When normal volunteers ate isocaloric wheat-based meals, their plasma insulin responses (peak concentration and area under curve) increased stepwise: whole grains less than cracked grains less than coarse flour less than fine flour. Insulin responses were also greater with fine maizemeal than with whole or cracked maize grains but were similar with whole groats, rolled oats, and fine oatmeal. The peak-to-nadir swing of plasma glucose was greater with wheat flour than with cracked or whole grains. In vitro starch hydrolysis by pancreatic amylase was faster with decreasing particle size with all three cereals. Correlation with the in vivo data was imperfect. Oat-based meals evoked smaller glucose and insulin responses than wheat- or maize-based meals. Particle size influences the digestion rate and consequent metabolic effects of wheat and maize but not oats. The increased insulin response to finely ground flour may be relevant to the etiology of diseases associated with hyperinsulinemia and to the management of diabetes.

Ectopic pregnancy is a well known complication of in-vitro fertilization (IVF) and embryo transfer. From March 1983 to December 1993, 3000 clinical pregnancies were achieved at Bourn Hall Clinic, including 135 ectopic pregnancies (4.5%). Of these ectopics 20 were heterotopic, eight ovarian, six bilateral tubal and the remainder were singleton tubal pregnancies. The main risk factor identified in the series was a history of pelvic inflammatory disease (P < 0.001). The data also showed that ectopic pregnancy is at present more prevalent among patients in whom tubal damage is the reason for treatment. There was slight statistical evidence (P = 0.05) that patients having ectopic pregnancies received a higher volume of culture medium than those having normal deliveries. There was also an apparent trend (P = 0.07, not significant) that high progesterone/oestradiol ratio on the day of embryo transfer was associated with ectopic pregnancy. There was no statistical evidence of association between ectopic pregnancy and a history of ectopic pregnancy, abortion, still birth, termination of pregnancy, neonatal death, tubal surgery, ovarian stimulation protocol, plasma concentration of oestradiol, luteinizing hormone and progesterone, number of oocytes retrieved, number or quality of embryos transferred, administration of general anaesthesia for embryo transfer, and the number of patent Fallopian tubes. Awareness of the risk factors associated with ectopic pregnancy plays an important part in the early diagnosis of this potentially fatal condition.

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A total of 20 cases of heterotopic pregnancy were encountered among 2650 clinical pregnancies (0.75%) resulting from in-vitro fertilization/embryo transfer at Bourn Hall Clinic (Cambridge, UK) during the period July 1984-July 1993. The aetiology of heterotopic pregnancy in the series is multifactorial, with tubal damage as the main factor. Transvaginal ultrasonography showed a high sensitivity for making correct diagnoses of heterotopic pregnancies compared with transabdominal ultrasonography (93.3 versus 50.0%). The mean plasma human chorionic gonadotrophin (HCG) concentration on day 13 after embryo transfer was similar to those of uncomplicated intrauterine pregnancies and hence was of no diagnostic value. The serial plasma HCG concentrations of patients who delivered were significantly higher than for those who aborted their intrauterine pregnancies (P < 0.01), although the sample of data available was too small to make firm inferences. It does appear that serial HCG concentrations may have a predictive value of fair accuracy regarding the outcome of the intrauterine pregnancy in heterotopic pregnancies. The clinical presentations of the 20 cases at first examination were quite variable, with 45% (9/20) of patients asymptomatic. Tubal pregnancy in one patient resolved spontaneously, two cases were treated by an injection of potassium chloride into the gestational sac and the remaining 17 cases were treated by salpingectomy. In 10 patients the intrauterine pregnancy resulted in live birth and the remaining 10 patients aborted spontaneously.

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