CO2 laser laparoscopy in infertile women with endometriosis and women with adnexal adhesions.

One hundred twenty-four infertile women either with endometriosis (n = 70) or with adnexal adhesions (n = 54) were treated with the carbon dioxide laser used laparoscopically and were followed for 18 months. Removal of endometriotic implants, vaporization of endometrioma capsules, and lysis of adnexal adhesions was accomplished. Postoperative pregnancy rates were as follows: 57% for patients with endometriosis (mild, 62%; moderate, 52%; severe, 42%) and 57% for patients with adnexal adhesions. No serious complications requiring laparotomy were encountered. When performed, second-look laparoscopy confirmed efficient removal of endometriosis.

Tubal infertility in relation to prior induced abortion.

One hundred twenty-seven women who had been given diagnoses of tubal infertility between 1979 and 1981 in King County, Washington, yet previously had been pregnant, were interviewed to determine their prior history of legally induced abortion. Their responses were compared with those of 395 women who conceived a child at the same time the infertile women began their unsuccessful attempt to become pregnant. In making the comparison, we adjusted for the effects of variables that in this population were related both to having an induced abortion and to the occurrence of infertility, i.e., age, number of prior pregnancies, number of sexual partners, cigarette smoking habits, Dalkon Shield (A. H. Robins Company, Richmond, VA) use, and whether the woman worked outside the home. The risk of tubal infertility in women who had had an induced abortion was not increased above that of other women (relative risk, 1.15; 95% confidence interval, 0.70 to 1.89). For women with two or more abortions, the relative risk was 1.29 (95% confidence interval, 0.39 to 4.20). When only the most recent pregnancy was considered, the relative risk was 1.19 (95% confidence interval, 0.72 to 1.97). Our results suggest that legal abortion, as performed during the past decade in the United States, does not carry an excess risk for future tubal infertility.

PIP: 127 women who had been given diagnoses of tubal infertility between 1979-81 in King County, Washington, yet previously had been pregnant, were interviewed to determine their prior history of legally induced abortion. Their responses were compared with those of 395 women who had conceived a child at the same time the infertile women began their unsuccessful attempt to become pregnant. In making the comparison, the authors adjusted for the effects of variables that in this population were related to both having an induced abortion and to the occurrence of infertility; i.e., age, number of prior pregnancies, number of sexual partners, cigarette smoking habits, Dalkon Shield (A.H. Robins Co., Richmond, Virginia) use, and whether the woman worked outside the home. The risk of tubal infertility in women who had had an induced abortion was not increased above that of other women (relative risk, 1.15; 95% confidence interval, 0.70-1.89). For women with 2 or more abortions, the relative risk was 1.29 (95% confidence interval, 0.39-4.20). When only the most recent pregnancy was considered, the relative risk was 1.19 (95% confidence interval, 0.72-1.97). Results suggest that that abortion, as performed during the past decade in the U.S., does not carry an excess risk for risk tubal infertility.

Unsuspected chronic pelvic inflammatory disease in the infertile female.

Diagnostic laparoscopy performed during an infertility evaluation identified 80 patients with hydrosalpinges (12% of all laparoscopic examinations performed for infertility). Despite these findings, only 20 (25%) of these patients reported a prior episode of acute pelvic inflammatory disease (PID), and only 18 (22.5%) had complaints of pelvic pain. Compared with a matched group of infertility patients with no endoscopic evidence of prior pelvic infection, those patients with hydrosalpinges were more likely to have used an intrauterine device and were less likely to have used an oral contraceptive. Since "silent" PID is a potential cause of infertility, endoscopic visualization of the female reproductive organs should be considered during the infertility evaluation. Moreover, in view of its insidious nature, the diagnosis of PID should be considered in a young sexually active patient with gynecologic complaints.

Outpatient laparoscopic interval female sterilization.

A 23-year retrospective review of laparoscopic sterilization in Ramathibodi Hospital, Bangkok, Thailand, is reported. A total of 9041 cases of outpatient laparoscopic interval female sterilizations were done from January 1973 to December 1995. Intraoperative complications occurred in 35 cases (0.39%) and hospital admissions totalled 65 cases (0.72%). Adnexal injuries were the most frequent complication. There was one case of death from anesthetic complication. Management and prevention of complications are discussed.

