Intense therapy in patients with locally advanced esophageal cancer beyond hope for surgical cure: a prospective, multicenter phase II trial of the Swiss Group for Clinical Cancer Research (SAKK 76/02)

BACKGROUND

There is no standard treatment for patients with locally advanced esophageal carcinoma without systemic metastasis in whom surgery is no longer considered a reasonable option.

PATIENTS AND METHODS

Patients with cervical esophageal tumors, locally very advanced stage (T4 and/or M1a) or locally advanced (T3 and/or N+) with comorbidities were included.

THERAPY

2 cycles of induction chemotherapy (cisplatin and docetaxel, both 75 mg/m(2) 3-weekly) followed by chemoradiation therapy (CRT) comprising a total radiation dose of 59.4 Gy together with docetaxel 15 mg/m(2) and cisplatin 25 mg/m(2) (5 weekly doses). Primary endpoint: Histologically proven freedom from local failure 6 months after CRT completion.

RESULTS

21 patients were included: 12 had locally very advanced tumors, 3 had cervical esophagus tumors, and 6 were medically unfit for surgery. 18 patients completed therapy per protocol. Grade 3/4 toxicities during CRT were thrombopenia (10%) and dysphagia (15%). 1 patient died due to herpes simplex infection. The primary endpoint was achieved by 4 patients, 6 were alive after median follow-up of 34 months, and median survival was 16 months. Most patients experienced lasting improvement of dysphagia following induction chemotherapy.

CONCLUSIONS

This regimen is feasible, showed clinically meaningful, long-lasting improvements in quality of life and resulted in long-term survival in 29% of the patients.

Abstract C28: Discovery of new protein biomarkers for prostate cancer diagnosis using a Pten-dependent mouse model and their validation in human patients

Purpose: The identification of novel biomarkers for the detection of localized cancers will have a profound impact on human health, especially for tumors with silent progression such as prostate cancer. Current prostate cancer biomarkers such as Prostate Specific Antigen (PSA) have limited accuracy and there is a need for improved non-invasive diagnostic tests.

Material and Methods: Blood is thought to pick up molecular cues as it circulates through the various tissues, collectively reflecting molecular processes active in those different tissues. To increase the proteomic detection sensitivity, we have developed a method for the selective analysis of N-glycosites from tissue and serum. The analysis of glycoproteins is ideally suited for the detection of such signatures because they are preferentially released from tissue and deposited in the bloodstream where they can be detected in a non-invasive fashion.

In our study we initially used the Pten conditional knock-out mouse model for prostate cancer progression. This model in which the different stages of the disease can be deliberately and reproductively induced and followed, allowed us to simulate with very high fidelity the early steps of the human disease. Under the assumption that proteins of interest are enriched in the tissue, we performed label-free comparative proteomics of Pten−/− and control tissue at different time points. Interesting candidates were then monitored in the corresponding mice sera by targeted mass spectrometry using Multiple Reaction Monitoring (MRM) at high sensitivity and selectivity.

Results: This approach enabled us to identify 785 N-linked glycoproteins, mostly located to relevant cellular compartments such as the extracellular space, the plasma membrane or the secretory pathway. Quantitative proteomic comparison of mice with homozygous Pten deletion and constitutive PKB activation with the corresponding control animals led to the identification of 153 candidate biomarkers differentially regulated in a Pten dependent manner.

The validation phase was carried out using 76 sera collected from patients with either benign prostatic hyperplasia (n=35) or localized prostate cancer (n=41). Candidate biomarkers were monitored by immunoassays and/or targeted mass spectrometry. Using a cross-validated logistic regression approach in our ongoing study, we have identified a 4-biomarker signature that correctly predicts 71% of cases (sens. 78%/spec. 63%). In comparison, PSA correctly predicted 67% (sens. 89%/spec. 32%) at a cutoff of 2 ng/ml. By combining PSA with the 4-biomarker signature, accuracy was greatly improved and 87% of the cases were correctly predicted (sens. 90/spec. 83%). We further extended our analysis to the discovery of novel candidate serum biomarkers for the discrimination of aggressive cancers (Gleason score>7) from slow progressing cancers (Gleason score<=6) that may be considered for active surveillance instead of immediate active treatment.

