, has been introduced, which consists of a transvaginal hydropelviscopy performed under local anaesthesia (17). This approach allows a complete exploration of the pelvis except for the visualization of the vesico-uterine pouch. Apart from tubal patency testing, it allows direct visualization of the tubal mucosa as salpingoscopy is feasible from the vaginal approach, ovarian drilling and limited adhaesiolysis or electrocoagulation of peritoneal endometriosis. HSG The first visual tubal patency test, hysterosalpingography (HSG), was performed by Rindfleisch in 1910. During HSG, a radiopaque contrast fluid is injected into the uterus transvaginally. Once the uterus and Fallopian tubes fill with contrast, this can be visualized on X-ray images. Using a suspension of bismuth, a non-toxic heavy metal as a contrast medium, his aim was to outline the uterine cavity in order to detect abnormalities of the

11 General introduction 1 uterus (18). Although this provided good diagnostic images, the suspension remained in the body for a long time and therefore another type of contrast medium was sought to replace bismuth. Lipiodol (Guerbet, Villepinte, France), an iodinated oil-solution, was developed in 1901 as a treatment for goiter, syphilis, cardiovascular problems and other diseases (19). Its first use as contrast medium during HSG was described in 1922. HSG with Lipiodol as oil-based contrast became a common tubal patency test in the investigation of infertility, suspected anomalies in the female genital tract and even to visualize and confirm intrauterine pregnancy in an era where pregnancy tests were lacking. Over the following decades, water soluble contrast media were developed as an alternative to oil-based contrast in HSG. The use of the less viscose water-based contrast media facilitated the implementation of serial HSG, during which a series of X-ray images are taken to evaluate the progression of contrast through the reproductive system. This dynamic approach provides more information than the initial HSG procedure where only one image is obtained hours or even a day after infusion of contrast medium to determine whether there is tubal patency (20). In the 1970’s this technique was implemented by tubal surgeons. Before IVF was introduced, tubal surgery was the only option for patients with tubal infertility and serial HSG allowed the surgeon to assess whether surgery could improve fertility. Especially, the visual appearance of water-based contrast made it possible to determine more accurately the preoperative chances of successful tubal reconstructive surgery when compared to the use of oil-based contrast as it is able to show more clearly the mucosal folds in the ampullar part of the tubes. Fertility enhancing effect of tubal flushing Since the 1930’s it has been reported that Lipiodol and later Lipiodol Ultra Fluid during HSG seemed to have a positive effect on the chance of pregnancy (21, 22). This potential pregnancy enhancing effect of oil-based contrast was the topic of interest in the H2Oil study (23). The H2Oil study was a multicentre randomized controlled trial (RCT) in the Netherlands, investigating the difference in ongoing pregnancies in couples with unexplained or mild male infertility within 6 months after tubal flushing during HSG with oil-based or water-based contrast. The 27 participating hospitals included a total of 1119 women, of which 557 women were randomized for HSG with use of oil-based contrast and 562 for water-based contrast. The ongoing pregnancy rate was significantly higher in the group receiving oil-based contrast (39.7 versus 29.1%, rate ratio (RR) 1.37; 95% confidence interval (CI) 1.16 to 1.61; P<0.001). A recent network meta-analysis included the H2Oil study and showed that the chance of clinical pregnancy within six months was significantly higher after tubal flushing with oil-based contrast than after tubal flushing with water-based contrast (five studies included, OR 1.67, 95% CI 1.38-2.03) (24). Live birth as outcome was only reported in two RCT’s (OR 2.18, 95% CI 1.30-3.65) and the certainty of evidence was low. The studies in this network meta-analysis mostly included

