Julian M. Jenkins

Complementary and alternative medicine utilisation in NHS and private clinic settings: a United Kingdom survey of 400 infertility patients.

Some evidence suggests that complementary and alternative medicine (CAM) has found increased utilisation among patients seeking infertility treatment, although there is little information available to quantify this phenomenon. This is important information as there is marketing for CAM directed to this group and professionals need to be aware of the treatments their patients are receiving. Patients attending for infertility diagnosis and treatment often ask the physician about CAM; this paper seeks to compare the prevalence of CAM use among infertility patients in National Health Service (NHS) and private clinics. This paper provides results of a survey of couples (n = 400) divided equally between NHS and private settings. Our data suggest a high use of CAM particularly among female private patients, although patients appear sceptical of the efficacy of such treatment which is consistent with the literature.

Hull and Rutherford classification of infertility

In 1991, the British Fertility Society commissioned an audit subcommittee to produce an all-encompassing classification system for infertility, which could be used as the basis for national audit. Accurate diagnosis is a basic necessity of good medical practice and determines the selection of appropriate treatment. In addition, assessment of treatment outcome by audit must be related not only to the specific type and severity of the disorder, but also to a number of important compounding variables, such as age of the female partner. Severity is a key factor in the selection of the most appropriate treatment in disorders such as tubal disease and endometriosis; therefore, the classification of these conditions needs to be therapy-oriented, providing a guide to prognosis. The classification system was determined by reference to the best available published data on outcome, in terms of time-specific cumulative pregnancy rates, at the time of preparation, and on information gleaned from surveys of opinion from the members of the British Fertility Society and the British Andrology Society. When used in conjunction with an appropriate computerheld database, codification of data using a classification system provides a powerful tool for clinical audit and research. Such systems allow analysis of the relative effectiveness of different methods of treatment for various patient groups, providing meaningful comparisons among practitioners and hospitals (Jenkins, 1999). A survey published in 2000 of all in vitro fertilization (IVF) centres in the UK indicated overwhelming support for central collection of computerized data by the Human Fertilisation and Embryology Authority (HFEA), which could be extended beyond the limited current dataset if a suitable classification system was available (Keay et al., 2000). This article presents an appendix outlining the classification system as it was first proposed in 1995, so that it may act as a foundation for the future development of an updated classification that could be adopted by the profession.

Assisted hatching in assisted reproduction

Assisted reproductive techniques including in vitro fertilisation and embryo transfer (IVF-ET) have become the principal method to resolve long term infertility. Despite major advances such as the introduction of intracytoplasmic sperm injection (ICSI) for severe male infertility, the proportion of embryos leading to live offspring has increased only marginally since the inception of assisted reproductive techniques . A successful outcome is dependent on many factors including the ability of the embryo to hatch from its zona pellucida – . Prolonged exposure of human embryos to in vitro culture could lead to loss of zona elasticity and hardening thus impairing their ability to hatch. Since Cohen et al. reported the first pregnancy after assisted hatching in 1988, several techniques to assist embryos to hatch from the zona have been developed with the aim of improving pregnancy rates. This review will consider zona pellucida physiology, zona hardening, different techniques of assisted hatching, who may benefit from assisted hatching and potential hazards. This article benefited from the publications identified in the protocol for the ongoing Cochrane systematic review in this area. These references were supplemented with a search of the Medline database and a hand search of appropriate journals and abstracts from relevant international meetings. However, this review did not seek to statistically combine the data from the diverse studies on assisted hatching, because, as will be shown below, the available techniques differ radically, potentially influencing both benefits and risks.

Is ovarian hyperstimulation syndrome associated with a poor obstetric outcome

Assisted conception techniques offer many infertile couples their best-in some cases only-chance of parenthood. In the UK alone there were 5665 births from cycles of in vitro fertilisation or intra-cytoplasmic sperm injection in the year ending 31 March 1997’. Although the aim of assisted conception treatment is a healthy baby, the obstetric outcome of pregnancies resulting from assisted conception cycles complicated by ovarian hyperstimulation syndrome remains poorly studied. Ovarian hyperstimulation syndrome is a complication of supraphysiologic ovarian stimulation designed to increase the numbers of oocytes and embryos available for assisted conception. A recent analysis of 10 years of data from Israel identified a rising incidence of ovarian hyperstimulation syndrome and suggested the existence of an ‘epidemic’ of this complication*. Worryingly, the same authors3 also reported a high incidence of adverse pregnancy outcomes in 104 in vitro fertilisation pregnancies complicated by severe or critical ovarian hyperstimulation syndrome in Israel between January 1987 and December 1996. Rates of miscarriage, preterm delivery, low birthweight, pregnancy-induced hypertension, gestational diabetes and placental abruption were higher in these pregnancies than in in vitro fertilisation pregnancies overall in reports from various other countries. In this article we examine the grounds for expecting an association between ovarian hyperstimulation syndrome and adverse pregnancy outcome and the available literature on the outcome of pregnancies complicated by ovarian hyperstimulation syndrome.

