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Background: Gender-based violence is a tool that primarily functions to maintain gendered power hierarchies. Manifestations of gender-based violence, sexual assault and street harassment have been shown to have significant effects on mental wellbeing in the global North, however there is little research centering the experiences and consequences of gendered harassment in the Africa region., Methods: We analyzed a cross-sectional random sample of 372 women attending a major university in Eswatini in 2017 to measure the prevalence of street harassment among female university students and assess the relationship between experiences of sexual assault, sexualized street harassment, and mental health outcomes in this population., Results: We found that in the previous 12 months, women reported experiencing high levels of sexual assault (20%), street harassment (90%), and depression (38%). Lifetime sexual assault, past 12 months sexual assault, and street harassment were all significantly associated with symptoms of depression. We created a structural model to test hypothesized causal pathways between street harassment, previous experiences of sexual assault, and symptoms of depression, with social support as a potential mediator. We found that a history of sexual violence significantly mediated the association between street harassment and depression, and that social support mediated a large proportion of the association between both forms of gender-based violence and depression., Conclusion: Sexualized street harassment is associated with increased depressive symptomology for nearly all women, however the effects are especially pronounced for women who have previous experiences of sexual violence. Sexualized street harassment functions as a tool to maintain gendered power hierarchies by reminding women of ongoing threat of sexual violence even in public spaces. Social support and solidarity among women is a potentially important source of resiliency against the physical and mental harms of all forms of gender based violence., (© 2024. The Author(s).)

Gender-based violence (GBV) research in public health has historically paid close attention to gender as a system of oppression, with less attention paid to the intersections between gender and other oppressive systems such as colonialism, white supremacy, and capitalism. In 2019, we adapted and pilot-tested an individual-level evidence-based sexual violence resistance intervention for university-attending women in Eswatini. We conducted a qualitative assessment of our adapted intervention's acceptability and feasibility using a critical pedagogy lens to explore how power operated in delivering an empowerment intervention, using in-depth interviews with intervention participants and facilitators. We analyzed interview transcripts thematically guided by a critical pedagogy framework and organized emergent themes into a concept map with two primary axes: participant-researcher-driven power and proximal-distal determinants. We located participant experiences with the intervention within three quadrants defined by these axes: 1) "Prescriptive," in which the researcher or facilitator primarily controls the content and delivery, with a principal focus on proximal risk reduction strategies; 2) "Solidarity," which emphasizes fostering critical consciousness among facilitators and intervention participants through dialogue, building collective power through participant-driven discussions of individual experiences; and 3) "Liberation," in which participants critically examined the power structures that underpinned their lived experiences, and expressed a desire to transform these in ways the intervention was not designed to address. These three quadrants suggest the existence of a fourth quadrant, "paternalistic," - in which the interventionist seeks to didactically educate participants about structural drivers of their own experience. Our analysis highlights a fundamental tension in the epistemology of GBV research: While there is a clear consensus that 'empowerment' is a necessary component of successful GBV interventions, "liberatory" approaches that cede power to participants are inherently antithetical to the scripted approach typically required for consistent replication in randomized control trials or other 'gold-standard' approaches for post-positivist evidence generation., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: In South Africa, Xpert ® MTB/RIF Ultra (Ultra) is the recommended diagnostic assay for TB with line-probe assays for first- (LPAfl) and second-line drugs (LPAsl) providing additional drug susceptibility testing (DST) for samples that were rifampicin-resistant (RR-TB). To guide implementation of the recently launched Xpert ® MTB/XDR (MTB/XDR) assay, a cost-outcomes analysis was conducted comparing total costs for genotypic DST (gDST) for persons diagnosed with RR-TB considering three strategies: replacing LPAfl/LPAsl (centralised level) with MTB/XDR vs. Ultra reflex testing (decentralised level). Further, DST was performed using residual specimen following RR-TB diagnosis., Methods: The total cost of gDST was determined for three strategies, considering loss to follow-up (LTFU), unsuccessful test rates, and specimen volume., Results: For 2019, 9,415 persons were diagnosed with RR-TB. A 35% LTFU rate between RR-TB diagnosis and LPAfl/LPAsl-DST was estimated. Unsuccessful test rates of 37% and 23.3% were reported for LPAfl and LPAsl, respectively. The estimated total costs were $191,472 for the conventional strategy, $122,352 for the centralised strategy, and $126,838 for the decentralised strategy. However, it was found that sufficient residual volume for reflex MTB/XDR testing is a limiting factor at the decentralised level., Conclusion: Centralising the implementation of XDR testing, as compared to LPAfl/LPAsl, leads to significant cost savings., Competing Interests: Conflicts of interest: none declared., (© 2024 The Authors.)

