***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: STUDY OBJECTIVE To determine whether the pain and discomfort of routine hysteroscopy with endometrial biopsy to diagnose infertility and endometrial pathology can be minimized by topical application of mepivacaine . DESIGN Prospect i ve , r and omized , double-blind study . SETTING The Department of Obstetrics and Gynecology at a teaching hospital in Rome , Italy . PATIENTS Eighteen women undergoing diagnostic hysteroscopy . INTERVENTIONS Hysteroscopy and endometrial biopsy were performed after transcervical injection of 5 ml 2 % mepivacaine or 5 ml saline solution into the uterine cavity . MEASUREMENTS AND MAIN RESULTS Difficulty introducing the hysteroscope was rated by the operator on a scale of 1 to 3 . An observer scored visible signs of each woman 's distress using a three-point scale . The patients reported their pain 15 , 30 , 60 , 120 minutes after the procedure on a visual analog scale . Mepivacaine was more effective than placebo according to all measurements . CONCLUSIONS Topical mepivacaine reduced the pain experienced during and after hysteroscopy and endometrial biopsy BACKGROUND Traditional and largely qualitative review s of evidence are now giving way to much more structured systematic overviews that use a quantitative method to calculate the overall effect of treatment . The latter approach is dependent on the quality of primary studies , which may introduce bias if they are of poor method ologic quality . OBJECTIVE To test the hypothesis that the inclusion of poor- quality trials in meta-analyses would bias the conclusions and produce incorrect estimates of treatment effect . METHODS An overview of r and omized trials of antiestrogen therapy in subfertile men with oligospermia was performed to test the hypothesis . Data sources included online search ing of MEDLINE and Science Citation Index data bases between 1966 and 1994 , scanning the bibliography of known primary studies and review articles , and contacting experts in the field . After independent , blind assessment , nine of 149 originally identified studies met the inclusion criteria and were selected . We assessed study quality independently . Outcome data from each study were pooled and statistically summarized . RESULTS There was a marginal improvement in pregnancy rate with antiestrogen treatment ( odds ratio , 1.6 ; 95 % confidence interval , 0.9 to 2.6 ) . Sensitivity analyses on the basis of method ologic quality demonstrated that poor- quality studies produced a positive effect with treatment , whereas no benefit was observed with high- quality studies . CONCLUSION The results of a meta- analysis are influenced by the quality of the primary studies included . Method ologically , poor studies tend to exaggerate the overall estimate of treatment effect and may lead to incorrect inferences Outpatient hysteroscopy is now regarded as the investigation of choice for abnormal uterine bleeding  as there is no longer any doubt that hysteroscopy is more effective than conventional curettage at identifying intrauterine pathology ( Gimpelson , 1984 ; Goldrath & Sherman , 1985 ; Gimpelson & Rappold , 1988 ; Loffer 1989 ) as it allows direct inspection of the uterine cavity , directed biopsy and appropriate therapeutic management . Another important advantage of hysteroscopy is that it can be performed without general anaesthesia and , in our experience , only 28.5 % of patients required local anaesthesia ; this was significantly associated with the need to dilate the cervix ( Hill et al. 1992 ) . In order to assess the role and efficacy of local anaesthesia before hysteroscopy , a r and omized placebo controlled double blind trial was performed comparing intracervical lignocaine with saline Objective To compare saline with and without added lignocaine and carbon dioxide distension for  out patient hysteroscopy  with regards to patient discomfort and hysteroscopic view OBJECTIVE To assess the efficacy of lignocaine spray during outpatient hysteroscopy in reducing the need for additional anesthesia and reducing the discomfort of the procedure . DESIGN A r and omized double-blind , placebo-controlled trial . SETTING An undergraduate university teaching hospital in London . PATIENT(S ) One hundred twenty patients undergoing outpatient hysteroscopy .  