Comparative analysis of hysterosalpingography and hysterosalpingo-contrast sonography for assessing tubal patency in women with endometriosis-related infertility: a propensity score-matched study

Archives of Gynecology and Obstetrics https://doi.org/10.1007/s00404-025-08008-4 RESEARCH Comparative analysis of hysterosalpingography and hysterosalpingo‑contrast sonography for assessing tubal patency in women with endometriosis‑related infertility: a propensity score‑matched study Wencai Tian1,4 · Baoli Xie1 · Feng Liang2 · Yingqin Huang3 · Qianwen Hu1 · Jiaxin Yu1 · Aiping Qin1 Received: 9 January 2025 / Accepted: 10 March 2025 © The Author(s) 2025 Abstract Purpose This study aimed to compare the clinical pregnancy rates of hysterosalpingography (HSG) with water-based contrast and hysterosalpingo-contrast sonography (HyCoSy) to investigate their impact on fertility outcomes in women with endometriosis-related infertility. Methods This retrospective study included 296 women with endometriosis-related infertility, aged 18–39, undergoing HSG or HyCoSy at the First Affiliated Hospital of Guangxi Medical University (January 2020–June 2022). Propensity score matching was applied to balance demographic and clinical variables. Clinical pregnancy outcomes were compared between the groups. Results The HSG group showed a higher clinical pregnancy rates compared to the HyCoSy group. Logistic regression demonstrated an odds ratio (OR) of 0.41 (95% CI 0.20–0.82, p < 0.001) for clinical pregnancy in the HyCoSy group compared to HSG. After propensity score matching, the OR was 0.37 (95% CI 0.18–0.75). Similar results were observed across multivariable and IPTW analyses, suggesting that HSG may be associated with better clinical pregnancy outcomes than HyCoSy. Conclusion Hysterosalpingography (HSG) with water-based contrast appears to be associated with higher clinical pregnancy rates compared to HyCoSy in women with endometriosis-related infertility. This suggests that HSG may be a more favorable diagnostic method for optimizing fertility outcomes, though further research is needed to confirm these findings. Keywords Hysterosalpingography (HSG) · Hysterosalpingo-contrast sonography (HyCoSy) · Fertility outcomes · Endometriosis-related infertility · Propensity score matching (PSM) What does this study add to the clinical work * Aiping Qin 1 Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China 2 Gynecology Department, The Reproductive Hospital of Guangxi Zhuang Autonomous Region, Nanning, China 3 Center for Reproductive Medicine, Maternal and Child Health Hospital in Guangxi, Guangxi 530021, China 4 Department of Obstetrics and Gynecology, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, Changsha, China This study suggests that hysterosalpingography (HSG) with water-based contrast appears to improve clinical pregnancy rates compared to hysterosalpingo-contrast sonography (HyCoSy) in women with endometriosis-related infertility. It highlights the importance of selecting diagnostic methods that not only evaluate tubal patency but also help improve fertility outcomes. Vol.:(0123456789) Archives of Gynecology and Obstetrics Introduction Materials and methods Tubal pathology represents a significant contributor to female infertility, with a prevalence ranging from 11 to 30%, often attributed to factors such as infections, prior surgical interventions, or conditions like endometriosis [1, 2]. Consequently, evaluating the fallopian tubes is a fundamental aspect of the fertility assessment process. Hysterosalpingography (HSG) remains the primary choice for assessing tubal patency during fertility investigations [3]. This technique is notable for its potential to improve female fertility. Initially employed for infertility screening and diagnosis [3], the expanded utilization of HSG among infertility patients underscores its efficacy in enhancing fertility outcomes [4–6]. A retrospective cohort study found no significant difference in IUI outcomes between women who underwent HSG and those who had laparoscopy, suggesting both tests have similar effects on treatment success [7]. However, the impact of HSG on fertility may vary based on the type of contrast agent utilized [8]. Research indicates that oilbased contrast agents may have an advantage over their water-based counterparts in enhancing conception in infertile individuals [9]. Hysterosalpingo-contrast sonography (HyCoSy) has emerged as a comparably effective alternative technique. It uses transvaginal ultrasonography combined with the injection of an echogenic contrast agent into the fallopian tubes and uterus to simultaneously visualize the ovaries. Studies have demonstrated that its accuracy in assessing tubal patency parallels that of HSG [10, 11]. Endometriosis is a challenging and complex disorder affecting about 10% of women of reproductive age worldwide [12]. Its prevalence highlights its significance as a contributing factor in intractable infertility cases, accounting for an estimated 30–50% of such instances [13]. Mental health issues, such as depression and anxiety, are also more common among infertile women, especially in Asia [14]. Our team’s earlier research [15] revealed that HSG using oil-based contrast agents may be more effective than water-based agents in increasing fertility in individuals struggling with endometriosis-related infertility. Currently, both HSG and HyCoSy are widely utilized hysterotubal ultrasonography techniques in clinical settings. However, the comparative efficacy of HSG with water-based contrast agents and HyCoSy in improving fertility outcomes in patients with endometriosis-related infertility remains unexplored. To address this question, we conducted a retrospective study comparing the impact of HyCoSy and HSG using iodinated water contrast agents on the success of pregnancies in patients with endometriosis-related infertility. Study design This study included patients who, between January 2020 and June 2022, received either HSG or HyCoSy at the First Affiliated Hospital of Guangxi Medical University due to infertility concurrent with endometriosis. The research protocol was approved by the Ethics Committee of the First Affiliated Hospital of Guangxi Medical University and followed the principles outlined in the STROBE Statement. The inclusion criteria were: (1) female patients aged 18–39 with endometriosis; (2) regular menstrual cycles; and (3) having undergone HSG. Exclusion criteria included: (1) a total motile sperm count after sperm wash of less than 3 million sperm per milliliter in the male partner (or less than 1 million sperm per milliliter in the absence of post-wash analysis); (2) uncontrolled endocrine disorders known to reduce natural pregnancy chances, such as the acute phase of systemic lupus erythematosus; (3) incomplete data. Baseline characteristics of the patients included age, comorbidities, BMI, length of infertility, smoking status, surgical history, total number of prior live births, miscarriages, and treatment after hysterosalpingography procedures. (...truncated)