134 Chapter 6 An HSG was scheduled in the follicular phase of the menstrual cycle after cessation of menstrual bleeding, or after cessation of progesterone induced bleeding in case of amenorrhea. Women were advised to take non-steroid anti-inflammatory drugs such as naproxen or ibuprofen as pain management the evening before and 2 hours before the HSG. During the procedure, the patient was placed in lithotomy position after which a speculum was inserted. The cervix was cannulated with a cervical vacuum cup, a metal cannula (hysterophore) or an HSG balloon catheter, depending on the preference of the physician performing the HSG and local availability. During the infusion of approximately 10 ml of oil-based (Lipiodol Ultra Fluid®, Guerbet, Villepinte, France) or water-based contrast medium (iodixanol, Visipaque®, General Electric Healthcare, Buc, France), four to six radiographs were obtained. The radiographs were examined by a gynaecologist, fertility doctor and/or radiologist to evaluate the patency of both Fallopian tubes. Participants assigned to the intervention group were given a short instruction of the VR headset prior to the HSG procedure. After meeting their physician and getting into lithotomy position on the radiology table, women placed the VR headset over their eyes. Participants were asked to wear the VR headset during the entire procedure, until all instruments were removed. Sound from the VR headset was switched off to enable participants to communicate with the physician performing the procedure at all times. A dedicated researcher was present during the entire procedure for technical support with the VR system. In case of complaints or potential side-effects of the VR headset, the participants were able to adjust or remove the headset themselves or ask for assistance from the dedicated researcher. Virtual Reality Technology The VR headset and software used in this study were CE-certified and obtained from SyncVR (SyncVR Medical B.V., Utrecht, the Netherlands). The head-mounted PICO G2 4K device (Pico Interactive Inc., San Francisco, United States of America) included a VR headset and a remote control (Figure 1a). Participants were able to navigate the VR headset on their own using the remote control. However, if they felt unsure navigating the system the researcher was able to take over control of the VR headset on a handheld device. SyncVR Relax & Distract is a software module installed on the VR headset which enables patients to choose between approximately twenty relaxing movies and breathing exercises, all designed for use in medical practice (Figure 1b,c). Games, requiring movement of the participant, and movies with an element of surprise were removed from the library to decrease the chance of sudden movements during the HSG procedure. It was thought that sudden movements were undesirable and unsafe for participants (Figure 1a-c).
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