Assisted conception on the NHS?

membrane ion transport, possibly as a result of hypoxia, is probably responsible for the development of cerebral oedema in diabetic ketoacidosis. Though the aetiology of the condition is still unclear, management must aim to minimise the risk. Cerebral oedema usually presents 2-24 hours after treatment has started, with abrupt neurological deterioration and coma followed by respiratory arrest. In retrospect warning signs, such as headache, incontinence, and behavioural changes are often present a few hours earlier. The only conventional treatment that may help is mannitol. This is most effective when given soon after the onset of oedema, with over half the reported patients left with mild or no disability.'9 The only danger is of plasma hyperosmolality after repeated doses. Dexamethasone does not seem to help and hyperventilation may be harmful since the fall in arterial carbon dioxide concentration will reduce cerebral perfusion pressure, predisposing to ischaemic damage. Finally, in view of the probable role of changes in plasma osmolality, abrupt changes in glucose and electrolyte concentrations should be avoided. Colloid and crystalloid replacement could be alternated during initial rehydration to maintain plasma osmolality while the fluid and electrolyte abnormalities are corrected. When possible, plasma osmo-lality and concentrations of blood glucose and plasma sodium should be monitored and the rates of insulin and saline infusion adjusted to avoid rapid reduction; a fall in osmolality of less than 5 mmol/h is optimal. By such intensive monitoring it may be possible to reduce the incidence of this devastating complication. 1 Rosenbloom AL. Intracerebral crises during treatment of diabetic ketoacidosis. Many infertile couples could be helped Assisted conception, which includes the use of in vitro fertilisation, gamete intrafallopian transfer, and intrauterine insemination, is unusual in many respects. Very few techniques have been introduced into medical practice and developed under the same degree of public and professional scrutiny. Test tube babies raised political, ethical, and social questions such that it is the only branch of British medicine whose practice is highly regulated by statute law.' With few exceptions health authorities have refused to fund assisted conception within the NHS so that its development and delivery have been almost entirely in the private sector. The dearth of well conducted trials of clinical efficacy is therefore unsurprising, although the registration of results through the Voluntary Licensing Authority, Interim Licensing Authority , and now the Human Fertilisation and Embryology Authority has provided a national audit of activity and results.2 …