Three successive pregnancies in a patient with Takayasu`s arteritis

Takayasu's arteritis is a rare non-specific obliterative panarteritis of unknown origin that occurs predominantly in young Asian and Oriental females of childbearing age and has been encountered in the UK. With the exception of a few large series from the Far East, much of the information on Takayasu's arteritis in pregnancy comes from isolated case reports with no long term follow-up after pregnancy. We report a patient with this condition who had three pregnancies during a 4-year follow-up period with no serious complications.

A comparison of osmotic dilators, Lamicel and Dilapan, and a prostaglandin E1analogue, gemeprost, for ripening the cervix before legal abortion

66 primigravid women were allocated at random to receive either intravaginal application of the prostaglandin El analogue, gemeprost, or intracervical insertion of 1 of 2 osmotic dilators, Lamicel or Dilapan, 3 hours before legal abortion at 7-14 weeks gestation. Insertion of the dilators was not possible in 5 patients. All 3 methods were otherwise equally effective in achieving cervical dilatation and there was no difference in the need for or resistance to further dilatation between the 3 groups. Gemeprost was the most easily administered, and would be the most appropriate for routine preoperative use.

Effects of the anti-oestrogens, clomiphene and tamoxifen, on the cervical factor in female infertility

The anti-oestrogens clomiphene and tamoxifen are successful therapeutic agents in the induction of ovulation but the associated pregnancy rates are low. One cause for this may be a direct anti-oestrogenic effect on cervical mucus, reducing its sperm penetrability. This potentially adverse effect has been shown to occur with clomiphene. In this study the effects of clomiphene and tamoxifen on the cervical factor are compared in women who were anovulatory or had defective ovulation. Forty fully investigated infertile women were randomly allocated to different treatment sequences after being observed for three control cycles. A double-blind placebo technique was used with four different treatment regimes. Serial serum progesterone and oestradiol were assayed. Cervical mucus from the periovulatory phase was assessed by means of the cervical score and in vitro sperm penetration tests. Both these anti-oestrogens can affect cervical mucus but their effect seems to be related more to the end-organ sensitivity of the individual than to a specific action of the drug per se.

Dose finding in a low-dose 21-day combined oral contraceptive containing gestodene

An open label, non-comparative study was carried out in 22 women over a total of five cycles. After an untreated cycle, oral administration of 20 microg ethinyl estradiol (EE) with 50 microg gestodene (GST) (tablets taken daily for 21 days with a break of 7 days) was commenced, and three treatment cycles were followed by an untreated follow-up control cycle. The ability of this formulation to inhibit ovulation and suppress ovarian activity was assessed by using hormonal parameters and ultrasound. One ovulation occurred during treatment. Luteinized unruptured follicles were observed in three cases in the second treatment cycle and in one case during the third treatment cycle. Follicle-like structures larger than 13 mm associated with a serum estradiol level of more than 30 pg/mL were noted in 19% of the women in the first treatment cycle. The rate of active follicle-like structures was 43% in the second treatment cycle and 28% in the third treatment cycle. The results were compared with previously reported findings of a preparation containing 20 microg EE and 75 microg GST. With regard to ovarian grading and endogenous hormone secretion, considerably more residual ovarian activity, with all parameters examined, was found in the 20 microg EE and 50 microg GST preparation compared to the 20 microg EE and 75 microg GST preparation. It was concluded that the 20 microg EE and 50 microg GST preparation administered for 21 days does not meet the requirements of a combined oral contraceptive with respect to ovulation inhibition.

Effect of 21-day and 24-day oral contraceptive regimens containing gestodene (60 microg) and ethinyl estradiol (15 microg) on ovarian activity

OBJECTIVE

To compare ovulation inhibition and ovarian activity with 21-day and 24-day regimens of a low-dose combined oral contraceptive (COC) containing 60 microg of gestodene and 15 microg of ethinyl estradiol.

DESIGN

Interventional observational study.

SETTING

Reproductive medicine unit.

PATIENT(S)

Fifty-eight healthy volunteers aged 18-35 years.

INTERVENTION(S)

Ovarian activity was monitored every other day with the use of ultrasound to measure the diameters of follicle-like structures and blood samples to measure serum concentrations of 17beta-E2 and progesterone. Subjects were observed for five cycles: pretreatment and posttreatment control cycles and three cycles in which the COC was administered for either 21 or 24 days of each cycle.

