Background:Ovarian hyperstimulation syndrome is a potentially serious complication of fertility treatments. Standard care often involves monitoring, then hospitalisation for severe cases. Some evidence suggests early outpatient paracentesis may prevent hospitalisation, but adequately powered randomised trials are lacking. Objectives:To establish the clinical and cost-effectiveness, safety and acceptability of early active outpatient management for moderate or severe ovarian hyperstimulation syndrome. Design and methods:A pragmatic, parallel, open-label, multicentre, superiority, adaptive, group sequential randomised controlled trial with an internal pilot was planned. The study included preliminary qualitative work and a post-trial survey. The main trial recruited participants with moderate or severe, early or late ovarian hyperstimulation syndrome from UK fertility clinics. Participants were randomised 1 : 1 to receive either outpatient paracentesis or usual care (conservative management). The primary outcome was ovarian hyperstimulation syndrome-related hospital admission within 28 days. Results:The trial was terminated early due to poor recruitment. Only 8 participants were randomised (5 to conservative management, 3 to outpatient paracentesis) across 3 of 9 opened sites, compared to the planned 224 participants. All eight had moderate ovarian hyperstimulation syndrome at baseline. Two participants were hospitalised for ovarian hyperstimulation syndrome-related reasons (one from each group). Six participants' symptoms resolved during follow-up, while two had unknown outcomes. There were no reported serious adverse events caused by the intervention. The post-trial survey of 16 fertility centres found increased use of preventive measures like freeze-all cycles, antagonist protocols and gonadotropin-releasing hormone trigger, during and after the SARS-CoV-2 (COVID-19) pandemic. Limitations:The small sample size precludes drawing any definitive conclusions about effectiveness, safety or cost-effectiveness. The study was severely impacted by the COVID-19 pandemic, affecting site set-up and recruitment, and changes in clinical practice during the pandemic may have reduced ovarian hyperstimulation syndrome cases. Conclusions:No definitive clinical conclusions can be drawn from this study about the effectiveness of outpatient management compared to conservative management. The pandemic prompted lasting modifications in ovarian hyperstimulation syndrome prevention strategies at many fertility clinics. Future work:Given the observed low incidence rates of ovarian hyperstimulation syndrome and challenges in recruitment, future research may need to consider alternative study designs in observational settings rather than randomised trials that reflect the changing reality of clinical management and prevention of ovarian hyperstimulation syndrome, particularly following the recent COVID pandemic. Additionally, the research community should reflect on strategies to improve trial resilience and adaptability in the face of major disruptions like pandemics. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR128137.

Septate uterus is the most common congenital uterine anomaly. It is associated with increased risks of adverse obstetric outcomes. Hysteroscopic metroplasty is the standard minimally invasive treatment in selected patients, although its effect on reproductive outcomes remains controversial. We present a case of hysteroscopic metroplasty in a 31-year-old woman with a complete uterine septum extending to the internal cervical os (class U2b5) and a history of preterm delivery at 26 weeks gestation. The procedure was performed using an operative hysteroscope with a bipolar Versapoint spring electrode. The septum was resected progressively under direct visualization until both ostia were identified at the same level and healthy pink myometrial tissue was seen. This video case report demonstrates a systematic approach to hysteroscopic metroplasty, providing practical guidance for surgeons performing this procedure. Careful patient selection and detailed counselling are essential to ensure that appropriate candidates understand the current evidence.

Objective: To describe a rare case of mature oocyte retrieval without an exogenous trigger during random-start controlled ovarian stimulation (RS-COS) coinciding with a very early intrauterine pregnancy. Design: Case report. Subject: A 32-year-old para 1 patient with inflammatory breast cancer (grade 3, T4N2M0, ER/PR negative, HER2 3+, Ki-67 60%). Exposure: Luteal-phase RS-COS using a gonadotropin-releasing hormone antagonist protocol with human menopausal gonadotropin (hMG) 300 IU daily. Egg retrieval was performed on day 12 after stimulation. Main Outcome Measures: Number and maturity of oocytes retrieved; occurrence of ovarian hyperstimulation syndrome (OHSS). Results: On day 10 of stimulation, 25 follicles measuring ≥12 mm were seen, of which 18 were in the right ovary. A gestational sac was seen in the uterine cavity. The serum human chorionic gonadotropin level was 2,563 IU/L. Oocyte retrieval from the right ovary was performed without administering a trigger. Nine metaphase II oocytes were retrieved and vitrified; mild clinical OHSS occurred. Conclusion: This case demonstrates that it may be possible to perform COS in early pregnancy and be able to retrieve mature oocytes without the use of an exogenous trigger. To our knowledge, there are no previous published reports of multiple metaphase II oocyte retrieval without an exogenous trigger during RS-COS.