12 Chapter 1 couples with unexplained or mild male infertility. Since the publication of this network meta-analysis, a Cochrane systematic review on this topic was published in 2020 which confirmed these findings (25). A Chinese replication study of the original H2Oil study was published in 2022, also showing a similar difference in ongoing pregnancy after the use of oil-based contrast during HSG when compared to water-based contrast (29.1 versus 20.1%, RR 1.44 , 95% CI 1.15-1.81, p=0.001) as well as a shorter time to pregnancy in favour of oil-based contrast (26). Results of large studies on the effect of tubal flushing in couples with other factors of infertility such as ovulation disorders, high risk of tubal pathology and advanced female age are currently lacking. Potential mechanisms To obtain a better understanding of which patient groups will benefit from the use of oil-based flushing, it is relevant to unravel the mechanism of action of the fertility enhancing effect. Different hypotheses explaining the mechanism have been formulated (27), placing the points of action in the endometrium (28), the fallopian tube (29), and the peritoneum (30, 31). The first theory is that the oil-based contrast, derived from poppy seed oil, affects the receptivity of the endometrium through opium receptors present in endometrial cells (32). This may enhance embryo implantation. Another theory hypothesizes that tubal flushing with oil-based contrast flushes accumulated debris and mucous plugs from the proximal part of the otherwise undamaged tubes, enhancing patency and improving the tubal cilia operation (27, 29). A post-hoc analysis of the H2Oil-study showed that the benefit of oil-based contrast is especially visible in women with higher pain scores during HSG, as in women with moderate to severe pain during HSG, the ongoing pregnancy rate was higher following the use of oil-based contrast compared to the use of water-based contrast (33). In women with lower pain scores, there was no difference in ongoing pregnancy rates between oil-based or water-based contrast. These results support the hypothesis that the fertility enhancing effect is associated with a mechanical flushing effect in the fallopian tube. The reported pain is presumed to be caused by an increase in intrauterine pressure prior to dislodgment of pregnancyhindering debris from the proximal part of otherwise anatomically normal fallopian tubes. One of the several differences in the chemical and physical characteristics between the two types of contrast media might be responsible for the increased flushing potential of oil-based contrast (33). Another possible mechanism taking place in the Fallopian tubes is enhancement of ciliary activity when the oil-based contrast surrounds the cilia and reduces friction. A decrease in friction will improve the function of the cilia, generating flow inside the Fallopian tubes and facilitating transport of gametes (27).

13 General introduction 1 Another theory is modulation of peritoneal macrophage activity by oil-based contrast which affects the conception and implantation mechanism positively (30). In vitro studies have demonstrated that oil-based contrast inhibits phagocytosis of macrophages in humans and rats, perchance phagocytosis of sperm (30, 31). A study by Izumi et al. confirms that oil-based contrast is incorporated in dendritic cells in the peritoneal cavity (34). By promoting more mature dendritic cells, altering cytokine and chemokines profiles in dendritic cells and increasing the number of T-cells, this modulates the immunological environment in the peritoneal cavity. Mature dendritic cells are likely to show decreased activity in sperm phagocytosis. Furthermore, the cytokine IL-10 in the endometrium is upregulated by oil-based contrast while a low presence of IL-10 has been related to repeated implantation failure. Together these may contribute to the fertility enhancing effect of HSG with oil contrast (34). In addition to the above mentioned hypotheses, it is possible that tubal flushing during HSG improves sperm transport through the cervix (35) as HSG requires manipulation and instrumentation to the cervix. Further research, both fundamental and clinical, is needed in order to provide more insight into the true mechanism(s), duration and dynamics of action of oil-based contrast. Safety Shortly after the first reports on the use of HSGs for the treatment of infertility, publications reporting on complications of HSG with Lipiodol emerged. The main severe complication was flow of contrast into the myometrial vessels, potentially leading to contrast entering the venous or lymphatic system (36). This complication is referred to as intravasation and may cause allergic reactions and oil embolisms with potentially harmful or even fatal results (37). Intravasation was attributed to the high viscosity and hydrophobic qualities of Lipiodol and therefore less viscose contrast media were developed, resulting in Lipiodol Ultra Fluid and various types of water-based contrast media (19). In a recent survey study, intravasation of oil-based contrast during HSG was estimated to occur in 5% of the cases in the Netherlands (38). An overview of the complete literature on the differences in complication rates between HSG with oil-based contrast and waterbased contrast is lacking. Discomfort Aside from the complication risk, HSG comes with several other downsides. Performing an HSG exposes the woman to ionizing radiation and requires the presence of a radiology department and radiographer. Additionally, HSG is usually experienced as