PIP: To evaluate outpatient laparoscopic sterilization, a retrospective review was conducted of all 9041 such procedures performed at Ramathibodi Hospital in Bangkok, Thailand, during 1973-95. Intraoperative complications occurred in 35 cases (0.39%) and there were 65 hospital admissions (0.72%). The 1 death in this series (mortality rate, 11/100,000 procedures) was due to an adverse reaction to neuroleptanalgesic drugs. Adnexal injuries, present in 20 cases, were the most frequent complication. There were 5 cases of bowel and mesenteric injuries, 3 retroperitoneal injuries, 3 uterine injuries, and 2 bladder injuries. By type of instrument, 26 cases involved electrocautery (generally mesosalpingeal and meso-ovarian bleeding); in another 7 cases, trocar insertion was implicated. Use, at this facility, of the Ramathibodi uterine elevator as a uterine manipulator is believed to have significantly reduced the incidence of uterine perforation, a major complication in studies from other settings. However, the overall safety of laparoscopic female sterilization depends on the skill and experience of the surgeon.

Mechanism of action of intrauterine devices: biochemical changes.

The mechanism of action of intrauterine devices varies from one type of device to another, although the principle of action is the same, namely, to interfere with the physiology of reproduction at the endometrial level. The biochemical changes of the endometrial tissue and the composition of the uterine fluid have been reviewed in relation to the use of inert, copper-medicated and steroid-releasing IUDs. All IUDs, whether inert or medicated, provoke a significant increase in the number of neutrophils, mononuclear cells and plasma cells, the presence of which is unrelated to the tissue infiltration of inflammatory cells occurring pre-menstrually of the normal menstrual cycle. The increase of leucocytes in IUD-users is compatible with a foreign body reaction which may be related to the antifertility effect. The addition of copper to an inert IUD has been shown to significantly alter the metabolism of the endometrial cells, e.g. the enzymatic activity and the DOVA-synthesis. The steroid-medicated IUDs represent a new approach to intrauterine contraception where the morphology of the endometrium is considerably altered, showing massive decidual changes, atrophic glands and sometimes atrophy of the whole functional layer. In addition, there is an important foreign body reaction, similar to that of the inert IUDs. The enzymatic activity, as well as the proliferative activity was significantly altered in the endometrium of these IUD-users. Changes in the endometrial fibrinolytic activity in IUD-users have been demonstrated to be related to the presence of irregular bleeding. Micro-traumata of the endometrium and the increased fibrinolytic activity may also interfere with the protective processes present in the physiologically normal endometrium. Further studies on the factors influencing the fertilizing ability of the spermatozoa in the female genital tract, as well as on the conditions of the human endometrium required for the implantation of a blastocyst, may yield important information for the improvement of intrauterine contraception.

Intrauterine devices and pelvic inflammatory disease: recent developments.

The potential relationship between use of intrauterine devices and pelvic inflammatory disease is one of the most important issues in contraception today. A number of large, sophisticated studies published since mid-1980 have clarified this association. All have consistently revealed an increased risk of pelvic inflammatory disease among intra-uterine device users, but the most objective of these studies indicate a relative risk compared to women using no method (1.5-2.6) lower than previous estimates. For most intrauterine device wearers, the increased risk of pelvic inflammatory disease persists for only a few months after insertion. The Dalkon Shield appears associated with a higher risk of pelvic inflammatory disease than the Lippes Loop, Saf-T-Coil, or copper devices. Careful selection of candidates for intrauterine devices may further reduce the risk of intrauterine device-associated pelvic inflammatory disease.

PIP: The potential relationship between use of IUDs and pelvic inflammatory disease (PID) is one of the most important issues in contraception today. A number of large sophisticated studies published since mid-1980 have clarified this association. All have consistently revealed an increased risk of PID among IUD users, but the most objective of these studies indicate a relative risk compared to women using no method (1.5-2.6) lower than previous estimates. For most IUD users, the increased risk of PID persists for only a few months after insertion. The Dalkon Shield appears associated with a higher risk of PID than the Lippes Loop, Saf-T-Coil, or copper devices. Taken together, these studies suggest that IUD use carries a small but real risk of PID that is attributable to endometrial contamination at the time of insertion. Careful selection of candidates for IUD use--white women aged 25 years or over who have only 1 sexual partner--can reduce this risk.

Microbiological and histological findings in the fallopian tubes of women using various contraceptive methods.

