In women who are identified to have hydrosalpinges during controlled ovarian stimulation during IVF, aspiration of hydrosalpinges during oocyte collection may be effective in improving pregnancy rates (Trial Registration Number: NCT00566956).

Objective 1. To develop and validate a method for measuring menstrual blood loss in a routine setting, and 2. To assess the value of measuring menstrual blood loss before endometrial ablation. Design A prospective, observational study. Setting Four Yorkshire hospitals: The General Infirmary at Leeds, St James's University Hospital, Leeds, St Luke's Hospital, Bradford and The Friarage Hospital, Northallerton. Participants Three hundred and seventy‐two women who had been offered endometrial ablation for menorrhagia. Measurement Sanitary material was washed with a nonioriic detergent in a known volume of water. The haemoglobin in a sample of solution was measured by mixing with sodium carbonate for spectrophotometric analysis. Interventions The menstrual blood loss result was revealed to each woman. Electrosurgical endometrial ablation was performed for those who decided to have surgery. Main outcome measures Proportion of women with normal menstrual blood loss ( 80 mL) who avoided surgery. Comparison of endometrial ablation outcome in women with and without genuine menorrhagia. Results Thirty‐six women (10%) with normal menstrual blood loss who declined surgery continued to avoid surgery after a mean of 27 months. Two hundred and ninety‐two women were followed up for one year after endometrial ablation. Those with genuine menorrhagia (n= 122) were less likely to be dissatisfied (9%vs 18%) (OR 23, 95% CI 1.1–4.7) or to require hysterectomy (4%vs 7%) (OR 1.8, 95% CI 06–52) than women with normal menstrual blood loss (n= 170). Conclusions The objective diagnosis of menorrhagia can be undertaken in a routine setting and may provide some women, who have a normal menstrual blood loss, sufficient reassurance to refrain from surgery. Women with genuine menorrhagia have a better outcome after endometrial ablation than those with normal menstrual blood loss.

More attention should be given to patients with hydrosalpinx prior to IVF treatment and patients should be counselled about the negative effect of hydrosalpinx on IVF outcome. There is a wide variation in the management of hydrosalpinx prior to IVF treatment in the UK and many treatment options may be questionable, as they are not yet based on evidence.

There is now considerable discussion whether intracytoplasmic sperm injection (ICSI) should be used in all cases of IVF. A critical and balanced view of the current literature is presented. The difficult question is how to identify men with apparently normal semen who are likely to fail to achieve a pregnancy using IVF. In conclusion, from both the safety and scientific viewpoint, ICSI should only be used in cases where success at IVF is regarded as unlikely.

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