INTERVENTION(S ) Application of lignocaine spray to the cervix , cervical canal , and uterine cavity during outpatient hysteroscopy . MAIN OUTCOME MEASURE(S ) The need to use additional anesthesia and the pain experienced at various steps of the procedure . RESULT ( S ) Women treated with active spray experienced significantly less pain when the cervix was grasped with a tenaculum at the start of hysteroscopy . There were no other significant differences in the outcome of hysteroscopy between the placebo and lignocaine groups , although there was a significant reduction in the use of additional anesthesia in both groups compared with historical controls . CONCLUSION ( S ) Lignocaine spray has beneficial effects on cervical but not uterine sensation . Pretreatment with either lignocaine or placebo seems to reduce the need for additional intracervical anesthesia during hysteroscopy OBJECTIVE : To compare a “ no touch ” approach to diagnostic hysteroscopy without anesthesia with traditional diagnostic hysteroscopy after intracervical injection of mepivacaine hydrochloride 3 % . METHODS : A total of 130 women undergoing diagnostic hysteroscopy were included in the study and were r and omized , using a computer-generated r and omization list to one of two treatment groups in a ratio of 2:1 . Eighty-three women underwent hysteroscopy without speculum , tenaculum , or anesthesia . Forty-seven women received intracervical anesthesia with 10 mL of 3 % mepivacaine hydrochloride solution injected at two sites ( 3:00 and 9:00 positions ) and underwent traditional hysteroscopy . Hysteroscopy was performed using a rigid 3.7-mm hysteroscope and a medium of 0.9 % saline , and the image was transmitted to a screen visible to the patient . A visual analog scale ( VAS ) consisting of a 10-cm line was used to assess the intensity of pain experienced during and after the procedure . Overall patient satisfaction was assessed during , immediately after , 15 minutes later , and 3 days after hysteroscopy . RESULTS : The mean pain score was significantly lower in the group without the use of speculum , tenaculum , or anesthesia ( VAS1 : 3.8±2.7 versus 5.34±3.23 , P=.01 ; VAS2 : 3.02±2.50 versus 4.57±3.30 , P=.008 ) . Patient satisfaction rate was similar in both groups . CONCLUSION : Patients reported significantly less pain with the altered approach to diagnostic hysteroscopy compared with patients undergoing the traditional procedure with anesthesia . This new approach can therefore be considered as a useful hysteroscopic technique . CLINICAL TRIAL REGISTRATION : Clinical Trials.gov , www . clinical trials.gov , NCT00319410 LEVEL OF EVIDENCE : BACKGROUND The study was design ed to compare local anaesthesia and conscious sedation for outpatient bipolar operative hysteroscopy in terms of pain control and patients ' satisfaction . METHODS A prospect i ve multicentre r and omized study was carried out in university hospitals and in a private endoscopy unit . A total of 166 women with surgically treatable lesions associated with infertility or abnormal uterine bleeding was considered eligible for the study . Patients were r and omized , using a computer-generated r and omization list , into two groups . Group A ( 82 patients ) underwent operative hysteroscopy with local anaesthesia . Group B ( 84 patients ) received conscious sedation . Operative hysteroscopy was performed with a bipolar electrosurgical device to cut , vaporize and coagulate . Main outcome measures were pain control during the procedure , the post-operative pain score at 15 and 60 min , and at 24 h after the procedure , and patients ' satisfaction rate . RESULTS All procedures were completed within 35 min , the amount of saline used varied from 400 - 1200 ml . There were no significant differences between local anaesthesia and conscious sedation in terms of pain control during the procedure and in postoperative pain at different intervals . Satisfaction rate was similar in the two groups . CONCLUSIONS Both local anaesthesia and conscious sedation can be used for operative hysteroscopy using a bipolar electrosurgical system without significant differences in terms of pain control and patients ' satisfaction STUDY OBJECTIVE To evaluate the amount of pain during  office hysteroscopy and endometrial biopsy  with and without intrauterine anesthesia . DESIGN Prospect i ve r and omized study ( Canadian Task Force classification I ) . SETTING Academic teaching center . PATIENTS A total of 82 women underwent outpatient hysteroscopy for evaluation of their uterine cavity . INTERVENTIONS R and omization to local cervical or combined cervical and intrauterine anesthesia . MEASUREMENTS AND MAIN RESULTS Amount of pain experienced during the procedure ; 10 , 30 , and 60 minutes after the procedure ; and during endometrial biopsy .  