The cost-effectiveness of screening for ovarian cancer: results from the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS)

Background:

To assess the within-trial cost-effectiveness of an NHS ovarian cancer screening (OCS) programme using data from UKCTOCS and extrapolate results based on average life expectancy.

Methods:

Within-trial economic evaluation of no screening (C) vs either (1) an annual OCS programme using transvaginal ultrasound (USS) or (2) an annual ovarian cancer multimodal screening programme with serum CA125 interpreted using a risk algorithm (ROCA) and transvaginal ultrasound as a second-line test (MMS), plus comparison of lifetime extrapolation of the no screening arm and the MMS programme using both a predictive and a Markov model.

Results:

Using a CA125–ROCA cost of £20, the within-trial results show USS to be strictly dominated by MMS, with the MMS vs C comparison returning an incremental cost-effectiveness ratio (ICER) of £91 452 per life year gained (LYG). If the CA125–ROCA unit cost is reduced to £15, the ICER becomes £77 818 per LYG. Predictive extrapolation over the expected lifetime of the UKCTOCS women returns an ICER of £30 033 per LYG, while Markov modelling produces an ICER of £46 922 per QALY.

Conclusion:

Analysis suggests that, after accounting for the lead time required to establish full mortality benefits, a national OCS programme based on the MMS strategy quickly approaches the current NICE thresholds for cost-effectiveness when extrapolated out to lifetime as compared with the within-trial ICER estimates. Whether MMS could be recommended on economic grounds would depend on the confirmation and size of the mortality benefit at the end of an ongoing follow-up of the UKCTOCS cohort.

Coasting (withholding gonadotrophins) for preventing ovarian hyperstimulation syndrome

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic and potentially life threatening condition resulting from excessive ovarian stimulation. Reported incidence of moderate to severe OHSS ranges from 0.6% to 5% of in vitro fertilization (IVF) cycles. The factors contributing to OHSS have not been completely explained. The release of vasoactive substances secreted by the ovaries under human chorionic gonadotrophin (hCG) stimulation may play a key role in triggering this syndrome. This condition is characterised by a massive shift of fluid from the intravascular compartment to the third space, resulting in profound intravascular depletion and haemoconcentration.

OBJECTIVES

To assess the effect of withholding gonadotrophins (coasting) on the prevention of ovarian hyperstimulation syndrome in assisted reproduction cycles.

SEARCH METHODS

For the update of this review, we searched the Cochrane Gynaecology and Fertility Group Trials Register, CENTRAL, MEDLINE (PubMed), CINHAL, PsycINFO, Embase, Google, and clinicaltrials.gov to 6 July 2016.

SELECTION CRITERIA

We included only randomized controlled trials (RCTs) in which coasting was used to prevent OHSS.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and extracted data. They resolved disagreements by discussion. They contacted study authors to request additional information or missing data. The intervention comparisons were coasting versus no coasting, coasting versus early unilateral follicular aspiration (EUFA), coasting versus gonadotrophin releasing hormone antagonist (antagonist), coasting versus follicle stimulating hormone administration at the time of hCG trigger (FSH co-trigger), and coasting versus cabergoline. We performed statistical analysis in accordance with Cochrane guidelines. Our primary outcomes were moderate or severe OHSS and live birth.

MAIN RESULTS

We included eight RCTs (702 women at high risk of developing OHSS). The quality of evidence was low or very low. The main limitations were failure to report live birth, risk of bias due to lack of information about study methods, and imprecision due to low event rates and lack of data. Four of the studies were published only as abstracts, and provided limited data. Coasting versus no coastingRates of OHSS were lower in the coasting group (OR 0.11, 95% CI 0.05 to 0.24; I² = 0%, two RCTs; 207 women; low-quality evidence), suggesting that if 45% of women developed moderate or severe OHSS without coasting, between 4% and 17% of women would develop it with coasting. There were too few data to determine whether there was a difference between the groups in rates of live birth (OR 0.48, 95% CI 0.14 to 1.62; one RCT; 68 women; very low-quality evidence), clinical pregnancy (OR 0.82, 95% CI 0.46 to 1.44; I² = 0%; two RCTs; 207 women; low-quality evidence), multiple pregnancy (OR 0.31, 95% CI 0.12 to 0.81; one RCT; 139 women; low-quality evidence), or miscarriage (OR 0.85, 95% CI 0.25 to 2.86; I² = 0%; two RCTs; 207 women; very low-quality evidence). Coasting versus EUFAThere were too few data to determine whether there was a difference between the groups in rates of OHSS (OR 0.98, 95% CI 0.34 to 2.85; I² = 0%; 2 RCTs; 83 women; very low-quality evidence), or clinical pregnancy (OR 0.67, 95% CI 0.25 to 1.79; I² = 0%; 2 RCTs; 83 women; very low-quality evidence); no studies reported live birth, multiple pregnancy, or miscarriage. Coasting versus antagonistOne RCT (190 women) reported this comparison, and no events of OHSS occurred in either arm. There were too few data to determine whether there was a difference between the groups in clinical pregnancy rates (OR 0.74, 95% CI 0.42 to 1.31; one RCT; 190 women; low-quality evidence), or multiple pregnancy rates (OR 1.00, 95% CI 0.43 to 2.32; one RCT; 98 women; very low-quality evidence); the study did not report live birth or miscarriage. Coasting versus FSH co-triggerRates of OHSS were higher in the coasting group (OR 43.74, 95% CI 2.54 to 754.58; one RCT; 102 women; very low-quality evidence), with 15 events in the coasting arm and none in the FSH co-trigger arm. There were too few data to determine whether there was a difference between the groups in clinical pregnancy rates (OR 0.92, 95% CI 0.43 to 2.10; one RCT; 102 women; low-quality evidence). This study did not report data suitable for analysis on live birth, multiple pregnancy, or miscarriage, but stated that there was no significant difference between the groups. Coasting versus cabergolineThere were too few data to determine whether there was a difference between the groups in rates of OHSS (OR 1.98, 95% CI 0.09 to 5.68; P = 0.20; I² = 72%; two RCTs; 120 women; very low-quality evidence), with 11 events in the coasting arm and six in the cabergoline arm. The evidence suggested that coasting was associated with lower rates of clinical pregnancy (OR 0.38, 95% CI 0.16 to 0.88; P = 0.02; I² =0%; two RCTs; 120 women; very low-quality evidence), but there were only 33 events altogether. These studies did not report data suitable for analysis on live birth, multiple pregnancy, or miscarriage.

AUTHORS' CONCLUSIONS

There was low-quality evidence to suggest that coasting reduced rates of moderate or severe OHSS more than no coasting. There was no evidence to suggest that coasting was more beneficial than other interventions, except that there was very low-quality evidence from a single small study to suggest that using FSH co-trigger at the time of HCG administration may be better at reducing the risk of OHSS than coasting. There were too few data to determine clearly whether there was a difference between the groups for any other outcomes.

Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial

BACKGROUND

Ovarian cancer has a poor prognosis, with just 40% of patients surviving 5 years. We designed this trial to establish the effect of early detection by screening on ovarian cancer mortality.

METHODS

In this randomised controlled trial, we recruited postmenopausal women aged 50-74 years from 13 centres in National Health Service Trusts in England, Wales, and Northern Ireland. Exclusion criteria were previous bilateral oophorectomy or ovarian malignancy, increased risk of familial ovarian cancer, and active non-ovarian malignancy. The trial management system confirmed eligibility and randomly allocated participants in blocks of 32 using computer-generated random numbers to annual multimodal screening (MMS) with serum CA125 interpreted with use of the risk of ovarian cancer algorithm, annual transvaginal ultrasound screening (USS), or no screening, in a 1:1:2 ratio. The primary outcome was death due to ovarian cancer by Dec 31, 2014, comparing MMS and USS separately with no screening, ascertained by an outcomes committee masked to randomisation group. All analyses were by modified intention to screen, excluding the small number of women we discovered after randomisation to have a bilateral oophorectomy, have ovarian cancer, or had exited the registry before recruitment. Investigators and participants were aware of screening type. This trial is registered with ClinicalTrials.gov, number NCT00058032.

FINDINGS

Between June 1, 2001, and Oct 21, 2005, we randomly allocated 202,638 women: 50,640 (25·0%) to MMS, 50,639 (25·0%) to USS, and 101,359 (50·0%) to no screening. 202,546 (>99·9%) women were eligible for analysis: 50,624 (>99·9%) women in the MMS group, 50,623 (>99·9%) in the USS group, and 101,299 (>99·9%) in the no screening group. Screening ended on Dec 31, 2011, and included 345,570 MMS and 327,775 USS annual screening episodes. At a median follow-up of 11·1 years (IQR 10·0-12·0), we diagnosed ovarian cancer in 1282 (0·6%) women: 338 (0·7%) in the MMS group, 314 (0·6%) in the USS group, and 630 (0·6%) in the no screening group. Of these women, 148 (0·29%) women in the MMS group, 154 (0·30%) in the USS group, and 347 (0·34%) in the no screening group had died of ovarian cancer. The primary analysis using a Cox proportional hazards model gave a mortality reduction over years 0-14 of 15% (95% CI -3 to 30; p=0·10) with MMS and 11% (-7 to 27; p=0·21) with USS. The Royston-Parmar flexible parametric model showed that in the MMS group, this mortality effect was made up of 8% (-20 to 31) in years 0-7 and 23% (1-46) in years 7-14, and in the USS group, of 2% (-27 to 26) in years 0-7 and 21% (-2 to 42) in years 7-14. A prespecified analysis of death from ovarian cancer of MMS versus no screening with exclusion of prevalent cases showed significantly different death rates (p=0·021), with an overall average mortality reduction of 20% (-2 to 40) and a reduction of 8% (-27 to 43) in years 0-7 and 28% (-3 to 49) in years 7-14 in favour of MMS.

INTERPRETATION

Although the mortality reduction was not significant in the primary analysis, we noted a significant mortality reduction with MMS when prevalent cases were excluded. We noted encouraging evidence of a mortality reduction in years 7-14, but further follow-up is needed before firm conclusions can be reached on the efficacy and cost-effectiveness of ovarian cancer screening.

FUNDING

Medical Research Council, Cancer Research UK, Department of Health, The Eve Appeal.

The Thessaloniki ESHRE/ESGE consensus on diagnosis of female genital anomalies

STUDY QUESTION

What is the recommended diagnostic work-up of female genital anomalies according to the European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) system?

SUMMARY ANSWER

The ESHRE/ESGE consensus for the diagnosis of female genital anomalies is presented.

WHAT IS KNOWN ALREADY

Accurate diagnosis of congenital anomalies still remains a clinical challenge because of the drawbacks of the previous classification systems and the non-systematic use of diagnostic methods with varying accuracy, some of them quite inaccurate. Currently, a wide range of non-invasive diagnostic procedures are available enriching the opportunity to accurately detect the anatomical status of the female genital tract, as well as a new objective and comprehensive classification system with well-described classes and sub-classes.

STUDY DESIGN, SIZE, DURATION

The ESHRE/ESGE CONgenital UTerine Anomalies (CONUTA) Working Group established an initiative with the goal of developing a consensus for the diagnosis of female genital anomalies. The CONUTA working group and imaging experts in the field have been appointed to run the project.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The consensus is developed based on: (i) evaluation of the currently available diagnostic methods and, more specifically, of their characteristics with the use of the experts panel consensus method and of their diagnostic accuracy by performing a systematic review of evidence and (ii) consensus for the definition of where and how to measure uterine wall thickness and the recommendations for the diagnostic work-up of female genital anomalies, based on the results of the previous evaluation procedure, with the use of the experts panel consensus method.

MAIN RESULTS AND THE ROLE OF CHANCE

Uterine wall thickness is defined as the distance between the interostial line and external uterine profile at the midcoronal plane of the uterus; alternatively, if a coronal plane is not available, the mean anterior and posterior uterine wall thickness at the longitudinal plane could be used. Gynecological examination and two-dimensional ultrasound (2D US) are recommended for the evaluation of asymptomatic women. Three-dimensional (3D) US is recommended for the diagnosis of female genital anomalies in 'symptomatic' patients belonging to high risk groups for the presence of a female genital anomaly and in any asymptomatic woman suspected to have an anomaly from routine evaluation. Magnetic resonance imaging (MRI) and endoscopic evaluation are recommended for the subgroup of patients with suspected complex anomalies or in diagnostic dilemmas. Adolescents with symptoms suggestive for the presence of a female genital anomaly should be thoroughly evaluated with 2D US, 3D US, MRI and endoscopically.

LIMITATIONS, REASONS FOR CAUTION

The various diagnostic methods should always be used in the proper way and evaluated by experts to avoid mis-, over- and underdiagnosis.

WIDER IMPLICATIONS OF THE FINDINGS

The role of a combined US examination and outpatient hysteroscopy should be prospectively evaluated. It is a challenge for further research, based on diagnosis, to objectively evaluate the clinical consequences related to various degrees of uterine deformity.

STUDY FUNDING/COMPETING INTERESTS

None.

Risk Algorithm Using Serial Biomarker Measurements Doubles the Number of Screen-Detected Cancers Compared With a Single-Threshold Rule in the United Kingdom Collaborative Trial of Ovarian Cancer Screening

PURPOSE

Cancer screening strategies have commonly adopted single-biomarker thresholds to identify abnormality. We investigated the impact of serial biomarker change interpreted through a risk algorithm on cancer detection rates.

