201 General discussion and future perspectives 9 Oil-based contrast can also be used in neonates and young children for cardiac procedures, in which case the contrast is injected intravenously. The FDA has recently issued a warning regarding the use of iodine-containing contrast intravenously in children as studies have linked this to a decreased functioning of the thyroid gland in 1-15% (24). The use of iodine-containing contrast during pregnancy is not mentioned in this warning. Long term follow-up of children born after an HSG with oil-based contrast is warranted to rule out an effect of (temporary) maternal thyroid dysfunction in the first trimester on neuro-cognitive development later in their offspring. Children born to mothers who participated in the original H2Oil study (3) are currently participating in a long-term follow-up study, the Neuro H2Oil study, in which neuro-cognitive development is investigated. The results are expected very soon. B. Improving HSG experience Virtual Reality has been proven an effective method for pain relief during various medical procedures (12). However, there are also several published studies reporting no significant effect of VR (25, 26) in line with the results of our study. Several points have been raised that can explain these contradicting findings. One of the explanations is the level of immersion or presence into the Virtual Reality. A higher level of immersion or presence indicates a greater feeling of actually being inside the VR, and this poses a greater distraction from physical sensations (27). The mean score of immersiveness (‘Experiencing to be inside the VR environment’) in our intervention group was 2.9 on a scale of 1.0-5.0, indicating that this potentially was suboptimal. This relatively low level of immersion can be caused by the lack of sound and subsequently being able to hear the physician and radiology technician. Additionally, the duration of the HSG procedure is longer than the duration of the movies available on the VR glasses. Once a movie ends, the user has to choose or wait for a new movie to start and this brings the user back into the ‘real world’. A study in which patients underwent a short (mean <4 minutes) diagnostic hysteroscopy showed a positive effect of VR (28), while another study in which the hysteroscopy took longer (median around 8 minutes) showed no effect (26). Yet we believe there still may be a role for the use of virtual reality in a variety of gynaecological procedures. As the application of VR is inexpensive and usually without adverse events, it is worth trying to optimize its use and study whether it can have a beneficial effect in different populations, different clinical settings or when the application is improved. Therefore we are setting up a study in which we will use VR for the reduction of anxiety and pain during ovarian punctures as part of an IVF treatment, a procedure that is regarded as painful with pain scores varying from 3.9 to 5.6 (scale 1-10) (29). The VR environments available will be critically reviewed and revised to optimize the VR experience.
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