Objective: To assess whether, in those requiring ongoing uterine stimulation after cervical ripening with oral misoprostol and membrane rupture, augmentation with low dose oral misoprostol is superior to intravenous oxytocin. Design: Open-label, superiority randomised trial Setting: Government hospitals in India Population: Women induced with oral misoprostol for hypertensive disease in pregnancy and requiring ongoing induction after membrane rupture Methods: Participants received misoprostol (25mcg orally two hourly) or titrated oxytocin through an infusion pump. Main Outcome Measure: Caesarean birth Results: 520 women were randomised and the baseline characteristics were comparable between the groups. The caesarean section rate was not reduced by the use of misoprostol (misoprostol 32.3% vs oxytocin 27.3%; adjusted odds ratio 1.226 (95% CI 0.81-1.85, p=0.33)). There were no differences in rates of hyperstimulation, fetal heart rate abnormalities, or maternal side effects, although the geometric mean time from randomisation to birth was 31 minutes longer with misoprostol. Fewer babies in the misoprostol arm were admitted to the special care unit (10 vs 21 in the oxytocin group) and there were no neonatal deaths in the misoprostol group, compared to 3 in the oxytocin arm. Women’s acceptability ratings were high in both study groups. Conclusion: Following cervical preparation with oral misoprostol and membrane rupture, the use of ongoing oral misoprostol for augmentation did not significantly reduce caesarean rates compared to oxytocin. The method, however, was safe for both mother and baby.

Objective: To describe the microbiome of the vagina and fallopian tubes, and its relation with hydrosalpinx. Design: Prospective case-control study. Population and Settings: Women who underwent salpingectomy for hydrosalpinx or other indications at our medical center . Main Outcome Measures: Samples obtained during surgery and were subjected to 16S rRNA amplicon sequencing, and analyses of alpha diversity and beta diversity meseaures were compared between sites and groups. Differential abundances of bacteria associated with vaginal dysbiosis was compared between cases and controls. Results: Nine women with hydrosalipnx, and 23 women without hydrosalpinx were included in the study. The mean age of studied women was 41 (range: 29-54), and most (89%) were premenopausal. After in silico decontamination, only 30% of control fallopian tubes samples, and 10% of case fallopian tubes samples, had evidence of bacterial presence. The vaginal microbiota of control patients showed greater abundance of lactobacilli whereas the vaginal microbiome of case patients contained relatively more bacterial vaginosis associated bacteria such as Prevotella, Gardenrella and Atopobium. A significant difference was found in alpha and beta diversity between the vaginal and FT microbiomes in control patients, as fallopian tubes samples were more diverse. We found that women with hydrosalpinx had a more “dysbiotic” vaginal microbiome, and in women without hydrosalpinx, microbial composition within the vagina and FT differed, possibly representing two distinct ecological environments. Conclusion: women undergoing salpingectomy for various reasons harbored bacteria within their FT, women with hydrosalpinx generally did not. This suggests that even though infection may be an underlying cause of hydrosalpinx, bacteria may not be present by the time patients require surgery.

Abstract Background: Maternal mental health influences the metabolism and growth of fetal brain structures affecting their skills up to adulthood. Objective: Main objective is whether music interventions improve modifiable maternal health outcomes. Search Strategy: Up to July 2023, randomized controlled trials (RCTs) investigating music during pregnancy were identified using MEDLINE, CENTRAL, WEB OF SCIENCE. Selection Criteria: Using COVIDENCE reviewers screened for RCTs with >3 interventions applying the Perceived Stress Scale (PSS), State-Trait-Anxiety Inventory (STAI), Edinburgh Postnatal Depression Scale (EPDS), or blood pressure (BP) as outcome measures. Data Collection and Analysis: The revised Cochrane risk-of-bias tool (RoB2) and the reversed Cohen’s d were applied to investigate the impact of target groups, frequency, type and selection of music programs. The review was registered via PROSPERO CRD42022299950. Main Results: From 251 records, 14 RCTs (16 intervention arms) and 2375 pregnancies were included. Music interventions varied from 3 to 84 active or passive music sessions per pregnancy or 10 to 60 minutes per day and significantly decreased PSS in 2/4, STAI in 8/9, EPDS in 3/4 and BP in 3/4 RCTs. RoB2 was high in 5/14, or “with concerns” in 9/14 studies. Stratifying the Cohen’s d in 14 interventions arms suggested a big effect in 234/469 mothers on BP, and in 244/489 mothers on maternal anxiety. Conclusion: The findings show the dretailed potential of music interventions on maternal BP, stress resilience or anxiety complementing our research on complex music interventions throughout pregnancy in times of pandemics, violent conflicts, or natural catastrophes. Funding: Clara Angela Foundation. Key words: Music in pregnancy, systematic review, maternal stress, anxiety, and depression.