MAIN OUTCOME MEASURE(S)

Occurrence of ovulation and evidence of ovarian activity.

RESULT(S)

The study was completed by 27 (90%) of the 30 subjects who received the 24-day regimen and by 24 (79%) of the 28 subjects who received the 21-day regimen. Ovulation was inhibited in all cycles in the 24-day group and in 74 of 75 cycles in the 21-day group. Luteinized unruptured follicles were seen in no cycles with the 24-day regimen and in 6 (8%) of 75 cycles with the 21-day regimen. Mean ovarian follicular development and serum 17beta-E2 and progesterone levels were lower in the 24-day group.

CONCLUSION(S)

The 24-day regimen is an innovative strategy for maintaining effective ovulation inhibition at ultra-low doses of contraceptive steroids.

Effect of age on the response of the hypothalamo-pituitary-ovarian axis to a combined oral contraceptive

OBJECTIVE

To examine the effect of age on the response to treatment with a combined oral contraceptive.

DESIGN

Prospective, controlled clinical study.

SETTING

Reproductive medicine unit in a tertiary care university medical center.

PATIENT(S)

Twenty-six healthy female volunteers aged 21-45 years.

INTERVENTION(S)

After a control cycle, all the women were given a combined oral contraceptive containing 20 microg of ethinylestradiol with 75 microg of gestodene for three cycles. The women were examined through the posttreatment cycle.

MAIN OUTCOME MEASURE(S)

Pituitary and ovarian activity was assessed with ultrasound and measurement of ovarian steroids.

RESULT(S)

Follicular activity was observed in all treatment cycles, although ovulation was inhibited. Ovarian suppression was maximal in cycle 1. Mean endogenous E2 levels were lower during cycles 2 and 3 in the older group. Serum FSH levels were higher in the control cycle and on day 28 of the treatment cycles in the older group. Most women ovulated during the posttreatment cycle.

CONCLUSION(S)

Combined oral contraceptives did not inhibit all ovarian activity; maximal suppression was seen in cycle 1. Less follicular activity was observed in cycles 2 and 3 in the older group. Raised FSH levels with age reflect increasing ovarian resistance to follicular development.

UK accident and emergency departments and emergency contraception: what do they think and do?

OBJECTIVES

A postal questionnaire survey was conducted to assess what staff in UK accident and emergency (A&E) departments thought of providing an emergency contraception service, the degree of enthusiasm in and level of provision of the service, and staff attitudes to the introduction or continuation of provision of the service.

METHODS

A questionnaire was sent to all 560 departments providing A&E services in the UK.

RESULTS

Of the 560 units sent questionnaires, 355 (63.4%) replied. Half the units were located in small county towns, and a quarter in large towns. Requests for emergency contraception were received by 96% of responding units, but only 57% provided treatment. Requests for emergency contraception in 84 of these units ranged between one and 50 per month. The A&E senior house officer (SHO) and the gynaecology SHO and registrar prescribed most of the pills. Nurses were more involved in nurse led or general practitioner (GP) led units. Initial treatment only was given by 77% of providing units while the remainder also discussed subsequent contraception. Follow up was arranged with GPs by 92 units, and with family planning clinics by 66 units. Information packs were available in only 37 providing units. A total of 155 of providing units felt it was worthwhile and 56% of respondents thought emergency contraception should be provided by A&E departments. However, 91 units could identify one or more groups within the hospital who were antagonistic to provision by A&E departments, of which non-A&E medical staff formed the largest group. Over the counter availability of emergency contraception was not supported by 62% of respondents.

CONCLUSION

The results show that while the female population appears to see a need for emergency contraception services to be provided in A&E departments, there is some reluctance by UK A&E departments to provide the service. Given the current interest in approaches to reducing unplanned pregnancies, especially in teenagers, provision of emergency contraception by A&E departments requires a pragmatic approach to ensure their cooperation in providing the service when alternative sources of provision are not available.