Background: Healthcare personnel (HCP) in high TB-burdened countries continue to be at high risk of occupational TB due to inadequate implementation of Tuberculosis Infection Prevention and Control (TB-IPC) measures and a lack of understanding of the context and relevance to local settings. Such transmission in the healthcare workplace has prompted the development and dissemination of numerous guidelines for strengthening TB-IPC for use in settings globally. However, a lack of involvement of healthcare personnel in the conceptualisation and development of guidelines and programmes seeking to improve TB-IPC in high-burden countries generally has been observed. Objectives: The aim of this review was to explore the inclusion of HCP in decision-making when designing the TB-IPC guidelines, in healthcare settings. Methods : A scoping review methodology was selected for this study to gain insight into the relevant research evidence, identifying and mapping key elements in the TB-IPC measures in relation to HCP as implementors. Results : Studies in this review refer to factors related to HCP's knowledge of TB-IPC, perception regarding occupational risks and behaviours, their role against a background of structural resource constraints, and guidelines' adherence. They report several challenges in TB-IPC implementation and adherence, particularly eliciting recommendations from HCP for improved TB-IPC practices. Conclusions : This review highlights a lack of participation in decision-making by the implementers of the policies and guidelines, yet adherence to TB-IPC measures is anticipated. Future research needs to focus more on consultations with users to understand the preferences from both within individual healthcare facilities and the communities. There is an urgent need for research on the participation of the implementers in the decision-making when developing TB-IPC policies and guidelines.

Background: This study evaluates the implementation and running costs of an HIV self-testing (HIVST) distribution program in Eswatini. HIVST kits were delivered through community-based and workplace models using primary and secondary distribution. Primary clients could self-test onsite or offsite. This study presents total running economic costs of kit distribution per model between April 2019 and March 2020, and estimates average cost per HIVST kit distributed, per client self-tested, per client self-tested reactive, per client confirmed positive, and per client initiating antiretroviral therapy (ART)., Methods: Distribution data and follow-up phone interviews were analysed to estimate implementation outcomes. Results were presented for each step of the care cascade using best-case and worst-case scenarios. A top-down incremental cost-analysis was conducted from the provider perspective using project expenditures. Sensitivity and scenario analyses explored effects of economic and epidemiological parameters on average costs., Results: Nineteen thousand one hundred fifty-five HIVST kits were distributed to 13,031 individuals over a 12-month period, averaging 1.5 kits per recipient. 83% and 17% of kits were distributed via the community and workplace models, respectively. Clients reached via the workplace model were less likely to opt for onsite testing than clients in the community model (8% vs 29%). 6% of onsite workplace testers tested reactive compared to 2% of onsite community testers. Best-case scenario estimated 17,458 (91%) clients self-tested, 633 (4%) received reactive-test results, 606 (96%) linked to confirmatory testing, and 505 (83%) initiated ART. Personnel and HIVST kits represented 60% and 32% of total costs, respectively. Average costs were: per kit distributed US$17.23, per client tested US$18.91, per client with a reactive test US$521.54, per client confirmed positive US$550.83, and per client initiating ART US$708.60. Lower rates for testing, reactivity, and linkage to care in the worst-case scenario resulted in higher average costs along the treatment cascade., Conclusion: This study fills a significant evidence gap regarding costs of HIVST provision along the client care cascade in Eswatini. Workplace and community-based distribution of HIVST accompanied with effective linkage to care strategies can support countries to reach cascade objectives., (© 2024. The Author(s).)