Objective: Approximately 50% women who give birth after Obstetric Anal Sphincter Injury (OASI) develop anal incontinence (AI) over their lifetime. We review current evidence for protective benefit of planned cesarean section (CS) to prevent AI after OASI. Design and setting: Systematic review and meta-analysis according to prospectively published methodology. Population and methods: All studies reporting outcomes after an OASI and subsequent birth by any mode. Main outcome measures: AI measurement after OASI and subsequent birth. Total AI, new/worsening AI, quality of life, satisfaction, regret. Results: 86 of 2472 screened studies met inclusion criteria. All studies contributing to meta-analyses were at high risk of bias. There was no evidence of difference in new or worsening AI after subsequent vaginal birth (VB) compared to subsequent CS after OASI across all time periods (p=0.53: CI 0.72-1.19; 9 studies, 2104 participants); ≤2y (p=0.83: CI 0.65-1.72; 7 studies, 569 participants) or ≥5y after subsequent birth (p=0.39: CI 0.65-1.18; 2 studies; 1535 participants). There was no difference between subsequent CS or VB in asymptomatic women or for other AI or QOL outcomes. There was no evidence of difference in AI in women who subsequently delivered vs those who did not (p=0.9: CI 0.71-1.34; 10 studies, 970 participants); or pre- subsequent birth vs post-subsequent birth (p=0.31; CI 0.51-1.25, 13 studies, 5496 participants). Conclusions: Due to evidence quality (majority non-randomised studies) we are unable to determine whether planned cesarean is protective against AI after OASI. Higher quality data is required to guide practice in this area, specifically in asymptomatic women and for long-term outcomes.

Objective: To investigate postnatal contraception use amongst physician women, who would be expected to be health-literate and therefore a possible “best case” scenario of postnatal contraception behaviours. Design: Secondary analysis of cross-sectional survey data Setting: United Kingdom Population or Sample: Registered physicians in the United Kingdom less than two years postpartum, aged 30-55 years old, who reported spontaneous conception. Methods: Secondary analysis of online, anonymous, survey data collected April - June 2021. Chi-squared or Fisher’s exact tests were used to compare efficacy of postnatal contraception by socio-demographics and experience of contraception counselling. A Sankey plot presents timing of initiation and type of postnatal contraception used. Main Outcome Measures: Postnatal contraception use; time postpartum at which contraception initiated; contraception efficacy. Results: Among the 146 women who had had sex postpartum, only 11.6% used a very effective method (LARC/ sterilisation) as first contraception, and 16.4% had had sex without appropriate postnatal contraception. Postnatal contraception-efficacy was associated with timing of initiation (p<0.001); 92.3% of women initiating contraception up to 3 weeks postpartum used effective or very effective methods. Contraception counselling at the place of birth was associated with initiation of effective or very effective postnatal contraception (p=0.041). Conclusions: Uptake of effective or very effective postnatal contraception in the first 6 months postpartum was low, despite a highly health-literate population. However, the significantly high proportion of women choosing these options less than 3 weeks postpartum indicates their acceptability where services are available.