The oviducts of seventy-three women undergoing sterilization by partial salpingectomy were submitted for microbiological and histologic studies. Twenty women were intrauterine device users, twenty-five women were oral contraceptive pill users and twenty-eight women used natural or barrier methods of contraception. Among intrauterine device users, there was an excess of mild and severe acute inflammatory histologic changes involving both the lumen and the tubal mucosa. Five of the eight intrauterine device users with acute inflammatory change had sterile tubal cultures.

PIP: The oviducts of 7o women undergoing sterilization by partial salpingectomy were subjected to microbiologic and histologic study. The objective was to determine whether there is a link between the histologic evidence of salpingitis and microbiological findings in the fallopian tubes of IUD users. Of the 73 subjects, 20 had been IUD users, 25 used oral contraceptives (OCs), and 28 were natural or barrier mehtod users. Microscopic examination revealed no significant differences between user groups with respect to edema, fibrosis, chronic inflammation, or granulomatous inflammation. However, acute inflammatory cells were found in the lumen and the mucosa of the right or left tube in an excess of IUD users. 5 of the 8 IUD users with acute inflammatory change had sterile tubal cultures. There were no differences between user groups with respect to the microbiologic organisms found in cervical or oviductal cultures, supporting the concept that inflammatory changes do not necessarily reflect the presence of infection. Further studies of the links between IUD use, sterile acute inflammation, and pelvic infection are recommended.

IUD (Nova-T) insertion following induced abortion.

In a prospective study, 86 women who had an IUD (Nova-T) inserted immediately after induced abortion were compared to 95 abortion patients who started another contraception (control I). Additionally, the rate of complications following IUD insertion in a Family Planning Clinic (control II) were studied in 83 non-pregnant women. The overall infection rate for post-abortion patients was 4.4% (5.8% in the study group, 3.2% in control I). No infections were observed in control group II. Confidence limits (95%) for the three groups were overlapping. Among the women in the study group, bleeding and pain were not more frequent, but if one of these complications occurred, it tended to be more serious and the duration was longer. The number of days before resumption of work after abortion was 3-4 days in both abortion groups. After three months, the continuation rate was 83% (71 of 86) in the study group, 76% (72 of 95) in control I and 93% (77 of 83) in control II. Sixty-nine of the 181 women admitted for legal abortion had been admitted for the same reason previously. In this study, the recurrence rate after 12 months was 0% in the study group and 4.2% (4 of 95) in control group I. The insertion of an IUD at the time of abortion seems to be an effective and acceptable solution to the problem of recurrent abortion.

Tubal conservation with ectopic gestations. A reappraisal.

Ectopic pregnancies have shown an increasing trend during the past decade. Factors that appear to be responsible are the intrauterine device (IUD), fallopian tube surgery (ligation reversals, reconstructive tuboplasty), and more effective antibiotics against pelvic inflammatory disease (precluding radical pelvic surgery). Our ability to diagnose an ectopic pregnancy at an earlier gestation (prior to rupture) through the use of highly sensitive pregnancy tests (Beta-HCG), ultrasonography, and diagnostic laparoscopy, has significantly altered our approach in treatment. Because these ectopic gestations are seen in a younger population, older nulliparous patients, and patients who desire future fertility, earlier diagnosis precludes an emergency approach to a now-elective procedure. In this paper, we will explore the pros and cons of conservative management for ectopic pregnancies, emphasizing present day evaluation and microsurgical approaches for repair.