A cross-sectional survey of Schistosoma haematobium prevalence was conducted among senior primary school pupils of Siphofaneni area, Eswatini. This area is devoid of potable water, with a newly constructed Lubovane dam and an LUSIP irrigation scheme. The objective of the study was to investigate the distribution of urinary schistosomiasis among Siphofaneni senior primary school pupils. Using simple random sampling, 200 partcipants were enroled from four of six schools in the area. Ten millimetres (10 ml) of urine samples were obtained from each participant and examined for S. haematobium eggs. The intensity of the infection was estimated by calculating the total number of S. haematobium eggs present in 10 ml urine. Out of 200 participants, 45% (n = 91) were males, and 55% (n = 109) were females. The mean age for participants was 13 years, and almost half (47%, n = 94) were in Grade 5. Overall, the prevalence of S. haematobium infection was 16% (32/200). More than half (59%, 19/32) of the Schistosomiasis cases were from females. Positive and significant associations were observed between the number of eggs (χ 2 =170.9) and the presence of red blood cells (χ 2 =49.2) at p = 0.001. In conclusion, the prevalence of Schistosomiasis is high among pupils enrolled in Siphofaneni area primary schools that needs comprehensive treatment and education to prevent from S. haematobium infection., Competing Interests: Conflicts of interest The authors declare no conflicts of interest in this study., (© 2023 T. S. B. Maseko et al., published by Sciendo.)

Background: Diabetes and hypertension are increasingly important population health challenges in Eswatini. Prior to this project, healthcare for these conditions was primarily provided through physician-led teams at tertiary care facilities and accessed by only a small fraction of people living with diabetes or hypertension. This trial tests and evaluates two community-based healthcare service models implemented at the national level, which involve health care personnel at primary care facilities and utilize the country's public sector community health worker cadre (the rural health motivators [RHMs]) to help generate demand for care., Methods: This study is a cluster-randomized controlled trial with two treatment arms and one control arm. The unit of randomization is a primary healthcare facility along with all RHMs (and their corresponding service areas) assigned to the facility. A total of 84 primary healthcare facilities were randomized in a 1:1:1 ratio to the three study arms. The first treatment arm implements differentiated service delivery (DSD) models at the clinic and community levels with the objective of improving treatment uptake and adherence among clients with diabetes or hypertension. In the second treatment arm, community distribution points (CDPs), which previously targeted clients living with human immunodeficiency virus, extend their services to clients with diabetes or hypertension by allowing them to pick up medications and obtain routine nurse-led follow-up visits in their community rather than at the healthcare facility. In both treatment arms, RHMs visit households regularly, screen clients at risk, provide personalized counseling, and refer clients to either primary care clinics or the nearest CDP. In the control arm, primary care clinics provide diabetes and hypertension care services but without the involvement of RHMs and the implementation of DSD models or CDPs. The primary endpoints are mean glycated hemoglobin (HbA1c) and systolic blood pressure among adults aged 40 years and older living with diabetes or hypertension, respectively. These endpoints will be assessed through a household survey in the RHM service areas. In addition to the health impact evaluation, we will conduct studies on cost-effectiveness, syndemics, and the intervention's implementation processes., Discussion: This study has the ambition to assist the Eswatini government in selecting the most effective delivery model for diabetes and hypertension care. The evidence generated with this national-level cluster-randomized controlled trial may also prove useful to policy makers in the wider Sub-Saharan African region., Trial Registration: NCT04183413. Trial registration date: December 3, 2019., (© 2023. The Author(s).)

Sexual assault on university campuses has attracted growing attention, but there is little data available on the scope of the problem in Southern Africa. We sought to measure the prevalence of campus sexual assault among female university students at the University of Eswatini and describe the experience of survivors using a mixed-methods study design. Women were randomly sampled from a list of all full-time female university students provided by the office of the registrar, and participants completed a brief behavioral survey in a private study office using a tablet with computer-assisted self-interview software. Women who indicated experiences of sexual violence during the survey were invited to self-identify themselves to study staff to participate in a follow-up qualitative interview. We measured sexual assault using the Sexual Experiences Survey-Short Form Version (SES-SFV). We found that women in University were over 6 times more likely to report forced or coerced sex in the previous 12 months than has been previously reported in the general population. Sixty percent of participants reported experiencing an attempted or completed sexual assault in their lifetime, and a total of 38% reported an assault in the past 12 months. The vast majority (93%) of assailants were known to their victim, and the majority (56%) of perpetrators were romantic partners. The majority of participants had never disclosed their assault, and victim blaming and stigma emerged as highly salient themes during in-depth qualitative interviews. Food insecurity, losing a parent before age 21, and hazardous drinking were all significantly associated with experiencing sexual assault in the previous 12 months, as was experiencing a previous assault before the age of 18. To our knowledge, this is the first generalizable study of campus sexual assault prevalence conducted in the Southern African region.

