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Study Question: Does the addition of exogenous LH to an IVF/ICSI stimulation protocol with recombinant FSH (r-FSH) and a GnRH antagonist improve the ovarian response and pregnancy rates in women of 35 years and older?, Summary Answer: Supplementation of LH during the second half of the follicular phase has no effect on pregnancy rates, implantation rates or on ovarian response in women of 35 years and older undergoing GnRH antagonist IVF/ICSI cycles., What Is Known Already: In IVF/ICSI stimulation protocols GnRH agonists or antagonists are administered to prevent a premature pituitary LH surge, which can have a detrimental effect on the IVF/ICSI procedure. In effect, GnRH analogues cause the levels of both gonadotrophins to drop. In order to allow follicle growth FSH is administered exogenously, whereas LH is usually not supplemented. Although GnRH analogues prevent LH surges, there is evidence that, particularly in older women, administration of GnRH analogues may cause endogenous LH levels to decrease excessively. Several studies have been performed to investigate whether the addition of recombinant LH (r-LH) to r-FSH improves cycle outcome. Only a few studies have analysed this issue in the GnRH antagonist protocol and the results of these trials obtained in older women (>35 years old) are conflicting., Study Design, Size, Duration: A multicentre RCT was performed between 2004 and 2010 in 253 couples who were undergoing IVF or ICSI. Women were 35 years or older and received ovarian stimulation in a protocol with r-FSH (Gonal-F 225 IU/day) starting from cycle day 3 and GnRH antagonist (Cetrotide 0.25 mg/day) from stimulation day 6. Randomization took place on stimulation day 6 to receive both r-FSH and r-LH (Luveris 150 IU/day) or continue with FSH alone. Randomization for r-LH supplementation was performed centrally by serially numbered, opaque, sealed envelopes, stratified by centre., Participants/materials, Setting, Methods: Of 253 subjects randomized, 125 received both r-FSH and r-LH and 128 received r-FSH only. Patients were recruited from the Division of Reproductive Medicine of the Obstetrics and Gynaecology department of four hospitals in the Netherlands., Main Results and the Role of Chance: There were no demographic or clinical differences between the groups. The intention-to-treat analysis revealed that of those receiving both r-FSH and r-LH, 35 (28.0%) had a clinical pregnancy, compared with 38 (29.7%) receiving only r-FSH (mean difference -1.5%; 95% confidence interval (CI) -9.4 to 12.7, P = 0.9). Ongoing pregnancy rates were 25 (20%) versus 28 (21.9%) (mean difference -1.9%; 95% CI -8.2 to 11.9, P = 0.9) and implantation rates 18.8 versus 20.7% (mean difference -1.9%; 95% CI -8.0 to 11.7, P = 0.6) in the 'r-FSH and r-LH' and 'r-FSH only' groups respectively., Limitations, Reasons for Caution: A limitation of our study is its early closure. This was done because the interim analysis after randomization of 250 patients indicated no benefit in any aspect of the experiment., Wider Implications of the Findings: Given previous data, including a Cochrane review, and our own results the evidence indicates that LH supplementation has no benefit on ongoing pregnancy rates in women of 35 years or older., Study Funding/competing Interest(s): Merck Serono Netherlands, an affiliate of Merck Serono SA- Geneva, an affiliate of Merck KGaA, Darmstadt, Germany has donated the r-LH (Luveris(®)). No conflict of interest to declare., Trial Registration Number: The trial was registered in the Dutch trial register (ISRCTN10841210).

Obstetric injury comprising tearing of the rectovaginal septum, rectal mucosa, and anal sphincter complex with limited or no involvement of the perineal body may implicate the sudden appearance of an elbow, foot or head in the anal orifice during the second phase of labour. This complex type of obstetric injury is highly uncommon and reports have rarely been published. There are no guideliness as to how to respond to this obstetric emergency and there is no time for consultation. In order to reach clinical recommendations on repair and management of this unexpected obstetric injury for the midwife or obstetrician, we report three such cases. The three described cases with their corresponding sequence of events and interventions illustrate that successful repair of these types of injury can often be achieved. To minimize factors leading to long-term complications, repair requires the involvement of an experienced gynaecologist and sometimes even a colorectal surgeon.

The Dutch parliament has recently accepted a tax law in which certain groups of alternative therapists can be exempt from VAT. To be eligible for this VAT exemption, the disciplines to which the therapists belong have to meet certain training requirements. In this article it is contended, in agreement with the Royal College of Physicians in the UK, that statutory regulation is inappropriate for disciplines whose therapies are neither of proved benefit nor appropriately tested. It legitimizes harmful therapies. This is illustrated by two serious accidents, previously described in this journal, caused by a chiropractor and a craniosacral therapist.

Discontentment with the massive violations of the influential Dutch Prime Minister's (Johan Rudolf Thorbecke) health laws led to the foundation of the Dutch Society Against Quackery, in 1880. Within a few years, the Society had more than 1,100 members. Initially, quackery mostly consisted of the unauthorized practice of medicine and the peddling of industrially manufactured ''secret remedies.'' Since the 50s however, the energy of the society focused mainly on magnetizers, especially after they gained support from the field of parapsychology, lay manipulators of the back and herb doctors. The most important object of the society since 1980 has been the fight against the so-called alternative medicine, of which Chinese acupuncture, homeopathy, manipulative therapy, anthroposophical medicine, and naturopathy are prominent targets. Despite numerous costly lawsuits, the society still survives and is probably the oldest as well as the largest of its kind in the world.

