Factors influencing the severity of pain during hysterosalpingography

No pain relief by virtual reality during hysterosalpingography (HSG): results from a randomized controlled trial

STUDY QUESTION

Is virtual reality (VR) an effective non-pharmacological tool to reduce procedural pain during hysterosalpingography (HSG)?

SUMMARY ANSWER

An HSG with VR does not reduce procedural pain scores compared to an HSG without VR.

WHAT IS KNOWN ALREADY

An HSG is often experienced as painful and uncomfortable. VR has been proven successful to reduce acute procedural pain during a variety of medical procedures and interventions.

STUDY DESIGN, SIZE, DURATION

We performed a two-centre open-label randomized controlled trial between January 2021 and October 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women scheduled for HSG as part of their infertility work-up were screened for participation. After informed consent, women were randomized between HSG with or without VR. Due to the nature of the intervention, the study was not blinded. VR was administered by a head-mounted device displaying nature movies and/or relaxation exercises. The primary endpoint was procedural pain measured using VAS (scale 0.0-10.0 cm). Procedural pain was divided into overall pain score and peak pain score during the procedure. It was measured immediately after HSG. Secondary endpoints included patient satisfaction, VR preferences, and adverse effects of VR.

MAIN RESULTS AND THE ROLE OF CHANCE

We included a total of 134 women, 69 to the intervention group (HSG with VR) and 65 to the control group (HSG without VR). The mean VAS for peak pain was 6.80 cm (SD 2.25) in the intervention group versus 6.60 cm (SD 2.40) in the control group (mean difference 0.28 (95% CI -0.57, 1.12), P = 0.52). The mean VAS for overall pain was 5.00 cm (SD 2.10) in the intervention group versus 4.90 cm (SD 2.13) in the control group (mean difference 0.06 (95% CI -0.71, 0.84), P = 0.88). The expectation that VR would be a good distraction from pain during HSG was correlated with both overall and peak pain scores. When correcting for this expectation, we found that women in the intervention group reported significantly higher scores, both in peak (adjusted MD 0.58 (95% CI -0.81, 1.97), P = 0.021) and overall (adjusted MD 0.43 (95% CI -0.84, 1.71), P = 0.013) pain, compared to the control group. There were no differences in the prevalence of symptoms that were considered as adverse effects of VR.

LIMITATIONS, REASONS FOR CAUTION

The study was not blinded. Reasons for declining participation in the study were anxiety or wanting full control during HSG, which might have created selection bias. The distraction score possibly indicates that the level of VR immersiveness was not optimal due to the lack of sound and/or the type of VR applications. Future studies should investigate whether more immersive or interactive VR applications could decrease procedural pain scores during HSG.

WIDER IMPLICATIONS OF THE FINDINGS

Since VR does not reduce procedural pain, this additional tool should not be used during HSG.

STUDY FUNDING/COMPETING INTEREST(S)

There was no external funding for this study. KR and AvH report receiving a travel grant from Merck outside the scope of this study. BM is supported by a National Health and Medical Research Council (NHMRC) investigator grant (GNT1176437) and BM reports consultancy for Merck, Organon, and Norgine and travel and research funding from Merck. BM holds stock for ObsEva. CL reports receiving research grants from Merck, and Ferring. KD and VM report receiving travel and speaker's fees from Guerbet and research grants from Guerbet. VM also reports research grants from Merck and Ferring. The remaining authors have nothing to declare.

TRIAL REGISTRATION NUMBER

The trial is registered prospectively in the Netherlands Trial Register (trialregister.nl registration number NL9203, currently accessible on trialsearch.who.int).

TRIAL REGISTRATION DATE

16-01-2021.

DATE OF FIRST PATIENT’S ENROLMENT

The first participant was enrolled on 19 January 2021.

