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• Elective single embryo transfer has been implemented in Belgium and Scandinavian countries to decrease the incidence of twin pregnancy and the associated complications. • The extra cost associated with achieving an equal number of pregnancies through elective single embryo transfer needs to be considered in the context of any additional neonatal care expenses associated with double embryo transfer. • Acceptable ongoing pregnancy and delivery rates have been obtained when comparing single with double embryo transfer. • Maternal age, previous attempts, day of embryo transfer and cost should be taken into account. Learning objectives: • To understand the issues raised when helping a couple choose single or double embryo transfer. Ethical issues: • Where does patient autonomy over treatment end and national regulation begin? • The management of obstetric complications and the long-term sequelae of premature birth should be factored in when considering treatment costs. Please cite this article as: Kosmas I, Van der Elst J, Devroey P, Tournaye H. Elective single embryo transfer. The Obstetrician & Gynaecologist 2008;10:163–169.

All women who attended an outpatient hysteroscopy clinic over a 12-month period were asked to participate in a prospective, randomized, controlled trial comparing pain levels associated with the "no-touch" technique or the traditional technique of performing hysteroscopy. One hundred twenty patients met the eligibility requirements and agreed to participate. They were randomized to undergo hysteroscopy with either the traditional or the no-touch technique (60 each). In addition, each group was further randomized to either a 2.9-mm or a 4.00-mm hysteroscope (30 each). In the no-touch group, 10 women required local anesthesia and/or cervical dilatation-2 in the 2.9-mm hysteroscope subgroup and 8 in the 4-mm subgroup. These women were converted to the traditional technique and hysteroscopy was successfully completed. Data were then analyzed on an intent-to-treat classification. The traditional technique followed the standard pattern of speculum insertion, use of Littlewood's tenaculum to hold the cervix, dilation of the cervix if needed, and hysteroscopy. A Pipelle de Cornier sampler was used to perform endometrial biopsy if required. In the no-touch technique, the hysteroscope was placed in the vagina with no speculum and then, with saline irrigant flowing, carefully inserted into the uterus through the cervical os without grasping. When an endometrial biopsy was necessary, Littlewood's tenaculum was used to hold the cervix. If cervical dilatation or intracervical local anesthesia was required, the procedure was converted to a traditional technique. Patient assessment of each technique was made immediately after hysteroscopy and included pain scores for several phases of the procedure. Patients were also asked if they would recommend the technique to a friend, if they would ask for general anesthesia for a future procedure, and if they found the procedure acceptable. Only one hysteroscopy, in which bleeding prevented hysteroscopic assessment, was considered not to be successful. More time was required to perform the traditional technique than the no-touch technique (7.8 minutes vs 5.9 minutes). Cervical dilatation was needed in 15 patients in the traditional group and 10 in the no-touch group. Local anesthesia was required in 13 and 11 patients in each group, respectively. One of the patients in the no-touch group received local anesthesia for the biopsy only and was not converted. Biopsies were taken in 42 patients in the traditional group and 40 patients in the no-touch group. The only statistically significant difference in pain scores was a greater perception of pain with biopsy in the no-touch group than in the traditional group. Otherwise, there were no differences in pain scores associated with insertion of the hysteroscope, hysteroscope inspection, placement of the speculum, local anesthetic, end of procedure, or 30 minutes after the end of hysteroscopy. The highest scores were reported by women who were converted from the no-touch to the traditional technique for the pain from injections for local anesthesia. Overall, 92% of women found the outpatient hysteroscopy experience very or fairly acceptable. Ninety-three percent would recommend it to a friend. Fifteen percent of women whose hysteroscope was 2.9 mm said they would ask for general anesthesia for any future hysteroscopies compared with 27% of women who were randomized to the 4.0-mm hysteroscope.