Conclusion: The use of a translational approach which relies on a genetically defined mouse model together with novel proteomics techniques and validation in human sera is thus an ideal starting point for the discovery of novel biomarkers.

Citation Information: Cancer Res 2009;69(23 Suppl):C28.

Primary manifestation of small lymphocytic lymphoma in the prostate

BACKGROUND

Infiltration of non-haematopoietic organs by small lymphocytic lymphoma/chronic lymphocytic leukaemia (SLL/CLL) is not unusual in late-stage disease and thus quite frequently encountered in post-mortem examinations. However, primary manifestation of SLL/CLL in the prostate is rarely diagnosed.

PATIENTS AND METHODS

We report two cases of primary prostatic SLL/CLL, in one case in combination with prostate carcinoma, and discuss diagnostic pitfalls, pathophysiological mechanisms and therapeutic management, together with an overview of the literature.

CONCLUSIONS

Lymphocytic infiltration of the prostate associated with obstructive symptoms is rare but can already occur in very early disease. Microscopically, SLL/CLL infiltration can be distinguished from chronic prostatitis by its pattern of infiltration and by immunohistochemistry. As the incidence of both SLL/CLL and prostatic carcinoma increases with age, composite tumours might occur more often in the future.

The epidemiology of infertility in the North East of Scotland

BACKGROUND

There is a perception that the prevalence of infertility is on the rise. This study aimed to determine the current prevalence of infertility in a defined geographical population, ascertain changes in self-reported infertility over time and identify risk factors associated with infertility.

METHODS

A postal questionnaire survey of a random population-based sample of women aged 31-50 years was performed in the Grampian region of Scotland. Questions addressed the following areas: pregnancy history, length of time taken to become pregnant each time, whether medical advice had been sought and self-reported exposure to factors associated with infertility.

RESULTS

Among 4466 women who responded, 400 (9.0%) [95% CI 8.1, 9.8] had chosen not to have children. Of the remaining 4066 women, 3283 (80.7%) [95% CI 79.5, 82.0] reported no difficulties in having children and the remaining 783 (19.3%) [95% CI 18.1, 20.5] had experienced infertility, defined as having difficulty in becoming pregnant for more than 12 months and/or seeking medical advice. In total 398 (9.8%) [95% CI 8.9, 10.7] women had primary infertility, 285 (7.0%) [95% CI 6.2, 7.8] had secondary infertility, 100 (2.5%) [95% CI 2.0, 2.9] had primary as well as secondary infertility. A total of 342 (68.7%) and 208 (73.0%) women with primary and secondary infertility, respectively, sought medical advice and 202 (59.1%) and 118 (56.7%) women in each group subsequently conceived. History of pelvic surgery, Chlamydial infection, endometriosis, chemotherapy, long-term health problems and obesity were associated with infertility. In comparison with a similar survey of women aged 46-50 from the same geographical area, the prevalence of both primary infertility (>24 months) [70/1081, (6.5%) versus 68/710 (9.6%) P = 0.02] and secondary infertility [29/1081 (2.7%) versus 40/710 (5.6%) P = 0.002] were significantly lower.

CONCLUSIONS

Nearly one in five women attempting conception sampled in this study experienced infertility, although over half of them eventually conceived. Fertility problems were associated with endometriosis, Chlamydia trachomatis infection and pelvic surgery, as well as obesity, chemotherapy and some long-term chronic medical conditions. There is no evidence of an increase in the prevalence of infertility in this population over the past 20 years.

