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Tension-free mid-urethral tapes have become the fashionable surgical treatment of stress urinary incontinence. These measures deal with the mechanical causes of stress, but a new approach focussing on the physiology of the urethral sphincter is now reported. The underlying principle is as follows: Continence is mainly controlled by the urethral sphincter complex, which in turn is dependent on smooth and striated muscle tone and supportive structures. The role of the striated sphincter, the rhabdosphincter, has received little attention, despite the fact that it forms a muscular coat that surrounds the urethra ventrally and laterally. Its function can be impaired by birth trauma, surgical injury, anatomical displacement and age. Injecting myoblasts derived from the woman’s own muscles has been an effective treatment of damaged muscles in other body tissues, such as the myocardium, so the concept of using a woman’s own cells to reinforce the urethral sphincter has physiological precedent. Taking muscle and fibre cells from the woman’s arm, growing them in culture and injecting them back into the rhabdosphincter is theoretically feasible, and the first report from an Austrian group’s research has been published (Strauss et al., Lancet 2007;369:2179–86). The technique is sophisticated using autologous myoblasts and fibroblasts prepared in cell culture, then injecting them transurethrally into the rhabdosphincter under ultrasonic guidance. These new cells regenerate the sphincter and combat atrophy of the urethral submucosa, allowing the normal mechanisms of continence to be restored. In the trial reported, 42 women received the cultured cell injections and another 21 were injected with collagen, which has a minor place in incontinence therapy. After 1 year, 90% of those receiving the cell injections were cured, that is they had no incontinence subjectively or objectively, whereas only 9% of those receiving collagen were cured. Contractility and mucosal thickness were also statistically significantly improved, as were the quality-of-life scores. After 3 years, there was no serious adverse effects, and the continence levels were maintained. It remains to be seen whether this method will be a long-term cure and whether it could be used in tandem with reconstructive surgery. It certainly is a novel approach with impressive early results, which could herald a new era in Urogynaecology. In developed countries, at least 1% of all conceptions are assisted. The highest prevalences are in Scandinavian countries, which have also led the way in policing standards, for example by mandating single embryo transfers and long-term outcomes follow up. One of the concerns of assisted reproduction technique is the genetic quality of embryos implanted. Because couples are, by definition, subfertile and often older, the risk of transmitting a genetic abnormality is higher than in the general population. One way of checking for defects is to carry out preimplantation screening of embryos. This is performed when the embryos are at the cleavage stage of development, when one or two cells are removed and tested for single-gene defects, using polymerase chain reactions, or for chromosomal abnormalities using fluorescence in situ hybridisation. These techniques prevent the implantation of genetically abnormal embryos and are used when abnormalities are more likely, such as carrier parents or in women aged 35-plus years. In general, in vitro fertilisation (IVF) results in these older women are disappointing, and preimplantation screening could be a means of improving results in this group by testing embryos and only implanting the genetically ‘normal ones’. This should theoretically improve success rates, but evidence for this has been lacking till now. Mastenbroek et al. from Holland (N Engl J Med 2007;357:9–17) monitored the outcome of IVF cycles when preimplantation screening was used, and when it was not. Intuitively, the screened embryos which are of lower genetic risk should produce more successful pregnancies, but the opposite was found. There were fewer continuing pregnancies in the screened group compared with the unscreened control group, causing the authors to counsel against preimplantation screening of embryos where maternal age is the primary indication. It is 30 years since the first successful assisted reproduction pregnancy and much needs to be discovered about its outcomes. The review by Sutcliffe and Ludwig (Lancet 2007;370:351–9) provides an excellent resume of assisted reproduction therapy. There are several conundrums about termination of pregnancy (TOP). The more developed a country, the more likely TOP is to be legal. The more liberal a country in terms of contraceptive availability and openness about sexual discussion, the lower the TOP rates. Conversely, the less developed a country, the greater the chance of TOP being illegal, unsafe and common, with the net result that TOP remains a major cause of maternal morbidity and mortality. Tolerance, be it moral, religious or legislative, are intrinsically linked to TOP. Places where women are stigmatised for seeking a TOP or where it is opposed on grounds of faith in divine beings, or where laws make it a crime, are the countries where women bear the brunt of unplanned pregnancies with unsafe terminations. The following figures make remarkable reading: Every year there are 210 million pregnancies in the world. One in five will end in