Objective: To better understand underlying factors of peripartum mortality we assessed variations in mortality by Robson 10-group classification. Design: Cross-sectional study. Setting: Prospectively collected perinatal e-registry data from 16 hospitals in Benin, Malawi, Tanzania and Uganda. Population: All women aged 13-49 who gave birth to a live or stillborn baby >1000g between July 2021 and December 2022. Methods: We compared peripartum mortality risk by Robson group and calculated proportional contributions to mortality. We assessed interactions between mortality and Caesarean sections using multivariable logistic regression and post-estimations margins. Main Outcome Measures: Peripartum mortality, defined as intrapartum stillbirths and very early (≤24 hours after birth) neonatal deaths. Results: We included 80 663 babies born to 78 085 women, of which 1 706 were intrapartum stillbirths and 617 very early neonatal deaths. Peripartum mortality was 5.2% (Benin), 1.6% (Malawi), 1.1% (Tanzania), and 3.7% (Uganda). The largest contributor to intrapartum stillbirths (27.8%) and very early neonatal deaths (23.3%) was Robson group 3 (multipara with cephalic term singleton in spontaneous labour) followed by group 10 (preterm birth). Intrapartum stillbirth risk in breech presentation (groups 6 and 7) was 5.1% in nullipara and 11.1% in multipara. A Caesarean section halved the odds of peripartum mortality in breech presentation in primipara (0.46; 95% CI 0.22-0.95). Conclusions: Our findings indicate a high share of peripartum mortality in lower obstetric risk groups and high mortality in breech deliveries and preterm births. This underscores the need to intensify actions to improve labour management.

A document by Andrew D Weeks. Click on the document to view its contents.

Recommendations for müllerian anomalies classificationSi Su1,2, Lan Zhu1*1 Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China2 Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China*Corresponding Author: Lan Zhu, MD, Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, No. 1 Shuaifuyuan, Dongcheng District, 100730, Beijing, China ([email protected])The word count for the main text: 506.In 2021, a new müllerian Anomalies Classification was proposed by American Society for Reproductive Medicine (ASRM 2021), 1 which was based on the American Fertility Society (AFS) 1988 2 and combined the benefits of existing classifications. However, mullerian anomalies is a group of complex diseases with various manifestations. And no consensus has been reached about the classification and diagnosis in clinical practice. The purpose of this study is to test the clinical application value of this new classification through the analysis of the cases from Peking Union Medical College Hospital in the past 20 years, and put forward valuable recommendations.A retrospective study was conducted using clinical data of hospitalized patients from January 2003 to December 2022 from Peking Union Medical College Hospital. Inclusion criteria included patients with 46, XX karyotype, diagnosed of müllerian anomalies, and clearly identified alterations of the uterus, cervix, and vagina. Clinical data of patients were collected through the hospital information system, and classification was performed based on the ASRM 2021. SPSS 25.0 version was used for data analysis.2671 patients were included, with an average visiting age of 28.9±10.0 years. The most common is septate uterus with 1144 cases (42.8%), followed by MRKH syndrome (20.4%), Herlyn-Werner-Wunderlich syndrome (HWWS) (10.4%), unicornuate uterus (7.4%), cervical agenesis (6.5%), uterus didelphys (5.6%), bicornuate uterus (2.9%), longitudinal vaginal septum (without uterine malformation) (2.0%), transverse vaginal septum (1.2%), complex anomalies (0.5%) and other anomalies (0.3%) (Table 1). It should be emphasized that HWWS was taken as an independent classification for statistical analysis, with reference to the clinical definition (uterus didelphys, obstructed hemivagina and ipsilateral renal agenesis).3,4 13 cases of complex anomalies were identified and 8 cases that could not be classified were classified as other anomalies (Supplement table 1).ASRM 2021 was proposed based on the AFS 1988, which is the most widely used classification in the past 30 years. We found ASRM 2021could distinguish most clinical patients well, but there are still some shortcomings. First, the classification of patients with uterine malformations and longitudinal/transverse/oblique vaginal septum is not clear. We recommend that patients with longitudinal vaginal septum and uterine anomalies should be classified into the uterine anomalies respectively, while others without uterine anomalies should be included in longitudinal vaginal septum. All transverse vaginal septum should be included in transverse vaginal septum, because the symptoms of transverse septum are prominent. A new type of HWWS should be added. Because the obstructive symptom is prominent. Second, we found several cases of complex anomalies. For these patients, multidisciplinary and individualized treatment should be carried out. The anomalies we found that are not currently classified include T-shaped uterus, congenital vaginal stenosis, and accessory and cavitated uterine masses (ACUM). With the deeper insight into this field, there may be a better way to classify them. The limitation of this study is that as a single-center retrospective study, there could be statistical biases.In conclusion, we put forward following suggestions for ASRM 2021 classification: 1) Minimize overlaps of classification and add a type of HWWS; 2) Update complex anomalies timely; 3) Add other anomalies classification.