Vaginal prostaglandin E2 gelversustablet in the induction of labour at term—a retrospective analysis

Our aim in this retrospective analysis was to compare labour outcomes between 145 consecutive women with unfavourable cervices, who received prostaglandin E2 vaginal gel (1-2 mg) for labour induction over a 3-month period, and 149 women receiving a prostaglandin E2 vaginal tablet (3 mg) over the following 3 months. Our results showed that cervical dilatation in the gel group was significantly more than in the tablet group at transfer to labour ward [4 cm (SD 2.5 cm) versus 3.3 cm (SD 2 cm), mean difference -0.7, 95% CI -1.2 to -0.2, P=0.01), with fewer women requiring oxytocin augmentation, but this was not statistically significant (41.4% versus 50%, RR 0.8, 95% CI 0.7-1.1). There were no significant differences in the mode of delivery in the number delivering vaginally within 24 hours of the induction (60.4% in the gel group versus 56.2% in the tablet group, RR1.1, 95% CI 0.9-1.4), in the number of doses of PGE2 administered, or in the neonatal outcomes between the two groups. In conclusion, there were no significant differences in labour or neonatal outcomes between prostaglandin E2 gel or tablet use in the induction of labour in this retrospective analysis.

Clomifene citrate or unstimulated intrauterine insemination compared with expectant management for unexplained infertility: pragmatic randomised controlled trial

OBJECTIVE

To compare the effectiveness of clomifene citrate and unstimulated intrauterine insemination with expectant management for the treatment of unexplained infertility.

DESIGN

Three arm parallel group, pragmatic randomised controlled trial.

SETTING

Four teaching hospitals and a district general hospital in Scotland.

PARTICIPANTS

Couples with infertility for over two years, confirmed ovulation, patent fallopian tubes, and motile sperm.

INTERVENTION

Expectant management, oral clomifene citrate, and unstimulated intrauterine insemination.

MAIN OUTCOME MEASURES

The primary outcome was live birth. Secondary outcome measures included clinical pregnancy, multiple pregnancy, miscarriage, and acceptability.

RESULTS

580 women were randomised to expectant management (n=193), oral clomifene citrate (n=194), or unstimulated intrauterine insemination (n=193) for six months. The three randomised groups were comparable in terms of age, body mass index, duration of infertility, sperm concentration, and motility. Live birth rates were 32/193 (17%), 26/192 (14%), and 43/191 (23%), respectively. Compared with expectant management, the odds ratio for a live birth was 0.79 (95% confidence interval 0.45 to 1.38) after clomifene citrate and 1.46 (0.88 to 2.43) after unstimulated intrauterine insemination. More women randomised to clomifene citrate (159/170, 94%) and unstimulated intrauterine insemination (155/162, 96%) found the process of treatment acceptable than those randomised to expectant management (123/153, 80%) (P=0.001 and P<0.001, respectively).

CONCLUSION

In couples with unexplained infertility existing treatments such as empirical clomifene and unstimulated intrauterine insemination are unlikely to offer superior live birth rates compared with expectant management.

TRIAL REGISTRATION

ISRCT No: 71762042.

Extraneural spread of glioblastoma--report of two cases

BACKGROUND

Glioblastoma, a highly aggressive tumor, accounts for the majority of all primary brain tumors in adults. Despite a destructive local growth pattern, extraneural spread of these tumors is extremely rare. CASE 1: We describe the case of a 58-year-old man with glioblastoma, in whom an epidural mass was diagnosed 5 months after initial local therapy of the brain. A positron emission tomography (PET) scan revealed multiple metastases in the lungs, in the retroperitoneum, and in the left trochanter minor region. A soft tissue swelling of the right thigh was histologically proven to be metastatic tissue from the primary glioblastoma. The patient died 11 months after initial diagnosis. CASE 2: A 47-year-old woman with recurrent glioblastoma had a long lasting complete response to chemotherapy. 2 years after initial diagnosis she presented with a pleural mass which was a metastasis of the formerly diagnosed glioblastoma.

CONCLUSION

Although systemic metastases in glioblastoma are rare, different organs can be involved.

