Innovative developments in pain and anxiety management for the infertile and endometriosis patient

This thesis centers around alleviating pain and anxiety, and thereby optimizing patient experiences, in the infertile and endometriosis patient. We focused on innovative approaches like Virtual Reality (VR) and Spinal Cord Stimulation (SCS), but also self-management strategies including dietary interventions. The results are presented in three parts. Part I: Pain and anxiety management using Virtual Reality in the infertile patient In Chapter 2 a systematic review with meta-analysis on the appliance of VR in (outpatient) gynaecological procedures was performed. A reduction in worst pain and procedural anxiety was seen, in favour of VR. All satisfaction scores were high with no significant difference between VR and non-VR. In Chapter 3 we studied the effect of VR on pain during hysterosalpingography (HSG). We found no disparity in reported average and worst pain scores between VR and non-VR. Nonetheless, women undergoing HSG with VR were significantly less willing to undergo another HSG without VR. In Chapter 4 we evaluated the efficacy of VR on pain and anxiety management during oocyte retrieval in IVF/ICSI treatment. We found no significant differences in anxiety, overall pain and peak pain between VR and non-VR. When looking at retrievals where 10 follicles or less were collected, we did see a significant benefit of VR on overall pain. Part II: Standardizing pain management and the appliance of Spinal Cord Stimulation in endometriosis In Chapter 5 we performed a multidisciplinary consensus meeting followed by an eDELPHI procedure to reach national consensus and a step-by-step guideline for pain management in endometriosis patients. The first two steps adhere to the WHO step-by-step approach, the third step consists of the addition of Tricyclic Antidepressants (TCAs) in case of neuropathic pain. Both the use of metamizol and opioids are recommended to only be used short-term. Muscarinic receptor antagonists are accepted treatment for bladder endometriosis. The use of COX-2 inhibitors were suggested but not presented as an established step. It was advised to prescribe magnesium oxide with all types of pain management because of their positive effect on gastro-intestinal symptoms. Proton pump inhibitors (PPIs) should be prescribed with use of NSAIDs, also when incidental. In Chapter 6 we collected all evidence regarding the appliance of SCS for visceral pain, between a broad number of diagnoses. We concluded that SCS applied for visceral pain could be effective in reducing symptoms, improving QoL and in reducing or even discontinuing pain medication use. In Chapter 7 we performed a feasibility pilot study, where SCS was applied in women diagnosed with endometriosis and intractable pain. SCS was effective in reducing general and worst pain, dysmenorrhea, chronic pelvic pain, dysuria and dyschezia. We saw improvements in QoL. All participants but one were able to reduce their analgesics. One participant requested device explantation. Part III: Dietary interventions in the chronic endometriosis patients In Chapter 8 we performed a survey study on the effect of the endometriosis diet on QoL. We found that the endometriosis diet positively influenced QoL, even more so when there was strict adherence. In Chapter 9 we studied the efficacy of the endometriosis diet and Low FODMAP diet on pain and QoL. We found that a diet positively influenced deep dyspareunia, dysuria, bloating and tiredness and improved QoL. In Chapter 10 we discussed why a glutenfree diet should not be recommended to women solely diagnosed with endometriosis. Its efficacy is based on only one study without a control group and without testing the participants for coeliac disease. Therefore it is possible that a strong placebo and nocebo effect plays a crucial role in the effectiveness of a glutenfree diet.