14 Chapter 1 uncomfortable or painful with a median pain score of 5.0 (VAS, scale 0.0-10.0) (33). Discomfort or pain during HSG can be caused by various steps of the procedure; installing the instrumentation, infusion of contrast and subsequent filling of the uterine cavity with pressure build-up, and finally spillage of contrast into the peritoneal cavity. Several analgesic interventions to support an HSG have been suggested, including topical (a spray on the cervix or intrauterine installations), oral, locally injected and intravenous pain medication. Meta-analysis only showed an effect for intravenous opioid analgesia (mean difference (MD) -3.53, 95% CI -4.29 to -2.77) and topical analgesics (MD -0.63 95% CI -1.06 to -0.19) when compared to placebo or no treatment (39). As intravenous opioids can lead to significant side effects and risks this requires continuous monitoring and is not a suitable option in most settings. The effect of topical analgesics is very small and the clinical relevance of this reduction in pain perception can be debated. Therefore, an effective method for pain relief during HSG, with a low risk profile, is needed. A relatively novel and innovative technique for non-pharmaceutical pain relief is the use of Virtual Reality (VR). This therapy is delivered through a head-mounted device, covering the eyes and optionally the ears, to take the user into a virtual world. Viewing and interacting with the virtual world distracts the user from physical stimuli and has been proven effective in the reduction of acute pain and pain caused by medical procedures (40). Virtual Reality has the potential to improve patient experiences during HSG by providing pain relief in addition to currently used pharmacological pain relief. Alternatives to HSG Other visual tubal patency tests have been developed that are more tolerable, are less invasive, are easier to perform and/or are less expensive when compared to surgery or HSG. In these tests, ionizing or echogenic contrast or coloured dye is infused into the cervix transvaginally, to detect whether there is overflow of contrast from the Fallopian tubes into the peritoneal cavity. The most common alternatives to HSG are hysterosalpingo-foam sonography (HyFoSy), hysterosalpingo-contrast sonography (HyCoSy), transvaginal hydrolaparoscopy (THL / fertiloscopy), and magnetic resonance hysterosalpingography (MR-HSG) (41). These alternatives have been investigated and compared to HSG and/or laparoscopy with varying results and there currently is no consensus on the diagnostic quality of each of these tests. The role or place of these tests is not yet established and therefore a comparative review is warranted.

15 General introduction 1 During HyFoSy, a foamy contrast liquid is inserted into the uterus transvaginally while at the same time a transvaginal ultrasound is made. The contrast contains air bubbles that give an echogenic reflection on the ultrasound monitor. As the contrast enters the genital tract, the shape of the uterine cavity and Fallopian tubes will be delineated and tubal patency can be established. This diagnostic procedure can be conducted by a gynaecologist, fertility doctor, nurse or sonographist and does not require radiation or the use of iodinated contrast A recent large multicentre RCT, the FOAM study, compared management based on the results of HyFoSy with management based on the results of HSG (42). The study concluded that management based on the results of the HyFoSy result in an equal number of pregnancies as management based on the results of HSG (difference -1.2%; 95% CI: -3.4% to 1.5%). Due to the design of the study, the therapeutic effect of the individually used tests could not be evaluated as all participants underwent both HyFoSy and HSG in a randomized order. The mean pain score, a secondary outcome of this study, was significantly lower for HyFoSy than for HSG (3.1 standard deviation 2.2) for HyFoSy and 5.4 (standard deviation 2.5) for HSG (p<0.001) which is in line with previous research reporting low pain scores during HyFoSy (43). TREATMENT OF INFERTILITY Depending on the results of the fertility work-up, and taking into account prognostic factors for conception, a treatment plan will be determined as can be seen in Figure 1 on the right hand side. There is a large variability in treatment options and strategies between different countries and regions. While in some countries a prognostic model such as the Hunault model is used (44), other countries rely on female age or duration of infertility alone in the decision to go for expectant management or start fertility treatment. Prognostic models have been developed to guide physicians in determining the best treatment strategy for the individual couple aiming to prevent overtreatment. The prognostic model of Hunault (44) takes into account female age, duration of infertility, referral status, whether the woman is facing primary or secondary infertility and the motility of the male partners semen. The algorithm then calculates the chance of natural conception within 12 months based on the given parameters. A prognosis of ≥30% chance of natural conception within 12 months will guide physicians to counsel patients for expectant management for a period of 6-12 months (45).