Initial management of infertility: an audit of pre-referral investigations and exploration of couples' views at the interface of primary and secondary care

This study aimed to audit pre-referral investigations in primary care, and survey patients' views on the referral process from primary to secondary care. Referral letters and case notes of 250 consecutive couples referred to the Aberdeen Fertility Centre were audited in order to establish whether mid-luteal serum progesterone, rubella status and semen analysis had been performed. Couples attending a specialist hospital clinic for the first time completed a questionnaire on their experience of the referral process and consultation. Mid-luteal progesterone was performed in 105 (51%) cases, rubella status checked in 42 (20%) cases and semen analysis arranged in 70 (34%) cases. Overall, 274 (93%) patients were satisfied or very satisfied with the hospital consultation compared to 216 (84%) who utilised the general practitioner (GP) consultation (p < or = 0.001); 79 (59%) women and 91 (68%) men wanted the current system of GP referral to continue (p < 0.001); and 74 (56%) women and 69 (52%) men (p < 0.001) favoured the option of direct self-referral.

CONCLUSIONS

Despite high levels of satisfaction among couples, there is scope for further improvement in terms of pre-referral fertility investigations. Further evaluation of the referral process is needed, and potential changes to the existing system should be considered.

Opportunistic screening for Chlamydia trachomatis in men attending three different secondary healthcare settings

OBJECTIVES

To assess the feasibility and acceptability of opportunistic Chlamydia trachomatis (CT) screening of asymptomatic men attending three different secondary healthcare settings and to investigate CT positivity in these settings.

METHODS

Men attending fracture, fertility and family planning (FP) clinics were invited to be screened by first-void urine and complete a questionnaire which collected demographic, sexual and behavioural characteristics, and their opinion about the screening process.

RESULTS

1290 men were approached, with 80% participating. The number of men approached, number providing a satisfactory urine specimen and CT positivity rate (95% CI) were, respectively, n = 401, n = 206, 14.6% (10.4 to 20.1) for the FP clinic, n = 505, n = 328, 1.2% (0.5 to 3.2) for the fracture clinic and n = 384, n = 319, 0.3% (0.1 to 1.8) for the fertility clinic. The highest rates of CT infection were found in men attending the FP clinics, aged between 20-24 years. Most of the men from all three clinics felt that the setting (87.9%) and specimen (97.7%) were acceptable.

CONCLUSION

Opportunistic chlamydial screening of asymptomatic men in three secondary healthcare settings found high positivity rates, but low uptake rates in a FP setting compared with fertility and fracture clinics. Innovative and targeted intervention strategies are required to engage this high-risk group of men in screening.

Effect of B vitamins and genetics on success of in-vitro fertilisation: prospective cohort study

BACKGROUND

There is a need to understand what affects the success of in-vitro fertilisation (IVF) and the rate of resulting twin births so that pregnancy rates can be improved and multiple gestations avoided. Our aim was to assess the role of B vitamins and genetics.

METHODS

We did a prospective cohort study of 602 women undergoing fertility treatment. We assessed intake of folate and vitamin B12 with a questionnaire and measured their plasma and red-blood-cell concentrations by radioimmunoassay. We measured five B-vitamin-related gene variants in women who received treatment and in 932 women who conceived naturally.

FINDINGS

The likelihood of a twin birth after IVF rose with increased concentrations of plasma folate (1.52, 1.01-2.28; p=0.032) and red-cell folate (1.28, 1.00-1.65; p=0.039). There was no association between folate and vitamin B12 levels and likelihood of a successful pregnancy. Women homozygous for the 1298 CC variant of methylenetetrahydro-folate reductase (MTHFR), rather than the AA variant, were less likely to produce a livebirth after IVF (0.24, 0.08-0.71; p=0.003) or to have had a previous pregnancy (0.42, 0.21-0.81; p=0.008).

