- Email: [email protected]
New procedures of ovarian stimulation
WEDNESDAY,
SEPTEMBER
SS3.04 GERMAN
SOCIETY
6
SESSION
ss3.04.02 HEMATOPOIETIC TRANSPLANT POTENTIAL OF UNRELATED AND RELATED CORD BLOOD: EXPERIENCE OF THE EUROCORDiNETCORD BANK DUSSELDORF T. Somville’, H. Riittge&, W. Meie?, 0. Bellmann“, A. Ring, HG. Schniirch6, H. Streng’, H. Lehnen’, M. Kusche’, U. Rosseck”‘, G. Kegler” and P. Wernet”. ‘Dept. of Gynecol. and Obstetrics H.-Heine-University Diisseldorf, ‘St.Antonius Wuppertal, 3EVK Diisseldorf, “Florence Nightingale, Diisseldorf, ‘AKH Viersen, 6 Lukashospital Neuss, ‘Josefinum, Augsburg, ‘Elisabeth Hospital Rheydt, ‘Marienhospital Aachen, “‘Dept. of Gynecology and Obstetrics Neuwerk, “Institute for Transplant Diagnostics and Cell Therapeutics, H.-Heine-University Diisseldorf. To date, hematopoietic stem cells from cord blood (CB) have been employed in over 1500 allogeneic (sibling and unrelated matched and mismatched transplantation’s worldwide. The examination and standardization of unrelated and related cord blood derived stem cell preparations and banking as well as their biological characterization was initiated in Diisseldorf already in 1993. Hitherto a total of 4615 CB samples (4513 unrelated, 132 for directed donations within the family; mean volume 90+25 ml, total nucleated cells (NC) 10+5x108) from cord blood have been defined by hematological, immunological and microbiological criteria. These CB samples were collected from the umbilical cord vein immediately after vaginal full term delivery or cesarean section and stored frozen in liquid nitrogen. Only 5.0 ml of a CB sample is required for routine laboratory testing as there are HLA-class I typing, HLA-class II typing by sequence-specific oligonucleotide probes (PCR-SSOP), ABO typing, sterility control, assessment of progenitor- and stem cells by colony forming- assays, and CD34+ status as well as for CMV, Hepatitis B, C, HIV, Parve B19 before releasing the CB unit for transplantation. With regard to viral infections maternal sera were tested for HBsAg , anti-HBc, anti-HCV; HIV-1-2, -HTLVI-II, -CMV and Syphilis. Within the last four years a total of 7400 preliminary searches, 920 extended unit reports were submitted to the CB bank Diisseldorf by fax or World Wide Web. Thusfar 102 unrelated and 3 related CB units were transplanted in over 40 different transplant centers world-wide. The median patient age was 6 years (range 0.3.48), the median weight 2lkg (range 4-70kg). The majority of the patient suffered from ALL (n=36), JCML (n=l) AML (n=13), CML (n=8) and Lymphoma (n= 5), MDS (n=6), AA (n=5), FA (n=2); 29 patients had genetic and acquired diseases. All CB samples as well as the patients blood samples were typed in Duesseldorf for HLA-class I by serology confirmed by PCRSSP and by high resolution DNA typing for HLA-DRBl and HLADQBl alleles. 94% of the 105 patients receiving unrelated CB were mismatched at one or more HLA-loci. Until now 41 patients transplanted with unrelated CB from Diisseldorf were evaluable for engraftment with an overall engraftment rate of 84% with a median time of 23days (range lo-57 days). 49% of the transplanted patients are alive with a median follow-up of 320 days.
ss3.04.03 NEW THERAPEUTIC APPROACHES IN CERVICAL CANCER PATIENTS A. Schneider and M. Passover, Dept. Gyn., University of Jena, University Hospital, Jena, Germany Objectives: The aim of the study was to investigate the effect of nerve sparing laparoscopic assisted radical vaginal hysterectomy (LARVH) type 3 for preservation of bladder function. Study Methods: 66 patients with cervical cancer FIG0 Stage lbl, lb2, 2a, and 2b underwent LARVH type 3. In 38 patients only the vascular part of the cardinal ligament was transected at the pelvic side wall and the neural part was preserved. In 28 patients the conventional type 3 procedure with complete transection of the vascular and neural part of the cardinal ligament and at the pelvic side wall had been done. Results: There was no difference in peri- and post- operative complications between both groups. Bladder training by suprapubic catheter was stopped at postoperative day 11.2 in the patients treated by the nerve sparing techniques compared to 21.4 days in patients treated by the conventional technique (p=O.O007). Length of the parametrium measured on the fresh specimen was 6.8 cm for both groups.