Cesarean Section Rates in India: A Retrospective Analysis of Districts and States from 2011 to 2019

Objective: Increased rates of pro-inflammatory and metabolic-related disorders, plus perinatal death and other pregnancy complications such as gestational diabetes (GDM), are consistently reported among women of Indian ethnicity. This study compares lipid profiles and early pregnancy biomarkers associated with metabolic dysfunction between healthy nulliparous pregnant women of Indian and European ethnicity. Design: a prospective cohort study. Setting: Australia, Ireland, New Zealand and the United Kingdom; 2004-2011. Population: 138 and 5,240 women of Indian and European ethnicity were included from the prospective Screening for Pregnancy Endpoints cohort study. Methods: Early pregnancy biomarkers were selected a priori on the basis of a potential association with the metabolic syndrome, diabetes/GDM or obesity, and compared between ethnic groups. Biomarkers that differed significantly between ethnic groups were adjusted for maternal age, body mass index, smoking, alcohol use and socioeconomic status. Main outcome measures: Mean values for 21 placental, metabolic, inflammatory and cardiovascular biomarkers, plus blood lipids, measured at 15±1 weeks gestation. Results: Ten biomarkers were significantly different by ethnicity, mostly consistent with a pro-inflammatory and less favourable metabolic profile in Indian women: PlGF (p=0.02), adiponectin (p<0.01), NGAL (p<0.01), TNFR1A (p<0.01), CXCL10 (p=0.01), ICAM-1 (p<0.01), ST2 (p<0.01), angiogenin (p<0.01), and proANP (p<0.01). We additionally found increased triglycerides (1.6±0.6 vs 1.5±0.6, p<0.01) and reduced HDL cholesterol (1.7±0.4 vs 1.9±04, p<0.01) in Indian mothers, compared with European. Conclusions: Low-risk mothers of Indian ethnicity have an overall less favourable metabolic health profile at early gestation compared with European women. Future research should investigate the association with pregnancy outcomes.

Objective: Few studies have examined whether number of births is associated with women’s aging. This study aims to evaluate the association of number of births with women’s biological aging, premature mortality and life expectancy. Methods: A total of 272,494 participants from UK biobank who completed the questionnaire on number of live births were enrolled at baseline. The number of births was categorized into 6 groups, and participants with one live birth was the reference group. General linear regression model and cox proportional hazards model were performed to evaluate the association of number of births with women’s biological aging and premature mortality. Restricted cubic spline (RCS) was used to visualize dose-response relationship. Moreover, the latest Office for National Statistics life tables rom was used to calculate the life expectancy. Results: During a median follow-up of 11.9 years, a total of 10,992 cases of all-cause premature death were documented. After adjustment for potential confounders, compared to women had one birth, childless women had greater premature death (hazard ratio, HR=1.17, 95%CI: 1.09-1.25), whereas women with two or three children had lower risk of premature death (HR=0.87, 95%CI:0.82-0.93, HR=0.90, 95%CI: 0.82-0.99), which showed a U-shaped relationship visualized by RCS (P<0.05 for non-linearity). Further, at age 40, childless women had 1.41 years lower life expectancy, and women with two children was related to 1.10 years higher life expectancy. Moreover, compared to women had one birth, the women with two or three children had lower corrected estimated values of FI, ΔKDM-biological age and HD, and the women with five or more children had higher corrected estimated values of FI, ΔKDM-biological age, and HD (all the P<0.05). Conclusions: The association of number of live births with women’s biological aging, premature mortality and life expectancy had a U-shape relation. The childless or five more child women were more likely to be aging with increased risk of premature death and decreased life expectancy years. The double-child women decreased aging process with lower risk of premature death and high life expectancy.