INTERPRETATION

Our findings suggest that MTHFR genotype is linked to a woman's potential to produce healthy embryos (possibly through interaction with genes related to DNA methylation). In women likely to have a successful IVF pregnancy, high folate status increases the likelihood of twin birth after multiple embryo transfer. Proposals to fortify the UK diet with folic acid could lead to an increase in the number of twins born after IVF.

Absence of conception after caesarean section: voluntary or involuntary?

BACKGROUND

Women who deliver by caesarean section have been shown to be less likely to have a subsequent pregnancy. It is not clear whether this is due to a direct effect of the procedure on future fertility or due to deliberate avoidance of a future pregnancy.

OBJECTIVE

To investigate whether absence of conception following caesarean section is voluntary or involuntary.

DESIGN

Follow up of a population-based retrospective cohort.

SETTING

Grampian region, Scotland.

POPULATION

Women who had no further viable pregnancies within 5 years of an initial delivery.

METHODS

Cases included women who delivered their first child by caesarean section between 1980 and 1995 but had no further viable pregnancies by December 2000. Controls included women who delivered their first child during the same period, by means of either spontaneous vaginal delivery (SVD) or instrumental vaginal delivery (IVD), and who had no further viable pregnancies by December 2000. Eligible women were identified from the Aberdeen Maternity and Neonatal Databank (AMND) and sent postal questionnaires to determine the extent to which not conceiving after first delivery was voluntary and the reasons for avoiding further pregnancies. Characteristics of the different mode of delivery groups were compared using univariate techniques.

MAIN OUTCOME MEASURES

Extent to which absence of conception following an initial delivery by caesarean section is voluntary.

RESULTS

Questionnaires were returned by 3204 (60%) of 5300 women identified from the AMND. Of these, 1675 women had not conceived at all during the follow-up period (median duration = 13 years). Absence of conception was voluntary in 488 (69%; 95% CI 66-73%) women following caesarean section, 340 (71%; 95% CI 67-76%) following SVD and 354 (72%; 95% CI 68-76%) following IVD. Few women considered seeking fertility treatment (caesarean section = 72 [10%], SVD = 50 [11%], IVD = 39 [8%]). Of the women who decided to delay or avoid a further pregnancy, fewer women who delivered by SVD reported that the birth experience influenced their decision (caesarean section = 163 [32%], SVD = 67 [18%], IVD = 136 [35%]; P < 0.001).

CONCLUSIONS

Irrespective of mode of delivery, not conceiving following the birth of the first child is mainly voluntary. The experience of the previous birth is one of several factors affecting women's decisions to avoid a subsequent pregnancy.

In vitro fertilisation for unexplained subfertility

BACKGROUND

In vitro fertilisation (IVF) is now a widely accepted treatment for unexplained infertility (RCOG 1998). However, with estimated live-birth rates per cycle varying between 13% and 28%, its effectiveness has not been rigorously evaluated in comparison with other treatments. With increasing awareness of the role of expectant management and less invasive procedures such as intrauterine insemination, concerns about multiple complications and costs associated with IVF, it is extremely important to evaluate the effectiveness of IVF against other treatment options in couples with unexplained infertility.

OBJECTIVES

The aim of this review is to determine, in the context of unexplained infertility, whether IVF improves the probability of live-birth compared with (1) expectant management, (2) clomiphene citrate (CC), (3) intrauterine insemination (IUI) alone, (4) IUI with controlled ovarian stimulation, and (5) gamete intrafallopian transfer (GIFT).

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched 23 March 2004), the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 3, 2004), MEDLINE (1970 to August 2004), EMBASE (1985 to August 2004) and reference lists of articles. We also handsearched relevant conference proceedings and contacted researchers in the field.

SELECTION CRITERIA

Only randomised controlled trials were included. Live-birth rate per woman was the primary outcome of interest.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility and quality of trials.