13
Conclusions: Nerve sparing LARVH type 3 allows preservation of the motoric function of the bladder without imparing radicalness of resection of the parametrium.
ss3.04.05 FRONTIERS Thomas
IN GYNECOLOGICAL ENDOCRINOLOGY University Women’s Hospital; Heidelberg, Germany
Selectic topics based on clinical trials mainly performed in Europe: Hyperandrogenism: workup according clinical feature; in cases with moderate and severe androgenisation an androgen producing tumor must be ruled out by serum testosterone (>1,5 ngiml) and DHEAS (> 7 pgiml); in infertility patients a 21.hydroxylase-deficiency must be suspected by 17.OH-progesterone > 4 ng/ml after ACTH stimulation test (25 IU i.m.) and verified by a gene sequenzing; if positive a screening of the partner and a dexamethasone therapy in early pregnancy until genetic diagnosis is recommended. Treatment option in non-infertility patients range from spironolactone, low dose OCs to OCs containing cyproterone acetate’), chlormadinone acetate’), dienogest’) or norgestimate (* not on the US market). Thrombophilia: increased risk for thrombosis by use of OC (up to 50. 200fold in patients with homocygous factor-V-Leiden mutation) as well as in HRT takers (2.3fold) (controls: l/l0 000). Family risk (history) for cardiovascular disease must be considered and if positive a screening is recommended for antithrombin III, protein-C, -S and APC-resistancy, exclusion of Factor-V-Leiden, and optional: homocysteine, lipids or carbohydrates. No differences in thrombophilia due to different progestagens used for OC and HRT. Contraception: New progestogens for oral hormonal contraception are or will be soon available: medrogestone (Wyeth), drospirenone (Schering). Progestogens with low androgenicity should be preferred. New 24.dayregimen with gestodene; clinical trials with Ocs containing natural estrogens. New ethinyl estradiol free oral hormonal contraceptives. The levonorgestrel releasing system (MirenaiSchering) has been accepted by more than 1.5 million users in Europe. Further innovations: vaginal rings, hormonal patches, implants and once-a-month injectable. HRT: 70 innovations (35 patches) are in clinical trials. Continuous, cyclic or intermittend use of progestogens might be selected for endometrial protection as well as a small levonorgestrel releasing IUS. Primary prevention of cardiovascular disease and Alzheimer must be prooven for ERT/HRT as well as their use following gynecological cancers. Breast cancer: HRT increases the chance the breast cancer diagnosis leading to a favorable prognosis and lower mortality when compared to non-HRT users.
SS3.04.06 NEW PROCEDURES OF OVARIAN STIMULATION. Klaus Diedrich, Michael Ludwig, Department of Gynecology Obstetrics, Medical University of Liibeck, Liibeck, Germany
and
Ovarian stimulation is an essential part of each treatment cycle in assisted reproductive technology (ART). However, especially in IVF these ovarian stimulation procedures have different problems like the risk of ovarian hyperstimulation syndrome (OHSS), patients discomfort due to the length of the procedure, hormonal withdrawal symptoms or cyst formation. Using the new drug class of LHRH antagonists, some of these problems can be avoided or significantly reduced in their incidence. Ovarian stimulation can be integrated in a spontaneous menstrual cycle. With Cetrorelix (Cetrotide, ASTA Medica AG, Frankfurt, Germany & Serono International S.A., Geneva, Switzerland) the first antagonist was available. It could be shown in a prospective, randomized study, that the risk of OHSS was significantly reduced with Cetrotide compared to the long protocol. Prospective, randomized studies using Cetrotide as well as prospective studies using the antagonist Ganirelix (Orgalutran, Organon GmbH, Oss, The Netherlands) showed, that antagonists can be used with either urinary gonadotrophins or recombinant FSH with the same success rates. There is an ongoing debate, whether antagonist protocols might lead to lower pregnancy rates compared to agonist protocols in ovarian stimulation. Until now, no prospective randomized study could show a significant difference in pregnancy rates. A tendency towards lower pregnancy rates in antagonist protocols might be due to a bias in the studies and to a learning curve, which is necessary to yield optimal results with this new drugs. An open worldwide observational study using Cetrotide showed
14
WEDNESDAY,
pregnancy rates in daily practice, which are in the range of the long protocol. In experienced centers no disadvantages for the patients could be seen, when Cetrotide was used instead of the long protocol.