PATIENTS AND METHODS

In the United Kingdom Collaborative Trial of Ovarian Cancer Screening, 46,237 women, age 50 years or older underwent incidence screening by using the multimodal strategy (MMS) in which annual serum cancer antigen 125 (CA-125) was interpreted with the risk of ovarian cancer algorithm (ROCA). Women were triaged by the ROCA: normal risk, returned to annual screening; intermediate risk, repeat CA-125; and elevated risk, repeat CA-125 and transvaginal ultrasound. Women with persistently increased risk were clinically evaluated. All participants were followed through national cancer and/or death registries. Performance characteristics of a single-threshold rule and the ROCA were compared by using receiver operating characteristic curves.

RESULTS

After 296,911 women-years of annual incidence screening, 640 women underwent surgery. Of those, 133 had primary invasive epithelial ovarian or tubal cancers (iEOCs). In all, 22 interval iEOCs occurred within 1 year of screening, of which one was detected by ROCA but was managed conservatively after clinical assessment. The sensitivity and specificity of MMS for detection of iEOCs were 85.8% (95% CI, 79.3% to 90.9%) and 99.8% (95% CI, 99.8% to 99.8%), respectively, with 4.8 surgeries per iEOC. ROCA alone detected 87.1% (135 of 155) of the iEOCs. Using fixed CA-125 cutoffs at the last annual screen of more than 35, more than 30, and more than 22 U/mL would have identified 41.3% (64 of 155), 48.4% (75 of 155), and 66.5% (103 of 155), respectively. The area under the curve for ROCA (0.915) was significantly (P = .0027) higher than that for a single-threshold rule (0.869).

CONCLUSION

Screening by using ROCA doubled the number of screen-detected iEOCs compared with a fixed cutoff. In the context of cancer screening, reliance on predefined single-threshold rules may result in biomarkers of value being discarded.

Factors affecting visualization of postmenopausal ovaries: descriptive study from the multicenter United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS)

OBJECTIVE

Transvaginal sonography (TVS) is core to any ovarian cancer screening strategy. General-population screening involves older postmenopausal women in whom ovarian visualization is difficult because of decreasing ovarian size and lack of follicular activity. We report on factors affecting the visualization of postmenopausal ovaries in the multicenter United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS).

METHODS

The UKCTOCS is a randomized controlled trial of 202 638 postmenopausal women with 50 639 women in the ultrasound scan arm. TVS is the primary screening modality in the ultrasound scan arm. Age, education, ethnicity, body mass index (BMI), previous pelvic surgery, lifestyle and reproductive factors, and a personal/family history of cancer were assessed for their effects on ovarian visualization at the initial TVS.

RESULTS

Between 11 June 2001 and 18 August 2007, 43 867 women underwent TVS. The median age and BMI of the women were 60.6 (interquartile range (IQR), 9.9) years and 25.7 (IQR, 5.8), respectively. The right ovary was visualized in 29 297 (66.8%) and the left ovary was visualized in 28 726 (65.5%). Visualization of ovaries decreased with previous hysterectomy (odds ratio (OR) = 0.534; 95% CI, 0.504-0.567), previous tubal ligation (OR = 0.895; 95% CI, 0.852-0.940), increasing age (OR = 0.953; 95% CI, 0.950-0.956), unilateral oophorectomy (OR = 0.224; 95% CI, 0.186-0.269) and being overweight (OR = 0.918; 95% CI, 0.876-0.962) or obese (OR = 0.715; 95% CI, 0.677-0.755). Increased visualization was observed with a history of infertility (OR = 1.134; 95% CI, 1.005-1.279) and increasing age (in years) at menopause (OR = 1.005; 95% CI, 1.001-1.009).

CONCLUSIONS

Several factors affect the visualization of postmenopausal ovaries. Their impact needs to be taken into consideration when developing quality assurance for ovarian ultrasound scanning or comparing study results as their prevalence may differ between populations.

Intraoperative imaging

Intraoperative image is a rapidly expanding field encompassing many applications that use a multitude of technologies. Some of the these applications have been in use for many years and are firmly embedded in, and indispensable to, clinical practice (e.g. the use of X-ray to locate foreign bodies during surgery or oocyte retrieval under ultrasound guidance. In others, the application may have been in use in one discipline but not yet fully explored in another. Examples include the use of intraoperative ultrasound with or without contrast enhancement for the detection of hepatic metastases not identified preoperatively, and the effect of such additional information on the ultimate operative procedure. Intraoperative identification of sentinel lymph nodes has been explored in many specialties to a varying extent, with the aim of fine tuning and avoiding unnecessary surgery. In both these instances, we do not know the long-term effect of these interventions on patient survival or quality of life. In this chapter, we will explore the available evidence on these applications and current advances in the new technology in general, with a specific focus on gynaecology.

Acceptance of transvaginal sonography by postmenopausal women participating in the United Kingdom Collaborative Trial of Ovarian Cancer Screening

OBJECTIVE

To assess pain and overall experience of transvaginal sonography (TVS) in asymptomatic postmenopausal women.

METHODS

In the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS), 50 639 postmenopausal women were randomized to undergo annual TVS at 13 trial centers in England, Wales and Northern Ireland. Together with the appointment letter for their annual scan, a random sample of 150 women per center was sent a detailed 48-item postal questionnaire regarding the screening experience. It included a specific question about pain using a score of 0-5, where 5 was severe pain and 3 was discomfort. To assess factors that might affect a woman's reported pain experience, the pain score was regressed on age, hormone replacement therapy use, body mass index, a history of hysterectomy, prolonged scanning time, ovarian visualization, scan result, sonographer's visualization rates and opinion of the women regarding the sonographer who performed the scan.

RESULTS

Between 7 July and 9 September 2009, 1950 randomly chosen women (150 per regional center) were sent the questionnaire. Of the 800 (41.0%) who returned the questionnaire, 651 could be linked to their TVS appointment. One-hundred and fifty-two (23.3%) women reported pain/discomfort (score 3-5) during TVS and 473 (72.7%) reported no discomfort (score 0-2). Only 23 (3.5%) women reported experiencing moderate/severe pain. Increasing discomfort/pain was independently associated with a history of hysterectomy and participant's reporting of prolonged scan time. Women who experienced pain on TVS were less compliant (odds ratio = 0.87) with the following year's scan compared with those who did not experience pain.

CONCLUSIONS

The majority of postmenopausal women found TVS acceptable. Pain influenced compliance and correlated with women's perception of increased scanning time and previous hysterectomy.

Coasting (withholding gonadotrophins) for preventing ovarian hyperstimulation syndrome

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic and potentially life threatening condition resulting from excessive ovarian stimulation. Reported incidence varies from 1% to 10% of in vitro fertilization (IVF) cycles. The factors contributing to OHSS have not been completely explained. The release of vasoactive substances secreted by the ovaries under human chorionic gonadotrophin (hCG) stimulation may play a key role in triggering this syndrome. This condition is characterised by a massive shift of fluid from the intra-vascular compartment to the third space resulting in profound intra-vascular depletion and haemoconcentration.

OBJECTIVES

To assess the effect of withholding gonadotrophins (coasting) on the prevention of ovarian hyperstimulation syndrome in assisted reproduction cycles.