EMLA (lidocaine-prilocaine) cream for pain relief during hysterosalpingography: a systematic review and meta-analysis of randomised placebo-controlled trials

We systematically investigated the efficacy and safety of EMLA (5% lidocaine-prilocaine cream) versus placebo for pain relief among infertile patients undergoing hysterosalpingography (HSG). We screened four databases from inception until 25 November 2020. We included only randomised placebo-controlled trials (RCTs) and assessed their risk of bias. The main efficacy outcomes included safety and pain scores during the different stages of HSG. The pooled outcomes were summarised as mean difference (MD) with 95% confidence interval (CI). Three RCTs were included, comprising 258 patients (131 and 127 patients received EMLA and placebo, respectively). All RCTs revealed an overall low risk of bias. EMLA significantly reduced pain perception during cervical instrumentation of tenaculum and cannula (MD = -1.53, 95% CI [-2.59, -0.47], p = 0.005) and at 24 h after completion of HSG (MD = -1.30, 95% CI [-2.57, -0.03], p = 0.04). Despite EMLA decreased pain perception during the other procedural stages of HSG, the differences were not statistically significant compared with placebo. EMLA was safe and free of local and systemic adverse reactions. This meta-analysis advocates that topical application of 5% EMLA cream is safe and correlates with decreased pain perception during HSG, particularly during the cervical instrumentation step and at 24 h after HSG completion.

Comparison of pain score between Foleys catheter and Leich-Wilkinson cannula in hysterosalpingography by numerical rating scale - A randomized control trial

Hysterosalpingography (HSG) is the first-line investigation in infertility assessment to assess tubal patency. Clinicians use various instruments, including the Leich-Wilkinson cannula, Rubin cannula, Jorcho's cannula, Whitehead cannula, and foley's catheter, to instill the dye in the uterus. We randomly allocated 60 patients planned for hysterosalpingography to evaluate tubal patency as part of fertility workup to either Intra-uterine foley's catheter arm or Leich-Wilkinson cannula arm. The research team measured and compared immediate and delayed numerical pain scores in both arms. We observed significantly lower pain scores in Foley's catheter arm as compared to the Leich-Wilkinson arm for both early (5.7 ± 3.01 vs. 7.8 ± 1.95) and delayed (0.15 ± 0.37 vs. 0.40 ± 0.50) evaluation. We established that using a Foley catheter for the HSG procedure was associated with lesser pain to the patient, with no evident difference regarding imaging of the uterus and tubes.

A meta-analysis of fertility and adverse outcomes in oil- and water-based contrast for hysterosalpingography

Infertility is the inability to conceive after one year of regular unprotected intercourse. There is a debate about the therapeutic effect of hysterosalpingography (HSG) and whether the selection of contrast materials makes a difference in the chance of subsequent conception. In this study, we aimed to compare the fertility-enhancing outcomes and adverse effects of oil and water-based contrasts in patients who underwent HSG. This systematic review and meta-analysis was conducted following the PRISMA guidelines. We searched the Web of Science, PubMed, and Scopus until September 2022. We included all primary randomized controlled trials evaluating the fertility-enhancing benefits of HSG in oil-based versus water-based contrast media in women of childbearing age with infertility. Eleven studies with 4,739 patients were selected. The pregnancy rate in the oil group was significantly higher than that in the water group [odds ratio (OR)=1.51 (1.23, 1.86), p<0.0001]. Our meta-analysis favored the oil group in abdominal pain and vaginal bleeding with the odd ratios of 0.73 (0.58, 0.91), (p=0.006) and 0.91 (0.46, 1.81), (p=0.79), respectively. Water-based contrast was associated with less intravasation [OR=2.09 (1.09-4.02), p=0.03]. There were no differences between the contrasts for miscarriage [OR=1.02 (0.71, 1.46), p=0.92], and ectopic pregnancy [OR=0.84 (0.27, 2.63), p=0.77]. HSG with oil-based contrast was related to a higher pregnancy rate, live birth rate, and intravasation rate. While HSG using a water-based contrast medium was associated with increased abdominal discomfort, vaginal bleeding, and the visual-analogue scale pain score.

Transvaginal four-dimensional hysterosalpingo-contrast sonography: Pain perception and factors influencing pain severity

AIM

The purpose is to investigate pain perception during transvaginal four-dimensional hysterosalpingo-contrast sonography (TV 4D-HyCoSy) and factors influencing pain severity.

