Given the pace of technological advancement and government mandates for healthcare and system transformation, there is an imperative for change. Health systems are highly complex in their design, networks and interacting components, and experience demonstrates that change is very challenging to enact, sustain and scale. Policy-makers, academics and clinicians all need better insight into the nature of this complexity and an understanding of the evidence-base that can support healthcare improvement (HCI), or quality improvement, interventions and make them more effective in driving change. The evidence base demonstrates the vital role of clinical engagement and leadership in HCI, and it is imperative that clinicians engage to improve front-line healthcare. The literature on HCI is vast, applies different and inconsistent terminology and encompasses often loosely defined and overlapping concepts. An increasingly broad range of disciplines has contributed to the available evidence base, but often discipline-specific perspectives frame these contributions. Available literature can also be overly driven by the generation of theoretical concepts and the advancement of academic understanding. It does not necessarily primarily provide focussed and pragmatic insights to guide and inform frontline practice. We aim to address these issues by summarising theories, frameworks, models and success factors for improvement in complex health systems to assist clinicians and others to engage and lead change. We integrate the field of HCI into the learning health system highlighting the key role of the clinician. We seek to inform stakeholders; clinicians and managers to guide the planning, enacting, sustaining and scaling of HCI.

Results: 15 studies were included encompassing 3,795 women; 1,246 in the subgroup 'mild male infertility' and 1,188 in 'normal semen quality'. Clinical pregnancy was reported by all studies, and there is no evidence of a difference between single and double IUI (figure 1). We could not identify a particular subgroup that could benefit from the intervention. Evidence for live birth, ectopic pregnancy, and miscarriage was too imprecise because they were reported by too few studies. Conclusions: Currently, there is no evidence to support the use of double IUI in clinical practice. It requires a second appointment and insemination, thus making the treatment more complex and expensive, without a clear evidence of a benefit. Nevertheless, evidence is still of low quality and our confidence in the effect estimate is limited: the true effect may be substantially different from the hereby demonstrated. Supporting information can be found in the online version of this abstract P26.05 Objectives: To identify, appraise and summarise the available data, concerning the real impact of HPV infection on the woman and the reproductive outcomes following in vitro fertilisation (IVF). Methods: We searched for studies on PubMed, Embase, Scopus, Lilacs and the Cochrane Central Register of Controlled Trials from inception to Mar-2017. Any type of HPV infection in the woman assessed through PCR, subfertility factors and IVF indications and protocols were considered. Our outcomes were live birth/ongoing pregnancy, clinical pregnancy and miscarriage. We assessed the relative risk (RR), using a random-effects model; heterogeneity was assessed by I 2 statistics. The quality of the evidence was evaluated using the recommendations from GRADE working group. Results: Data from eight studies evaluating 208 women with HPV infection and 965 women without HPV infection were included in the analyses. The pooled results showed no significant difference in live birth/ongoing pregnancy (RR=1.16, 95%CI=0.88-1.53, I 2 =0%, 6 studies, 983 women), clinical pregnancy (RR=1.06, 95%CI=0.74-1.54, I 2 =61%, 8 studies, 1173 women), and miscarriage rates (RR=1.58, 95%CI=0.93-2.69, I 2 =8%, 6 studies, 290 clinical pregnancies). The overall quality of the evidence was very low, downgraded two levels because of serious limitations of included studies (observational studies) and imprecision. Conclusions: The available evidence is still insufficient to conclude about the effect of the HPV infection of the woman have on the most important reproductive outcomes following IVF; however, it suggests that the effect (negative or positive) is not very large for live birth/ongoing pregnancy and clinical pregnancy rates. P26.06 Evaluating tubal patency using three different ultrasound techniques: interobserver reliability, agreement and diagnostic accuracy Objectives: To estimate the interobserver reliability, agreement and diagnostic accuracy of offline analyses of three different ultrasound techniques for assessing tubal patency. Methods: Fifty women were evaluated for tuba...

Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility. Lifestyle change alone is considered the first-line treatment for the management of infertile anovulatory PCOS women who are overweight or obese. First-line medical ovulation induction therapy to improve fertility outcomes is clomiphene citrate, whilst gonadotrophins, laparoscopic ovarian surgery or possibly metformin are second line in clomiphene citrate-resistant PCOS women. There is currently insufficient evidence to recommend aromatase inhibitors over that of clomiphene citrate in infertile anovulatory PCOS women in general or specifically in therapy naive or clomiphene citrate-resistant PCOS women. IVF/ICSI treatment is recommended either as a third-line treatment or in the presence of other infertility factors.

This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.