Objective: To explore the potential factors that contribute to the occurrence of medical abortion(MA) through a Mendelian randomization(MR) study. Design: Univariate MR(UVMR) and multivariate MR(MVMR) analyses. Setting: Genetic variants from European populations. Population or Sample: Instrumental variants for MA were obtained from FinnGen with 36,232 cases and 149,622 controls. Methods: The inverse variance weighting method was adopted as the primary analysis. Main outcome measures: The associations of MA with household income(HI), education attainment(EA), cognitive performance(CP), risky behaviors: smoking behavior(SB), alcohol consumption(AC), and reproductive traits: age at first sexual intercourse(AFS), lifetime number of sexual partners(LNSP), age at first birth(AFB), age at last birth(ALB). Results: In the UVMR, increasing HI, EA, AFS and AFB appeared to reduce MA risk(HI, OR=0.569, P = 7.93E-08; EA, OR=0.875, P = 6.02E-21; AFS, OR=0.439, P = 5.17E-25; AFB, OR=0.815, P = 5.46E-12), whereas SB and LNSP appeared to add to MA risk((SB, OR=1.424, P =8.32E-11; LNSP, OR=2.777, P =2.14E-11). In the MVMR, EA, SB, LNSP and AFS seems to be the predominant risk factor for MA risk with the independent effect, while HI had no effect after controlling EA(HI in model 1, OR=0.890, P = 5.78E-01). AFB functioned as mediators in the causal chain of MA risk reduction by EA, with the mediated proportion of AFS and AFB being 57.8%. Conclusions: Our MR study demonstrated the causal potential of the associations of HI, EA, SB, LNSP, AFS and AFB with medical abortion.

A document by Hiba J. Mustafa. Click on the document to view its contents.

Objectives:  Pre-eclampsia is a hypertensive disorder of pregnancy which, left untreated, can cause significant foeto-maternal morbidity. Accordingly, the National Institution for Health and Care Excellence (NICE) recommends that high-risk women be prescribed daily prophylaxis with 75-150mg aspirin from twelve weeks’ gestation until delivery. NICE stratifies risk using eleven maternal risk factors; however, no secondary research has been published evaluating the diagnostic accuracy of this algorithm. This systematic review and meta-analysis evaluates the sensitivity and specificity of the NICE risk‑stratification algorithm in predicting pre‑eclampsia in pregnant women ≥16 years. Methods: Systematic searches were conducted using PubMed, Cochrane Library and SCOPUS to identify relevant papers with a CBEM Level of Evidence ≤4. A total of twenty eligible studies and 892,061 pregnancies were included in our analyses. The logit-transformed sensitivities and specificities from each study were modelled as a bivariate distribution with random effects in order to generate maximum-likelihood estimates (MLEs) for the overall sensitivity and specificity of the algorithm in predicting pre-eclampsia. Results: MLEs for the NICE algorithm’s sensitivity and specificity were 44.4% (95% CI 33.7-55.5) and 88.3% (95% CI 83.9-91.6), respectively. Significant heterogeneity was exhibited between the sensitivities  (I2=99.8%, 95% CI = 99.54-99.65) and specificities (I2=99.88%, 95% CI = 99.87-99.89) calculated by each of the included studies. Consequently, there is a low degree of certainty in these estimates. Conclusions: The NICE risk‑stratification algorithm performs remarkably poorly when used to predict pre‑eclampsia in any of three gestational categories. Clinicians should advise women that around 1 in 5 high-risk patients and 1 in 25 low-risk patients go on to develop pre‑eclampsia. However, future studies will likely alter the values of these statistics and the confidence therein. Key Words: Pre-eclampsia, High-risk Pregnancy, Sensitivity and Specificity, Predictive Value of Tests, Clinical Decision Rules.

Objective: To assess the association between chronotype and depressive symptoms in an infertile population undergoing assisted reproductive technology. Design: Cross-sectional study. Setting: The First Affiliated Hospital of Anhui Medical University Reproductive Medicine Center in Hefei, China. Population: 1022 infertile patients who sought assisted reproductive technology at the Center between August and October 2022, were assessed for inclusion in this study. Methods: On the day of ovulation injection, we collected socio-demographics by inviting infertile patients to complete questionnaires and assessed the subjects’ chronotypes through the Morning and Evening Questionnaire-5 Items (MEQ-5). Main Outcome Measures: Depressive symptoms, assessed with validated Patient Health Questionnaire-9 (PHQ-9) and expressed as PHQ-9 scores. Results: Overall, 9%, 68%, and 22% of participants were categorized as evening, neutral, and morning chronotypes, respectively. There were significant differences between chronotype on levels of depressive symptoms, subjects with morning chronotype (odds ratios = 0.32, 95% confidence intervals: 0.18-0.57) and neutral chronotype (odds ratios = 0.47, 95% confidence intervals: 0.28-0.77) had lower odds of depressive status, compared to those with evening chronotype, but no partner effect of chronotype was found ( p >0.05, respectively). Conclusions: Our findings suggest that morning and neutral chronotypes may be significantly associated with a lower likelihood of depressive symptoms. In addition, the effect of earlier chronotypes in men on depressive symptoms in women warrants relevant clinical attention when considering treatment.

