Editor's Choice

This issue is a first for the journal, one devoted to a theme, in this case Reproductive Medicine. It is not a supplement. It replaces our normal November issue. The articles have been peer reviewed in the normal way and have the same academic status as those in a conventional issue. We hope readers enjoy it and if the feedback is good there will be more. Advances in reproductive technology need to be both evaluated properly and used ethically. Pre-implantation genetic diagnosis (PGD) is currently used to screen embryos for a limited number of inherited conditions, but could be used for much wider embryo selection (pp. 1165–1173). Preliminary data indicate that it is probably safe and reliable, but long-term follow-up results are limited and any misdiagnosis might have devastating consequences. The authors emphasise the need to restrict PGD to medical purposes and to prevent its use for eugenic selection. In Finland (pp. 1229–1235) infertile and parous women both endorse the need for regulation despite having divergent views on access to fertility treatment. Allan Templeton explores some of the challenges faced by fertility specialists today (pp. 1161–1162), and argues that despite greater acceptance of public funding for infertility and the presence of treatment guidelines, we need a national framework for delivery. On page 1163 Cynthia Farquhar and Neil Johnson assess the evidence base. Some questions have been answered by systematic reviews but, for many more, there is little or no trial evidence. Nevertheless, even inconclusive reviews can guide research. Large trials have changed clinical practice in obstetrics. It is time for similar trials in infertility. On page 1174, Sacks and Trew question the presumed irrelevance of tubal surgery in the post IVF era and argue for surgery for minimal or mild tubal damage. IVF should be reserved for more severe cases. They also highlight the absence of a universally agreed system for classifying tubal disease. The advantage of such a classification is demonstrated by Akande and colleagues (pp. 1236–1241) in a prospective study of women with objectively assessed tubal status. In comparison with women with severe tubal disease, the odds (95% CI) of live birth in cases of mild and moderate tubal disease are 14 (4.5–42) and 6.5 (2.5–17) respectively. The wide confidence intervals reflect the relatively small sample size, but the predictive value of this form of tubal evaluation is not in doubt. Tubal function is the indirect focus of two more papers. In a case-control study from Mexico (pp. 1254–1260), there was no association between abortion and tubal infertility and in a study from Scotland, (pp. 1261–1268) opportunistic screening of women for Chlamydia trachomatis to prevent complications such as pelvic inflammatory disease, appears to produce no net cost savings. The best way to treat pelvic endometriosis continues to provoke debate. A survey of U.K. consultants, (pp. 1269–1272) reveals that although they routinely undertake laparoscopic diagnosis and surgery, their techniques and clinical beliefs vary widely. The majority (76%) felt that they could confidently diagnose endometriosis, but this confidence is not shared by the authors of a systematic review of the accuracy of laparoscopy (pp. 1204–1212). Despite the poor quality of the studies in the review, it seems clear that a negative diagnosis of endometriosis is accurate, but a positive diagnosis is of limited value. This has serious consequences given the potential for morbidity associated with unnecessary medical and surgical treatment. In a separate review, Vercellini and colleagues (pp. 1213–1217) show that, like other types of endometriosis, lower intestinal disease is more likely to occur on the left side. This finding supports the implantation theory of aetiology. On page 1294, Walker and colleagues report on the maternal risks of multiple pregnancy. Analysis of data from a large Canadian database shows a significant increase in obstetric complications, including a two-fold rise in the risk of maternal death. The growing number of multiple pregnancies in many countries can be directly attributed to fertility treatment involving stimulation of multiple ovarian follicles. In IVF, the risk can be minimised by transferring fewer embryos, but superovulation poses a greater challenge. A paper from France (pp. 1277–1282) reports on results of a less aggressive regimen of ovarian stimulation using lower doses of gonadotrophins. Used in conjunction with intra-uterine insemination, live birth rates of 21% per woman were achieved with a multiple pregnancy rate of less than 10%. Despite its observational nature and the absence of a control group, this study shows that a commitment to ensure patient safety is compatible with acceptable rates of success.

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