MAIN RESULTS

Ten randomised controlled trials were identified. In two we could not extract data separately for unexplained infertility cases, two were non-randomised, one did not report valid rates (included in the review but not in the meta-analysis); leaving four trials for analysis. One trial compared two different interventions (IVF versus IUI with or without ovarian stimulation) and one study compared three interventions (IVF versus IUI with ovarian stimulation and GIFT). The numbers of trials assessing the effectiveness of IVF with the other treatments were as follows: IVF versus expectant management (two), IVF versus IUI (one), IVF versus IUI with ovarian stimulation (two) and IVF versus GIFT (three). Live-birth rate per woman was reported in three studies and three studies determined clinical pregnancy rate per woman. Multiple pregnancy rate was reported in three trials. Two studies reported ovarian hyperstimulation syndrome (OHSS) as an outcome measure. There were no comparative data for clomiphene citrate and no comparative data on live-birth rates for GIFT. There was no evidence of a difference in live-birth rates between IVF and IUI either without (OR 1.96; 95% CI 0.88 to 4.4) or with (OR 1.15; 95% CI 0.55 to 2.4) ovarian stimulation. There were significantly higher clinical pregnancy rates with IVF in comparison to expectant management (OR 3.24; 95% CI 1.07 to 9.80). There was no significant difference between IVF and GIFT for the one RCT that reported live-birth rates (OR 2.57; 95% CI 0.93 to 7.08). However, there was a significant difference in the clinical pregnancy rates between IVF and GIFT, with pregnancy rates greater for IVF (OR 2.14; 95% CI 1.08 to 4.2). There was no evidence of a difference in the multiple pregnancy rates between IVF and IUI with ovarian stimulation (OR 0.63; 95% CI 0.27 to 1.5), however, IVF had a higher rate than GIFT (OR 6.3; 95% CI 1.7 to 23). Clinical heterogeneity was present among the studies included. However, there was no evidence of statistical heterogeneity, which allowed the studies to be combined for statistical analysis.

AUTHORS' CONCLUSIONS

Any effect of IVF relative to expectant management, clomiphene citrate, IUI with or without ovarian stimulation and GIFT in terms of live-birth rates for couples with unexplained subfertility remains unknown. The studies included are limited by their small sample size so that even large differences might be hidden. Live-birth rates are seldom reported. Periods of follow up are inadequate and unequal. Adverse effects such as multiple pregnancies and ovarian hyperstimulation syndrome have also not been reported in most studies. Larger trials with adequate power are warranted to establish the effectiveness of IVF in these women. Future trials should not only report rates per woman/couple but also include adverse effects and costs of the treatments as outcomes. Factors that have a major effect on these outcomes such as fertility treatment, female partner's age, duration of infertility and previous pregnancy history should also be considered.

Fertility and ageing

The late 20th century trend to delay birth of the first child until the age at which female fecundity or reproductive capacity is lower has increased the incidence of age-related infertility. The trend and its consequences have also stimulated interest in the possible factors in the female and the male that may contribute to the decline in fecundity with age; in the means that exist to predict fecundity; and in the consequences for pregnancy and childbirth. In the female, the number of oocytes decreases with age until the menopause. Oocyte quality also diminishes, due in part to increased aneuploidy because of factors such as changes in spindle integrity. Although older male age affects the likelihood of conception, abnormalities in sperm chromosomes and in some components of the semen analysis are less important than the frequency of intercourse. Age is as accurate as any other predictor of conception with assisted reproductive technology. The decline in fecundity becomes clinically relevant when women reach their mid-30s, when even assisted reproduction treatment cannot compensate for the decline in fecundity associated with delaying attempts at conceiving. Pregnancies among women aged >40 years are associated with more non-severe complications, more premature births, more congenital malformations and more interventions at birth.

A randomized trial of mifepristone (10 mg) and levonorgestrel for emergency contraception

OBJECTIVE

To compare the efficacy, patient acceptability and adverse effects of low-dose mifepristone (10 mg) with the levonorgestrel regimen (2 doses of 750 microg given 12 hours apart) for emergency contraception.

