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Table of Contents
Year : 2021  |  Volume : 14  |  Issue : 3  |  Page : 120-123

First experience with hysterosalpingo-foam sonography (HyFoSy) for office tubal patency testing in Dubai hospital

Department of Obstetrics and Gynecology, Dubai Hospital, Dubai, UAE

Date of Submission22-Dec-2020
Date of Decision25-Jul-2021
Date of Acceptance14-Aug-2021
Date of Web Publication01-Oct-2021

Correspondence Address:
Tazeen Makhdoom
Department of Obstetrics and Gynecology, Dubai Hospital, Dubai
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hmj.hmj_100_20

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Background: The present study was conducted to describe the first experience with hysterosalpingo-foam sonography (HyFoSy) as a routine office procedure to check for tubal patency in infertility clinic of Dubai Hospital. Materials and Methods: A retrospective, observational study was conducted. Hundred patients with subfertility and low risk of tubal pathology were examined. A non-toxic HyFoSy foam containing hydroxymethyl cellulose and glycerol was applied through the cervical applicator for contrast sonography. Tubal patency was determined by transvaginal ultrasound by demonstrating echogenic dispersion of foam in Fallopian tubes and or in the peritoneal cavity. Only in cases where patency could not be demonstrated, hystosalpingogram/laparoscopy was performed as a control. Inclusion Criteria: All patients who underwent HyFoSy in infertility clinic in Dubai hospital were included in the study. Exclusion Criteria: Any patient with active tubal disease such as pelvic inflammatory disease, endometriosis and previous ectopic pregnancy were excluded from the study. Results: One hundred patients were observed in the study. HyFoSy was successful in 97 patients (97%) and was failed in three patients (3%). Bilateral patency was seen in 72 patients (74%), bilateral blockage was seen in six cases (6.1%), delayed spill was seen in five patients (5%) and hydrosalpinx was found in 1 patient (1%). Antibiotics were given to 97 patients (100%). Out of the 97 patients who successfully underwent HyFoSy, 17 conceived within 6 months after the procedure. Conclusion: HyFoSy is a successful procedure to demonstrate tubal patency as the first step office procedure.

Keywords: Hystosalpingogram, pelvic inflammatory disease, subfertility, tubal patency test, ultrasound

How to cite this article:
Makhdoom T, Khalid L, Hubaishi N. First experience with hysterosalpingo-foam sonography (HyFoSy) for office tubal patency testing in Dubai hospital. Hamdan Med J 2021;14:120-3

How to cite this URL:
Makhdoom T, Khalid L, Hubaishi N. First experience with hysterosalpingo-foam sonography (HyFoSy) for office tubal patency testing in Dubai hospital. Hamdan Med J [serial online] 2021 [cited 2021 Dec 7];14:120-3. Available from: http://www.hamdanjournal.org/text.asp?2021/14/3/120/327422

  Introduction Top

Tubal patency testing is an essential part of female subfertility evaluation. About 30%–40% of female subfertile patients suffer from tubal abnormalities.[1] Tubal disease comprises of various different pathologies such as obstruction, stenosis, dilation and impaired peristaltic function.[2] The most common cause of tubal pathology is pelvic inflammatory disease (PID).[2] Fibroids, previous pelvic surgery, endometriosis and pelvic tuberculosis are some of the other important causes of tubal factor infertility.[2] The location and severity of the tubal pathology are used to determine the treatment for tubal infertility.[2] An incorrect diagnosis may result in in vitro fertilisation (IVF) or an unwanted tubal reconstructive surgery, that is why accurate evaluation of  Fallopian tube More Detailss is crucial.[2] Laparoscopy with a dye test, hysterosalpingography (HSG), selective salpingography, hysterosalpingo-contrast sonography (HyCoSy) and hysterosalpingo-foam sonography (HyFoSy) are some of the available tests to check for tubal patency. Screening for a tubal occlusion using hysterosalpingo-contrast-ultrasonography should be considered, wherever facilities and expertise are available. For women who do not have co-morbidities, it is an effective alternative to hysterosalpingography.[3] For diagnosing tubal blockage, sonohysterography with the use of contrast medium is better than hysterosalpingography and comparable to laparoscopic chromotubation.[4] HyFoSy is a relatively new technique introduced in Dubai hospital in 2015 and gradually became an essential part of infertility investigation for the patients who attend infertility clinic in Dubai hospital.