16 Chapter 1 PSYCHOLOGICAL IMPACT The treatment of infertility, whether this is an advice for expectant management or medically assisted reproduction (MAR) technique, poses a high psychological burden (46). The entire path of infertility, from the wish to conceive to fertility treatments, is associated with an increased stress level and a reduced quality of life for both women and men (47, 48) (see figure 1). The uncertainty, prolonged unfulfilled wish for a child and repeated setbacks have a large impact on wellbeing in general. Coronavirus Disease 2019 (COVID-19) led to a pandemic during the course of this PhDtrack and was a big cause for stress and a reduced quality of life for people worldwide as it impacted the economy and led to environmental, health-related and political problems (49). As the path of infertility, COVID-19 came with great uncertainty and repeated setbacks. Being quarantined seems to impact women more than man; women showed a higher anxiety level and lower quality of life than man during the pandemic in a Spanish study (50). During the pandemic, governments and health care institutions had to relocate health care workers and available resources in order to focus on the care for patients with COVID-19, and measures had to be taken to prevent further spread of the disease, which resulted in several lockdowns and a halt in healthcare for patients with non-threatening diseases. In the Netherlands, all fertility care was stopped completely in March 2020 except for patients in need of fertility preservation due to oncological indications. From May 2020, fertility care was slowly restarted but remained at a lower capacity (approximately 70% in comparison to 2019) due to the preventative measures in all hospitals and clinics up to the spring of 2022. This resulted in couples with infertility being put on hold for a prolonged period before fertility work-up could start and they found themselves in growing uncertainty. In addition, due to the lower capacity of infertility clinics, patients faced long waiting lists for fertility treatments as well. Although infertility is not a life threatening disease, it is likely that the COVID-19 pandemic has aggravated the psychological burden that infertility is associated with. AIM OF THIS THESIS In this thesis, we continue where the H2Oil-study (23) and it’s follow-up study (51) have left us. As the fertility enhancing effect of oil-based contrast is now established for women with unexplained infertility and a low risk for tubal pathology, we want to examine the safety of this contrast, the duration of the fertility enhancing effect, and

17 General introduction 1 whether the fertility enhancing effect is also present in other subgroups of infertile women. Furthermore we want to compare the diagnostic quality of the HSG with more contemporary tubal patency tests and examine an innovative method for pain reduction during HSG. As the recent COVID-19 pandemic had an profound global effect on elective health care, we wanted to investigate the psychological impact of the COVID-19 pandemic on women facing infertility. OUTLINE In Chapter 2, we start with an investigation into the duration of the fertility enhancing effect of tubal flushing with oil-based contrast in women with idiopathic infertility. With this secondary analysis of the H2Oil study and it’s follow-up study, we aim to gain more insight in the mechanism of action of the fertility enhancing effect of oil-based contrast. In this chapter, we will answer the question: Does the fertility-enhancing effect of tubal flushing during HSG change over time? The H2Oil study excluded three important subgroups of women: women of advanced age (39 years of age or over), women with an increased risk for tubal pathology based on their medical history and women with ovulation disorders. In chapter 3 we present the H2Oil2 study, an ongoing international randomized controlled trial in which we study these three groups that were excluded from the H2Oil study. The research question is: What is the effectiveness and cost-effectiveness of the use of oil-based versus waterbased contrast medium during HSG in terms of live birth in women who are 39 years or older, women wo have a high risk for tubal pathology or who have an ovulation disorder? The results of this study together with its cost-effectiveness analysis will help clinicians and policy-makers to determine what the most appropriate use of contrast is for each patient group. In Chapter 4 we also look into the most appropriate use of resources for specific patient groups. Using the H2Oil-study database, we tested the previously studied hypothesis that IUI has a greater beneficial effect on pregnancy chances than expectant management in couples with a low prognosis for natural conception compared to couples with a good prognosis. The research question was: Can we replicate the finding that the benefit of IUI-ovarian stimulation compared to expectant management for couples with unexplained infertility depends on the prognosis of natural conception? Aside from the beneficial effect of HSG with oil-based contrast, we also look at potential downsides in this thesis. Chapter 5 gives an overview of all literature reports on