SS3.05 INTERACTIVE
SESSION
ss3.05 SOLVING THE DILEMMAS, AN OBSTETRICAL ISSUE (I AND II) Ernesto Instituto National de Perinatologia, Mexico Cty, Mexico Preterm labor remains as a worldwide public health problem; lack of evidence and consensus over diagnostic and therapeutic issues still generate an enormous amount of controversy. This course is designed to review the way to approach this problem, confront different ways to handle it, hear the experts opinion and take a look at the evidence in an interactive session which includes case presentations. Main objects are to review etiology and epidemiology, identify risk, approach prevention, discuss management, anticipate potential complications, improve fetal outcome and consider delivery options. The course will start with a brief review lecture based on evidence followed by several short controversial case presentations covering different aspects of the topic; by electronic means the audience will have the opportunity to test its skills, compare and discuss them with the rest of the participants.
PS3.01 PRESIDENT’S
SESSION
PS3.01.03 PARTNERSHIPS FOR SAFE MOTHERHOOD: HOW MUCH IS A MOTHER WORTH? .I. E. Thomuson, University of Pennsylvania, Philadelphia, PA, United States This paper will address the power of partnerships in promoting Safe Motherhood globally and locally. Particular attention will be given to the role of the International Confederation of Midwives (ICM), FIGO, and WHO as partners in promoting the health of women and childbearing families throughout the world, including their participation with others on the Interagency Group on Safe Motherhood (IAG). Examples of these important partnerships will be drawn from joint efforts in upgrading the knowledge and skills of midwives through pre-Congress workshops, the promotion of Life Saving Skills in the developing world, and the setting of international competencies and standards for all those with “midwifery skills” who are vital in any effort to reduce maternal morbidity and mortality throughout the world. Skilled attendance at birth is one of the lessons learned from over 10 years of the global Safe Motherhood Initiative, and will be used as one example of the power of partnerships that promote the health of women. The discussion of the collaborative relationships between midwives and obstetricians at local, national, regional and global levels will focus on those aspects of this inter-professional relationship that promote the health of women with seamless, high quality, evidenced-based childbearing care from village through hospital, as needed. Discussion will highlight some of the inter-professional conflicts during the past decades as well as successes based on mutual respect, trust, and appropriate use of the unique competencies of both obstetricians and midwives in the care of women during their childbearing years. Examples from developed and developing nations will be used to answer the question, “How much is a mother worth?” The summary of this paper will focus on the values and ethics of Safe Motherhood, and the basic human rights that are needed by women in order to survive one of their most important roles in any society -that of bearing and caring for the world’s children. Midwives and obstetricians working together can make a difference in lives of all the world’s women and families.
PS3.02.02 CONTRACEPTION IN 2050 Professor R V Short, Department of Obstetrics & Gynecology, Women’s Hospital, University of Melbourne, Australia
Royal
By 2050, the population of the world will be around 10 billion. Many developed countries will have falling populations, as the increasing costs
SEPTEMBER
6
of educating children make childbearing prohibitively expensive, and as women choose to postpone marriage and childbearing for the sake of their careers. Improved sex education in school, and free availability of condoms, the oral contraceptive pill and emergency contraception will hopefully reduce the current high rates of teenage pregnancy and abortion. After achieving their desired family size, women will increasingly opt for forms of contraception like gestagen-releasing intrauterine devices that reduce menstrual blood loss, thereby avoiding the need for a hysterectomy as the menopause approaches. It seems unlikely that we will develop an effective hormonal or immunological contraceptive for men. The rising divorce rate is likely to make male and female sterilization less popular options. The situation in developing countries, where most of the population growth will be taking place, will be very different. The inexorable spread of HIV infection form Africa to Asia, with India as its new epicentre, will drastically reduce life expectancies, with early childbearing as the probable response. The condom is likely to remain the only contraceptive that offers protection against the rising tide of sexually transmitted diseases. Massive educational efforts will be needed among adolescents to increase condom acceptability and use. Loose fitting, re-usable plastic condoms might be more “sensational” and cost effective than the current latex varieties. They would also be more compatible with a range of new topical microbicides and HIV receptor blockers that should afford additional protection to men and women against sexually transmitted diseases. As abortion becomes legal in more and more developing countries, maternal mortality rates should fall. Cheap non-surgical means of female sterilization will also have an important role to play as desired family size continues to decline.