PIP: This article examines causal factors of ectopic pregnancy, discusses management with emphasis on tubal conservation, and updates information on diagnosis, fertility maximization, and minimization of risks of recurrent ectopic gestations. The common factor in ectopic gestations appears to be a delay in the transport of the fertilized ovum to the uterus, allowing the embryo to develop invasive trophoblast. Factors that appear to have increased the incidence of ectopic pregnancy over the past include increased sexual exposure, more effective theraphy for pelvic inflammatory disease, IUDs, tubal surgery, and surgical sterilization reversals. 77% of extrauterine gestations occur in the middle and distal thirds of the fallopian tube, with clinical manifestations largely determined by the site of implantation. Abdominal pain, amenorrhea/vaginal bleeding, and a pelvic mass are the classic signs of an ectopic pregnancy. Newer diagnostic procedures including serum human chorionic gonadotropin-beta subunit assay pregnancy testing supported by ultrasonography and laparoscopy have allowed the vast majority of tubal pregnancies to be diagnoses before rupture, permitting surgery to be undertaken more for the purpose of preserving fertility than for saving the mother's life. Factors in selecting candidates for conservative surgery include medical stability of the patient, parity, desire for future pregnancy, age under 35, mid or distal tubal gestation, prior ectopic gestation or tubal surgery. Considerations influencing the surgical approach for appropriate candidates include location of the pregnancy, condition of the involved and contralateral tube and ovary, pelvic anomalies, previous surgery, and need for ancillary procedures. If the ectopic gestation is located in the mid to distal segment of the fallopian tube, a segmental resection or salpingostomy using microsurgery should give a good anatomic and functional result. A review of the literature indicates that, contrary to prevailing opinion, recurrent etopic gestations are not more common in patients undergoing tubal conservation than in those undergoing more radical procedures. Recent data have shown term pregnancy rates of 40-55% and recurrent ectopic pregnancy rates of 5% in patients with conservative procedures, the improved rate being attributed to availability of microsurgical techniques, finer suture and minimal surgical trauma, which lead to less adhesions and scarring. tudies have indicated that use of Dextran minimizes pelvic adhesion formation, decreasing anatomic distortion leading to subsquent infertility or ectopic pregnancy.

Preventive lymecycline therapy in women with a history of pelvic inflammatory disease undergoing first-trimester abortion: a clinical, controlled trial.

In a clinical, controlled trial 55 women with a history of pelvic inflammatory disease (PID) undergoing first-trimester abortion were randomized to either lymecycline therapy or placebo. Twenty-four women received lymecycline capsules 300 mg b.i.d. for 14 days starting on the morning of the abortion and 31 received similar placebo medication. In the lymecycline group 2 women (8.3%) and in the placebo group 7 (22.6%) contracted postabortal PID, a non-significant difference (p greater than 0.2). The variables age, gestational age, number of spontaneous abortions, births and episodes of PID, and Hegar size were not associated with the rate of postabortal PID. Women without previous induced abortions had a significantly increased rate of postabortal infection (p = 0.02), but the treatment did not influence this rate. Three women had a positive culture for Chlamydia trachomatis at the time of abortion and two of these had postabortal PID. None of 7 women with postabortal PID had significant increases in IgA, IgG or IgM chlamydia antibody titers, but two women with uncomplicated abortions had serological evidence of infection. The number of hospital days and amounts of antibiotics prescribed to women with postabortal PID were not significantly different between the two treatment groups (p greater than 0.05). Women with a history of PID had an elevated risk of postabortal PID warranting the use of some sort of prophylaxis, and screening for C. trachomatis in an abortion population is recommended.

PIP: To assess the efficacy of prophylactic antibiotics on postabortal infection in women with a history of pelvic inflammatory diseases (PID), 55 such women undergoing 1st-trimester pregnancy termination were randomly assigned to receive either lymecycline therapy or placebo. Chlamydial antibodies were investigated in all women before and after the abortion. 24 women received 300 mg lymecycline capsules for 14 days, starting on the morning of the abortion procedure; the remaining 31 women received placebo medication on the same schedule. Postabortal PID occurred in 2 women (8.3%) in the lymecycline group and 7 women (22.6%) in the placebo group--a nonsignificant difference. Age, gestational age, number of spontaneous abortions, births, previous episodes of PID, Hegar size, and the presence of C trachomatis did not influence the rate of postabortal PID. Although women with no previous abortions had a significantly higher rate of infection, this rate was not influenced by the preabortion treatment mode. C trachomatis was identified in 3 of 53 women for whom cultures were obtained; 2 of these women contracted postabortal PID. None of the 7 women with postabortal PID had significant increases in IgA, IgG, or IgM chlamydia antibody titers, although 2 women with uncomplicated abortions had serologic evidence of infection. Use of lymecycline did not significantly reduce the number of hospital days or amounts of antibiotics required among women with postabortal PID. Overall, the high rate of postabortal PID recorded in this study among women with a history of PID (23%) supports the use of some sort of prophylactic method. Since these women do not seem to harbor chlamydial infection more often than women without previous PID, penicillin or ampicillin may be effective.

Torsion of the fallopian tube following tubal sterilization by electrocoagulation via a laparoscope.

Sterilization of the fallopian tube via a laparoscope is being performed with increasing frequency. A rare but serious late complication of this procedure is tubal torsion, which occurs especially after monopolar electrocoagulation where the mesosalpinx is extensively damaged. We present a case in which this complication occurred after bipolar electrocoagulation.