Human ovarian granulosa cells and follicular fluid indices: the relationship to oocyte maturity and fertilization in vitro

The study investigates the correlation between oocyte maturity and fertilization and a variety of hormonal parameters in follicular fluid and ovarian granulosa cells. A methodology for purification of granulosa cells from contaminating blood cells is also established. A total of 63 follicular aspirates were collected at oocyte retrieval from 30 women superovulated using the long luteinizing hormone-releasing hormone (LHRH analogue)/human menopausal gonadotrophin regimen. Oestradiol, progesterone, testosterone and human chorionic gonadotrophin (HCG) were quantified in follicular fluid and granulosa cells were immunostained for human chorionic gonadotrophin. Immunopurification of granulosa cells from contaminating blood cells was performed. HCG in follicular fluid was significantly high in follicles yielding immature (grade 3) oocytes (P=0.002); there was no correlation with fertilization. Aspirates from follicles containing mature (grade 1) oocytes and oocytes that subsequently fertilized had significantly more granulosa cells immunobound to HCG (P < 0.001, P=0.02). Moreover, the immunomagnetic purification technique provided >98% pure population of granulosa cells. The data demonstrate that HCG in follicular fluid and on granulosa cells may help to predict oocyte maturity and fertilization. Furthermore, immunomagnetic beads provide a reliable procedure for the purification of ovarian granulosa cells.

Zoonotic and viral infection in fetal loss after 12 weeks

One hundred and thirty-six women from an urban, rural and farming community were recruited to a study of infectious causes of midtrimester miscarriage (n = 85), stillbirth (n = 32), or termination for developmental (n = 17) or chromosomal (n = 2) abnormalities. No woman had evidence of acute infection with toxoplasma, listeria, leptospira or Chlamydia psittaci (ovine enzootic abortion). One woman had midtrimester miscarriage associated with primary cytomegolovirus infection and five women had evidence of parvovirus B19 infection, although fetal infection was not proven. Zoonoses were not identified as a cause of fetal loss or malformation in this at-risk population, but parvovirus B19 was a significant cause of midtrimester fetal loss.

Modulation of uterine artery resistance to blood flow by the oral contraceptive pill

The changes in uterine artery resistance to blood flow were studied during a normal ovulatory cycle (control) and during a cycle on the combined oral contraceptive pill in 10 healthy women, aged 18-35 years, using transvaginal color Doppler imaging. Ovulation was monitored using ultrasound and hormonal assays during both cycles. The Pulsatility Index (PI) was used as a measure of uterine artery resistance, on days 8 (midproliferative) and 22 (midluteal) of the control cycle and on days 22 (maximal ovarian suppression) and 28 (minimal ovarian suppression) of the pill cycle. During the pill cycle, the uterine artery resistance decreased from a mean PI = 4.37 (range 2.4-7.95) on day 22 to a mean of 2.79 (1.94-4.99) on day 28, p = 0.006. The uterine artery resistance was significantly higher on day 22 during the pill cycle compared to the same day of the control cycle, p < 0.0001. Anovulatory cycles on the oral contraceptive pill are associated with an increase in uterine artery resistance and a decrease in uterine perfusion, this effect being reversed during the pill-free week.

A multicenter European survey of the attitudes to contraception in women at high risk or with established cardiovascular disease

OBJECTIVES

The survey was designed to study the attitudes of gynecologists from 11 European centers providing guidance in contraception to women at high risk and women with cardiovascular disease.

METHODS

Attitudes were registered by means of a standard questionnaire.

RESULTS

Most contributors reported that, in women with venous thrombosis (10/11), deep venous thrombosis (10/11), coagulation disorders (11/11) and stroke (8/11), they prefer to prescribe methods other than combined oral contraceptives (COCs). A history of myocardial infarction was considered a relative contraindication and some experts suggested that, in some cases, the use of third-generation COCs may be possible. COCs were not recommended in women with severe cardiovascular disease and in those over 35 years of age with light or moderate cardiovascular disease, heavy smokers (over 20 cigarettes per day), or those presenting with severe hyperlipidemia.

CONCLUSION

The pill is not considered appropriate for women with clinically established cardiovascular diseases or in cases where more than two coronary risk factors exist. COCs may safely be given to women with elevated blood pressure as long as it is lower than 160/100 mmHg, in cases of light and moderate cardiovascular disease as long as the patient is less than 35 years of age, in women who are not heavy smokers, in the presence of a light or moderate degree of hyperlipidemia, and in uncomplicated diabetes mellitus provided that there are no additional risk factors. In these cases, third-generation COCs are preferred. The co-operation of the cardiologist is desirable in order to classify cardiovascular disease and for patient follow-up.

