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Safety of Lipiodol use for assessment of tubal patency and therapeutic tubal flushing – Fluoroscopy versus ultrasound?

Oil-soluble contrast media (OSCM) were routinely used for assessment of fallopian tubal patency for many decades, but were subsequently superceded by water-soluble contrast media (WSCM) in the 1980s, due to perceived superior safety profiles and fewer technical challenges. In 2017, a large, multicentre, randomised trial (H2OIL trial) compared women with unexplained infertility undergoing a diagnostic hysterosalpingogram (HSG), utilising fluoroscopy with either Lipiodol (OSCM) or WSCM. An increased ongoing pregnancy rate of 39.7% was demonstrated in the Lipiodol group, compared with 29.1% in the WSCM group. As a result of the subsequent renewed interest in Lipiodol tubal flushing, ultrasound techniques previously used for assessment of tubal patency have been adopted for use with Lipiodol. The number of ultrasound Lipiodol tubal flushing procedures is increasing rapidly in Australia and New Zealand, with ultrasound being considered desirable due to the lack of radiation, ready availability of ultrasound and limited availability of fluoroscopy units. An RANZCR media release from 18 October 2019 further validated the use of ultrasound for Lipiodol procedures, stating that ‘using ultrasound rather than X-ray to guide flushing of the uterus and fallopian tubes can increase pregnancy rates and avoid unnecessary radiation exposure’. There is already extensive historical and more recent evidence that Lipiodol can be safely instilled into the uterus and fallopian tubes under fluoroscopic guidance. However, the safety of Lipiodol tubal flushing procedures using ultrasound has not been established. Lipiodol is a radiographic contrast agent, developed for use under conditions of radiographic visualisation. The potentially suboptimal soft tissue contrast/visibility of Lipiodol and limited field of view with ultrasound may have potential safety implications with regards to early detection of intravasation and reducing the risk of iodine toxicity related to excessive peritoneal spill of Lipiodol. Based on our experience of over 1000 Lipiodol studies using fluoroscopy, we consider that myometrial intravasation is likely to be detected more promptly using fluoroscopy, with smaller volumes of Lipiodol needed for confirmation of bilateral tubal flushing.