PIP: This article describes a case in which tubal torsion occurred as a complication of bipolar electrocoagulation via a laparoscope. The patient, a 37-year old woman who had undergone bipolar electroagulation of her fallopian tubes via a laparoscope 11 months earlier, presented with an acute abdomen. A preoperative diagnosis of torsion of an ovarian cyst was made. The right adnexa, including the entire fallopian tube and ovary, was infarcted and presented as a 10 x 7 x 4 cm mass that had undergone a torsion of 540 degrees. A right salpingo-oophorectomy and a left salpingectomy were performed, and microscopic examination confirmed the gross finding of infarction of the right adnexa and a left hydrosalpinx. Altogether, 14 case of tubal torsion following tubal sterilization have been reported since 1956. Of these, this is the 6th case associated with electrocoagulation. The interval between the sterilization procedure and presentation with torsion has ranged from 5 months to 8 years. Many patients present at the middle of their menstrual cycle. There is generally a history of acute onset of abdominal pain which may be generalized or localized to the lower abdomen or either iliac fossa (most commonly the right). The pain is usually not associated with gastroin estinal symptoms. Unlike acute salpin gitis, there is no fever or leucocytosis in early cases. There are signs of peritoneal irritation in the involved iliac fossa and an adnexal mass can usually be palpated on vaginal examination. Abnormal mobility and an abnormal bulk of tube appear to be required before the fallopian tube will undergo torsion. Increased mobility is caused by severing or at least constricting the attachment of the tube to the uterus. The increased bulk of the tube is produced when secretions from the tube can no longer travel into the uterus, resulting in a hydrosalpinx.

Genital infections in women undergoing therapeutic abortion.

We studied the prevalence of genital infections and the frequency of infectious complications in 170 women who requested an abortion in Antwerp, Belgium, where termination of pregnancy is still illegal. Chlamydia were isolated in 12% of these women, compared to a 0.6% isolation rate for N. gonorrhoeae. After the abortion 5.5% developed PID and 3% endometritis. There was a strong correlation between an infection with C. trachomatis before abortion and the appearance of infectious complications after the aspiration curettage. No such relationship was found with any other micro-organism. Depending on the prevalence of C. trachomatis in a given population, screening followed by selective treatment or prophylactic use of antimicrobial medication for all women is indicated to prevent post-abortum infections.

Background factors of ectopic pregnancy. I. Frequency distribution in a case-control study.

Two hundred and five patients with ectopic pregnancy in a well-defined Swedish population were interviewed with respect to prior disease and pregnancy histories as well as various constitutional and socioeconomic factors. The results were compared with those of two control groups, i.e. 110 early pregnant women intending to continue the gestation to term as well as 101 women seeking voluntary interruption of pregnancy. The results provide evidence that several may be involved in the etiology of ectopic pregnancy, including abdominal (or pelvic) surgery, previous ectopic pregnancy and pelvic inflammatory disease. Furthermore, a history of infertility is strongly correlated to ectopic pregnancy. On the other hand, there is no evidence that uncomplicated spontaneous or induced abortion, parity or marital status are important factors.

PIP: To further understanding of the etiology of ectopic pregnancy, selected background variables and pregnancy histories were compared among 205 women treated for ectopic pregnancy and 2 groups of controls--110 women in early pregnancy intending to carry the pregnancy to term and 101 women seeking voluntary pregnancy termination. The study findings suggested that previous ectopic pregnancy, abdominal surgery, infertility, and pelvic inflammatory disease (PID) may be involved in the etiology of ectopic pregnancy. 37% of ectopic pregnancy cases reported a history of involuntary fertility of at least 1 year's duration compared with 18% of the delivery controls and 3% of the abortion controls. 15% of cases had a history of prior ectopic pregnancy compared with 2% of the delivery controls and none of the abortion controls. 44% of cases but only 17% of both groups of controls had a history of abdominal surgery, i.e. laparotomy. Finally, a history of PID was found in 34% of cases compared with 21% of delivery controls and 15% of abortion controls. Nationality, marital status, profession parity, uncomplicated legal or spontaneous abortion, endometritis, bleeding abnormalities, intercurrent disease, physical constitution, cigarette smoking, and alcohol consumption did not differ significantly between ectopic pregnancy cases and controls. Multivariate analysis or logistic models is suggested to provide more detailed information concerning the validity of possible risk factors and to assess confounding factors.