18 Chapter 1 complications after HSG with oil-based contrast and the potential differences with the safety profile of water-based contrast. It answers the question: What are the frequencies of complications during or after an HSG with oil-based contrast in infertile women and/ or their offspring? Another downside of HSG is the discomfort or pain that patients experience during the procedure. In chapter 6 we explore whether the use of virtual reality can improve the patient experience by distraction and relaxation. The research question in this chapter is: Is Virtual Reality an effective tool to reduce procedural pain during HSG? After several studies investigating HSG, we will also look into other visual tubal patency tests. We are performing a review comparing the diagnostic test accuracy of the most commonly used tubal patency tests: HSG, HyFoSy, HyCoSy, THL and MR-HSG. The protocol for this study, designed to answer the question ‘What is the diagnostic accuracy of the various types of visual tubal patency tests for diagnosing tubal occlusion?’ can be found in chapter 7. Finally, we conduct a national survey study among women whose fertility work-up or treatment or endometriosis treatment was paused due to the COVID-19 pandemic in 2020. With this survey we want to answer the following research question: What is the impact of the treatment pause on quality of life and quality of care of patients with infertility or endometriosis in the Netherlands? The results are presented in chapter 8.

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20 Chapter 1 23. 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. N Engl J Med. 2017;376(21):2043-52. 24. Wang R, van Welie N, van Rijswijk J, Johnson NP, Norman RJ, Dreyer K, et al. Effectiveness on fertility outcome of tubal flushing with different contrast media: systematic review and network meta-analysis. Ultrasound Obstet Gynecol. 2019;54(2):172-81. 25. Wang R, Watson A, Johnson N, Cheung K, Fitzgerald C, Mol BWJ, et al. Tubal flushing for subfertility. Cochrane Database Syst Rev. 2020;10:CD003718. 26. Zhang J, Lan W, Wang Y, Chen K, Zhang G, Yang W, et al. Ethiodized poppyseed oil-based contrast medium is superior to water-based contrast medium during hysterosalpingography regarding image quality improvement and fertility enhancement: A multicentric, randomized and controlled trial. EClinicalMedicine. 2022;46:101363. 27. Roest I, Hajiyavand AM, Bongers MY, Mijatovic V, Mol BWJ, Koks CAM, et al. What is the fertility-enhancing effect of tubal flushing? A hypothesis article. J Obstet Gynaecol. 2022:1-7. 28. Johnson NP, Bhattu S, Wagner A, Blake DA, Chamley LW. Lipiodol alters murine uterine dendritic cell populations: a potential mechanism for the fertility-enhancing effect of lipiodol. Fertil Steril. 2005;83(6):1814-21. 29. Kerin JF, Williams DB, San Roman GA, Pearlstone AC, Grundfest WS, Surrey ES. Falloposcopic classification and treatment of fallopian tube lumen disease. Fertility and Sterility. 1992;57(4):731-41. 30. Johnson JV, Montoya IA, Olive DL. Ethiodol oil contrast medium inhibits macrophage phagocytosis and adherence by altering membrane electronegativity and microviscosity. Fertility and Sterility. 1992;58(3):511-7. 31. Mikulska D, Kurzawa R, Rozewicka L. Morphology of in vitro sperm phagocytosis by rat peritoneal macrophages under influence of oily contrast medium (Lipiodol). Acta Eur Fert. 1994. 32. Totorikaguena L, Olabarrieta E, Matorras R, Alonso E, Agirregoitia E, Agirregoitia N. Mu opioid receptor in the human endometrium: dynamics of its expression and localization during the menstrual cycle. Fertil Steril. 2017;107(4):1070-7 e1. 33. van Welie N, Dreyer K, van Rijswijk J, Verhoeve HR, Goddijn M, Nap AW, et al. Treatment effect of oil-based contrast is related to experienced pain at HSG: a post-hoc analysis of the randomised H2Oil study. Hum Reprod. 2019;34(12):2391-8. 34. Izumi G, Koga K, Takamura M, Bo W, Nagai M, Miyashita M, et al. Oil-Soluble Contrast Medium (OSCM) for Hysterosalpingography Modulates Dendritic Cell and Regulatory T Cell Profiles in the Peritoneal Cavity: A Possible Mechanism by Which OSCM Enhances Fertility. J Immunol. 2017;198(11):4277-84. 35. Suarez SS, Pacey AA. Sperm transport in the female reproductive tract. Hum Reprod Update. 2006;12(1):23-37. 36. Robins SA, Shapira AA. The value of hysterosalpingography: a study of 1000 cases. N Engl J Med. 1931;205:380-95. 37. Dusak A, Soydinc HE, Onder H, Ekinci F, Goruk NY, Hamidi C, et al. Venous intravasation as a complication and potential pitfall during hysterosalpingography: re-emerging study with a novel classification. J Clin Imaging Sci. 2013;3:67. 38. Roest I, van Welie N, Mijatovic V, Dreyer K, Bongers M, Koks C, et al. Complications after hysterosalpingography with oil- or water-based contrast: results of a nationwide survey. Hum Reprod Open. 2020;2020(1):hoz045. 39. Hindocha A, Beere L, O’Flynn H, Watson A, Ahmad G. Pain relief in hysterosalpingography. Cochrane Database Syst Rev. 2015(9):CD006106. 40. Mallari B, Spaeth EK, Goh H, Boyd BS. Virtual reality as an analgesic for acute and chronic pain in adults: a systematic review and meta-analysis. J Pain Res. 2019;12:2053-85.