Shorter pill-free interval in combined oral contraceptives decreases follicular development

The objective of the study was to determine the suppressive effect on ovarian activity of 20 micrograms ethinylestradiol plus 75 micrograms gestodene administered for 21 or 23 days. The study was designed as a double-blind, randomized, multicenter trial in 60 women. A pre-treatment cycle, three treatment cycles and a post-treatment period were monitored by ovarian ultrasound and by LH, FSH, 17 beta-estradiol and progesterone measurements every other day. No ovulation and no luteinized, unruptured follicle were observed. Suppression of ovarian activity was more pronounced by the 23-day regimen. 17 beta-Estradiol serum levels during the last six days of a cycle and during the first six days of the next cycle were significantly less (p < 0.05) in the 23-day regimen. The superiority of the 23-day regimen in comparison to the 21-day regimen with regard to the suppression of ovarian activity was shown in this study. The observed differences in the 17 beta-estradiol levels and follicular development between a 21-day and 23-day preparation combine to suggest that shortening the pill-free interval in combined oral contraceptives may increase the contraceptive safety margin in women on low-dose formulations.

Short communication: the effect of mode of delivery on contractile function of placental arteries in vitro

This study was designed to determine the effect of the mode of delivery on the in vitro assessment of placental blood vessel function. Twenty-two subjects with uncomplicated pregnancies, normal antenatal Doppler flow velocity waveforms and normal birth weights were recruited for the study. The 11 subjects who were delivered by elective caesarean section were matched with 11 controls, who had uncomplicated labours and spontaneous vaginal delivery. Two tertiary chorionic plate arteries were dissected free 1 h after delivery and mounted in a myograph. Cumulative concentration response curves were constructed to the thromboxane A2 analogue U46619, prostaglandin F2 alpha and angiotensin II. After a period of 12 h a further two vessels were mounted and a concentration response curve to U46619 was repeated to determine whether a delay of several hours after delivery would have an effect on the responses of these vessels. These placental arteries constrict to U46619, prostaglandin F2 alpha and angiotensin II in a dose-dependent manner. There was no statistical difference in the maximum contractile responses or pD2 values between the different modes of delivery. A delay in dissection of up to 12 h had no effect on the maximum response or pD2 with U46619. Therefore, contractile function of placental arteries is unaffected by mode of delivery or a delay in dissection.

Human chorionic gonadotrophin and steroid concentrations in follicular fluid: the relationship to oocyte maturity and fertilization rates in stimulated and natural in-vitro fertilization cycles

The study investigates the relationship of follicular fluid steroids and human chorionic gonadotrophin to oocyte maturity and fertilization rates in stimulated and natural cycles. Oestradiol, progesterone, testosterone and human chorionic gonadotrophin were quantified in 129 samples of follicular fluid and the progesterone:oestradiol ratio calculated. Both stimulated cycles (short and long luteinizing hormone-releasing hormone/human menopausal gonadotrophin regimens) and natural cycles were compared. A total of 60 women were studied, 20 in each group. In the natural cycles, testosterone was significantly lower in follicles with intermediate oocytes (P = 0.015). Both oestradiol and testosterone were significantly lower in stimulated cycles compared to natural cycles (P = 0.032 and P = 0.034 respectively). In the ovarian stimulation cycles, the progesterone:oestradiol ratio was significantly higher when oocytes fertilized (P = 0.052). Moreover, in the stimulated cycles, oestradiol and human chorionic gonadotrophin were singnificantly lower in the short protocol compared to the long protocol. The data demonstrate that the hormonal milieu of the follicle is altered in down-regulated stimulated cycles to varying degrees, depending partially on the type of protocol used. Furthermore, the progesterone:oestradiol ratio, rather than individual hormone concentrations, may be a useful predictor of the fertilizing capacity of the oocytes.