Imaging of hydrosalpinx with torsion following tubal sterilization.

Hydrosalpinx following tubal sterilization has been observed with increasing frequency. Women who have had PID or who have used IUDs might be at risk of developing this condition because they may already have occluded tubes from prior salpingitis. If a previously occluded tube is ligated or cauterized so that a second occlusion is created, hydrosalpinx may be anticipated. Often bilateral, hydrosalpinx may be present for years. Recurrent pelvic pain may signify intermittent noninfarctive torsion, but severe acute pain is a sign of torsion with impending infarction and gangrene in some patients. This condition has been detected by ultrasound and CT, enabling preoperative diagnosis. Presumably it will also be imaged by MR. Nontorsive hydrosalpinx is usually imaged as a thin-walled adnexal cyst. Torsion with infarction is seen as a larger cystic structure with thicker walls and internal debris from venous congestion and internal hemorrhage. Since 25 of 30 patients with post-tubal sterilization hydrosalpinx have presented with acute torsion, the significance of a nontorsive hydrosalpinx detected by any imaging modality should not be disregarded. Surgical removal or percutaneous puncture and drainage should be considered. Awareness of the patient's medical history is the key to diagnosis.

PIP: Tubal sterilization, most commonly by means of ligation or cauterization, is performed every year on over 500,000 women in the U.S. It is generally regarded as a safe and effective means of pregnancy prevention. It has been reported, however, that 3 of 1,000 women become pregnant with 2 years of sterilization. In a recent study, 12% of pregnancies occurring after tubal ligation and 51% of pregnancies following tubal cauterization were ectopic. After several years, surgically sterilized fallopian tubes exhibit pathologic changes. After 5 years of sterilization, 80% of patients develop dilation of the proximal stump lumen, which may be filled with blood and fragments of menstrual endometrium. 39% of patients develop fibrosis of the distal stumps after 5 years of sterilization. If the lumen becomes blocked at 2 sites, hydrosalpinx forms as a result of tubal epithelium secretions. This condition has increasingly been observed as a consequence of tubal sterilization. Since 1956, 30 cases of hydrosalpinx due to tubal ligation and cauterization have been reported. In 25 of these cases, torsion of the hydrosalpinx resulted in acute abdominal pain; in some cases, gangrene had developed. On average, 3.8 years elapsed between tubal sterilization and clinical presentation. Hydrosalpinx has been detected through both computerized tomography and ultrasound, allowing for preoperative diagnosis. It is usually imaged as a thin-walled adnexal cyst. Torsion is seen as a larger cystic structure with thicker walls. The key to diagnosis is awareness of a patient's medical history.

Factors predicting abnormal hysterosalpingographic findings in patients treated for acute pelvic inflammatory disease.

One hundred forty-six consecutive inpatients with acute pelvic inflammatory disease (PID) were randomly treated either with the combination of doxycycline and metronidazole or with the combination of penicillin G/amoxicillin and metronidazole. Forty-three women underwent hysterosalpingography (HSG) 6 months after the treatment, and a multivariate statistical analysis was used to study the effect of 11 different variables (parity, history of previous abortion, history of previous PID, use of an intrauterine contraceptive device (IUD), use of oral contraceptives, presence of adnexal mass, results of cervical cultures for Neisseria gonorrhoeae, and Chlamydia trachomatis, presence of serum antichlamydial antibodies, penicillin-metronidazole treatment, and doxycyclin-metronidazole treatment) on the hysterosalpingographic findings. Abnormal HSG was most likely to occur in women who had antichlamydial antibodies present in the serum, an adnexal mass detected on the initial bimanual examination, or had an IUD (positive associations) and least likely to occur in women who had been treated with the combination of doxycycline and metronidazole (negative association).

Time to conception after IUD removal: importance of duration of use, IUD type, pelvic inflammatory disease and age.

Some investigations of IUD use have demonstrated impaired ability to become pregnant after removal, while others have not. None of these studies, however, have adequately considered such potentially influencing variables as age and a history of pelvic inflammatory disease (PID). To study the effect of length of IUD use, IUD type and the modifying influences of age and PID history on time required to conceive, we followed women trying to become pregnant after removal of their IUD. Five hundred forty women in Ljubljana, Yugoslavia who were first fitted with an IUD between 1964 and 1972 and had their IUD removed in order to become pregnant were followed through 1980. We found no relationship between the duration of IUD use or type of IUD used, but increasing age and a history of PID each decreased the monthly probability of conception. These findings, along with other recent work, indicate that IUDs are a safe and efficacious contraceptive for women at low risk for sexually transmitted diseases.

