144 Chapter 6 10-point VAS). Additionally, they reported a statistically significant reduction in mean anxiety score when VR was used during office hysteroscopy (15). The mean duration of the hysteroscopy procedure in the study by Deo et al. was less than 4 minutes in both the intervention and control group. Although we did not record procedure length in our study, the average time of a HSG procedure is expected to be longer. The applications on our VR headset had a duration of approximately two minutes each. Women subsequently had to choose another VR application or were transitioned into a new application automatically, which might have reduced the submersion in the VR environment and therefore negatively affect procedural distraction and pain reduction. A recent study provided VR during postpartum episiotomy repair, adding it to standard care consisting of lidocaine infiltration (5ml of 2% solution). Virtual Reality was found to decrease pain significantly during episiotomy repair when compared to standard analgesics alone (VAS 9.0±12.6 versus 23.6±19.8 respectively with an intergroup p-value of 0.038, scale 0.0-100.0) (16). It should be noted that in this small study (n=30), the mean episiotomy depth was shorter in the intervention group (p=0.042), possibly resulting in a shorter procedure time. This could possibly influence the main findings. A group in China is currently conducting a similar study to ours, randomizing 200 women between an HSG with VR or a blank control during HSG (6) . In addition to pain, anxiety, satisfaction, acceptance and immersion, they will also record physiological parameters (i.e. pulse rate, blood pressure and oxygen saturation) to relate to the primary outcome. Participants in the intervention group will receive a VR system that includes noise-reducing headphones to convey sound, in contrast to our VR system without auditory stimuli. Explanations The lack of effect in overall pain and peak pain score during HSG using VR versus no VR can have several reasons. One explanation might be that because of the nature of this study, there was some emphasis on the fact that the HSG procedure could be painful. During study counselling, it was mentioned to women that the HSG procedure might be somewhat uncomfortable, similar to heavy menstrual cramping. Therefore, women might have expected the HSG to be painful, prior to the procedure. This might be an explanation for the similar reported pain scores after the HSG procedure in the intervention- and control group. Women randomized for VR glasses during HSG might not have experienced as much pain relief from the intervention as they expected, whereas women randomized for HSG without VR glasses reported that the procedure was “not as uncomfortable as they expected”. It might also explain why expectation prior to the HSG procedure influenced the reported pain scores. A previous study found that participants experienced more pain
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