an elective early termination. The vast majority (97%) of unsafe terminations will be carried out in developing countries. One hundred and thirty-seven million women worldwide want, but lack access to, contraception. In developed regions, such as Europe, safe TOP is available, and in the UK, there are moves to make TOP requests less complex to administer, so they can be performed earlier. However, restrictions remain on where the termination can be performed and who is in charge (Kmietowicz, BMJ 2007;335:14). At the other end of the spectrum, some countries make TOP a crime, even if the mother’s life is in danger—Chile, Honduras, El Salvador, Nicaragua and The Vatican being examples. Some have draconian laws with prison sentences of 4–6 years for women and doctors procuring TOP. Latin America is considered an emerging region, and this status is reflected in its varied stances on contraceptive use and TOP. Mexico City has recently passed laws legalising TOP up to 12 weeks of gestation. Colombia has recently relaxed its restrictions slightly, while Nicaragua has gone the other way, passing legislation outlawing TOP under any circumstances. Brazil is in flux. Pope Benedict on a recent visit said politicians who supported TOP laws should be excommunicated, which did little to solve the problem, so a national referendum is planned. No date has been set, and since Brazil has the largest Roman Catholic population in South America, it will undoubtedly be a hot topic (Replogle, Lancet 2007;370:305–6). Portugal—its former coloniser and with a similar religious demography—voted to legalise TOP up to 10 weeks of gestation in February this year. But still the most vulnerable remain the most at risk. Kenya, where TOP is legal only to save the mother’s life, has 300 000 unsafe TOPs per year, accounting for 50% of that country’s maternal mortality. The Millennium Goal to massively reduce maternal mortality by 2015 needs funds for population control and part of every successful family planning strategy in the past has been access to legal and safe TOP. TOP should be legal, safe and rarely needed. Supplementing a woman’s diet with folic acid reduces her chances of having a child with a neural tube defect. This has been shown in experimental and observational studies, and for the last 15 years, all women have been encouraged to take folate periconceptually. But this message has failed to have the desired effect, even in developed countries, so foodstuff fortification has been implemented by adding folic acid to staple foods such as flour, corn meal and pasta by the milling industry. In the case of Canada, this was a decade ago, so data are now available showing the effects of this national intervention. de Wals et al. (N Engl J Med 2007;357:135–42) report a halving of the incidence of neural tube defects following fortification. Dividing their results into regions, they noted that the largest reductions were in the previously worst affected area, and these reductions coincided with the years when fortification was introduced (around 1998). The figures for the whole of Canada dropped from 1.6 to 0.9 per 1000 births. No untoward adverse effects has been reported, so their results strengthen the argument for fortification policies or even more imaginative methods such as adding folic acid to oral contraceptive pills. A Dutch doctor has been struck off the medical register for treating a woman with breast cancer by ‘alternative’ care. An actor and comedian, Sylvia Millecam had a lump in her breast diagnosed as cancer. It was 3–4cm in diameter, but she did not want conventional treatment, so the doctor in question used magnetic field therapy and other alternative cures for 6 months, by which time the tumour had more than doubled in size. She died in less than a year from diagnosis. He argued that if he had insisted on standard oncological treatment, his patient would have been ‘lost’ to follow up. He kept inadequate notes and prevented her from having a mainstream medical opinion. He was originally suspended from the medical register for 6 months but appealed, only to be struck off for life (Sheldon, BMJ 2007;335:13). When obstetricians attend conferences—birth rates decline. This quirky piece of information has been unearthed by studying birth rates in Australia and the USA when these country’s national obstetric conferences are taking place. Dobson (BMJ 2007;335:66–7) quotes data showing a drop of up to 4% in deliveries in the 5 days around the conference dates, and this is reproducible over the past decade. Presumably, this is because these doctors plan routine inductions and elective caesarean sections so they can complete the care of their patients. Readers are at liberty to decide whether this constitutes good or bad practice. Yes, it seems a little is good for you. If you are middle-aged and have mild hypertension, then a piece of dark chocolate a day will lower your blood pressure. Taken over a few months, systolic pressure was reduced by 3 mmHg and diastolic by 2 mmHg in a small study from Germany (JAMA 2007;298:49–60). Technically, 6.3 g of dark chocolate contains 30 mg of polyphenols, which statistically raised plasma markers of nitric oxide and oxidative stress, which coincide with vasodilatation. Milk chocolate had no effect and the researchers are at great pains to point out that nobody in their study group gained weight. Good news for those who enjoy dark chocolate in moderation.

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