299
Relaxin cannot match the clinical utility of the head of the family, insulin, but its occurrence as a systemic and local hormone in the reproductive cycle of women warrants further study. Department of Pathology, Washington University School of Medicine, Barnes Hospital, St Louis, Missouri
GWEN MAZOUJIAN
Department of Anatomy and Reproductive Biology, John A Burns School of Medicine, University of Hawaii, Honolulu, Hawaii 96822, USA
GILLIAN D. BRYANT-GREENWOOD
1. Hisaw FL.
Experimental relaxation of the pubic ligament of the guinea pig. Proc Soc Exp Biol Med 1926; 23: 661-63. James R, Niall H, Kwok SC, Bryant-Greenwood GD. Primary structure of porcine relaxin: homology with insulin and related growth factors. Nature 1977; 267:
2
544-46.
Koay ESC, Bryant-Greenwood GD, Yamamoto S, Greenwood FC. The human fetal membranes: a target tissue for relaxm. J Clin Endocrinol Metab 1986; 62: 513-21. 4. Nardi E, Bigazzi M, Agrimonti F, et al. Relaxin and fibrocystic disease of the mammary gland. In: Bigazzi M, Greenwood FC, Gasparri F, eds. Biology of relaxin and its role in the human. Amsterdam: Excerpta Medica, 1983. 417-19. 5. Peaker M, Taylor E, Tashima L, Redman TL, Greenwood FC, Bryant-Greenwood GD. Relaxin detected by immunocytochemistry and northern analysis in the mammary gland of the guinea pig. Endocrinology 1989; 125: 693-98. 6 Boyd S, Kendall JZ, Mento N, Bryant-Greenwood GD. Relaxin immunoactivity in plasma during the reproductive cycle of the female guinea pig. Biol Reprod 1981; 24: 3.
405-14. 7.
8.
Koay ESC, Bagnell CA, Bryant-Greenwood GD, Lord SB, Cruz AC, Larkin LH. Immunocytochemical localization of relaxin in human decidua and placenta. J Clin Endocrinol Metab 1985; 60: 859-63. Sakbun V, Ali SM, Greenwood FC, Bryant-Greenwood GD. Human relaxin in the amnion, chorion, decidua parietalis, basal plate and placental trophoblast by immunocytochemistry and northern analysis. J Clin Endocrinol Metab (in press).
False alarms of breast
cancer
SIR,-Dr Devitt (Nov 25, p 1257) reports that 87% of signs and symptoms of breast cancer were false alarms, and that only 8% of 224 accidentally found breast cancers were associated with pain. We have recently reviewed referrals for mammograms, in women with symptoms 18 months before and after the start of the current breast screening programme in Camberwell (south-east London). There has been a 42% increase in such referrals since the start of screening. Most of these referrals were from a menopause clinic and general practitioners. Patients referred from the clinic had routine mammograms before hormone replacement therapy. We therefore examined referrals from general practitioners. Most were for pain, a lump or nodularity, and other reasons such as family history. In about 50% of patients referred with a lump, positive mammograph findings were reported; however, in only 4-4% of patients referred for pain, nodularity, or another reason were mammograms reported as showing changes suspicious of malignancy needing further evaluation such as magnified views, ultrasonography, or biopsy. These findings are in accord with those of Devitt. We believe that a better understanding of the signs and symptoms of breast cancer would reduce the number of referrals for unnecessary mammograms and appointments to already stretched breast clinics. Department of Surgery, Rayne Institute, London SE5 9NU, UK
Conception
W. I. H. GARSTIN Z. KAUFMAN M. BAUM
rates and in-vitro fertilisation
SIR,-It has been argued that infertility is a social issue rather than a disease, that in-vitro fertilisation (IVF) is not all that successful, and that resources should be applied to the prevention of infertility.l,2 However, no-one has come up with an effective programme for the prevention of infertility. Disease or social problem, infertility is referred to doctors and it affects 10-15% of all married couples in the reproductive age group, making it one of the most common conditions encountered in clinical practice. We contend that IVF is an essential technique in the management of infertility-indeed it is the treatment of choice for infertility due to severe tubal damage.3 Wagner and St Clair1,2 lament the lack of randomised trials to ascertain the efficacy of IVF, but this is not a valid point because, for
Cumulative conception rate in 4777 IVF cycles classified and in the normal population. a 25-29, b= 30-34, c = 35-38, and d = IVF cycles n=normal population in UK. =
most
by age
39 years old, for women
on
indicators, IVF is advocated only when conventional
have failed. The argument that not all clinics are alike and that success rates depend on the skills of the practitioners applies to many surgical disciplines other than IVF. In our view success rates with any infertility therapy are best related to the cumulative conception rate (CCR) after specified periods of treatment. One does not judge the success of ovulation induction or donor insemination for male infertility by the pregnancy rate after one cycle of therapy. The figure shows the CCR (only clinical pregnancies included) in over 2500 couples undergoing almost 4800 consecutive IVF cycles.The success of IVF is immediately apparent when the CCR is compared with that seen in the normal population in the UK, assuming normal cohabitation and no coital problems.sUnfortunately, success in IVF programmes is diluted because of the high proportion of older women who seek treatment. This mirrors the situation in the normal population. For example, the fecundability (monthly probability of pregnancy when the opportunity for pregnancy exists) in women having artificial insemination with donor semen is 0’ 11 if the women are aged 25 years but is only 0-065 if the women are aged 35.6 No-one suggests that IVF is of benefit to all infertility patients but it is no longer an experimental procedure. Faced with an infertile couple doctors must try their best to help, and frequently IVF is the only realistic solution. treatments
.