Review of the organized support network for infertility patients in licensed units in the UK

In acknowledging that 'counselling is generally recognized as beneficial', the Human Fertilization and Embryology Authority (HFEA) Code of Practice requires that all infertility units provide counselling facilities to be available for patients. In this study, we intended to evaluate the support and counselling services made available by the licensed units in the UK. A questionnaire consisting of 30 questions was designed and sent to every licensed treatment unit in the UK. The data were coded on a nominal scale and, using a data entry program, loaded onto a computer. Using the Statistical Package for the Social Sciences program, a non-parametric frequency analysis was performed. Associations were examined with cross-tabulations and chi 2 analysis. A total of 62 units (61.4%) responded to the questionnaire, from both the private and National Health Service sectors. Of these, 95% have their own counsellor, most of whom (84%) practised on the premises. One-third of these counsellors had a dual role, mainly as nurses, social workers or in administration; 98.6% were trained in counselling, with only 28% having either the Certificate or Diploma in Counselling. One-third (32.2%) of centres charged for counselling, with only 13 units indicating their charges. The majority of centres (78.8%) do not actively follow-up patients after counselling and one-quarter (25.5%) did not have a specific counselling room. Over two-thirds (68.4%) of centres described their support network as adequate. The results of this survey suggest that, although the requirements of the HFEA Code of Practice are being adhered to reasonably well, overall patient uptake of counselling is low.(ABSTRACT TRUNCATED AT 250 WORDS)

CD44 is expressed throughout pre-implantation human embryo development

The cell surface glycoprotein CD44 has been demonstrated in a variety of cell types in embryonic and adult tissues. We have established that CD44 is present on human oocytes, cumulus cells, early embryos and pre-hatched blastocysts by indirect immunofluorescence. We have also shown that CD44 is present on 8-11 week placental stroma cells, but not on the trophoblast. These findings demonstrate that CD44 is present throughout preimplantation development, and that down-regulation occurs on the embryonic surface after implantation.

An analysis of the corrosion process of the Nova-T IUD

OBJECTIVE

To measure the copper from Nova-T IUDs that have been used for up to 9 years. To examine the composition and extent of surface deposits on these used IUDs.

DESIGN

Nova-T IUDs were randomly collected at normal replacement or removal. The copper, silver and calcium content was quantified by X-ray fluorescence; surface topography and analysis was by scanning electron microscopy and X-ray dispersive analysis.

RESULTS

Copper loss slowly increased at an exponential rate over the study period but the copper was stabilized by the silver core and did not show increased fragmentation with extended use. No corrosion of the silver core was detected. Calcium- and sulfur-containing surface deposits built up on the copper but did not modify the rate of copper release.

CONCLUSIONS

The mean rate of copper loss was 0.25 mumol/day during the first 40 months of use, which is not significantly different from that of similar IUDs without a silver core. The silver core of the copper coil on the Nova-T IUD prevented its fragmentation. Surface deposits containing calcium and sulfur that built up on the IUD did not affect the rate of copper loss.

Profile of young people's advice clinic in reproductive health, 1988-93

For an unprepared sexually active teenager the 1990s present a minefield of potential problems in addition to the most obvious problems of unplanned pregnancy and sexually transmitted disease. Promoting the importance of a healthy sexual and reproductive life to young people requires openness, better sex education, realistic discussion of related issues, and provision of contraception, as well as support if things go wrong. The Woodhouse Park Clinic in south Manchester opened in October 1988 with the aim of providing weekly advice sessions to young people up to the age of 18. Advice is given on topics such as substance misuse and smoking as well as on family planning. Attendance has steadily increased over the years; from April to June 1993 the average number of attenders per session was 39, one third of whom were young men.

Endometrial structure after superovulation: a prospective controlled study

OBJECTIVE

To demonstrate the effect of superovulation using a GnRH agonist (GnRH-a) and hMG and hCG on endometrial structure.

DESIGN

Prospective, case-controlled study.

SETTING

Tertiary referral assisted reproduction unit in an academic department.

PATIENTS

Eleven women undergoing GIFT or IVF, without ET.

INTERVENTIONS

All women were treated with a long stimulation regimen using the depot GnRH-a Goserelin (ICI, Macclesfield, United Kingdom) and hMG and hCG.

MAIN OUTCOME MEASURES

Comparison of endometrial biopsy specimens taken 4 days after ovulation in an unstimulated cycle with specimens taken 4 days after oocyte recovery, using standard dating criteria and morphometric analysis.

RESULTS

There was no difference in endometrial glandular development as assessed by either standard criteria or morphometric analysis.

CONCLUSIONS

Superovulation preceded by pituitary down regulation is not associated with abnormal endometrial glandular development, even though supraphysiological levels of E2 and P are induced.