METHODS

This randomized controlled trial compared mifepristone (10 mg) to levonorgestrel (2 doses of 750 microg given 12 hours apart) in the context of emergency contraception within 120 hours of unprotected intercourse. The primary outcome measure was unintended pregnancy. Secondary outcomes included adverse effects experienced by women, acceptability of the method of emergency contraception used, and the timing of the first menstrual cycle after treatment.

RESULTS

The total number of women recruited was 2,065. The crude pregnancy rates were 1.3% and 2.0% for mifepristone and levonorgestrel (P = .46), with 77% and 64% of expected pregnancies prevented, respectively. Women receiving mifepristone were more likely to have a delayed onset of the subsequent menstrual cycle after treatment (P < .001), whereas those having levonorgestrel were more likely to have an early onset of the subsequent menstrual cycle (P < .001). Acceptability levels were high for both methods, with 94% of women receiving mifepristone and 91% receiving levonorgestrel expressing satisfaction. There was no difference in adverse effects (nausea, vomiting, breast tenderness, abdominal pain, lethargy, headache, hot flushes, and dizziness) experienced by women in the 2 groups.

CONCLUSION

This study suggests that a small dose of mifepristone is not less effective than levonorgestrel for emergency contraception. Both regimens were highly acceptable to women.

Evaluation of endocervical, first-void urine and self-administered vulval swabs for the detection of Chlamydia trachomatis in a miscarriage population

OBJECTIVE

To compare, in parallel, different approaches of opportunistically screening women with bleeding in early pregnancy for Chlamydia trachomatis.

DESIGN

Prospective observational [corrected] study.

SETTING

Early pregnancy assessment unit, University hospital, Scotland, UK.

POPULATION

Over 200 consecutive women admitted to an early pregnancy assessment unit were recruited. All had a positive pregnancy test, a history of vaginal bleeding and were less than 24 weeks of gestation. Women with recent antibiotic use, heavy vaginal bleeding and cervical shock excluded.

METHODS

Each women provided two or more of the following specimens: a self-administered vulval swab, first-void urine and/or endocervical swab. Following screening, each completed a semi-structured questionnaire assessing the acceptability of each method undertaken.

MAIN OUTCOME MEASURE

Subjective rating of the screening methods; prevalence; method performance, including proportion requiring repeat testing.

RESULTS

The majority accepted screening, with moderate prevalence rates (95% CI) 3.9% (2.0-7.4%) identified. All positive women were less than 30 years of age. Parallel screening exposed the potential of reduced test performance with urine. Non-invasive sampling was more acceptable, but more likely to require repeat testing.

CONCLUSION

Both acceptability and the effect of bleeding on test performance need further assessment before a particular specimen can be recommended for screening this population of women for C. trachomatis.

Experiences in method development for the analysis of in vitro study solutions for content

Effects of drugs on the cardiovascular system are required to be assessed as part of safety pharmacology, in particular using the in vitro Human Ether-a-go-go Related Gene Product (HERG) and Purkinje fibre studies and can be used to predict safety margins prior to administration to man. Recent International Conferences on Harmonization (ICH) regulations, draft ICHS7B guidelines, indicate that levels of drug in bath solutions used should be measured if quantitative data are to be obtained for the estimation of safety margins. To accurately measure drug concentrations in bath solutions, a validated analytical method is required. This method is required to be accurate, precise, specific, and robust, and due to the increased potency of new drugs, liquid chromatography with mass spectrometric detection (LC-MS) has become the method of choice. Recent experiences validating methods for the analysis of a wide range of drugs in bath solutions has presented a major issue regarding the solubility of some drugs in bath solutions. This has resulted in the requirement of a different approach to the analysis of, in particular, lipophilic drugs that has in turn highlighted the potential for the significant overestimation of the drug concentration in these bath solutions and therefore inaccurate calculation of safety margins.