21 General introduction 1 41. Grigovich M, Kacharia VS, Bharwani N, Hemingway A, Mijatovic V, Rodgers S. Evaluating Fallopian tube patency: wha the radiologist needs to know. RadioGraphics. 2021;41(6). 42. van Welie N, van Rijswijk J, Dreyer K, van Hooff MHA, de Bruin JP, Verhoeve HR, et al. Can hysterosalpingo-foam sonography replace hysterosalpingography as first-choice tubal patency test? A randomized non-inferiority trial. Hum Reprod. 2022;37(5):969-79. 43. Dreyer K, Out R, Hompes PG, Mijatovic V. Hysterosalpingo-foam sonography, a less painful procedure for tubal patency testing during fertility workup compared with (serial) hysterosalpingography: a randomized controlled trial. Fertil Steril. 2014;102(3):821-5. 44. Hunault CC, Habbema JD, Eijkemans MJ, Collins JA, Evers JL, te Velde ER. Two new prediction rules for spontaneous pregnancy leading to live birth among subfertile couples, based on the synthesis of three previous models. Hum Reprod. 2004;19(9):2019-26. 45. Guideline-Unexplained infertility: Dutch Society of Obstetrics and Gynaecology; 2020 [Available from: 46. Cousineau TM, Domar AD. Psychological impact of infertility. Best Pract Res Clin Obstet Gynaecol. 2007;21(2):293-308. 47. Aarts JW, van Empel IW, Boivin J, Nelen WL, Kremer JA, Verhaak CM. Relationship between quality of life and distress in infertility: a validation study of the Dutch FertiQoL. Hum Reprod. 2011;26(5):1112-8. 48. Chachamovich JR, Chachamovich E, Ezer H, Fleck MP, Knauth D, Passos EP. Investigating quality of life and health-related quality of life in infertility: a systematic review. J Psychosom Obstet Gynaecol. 2010;31(2):101-10. 49. El Keshky MES, Basyouni SS, Al Sabban AM. Getting Through COVID-19: The Pandemic’s Impact on the Psychology of Sustainability, Quality of Life, and the Global Economy - A Systematic Review. Front Psychol. 2020;11:585897. 50. Ferreira LN, Pereira LN, da Fe Bras M, Ilchuk K. Quality of life under the COVID-19 quarantine. Qual Life Res. 2021;30(5):1389-405. 51. van Rijswijk J, van Welie N, Dreyer K, Pham CT, Verhoeve HR, Hoek A, et al. Tubal flushing with oil-based or water-based contrast at hysterosalpingography for infertility: long-term reproductive outcomes of a randomized trial. Fertil Steril. 2020;114(1):155-62.