SETTING: Since 2015, Eswatini has been scaling up bedaquiline (BDQ) and delamanid (DLM) based drug-resistant TB treatment regimens under programmatic conditions. OBJECTIVE: Identification of factors associated with treatment outcomes in patients receiving BDQ and/or DLM either as a new treatment initiation or drug substitution. DESIGN: This is a retrospective cohort study of patients receiving BDQ and/or DLM in Eswatini between March 2015 and October 2018. We describe factors associated with unfavourable treatment outcomes (death, lost to follow-up, treatment failure and amplification of resistance) and culture conversion using multivariable flexible parametric survival and competing-risks regression analyses. RESULTS: Of 352 patients receiving BDQ and/or DLM, 7.8% and 21.2% had an unfavourable treatment outcome at 6 and 24 months, respectively. Predictors were age ≥ 60 years (adjusted hazard ratio aHR 4.49, 95%CI 1.61-12.57) vs. age 20-39 years, and a treatment regimen combining both drugs (aHR 4.49, 95%CI 1.61-12.57) vs. BDQ only. The probability of culture conversion was increased for two health facilities and patients with a poly resistance profile (adjusted sub-hazard ratio 2.01, 95%CI 1.13-3.59) vs. multidrug resistance. CONCLUSION: Single use of BDQ or DLM was associated with low rates of unfavourable outcomes, suggesting that these medications may be effectively adopted at scale under routine programmatic conditions. Combined use of BDQ and DLM was a risk factor for unfavourable outcomes and should prompt for collection of more data on the combined use of these medications.

Background: Tuberculosis (TB) is amongst the top five causes of death in women of childbearing age (15-≤44 years). Little is known about treatment of pregnant women with drug-resistant TB (DR-TB). Treatment for pregnant women remains challenging and more complex in DR-TB/HIV co-infection, where an evidence-based guide to clinical practice is limited. The study reviewed treatment and pregnancy outcomes and birth outcomes of their new-born in a cohort of pregnant women with DR-TB from three MDR-TB hospitals during 2010 and 2018., Design/methods: Data were extracted from: TB register and patient clinic notes using a standardized case record form. Information on DR-TB treatment, pregnancy and Adverse Drug Events (ADEs) of twenty-six pregnant women treated with individualized second-line TB medications were captured. The frequency of favourable and adverse outcomes regarding disease and pregnancy were evaluated., Results: The mean age was 29 years (SD ±5.1), with the minimum and maximum age of 21 and 40 years, respectively. Eleven (42.3%) were previously treated with first-line TB drugs, 11 (42.3%) never treated before and 4 (15.4%) were previously treated for DR-TB. Of the 26 women, 15 (57.7%) had at least one ADE, but most had more than one ADE. Seventeen women were successfully treated, and 22 live births recorded. Live birth outcome was significantly associated with trimester of initiation of DR-TB treatment (p = 0.036). The proportion of live births for the pregnancy trimester when DR-TB treatment was initiated, were 60.0%, 90.9% and 100.0%, for first, second and third trimester, respectively., Conclusion: DR-TB treatment should be delayed until after the first trimester. Routine pharmacovigilance surveillance integrated antenatal and delivery services with an integrated record of DR-TB treatment during pregnancy is recommended. Prospective studies using standardised case record forms for DR-TB treatment for pregnant women could provide more insight on the effect of DR-TB treatment on the birth outcome., Competing Interests: The authors have declared that no competing interests exist.

SETTING: In South Africa prior to 2016, the standard treatment regimen for multidrug- and rifampicin-resistant tuberculosis (MDR/RR-TB) was 24 months long and required daily injectable aminoglycoside (IA) treatment during the first 6 months. Recent evidence supports the replacement of IA with well-tolerated oral bedaquiline (BDQ) and a shortened 9-12 month regimen. DESIGN: Using a Markov model, we analyzed the 5-year budgetary impact and cost per successful treatment outcome of four regimens: 1) IA long-course, 2) oral long-course, 3) IA short-course, and 4) oral short-course. We used the South African MDR/RR-TB case register (2013-2015) to assess treatment outcomes for the then-standard IA long-course. Data on the improvement in outcomes for BDQ-based regimens were based on the literature. Costs were estimated from the provider perspective using costs incurred to provide decentralized treatment for MDR-TB at a Johannesburg hospital. RESULTS: Based on our analysis, by 2023, the cost/successful outcome for the four regimens was respectively 1) US$7374, 2) US$7860, 3) US$5149, and 4) US$4922. The annual total cost of each regimen was US$37 million, US$43 million, US$26 million, and US$28 million. CONCLUSION: Despite the high cost of BDQ, a BDQ-based shortened regimen for the treatment of MDR/RR-TB will result in improved treatment outcomes and cost savings for South Africa.