Pleural effusion as the predominant manifestation of severe ovarian hyperstimulation syndrome (OHSS) is rare and may occur with minimal or absent ascites. We present a recent retrospective case series from two UK centres describing presentation, investigations, management and outcomes of three patients developing large pleural effusions after medically assisted reproduction (MAR) in 2024-2025. All patients underwent antagonist stimulation with human chorionic gonadotropin (hCG) trigger and single fresh day-5 blastocyst transfer. Pleural effusions were diagnosed within a week of transfer, were predominantly right sided, and occurred despite modest ovarian enlargement and minimal or absent ascites. Patients required ultrasound-guided intercostal drainage with controlled outflow and albumin support. Pleural biochemistry was assessed in one case and this met 'Light's criteria' for exudate effusions. All patients improved rapidly after drainage and supportive management. Two pregnancies continued (one to term, one viable at 7 weeks), and one cycle did not result in pregnancy. In conclusion, pleural-predominant OHSS is a rare, yet recognisable phenotype. Early thoracic ultrasound, with careful interpretation of pleural biochemistry (including the serum-pleural albumin gradient in equivocal cases), avoidance of diuretics, selective albumin for intravascular support, timely ultrasound-guided drainage and venous-thromboembolism prophylaxis can optimise management. These cases also highlight the importance of preventive OHSS measures for future cycles.

We present a step-by-step approach for hysteroscopic myomectomy in patients with submucosal fibroids, focusing on key surgical techniques that enhance safety, preserve uterine integrity, and ensure complete fibroid removal. A 49-year-old woman with heavy menstrual bleeding presented with a type I submucosal fibroid measuring 32 × 23 × 20 mm. The procedure was performed using a 27 Fr bipolar resectoscope. Intraoperative strategies include: minimal cervical dilation to reduce fluid leakage, continuous saline infusion with controlled suction for optimal visibility, avoidance of repeated scope removal to maintain intrauterine pressure and identification of myometrial margins to ensure complete resection and prevent perforation. This video highlights essential surgical techniques and intraoperative considerations for performing safe and effective hysteroscopic myomectomy. Attention to fluid management, visualization, and preservation of cervical and uterine integrity is critical for optimal outcomes, especially in women with prior uterine surgery or fertility concerns.

Background:Ovarian hyperstimulation syndrome is a significant complication of fertility treatment, where the ovaries become enlarged if they are overstimulated, resulting in fluid leakage. Ovarian hyperstimulation syndrome can be classified as mild, moderate or severe. Symptoms vary dependent on severity but can include abdominal swelling, pain, nausea and vomiting, and shortness of breath. Treatment typically consists of monitoring initially, with active intervention if the condition progresses to a severe state, requiring hospitalisation. This study explored the acceptability and feasibility of outpatient paracentesis, and of gonadotropin-releasing hormone antagonists, as early interventions for ovarian hyperstimulation syndrome. Methods:We conducted qualitative semi-structured interviews with healthcare professionals from fertility clinics (n = 8) and patients who had experienced ovarian hyperstimulation syndrome (n = 10) across six United Kingdom fertility clinics. Interviews explored views on the proposed treatment protocols, and potential barriers and facilitators to randomised controlled trials evaluating these treatments. Results:Both healthcare professionals and patients were supportive of the proposed trials. Key findings included that healthcare professionals recommended clarity on patient eligibility, hospitalisation criteria and consent procedures. Patients expressed a desire to be given more detailed information about potential trials and had mixed opinions on self-monitoring. There were some concerns from both parties about treatment risks, particularly the paracentesis. Healthcare professionals noted a shift to more preventative practice due to the COVID-19 pandemic. Conclusions:Outpatient paracentesis and gonadotropin-releasing hormone antagonists were perceived as promising interventions. Potential concerns and recommendations around both acceptability and feasibility were raised, which were used to refine the treatment protocols for the Shaping and Trialling Outpatient Protocols for Ovarian Hyperstimulation Syndrome trial. Funding:This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR128137.

Anovulation refers to the absence of ovulation and is one of the most common causes of infertility. This review highlights the underlying causes of anovulation and discusses various techniques used to address anovulation-related infertility. Ovulation induction remains an effective treatment to overcome infertility caused by anovulation. A comprehensive approach to ovulation induction involves a combination of lifestyle modifications, medical therapies and surgical methods. Medications for ovulation induction aims to encourage the development of a single dominant follicle, while reducing the complications of ovarian hyperstimulation and multiple pregnancies. Laparoscopic ovarian drilling serves as an adjunct second-line treatment. This review aims to guide clinicians in selecting the safest and most effective treatment, tailored to the individual needs of each patient.