Age related changes in the female reproductive cycle

OBJECTIVE

To investigate the effect of age on the control of the reproductive cycle in regularly menstruating women.

DESIGN

In this prospective study all women were seen regularly during both the follicular and luteal phases. Ultrasound scanning was used to confirm ovulation and measurements were taken to assess follicular development and endometrial thickness. Serum gonadotrophin levels on day 4 of the cycle, the maximum periovulatory oestradiol and progesterone on the seventh day after ovulation were measured and compared in different age groups.

SUBJECTS & SETTING

Fifty-six healthy, regularly menstruating women were recruited from volunteers amongst staff of the University Hospital of South Manchester.

RESULTS

Ovulation occurred later in the cycle for older women, with mean follicular phase length increasing from 13.9 days (in group 21-25 years) to 15.9 days (in group 37-45 years (P < 0.05). The mean of the maximum follicular diameter prior to rupture was significantly smaller in the older women: 16.7 mm in the 37 to 45 years old group compared with 19.6 mm, 21.6 mm and 21.3 mm in the 21 to 25, 26 to 31 and 32 to 36 years old age groups, respectively (P < 0.001). The maximum thickness of the endometrium in the luteal phase was greatest for older women: 15.9 mm in the age group 37 to 45 years compared with 12.1 mm in the age group 21 to 25 years (P < 0.001). Serum gonadotrophin concentrations during menses were higher with increased age; mean follicle stimulating hormone was 4.8 iu/l in the age group 21 to 25 years, and 8.5 iu/l in the age group 37 to 45 years (P < 0.001). Mean luteinising hormone was 4.5 iu/l in age group 21 to 25 years and 7.21 iu/l in age group 37 to 45 years (P < 0.001). Mean ovarian steroid concentrations were no different.

CONCLUSIONS

These data illustrate significant age related differences in the pituitary-ovarian axis and endometrial thickness. This has implications for the management of older women in assisted reproduction and fertility control programmes.

A comparison of the effects of two monophasic low dose oral contraceptives on the inhibition of ovulation

Fifty-three women were randomly allocated to one of two combined low-dose monophasic oral contraceptives (20 micrograms ethinyl estradiol with 75 micrograms gestodene or 20 micrograms ethinyl estradiol with 150 micrograms desogestrel). The ability of these formulations to inhibit ovulation was compared using hormonal parameters and ovarian ultrasound. The effects on three treated cycles were compared with pre- and post-treatment cycles. No ovulations occurred in either group during therapy. Twenty-one percent of women were observed to show some follicle-like structures accompanied by raised serum estradiol in at least one treatment cycle. No significant differences between the two preparations were demonstrated on residual ovarian function. The secretion of estradiol and progesterone was significantly reduced throughout all three treatment cycles. Mean LH and FSH concentrations were comparable with both treatments. A secondary analysis of cycle control and tolerance was undertaken. Significantly less bleeding was seen in the gestodene group during cycle 2 (p = 0.02). There were no differences between the two treatments with respect to the other cycle control parameters. Approximately half the women recorded intracyclic bleeding during the first treatment cycle. This improved during cycles 2 and 3. Both formulations were tolerated well.

Training in family planning

In spite of extensive programmes for training in family planning and extensive services in contraception in the UK, the number of unplanned pregnancies has not decreased. On the contrary it is increasing. Medical graduates are now educated in methods of contraception. There is an extensive programme for postgraduates, regulated by the Joint Committee on Contraception (JCC), which is well integrated and co-ordinated. The provision of good training opportunities at a local level will be enhanced by the establishment of consultant posts in Reproductive Health/community Gynaecology and the development of higher training programmes to meet the projected expansion of these posts. They can play a role in education in reproductive health with respect to sexuality and personal relationships, as well as in the provision of family planning services and training to all reproductive health care professionals and teachers.

Quantification of the in vitro activity of some compounds with spermicidal activity

The in vitro spermicidal activity of the commonly used surfactant spermicides and the antiseptic chlorhexidine, were quantified in a statistically reproducible manner, using donor semen and image capture analysis. The spermicidal activity was expressed as the ED50 under defined assay conditions. Using these parameters, the order of spermicidal activity was: Menfegol > nonoxynol-9 approximately benzalkonium chloride > sodium docusate > chlorhexidine. These differences were statistically significant.

