[Sensible family planning: pitfalls and dilemmas]. / Verstandige gezinsplanning: valkuilen en dilemma's.

In a recent article in this journal it was stated that Dutch women were sensible in having their first child between the ages of 25 and 35 years. One of the conclusions was that associated health risks increase after the age of 35 but are still acceptable even at the age of 40. We demonstrate that these conclusions were based on flawed assumptions. Postponing pregnancy until after the age of 30 increases the risks of infertility and breast cancer. Motherhood at a later age is associated with an increase in obstetrical complications, miscarriage and other adverse effects on the child. Therefore, for couples planning a family with 2 children or more, it would be sensible to have the first pregnancy not long after the mother reaches the age of 30 years, or even earlier. Couples should be informed on the risks of late parenthood in order to be able to take the right decisions concerning family planning.

[Perinatal mortality in The Netherlands: an audit is now more necessary than ever]. / Perinatale sterfte in Nederland: audit dringend nodig.

In 1999, The Netherlands was found to have the highest perinatal mortality rate (11.4 per thousand), according to the WHO definition, in comparison with 14 other European countries. Many explanations were given, amounting essentially to a higher percentage of women with one or more risk factors (higher age at delivery, more non-western immigrants, and more multiple pregnancies). Furthermore, screening for congenital anomalies was not yet an issue at that time in The Netherlands. Finally, Dutch obstetricians and paediatricians have a restrictive policy regarding the treatment of newborns with a very poor prognosis. There are, however, also doubts about the quality of the delivered perinatal care. In an audit feasibility study in 2004 in a representative part of The Netherlands, it was found that in 9% of the cases of perinatal mortality, substandard care was (very) probably related to the mortality. In The Netherlands, a nationwide perinatal audit programme will start this year. The Netherlands, with its specific obstetric care system, has the obligation to look for the causes of perinatal mortality and to introduce improvements based on the results of a perinatal audit. Hasty conclusions are a threat to a careful audit.

[Obstetric care in The Netherlands under assessment again]. / De verloskundige zorg in Nederland opnieuw de maat genomen.

According to the Peristat II study, based on data from 2004, The Netherlands has almost the highest perinatal mortality rate in Europe. In 2006 perinatal mortality in The Netherlands was also higher than in the Flemish part of its neighbouring country Belgium (10.40 per thousand versus 7.76 per thousand). The difference in perinatal mortality between Flanders and The Netherlands cannot be explained by the risk factors analysed in the Peristat study, nor by the Dutch system of home deliveries. It is more likely that the attitude of Dutch professionals is too expectative, based on too much confidence in a non-intervention policy. Since the Peristat I publication many measures have been taken in The Netherlands in order to improve the quality of perinatal care. The most important are the start of the perinatal audit preparations, better prenatal screening and the introduction of preconception care.

[The consequences of postponing pregnancy]. / Gevolgen van uitstel van zwangerschap.

The postponement of childbearing is determined by societal factors and is related to the fact that it is often difficult for women to combine an education, a job or a career with having children and taking care of a family. Especially gynaecologists are increasingly confronted with women who undergo the medical consequences of such postponement. Postponing the first pregnancy is accompanied by an increased risk of unwanted infertility. If women do succeed in becoming pregnant later in life, there is an increased risk of complications during pregnancy and delivery. The child runs a greater risk of chromosomal aberrations and of mental and physical handicaps related to increased numbers of premature births and fertility treatments. All these problems begin to increase after age 30, but especially after age 35. Finally, the risk of breast cancer is also increased if a woman delays the birth of her first child or remains childless.

Stress and outcome success in IVF: the role of self-reports and endocrine variables.