SEPTEMBER
SS3.04 GERMAN
SOCIETY
6
SESSION
ss3.04.02 HEMATOPOIETIC TRANSPLANT POTENTIAL OF UNRELATED AND RELATED CORD BLOOD: EXPERIENCE OF THE EUROCORDiNETCORD BANK DUSSELDORF T. Somville’, H. Riittge&, W. Meie?, 0. Bellmann“, A. Ring, HG. Schniirch6, H. Streng’, H. Lehnen’, M. Kusche’, U. Rosseck”‘, G. Kegler” and P. Wernet”. ‘Dept. of Gynecol. and Obstetrics H.-Heine-University Diisseldorf, ‘St.Antonius Wuppertal, 3EVK Diisseldorf, “Florence Nightingale, Diisseldorf, ‘AKH Viersen, 6 Lukashospital Neuss, ‘Josefinum, Augsburg, ‘Elisabeth Hospital Rheydt, ‘Marienhospital Aachen, “‘Dept. of Gynecology and Obstetrics Neuwerk, “Institute for Transplant Diagnostics and Cell Therapeutics, H.-Heine-University Diisseldorf. To date, hematopoietic stem cells from cord blood (CB) have been employed in over 1500 allogeneic (sibling and unrelated matched and mismatched transplantation’s worldwide. The examination and standardization of unrelated and related cord blood derived stem cell preparations and banking as well as their biological characterization was initiated in Diisseldorf already in 1993. Hitherto a total of 4615 CB samples (4513 unrelated, 132 for directed donations within the family; mean volume 90+25 ml, total nucleated cells (NC) 10+5x108) from cord blood have been defined by hematological, immunological and microbiological criteria. These CB samples were collected from the umbilical cord vein immediately after vaginal full term delivery or cesarean section and stored frozen in liquid nitrogen. Only 5.0 ml of a CB sample is required for routine laboratory testing as there are HLA-class I typing, HLA-class II typing by sequence-specific oligonucleotide probes (PCR-SSOP), ABO typing, sterility control, assessment of progenitor- and stem cells by colony forming- assays, and CD34+ status as well as for CMV, Hepatitis B, C, HIV, Parve B19 before releasing the CB unit for transplantation. With regard to viral infections maternal sera were tested for HBsAg , anti-HBc, anti-HCV; HIV-1-2, -HTLVI-II, -CMV and Syphilis. Within the last four years a total of 7400 preliminary searches, 920 extended unit reports were submitted to the CB bank Diisseldorf by fax or World Wide Web. Thusfar 102 unrelated and 3 related CB units were transplanted in over 40 different transplant centers world-wide. The median patient age was 6 years (range 0.3.48), the median weight 2lkg (range 4-70kg). The majority of the patient suffered from ALL (n=36), JCML (n=l) AML (n=13), CML (n=8) and Lymphoma (n= 5), MDS (n=6), AA (n=5), FA (n=2); 29 patients had genetic and acquired diseases. All CB samples as well as the patients blood samples were typed in Duesseldorf for HLA-class I by serology confirmed by PCRSSP and by high resolution DNA typing for HLA-DRBl and HLADQBl alleles. 94% of the 105 patients receiving unrelated CB were mismatched at one or more HLA-loci. Until now 41 patients transplanted with unrelated CB from Diisseldorf were evaluable for engraftment with an overall engraftment rate of 84% with a median time of 23days (range lo-57 days). 49% of the transplanted patients are alive with a median follow-up of 320 days.
ss3.04.03 NEW THERAPEUTIC APPROACHES IN CERVICAL CANCER PATIENTS A. Schneider and M. Passover, Dept. Gyn., University of Jena, University Hospital, Jena, Germany Objectives: The aim of the study was to investigate the effect of nerve sparing laparoscopic assisted radical vaginal hysterectomy (LARVH) type 3 for preservation of bladder function. Study Methods: 66 patients with cervical cancer FIG0 Stage lbl, lb2, 2a, and 2b underwent LARVH type 3. In 38 patients only the vascular part of the cardinal ligament was transected at the pelvic side wall and the neural part was preserved. In 28 patients the conventional type 3 procedure with complete transection of the vascular and neural part of the cardinal ligament and at the pelvic side wall had been done. Results: There was no difference in peri- and post- operative complications between both groups. Bladder training by suprapubic catheter was stopped at postoperative day 11.2 in the patients treated by the nerve sparing techniques compared to 21.4 days in patients treated by the conventional technique (p=O.O007). Length of the parametrium measured on the fresh specimen was 6.8 cm for both groups.