[The Instructions to Authors state no abstract is required for a Research Letter but the submission sysem demands one, so this text is included.] In order to assess whether measuring HE4 might add to the performance of CA125 in diagnosing ovarian cancer, we measured both markers in 33 individuals with elevated CA125. We found that HE4 elevated above 150 pmol/l was present in all 9 cases of ovarian cancer and in the single case of pancreatic cancer.  HE4 levels below 77pmol/l seen in 16 cases were associated with non-malignant gynaecological conditions and with there being no identified cause for elevated CA125. Two cases with HE4 between 77 and 149 pmol/l had no gynaecological conditions and 2 had no an identifiable cause.  Measuring both markers could lead to improved sensitivity and specificity of the initial diagnostic step.

Background: The prevalence of infertility has rarely been synthesized at the global level. Objective: To conduct a systematic review and meta-analysis to assess the community-based global prevalence of infertility. Search Strategy: PubMed, MEDLINE, Web of Science, and Science Direct were searched from inception until October 2022. Selection Criteria: Studies were included if they were published in English, had quantitative data, and reported the community-based prevalence of infertility. Data Collection and Analysis: Two authors independently extracted data. Random-effects meta-analysis was used to derive the pooled prevalence of infertility. Variations in the prevalence estimates in different subgroups. Univariate meta-regression was used to explore possible sources of heterogeneity. Main Results: The findings indicated the pooled prevalence of infertility was 12.87% (95% CI,12.41%-13.33%). The prevalences of primary infertility and secondary infertility were 7.34% and 6.01%, respectively. The overall prevalence of infertility among people was the highest in Africa (16.73%) and lowest in the North America (8.84%). Lower prevalence in cohort or prospective follow-up studies (9.75%) than in cross-sectional studies (12.93%). Women aged 35 and above had a higher prevalence of infertility (11.68%) compared to women below 35 years old (5.92%). The prevalence of infertility increased with the number of years, and increased with the degree of literature bias from low to high. Conclusions: This community-based study estimated the global prevalence of infertility to be 12.87% and suggested that an upward trend of the prevalence of infertility may persist in the future.

Objective: Evaluate NHS-funded fertility treatment policies across England, Scotland, and Wales, assessing their alignment with the needs of those trying to conceive and comparing eligibility against NICE guidance. Design: Review of current NHS-funded fertility treatment policies and retrospective analysis of participant data. Setting: Not applicable. Population: Reproductive-age UK-based women using Hertility Health services from 2021-2023, focusing on those actively trying to conceive (TTC) or planning future pregnancies. Methods: Policy evaluation and data review without interventions. Main Outcome Measures: Eligibility for NHS-funded fertility treatment under UK regional policies versus NICE guidance. Results: In total, out of 2980 individuals actively trying to conceive and 6282 individuals planning for future pregnancies, 1700 (57.0%) and 2750 (43.8%) respectively would be ineligible for state-funded treatment under current regional policies: 1551 (57.7%) in England, 123 (53.2%) in Scotland, and 26 (41.9%) in Wales for those actively trying to conceive, and 2558 (43.9%), 146 (41.7%), and 46 (44.2%) for those planning future pregnancies respectively. In contrast, only 248 (8.3%) of those actively trying to conceive and 149 (2.4%) of those planning for future pregnancies would be ineligible if the NICE guidance were universally applied. Conclusions: By imposing outdated clinical and non-clinical qualifying criteria, the current NHS-funded fertility treatment policies exclude a substantial number of individuals requiring treatment. This necessitates a swift policy overhaul, as promised in the 2022 UK Women’s Health Strategy, to avoid further age-related fertility loss in women who require treatment imminently.