HyFoSy is an advanced technique that uses ultrasound to reveal abnormalities of Fallopian tubes or tubal blockage. It uses EXEM gel foam which is a safer alternative, in comparison to the laparoscopy dye test or the traditional hysterosalpingogram (HSG) when testing for tubal patency.[5] HyFoSy can be done as an office procedure with transvaginal ultrasound and it is found to be as accurate as hysterosalpingogram (HSG). Using foam gel produces bright echoes that indicates the Fallopian tubes as they normally do not appear on the routine pelvic scan.[5] Due to the use of the contrast medium, echovist, this procedure was previously known as hysterosalpingocontrast-sonography (HyCoSy).[5] EXEM gel was introduced in 2007 by Netherlands containing hydroxyethyl cellulose gel which is more stable for several minutes to be visualised in the tubes and peritoneal cavity by transvaginal ultrasound. We started HyFoSy in the infertility department of Dubai hospital in 2015 and we are using it as an office procedure for tubal testing for our infertility patients till now.

  Materials and Methods Top

This study is a retrospective observational study. In our study, in 100 patients with subfertility were examined by HyFoSy to demonstrate tubal patency. We had four age groups: 23–30 years is 21%, 31–35 years is 25%, 36–40 years is 37% and >40 years is 17%. Fifty-nine percent of the patients had primary infertility and 41% of the patients were secondary infertility.

All patients were at a low risk for tubal disease. Chlamydia testing was not done, and all the patients received antibiotic prophylaxis, 1 g single dose azithromycin after the procedure to prevent pelvic infection. One patient had a history of chronic tubal disease which later presented to the hospital as PID. All the patients were given 1-g voltaren suppository (diclofenac sodium) per rectum 30 min before the procedure. We performed all HyFoSy procedures in the post-menstrual phase. An informed consent was taken from all the patients and they were informed about the risk and complications and safety of the procedure. Before the procedure, detailed history including age, type and duration of infertility, any previous pelvic pathology, previous investigations regarding Fallopian tubes and previous infertility treatment were noted. Transvaginal ultrasound was performed to see the uterine size, endometrial lining, localise both ovaries, and to notice any endometrial pathology, presence and absence of ovarian cyst, and hydrosalpinx and was documented on hyfosyform as shown in [Table 1]. After inspection of the uterine cervix with speculum, a cervical balloon applicator shown in [Figure 2] was introduced into the cervix under aseptic conditions and balloon is filled with 1.5 cc normal saline to be retained in uterine cavity. In minority of patients, a tenaculum was used for acutely anteverted or retroverted uterus or a pinpoint cervix. A syringe containing the foam is attached to the applicator. Exem gel is prepared in 20 ml of syringe and it is shifted to anot her syringe and kept pushing between two syringes to mix it thoroughly before it is inserted in the uterine cavity [Figure 1]. It is an excellent foam to show echogenicity for at least 5 min and sufficient fluid to pass through the patent tube. The foam was then injected into the uterine cavity by pushing the plunger of the syringe by an assistant. After identifying the foam inside the cavity in a longitudinal plain, the transducer was rotated to the transverse plain to visualise the distention of Fallopian tube on both sides shown in [Figure 3]. The foam is dispersed into the peritoneal cavity and it was visualised after localising the ovary. All the findings were noted on a HyFoSy form for the uniform collection of the data. In cases of failed HyFoSy or blocked tubes, HSG and laparoscopy was arranged to confirm tubal blockage.
Table 1: Transvaginal ultrasound findings

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Figure 1: ExEm foam kit

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Figure 2: Catheter set (front)

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Figure 3: Ultrasound imaging represents tubal filling and spilling is seen after injection of hysterosalpingo-foam sonography dye

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  Results Top

The Statistical Package for the Social Sciences (SPSS), version 25.0 (IBM Corp, Armonk, NY, USA), was used to analyze the data. As the number of patients was small because hyfosy is highly specialised test and is not very frequently performed in infertility clinic, we were unable to get statistical significance in the study.