CHAPTER 2 How long does the fertility-enhancing effect of hysterosalpingography with oil-based contrast last? Kimmy Rosielle‡, Nienke van Welie‡, Kim Dreyer, Joukje van Rijswijk, Cornelis B. Lambalk, Nan van Geloven, Velja Mijatovic, Ben Willem J. Mol, Rik van Eekelen, on behalf of the H2Oil Study Group ‡These authors contributed equally to this work. Reprod Biomed Online. 2020 Dec;41(6):1038-1044

24 Chapter 2 ABSTRACT Research question Does the fertility-enhancing effect of tubal flushing during hysterosalpingography (HSG) with oil-based contrast change over time? Design This was a secondary analysis of the H2Oil (long-term follow-up) study, a multicentre randomized controlled trial evaluating the effectiveness of oil-based and water-based contrast during HSG. The main outcome was ongoing pregnancy. Cox proportional hazards models for time to ongoing pregnancy were fitted over 3 years of follow-up. Results Data on 1107 couples were available; 550 couples had oil-based contrast and 557 waterbased contrast at HSG. Ongoing pregnancy rates after 3 years were 77% and 71%, respectively. Median follow-up was 9–10 months (5th—95th percentile: <1 to 36). The hazard ratio for ongoing pregnancy for oil versus water over 3 years of follow-up was 1.26 (95% confidence interval [CI] 1.10–1.45). The scaled Schoenfeld residual plots showed a decrease in hazard ratio that was linear with log-transformed time. After including an interaction with log-transformed time, the hazard ratio immediately after HSG was 1.71 (95% CI 1.27–2.31) and reduced to no effect (hazard ratio of 1) at approximately 2 years. There was no evidence for a change in hazard ratio over time in a subgroup of women who experienced pain during HSG. Conclusions The hazard ratio for ongoing pregnancy of oil-based versus water-based contrast was 1.71 immediately after HSG, gradually decreasing and plateauing towards a hazard ratio of 1 (indicating no effect) after approximately 2 years. This supports the hypothesis that oil-based contrast might dislodge debris or mucus plugs from the Fallopian tubes, but this has yet to be definitively proved.

25 Duration of the fertility enhancing effect of HSG with oil-based contrast 2 INTRODUCTION Hysterosalpingography (HSG) is a commonly applied tubal patency test during fertility workup (1, 2). Although it was first introduced as a diagnostic test, therapeutic effects have been debated in studies for many years, especially regarding HSG with use of oilbased contrast (3). In 2017, a multicentre randomized controlled trial (RCT) (under the name of the H2Oil study) showed that HSG using oil-based contrast resulted in a 10% higher absolute ongoing pregnancy rate within 6 months compared with the use of water-based contrast (relative risk 1.37, 95% CI 1.16–1.61) (4). Two subsequent meta-analyses confirmed these findings (5, 6). The most recent meta-analysis aimed to evaluate the long-term effects of tubal flushing; however, only three studies reported a follow-up of more than 12 months, so no definitive conclusions could be drawn (6). This emphasized the need for long-term follow-up studies. Recently, the long-term reproductive outcomes of HSG with oil-based versus water-based contrast have been published (under the name of the H2Oil follow-up study). Over a 5-year follow-up period, HSG with oil-based contrast during fertility workup resulted in more ongoing pregnancies, more live births and a shorter time to pregnancy compared with HSG with water-based contrast (7). However, it remained uncertain whether the 5-year effect was explained by the initial effect of oil-based contrast immediately after HSG or whether the effect was long(er) lasting. Exploring the duration of this fertilityenhancing effect might provide more information on the mechanism of effect of oilbased contrast. To date, this has remained unclear. Several potential mechanisms have been suggested. They can be categorized according to their location of action: the fallopian tube, the endometrium and the peritoneum. First, tubal flushing, i.e. mechanical flushing of debris or mucus plugs or unblocking of peritubal adhesions, can clear passage of otherwise normal fallopian tubes (8). Second, uterine bathing with oil-based contrast can enhance endometrial receptivity. Oil-based contrast is produced from poppy seed and contains opium alkaloids, which potentially interact with opioid receptors in the endometrium (9) or through alterations of the uterine immune response (10). A third potential mechanism is that oil-based contrast reduces peritoneal macrophage phagocytosis and macrophage adherence, by forming an oily layer over the macrophages changing their shape and surface configuration (11). Previous studies showed that sperm phagocytosis is inhibited in vitro by oil-based contrast (12, 13).

