**18. Exploration of the implantation site**

endometrial cavity in group B with a significant superiority over HSG. Blocked tubes were diagnosed in 9% and 11.5%, 5.1% and 6.4% and 3.8% and 5.1% using VOH, HSG and DL on right and left sides respectively. There was a high percentage of agreement in the diagnosis of uterine abnormalities between HSG and VOH (96%, k=0.394). n the other hand, the percentage of agreement between VOH and HSG is less (86%, k=0.214) and is much less between VOH and laparoscopy (82%, k=0.148) regarding tubal patency testing. Generally, VOH was an

We concluded that VOH seems feasible, safe, simple, tolerable and quick out-patient proce‐ dure. It can diagnose intrauterine abnormalities in 23.7% of infertile women with normal HSG. VOH achieves marvelous agreement with HSG in diagnosing uterine abnormalities (96%), excellent agreement with HSG (86%) for tubal patency testing and very good agreement with DL (82%) regarding tubal patency. Diagnostic indices including accuracy of either HSG or DL would increase if combined with VOH. We recommend adding OH to the routine diagnostic work-up of infertile couples prior to laparoscopy. Nevertheless, whether its use would increase pregnancy rate among infertile women requires a further longitudinal comparative study.

**16. Diagnostic accuracy of combined tests for assessment of uterine and**

Sometimes the fallopian tubes appear normal at HSG and even laparoscopy but pregnancy doesnot occur due to some hidden intratubal fine lesions at the fertilization site (ampulla). Intratubal examination can only be done using falloposcopy (from the cervical side) or salpingoscopy (from the fimbrial side). Going inside the tube allows proper exploration of the endosalpnix. Lost or destroyed major or minor folds may explain infertility. Detection of fine

**VOH + HSG (for assessment of tubal** **VOH+ laparoscopy (for assessment of tubal**

**patency)**

**patency)**

**VOH + HSG (for assessment of uterine**

Sensitivity 97.4% 50% 94% Specificity 56.2% 16.6% 33.3% Positive predictive value 80.9% 76.2% 94% Negative predictive value 90% 5.9% 33.3% Accuracy 59.2% 44.7% 89.5%

**factor)**

**17. Endoscopic exploration of the fertilization site**

adhesions or tiny polypi is feasible by salpingoscopy.

acceptable procedure with mild pain and feasible in most cases.

**tubal factors**

22 Contemporary Gynecologic Practice

Implantation site is located on the posterior endometrium at midline 10-15 mm from the fundus. Hysteroscopy can detect tiny lesions at the implantation site like fine adhesions, polypi or small septum. Implantation failure may be caused by abnormal cytokine expression by embryos and endometrium. As proved in many studies, endometrial injury would induce release of cytokines that may increase implantation. Practically, site-specific endometrial injury in the follicular phase with the edge of the office hysteroscopy lens would enhance implantation in cases with unexplained infertility. Nevertheless, the real implementation of this procedure requires more randomized studies.
