209 Summary A renew the infertility guidelines with evidence-based advice on the type of contrast to use in the three studied patient groups. The database of the first H2Oil study comprises 1119 women with unexplained infertility and details of their fertility work-up, treatments and outcomes are all reported. This present a unique opportunity to replicate a previously formulated hypothesis. In previous work, the prognosis for natural conception (poor, medium or good) was found to be a predictor for the benefit of intra-uterine insemination with mild ovarian stimulation (IUI-MOH) treatment as opposed to expectant management. After performing the same analysis on the H2Oil database, in Chapter 4, this interaction between prognosis and therapeutic effect of IUI-MOH was not found. We did, however, confirm that couples with a longer duration of infertility benefitted more from IUI-MOH in comparison to expectant management. These findings can also be used by physicians to advice couples with a short duration of infertility to pursue natural conception. Despite the convincing results of the H2Oil study which were published in 2017, we noticed that physicians were still hesitant to use oil-based contrast. One of the reasons was a fear of complications. When the contrast fluid enters the bloodstream through uterine vessels, this so-called intravasation can lead to oil-embolism and can have severe complications when an oil-embolus reaches the lungs or brain circulation. In Chapter 5 we performed a systematic literature review to obtain information on all possible complications of HSGs with oil-based contrast. We did not use a time restriction or language restriction to make sure that all useful and available articles were found. Combining all published data from 8 RCTs, 41 cohort studies and 59 case reports, the incidence of intravasation was found to be 2.7% during HSGs with oil-based contrast, in comparison to 2.0% with water-based contrast. The second most frequently reported complication was infection, which was reported in 20 studies. The frequency was 0.9% after the use of oil-based contrast and 1.9% after water-based contrast, however, when including only studies published after the widespread use of antibiotics these numbers decrease to 0.55% and 0.35% respectively. Based on these results we conclude that safety concerns should not be a reason to withhold women an HSG with oil-based contrast. The HSG is an uncomfortable or painful procedure for most women, with studies reporting a pain score of 3 to 5 on a scale of 0-10. Multiple types of pain medication have been tried, including tablets, intravenous medication and local injections. None of these give a satisfactory reduction in pain without major side effects. In Chapter 6 we described our randomized controlled trial in which we studied whether the use of Virtual Reality can reduce discomfort and/or pain. Virtual Reality is a relatively new technique that has proven effective in pain reduction during various medical procedures. As it
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