Between 1986 and 2003, research efforts on complementary and alternative medicine (CAM) were subsidized by the Dutch government. This led to 12 academic theses and a considerable number of papers in medical journals. In our review, we have summarized the results of this research, grouped by therapeutic category (that is, acupuncture, paranormal therapies, naturopathy, manual therapies, homeopathy and anthroposophical medicine.) Of the 12 theses, four were written in Dutch, three of which were not subsequently published in peer-reviewed journals, while the fourth, on enzyme therapy, led to a number of papers in Dutch medical journals. In three instances, mildly positive findings were reported: on the efficacy of manual therapies, the use of acupuncture analgesia in surgery, and an elimination diet against migraine and tension headaches. These positive conclusions can easily be explained by methodological shortcomings (e.g., not using credible placebo-control groups); in the other nine theses, the researchers themselves had drawn negative conclusions. The Dutch government ended its financial support for CAM research in 2006.

Until recently, alternative doctors and healers used to employ alternative ways of making their alternative diagnoses such as electro-acupuncture, iridiscopy, plantar reflexology, live blood analysis, aura reading and bioresonance methods. Two recent papers report the emergence of unjustified diagnoses, resulting from clinical chemistry testing in commercial laboratories with an alternative philosophy and character. Dutch law considers medicine to be a profession for which no special knowledge is demanded. Even incorrect diagnostic procedures and the diagnosis of non-existent diseases by these laboratories is not illegal, in spite of the resulting detrimental effects to the health and the purse of patients. Some would consider the Dutch law in this respect too liberal.

The popular 45-year-old Dutch actress Sylvia Millecam died in August 2001 from untreated advanced breast cancer. She refused standard medical treatment and sought solace in many alternative healers, including three medical physicians. The Dutch Healthcare Inspection accused the three physicians of malpractice and asked the Medical Disciplinary Tribunal to pass judgment. In April 2006 one physician was struck from the physician register and the other two were suspended for 1 year and 6 months, respectively. These unusually severe measures were based mainly on the fact that they had neglected professional standards as defined by specialty boards, they had presented themselves as professional physicians and they had not tried hard enough to convince Millecam of the need for standard treatment. The Tribunal did not accept the strong desire of the patient to undergo only alternative treatment as a defence. Notably, the judgment of the Tribunal seems to be more severe than the present bylaws of medical-scientific bodies and the Dutch Medical Association (KNMG), which are apparently too lenient regarding the use of alternative treatments by their members.

One doctor denied an existing fatal malignancy and diagnosed cancer in patients who did not have it. He and two other doctors gave the impression that they could cure patients by methods of which the efficacy has not been demonstrated. All three were members of a society for alternative medicine; two of them no longer are. The third, an internist, is still a member of his alternative scientific medical society, but of the Netherlands Association of Internal Medicine as well. A clinical chemist with a private laboratory that continually diagnoses nutritional deficiencies in a disputable way, and a neurologist who cooperates with a highly controversial American back physician were not expelled from their associations nor corrected by them. The Dutch Health Inspectorate is investigating dysfunctioning physicians and may well take action against them. The medical-scientific societies could well pay closer attention to their task of promoting the quality of the professional activities of their members.

The popularity of alternative medicine certainly also affects patients suffering from infertility. Alternative medicine started in the seventies but there have always been unorthodox practitioners, treating infertile women and men. Some historical examples will be described. The claims made for alternative medicine in the lay press have not been accompanied by similar reports in the mainstream medical journals. Practitioners and advocates of alternative medicine have used several strategies to defend their position. These were mostly of a philosophical nature, but more recently the practitioners of alternative medicine admit that the effectiveness of their therapies should be proven in randomized trials, as is considered mandatory in regular medicine. There are very few well-designed papers on the effectiveness of alternative medicine with the exception of one kind of paper that is hard for editors of medical journals to resist: seemingly impeccable papers proving absurd claims, whose mechanisms of action are, for instance, completely incomprehensible. We argue that this type of paper should be rejected for publication and indeed offer explanations for their mere existence.

In May 1999 the Amsterdam Court of Justice decided that a retired internist and propagandist of his own alternative cancer therapy, could rightfully be called a quack by his critics. Recently this judgment was reversed on appeal. The first court used the medical definition of quackery: a treatment of which the supposed benefits are unsubstantiated. The court of appeal, however, took into consideration that to the general public calling someone a quack is an indication that this person is a swindler and practises medicine unlawfully. This definition is supported by the most authoritative Dutch dictionary. Apparently a different semantic interpretation of the term quack has led to these strongly diverging verdicts. The terms quack and quackery are indispensable in the public debate on alternative medicine.

In 1998 and 1999 three new charity foundations were established in the Netherlands, covering the same areas as the Dutch Heart Foundation, the Netherlands Cancer Foundation and the National Rheuma Foundation respectively. Analysis of the set-up of the three new foundations, of their philosophy, their constitutions and the background of the persons involved shows a remarkably uniform pattern, making it very likely that the set-up of these alternative foundations is a part of the marketing strategy of some Dutch wholesalers in orthomolecular drugs. More legal regulation of charity foundations is seriously needed.

From 1967 to 1973 serum samples of 1709 infertile women were tested for antispermatozoal antibodies with the gelatin agglutination test. In 110 cases sperm agglutinins were demonstrated in titers ranging from 4 to 1024. The clinical data of 99 couples were evaluable, and in 65 there appeared to be unexplained infertility. Out of these 65 women, 44 became pregnant in the posttesting follow-up period of 6 to 13.5 years (median, 10 years). With increasing titers there was a significant decrease in the probability of becoming pregnant. Of the women who became pregnant, in general, those with higher titers had to wait longer for their pregnancy than those with lower titers. Moreover, with increasing titers there was a tendency toward a longer duration of infertility before the serum was tested. This latter observation supports the contention that the agglutinin titer influences the fecundability rate. The titers of those becoming pregnant and those remaining infertile, however, showed considerable overlap. Favorable results in the postcoital test were associated with a better prognosis, but this was independent of the titers.