METHODS

This was a retrospective study included 340 women who underwent TV 4D-HyCoSy examination from January 2016 to October 2017. The factors were recorded, including age, childbearing history, infertility type, history of pelvic inflammation, pelvic surgery, history of uterine manipulation, history of ectopic pregnancy, atropine delivery mode, uterine position, uterine malformation, uterine lesion, fibroid, intrauterine adhesion, polycystic ovary, endometrial implantation cyst, dysmenorrhea score, the degree of patency of fallopian tube and contrast agents dosage. Pain was evaluated during and after TV 4D-HyCoSy. The time point of peak pain was evaluated and the influencing factors of moderate/severe pain were analyzed.

RESULTS

The highest pain occurred at contrast instillation. The independent influencing factors of moderate/severe pain were age (P = 0.021), dysmenorrhea score (P = 0.003) and tubal patency (P < 0.001). Further analysis showed that age affected the pain score when TV 4D-HyCoSy started and the peak pain occurred. Dysmenorrhea score and tubal patency affect the pain score at most time points.

CONCLUSION

Age, dysmenorrhea score and tubal patency are factors influencing the severity of pain during TV 4D-HyCoSy.

Effect of education and counselling on reducing pain and anxiety in women undergoing hysterosalpingography: A randomised controlled trial

AIMS AND OBJECTIVES

To investigate the effects of education and counselling on anxiety and pain in women undergoing hysterosalpingography (HSG) as part of infertility treatment.

BACKGROUND

The hysterosalpingography has an important diagnostic role in finding the cause of infertility and making a decision on management of treatment. In addition, it is considered a feared procedure in the infertility process and the one about which very little is known. Women often experience anxiety and pain during the HSG procedure.

DESIGN

A randomised controlled trial.

METHODS

The CONSORT guidelines have been used to describe the methods. Women who were diagnosed with infertility between February-October 2016 were included in the study. The participants were randomised and divided into intervention (52) and control (53) groups. The sociodemographic and obstetric data collection form, the State-Trait Anxiety Inventory and a visual analogue scale were used before the procedure. After the questionnaires were applied to the intervention group, individual learning and counselling sessions were given about the hysterosalpingography process. Brochures were also distributed to the patients for their reference after the learning session. The control group received standard care.

RESULTS

When the intervention and control groups were compared, it was found that the education and counselling given before the HSG procedure significantly decreased the level of pain and anxiety felt by women. In addition, a significant positive correlation was found between pain and anxiety after the training in the intervention group.

CONCLUSIONS

This study indicates that the education and counselling given to women before the HSG procedure are effective interventions for reducing pain and anxiety in women undergoing HSG.

RELEVANCE TO CLINICAL PRACTICE

With the application of HSG education and counselling, and the distribution of brochures to each patient, pain and anxiety can be reduced during the HSG procedure.

An investigation into the effect of evening primrose in dilatation of cervix and pain during and after hysterosalpingography

Hysterosalpingography is one of the essential diagnostic methods for examining women who have difficulty becoming pregnant. This procedure is somehow invasive and is associated with numerous complications such as allergic sensitivity, pain, abdominal cramps and shock. Therefore, this study aimed to investigate the effect of evening primrose on cervical length and pain during and after hysterosalpingography. In this double-blind clinical trial, 66 candidates for hysterosalpingography were randomly divided into two groups. A group received 1000 mg of evening primrose orally for two days prior to hysterosalpingography, while the control group received a placebo drug similar in size to evening primrose three days prior to hysterosalpingography. The pain level was recorded based on the Visual Analogue Scale (VAS), during tenaculum placement but also immediately and four hours after hysterosalpingography. Finally, the data were analyzed using SPSS (version 20). There was a significant difference between the two groups in terms of pain during insertion of speculum and injection of the contrast medium (p <0.05). Less pain was reported in the evening primrose group compared to placebo. There was no significant difference between the two groups in terms of the length and diameter of the cervix (p <0.05). Given the fact that it is a medicinal plant with no complications and can reduce pain during speculum insertion and during contrast medium injection, evening primrose seems to be a good drug for managing pain during hysterosalpingography.