The typical agent used for final oocyte maturation and resumption of meiosis in in-vitro fertilisation (IVF) has been human chorionic gonadotropin (hCG). This acts as a surrogate for the physiological spontaneous luteinising hormone (LH) surge. Gonadotropin-releasing hormone agonist (GnRH-a) has been used as an alternative trigger in cycles where endogenous LH control is achieved using GnRH-antagonist and has been shown to be an effective method of reducing the risk of OHSS. However, GnRHa trigger is associated with poor corpus luteum function, leading to impaired endometrial receptivity. A combination of a GnRHa and hCG (dual trigger) was proposed to improve IVF cycle outcomes, especially in poor and normo-responder patients. Dual trigger aims to provide a more physiological alternative to HCG-only trigger while obviating some of the problems associated with GnRHa alone. Clinical evidence now supports the value of dual trigger where there has been a previous low proportion of mature eggs or where there is a suboptimal LH response to GnRHa alone. In poor responders, dual triggers could be considered as an effective first line. Dual trigger allows for comparable outcomes in normal and high responders, allowing the possibility of fresh embryo transfer with good clinical pregnancy and live birth rates while minimising OHSS risk.

Pre-implantation genetic testing (PGT) is a specialized technique that combines in vitro fertilization (IVF) technology with genetic testing. This paper provides a comprehensive overview of the different types of PGT, including PGT-A, PGT-M, and PGT-SR, highlighting their roles in reducing miscarriage rates, optimizing embryo selection, and minimizing the transmission of genetic conditions. Additionally, it discusses the technical aspects of embryo biopsy, the challenges associated with mosaicism, and ethical considerations, and patient counselling.

Ovarian hyperstimulation syndrome (OHSS) is a serious iatrogenic complication of ovarian stimulation with gonadotropins. It is characterized by enlarged ovaries along with fluid shift from intravascular compartment to the extravascular space. Clinical features include abdominal distension, discomfort, ascites, and pleural effusion. There is a risk of thromboembolism, and renal and respiratory dysfunction. Presence of polycystic ovaries, raised Antral Follicle Count, high Anti-Mullerian hormone, and occurrence of pregnancy in the treatment cycle are risk factors. GnRH antagonist protocol, individualized FSH dose, GnRH agonist trigger, elective cryopreservation of all embryos and dopamine agonists are important preventative measures. All women at risk of OHSS should have adequate information and access to 24-hour care. Women presenting with possible OHSS should be assessed and investigated to confirm the diagnosis and classify severity. Mild and moderate OHSS can be managed on an outpatient basis, while severe OHSS often needs in-patient care. Principles of management are maintaining intravascular hydration by encouraging fluid intake guided by thirst, close monitoring of fluid balance, prevention of thromboembolic complications, drainage of ascites in selected cases and symptom relief. If conception occurs in the treatment cycle, the course of OHSS is likely to be more severe and protracted.

Administration of follicle-stimulating hormone (FSH) is a key component of ovarian stimulation during assisted reproductive treatments (ART). Ovarian hyperstimulation syndrome (OHSS) is a complication of ovarian stimulation resulting in an exaggerated systemic response with a risk of serious morbidity. Various management strategies involving the optimisation of FSH administration are used to prevent the risk of OHSS. This review aimed to evaluate the current evidence for the use of FSH in ovarian stimulation and prevention of OHSS. A comprehensive literature search was performed using multiple electronic databases, including MEDLINE, SCOPUS and the Cochrane Library, to identify relevant systematic reviews and primary studies. Personalised dosing of FSH is associated with a lower incidence of moderate or severe OHSS, while the effect on live birth rate (LBR) remains uncertain. There is no significant difference in the risk of OHSS between using urinary and recombinant preparations of FSH. Long-acting and daily recombinant FSH preparations have a similar risk profile in predicted normal responders. Follitropin delta, a newer preparation, has shown a lower incidence of early OHSS and a higher LBR. The routine measurement of serum hormone levels in addition to ultrasound monitoring does not reduce the risk of OHSS. Coasting and FSH dose reduction may lower the incidence of OHSS in the event of response. Evidence-based use of FSH should be applied in practice to optimise patient safety without compromising treatment outcomes. More studies assessing the outcomes of FSH use in various patient subgroups are required to further assess and reduce the risk of OHSS.