SEARCH STRATEGY

For the update of this review we searched the Cochrane Menstrual Disorders and Subfertility Review Group Trials Register (July 2010), CENTRAL (inception to July 2010), MEDLINE (PubMed) (inception to July 2010), and EMBASE (inception to July 2010) for randomised controlled trials (RCTs) in which coasting was used to prevent OHSS.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) in which coasting was used to prevent OHSS were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and extracted data. Disagreements were resolved by discussion. Study authors were contacted to request additional information or missing data. The intervention comparisons were coasting versus early unilateral follicular aspiration (EUFA), no coasting or other interventions. Statistical analysis was performed in accordance with the Cochrane Menstrual Disorders and Subfertility Group guidelines.

MAIN RESULTS

This updated review identified 16 studies of which four met the inclusion criteria. There was no evidence of a difference in the incidence of moderate and severe OHSS (odds ratio (OR) 0.53, 95% CI 0.23 to 1.23), live birth (OR 0.48, 95% CI 0.14 to 1.62; P = 0.24) or in the clinical pregnancy rate (OR 0.69, 95% CI 0.44 to 1.08) between the groups. Significantly fewer oocytes were retrieved in coasting groups compared with GnRHa (OR -2.44, 95% CI -4.30 to -0.58; P = 0.01) or no coasting (OR -3.92, 95% CI -4.47 to -3.37; P < 0.0001). Data for coasting versus EUFA were not pooled for number of oocytes retrieved due to heterogeneity (I(2) = 87%).

AUTHORS' CONCLUSIONS

There was no evidence to suggest a benefit of using coasting to prevent OHSS compared with no coasting or other interventions.

Impact on mortality and cancer incidence rates of using random invitation from population registers for recruitment to trials

BACKGROUND

Participants in trials evaluating preventive interventions such as screening are on average healthier than the general population. To decrease this 'healthy volunteer effect' (HVE) women were randomly invited from population registers to participate in the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) and not allowed to self refer. This report assesses the extent of the HVE still prevalent in UKCTOCS and considers how certain shortfalls in mortality and incidence can be related to differences in socioeconomic status.

METHODS

Between 2001 and 2005, 202 638 postmenopausal women joined the trial out of 1 243 312 women randomly invited from local health authority registers. The cohort was flagged for deaths and cancer registrations and mean follow up at censoring was 5.55 years for mortality, and 2.58 years for cancer incidence. Overall and cause-specific Standardised Mortality Ratios (SMRs) and Standardised Incidence Ratios (SIRs) were calculated based on national mortality (2005) and cancer incidence (2006) statistics. The Index of Multiple Deprivation (IMD 2007) was used to assess the link between socioeconomic status and mortality/cancer incidence, and differences between the invited and recruited populations.

RESULTS

The SMR for all trial participants was 37%. By subgroup, the SMRs were higher for: younger age groups, extremes of BMI distribution and with each increasing year in trial. There was a clear trend between lower socioeconomic status and increased mortality but less pronounced with incidence. While the invited population had higher mean IMD scores (more deprived) than the national average, those who joined the trial were less deprived.

CONCLUSIONS

Recruitment to screening trials through invitation from population registers does not prevent a pronounced HVE on mortality. The impact on cancer incidence is much smaller. Similar shortfalls can be expected in other screening RCTs and it maybe prudent to use the various mortality and incidence rates presented as guides for calculating event rates and power in RCTs involving women.

Coasting (withholding gonadotrophins) for preventing ovarian hyperstimulation syndrome

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic and potentially life threatening condition resulting from excessive ovarian stimulation. Reported incidence varies from 1% to 10% of in vitro fertilization (IVF) cycles. The factors contributing to OHSS have not been completely explained. The release of vasoactive substances secreted by the ovaries under human chorionic gonadotrophin (hCG) stimulation may play a key role in triggering this syndrome. This condition is characterised by a massive shift of fluid from the intra-vascular compartment to the third space resulting in profound intra-vascular depletion and haemoconcentration.

OBJECTIVES

To assess the effect of withholding gonadotrophins (coasting) on the prevention of ovarian hyperstimulation syndrome in assisted reproduction cycles.

SEARCH STRATEGY

For the update of this review we searched the Cochrane Menstrual Disorders and Subfertility Review Group Trials Register (July 2010), CENTRAL (inception to July 2010), MEDLINE (PubMed) (inception to July 2010), and EMBASE (inception to July 2010) for randomised controlled trials (RCTs) in which coasting was used to prevent OHSS.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) in which coasting was used to prevent OHSS were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and extracted data. Disagreements were resolved by discussion. Study authors were contacted to request additional information or missing data. The intervention comparisons were coasting versus early unilateral follicular aspiration (EUFA), no coasting or other interventions. Statistical analysis was performed in accordance with the Cochrane Menstrual Disorders and Subfertility Group guidelines.

MAIN RESULTS

This updated review identified 16 studies of which four met the inclusion criteria. There was no evidence of a difference in the incidence of moderate and severe OHSS (odds ratio (OR) 0.53, 95% CI 0.23 to 1.23), live birth (OR 0.48, 95% CI 0.14 to 1.62; P = 0.24) or in the clinical pregnancy rate (OR 0.69, 95% CI 0.44 to 1.08) between the groups. Significantly fewer oocytes were retrieved in coasting groups compared with GnRHa (OR -2.44, 95% CI -4.30 to -0.58; P = 0.01) or no coasting (OR -3.92, 95% CI -4.47 to -3.37; P < 0.0001). Data for coasting versus EUFA were not pooled for number of oocytes retrieved due to heterogeneity (I(2) = 87%).

AUTHORS' CONCLUSIONS

There was no evidence to suggest a benefit of using coasting to prevent OHSS compared with no coasting or other interventions.

Sensitivity of transvaginal ultrasound screening for endometrial cancer in postmenopausal women: a case-control study within the UKCTOCS cohort

BACKGROUND

The increase in the worldwide incidence of endometrial cancer relates to rising obesity, falling fertility, and the ageing of the population. Transvaginal ultrasound (TVS) is a possible screening test, but there have been no large-scale studies. We report the performance of TVS screening in a large cohort.

METHODS

We did a nested case-control study of postmenopausal women who underwent TVS in the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) following recruitment between April 17, 2001, and Sept 29, 2005. Endometrial thickness and endometrial abnormalities were recorded, and follow-up, through national registries and a postal questionnaire, documented the diagnosis of endometrial cancer. Our primary outcome measure was endometrial cancer and atypical endometrial hyperplasia (AEH). Performance characteristics of endometrial thickness and abnormalities for detection of endometrial cancer within 1 year of TVS were calculated. Epidemiological variables were used to develop a logistic regression model and assess a screening strategy for women at higher risk. Our study is registered with ClinicalTrials.gov, number NCT00058032, and with the International Standard Randomised Controlled Trial register, number ISRCTN22488978.