Hallam Medical Centre, London W1 N 1AF, UK, King’s College School of Medicine and Dentistry, London SE5, and Royal Postgraduate Medical School, London
S. L. TAN C. STEER P. ROYSTON P. RIZK B. A. MASON S. CAMPBELL
Wagner MG, St Clair PA. Are in-vitro fertilisation and embryo transfer of benefit to all? Lancet 1989; ii: 1027. 2. St Clair PA, Wagner MG Benefits of in-vitro fertilisation. Lancet 1989; ii: 1447. 3. Hull MGR, Glazener CMA, Kelly NJ, et al. Population study of causes, treatment, and outcome of infertility. Br Med J 1985; 291: 1693. 4. Tan SL, Mason BA, Royston P, et al. Cumulative conception rates in m-vitro fertilisation. Proceedings of the XIIth Asian and Oceanic Congress of Obstetrics and Gynaecology (Taipei, 1989). 5. Cooke ID, Sulaiman RA, Lenton EA, Parsons RJ. Fertility and infertility statistics: their importance and application. Clin Obstet Gynaecol 1981; 8: 531. 6. Jansen RPS Fertility in older women. IPPF Med Bull 1984; 18: 2 1.
Leishmaniasis
masking tuberculosis
p 1396) draws attention to the of tuberculosis after visceral leishmaniasis (VL). He suggests that tuberculosis lies latent and can be unmasked after treatment for VL or as a result of the functional abnormalities of kala-azar. However, we submit the opposite view-that tuberculosis occurred as a consequence of latent kala-azar.
SIR,-Dr Chaudhuri (Dec 9,
occurrence
Relaxin cannot match the clinical utility of the head of the family, insulin, but its occurrence as a systemic and local hormone in the reproductive cycle of women warrants further study. Department of Pathology, Washington University School of Medicine, Barnes Hospital, St Louis, Missouri
GWEN MAZOUJIAN
Department of Anatomy and Reproductive Biology, John A Burns School of Medicine, University of Hawaii, Honolulu, Hawaii 96822, USA
GILLIAN D. BRYANT-GREENWOOD
1. Hisaw FL.
Experimental relaxation of the pubic ligament of the guinea pig. Proc Soc Exp Biol Med 1926; 23: 661-63. James R, Niall H, Kwok SC, Bryant-Greenwood GD. Primary structure of porcine relaxin: homology with insulin and related growth factors. Nature 1977; 267:
2
544-46.
Koay ESC, Bryant-Greenwood GD, Yamamoto S, Greenwood FC. The human fetal membranes: a target tissue for relaxm. J Clin Endocrinol Metab 1986; 62: 513-21. 4. Nardi E, Bigazzi M, Agrimonti F, et al. Relaxin and fibrocystic disease of the mammary gland. In: Bigazzi M, Greenwood FC, Gasparri F, eds. Biology of relaxin and its role in the human. Amsterdam: Excerpta Medica, 1983. 417-19. 5. Peaker M, Taylor E, Tashima L, Redman TL, Greenwood FC, Bryant-Greenwood GD. Relaxin detected by immunocytochemistry and northern analysis in the mammary gland of the guinea pig. Endocrinology 1989; 125: 693-98. 6 Boyd S, Kendall JZ, Mento N, Bryant-Greenwood GD. Relaxin immunoactivity in plasma during the reproductive cycle of the female guinea pig. Biol Reprod 1981; 24: 3.
405-14. 7.
8.
Koay ESC, Bagnell CA, Bryant-Greenwood GD, Lord SB, Cruz AC, Larkin LH. Immunocytochemical localization of relaxin in human decidua and placenta. J Clin Endocrinol Metab 1985; 60: 859-63. Sakbun V, Ali SM, Greenwood FC, Bryant-Greenwood GD. Human relaxin in the amnion, chorion, decidua parietalis, basal plate and placental trophoblast by immunocytochemistry and northern analysis. J Clin Endocrinol Metab (in press).