Persistent Müllerian duct syndrome (PMDS) is a rare difference of sex development, characterized by the presence of Müllerian duct derivatives in 46,XY individuals with male-typical development. PMDS typically presents during childhood with features of cryptorchidism, inguinal hernia or transverse testicular ectopia. Untreated PMDS is associated with risks of infertility and malignancy. Infertility is common, arising from cryptorchidism, anatomical malformations (such as epididymal aplasia) or extrinsic compression of the ejaculatory duct by Müllerian structures. At the time of diagnosis, just one in five men with PMDS are reported to have conceived naturally. Preservation of fertility potential requires prompt diagnosis and management via a holistic patient-centred approach that addresses the underlying cause. With cryptorchidism, which is a common manifestation of PMDS, early orchidopexy is the key initial intervention. The input of fertility specialists and assisted reproductive techniques can further support successful conception. Beyond its effects on fertility, PMDS carries a risk of malignant transformation in the testes and Müllerian structures, warranting complex management with inclusion of a multi-disciplinary team and consideration of orchidopexy, orchidectomy, excision of Müllerian remnants and onward surveillance. Thus, although rare, PMDS is an important cause of male factor infertility that might be encountered by urologists. Preservation of fertility potential requires a high index of clinical suspicion and timely intervention. Raising awareness of PMDS among clinicians is crucial to improve its detection, advance its clinical management and provide a basis for future research. Persistent Müllerian duct syndrome (PMDS) is a rare difference in sex development, characterized by the presence of Müllerian duct derivatives in 46,XY individuals with male-typical development. Untreated PMDS is associated with risks of infertility and malignancy. In this Review, the authors provide an comprehensive primer on the epidemiology, pathophysiology and management of the condition, considering the need for a high index of clinical suspicion and timely intervention, raised awareness of PMDS among clinicians and multidisciplinary care to optimize outcomes for patients.

Introduction Ovarian hyperstimulation syndrome (OHSS) is the most significant short-term complication of pharmacological ovarian stimulation. Symptoms range from mild abdominal discomfort to rare complications such as renal failure, thromboembolism and respiratory distress syndrome.Currently, clinical practice typically involves monitoring the patient until the condition becomes severe, at which point they are admitted to hospital, where drainage of ascitic fluid (paracentesis) may take place. Preliminary studies have indicated that earlier outpatient paracentesis may reduce the progression of OHSS and prevent hospitalisation in women.Methods and analysis This UK, multicentre, pragmatic, two-arm, parallel-group, adaptive (group sequential with one interim analysis), open-label, superiority, confirmatory, group sequential, individually randomised controlled trial, with internal pilot will assess the clinical and cost-effectiveness and safety of outpatient paracentesis versus conservative management (usual care) for moderate or severe OHSS. 224 women from 20 National Health Service and private fertility units will be randomised (1:1) and followed up for up to 13.5 months. The primary outcome is the rate of OHSS related hospital admission of at least 24 hours within 28 days postrandomisation. The primary analysis will be an intention to treat with difference in hospitalisation rates as measure of treatment effect. Secondary outcomes include time to resolution of symptoms, patient satisfaction, adverse events and cost-effectiveness. A qualitative substudy will facilitate the feasibility of recruitment. Participant recruitment commenced in June 2022.Ethics and dissemination London—Southeast Research Ethics Committee approved the protocol (reference: 22/LO/0015). Findings will be submitted to peer-reviewed journals and abstracts to relevant national and international conferences, as well as being disseminated to trial participants and patient groups.Trial registration number ISRCTN71978064.

As more women prioritize education, career growth, and personal milestones, family planning is increasingly postponed until later in life. Contributing factors such as advanced education, career ambitions, highly effective contraceptive methods, and finding life partners at later stages have led to a growing interest in fertility treatments for women over 50. However, pursuing pregnancy at this age comes with significant clinical and ethical challenges. Women over 50 face elevated risks of aneuploidy, miscarriage, pre-eclampsia, gestational diabetes, and preterm delivery. These complications necessitate rigorous pre-treatment evaluations, enhanced monitoring protocols, and comprehensive care throughout pregnancy. Additionally, ethical concerns arise regarding the welfare of both mother and child, as well as the societal implications of offering fertility treatments to this demographic. This spotlight article explores the clinical risks, ethical considerations, and practical approaches to managing fertility treatment in women over 50.

The importance of menopause and the short and long term effects of this have been underestimated and under discussed. With the media currently highlighting issues that affect women, it is important to understand menopause, the effects of this and how to mitigate these effects. When prescribing any drug or treatment, the risks must be properly discussed and women given as much information as possible to make an informed choice about their health. This is likely to look different for every woman who comes for a consultation as menopause and subsequent reactions to HRT are individual.