One hundred patients were recruited in the study. In 97/100 (97%) of cases, it was successful in terms of adequate filling of the uterine cavity bilateral Fallopian tubes and pouch of Douglas. In remaining 3/100 (3%) of cases, HyFoSy was a fail. The first case was due to cervical polyp, HyFoSy was repeated after polypectomy, the patient was found to have bilateral patent tubes. The second and third cases were due to stenosed cervix, one patient has had HSG later on which showed unilateral tubal blockage, the third patient was offered HSG/laparoscopy, but the patient defaulted. Ninety-six/100 (96%) of the patients did not have any previous investigation of tubal factor infertility and HyFoSy was used as a primary tool. In the remaining 4/100 (4%) cases with a history of previous investigation of tubal factor infertility, 2 HyFoSy was done upon patient request, 2 had been investigated by HSG in another facility and it had shown tubal blockage, our HyFoSy showed bilateral patency; however, delayed spill was seen in one of them showing discordance in two techniques.

Bilateral patency was observed in 72/97 cases (74%) and bilateral blockage was observed in 6/97 cases (6.1%), rest of the 19 cases were showing unilateral tubal occlusion either right or left. Hence, almost 25/97 (25.7%) patients showed tubal abnormalities as a cause of their infertility. Delayed spill was noticed in five cases (5.1%) due to tubal spasm and hydrosalpinx was observed in 1 case (1%).

Out of the 6/97 (6.1%) patients with bilateral tubal blockage, they were planned for further confirmation by laparoscopy and dye test. Two/6 patients underwent laparoscopy and dye test, for one of the patients, tubal blockage was confirmed. For the other patient, dye test could not be performed due to dense adhesions. One/6 patient was booked for laparoscopy but did not attend the surgery. One/6 patient was referred for IVF due to severe male factor infertility. Remaining 2/6 was lost to follow-up. Prophylactic antibiotic coverage was given in 97 patients (100%). Average pain score among the patients was 3/10 which showed that HyFoSy is a well-tolerated office procedure. Seventeen/97 (17.5%) patients conceived after HyFoSy, 3 patients after clomid induction, 1 with HCG trigger and the rest conceived spontaneously. Further management was done for these patients in infertility clinic after the HyFoSy procedure, as shown in [Table 2].
Table 2: Further management percentages

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  Discussion Top

In comparison to HSG, HyFoSy avoids exposure from the side effects of iodine allergy and ionising radiation; hence, it can be used as an alternative to HSG for the assessment of Fallopian tubes.[2] Furthermore, pelvic organs such as ovaries, uterine myometrium, endometrium and uterine abnormalities such as endometrium polyp and sub-mucus fibroids can be detected by real-time ultrasound and even three-dimensional ultrasound when used at the time of doing HyFoSy.[2]

In our study, we detected uterine abnormalities during the process of HyFoSy by injecting normal saline into the uterine cavity before the injection of dye. The risk of pelvic infection is also very low in HyFoSy, although it is between 0.3 and 1.3 with HSG.[2] In our study, only one patient developed PID after HyFoSy despite she was given antibiotics after the procedure she underwent laproscopic salpingectomy and drainage of tubo-ovarian-abscess. Culture and sensitivity showed acute on chronic salpingitis with pyosalpinx. The patient recovered soon and was discharged from hospital in good health.

HyFoSy is usually performed within the fertility clinic which makes this procedure feasible and practical. Hence, the patient does not need to be transferred to other team which increases patient satisfaction. The HyFoSy test shows good concordance with laparoscopy and dye test (80.4%–92.5%) and HSG (83.8%–90.5%).[2] Although, in our study, we did not compare HyFoSy with other two techniques as it was not a randomised control study and we only confirmed the cases of bilateral tubal occlusion with laparoscopy and dye test.

