133 VR for pain relief in HSG 6 during hysteroscopy and episiotomy repair (14-16). Aside from targeting pain, VR can also lead to lower stress scores (17) and anxiety scores (Hoxhallari et al., 2019) during medical procedures. When used in a perioperative setting, VR is associated with a lower stress score (18) and higher satisfaction score (Haisley et al., 2020). Considering these favorable outcomes of VR on procedural pain, it is expected that the application of VR could lead to a reduction in pain during HSG. Therefore, the aim of this study is to investigate whether VR is an effective non-pharmacological method to reduce pain during HSG in infertile women undergoing infertility workup. MATERIALS AND METHODS Study design This randomized controlled trial was performed in one university hospital, with two locations, and one teaching hospital in the Netherlands. The study was approved by the institutional review board of the Amsterdam UMC, location VUmc (reference number 2020.0687). The trial was prospectively registered in the Dutch trial register (www. trialregister.nl; registration number NL9203). Participants All women referred for HSG were screened for eligibility. Women were eligible for study participation if they were scheduled for an HSG during infertility workup and had sufficient knowledge of the Dutch or English language to read and understand the patient information sheet. Women were excluded from study participation if they had a history of surgery to the cervix, if they had had an HSG before, if they had a known allergy to iodinated contrast and if they currently used antidepressants, sedatives or analgesics on a daily basis. Randomization After providing written informed consent, participants were randomized between HSG with VR (intervention group) or HSG without VR (control group). Randomization was performed in a 1:1 ratio with variable block sizes varying from 4-8 using the web-based system Castor (Castor Electronic Data Capture, Ciwit BV, Amsterdam, the Netherlands) and stratified per centre. Due to the nature of the intervention, blinding of participants and physicians was not possible. Study procedures The HSG was performed according to local standard procedure protocols. Prior to the procedure, all women received oral and written information on the HSG procedure.
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