195 General discussion and future perspectives 9 In our randomized controlled trial, presented in Chapter 6, we demonstrated that VR is not effective at reducing peak pain or overall pain during HSG when compared to a control group (VAS peak pain 7.0 vs 6.6, p=0.40 and overall pain 5.0 vs 4.9, p=0.80). Time spend thinking about pain during the procedure was also rated similar in the two groups (3.26 vs 3.52 on scale 1-5, p=1.72). Prior to the procedure, most patients (77%) expected that VR would be able to distract them from the procedure. Only 19% of patients expected that VR would be able to reduce their discomfort. Women in the intervention group scored their level of distraction as mean 3.54 on a scale of 1-5, but scored their level of being immersed into the VR lower at mean 2.85. Once women were asked what type of VR surrounding they would prefer, most women mentioned that they thought a comedy series or more engaging nature films with baby animals would work best as a distraction. C. Alternatives to HSG The discomfort of HSG is one of the reasons for clinicians to look for alternative tubal patency tests. Other disadvantages of HSG include the use of ionizing radiation and iodine containing contrast, the need for a radiology department and a technician, and the costs. Alternative visual tubal patency tests have been developed over the last decades that are more patient friendly, do not require X-ray techniques and are less costly. Nowadays, different modalities are used for the evaluation of tubal patency: ultrasound (hysterosalpingo-foam-sonografy (HyFoSy), hysterosalpingo-contrast-sonography with use of saline (HyCoSy), both in 2D and 3D imaging), MRI (MR-HSG) and transvaginal hydrolaparoscopy (THL). All these alternatives to HSG have their own advantages and disadvantages, and their implementation in fertility work-up varies greatly between countries and regions. Studies have been performed to compare the tests to each other or to HSG, in order to establish the correct position for each of the tests within the fertility work-up. However, the diagnostic accuracy of all these types of tubal patency tests has not been compared to each other and to the current reference standard, laparoscopy and dye testing, systematically. We are currently undertaking a Cochrane review, of which the protocol can be found in Chapter 7, to answer the question: What is the diagnostic accuracy of the various types of visual tubal patency tests for diagnosing tubal occlusion?
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