HSG is usually widely available and luminal abnormalities and the detection of the site of tubal blockage can be assessed. It does not need any training to perform HSG in contrast to HyFoSy. It also allows tubal cannulation to be done at the same time if proximal occlusion is suspected.[2]

On the other hand, laparoscopy and dye tests are more appropriate first-line assessment in case of other pelvic pathologies such as PID, previous ectopic pregnancy, endometriosis and adhesions.[2] As laparoscopy is an invasive procedure with all the complications associated with anaesthesia and surgery, which needs expertise so laparoscopy should be used for the verification of tubal occlusion and concomitant pelvic disease.

HyFoSy has limitations, and in some patients, a second test is required. We had 3 failed HyFoSy due to cervical polyp and stenosis which needed minimal invasive surgery later on. In case of tubal occlusion, it needs further investigation in terms of HSG or laparoscopy if patient is not referred for assisted reproductive technique. In some cases, there is tubal spasm which creates false positive tubal occlusion so that is why flow of dye in the tubes should be observed for at least 20–30 s.[6] In our study, we noticed delayed spill in 5/97 cases (5.1%). Tubal spasm maybe caused by temporary blockage of the tube by blood clot, mucus plug, mucosal edema or muscle spasm.[2]

Some minor complications include of HyFoSy include nausea, vomiting, sweating and vaso-vagal reaction.[7] A very minimal number of our patients had nausea and sweating, and none of them had vaso-vagal reaction as we avoided the use of tenaculum and very slow injection of dye during the procedure. Pain, bleeding and infection are some of the other side effects, the average pain score was 3 to 4 out of 10 in our study.

  Conclusion Top

This is the first study done in OBGYN Department of Dubai Hospital having an experience with infusion of EXEM foam and as first step office procedure for tubal testing in infertility patient. HyFoSy is a safe and well-tolerated procedure without any complications. The foam is also non-embryo toxic as well as non-allergic and patients can have normal pregnancy during the same cycle. It is a cost-effective alternative to HSG and laparoscopy. Moreover, these invasive procedures are recommended only in cases where tubal patency cannot be demonstrated.

The drawback of the study is the limited number of patients (small sample size) and retrospective in nature, our study did not give statistical proven results and we hope to conduct large prospective study to analyse further.

Author's role

Makhdoom T. is privileged to have performed several HyFoSy procedures as a part of infertility team in Dubai Hospital. She is the principal author.

Khalid L, Hubaishi N (clinical care of patients and proof-reading) they are co-authors.

Ethical clearance

This study was approved by Dubai Scientific Research Ethical committee (DSREC )with approval number DSREC-06/2021_10.


We are thankful to Hanifa H and Eugene M (Data collection), Yousaf Z and our infertility team for successfully doing HyFoSy procedure with minimal complications.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Exalto N, Emanuel MH. Clinical aspects of HyFoSy as Tubal patency test in subfertility workup. Biomed Res Int 2019;2019:4827376.  Back to cited text no. 1
Rajesh H, Lim SL, Yu SL. Hysterosalpingo-foam sonography: Patient selection and perspectives. Int J Womens Health 2016;9:23-32.  Back to cited text no. 2
“Fertility: Assessment and Treatment for People with Fertility Problems.” National Center for Biotechnology Information, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/21089236/.  Back to cited text no. 3
Kodaman PH, Arici A, Seli E. Evidence-based diagnosis and management of tubal factor infertility. Curr Opin Obstet Gynecol 2004;16:221-9.  Back to cited text no. 4
Reis MM, Soares SR, Cancado ML, Camargos AF. Hysterosalpingocontrast sonography (HyCoSy) with SH U 454 (Echovist) for the assessment of tubal patency, Hum Reprod, 1998, vol. 13 (pg. 3049-3052).  Back to cited text no. 5
Saunders RD, Shwayder JM, Nakajima ST. Current methods of tubal patency assessment. Fertil Steril 2011;95:2171-9.  Back to cited text no. 6
Marci R, Marcucci I, Marcucci AA, Pacini N, Salacone P, Sebastianelli A, et al. Hysterosalpingocontrast sonography (HyCoSy): Evaluation of the pain perception, side effects and complications. BMC Med Imaging 2013;13:28.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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