146 Chapter 6 their avatar by using body trackers). Relevant for our study were the following criteria: presence, interactivity and customization. By optimizing the participants’ presence, or immersiveness, in the VR environment, they might report lower overall and peak pain scores. Interactivity of the VR program is related to presence as well. Both contribute to pain reduction: a higher level of interaction with the VR environment and presence in the VR environment, might lead to better distraction from the procedure and therefore a higher pain threshold and less experienced pain. Finally, customization is an important factor in the effectiveness of Virtual Reality. Involvement in the choice or even design of the VR application can contribute to pain reduction. In our study, women were able to choose between the different VR applications, i.e. nature films and breathing exercises. However, women were not able to design or modify their VR application. In obstetrics, it is known that one-to-one coaching of labouring women reduces the level of experienced pain and the need for pharmacological pain relief (24). In daily practice, coaching with use of breathing techniques is often used during HSG if the physician or radiology technician feels this is beneficial for the woman. With our intervention, VR during HSG, it is often not possible to coach the woman at the same time because it might decrease immersiveness. It is therefore possible that our results do not show that VR is not effective, but rather show that VR is not more effective in reducing discomfort as compared to coaching with breathing techniques. However, we feel that a comparison of regular care without coaching as a control group would not have been ethical. Implications As mentioned before, the VR applications that we used can potentially be altered to provide a more engaging and immersive experience. However, after our experience counseling potential participants, we feel that for some women a maximum immersive experience would be optimal while other women want to have the ability to distract themselves when desired but be present during the procedure at other times. Therefore, a more personalized VR application might potentially lead to lower pain scores. More information on what type of VR suits which patient characteristic is necessary. Patient characteristics can include preferred coping strategies, preferred level of control during a medical procedure, preferences on the types of movie content (comedy, nature, animals) and/or whether they would prefer to play games. For future studies, it could be advised to further optimize this customization by studying the patient characteristics (i.e. preferences on coping mechanisms and level of control, type of VR application), presence and interactivity. This could contribute to VR immersiveness, thereby optimizing pain reduction during the HSG procedure when applying a VR headset. We would therefore recommend future studies to pay attention to VR immersiveness, and to optimize VR immersiveness to hopefully improve VR effectivity.
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