BACKGROUND: The aim of this study was to examine the associations between urinary levels of the stress hormones adrenaline, noradrenaline and cortisol during treatment with self reported stress, in order to investigate the mechanism for the previously observed negative association of anxiety and depression with the outcome of IVF/ICSI. METHODS: In a multicentre prospective cohort study, women entering their first cycle of IVF/ICSI treatment were asked to participate. From each participant nocturnal urine samples were collected; pre-treatment, before oocyte retrieval and before embryo-transfer (ET), to assess hormonal concentrations. Additionally, two questionnaires were administered before the start of the treatment to measure anxiety and depression. RESULTS: 168 women completed the questionnaires and collected at least two urine specimens. A significant positive correlation between urinary adrenaline concentrations at baseline and ET and the scores on depression at baseline were found. In women with successful treatment, lower concentrations of adrenaline at oocyte retrieval and lower concentrations of adrenaline and noradrenaline at ET, compared with unsuccessful women, were found. CONCLUSIONS: The significant positive association of adrenaline concentration with pregnancy and with depression suggested that this adrenal hormone could be one of the links in the complex relationship between psychosocial stress and outcome after IVF/ICSI.

The effect of episodic anxiety on an in vitro fertilization and intracytoplasmic sperm injection treatment outcome: a pilot study.

This study examines whether the inconsistent and contradictory findings from prospective studies on the effect of psychosocial factors on treatment outcome of in vitro fertilization (IVF) can be explained by the fact that no clear distinction has been made between acute and chronic emotional stress responses. Because chronicity is difficult to measure within the context of an IVF-procedure, the focus of the present study was on episodic anxiety. We compared its predictive value on treatment outcome after the second IVF and intracytoplasmic sperm injection (ICSI) with the predictive value of trait anxiety and acute anxiety. In a prospective study with 47 women who failed to conceive after the first IVF, state anxiety was measured both before and after the first IVF treatment. Episodic anxiety was operationalized as high state anxiety both before and after the first IVF treatment Student's t-test and logistic regression analysis were used to determine the predictive value of episodic anxiety compared with acute or trait anxiety. Women with episodic anxiety, but not those with high levels of trait or acute anxiety, were less likely to become pregnant after the second IVF/ICSI. The results suggest that future studies should differentiate between acute and chronic stress, when examining the effects of psychosocial factors on treatment outcome after a fertility treatment

A randomized placebo-controlled study of the effect of transdermal vs. oral estradiol with or without gestodene on homocysteine levels.

OBJECTIVE: To assess the effect of transdermal vs. oral administration of E2 on plasma homocysteine levels and to evaluate the impact of adding a progestogen to these regimens. DESIGN: Prospective, double-blind, double-dummy, placebo-controlled study. SETTING: Outpatient clinics in two university hospitals and two teaching hospitals in The Netherlands. PATIENT(S): One hundred fifty-two healthy hysterectomized postmenopausal women. INTERVENTION(S): Thirteen 28-day treatment cycles with placebo (n = 49); transdermal 17beta-E2, 50 microg (n = 33), oral E2, 1 mg (n = 37), or oral E2, 1 mg, plus gestodene, 25 microg (n = 33), followed by four cycles of placebo in each group. MAIN OUTCOME MEASURE(S): Fasting plasma total homocysteine concentrations at baseline and cycle 4, 13, and 17. RESULT(S): Mean (+/-SD) homocysteine concentrations in the oral E2 group decreased from baseline to cycle 4 (9.0 +/- 2.5 micromol/L vs. 8.2 +/- 2.0 micromol/L; mean change, -7.6%). Homocystine values in the oral E2 plus gestodene group did not change substantially from baseline to cycle 4 (8.9 +/- 1.6 micromol/L vs. 8.6 +/- 2.0 micromol/L; mean change, -4.4%). No significant changes were observed in the transdermal E2 group. After four washout cycles, the homocysteine concentration had returned to baseline values in all groups. CONCLUSION(S): Oral E2 therapy reduced the homocysteine concentration more than did therapy with transdermal E2 or oral E2 plus gestodene. This finding may indicate a role of liver metabolism and suggests that gestodene has a negative effect on these changes.

Randomised clinical trial on the effect of the Dutch obstetric peer review system.