26 Chapter 2 More knowledge on the duration of the fertility-enhancing effect of oil-based contrast might contribute to the understanding of the underlying mechanism. It was postulated that an effect on the endometrium or on the immune response in the peritoneum would be short lasting, and that dislodging of mucus or debris from the proximal parts of the Fallopian tubes might be painful but longer lasting (i.e. over multiple cycles). This information can contribute to the search for the mechanism underlying the fertilityenhancing effect of oil-based contrast. The present study investigated whether or not the fertility-enhancing effect of HSG using oil- versus water-based contrast would change over time. MATERIALS AND METHODS The H2Oil study was a multicentre RCT comparing oil-based and water-based contrast in women scheduled for HSG during their fertility workup (Netherlands Trial Register [NTR] 3270) and was approved by the Institutional Review Board of the Amsterdam University Medical Centre – Academic Medical Centre (reference 2008.362, dated 12 February 2009). The H2Oil follow-up study assessed the long-term outcomes of the H2Oil trial (NTR 6577) and was approved by the Institutional Review Board of the Amsterdam University Medical Centre – VU University Medical Centre (reference 2017.221, dated 14 June 2017). Study details and results have previously been published (4, 7). In short, the H2Oil trial recruited a total of 1119 participants in a network of 27 hospitals in the Netherlands between 3 February 2012 and 29 October 2014 (4). Participating infertile women were aged between 18 and 39 years, had an ovulatory cycle, had a low risk of tubal pathology according to their medical history, were without known endocrine disorders and had partners that had a total motile sperm count after sperm wash of more than 3 million/ ml. They had been trying to conceive for at least 1 year and were scheduled for tubal patency testing with HSG at the end of the fertility workup. After informed consent, couples were randomized for HSG with oil-based contrast or water-based contrast. In the H2Oil follow-up study, data regarding fertility treatments and pregnancies were collected until 3–5 years after randomization (7). Study outcomes The main outcome was ongoing pregnancy, defined as an ultrasound-confirmed positive heartbeat beyond 12 weeks of gestation. Additional to various other pregnancy outcomes, data on fertility treatments were collected. The start of follow-up was defined as 2 weeks before HSG (reflecting the first day of the menstruation before HSG). Time to pregnancy was defined as 2 weeks before HSG to the first day of menstruation before

27 Duration of the fertility enhancing effect of HSG with oil-based contrast 2 conception leading to an ongoing pregnancy, loss to follow-up or end of study follow-up, whichever occurred first. Median follow-up was calculated as the 50th percentile in all numerical follow-up values. Pain experienced during HSG was reported using a visual analogue scale (VAS) score (range 0.0 to 10.0 in centimetres). Primary analysis For long-term follow-up up to 3 years, first a Cox proportional hazards model was fitted for time to pregnancy data with the randomization allocation, i.e. oil versus water, and the overall hazard. Scaled Schoenfeld residuals were then derived and plotted to visualize the change in log hazard ratio over time; a chi-squared test was applied to the residuals to test the plausibility of the proportional hazards assumption that ‘the relative effect is stable over time’ (14). For these tests and plots, both regular time and log-transformed time were used. The non-linear and linear interactions transformed time were added to the Cox model, and the best fitting model was determined by looking at the P-value for the interaction and/or whether the model had lowest Akaike information criterion (AIC) (15, 16). This best-fitting model was used to quantify the change of effect of oil- versus water-based contrast over time by estimating hazard ratios at different time points during follow-up: at 2 weeks of follow-up (which is directly after HSG), and after 1 month (which is the start of the next menstrual cycle after HSG), 3 months, 6 months, 9 months, 1 year, 2 years and 3 years. The number of pregnancies per group per cycle during the first 6 months after HSG and their relative risks were tabulated to look for a trend over time shortly after HSG. Sensitivity analyses Three sensitivity analyses were conducted. For the first, it was postulated that women might experience pain at HSG when the contrast fluid removed debris or mucus plugs from their Fallopian tubes. If this were the mechanism of action, there might not be any change over time in the effect of oil-based contrast versus water-based contrast in this group. To test this, the steps from the primary statistical analysis were repeated in the subgroup of women who experienced pain during the HSG procedure, defined as a pain score of 6 points or more on the VAS. Second, it was postulated that starting IVF at some point during follow-up might distort the effect of oil versus water given the hypothesis that oil-based contrast would flush debris or mucus plugs, as IVF bypasses the Fallopian tubes. For this reason, follow-up was censored, i.e. stopped, when couples started IVF, and the steps in the primary statistical analysis were repeated.