We used a visual analog scale ranging from 0 to 10 ( 0 : no pain , 10 : excruciating pain ) . Of 82 patients , 4 patients were excluded , 36 patients underwent hysteroscopy using local cervical anesthesia , and 42 others with combined cervical and intrauterine anesthesia . The mean age of the patients in the local group was 37.4 + /- 0.8 years and in the combined group was 38.3 + /- 0.7 years . In both groups , patients experienced significantly more pain during and 10 minutes after the procedure than 30 and 60 minutes after . No significant differences occurred in the pain scores during the hysteroscopy , and 10 , 30 , and 60 minutes after between the 2 anesthesia groups . The pain score in the local group during endometrial biopsy was significantly higher than during ( p < .05 ) , 10 minutes after ( p < .001 ) , 30 minutes after ( p < .001 ) , and 60 minutes after ( p < .001 ) the procedure , respectively . In the combined group , compared with the pain score during endometrial biopsy , the scores during the hysteroscopy ( p < .05 ) , 10 minutes after ( p < .01 ) , 30 minutes after ( p < .001 ) , and 60 minutes after ( p < .001 ) the procedure were also less , respectively . CONCLUSION Intrauterine anesthesia with medicated saline as a distending medium is ineffective . Endometrial biopsy is associated with more pain than hysteroscopy OBJECTIVE To determine the feasibility and patient satisfaction of female sterilisation using the Essure system in an outpatient hysteroscopy clinic without conscious sedation or general anaesthesia . DESIGN Prospect i ve cohort study . SETTING Outpatient hysteroscopy clinic in a large teaching hospital . POPULATION Women undergoing outpatient hysteroscopic sterilisation using the Essure system for permanent fertility control . METHODS Demographic and procedural data were prospect ively collected from 112 consecutive women undergoing outpatient hysteroscopic sterilisation without sedation or general anaesthesia .  A hysterosalpingogram ( HSG ) was performed routinely in all women 3 months after the procedure to confirm bilateral tubal occlusion . Postal question naires were sent at this time enquiring about patient satisfaction and experience with the outpatient procedure . Multivariable logistic regression was used to identify factors independently predictive of successful completion of the procedure . MAIN OUTCOME MEASURES Technical feasibility , predictive factors for technical success ( operator , body mass index , uterine size , axis , menstrual phase and cervical stenosis ) , complications , tubal occlusion on HSG , patient satisfaction and procedure-related experience . RESULTS Successful bilateral tubal placement of the Essure microinserts  was achieved in 103/112 ( 92 % , 95 % CI 85 - 96 % ) women . Nonsecretory phase of the menstrual cycle ( P = 0.04 ) and a clinical ly normal-sized uterus ( P = 0.003 ) were independently predictive for successful completion of the outpatient procedure on multivariable modelling . There were no major procedure-related complications recorded , but transient vasovagal reactions occurred in 5/112 ( 5 % ) women . Of the original cohort of 112 women with successful procedures , 84 women were 3 months postprocedure and had undergone a HSG . Bilateral tubal occlusion was confirmed in 83/84 ( 99 % , 95 % CI 94 - 100 % ) women at 3 months and in 100 % at 6 months . Seventy-six of 84 ( 91 % ) had returned the question naires , and 70/73 ( 96 % , 95 % CI 88 - 99 % ) were satisfied with their overall experience of the procedure including radiological follow up , with most reporting being ' very satisfied ' ( 64/73 , 88 % , 95 % CI 78 - 94 % ) . CONCLUSIONS Outpatient hysteroscopic sterilisation using the Essure system without sedation or general anaesthesia is a successful and safe procedure associated with high rates of patient satisfaction . If practical , women should be scheduled to have their procedures in the proliferative phase of the menstrual cycle to optimise successful placement of Essure devices , especially if the uterus is clinical ly enlarged OBJECTIVE To evaluate the efficiency of par 
    Output:
    
Paracervical local anaesthetic injection is the best method of pain control for women undergoing hysteroscopy as out patients