Jim X. Wang

Body mass and probability of pregnancy during assisted reproduction treatment: retrospective study.

Being underweight or overweight has an adverse effect on reproduction.1,2 Overweight women have a higher incidence of menstrual dysfunction and anovulation, possibly because of altered secretion of pulsatile gonadotropin releasing hormone, sex hormone binding globulin, ovarian and adrenal androgen, and luteinising hormone and also because of altered insulin resistance. The prevalence of obesity in infertile women is high, but there is no conclusive evidence that extremes of weight are associated with a low rate of pregnancy in women receiving assisted reproduction treatment. This study examined whether body mass index (weight (kg)/(height (m)2)) is associated with reduced fecundity (the probability of achieving at least one pregnancy during treatment) in women receiving assisted reproduction treatment.

Surgically obtained sperm, and risk of gestational hypertension and pre-eclampsia

The cause of pre-eclampsia is unknown, although a partner-specific immune maladaptation might be involved. We compared rates of pre-eclampsia and gestational hypertension in women whose genital tracts had and had not been exposed to their partners sperm cells. Our aim was to ascertain whether or not protective partner-specific immune-tolerance is conveyed by sperm cells, rather than seminal fluid. Our findings indicate that, compared with women exposed to their partners sperm cells and seminal fluid--ie, those treated with in-vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) with ejaculated sperm--the risk of hypertension was doubled and the risk of pre-eclampsia tripled in those never exposed to their partners sperm--ie, those treated with ICSI done with surgically obtained sperm.

Should we continue or stop insulin sensitizing drugs during pregnancy

Purpose of review The use of insulin sensitizing drugs such as metformin in polycystic ovary syndrome has been increasingly popular and validated by systematic reviews. There has also been an interest in the use of metformin for gestational diabetes. However, administration of metformin to prevent miscarriage is controversial and widespread use of this drug in early pregnancy requires investigation. Recent findings There are claims that miscarriage and gestational diabetes are more common in polycystic ovary syndrome and that use of insulin sensitizers improves outcomes dramatically. This review suggests there is no evidence for increased risk of miscarriage solely due to polycystic ovary syndrome and that there are insufficient data for promoting therapy with metformin. There is some reason for use of metformin in mid-pregnancy for gestational diabetes but better evidence from randomized controlled trials is urgently needed. Summary The use of metformin in early pregnancy for reducing the risk of miscarriage should be avoided outside of the context of properly designed prospective randomized trials. Safety in early pregnancy appears to be reassuring but not completely proven. The use of metformin in mid-pregnancy for gestational diabetes appears more logical but also needs adequate trials before general use is advocated.

Patterns of Surgical Treatment for Women with Breast Cancer in Relation to Age

Abstract:  Although treatment recommendations have been advocated for all women with early breast cancer regardless of age, it is generally accepted that different treatments are preferred based on the age of the patient. The aim of this study was to assess the pattern of breast cancer surgery after adjusting for other major prognostic factors in relation to patient age. Data on cancer characteristics and surgical procedures in 31,298 patients with early breast cancer reported to the National Breast Cancer Audit between 1999 and 2006 were used for the study. There was a close association between age and surgical treatment pattern after adjusting for other prognostic factors, including tumor size, histologic grade, number of tumors, lymph node positivity, lymphovascular invasion (LVI), and extensive intraduct component. Breast Conserving Surgery (BCS) was highest among women aged ≤40 years (OR = 1.140; 95% CI: 1.004–1.293) compared to women aged 51–70 years (reference group). BCS was lowest in women aged >70 years (OR = 0.498, 95% CI: 0.455–0.545). Significantly more women aged ≤50 years underwent more than one operation for breast conservation (20.4–24.8%) compared with women aged >50 years (11.4–17.0%). Women aged >70 years were more likely to receive no surgical treatment, 3.5% versus 1.0–1.3% in all other age groups (≤40, 41–50 51–70 years). There is an association between patient age and the type of breast cancer surgery for women in Australia and New Zealand. Women age ≤40 years are more likely to undergo BCS despite having adverse histologic features and have more than one procedure to achieve breast conservation. Older women (>70 years) more commonly undergo mastectomy and are more likely to receive no surgical treatment.

Risk factors for preeclampsia in multiparous women: Primipaternity versus the birth interval hypothesis