FINDINGS

48,230 women underwent TVS in the UKCTOCS prevalence screen. 9078 women were ineligible because they had undergone a hysterectomy and 2271 because their endometrial thickness had not been recorded; however, 157 of these women had an endometrial abnormality on TVS and were included in the analysis. Median follow-up was 5·11 years (IQR 4·05-5·95). 136 women with endometrial cancer or AEH within 1 year of TVS were included in our primary analysis. The optimum endometrial thickness cutoff for endometrial cancer or AEH was 5·15 mm, with sensitivity of 80·5% (95% CI 72·7-86·8) and specificity of 86·2% (85·8-86·6). Sensitivity and specificity at a 5 mm or greater cutoff were 80·5% (72·7-86·8) and 85·7% (85·4-86·2); for women with a 5 mm or greater cutoff plus endometrial abnormalities, the sensitivity and specificity were 85·3% (78·2-90·8) and 80·4% (80·0-80·8), respectively. For a cutoff of 10 mm or greater, sensitivity and specificity were 54·1% (45·3-62·8) and 97·2% (97·0-97·4). When our analysis was restricted to the 96 women with endometrial cancer or AEH who reported no symptoms of postmenopausal bleeding at the UKCTOCS scan before diagnosis and had an endometrial thickness measurement available, a cutoff of 5 mm achieved a sensitivity of 77·1% (67·8-84·3) and specificity of 85·8% (85·7-85·9). The logistic regression model identified 25% of the population as at high risk and 39·5% of endometrial cancer or AEH cases were identified within this high risk group. In this high-risk population, a cutoff at 6·75 mm achieved sensitivity of 84·3% (71·4-93·0) and specificity of 89·9% (89·3-90·5).

INTERPRETATION

Our findings show that TVS screening for endometrial cancer has good sensitivity in postmenopausal women. The burden of diagnostic procedures and false-positive results can be reduced by limiting screening to a higher-risk group. The role of population screening for endometrial cancer remains uncertain, but our findings are of immediate value in the management of increased endometrial thickness in postmenopausal women undergoing pelvic scans for reasons other than vaginal bleeding.

Female genital tract morbidity and sexual function following vaginal delivery or lower segment caesarean section

A total of 208 women were assessed 2 years' post-delivery to record the prevalence of subjective urinary and faecal incontinence, incontinence of flatus, dyspareunia, subjective depression and sexual satisfaction. This was correlated with mode of delivery. A sample population was selected from the Cardiff Birth Survey Database, in accordance with strict inclusion and exclusion criteria. Each woman was invited to complete and return a postal questionnaire addressing symptoms of pelvic floor dysfunction. There was a significant decrease in sexual satisfaction scores in women who underwent vaginal delivery in comparison with those who underwent elective caesarean section at 2 years follow-up. There was also a significant increase in the prevalence of urinary incontinence, incontinence of flatus, dyspareunia and subjective depression in women who underwent vaginal delivery.

Neonatal desensitization allows long-term survival of neural xenotransplants without immunosuppression

Preclinical development of human cells for potential therapeutic application in neurodegenerative diseases requires that their long-term survival, stability and functional efficacy be studied in animal models of human disease. Here we describe a strategy for long-term immune protection of human fetal and stem cell-derived neural cells transplanted into the adult rat brain, by desensitizing the host rat to similar cells in the neonatal period, without the need for additional immunosuppression.

Clinical and health service implications of second generation endometrial ablation devices

PURPOSE OF REVIEW

This review evaluates the current evidence on the efficacy, safety and cost-effectiveness of the ever-increasing number of second-generation endometrial ablation devices.

RECENT FINDINGS

The literature covered by this review includes (1) evidence on long-term benefit, avoidance of hysterectomy and improvement in quality of life, (2) applicability of these techniques in the outpatient environment under local or no anaesthesia, (3) frequency and nature of early and delayed complications associated with these devices, (4) impact on clinical practice and the health service, and (5) implications for research.

SUMMARY

Where appropriate, second-generation devices are rapidly becoming the first-line surgical choice for the management of heavy menstrual bleeding. This has both cost-savings and negative implications for the health service. There is also emerging evidence that improvement in quality of life is more relevant to women than amenorrhoea rates. What has come to light from this review is the lack of accurate data on adverse events rate, and the urgent need for a better appreciation of the frequency and nature of complications.

Fluorescein isothiocynate-dextran uptake by chinese hamster ovary cells in a 1.5 MHz ultrasonic standing wave in the presence of contrast agent

Uptake of fluorescein isothiocynate-dextran (FITC-dextran) by Chinese hamster ovary cells was studied after exposure to ultrasonic standing wave (USW) in presence of Optison, an ultrasound contrast agent. Confluent Chinese hamster ovary cells were harvested and suspended in phosphate-buffered saline + 0.1% bovine serum albumin containing FITC-dextran (10, 40, and 500 kDa) at 10 microM final concentration. The suspension was seeded with contrast agent (75 microL/mL) and exposed to a 1.5 MHz USW system at acoustic pressures ranging from 0.98 to 4.2 MPa. Macromolecular uptake was assessed by fluorescent microscopy and quantified by flow cytometry 10 min after exposure. FITC-dextran positive cells, as assessed by flow cytometry, were 1 +/- 0.05% and 2.58 +/- 0.27% for acoustic pressures of 1.96 and 4.2 MPa, respectively (p = 0.006). Fluorescent microscopy indicated a degree of macromolecular loading at 0.98 MPa with 46% of peripherally FITC-dextran- and/or propidium iodide-stained cells coincident with the appearance of significant frequency (f0/2 and 2 f0) emission signals. At higher pressures, high macromolecular loading with 6% peripherally stained cells at 1.96 MPa was associated with lower order emission signals and white noise. The study conclusively demonstrates macromolecular loading in an USW, a significantly higher macromolecular loading at higher pressures and indicates potential of emission signals for a feedback loop to control the acoustic power outputs and fine-tune the biologic effects associated with sonoporation.

Telomere instability in the male germline

Telomeres play a key role in upholding the integrity of the genome, and telomerase expression in spermatogonial stem cells is responsible for the maintenance of telomere length in the human male germline. We have previously described extensive allelic variation in somatic cell telomere length that is set in the zygote, the ultimate source of which may be the germline. This implies that despite telomerase activity, substantial telomere length variation can be generated and tolerated in the germline; in order to investigate this further, we have examined the nature of telomere length variation in the human male germline. Here, we describe an analysis of both genome-wide telomere length and single molecule analysis of specific chromosome ends in human sperm. We observed individual specific differences in genome-wide telomere length. This variation may result from genetic differences within the components that determine the telomere length setting of each individual. Superimposed on the genome wide telomere length setting was a stochastic component of variation that generates germ-cells containing severely truncated telomeres. If not re-lengthened during early embryogenesis, such telomeres may limit the replicative capacity of cells derived from the zygote and have the potential to create fusagenic chromosomes, unbalanced translocations and terminal micro-deletions. These data may have implications for the genetic determination of ageing, genetic disease and fertility.