The project "Obstetric Peer Review Interventions" (Verloskundige Onderlinge Kwaliteitsspiegeling Interventies, VOKSINT) was set-up in The Netherlands in 1994. It provided annual comparison data (quality ranking, league tables) for secondary care obstetric departments adjusted for population differences, based on the data registered in the Perinatal Database of The Netherlands (Landelijke Verloskunde Registratie, LVR). The aim of the so-called VOKS reports was to influence obstetricians' interventions in such a way that they led to a more homogeneous policy. To assess this influence, a trial was set-up, with departments randomly assigned to be or not to be informed about the VOKS results. Obstetric intervention rates and the morbidity of newborns including neonatal neurological examinations (NNEs) were assessed. Obstetric intervention rates were similar in the report group and the control group. Practice in the report group became more homogeneous (adjusted for population differences) than in the control departments, but this was only statistically significant for term caesarean section.

Evaluation of 239 cases of perinatal death using a fundamental classification system.

OBJECTIVE: To classify 239 cases of perinatal death in a newly introduced classification system for underlying causes of perinatal death. DESIGN: Prospective, descriptive. SETTING: Dutch healthcare region Delft-Westland-Oostland (DWO). MATERIALS AND METHODS: In 10 years (1983-1992), all cases of perinatal death with a birthweight above 500 g (n=239) were included into the study. We used a classification model based upon the underlying cause of death using simple principles of obstetrical and neonatal pathology. A team consisting of a gynaecologist, neonatologist and pathologist classified all cases of perinatal death into seven groups to determine the "most-probable" cause of death. RESULTS: Birth trauma was seen in two cases (0.8%). Infections were seen in 16 cases (6.8%). Acute/subacute placental pathology in 77 cases (32.2%) and chronic placental pathology in 50 cases (21%). Bloodtype antagonism was seen in two cases (0.8%). Lethal congenital malformations in 55 cases (23%). Complications of pre-viable delivery in 20 cases (8.4%). Unclassifiable were 17 cases (7%): two cases could not be classified despite thorough investigation (1%) and 15 cases were lost for follow-up (6%). CONCLUSIONS: Classification of perinatal death causes by using our fundamental classification system gives insight in the possible underlying causes of death. The results of such a classification can be used as guidelines for preventive measures in the future.

Fundamental classification of perinatal death. Validation of a new classification system of perinatal death.

OBJECTIVE: To validate a newly introduced classification system for the registration of perinatal mortality. DESIGN: Descriptive. SETTING: Dutch Healthcare region Delft-Westland-Oostland (DWO). MATERIAL AND METHODS: In a 10-years period (1983-1992), all cases of perinatal death with a birthweight above 500 g (n=239) were included into the study. Six assessors: four gynaecologists and two paediatricians were asked to classify all cases using a classification model proposed by the authors. This model is based on the underlying cause of death using simple principles of obstetrical and neonatal pathology: birth trauma, infection, placenta or cord pathology, pathology of immune tolerance of mother and fetus, congenital malformation of the fetus and complications of a pre-viable delivery. Therefore, we used the term fundamental classification. The six assessors worked independently of each other in classifying all cases of perinatal death, were not involved in the original development of the system and were unaware of the results of the classification of their colleagues. Agreement beyond chance between assessors was calculated using kappa's coefficient for multiple observers and multiple test results. RESULTS: Overall kappa was 0.70 (95% confidence interval (C.I.) 0.68-0.72). Reproducibility was poor for the categories trauma and unclassifiable, fair for the categories infections and placental/cord pathology, and very good to excellent for the categories maternal immune system pathology, congenital malformations and complications of prematurity. CONCLUSIONS: The proposed system showed a good level of agreement and appeared to be simply applicable. It offers a good insight in the underlying cause of death with the possibility for recognising preventive factors in future pregnancies and will enable (inter)national comparisons in causes of perinatal death. A reliable uniform registration of perinatal death based on the underlying causes should be the basis for improvement of the quality of perinatal care.