Evidence-based reproductive medicine.

Madam I look forward to the arrival of the Journal. It is always a good read, full of relevant and practical information – much more ‘user-friendly’ than most journals I receive these days. July’s edition seemed particularly interesting with a number of interesting articles. However, my interest was quickly replaced by irritation. There is a lot to be said for evidencebased medicine (EBM) and it is always helpful to have a review of the current evidence available in order to provide women with accurate information when discussing contraception. However, it is not sufficient just to provide the ‘evidence’. EBM must consider that clinicians need practical guidance with decision making. The Clinical Effectiveness Unit (CEU) product review of the desogestrel-only pill is just one example of EBM being unhelpful to our clinical practice. It states: ‘an evidence-based recommendation cannot be made that the desogestrel-only pill is different from other POPs in terms of efficacy, nor that it is similar to combined oral contraception (COC) in this respect.’1 The recommendation is based on insufficient evidence to support lower failure rates with the desogestrel pill. This is despite another study showing that the desogestrel-only pill was sufficient to inhibit ovulation in 97% of cycles and that this is its primary mode of action. The suggestion that the data provided by the manufacturers may not be credible raises an additional concern. In the same edition an excellent article on evidence-based reproductive health by Robbie Foy quotes a Chinese proverb: ‘Be careful what you wish for: it may come true’.2 The author adds that pharmaceutical industryfunded trials tend to report more favourable findings than those funded by other means, noting that one of the trial authors for the desogestrelonly pill studies is affiliated to the company that manufactures the pill. If this is an issue, then we must equally be assured that none of those undertaking the desogestrel-only pill review have any relevant associations with the manufacturers of other progestogen-only pills (POPs), who are unlikely to welcome this new competitor. I am not denying the need for more unbiased clinical trial evidence; I am just despairing at our sudden inability to put the information to practical rather than theoretical use. Are we really supposed to tell women that a POP that inhibits ovulation in 97% of cycles is no more effective than currently available POPs? One final point refers to the FFPRHC Guidance on Contraceptive Choices for Women with Inflammatory Bowel Disease3 which includes the repeated comment that WHO 3 implies cannot use, e.g. ‘Women with primary sclerosing cholangitis should not use the POP (WHO Category 3 – risks outweigh the benefits)’. I am concerned that the CEU is perpetuating this misinterpretation of the WHO 3 category that does not absolutely contraindicate use, although other methods should be the first choice.