13
Conclusions: Nerve sparing LARVH type 3 allows preservation of the motoric function of the bladder without imparing radicalness of resection of the parametrium.
ss3.04.05 FRONTIERS Thomas
IN GYNECOLOGICAL ENDOCRINOLOGY University Women’s Hospital; Heidelberg, Germany
Selectic topics based on clinical trials mainly performed in Europe: Hyperandrogenism: workup according clinical feature; in cases with moderate and severe androgenisation an androgen producing tumor must be ruled out by serum testosterone (>1,5 ngiml) and DHEAS (> 7 pgiml); in infertility patients a 21.hydroxylase-deficiency must be suspected by 17.OH-progesterone > 4 ng/ml after ACTH stimulation test (25 IU i.m.) and verified by a gene sequenzing; if positive a screening of the partner and a dexamethasone therapy in early pregnancy until genetic diagnosis is recommended. Treatment option in non-infertility patients range from spironolactone, low dose OCs to OCs containing cyproterone acetate’), chlormadinone acetate’), dienogest’) or norgestimate (* not on the US market). Thrombophilia: increased risk for thrombosis by use of OC (up to 50. 200fold in patients with homocygous factor-V-Leiden mutation) as well as in HRT takers (2.3fold) (controls: l/l0 000). Family risk (history) for cardiovascular disease must be considered and if positive a screening is recommended for antithrombin III, protein-C, -S and APC-resistancy, exclusion of Factor-V-Leiden, and optional: homocysteine, lipids or carbohydrates. No differences in thrombophilia due to different progestagens used for OC and HRT. Contraception: New progestogens for oral hormonal contraception are or will be soon available: medrogestone (Wyeth), drospirenone (Schering). Progestogens with low androgenicity should be preferred. New 24.dayregimen with gestodene; clinical trials with Ocs containing natural estrogens. New ethinyl estradiol free oral hormonal contraceptives. The levonorgestrel releasing system (MirenaiSchering) has been accepted by more than 1.5 million users in Europe. Further innovations: vaginal rings, hormonal patches, implants and once-a-month injectable. HRT: 70 innovations (35 patches) are in clinical trials. Continuous, cyclic or intermittend use of progestogens might be selected for endometrial protection as well as a small levonorgestrel releasing IUS. Primary prevention of cardiovascular disease and Alzheimer must be prooven for ERT/HRT as well as their use following gynecological cancers. Breast cancer: HRT increases the chance the breast cancer diagnosis leading to a favorable prognosis and lower mortality when compared to non-HRT users.
SS3.04.06 NEW PROCEDURES OF OVARIAN STIMULATION. Klaus Diedrich, Michael Ludwig, Department of Gynecology Obstetrics, Medical University of Liibeck, Liibeck, Germany
and
Ovarian stimulation is an essential part of each treatment cycle in assisted reproductive technology (ART). However, especially in IVF these ovarian stimulation procedures have different problems like the risk of ovarian hyperstimulation syndrome (OHSS), patients discomfort due to the length of the procedure, hormonal withdrawal symptoms or cyst formation. Using the new drug class of LHRH antagonists, some of these problems can be avoided or significantly reduced in their incidence. Ovarian stimulation can be integrated in a spontaneous menstrual cycle. With Cetrorelix (Cetrotide, ASTA Medica AG, Frankfurt, Germany & Serono International S.A., Geneva, Switzerland) the first antagonist was available. It could be shown in a prospective, randomized study, that the risk of OHSS was significantly reduced with Cetrotide compared to the long protocol. Prospective, randomized studies using Cetrotide as well as prospective studies using the antagonist Ganirelix (Orgalutran, Organon GmbH, Oss, The Netherlands) showed, that antagonists can be used with either urinary gonadotrophins or recombinant FSH with the same success rates. There is an ongoing debate, whether antagonist protocols might lead to lower pregnancy rates compared to agonist protocols in ovarian stimulation. Until now, no prospective randomized study could show a significant difference in pregnancy rates. A tendency towards lower pregnancy rates in antagonist protocols might be due to a bias in the studies and to a learning curve, which is necessary to yield optimal results with this new drugs. An open worldwide observational study using Cetrotide showed
14
WEDNESDAY,
pregnancy rates in daily practice, which are in the range of the long protocol. In experienced centers no disadvantages for the patients could be seen, when Cetrotide was used instead of the long protocol.