Comparison of midazolam and dexmedetomidine for pain relief during and after hysterosalpingography in women with infertility

Patients feel uncomfortable with cervical manipulation, uterine distension and stimulation of peritoneum during hysterosalpingography (HSG) and experience lower abdominal pain during and after the procedure. Pain during the procedure has a negative effect on the adaptation of patients to treatment and physicians are trying to overcome this unpleasant situation. Therefore, the aim of this study was to compare the effect of midazolam and dexmedetomidine on reducing pain and spasm of fallopian tubes during and after HSG procedure in women with infertility. In a double-blind randomized controlled trial, 102 patients were randomly divided into two groups, midazolam and dexmedetomidine. The pain was recorded during injection and immediately after injection and 30 minutes after HSG, and then the complications of injection were recorded. Finally, the data were analyzed using SPSS version 20. Based on the results presented herein, no significant difference was found between the two groups in terms of vasovagal reaction, spasticity of the tube and the side of the spastic tube and uterine cavity anomalies (p <0.05). However, the pain showed a significant difference between the two groups during the injection, immediately or at 30 minutes after the procedure (p = 0.0001). The pain in the midazolam group was less than that of dexmedetomidine. Furthermore, there was no significant difference between the two groups regarding spasticity (p <0.05). There is a benefit in terms of pain reduction with the use of dexmedetomidine when comparing with midazolam injection. However, dexmedetomidine does not cause side effects in patients and can be used to reduce pain during injection.

Implementing a holistic approach to a radiographer-led Hysterosalpingogram (HSG) service: A review of impact and patient perception

INTRODUCTION

Radiographer role development has touched boundaries across the multidisciplinary team and more recently branched into the field of gynaecology. Radiographers are now able to perform tasks that were traditionally performed by radiologists and gynaecologists to implement a radiographer-led Hysterosalpingogram (HSG) service. The aims of the study were to (i) implement a radiographer-led HSG service with a view to decreasing waiting times. (ii) To determine ladies perceptions and satisfaction levels.

METHOD

Local clinical guidelines were developed with the radiologist/gynaecologist and trainee HSG radiographers. A robust system of work was initiated which required maintaining comprehensive log books to record examinations performed and reports written. These were audited and compared with those of the radiologist. Audit cycles were monitored through Q Pulse to ensure good practise was maintained. Patient satisfaction surveys were developed and distributed to 100 consecutive ladies attending for HSG over a 6 month period from January-July 2017.

RESULTS

The radiographer-led service has increased the number of appointment slots offered for HSG's throughout the year as the service now runs every week. HSG's were performed by 5 staff members but now only require 3 staff. A 75% response rate was achieved from the questionnaire survey and shows high patient satisfaction levels. Ladies reported being better informed about their examination resulting in decreased anxiety, concerns and discomfort.

CONCLUSION

The implementation of this service has successfully reduced waiting lists for HSG examinations from 14 to 0 weeks. The Trust has saved £15,000 on staff salaries per annum since the service started.

Effect of intramuscular hyoscine-n-butyl bromide on fallopian tube spasm and pain perception during and after hysterosalpingography in infertile women: A randomized single-blind controlled clinical trial

Background: Hysterosalpingography plays an important role in diagnostic work-up and treatment planning for infertile women. This procedure is usually uncomfortable and painful. The present study plans to investigate the effect of intramuscular Hyoscine-N-Butyl Bromide (HBB) on fallopian tube spasm and pain perception during and after hysterosalpingography (HSG) in infertile women.