Comparison of Yuzpe regimen, danazol, and mifepristone (RU486) in oral postcoital contraception

OBJECTIVE

To compare the effectiveness and acceptability of three regimens of postcoital contraception.

DESIGN

Randomised group comparison of ethinyloestradiol 100 micrograms plus levonorgestrel 500 micrograms repeated after 12 hours (Yuzpe method); danazol 600 mg repeated after 12 hours; and mifepristone 600 mg single dose.

SETTING

Community family planning clinic.

SUBJECTS

616 consecutive women with regular cycles aged 16 to 45 years.

MAIN OUTCOME MEASURES

Number of pregnancies, incidence of side effects, and timing of next period.

RESULTS

The raw pregnancy rates (with 95% confidence intervals) for the Yuzpe, danazol, and mifepristone groups were 2.62% (0.86% to 6.00%), 4.66% (2.15% to 8.67%), and 0% (0% to 1.87%) respectively. Overall, these rates differed significantly (chi 2 = 8.988, df = 2; p = 0.011). The differences between the mifepristone and Yuzpe groups and between the mifepristone and danazol groups were also significant. Side effects were more common and more severe in the Yuzpe group (133 women (70%)) than in either the danazol group (58 (30%)) or the mifepristone group (72 (37%)). The Yuzpe regimen tended to induce bleeding early but mifepristone prolonged the cycle. Three women bled more than seven days late in the Yuzpe group compared with 49 in the mifepristone group.

CONCLUSIONS

Mifepristone was effective in reducing expected pregnancy rates and the Yuzpe method also had a clinical effect. Danazol had little or no effect. A further multicentre trial is needed.

Pituitary-ovarian function in women with minimal or mild endometriosis and otherwise unexplained infertility

OBJECTIVE

To determine whether abnormalities of pituitary-ovarian function are associated with minor degrees of endometriosis in women with otherwise unexplained infertility.

DESIGN

Comparison of pituitary-ovarian function in a group of 22 patients with that in a control group of 10 healthy fertile women.

PATIENTS

Twenty-two women with minimal or mild endometriosis and otherwise unexplained infertility.

MEASUREMENTS

Ovarian ultrasound and radioimmunoassay of pituitary and ovarian hormones.

RESULTS

Abnormalities, including luteinization of unruptured follicles, broad LH surges and low concentrations of progesterone during the luteal phase, were demonstrated in 82% of study cycles.

CONCLUSION

Pituitary-ovarian dysfunction appears to be associated with minimal or mild endometriosis in women with otherwise unexplained infertility but the diversity of endocrine abnormalities demonstrated suggests that endometriosis is unlikely to be an aetiological factor in their development.

Undergraduate education and recruitment in obstetrics and gynaecology

The extent and quality of exposure to obstetrics and gynaecology that is required in the undergraduate curriculum has bearing on the knowledge, clinical skills and behaviour that are expected from the student. How much involvement should clinical obstetricians and gynaecologists have in teaching human reproduction and basic physiology and related science to the undergraduate? Who should teach sexual medicine? What is the extent of practical experience which students should have? Should the student have an opportunity to study a particular area in the discipline at depth in order to encourage interest and involvement and thereby facilitate recruitment? These issues are being addressed in curricular changes in Manchester, and option teaching is considered to have the potential of enhancing interest in obstetrics and gynaecology as a definitive career.

The efficacy and acceptability of a low-dose levonorgestrel intravaginal ring for contraception in a UK cohort

The efficacy and acceptability of a levonorgestrel-releasing intravaginal ring (IVR) for contraception was assessed in a British cohort studied as part of a multicentre, multinational clinical trial performed under the auspices of the World Health Organisation. One-hundred-and-fifty women took part in the study in two UK centres and completed 1417.5 months of method use. Fifty-nine women discontinued use of the IVR before the end of one year giving an overall discontinuation rate of 39.9 per 100 woman-years. The discontinuation for pregnancy with the ring in situ, was 3.0 per 100 woman-years (life table analysis). Menstrual disturbance, vaginal problems and involuntary expulsion resulted in discontinuation rates of 8.9, 8.4 and 1.6 per 100 woman-years, respectively. This method is an acceptable and effective method of contraception for women.