Number of embryos for transfer following in-vitro fertilisation or intra-cytoplasmic sperm injection

BACKGROUND

The traditional reliance on the transfer of multiple embryos during in vitro fertilisation (IVF) in order to maximise the chance of pregnancy, has resulted in increasing rates of multiple pregnancies. Women undergoing IVF had a 20 - fold increased risk of twins and 400 - fold increased risk of higher order pregnancies (Martin 1998). The maternal and perinatal morbidity and mortality as well as national health service costs associated with multiple pregnancies is significantly high in comparison with singleton births (Luke 1992; Callahan 1994; Goldfarb 1996). Single embryo transfer is now being considered as an effective means of reducing this iatrogenic complication. This systematic review evaluates the effectiveness of elective two embryo transfer in comparison with single and more than two embryo transfer following IVF and ICSI (intra cytoplasmic sperm injection) treatment.

OBJECTIVES

The aim of this review is to determine, whether in couples who undergo IVF/ICSI: (1) the elective transfer of two embryos improves the probability of livebirth compared with: (a) Single embryo transfer, (b) Three embryo transfer or (c) Four embryo transfer.(2) the elective transfer of three embryos improves the probability of livebirth compared with: (a) Single embryo transfer, or (b) Four embryo transfer,

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group's trials register (searched June 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003), MEDLINE (1970 to 2003), EMBASE (1985 to 2003) and reference lists of articles. We also handsearched relevant conference proceedings and contacted researchers in the field.

SELECTION CRITERIA

Only randomised controlled trials were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility and quality of trials.

MAIN RESULTS

We found no studies that compared a policy of transferring multiple embryos on one cycle versus a policy of cryo- preservation and transfer of a single embryo over multiple cycles. We also found no trials comparing transfer of two versus three embryos. Three small, poorly reported trials compared transfer of two versus one embryo in a single cycle, and one small, poorly reported trial compared transfer of two versus four embryos in a single cycle. The clinical pregnancy rate per woman/couple associated with two embryo transfer was significantly higher compared to single embryo transfer (OR 2.08, 95% CI 1.24 to 3.50; test for overall effect p = 0.006). The live birth rate per woman/couple associated with two embryo transfer was also significantly higher than that associated with single embryo transfer (OR 1.90, 95% CI 1.12 to 3.22, test for overall effect p=0.02). The multiple pregnancy rate was significantly lower in women who had single embryo transfer (OR 9.97, 95% CI 2.61 to 38.19; p = 0.0008). The effectiveness of double embryo transfer versus four embryo transfer was tested in a single trial. There was no statistically significant differences in the clinical pregnancy rate (OR 0.75, 95% CI 0.26 to 2.16; p=0.6), and multiple pregnancy rates (OR 0.44. 95% CI 0.10 to 1.97; p = 0.28) between the two groups. The livebirth rate in the four embryo transfer group was higher compared to the two embryo transfer group, but the results were not statistically significant (OR 0.35, 95% CI 0.11 to 1.05; p = 0.06).

REVIEWERS' CONCLUSIONS

The results of this systematic review suggest that live birth and pregnancy rates following single embryo transfer are lower than those following double embryo transfer as are the chances of multiple pregnancy including twins. As such, it is unlikely that the conclusions are robust enough to catalyse a change in clinical practice. The studies included are limited by their small sample size, so that even large differences might be hidden. Cumulative livebirth rates are seldom reported. The data were inadequate to draw conclusions about single embryo transfer and first frozen single embryo transfer (1FZET) or subsequent single frozen embryo transfers. Until more evidence is available single embryo transfer may not be the preferred choice for all patients undergoing IVF/ICSI. Clinicians may need to individualise protocols for couples based on their risks of multiple pregnancy. A definitive pragmatic, large multi centre randomised controlled trial comparing single embryo versus double embryo transfer in terms of clinical and cost effectiveness as well as acceptability is required. The primary outcome measured should be cumulative livebirth per woman/couple.