Methods: This randomized single-blind controlled clinical trial (IRCT2017021132455N2) was conducted on infertile women scheduled for HSG in one radiology clinic affiliated to Arak University of Medical Sciences between July and August 2017. Patients were selected by convenience sampling and were randomly assigned to HBB (n=50) and a control group (n=50). Women received 20 mg/1cc HBB intramuscularly in the intervention group, 30 minutes before the procedure. Women in the control group did not receive any medication. The patients were requested to complete the Numeric Pain Rating Scale after injection of the dye, and also 30 minutes following the end of the HSG. Presence or absence of tubal spasm was determined after checking the radiographic images. For the data analysis using SPSS version 18, descriptive statistics, and analytical tests such as independent sample t-test, Mann- Whitney test, chi-square or Fisher’s exact tests and logistic regression and ANCOVA were used.

Results: Statistically significant differences were not observed in pain scores between the HBB and the control groups at the point of dye injection and 30 minutes after ending the HSG (p>0.05). Also, tubal spasm in the HBB group was lower than in the control group, but the differences were not statistically significant between the two groups (p=0.37).

Conclusion: The use of intramuscular HBB before HSG has no advantage in reducing tubal spasm and the induced pain during dye injection and 30 minutes after the HSG procedure. Thus, we don’t recommend HBB use before the HSG in order to relief from pain and spasm.

Experiences of Spanish women undergoing hysterosalpingography as part of the infertility process: a phenomenological study

AIMS AND OBJECTIVES

To describe and understand the experiences and perceptions of women who undergo hysterosalpingography as part of the infertility process.

BACKGROUND

Nurses and midwives should conduct research into the emotional aspects of caring for patients undergoing infertility treatment. The hysterosalpingography is considered to be the most feared test in the infertility process and the one about which very little is known.

DESIGN

A phenomenological qualitative study.

METHODS

Ten Spanish women who had undergone hysterosalpingography participated in this study. In-depth interviews were carried out between October 2012-May 2013. Data analysis was performed with the help of atlas.ti software to identify emerging themes.

RESULTS

The experience of the participants who underwent hysterosalpingography during the infertility process is represented by the following three themes: (1) becoming a mother to feel complete as a person and as a woman, with the subthemes 'maternity as a life objective' and 'maternity in terms of gender identity'; (2) infertility--an intimate experience which provokes negative feelings, with the subthemes 'negative feelings regarding own infertility' and 'infertility as an experience that is little shared with others'; (3) Undergoing hysterosalpingography, with the subthemes 'feelings regarding hysterosalpingography', 'treatment by medical providers' and 'areas for improvement regarding the service given by the providers'.

CONCLUSION

For women who undergo hysterosalpingography, maternity may be seen as a life objective that could identify them as women. Results suggest that although infertility is experienced with negative feelings such as anxiety, frustration and sadness, hysterosalpingography seems to be related with both hope and fear when facing the test.

RELEVANCE TO CLINICAL PRACTICE

Knowing the experiences of these women could help nurses, midwives and physicians to provide better patient-centred care.

Information seeking and perceptions of anxiety and pain among women undergoing hysterosalpingography

OBJECTIVE

Hysterosalpingography (HSG) is an accepted diagnostic tool for infertility workup and is considered an invasive procedure that is generally regarded as uncomfortable and painful, though research on psychological consequences is scarce and outdated. The study objective was to investigate women's experience of HSG in terms of fear, anxiety and pain, as compared to colposcopy.

STUDY DESIGN

This cross sectional questionnaire study was conducted at two public women's health clinics in Israel between January 2013 and March 2014. 137 women were included in the study. 42 consecutively sampled women referred for outpatient HSG and 95 consecutively sampled women referred for outpatient diagnostic colposcopy. The main outcome measures were: state-trait anxiety, information seeking behavior, fear of pain, fear of the results, retrospective pain.

RESULTS

Compared to those undergoing colposcopy, women undergoing HSG expressed significantly higher anxiety prior to the procedure, feared the pain involved more, and rated the procedure as more painful retrospectively. HSG patients tended to report a higher degree of information seeking. Information seeking was correlated with higher anxiety among HSG but not colposcopy patients.

CONCLUSION(S)

HSG is a highly stressful procedure associated with fear, anxiety, pain and information seeking. Research is needed to find possible ways of ameliorating these emotions and behaviors as they may have negative impact on patient cooperation.