Introduction. To determine whether the risk of preeclampsia in multiparous women with a previous normal pregnancy is related to changing paternity or to prolonged birth interval, a retrospective study was conducted at the Lyell McEwin Health Service (University of Adelaide). Methods. The study included all multiparous women known to the hospital because of their preceding 1st delivery in the same hospital followed by their 2nd and/or 3rd ongoing pregnancy resulting in a delivery in the period 2001 – 2003. Case records were analyzed for birth interval, pregnancy interval, paternity and recognized risk factors such as booking weight and smoking. For the analysis both the International Society for the Study of Hypertension in Pregnancy (ISSHP) definition and the more recently introduced classification by the Australian Society for the Study of Hypertension in Pregnancy (ASSHP) were used. Results. In the 656 women in this study cohort, 148 (26.2%) women had a different partner in their 2nd and/or 3rd ongoing pregnancy. Using the ISSHP definition for preeclampsia, changing partners had an odds ratio (OR) of 1.304 (95% CI 0.43 – 3.99); using ASSHP criteria an OR of 1.556 (95% CI 0.6506 – 3721); and looking at the combined group of pregnancy-induced hypertensive disorders an OR of 1.99 (95% CI 1.01 – 3.89). A longer birth interval if anything was associated with a lower risk of preeclampsia (non-significant), whatever definition was used. Also the inter-pregnancy interval did not show a consistent relation with the risk for developing a hypertensive complication. Conclusions. The results of this study on risk factors for preeclampsia in multiparous women appear to be in line with the primipaternity hypothesis, but are in direct contrast with the so-called birth interval hypothesis.

Survival from breast cancers managed by surgeons participating in the National Breast Cancer Audit of the Royal Australasian College of Surgeons

Background:  The National Breast Cancer Audit (NBCA) of the Royal Australasian College of Surgeons has collected data on early breast cancer since 1998. In this project, deaths were traced by linkage of NBCA patient identifiers (first three digits of surname and date of birth) with the National Death Index that covers all deaths in Australia.

Are males with early breast cancer treated differently from females with early breast cancer in Australia and New Zealand

UNLABELLED Breast cancer in males is much rare than in females so in practice, male breast cancer treatment is likely to follow the guidelines developed for female breast cancer patients. The objective of this study is to compare the characteristics and treatment pattern of male breast cancer patients with comparable subgroups of female breast cancer patients using data submitted to the National Breast Cancer Audit. This is a retrospective analysis of 151 male breast cancers diagnosed and treated between 2000 and 2008. Most of the male early breast cancer cases in this group were symptomatic ones in men aged >50 years with one invasive tumour. There was a similar proportion of lymph node positive cancer among males and females, although male breast cancer was more likely to be unifocal (P=0.007) and oestrogen receptor positive (P=0.001). Male breast cancer patients almost always underwent mastectomy and a significant proportion of them (11%) received no surgical treatment. There were no differences in axillary surgery although males were more likely to undergo a level 2 axillary surgery and less likely to have sentinel node biopsy. Male patients were significantly less likely to undergo radiotherapy, chemotherapy or hormonal therapy for oestrogen receptor positive tumours. CONCLUSION While the female oriented treatment guidelines are available, male patients with early breast cancer received different surgical and adjuvant treatment from comparable females.

Commentary: how surgical audits can be used to promote the update of surgical evidence.

Evidence‐based medicine (EBM) is an important advance in health care. The Australian Safety and Efficacy Register of New Interventional Procedures – Surgical (ASERNIP‐S), the Royal Australasian College of Surgeons, has been at the forefront of promoting EBM in surgery by developing systematic reviews and managing surgical audits. In EBM, uptake of evidence is just as important as establishing the evidence. The prospective, long‐term data collection of surgical audits on treatment processes and outcomes often have a high patient and surgeon coverage and make them extremely valuable as a tool for assessing the uptake of evidence. Surgical audits can be used: (i) to assess practice trends and the impact of systematic reviews or clinical guidelines on treatment practice, (ii) to identify the disparities in the uptake of evidence, and (iii) to promote further research on how to bridge evidence–practice gaps and to overcoming possible barriers for the evidence uptake. The information gathered through the audit data assessment on evidence‐uptake can be used to improve evidence dissemination and identify possible barriers to the uptake of evidence.

TRENDS IN SURGICAL TREATMENT OF YOUNGER PATIENTS WITH BREAST CANCER IN AUSTRALIA AND NEW ZEALAND

Background:  The optimal surgical treatment of early breast cancer in young women is not fully determined, while past reports indicate a trend to the increased use of breast‐conserving surgery (BCS). This study aims to assess the trend in Australia and New Zealand of BCS use between 1999 and 2006 and to determine pathological factors associated with it.

Risk factors for the deterioration of glucose metabolism in polycystic ovary syndrome

Women with polycystic ovary syndrome (PCOS) have a high risk of abnormal glucose metabolism, which deteriorates gradually over time. This study was designed to assess contributing factors to the rate of deterioration of glucose metabolism over the 4- to 7-year follow-up period. The study group included 67 PCOS women who had normal glucose tolerance in the initial test in 1990-1992. There was a significant increase in both fasting and 2-h glucose concentrations, and body weight, over the follow-up period. The initial obesity, expressed as waist:hip ratio and BMI, was significantly related to the increase of glucose concentrations, while weight gain was not a significant factor. The overweight/obese PCOS women have a faster deterioration of glucose metabolism over the follow-up period than the non-obese ones. Moderate weight gain has no significant detrimental effect on the rate of deterioration of glucose metabolism.