Addressing the rising incidence of self-harm and the demand this places on emergency departments (EDs) are UK Government healthcare priorities. A history of self-harm is linked with suicide risk, so self-harm is a public health issue. The ED is the first point of contact for many people who self-harm so it plays a pivotal role in access to services. Research has highlighted difficulties around triage and assessment in EDs of patients who self-harm, especially frequent attenders. The evidence base on patient experience related to addressing negative staff attitudes is lacking, despite their potent nature and impact on care. Limited knowledge of self-harm aetiology and clinical inexperience have been found to be fundamental to nurses' negative attitudes when dealing with patients who self-harm. This has been linked to negative patient outcomes, including a reluctance to engage with services. This article acknowledges positive changes that have been made and highlights the importance of the triage stage, which is a potential service improvement area, where it would be possible to start and drive positive change in the care of people who self-harm. To address knowledge gaps in education and management, clinical understanding of the aetiology of self-harm should be improved with the aid of education on self-harm cycles. Nurses should also be made aware of common myths surrounding self-harm, as these are barriers to care. Recommendations for practice include partnership working and the urgent need for formal education on this topic for all health professionals working in EDs.

Equity in health implies that ideally everyone could attain their full health potential and that no one should be disadvantaged from achieving this potential because of their social position or other socially determined circumstances. Making cities and human settlements inclusive, safe, resilient and sustainable contributes towards ensuring healthy lives and promoting well-being for all at all ages in dignity, equality and in a healthy environment. This paper illustrates a case of applying the Urban Health Equity Assessment and Response Tool (Urban HEART) in a small town in Africa. It describes the process followed, facilitating factors and challenges faced. A descriptive single-case study design using qualitative research methods was adopted to collect data from purposively selected respondents. The study revealed that residents of the Matsapha peri-urban informal settlements faced challenges with conditions of daily living which impacted negatively on their health. There were health equity gaps. The application of the tools was facilitated by the formation of an all-inclusive team, intersectoral collaboration and incorporating strategies for improving urban health equity into existing programmes and projects. Urban HEART is a simple and easy to use valuable tool for pursuing the goal of health equity towards attaining sustainable development through evidence-based approaches for intersectoral action and community involvement.

Background: Adherence to tuberculosis (TB) treatment and antiretroviral therapy (ART) reduces morbidity and mortality among persons co-infected with TB/HIV. We measured adherence and determined factors associated with non-adherence to concurrent TB treatment and ART among co-infected persons in two provinces in South Africa., Methods: A convenience sample of 35 clinics providing integrated TB/HIV care was included due to financial and logistic considerations. Retrospective chart reviews were conducted among persons who received concurrent TB treatment and ART and who had a TB treatment outcome recorded during 1 January 2008-31 December 2010. Adherence to concurrent TB and HIV treatment was defined as: (1) taking ≥80% of TB prescribed doses by directly observed therapy (DOT) as noted in the patient card; and (2) taking >90% ART doses as documented in the ART medical record during the concurrent treatment period (period of time when the patient was prescribed both TB treatment and ART). Risk ratios (RRs) and 95% confidence intervals (CIs) were used to identify factors associated with non-adherence., Results: Of the 1,252 persons receiving concurrent treatment, 138 (11.0%) were not adherent. Non-adherent persons were more likely to have extrapulmonary TB (RR: 1.71, 95% CI: 1.12 to 2.60) and had not disclosed their HIV status (RR: 1.96, 95% CI: 1.96 to 3.76)., Conclusions: The majority of persons with TB/HIV were adherent to concurrent treatment. Close monitoring and support of persons with extrapulmonary TB and for persons who have not disclosed their HIV status may further improve adherence to concurrent TB and antiretroviral treatment.