SS3.05 INTERACTIVE
SESSION
ss3.05 SOLVING THE DILEMMAS, AN OBSTETRICAL ISSUE (I AND II) Ernesto Instituto National de Perinatologia, Mexico Cty, Mexico Preterm labor remains as a worldwide public health problem; lack of evidence and consensus over diagnostic and therapeutic issues still generate an enormous amount of controversy. This course is designed to review the way to approach this problem, confront different ways to handle it, hear the experts opinion and take a look at the evidence in an interactive session which includes case presentations. Main objects are to review etiology and epidemiology, identify risk, approach prevention, discuss management, anticipate potential complications, improve fetal outcome and consider delivery options. The course will start with a brief review lecture based on evidence followed by several short controversial case presentations covering different aspects of the topic; by electronic means the audience will have the opportunity to test its skills, compare and discuss them with the rest of the participants.
PS3.01 PRESIDENT’S
SESSION
PS3.01.03 PARTNERSHIPS FOR SAFE MOTHERHOOD: HOW MUCH IS A MOTHER WORTH? .I. E. Thomuson, University of Pennsylvania, Philadelphia, PA, United States This paper will address the power of partnerships in promoting Safe Motherhood globally and locally. Particular attention will be given to the role of the International Confederation of Midwives (ICM), FIGO, and WHO as partners in promoting the health of women and childbearing families throughout the world, including their participation with others on the Interagency Group on Safe Motherhood (IAG). Examples of these important partnerships will be drawn from joint efforts in upgrading the knowledge and skills of midwives through pre-Congress workshops, the promotion of Life Saving Skills in the developing world, and the setting of international competencies and standards for all those with “midwifery skills” who are vital in any effort to reduce maternal morbidity and mortality throughout the world. Skilled attendance at birth is one of the lessons learned from over 10 years of the global Safe Motherhood Initiative, and will be used as one example of the power of partnerships that promote the health of women. The discussion of the collaborative relationships between midwives and obstetricians at local, national, regional and global levels will focus on those aspects of this inter-professional relationship that promote the health of women with seamless, high quality, evidenced-based childbearing care from village through hospital, as needed. Discussion will highlight some of the inter-professional conflicts during the past decades as well as successes based on mutual respect, trust, and appropriate use of the unique competencies of both obstetricians and midwives in the care of women during their childbearing years. Examples from developed and developing nations will be used to answer the question, “How much is a mother worth?” The summary of this paper will focus on the values and ethics of Safe Motherhood, and the basic human rights that are needed by women in order to survive one of their most important roles in any society -that of bearing and caring for the world’s children. Midwives and obstetricians working together can make a difference in lives of all the world’s women and families.
PS3.02.02 CONTRACEPTION IN 2050 Professor R V Short, Department of Obstetrics & Gynecology, Women’s Hospital, University of Melbourne, Australia
Royal
By 2050, the population of the world will be around 10 billion. Many developed countries will have falling populations, as the increasing costs
SEPTEMBER
6
of educating children make childbearing prohibitively expensive, and as women choose to postpone marriage and childbearing for the sake of their careers. Improved sex education in school, and free availability of condoms, the oral contraceptive pill and emergency contraception will hopefully reduce the current high rates of teenage pregnancy and abortion. After achieving their desired family size, women will increasingly opt for forms of contraception like gestagen-releasing intrauterine devices that reduce menstrual blood loss, thereby avoiding the need for a hysterectomy as the menopause approaches. It seems unlikely that we will develop an effective hormonal or immunological contraceptive for men. The rising divorce rate is likely to make male and female sterilization less popular options. The situation in developing countries, where most of the population growth will be taking place, will be very different. The inexorable spread of HIV infection form Africa to Asia, with India as its new epicentre, will drastically reduce life expectancies, with early childbearing as the probable response. The condom is likely to remain the only contraceptive that offers protection against the rising tide of sexually transmitted diseases. Massive educational efforts will be needed among adolescents to increase condom acceptability and use. Loose fitting, re-usable plastic condoms might be more “sensational” and cost effective than the current latex varieties. They would also be more compatible with a range of new topical microbicides and HIV receptor blockers that should afford additional protection to men and women against sexually transmitted diseases. As abortion becomes legal in more and more developing countries, maternal mortality rates should fall. Cheap non-surgical means of female sterilization will also have an important role to play as desired family size continues to decline.