The role and applications of ultrasound in ambulatory gynaecology

Ultrasound has changed gynaecological practice and continues to do so. One of the earliest applications of abdominal scanning in gynaecology was for monitoring follicular development during fertility treatment with clomiphene citrate or gonadotrophins in the 1960s and 1970s. Subsequently, it was natural that with the introduction of in vitro fertilization, abdominal and transvaginal ultrasound played a key role in the development of oocyte retrieval techniques. These were truly the first interventional ultrasound-guided ambulatory procedures in gynaecology. In this chapter, the reader will be introduced to the roles that the various ultrasound modalities play in our current daily practice, and how they have changed the management of numerous gynaecological conditions in both diagnostic and therapeutic contexts. We will also outline the recent developments and the 'hot' research topics in this field.

Cavitation bubble-driven cell and particle behavior in an ultrasound standing wave

The behavior of human erythrocytes and 1-microm-diameter fluorescent latex beads in the presence of Optison contrast agent in a single half-wavelength (lambda/2) ultrasound standing wave (USSW) resonator has been studied. The particle movements were observed with an epi-fluorescent microscope and the velocity of the particles and cells was measured by particle image velocimetry (PIV). Acoustic emissions were monitored with a microphone and a spectrum analyzer. Optison contrast agent disintegrated immediately on exposure to ultrasound of 0.98-MPa acoustic pressure amplitude or higher in a chamber driven at its resonance frequency of 1.56 MHz. A discrete cloud of active microbubbles, detected at the pressure node plane, disappeared gradually and was completely lost within 15 s. The microscopy showed three-dimensional regions of circulation of both 1-microm tracer particles and erythrocytes in planes perpendicular to the pressure node plane. A numerical simulation showed that, for parameters that conform to the experimental conditions, a bubble of a subresonance size moves towards and translates about a pressure node plane. This result is in agreement with the experimental observation that the particle and cell circulation is induced by the presence and/or translational motion of microbubbles at the pressure node plane.

Value of the serum estradiol level for preventing ovarian hyperstimulation syndrome: a retrospective case control study

OBJECTIVE

To assess the value of different serum E(2) cut-off levels for predicting women at risk for ovarian hyperstimulation syndrome (OHSS).

DESIGN

Retrospective case-control study of a cohort of women undergoing assisted reproduction treatment (ART) over 12 months.

SETTING

Tertiary university hospital.

PATIENT(S)

The study group included women with OHSS who fulfilled the endocrine inclusion criteria (n = 40). The control group was a random sample (n = 40) from the cohort of women undergoing ART.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

To evaluate the sensitivity and specificity of different serum E(2) cut-off levels on day 11 of ovarian stimulation in preventing the establishment of OHSS.

RESULT(S)

Three hundred ninety-nine cycles (IVF and intracytoplasmic sperm injection) were undertaken between June 2000 and May 2001. The study group (n = 40) was compared with the control group (n = 40) undergoing ART during the same period of time. On day 8 of ovarian stimulation, the mean (SD) E(2) level in the study group was 8,517(5.3) pmol/L (2,320 pg/mL), and in the control group it was 2,540 (2.6) pmol/L (691 pg/mL). On day 11 of stimulation the mean (SD) E(2) level was 15,662 (4.2) pmol/L (4,266 pg/mL) and 5,804 (4.5) pmol/L (1,581 pg/mL), respectively. Twenty-four (60%) women who developed OHSS had E(2)levels >6,000 pmol/L (1,634 pg/mL) on day 8 and above 11,000 pmol/L (2,996 pg/mL) on day 11. Sixteen (40%) had E(2) levels <6,000 pmol/L (1,634 pg/mL) on day 8, but all had levels above 11,000 pmol/l (2,996 pg/mL) on day 11.

CONCLUSION(S)

A serum E(2) level of 12,315 pmol/L (3,354 pg/mL) on day 11 of ovarian stimulation gives a sensitivity and specificity of 85% for the detection of women at risk for OHSS.

A Modified OSCE Assessing the Assimilation and Application of Ethical Principles Relevant to Obstetric and Gynaecological Practice

OBJECTIVE

To develop and evaluate a modified OSCE assessing the assimilation and application of a range of ethical principles relevant to Obstetric and Gynecological practice.

SETTING

Candidates for an SpR training rotation Methods. Twenty six candidates working in Obstetrics and Gynecology were presented with four questions covering a range of relevant ethical scenarios. Their responses were assessed using a marking schedule. The marking schedule was evaluated against a checklist developed for assessing postgraduate medical examinations. Inter-rater reliability was assessed by calculating Kappa values for each question. The items in the marking schedule were also assessed to determine the level of agreement between the two examiners. To assess the contribution of each question to the total score, the question to total score correlations were calculated. The discriminatory capacity of each question was also assessed.

RESULTS

The development of the examination met almost all of the criteria in the checklist for developing a postgraduate examination. Inter-rater reliability was reasonable (4 weighted Kappas ranged from 0.53 - 0.75). There was a high level of agreement between examiners as to whether a candidate had answered an item on the marking schedule correctly. The degree of discrimination of items in the marking schedule was consistent with clinical opinion on the importance of questions.

CONCLUSION

This modified OSCE examination demonstrates the feasibility of testing ethical principles relevant to practice in Obstetrics and Gynecology in candidates for postgraduate posts. It meets most of the criteria laid down in a checklist developed to assess postgraduate medical examinations.

Spontaneous multiple pregnancy after uterine artery embolization for uterine fibroid: case report

Uterine artery embolization (UAE) is an effective non-surgical treatment for uterine myomas. Effects on fertility preservation are still under investigation. Various complications have been reported as well as few pregnancies. We report a case of spontaneous twins pregnancy following UAE in a woman who desired to preserve fertility.

Contrast agent bubble and erythrocyte behavior in a 1.5-MHz standing ultrasound wave

Human erythrocytes and Optison contrast agent have been exposed to ultrasound, both alone and in combination, in a single-half-wavelength chamber driven at its resonance frequency (fo) of 1.5 MHz. Cell movements were recorded by video microscopy at speeds up to 500 frames/s. The hypothesis that cells near a standing wave pressure node might be stressed by the microbubble products of sonicated contrast agent was examined. In the absence of contrast agent, cells moved rapidly to form an aggregate in the standing wave pressure node plane. First subharmonic and second harmonic emissions were detected from cell-contrast agent suspensions immediately on exposure to a threshold peak pressure amplitude of 0.98 MPa. Emissions at 3fo/2 occurred at 1.47 MPa, whereas white noise and lower-order subharmonic emissions coincided with the appearance of visible bubbles at a threshold of approximately 1.96 MPa. Cells exposed together with contrast agent at a pressure of 0.98 MPa precessed very rapidly about the pressure node plane. This behavior was discussed in the context of a recent analysis predicting that, in contrast to the situation for lower-pressure amplitudes, subresonant size bubbles translate about pressure node plane if the driving pressure amplitude is sufficiently high. Many precessing erythrocytes were clearly spiculated and this morphology persisted after the cells had left the area of precession. Hemoglobin release was significant under conditions inducing precession with first subharmonic and first harmonic emissions. Protein release increased discontinuously near the pressure thresholds, where more complex categories of frequency emission were detected. The potential of this system, which induces erythrocyte morphology changes and some protein release at the first emission threshold, to provide some control on the membrane-permeabilizing stress experienced by cells in a cavitation field is discussed.

