16 Chapter 1 PSYCHOLOGICAL IMPACT The treatment of infertility, whether this is an advice for expectant management or medically assisted reproduction (MAR) technique, poses a high psychological burden (46). The entire path of infertility, from the wish to conceive to fertility treatments, is associated with an increased stress level and a reduced quality of life for both women and men (47, 48) (see figure 1). The uncertainty, prolonged unfulfilled wish for a child and repeated setbacks have a large impact on wellbeing in general. Coronavirus Disease 2019 (COVID-19) led to a pandemic during the course of this PhDtrack and was a big cause for stress and a reduced quality of life for people worldwide as it impacted the economy and led to environmental, health-related and political problems (49). As the path of infertility, COVID-19 came with great uncertainty and repeated setbacks. Being quarantined seems to impact women more than man; women showed a higher anxiety level and lower quality of life than man during the pandemic in a Spanish study (50). During the pandemic, governments and health care institutions had to relocate health care workers and available resources in order to focus on the care for patients with COVID-19, and measures had to be taken to prevent further spread of the disease, which resulted in several lockdowns and a halt in healthcare for patients with non-threatening diseases. In the Netherlands, all fertility care was stopped completely in March 2020 except for patients in need of fertility preservation due to oncological indications. From May 2020, fertility care was slowly restarted but remained at a lower capacity (approximately 70% in comparison to 2019) due to the preventative measures in all hospitals and clinics up to the spring of 2022. This resulted in couples with infertility being put on hold for a prolonged period before fertility work-up could start and they found themselves in growing uncertainty. In addition, due to the lower capacity of infertility clinics, patients faced long waiting lists for fertility treatments as well. Although infertility is not a life threatening disease, it is likely that the COVID-19 pandemic has aggravated the psychological burden that infertility is associated with. AIM OF THIS THESIS In this thesis, we continue where the H2Oil-study (23) and it’s follow-up study (51) have left us. As the fertility enhancing effect of oil-based contrast is now established for women with unexplained infertility and a low risk for tubal pathology, we want to examine the safety of this contrast, the duration of the fertility enhancing effect, and
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