The predictive value of the ‘Hull & Rutherford’ classification for tubal damage

Objective  This study explores the predictive value for live birth following tubal reconstructive surgery of the ‘Hull and Rutherford’ (H&R) classification system.

Progestogen therapy and prevention of functional ovarian cysts during pituitary desensitisation with GnRH agonists

Henshaw R. C., Cooper K., El-Refaey H., Smith N. C. & Templeton A.A. (1993) Medical management of miscarriage: non surgical uterine evacuation of incomplete and inevitable spontaneous abortion. Br Med J 306,894-895. Peyron R., Aubeny E., Targosz V. et al. (1993) Early termination of pregnancy with mifepristone (RU486) and the orally active prostaglandin misoprostol. N Engl J Med 21, 1501-1513. Wilcox A. J., Weinberg C. R., OConnor J. F. et al. (1988) Incidence of early pregnancy loss. N Engl J Med 319, 189-194.

The Practical Implications of a Raised Serum FSH and Age on the Risk of IVF Treatment Cancellation Due to a Poor Ovarian Response

AbstractPurpose: Chronological age, or biological age as indicated by elevated FSH levels, are related to ovarian reserve. This study addresses the likelihood of cancellation of IVF treatment due to a poor ovarian response utilising both basal serum FSH and womans age. Methods: A prospective cohort of 536 infertile but ovulating women were studied in their first cycle of IVF treatment. Standardised methods of pituitary desensitisation and ovarian stimulation prior to IVF treatment were employed. Treatment cycles cancelled due to a poor ovarian response to gonadotrophins were studied. A series of logistic regression models were used to explore the probabilities of cancellation in relation to age and FSH. Results: Both age and basal serum FSH levels were independently associated with the risk of treatment cancellation. A low risk of treatment cancellation was observed in women under the age of 35 irrespective of serum FSH, however in older women the risk of treatment cancellation was most likely in women with a high FSH. Conclusions: In combination both age and FSH may serve as a valuable indicator of poor ovarian response leading to treatment cancellation. However, among older women FSH has particular importance, while less so in younger women with regular menstrual cycles.

Information Technology for postgraduate education: survey of facilities and skills in the South West Deanery

Objective To determine the Information Technology (IT) infrastructure available to, and IT skills of, obstetric specialiast registrars across the South West Denery.

ReproMED on the Internet today and tomorrow.

ReproMED comprises a range of projects applying and researching the role of information technology to support clinical care, education and research in reproductive medicine. This article traces the development of ReproMED on the Internet and concludes by speculating on the future. The project started with a critical evaluation of the infertility information needs of general practitioners and the role of hypertext in meeting those needs, leading to the production of a ReproMED CD-Rom. However, as the project was under development in 1995, Microsoft launched its first web browser amid major expansions of the Internet, thus the project switched to a series of websites and played host to national bodies including the British Fertility Society and the British Andrology Society. After a critical evaluation of the role of the Internet in supporting postgraduate medical education in the southwest region, reproductive medicine training over the Internet was piloted. This pilot was followed by a series of similar training programmes for junior doctors, specialists and general practitioners, leading to the establishment of a formal MSc delivered principally over the Internet. In addition to professional education and research, the ReproMED websites provide patients with extensive interactive information. The future holds many exciting possibilities with rapid technological developments and ever-increasing information needs.

Bemfola® fixed dose pens potentially reduce drug wastage and associated costs of infertility treatment

Abstract Bemfola® is a recombinant follicle-stimulating hormone (FSH) used during infertility treatment. One main differentiator between FSH products is their delivery device; consisting of multi-dose pens (Gonal-f®), vials or multi-dose preparations (Menopur®), or adjustable daily disposable dose pens (Bemfola®). To determine the potential impact of delivery device on drug wastage during infertility treatment this study retrospectively analysed Gonal-f® and Menopur® prescription and usage data from five UK clinics. Incurred drug wastage was then compared to potential Bemfola® drug wastage. Data collected included: (i) number of treatment cycles; (ii) daily FSH dose; (iii) length of treatment; (iv) dose adjustment following ultrasound scan; (v) FSH formulation(s) prescribed and (vi) agonist/antagonist protocol used. Treatment with Gonal-f® (4078 cycles) and Menopur® (646 cycles) resulted in an average drug wastage of 160 and 294 IU per treatment cycle. Use of Bemfola® instead of Gonal-f® and Menopur® may reduce the wastage to 104 and 61 IU per cycle, respectively. The use of Bemfola®, across all 4724 cycles, could result in a drug wastage reduction of up to 376,800 IUs with an associated cost saving of £100,011. Bemfola® is a viable alternative to Gonal-f® and Menopur® with its drug delivery system potentially reducing drug wastage and associated costs during infertility treatment.