Spontaneous expulsion of three large fibroids after uterine artery embolization

OBJECTIVE

To report a case of uneventful expulsion of huge fibroids after uterine artery embolization. Case report.

SETTING

The Department of Obstetrics and Gynaecology of a university hospital.

PATIENT(S)

A 45-year-old woman who underwent uterine artery embolization for fibroids.

INTERVENTION(S)

Transfemoral selective bilateral uterine artery catheterization and injection of 500-700 microm polyvinyl alcohol particles.

RESULT(S)

Recovery of the patient. The spontaneous expulsion of three fibroids on three different occasions over several months resulted in a significant reduction in menstrual loss and dysmenorrhea.

CONCLUSION(S)

Delivering fibroids or sections of fibroids may be a natural process after uterine artery embolization, therefore it is essential to warn women about the possible risk. Close follow-up is also essential. The size of the fibroids discharged did not require hysterectomy. Adequate antibiotic cover may be necessary to prevent sepsis.

Uterine endometrial thermal balloon therapy for the treatment of menorrhagia: long-term multicentre follow-up study

BACKGROUND

Initial reports from observational and randomized trials of uterine endometrial thermal balloon therapy (UBT) suggested good results as judged by return to eumenorrhoea or less and patient satisfaction. Long-term follow-up data remained limited by the small numbers of patients and duration of follow-up. We present long-term (4-6 years) follow-up data from a cohort of women previously treated with UBT for menorrhagia.

METHODS

Of the 260 questionnaires sent to women eligible for long-term follow-up from 10 centres, 188 (72%) replies were received. The primary outcome measure was avoidance of hysterectomy.

RESULTS

In women who responded to the questionnaire, 25 had undergone hysterectomy and 21 had had repeat ablation. At 4-6 years after UBT, the probability of avoiding hysterectomy was 86% of all women, and of avoiding re-ablation was 88% of non-hysterectomized women. Overall, the probability of avoiding any surgery was 75%. Women with an axial or retroverted uterus were at greater risk of hysterectomy or re-ablation. Among the participants, 47% of the non-hysterectomized women were amenorrhoeic, 30% were hypomenorrhoeic, 13.6% were eumenorrhoeic and 8.5% had heavy periods.

CONCLUSIONS

This is the first long-term follow-up report of a second-generation endometrial ablation procedure and confirms our initial experience. The high rate of hysterectomy avoidance over 5 years or more is very encouraging for this technology.

Embryo freezing for preventing ovarian hyperstimulation syndrome: a Cochrane review

This paper is based on a Cochrane review published in The Cochrane Library, issue 3, 2002 (see www.CochraneLibrary.net for information) with permission from The Cochrane Collaboration and Update Software. Cochrane reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and The Cochrane Library should be consulted for the most recent version of the review.

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic condition resulting from an excessive ovarian response to superovulation medication. The objective of this review was to evaluate the effectiveness of cryopreservation (embryo freezing) when compared with human i.v. albumin infusion and with fresh embryo transfer for the prevention of OHSS.

METHODS

This was based on a Cochrane Review. Randomized controlled trials in which either human i.v. albumin or cryopreservation of all embryos was used as a therapeutic approach to OHSS were included. The participants were women down-regulated by GnRH agonist, undergoing superovulation in IVF/ICSI cycles. The interventions compared were cryopreservation versus i.v. human albumin administration and elective cryopreservation of all embryos versus fresh embryo transfer. The primary outcomes were: incidence of moderate and severe OHSS versus nil/mild OHSS, and clinical pregnancies/woman. Statistical analysis was performed in accordance with the Cochrane Menstrual Disorders and Subfertility Group guidelines.

RESULTS

Seventeen studies were identified, two of which met our inclusion criteria. One study was included where cryopreservation was compared with i.v. human albumin administration and another where elective cryopreservation of all embryos was compared with fresh embryo transfer. In both interventions no difference was found in all the outcomes examined between the two groups.

CONCLUSIONS

This review has shown that there is insufficient evidence to support routine cryopreservation and insufficient evidence for the relative merits of i.v. albumin versus cryopreservation.

Observational case reports of intra- and postoperative ultrasound monitoring of uterine balloon ablation

Uterine balloon ablation (UBT) is an established treatment of women with menorrhagia. Success rates in terms of amenorrhoea following UBT vary between about 15 and 40%. The aim of these case reports was to attempt to explain some of the reasons behind the low amenorrhoea rate as well as the variation seen in outcome. This was facilitated by intraoperative ultrasound observation of the position of the heater element within the uterine cavity, including its proximity to the endometrial walls and the direction of microbubbles produced by the heater element. These findings were then correlated with postoperative ultrasound findings and clinical outcome. The position of the balloon catheter within the uterine cavity varied and we hypothesise that this may have an effect on outcome. A thin postoperative endometrium on ultrasound signifies successful ablation, yet is not always associated with a cessation of troublesome menorrhagia, nor patient satisfaction.

Quantification of power Doppler energy and its future potential

OBJECTIVE

To test a new software package (Color Quantifier, Kinetic Imaging, Liverpool, United Kingdom) that quantifies power Doppler energy and to determine its reproducibility.

DESIGN

Intraobserver and interobserver reproducibility study.

SETTING

University tertiary referral center.

PATIENT(S)

Transvaginal power Doppler ultrasound images were recorded from women taking part in a study evaluating the physiological vascular changes in the uterus and ovaries during the normal menstrual cycle.

INTERVENTION(S)

Nineteen consecutive frames of regions of interest in the uterus, ovary, and follicle, respectively, were analyzed by each of four observers on 10 occasions.

MAIN OUTCOME MEASURE(S)

Analysis of variance to determine the image and observer effect as well as the intraobserver and interobserver coefficients of variation.

RESULT(S)

Significant image and observer effects were found. However, the image effect was by far the largest component of the total variation. The large image-to-image variability was expected because the cardiac cycle was included within the 19 frames (images) analyzed. The combined intraobserver and interobserver variation, expressed as the coefficients of variation, was found to be small for the above indices (as low as 1.9%), particularly for total ovary and endometrium.

CONCLUSION(S)

The indices obtained with this color quantification software are reproducible in an in vitro setting using prerecorded images. Its applicability as a useful assay in the clinical setting requires further evaluation.