False alarms of breast
cancer
SIR,-Dr Devitt (Nov 25, p 1257) reports that 87% of signs and symptoms of breast cancer were false alarms, and that only 8% of 224 accidentally found breast cancers were associated with pain. We have recently reviewed referrals for mammograms, in women with symptoms 18 months before and after the start of the current breast screening programme in Camberwell (south-east London). There has been a 42% increase in such referrals since the start of screening. Most of these referrals were from a menopause clinic and general practitioners. Patients referred from the clinic had routine mammograms before hormone replacement therapy. We therefore examined referrals from general practitioners. Most were for pain, a lump or nodularity, and other reasons such as family history. In about 50% of patients referred with a lump, positive mammograph findings were reported; however, in only 4-4% of patients referred for pain, nodularity, or another reason were mammograms reported as showing changes suspicious of malignancy needing further evaluation such as magnified views, ultrasonography, or biopsy. These findings are in accord with those of Devitt. We believe that a better understanding of the signs and symptoms of breast cancer would reduce the number of referrals for unnecessary mammograms and appointments to already stretched breast clinics. Department of Surgery, Rayne Institute, London SE5 9NU, UK
Conception
W. I. H. GARSTIN Z. KAUFMAN M. BAUM
rates and in-vitro fertilisation
SIR,-It has been argued that infertility is a social issue rather than a disease, that in-vitro fertilisation (IVF) is not all that successful, and that resources should be applied to the prevention of infertility.l,2 However, no-one has come up with an effective programme for the prevention of infertility. Disease or social problem, infertility is referred to doctors and it affects 10-15% of all married couples in the reproductive age group, making it one of the most common conditions encountered in clinical practice. We contend that IVF is an essential technique in the management of infertility-indeed it is the treatment of choice for infertility due to severe tubal damage.3 Wagner and St Clair1,2 lament the lack of randomised trials to ascertain the efficacy of IVF, but this is not a valid point because, for
Cumulative conception rate in 4777 IVF cycles classified and in the normal population. a 25-29, b= 30-34, c = 35-38, and d = IVF cycles n=normal population in UK. =
most
by age
39 years old, for women
on
indicators, IVF is advocated only when conventional
have failed. The argument that not all clinics are alike and that success rates depend on the skills of the practitioners applies to many surgical disciplines other than IVF. In our view success rates with any infertility therapy are best related to the cumulative conception rate (CCR) after specified periods of treatment. One does not judge the success of ovulation induction or donor insemination for male infertility by the pregnancy rate after one cycle of therapy. The figure shows the CCR (only clinical pregnancies included) in over 2500 couples undergoing almost 4800 consecutive IVF cycles.The success of IVF is immediately apparent when the CCR is compared with that seen in the normal population in the UK, assuming normal cohabitation and no coital problems.sUnfortunately, success in IVF programmes is diluted because of the high proportion of older women who seek treatment. This mirrors the situation in the normal population. For example, the fecundability (monthly probability of pregnancy when the opportunity for pregnancy exists) in women having artificial insemination with donor semen is 0’ 11 if the women are aged 25 years but is only 0-065 if the women are aged 35.6 No-one suggests that IVF is of benefit to all infertility patients but it is no longer an experimental procedure. Faced with an infertile couple doctors must try their best to help, and frequently IVF is the only realistic solution. treatments
.
Hallam Medical Centre, London W1 N 1AF, UK, King’s College School of Medicine and Dentistry, London SE5, and Royal Postgraduate Medical School, London
S. L. TAN C. STEER P. ROYSTON P. RIZK B. A. MASON S. CAMPBELL
Wagner MG, St Clair PA. Are in-vitro fertilisation and embryo transfer of benefit to all? Lancet 1989; ii: 1027. 2. St Clair PA, Wagner MG Benefits of in-vitro fertilisation. Lancet 1989; ii: 1447. 3. Hull MGR, Glazener CMA, Kelly NJ, et al. Population study of causes, treatment, and outcome of infertility. Br Med J 1985; 291: 1693. 4. Tan SL, Mason BA, Royston P, et al. Cumulative conception rates in m-vitro fertilisation. Proceedings of the XIIth Asian and Oceanic Congress of Obstetrics and Gynaecology (Taipei, 1989). 5. Cooke ID, Sulaiman RA, Lenton EA, Parsons RJ. Fertility and infertility statistics: their importance and application. Clin Obstet Gynaecol 1981; 8: 531. 6. Jansen RPS Fertility in older women. IPPF Med Bull 1984; 18: 2 1.
Leishmaniasis
masking tuberculosis
p 1396) draws attention to the of tuberculosis after visceral leishmaniasis (VL). He suggests that tuberculosis lies latent and can be unmasked after treatment for VL or as a result of the functional abnormalities of kala-azar. However, we submit the opposite view-that tuberculosis occurred as a consequence of latent kala-azar.
SIR,-Dr Chaudhuri (Dec 9,
occurrence
