132 Chapter 6 INTRODUCTION Infertility affects 11.4% of women wishing to conceive in the Netherlands and can compromise quality of life significantly (1, 2). Among the most common causes of infertility are tubal pathology and pelvic adhesions; therefore evaluation of the Fallopian tubes is part of the fertility work-up (3, 4). The traditional method for evaluation of the Fallopian tubes during fertility work-up is hysterosalpingography (HSG). During HSG, iodine-containing contrast is infused into the uterine cavity and subsequently into the Fallopian tubes. The contrast is visualized using fluoroscopy guiding to determine whether the Fallopian tubes are patent. The HSG was initially introduced as a diagnostic test. However, it has also been proven to have a therapeutic effect in women with unexplained infertility, especially when oil-based contrast is used (5-7). HSG as a tubal patency test can cause discomfort and pain during and immediately after the procedure, with average reported pain scores ranging from 3.7 to 5.0 on the Visual Analogue Scale (VAS, scale 0.0-10.0cm) (8-10). The painful cramping sensations are caused by cannulation of the cervix with instruments, distention of the uterine cavity due to infusion of contrast, increase of pressure in the Fallopian tubes and peritoneal irritation caused by contrast spillage from the Fallopian tubes (11). The different parts of the female reproductive system are innervated by different pathways and nerves, making it difficult to target the overall pain with local analgesics (12). Several regimens of analgesics have been studied using various routes of administration, i.e. oral, topical (a spray on the cervix or intrauterine installation with analgesics), locally injected and intravenous administration of analgesics. A meta-analysis by Hindocha et al. showed that topical and locally injected analgesics can reduce the median pain score during the procedure (mean difference (MD) -0.63, 95%CI -1.06 to -0.19 after topical analgesics and MD -1.31, 95% CI -1.55 to -1.07 after locally injected analgesics), although the quality of evidence was low to very low (11). The most obvious pain reduction was established by intravenous opioids (MD −3.53, 95% CI −4.29 to −2.77). However, because of potential cardiorespiratory side effects, the administration of intravenous opioids requires continuous monitoring, making this a less attractive mode of pain management to apply during HSG. Virtual Reality (VR) has recently been introduced in medical practice and can be used to reduce pain and anxiety in a non-pharmacological way. It creates a distraction from the present and diverts attention away from physical sensations by taking the user into a three-dimensional virtual world, usually without any major side effects (13). Virtual Reality for medical use has been proven successful in decreasing acute pain during different medical procedures and interventions, including a reduction in procedural pain
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