Uterine thermal balloon therapy for the treatment of menorrhagia: the first 300 patients from a multi-centre study. International Collaborative Uterine Thermal Balloon Working Group

OBJECTIVE

To evaluate the safety and efficacy of thermal balloon therapy for menorrhagia.

DESIGN

Prospective, observational study.

SETTING

Fifteen centres in Canada and Europe.

POPULATION

Two hundred and ninety-six eligible women for whom follow up data were available for three months or more. Eligible women included those for whom further fertility was not a concern, were not postmenopausal, suffered from intractable menorrhagia, had a normal uterine cavity, and who were fully informed regarding the investigational nature of uterine thermal balloon therapy.

METHODS

Three hundred and twenty-one procedures of balloon endometrial ablation were performed using the same protocol between June 1994 and August 1996. Exclusion criteria included structural uterine abnormality or (pre) malignant lesions. Treatment entailed controlled heating of fluid in an intrauterine balloon. General anaesthesia was employed in the 61% of procedures while local anaesthesia with or without sedation was used in 39% of cases.

ANALYSIS

Follow up data at 3 and/or 6, and/or 12 months were required for inclusion in the analysis. A paired t test, Wilcoxon signed-ranks test, and multiple and logistic regression analyses were used to evaluate the changes in bleeding and dysmenorrhoea patterns, and possible confounding variables, respectively. Success was defined as the subjective reduction of menses to eumenorrhoea or less.

RESULTS

No intra-operative complications occurred, and post-operative morbidity was minimal. Success of the procedure was constant over the year (range 88%-91%). Treatment led to a significant decrease in the duration of menstrual flow and severity of pain (P < 0.0001). Increasing age, higher balloon pressure, smaller uterine cavity, and a lesser degree of pre-procedure menorrhagia were associated with significantly improved results. Pre-treatment with gonadotrophin releasing hormone agonists increased amenorrhoea and spotting rates (P = 0.03), but was only used in 5% of cases.

CONCLUSION

Thermal balloon endometrial ablation appears to be safe, as well as effective in properly selected women with menorrhagia and is potentially an outpatient procedure.

Morphology and ultrastructure of fallopian tube epithelium at different stages of the menstrual cycle and menopause

The Fallopian tube has been reported to undergo cyclical changes. However, many studies of tubal ultrastructure have either examined one segment of the tube only or studied animal oviducts. The aim of this study was to document in detail the combined morphological and ultrastructural features of the epithelial lining along the length of the tube in women at different stages of the menstrual cycle. We report an increase in the proportion of ciliated cells along the tube, being highest in the fimbriae, but no substantial difference between the follicular and luteal phases of the menstrual cycle. In the late follicular phase, fragments of cytoplasmic and cellular material were seen in the isthmic lumen but not in the outer tubal segments. Similarly, surface domes and secretory granules were more prominent in the mid-tube and ampullary sections than in the fimbriae. This surface activity was followed by relative quiescence in the early/mid luteal phase with reversion to a more active surface but with little secretory activity in the late luteal phase. These findings along the Fallopian tube substantiate the concept of functional differentiation between the different segments and necessitate further studies to determine its clinical relevance.

A comparative morphological and ultrastructural study of endometrial gland and fallopian tube epithelia at different stages of the menstrual cycle and the menopause

Cyclical ultrastructural changes in the endometrium and Fallopian tube have been reported previously but in different subjects. The aim of this study is to compare cyclical changes in endometrial gland and tubal (isthmic, mid-tube, ampulla, and fimbria) epithelia in the same subjects with a view to identifying any similarities or differences which may have clinical implications for assisted reproduction treatment. Endometrial and Fallopian tube samples were obtained from women undergoing hysterectomy and salpingectomy. We report similar epithelial surface changes taking place in the endometrial glandular and endosalpingeal epithelia with the exception of the fimbriae. Secretions within endometrial gland lumen and the isthmus increase throughout the late follicular phase and before ovulation, then dissipate in these two regions simultaneously in the early/mid luteal phase. Similarly, in the late follicular and pre-ovulatory phases, the process of granule secretion is similar in the glandular epithelium, isthmus and ampulla. In the fimbriae, no comparable activity is noted during these phases of the menstrual cycle. The differences reflect the functional differentiation between these regions. Equally, the observed similarities highlight the need for further comparative studies to determine the role of these secretions in early embryonic development and their clinical relevance.

Comparative immunohistochemical study of oestrogen and progesterone receptors in the fallopian tube and uterus at different stages of the menstrual cycle and the menopause

Oestrogen and progesterone are known to require their corresponding steroid receptors to manifest structural and functional effects in the Fallopian tube, uterus and other target organs. This study compares cyclical variations of these receptors in the uterus and in different segments of the Fallopian tube in the same subjects using an immunocytochemical technique. The results show that in the Fallopian tube, isthmic and ampullary epithelial and stromal oestrogen receptors increased in the follicular phase to a peak at mid cycle and then declined in the late luteal phase. The intensity of immunostaining of oestrogen receptors was less in the Fallopian tube than in endometrial glandular epithelium. The fimbrial end demonstrated an opposite pattern of staining to other segments of the tube. Progesterone receptor immunostaining was more intense than that for oestrogen receptors in the follicular phase, and, whereas it disappeared completely from the endometrial glandular epithelium in the late luteal phase, positive staining was clearly visualized in the tubal epithelium and stroma and endometrial stroma at this stage of the menstrual cycle. These differences in the steroid receptor content may reflect the changing and different functional roles of these regions and may have important implications on human reproduction.

A critical appraisal of assisted reproduction techniques

Several treatments for infertility have been promoted with only little supporting objective data demonstrating their therapeutic value. The choice of an assisted reproductive technique depends on a balance between numerous factors. Seldom is the choice absolute as in patients with tubal block. There is conflicting evidence on the efficacy of simpler methods such as ovarian stimulation with or without artificial insemination and the available data suggest that the more invasive methods such as gamete intra-Fallopian transfer or in-vitro fertilization are more effective in the treatment of couples with unexplained infertility. Equally, there is no conclusive evidence that pregnancy rates with any of the invasive techniques are superior to any others. However, a higher implantation rate following tubal embryo transfers is observed in many studies. This review presents a critical assessment of the effectiveness of assisted reproductive techniques.

The management of predicted ovarian hyperstimulation involving gonadotropin-releasing hormone analog with elective cryopreservation of all pre-embryos

Severe ovarian hyperstimulation syndrome complicates up to 6% of IVF treatment cycles. We have utilized our pre-embryo cryopreservation program to manage incipient ovarian hyperstimulation syndrome in an alternative way. Four women, who were at risk of developing ovarian hyperstimulation syndrome, underwent oocyte retrieval, but not embryo replacement. Instead, resulting pre-embryos were cryopreserved for future transfer. The four patients have since become pregnant. Three conceived after thawed embryo replacement cycles, and the fourth conceived spontaneously 1 month after the stimulation cycle. This approach offers maximum flexibility in the management of ovarian hyperstimulation syndrome.