14 Chapter 1 uncomfortable or painful with a median pain score of 5.0 (VAS, scale 0.0-10.0) (33). Discomfort or pain during HSG can be caused by various steps of the procedure; installing the instrumentation, infusion of contrast and subsequent filling of the uterine cavity with pressure build-up, and finally spillage of contrast into the peritoneal cavity. Several analgesic interventions to support an HSG have been suggested, including topical (a spray on the cervix or intrauterine installations), oral, locally injected and intravenous pain medication. Meta-analysis only showed an effect for intravenous opioid analgesia (mean difference (MD) -3.53, 95% CI -4.29 to -2.77) and topical analgesics (MD -0.63 95% CI -1.06 to -0.19) when compared to placebo or no treatment (39). As intravenous opioids can lead to significant side effects and risks this requires continuous monitoring and is not a suitable option in most settings. The effect of topical analgesics is very small and the clinical relevance of this reduction in pain perception can be debated. Therefore, an effective method for pain relief during HSG, with a low risk profile, is needed. A relatively novel and innovative technique for non-pharmaceutical pain relief is the use of Virtual Reality (VR). This therapy is delivered through a head-mounted device, covering the eyes and optionally the ears, to take the user into a virtual world. Viewing and interacting with the virtual world distracts the user from physical stimuli and has been proven effective in the reduction of acute pain and pain caused by medical procedures (40). Virtual Reality has the potential to improve patient experiences during HSG by providing pain relief in addition to currently used pharmacological pain relief. Alternatives to HSG Other visual tubal patency tests have been developed that are more tolerable, are less invasive, are easier to perform and/or are less expensive when compared to surgery or HSG. In these tests, ionizing or echogenic contrast or coloured dye is infused into the cervix transvaginally, to detect whether there is overflow of contrast from the Fallopian tubes into the peritoneal cavity. The most common alternatives to HSG are hysterosalpingo-foam sonography (HyFoSy), hysterosalpingo-contrast sonography (HyCoSy), transvaginal hydrolaparoscopy (THL / fertiloscopy), and magnetic resonance hysterosalpingography (MR-HSG) (41). These alternatives have been investigated and compared to HSG and/or laparoscopy with varying results and there currently is no consensus on the diagnostic quality of each of these tests. The role or place of these tests is not yet established and therefore a comparative review is warranted.
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