What is good practice in ultrasound (US), and more specifically during the different stages of transvaginal oocyte retrieval, based on evidence in the literature and expert opinion on US practice in ART? This document provides good practice recommendations covering technical aspects of US-guided transvaginal oocyte retrieval (oocyte pick up: OPU) formulated by a group of experts after considering the published data, and including the preparatory stage of OPU, the actual procedure and post-procedure care. US-guided transvaginal OPU is a widely performed procedure, but standards for best practice are not available. A working group (WG) collaborated on writing recommendations on the practical aspects of transvaginal OPU. A literature search for evidence of the key aspects of the procedure was carried out. Selected papers (n = 190) relevant to the topic were analyzed by the WG. The WG members considered the following key points in the papers: whether US practice standards were explained; to what extent the OPU technique was described and whether complications or incidents and how to prevent such events were reported. In the end, only 108 papers could be used to support the recommendations in this document, which focused on transvaginal OPU. Laparoscopic OPU, transabdominal OPU and OPU for IVM were outside the scope of the study. There was a scarcity of studies on the actual procedural OPU technique. The document presents general recommendations for transvaginal OPU, and specific recommendations for its different stages, including prior to, during and after the procedure. Most evidence focussed on comparing different equipment (needles) and on complications and risks, including the risk of infection. For these topics, the recommendations were largely based on the results of the studies. Recommendations are provided on equipment and materials, possible risks and complications, audit and training. One of the major research gaps was training and competence. This paper has also outlined a list of research priorities (including clarification on the value or full blood count, antibiotic prophylaxis and flushing, and the need for training and proficiency). The recommendations of this paper were mostly based on clinical expertise, as at present, only a few clinical trials have focused on the oocyte retrieval techniques, and almost all available data are observational. In addition, studies focusing on OPU were heterogeneous with significant difference in techniques used, which made drafting conclusions and recommendations based on these studies even more challenging. These recommendations complement previous guidelines on the management of good laboratory practice in ART. Some useful troubleshooting/checklist recommendations are given for easy implementation in clinical practice. These recommendations aim to contribute to the standardization of a rather common procedure that is still performed with great heterogeneity. The meetings of the WG were funded by ESHRE. The other authors declare that they have no conflict of interest. NA. ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic potentially life-threatening condition resulting from excessive ovarian stimulation. The crucial event in the development of OHSS is the administration of human chorionic gonadotropin (hCG). The early onset of OHSS typically presents in the luteal phase as a consequence of ovulatory hCG. The late onset of OHSS presents in early gestation when endogenous hCG further stimulates the ovary. Many strategies have been proposed for OHSS prevention, but they may reduce but not eliminate the risk. This article reviews the evidence related to the elective cryopreservation of all embryos and their subsequent transfer in women at risk of OHSS. More research is needed to determine whether using elective cryopreservation of embryos can reduce the rate of severe OHSS in in vitro insemination (IVF)/intracytoplasmic sperm injection (ICSI). Results from many retrospective studies are encouraging, but prevention in terms of (1) identification of the high-risk population using new biochemical markers of ovarian response such as anti-Müllerian hormone, (2) tailoring ovarian stimulation and using less aggressive protocols (gonadotropin-releasing hormone antagonists or mild IVF), and (3) blastocyst culture to allow clinical monitoring of early-onset OHSS, with eventual blastocyst cryopreservation, might represent a multistep approach worth further investigation.

BACKGROUND: Ultrasound-guided embryo transfer (US-GET) is a widely performed procedure, but standards for the best practice are not available. OBJECTIVE AND RATIONALE: This document aims to provide an overview of technical aspects of US-GET after considering the published data and including the preparation for the embryo transfer (ET) procedure, the actual procedure, the post-procedure care, associated pathologies, complications and risks, quality assurance and practitioners’ performance. SEARCH METHODS: A literature search for evidence on key aspects of the ET procedure was carried out from database inception to November 2021. Selected papers (n = 359) relevant to the topic were analysed by the authors. The following key points were considered in the papers: whether ultrasound (US) practice standards were explained, to what extent the ET technique was described and whether complications or incidents and how to prevent such events were reported. In the end, 89 papers could be used to support the recommendations in this document, which focused on transabdominal US-GET. OUTCOMES: The relevant papers found in the literature search were included in the current document and described according to the topic in three main sections: requirements and preparations prior to ET, the ET procedure and training and competence for ET. Recommendations are provided on preparations prior to ET, equipment and materials, ET technique, possible risks and complications, training and competence. Specific aspects of the laboratory procedures are covered, in particular the different loading techniques and their potential impact on the final outcomes. Potential future developments and research priorities regarding the ET technique are also outlined. LIMITATIONS, REASONS FOR CAUTION: Many topics were not covered in the literature review and some recommendations were based on expert opinions and are not necessarily evidence based. WIDER IMPLICATIONS: ET is the last procedural step in an ART treatment and is a crucial step towards achieving a pregnancy and live birth. The current paper set out to bring together the recent developments considering all aspects of ET, especially emphasizing US quality imaging. There are still many questions needing answers, and these can be subject of future research. STUDY FUNDING/COMPETING INTEREST(S): No funding. A.D.A. has received royalties from CRC Press and personal honorarium from Cook, Ferring and Cooper Surgical. The other co-authors have no conflicts of interest to declare that are relevant to the content of this article.

Polycystic ovary syndrome (PCOS) is the expression of a complex alteration of the reproductive system. It is characterised by the increase in androgens, causing symptoms such as hirsutism, as well as infertility in many. This paper reviews whether Clomiphene Citrate, Letrozole and Inositol function better as monotherapy or combined therapy for anovulatory infertile PCOS patients. Ovulation and pregnancy rate were used as primary outcomes. PubMed and Scopus were the search engines of choice. Papers were excluded if patients were undertaking other fertility interventions, overlapping populations and non-RCT papers. It was found that co-prescribing Letrozole or Clomiphene Citrate alongside Metformin should be considered, Inositol should be examined as an alternative insulin sensitiser to Metformin and studies should be undertaken to identify the ideal dose and duration of Inositol therapy. Further large, well-designed, multi-centre studies should be conducted to solidify the claims of this review.