Inflammatory bowel diseases (IBD) are characterized by wasting and chronic intestinal inflammation triggered by various cytokine-mediated pathways. In recent years, it was shown that T helper 17 (Th17) cells are involved in the pathogenesis of IBD, which makes them an attractive therapeutic target. Th17 cells preferentially produce interleukin (IL)-17A-F as signature cytokines. The role of the interplay between host genetics and intestinal microbiota in the pathogenesis of IBD was demonstrated. Probiotics are live microorganisms that when orally ingested in adequate amounts, confer a health benefit to the host by modulating the enteric flora or by stimulating the local immune system. Several studies indicated the effectiveness of probiotics in preventing and treating IBD (ulcerative colitis, and Crohn's disease). Furthermore, there is mounting evidence of probiotics selectively targeting the Th17 lineage in the prevention and management of inflammatory and autoimmune diseases such as IBD. This review highlights critical roles of Th17 cells in the pathogenesis of IBD and the rationale for using probiotics as a novel therapeutic approach for IBD through manipulation of Th17 cells. The potential molecular mechanisms by which probiotics modulate Th17 cells differentiation and production are also discussed.

Aims:   To test the efficacy of four wipe cloth types (cotton bar towel, nonwoven, microfibre and blended cellulose/cotton) with either quaternary ammonia cleaning solution or silver dihydrogen citrate (SDC) in cleaning food contact surfaces., Methods:   Swab samples collected from untreated, cloth-treated and cloth disinfectant-treated surfaces were subjected to hygiene monitoring using adenosine triphosphate (ATP) bioluminescence and aerobic total plate counting (TPC) assays., Results:   Adenosine triphosphate measurements taken after wiping the surfaces showed poor cleaning by nonwoven cloths (2·89 RLU 100 cm(-2) ) than the microfibre (2·30 RLU 100 cm(-2) ), cotton terry bar (2·26 RLU 100 cm(-2) ) and blended cellulose/cotton cloth types (2·20 RLU 100 cm(-2) ). The cellulose/cotton cloth showed highest log reduction in ATP-B RLU values (95%) and CFU values (98·03%) when used in combination with SDC disinfectant., Conclusions:   Cleaning effect of wiping cloths on food contact surfaces can be enhanced by dipping them in SDC disinfectant. ATP-B measurements can be used for real-time hygiene monitoring in public sector, and testing microbial contamination provides more reliable measure of cleanliness., Significance and Impact of the Study:   Contaminated food contact surfaces need regular hygiene monitoring. This study could help to estimate and establish contamination thresholds for surfaces at public sector facilities and to base the effectiveness of cleaning methods., (© 2012 The Authors. Journal of Applied Microbiology © 2012 The Society for Applied Microbiology.)

Objective: To investigate the effect of Aloe excelsa powder on diabetes., Design: The experiment was carried out in the laboratory on both normal and diabetic rats. Diabetes was induced in the rats by using streptozotocin. Thereafter, blood samples were taken from both the normal and diabetic rats and the sugar levels measured by using the Accutrend Alpha blood glucose monitoring kit., Setting: The experiment was conducted in the laboratory in the Faculty of Medicine at the University of Zimbabwe., Subjects: A total of 280 male albino rats weighing 250 g on average were used. They were obtained from the Animal House of the Medical School at the University of Zimbabwe., Main Outcome Measures: Reduction in sugar levels., Results: The Aloe excelsa powder produced a dose-dependent reduction in the blood glucose in blood glucose levels. It also compared well with the effect of insulin., Conclusion: This study shows that Aloe excelsa has significant activity on glucose levels in rats and this, therefore, confirms the claims by traditional healers that this plant has anti-diabetic effects.

A total of 40 women who demonstrated premature luteinization (serum progesterone > or = 3.5 nmol/l (1.1 ng/ml) on or before the day of human chorionic gonadotrophin (HCG) administration) during ovarian stimulation with human menopausal gonadotrophins (HMG) were restimulated in 46 subsequent cycles after pituitary desensitization with the gonadotrophin-releasing hormone agonist (GnRHa, 1 mg), leuprolide acetate. Five women were treated with a double dose of agonist (2 mg) when premature luteinization was determined on the single dose protocol. In HMG-only cycles, a frank luteinizing hormone (LH) surge was detected in 30 cycles; 15 cycles were cancelled because of premature ovulation. In agonist cycles there were no cancellations, although 25 cycles demonstrated premature luteinization and in six cycles a frank LH surge was detected. Doubling the dose of the agonist did not prevent premature luteinization. Agonist cycles with and without premature luteinization did not differ in any in-vitro fertilization (IVF) outcome parameters (ampoules of gonadotrophins, day of HCG administration, peak oestradiol concentration, number of oocytes retrieved, fertilized, transferred or cryopreserved). We conclude that in patients who demonstrate premature luteinization in a gonadotrophin-only cycle, pituitary desensitization may not completely eliminate subtle luteinization or a frank LH surge.