Going Green in Reproductive Surgery: A Comparative Study of ICG and Methylene Blue

INTRODUCTION: Methylene blue is the most commonly used dye for chromopertubation; however, its diagnostic reliability may be influenced by factors such as uterine manipulator positioning and intrauterine pressure during instillation. Indocyanine green (ICG), a fluorescence-based contrast agent, has emerged as a promising alternative due to its enhanced visualization capabilities and favorable safety profile. OBJECTIVE: This study aims to compare the effectiveness of ICG and methylene blue in assessing fallopian tube patency. METHODS: This retrospective cohort study was conducted at a single tertiary academic medical center and included all patients who underwent benign minimally invasive gynecologic surgery with chromopertubation between October 2024 and March 2025. Women who underwent chromopertubation with indocyanine green (ICG) comprised the study group and were compared to those who underwent the procedure with methylene blue (control group). Demographic, clinical, and intraoperative data were collected from electronic medical records. The primary outcome was defined as the rate of bilateral tubal patency, as assessed intraoperatively. RESULTS: A total of 44 patients were included, of whom 23 (52%) were in the ICG group and 21 (48%) in the methylene blue group. Median age and BMI were comparable. History of chlamydia infection was similar between groups (ICG: 9% vs MB: 14%, p=0.56). Endometriosis was more frequent in the methylene blue group (p=0.08). Bilateral tubal patency was observed in 36% (ICG) vs 33% (MB), with no significant difference. Grossly normal and patent tubes were also comparable (23% vs 29%, p=0.60), as was the rate of bilateral occlusion (∼40%, p=0.94). Notably, unilateral salpingectomy was significantly more common in the ICG group (17% vs 0%, p=0.04), potentially reflecting improved visualization and diagnostic accuracy. CONCLUSIONS: ICG demonstrates comparable effectiveness to methylene blue in evaluating tubal patency and may offer enhanced diagnostic precision, leading to more targeted surgical interventions. Larger prospective studies are warranted to validate these findings and further explore the utility of ICG in reproductive surgery.