PIP: Previous investigations of IUD use have demonstrated impaired ability to become pregnant after removal, while other studies have not. None of these studies, however, have adequately considered such potentially influencing variables as age and a history of pelvic inflammatory disease (PID). This investigation uses regression analysis to assess the influence of various factors individually on time to conceive. 540 women in Ljubljana, Yugoslavia, who were 1st fitted with an IUD between 1964 and 1972 and had their IUD removed to become pregnant, were followed through 1980. The COX regression model is used to assess simultaneously the influences of length of IUD use, device type (Lippes Loop), age at removal, parity, previous PID history, and duration of marriage on time to conception, thus controlling for the interrelationships between variables. This technique estimates the probability of conceiving at different times. Results indicate that duration of IUD use did not affect the time to conception. In addition, IUD type, duration of marriage or parity did not affect the time required to conceive. These findings demonstrate that the use of IUDs does not, in and of itself, lead to problems with subsequent fertility. However, these results underscore the importance of limiting IUDs to women who are not at high risk of sexually transmitted diseases.

Role of sexual behavior in the development of pelvic inflammatory disease.

The role of sexual behavior in the development of pelvic inflammatory disease (PID) is not well understood. In general the literature is limited and flawed in the methods used to assess sexual behavior. Good evidence suggests that PID in Western society is a sexually transmitted disease. For number of partners, frequency of intercourse, time of intercourse and sexual life-style the evidence suggests that those variables have a significant role in the development of PID. It is important to assess PID in the context of all its risk factors, including sexual behavior, race, prior history of PID and IUD use.

PIP: The role of sexual behavior in the development of pelvic inflammatory disease (PID) has not been adequately assessed. Nonetheless, clinical reports, the age structure of PID patients, and the striking association of the sexual revolution with increased rates of PID provide support for the hypothesis that the development of PID is clearly associated with sexual activity. Although flawed in design and method, several studies have suggested that multiple sexual partners are a significant risk factor for the development of PID. Other studies aimed at determining the effect of frequency of intercourse, timing of intercourse, and sexual life style have provided inconclusive results. The inaccuracy of clinical diagnosis of PID limits the reliability of the results of many studies. Other obstacles have included the failure to describe confounding variables in the selection of controls and the questionable reliability and validity of information gathered on sexual history. Researchers must aggressively pursue the study of PID in the context of all its risk factors, including sexual behavior, prior history of PID, race, socioeconomic status, and IUD use. The findings generated from such research would enable physicians to counsel patients on the risks of certain aspects of sexual behavior.

Prevention of sexually transmitted diseases in women.

The frequency and severity of sexually transmitted diseases (STDs) and their sequelae, including sterility, numerous perinatal infections, genital tract neoplasia and possibly death (from ectopic pregnancy, ruptured tuboovarian abscess, human immunodeficiency virus-1 and hepatitis B virus infection), should be acknowledged by all sexually active individuals. Aspects of sexuality that place individuals at risk of STDs must be reexamined. Health care providers must effectively inform patients and the public of these often-ill-appreciated risks in a straightforward fashion, free of judgmental and punitive attitudes. New, more-effective means of prevention, diagnosis and treatment are being sought using research techniques in microbiology, immunology and behavioral science. In the meantime, medical screening, treatment and contact tracing should be carried out for patients and their sexual partners. Sexually active individuals must be empowered with knowledge and emboldened to protect themselves and their established or potential families from these common infections. Existing means of screening and treating must be utilized fully.

Preventing infection related to insertion of an intrauterine device.

A study was undertaken to determine whether pelvic inflammatory disease (PID) resulting from the insertion of an intrauterine device (IUD) could be eliminated by inserting the IUD during ovulation and administering prophylactic antibiotics to cover insertion. IUDs, 95% of which were Progestaserts, were inserted within two days of probable ovulation in 288 patients. These study patients were compared with a matched control group of 288 patients not using IUDs. None of the 288 IUD patients (totaling 619 woman-years of IUD use) developed PID after insertion, and only 0.5% per 100 woman-years developed PID later. The incidence of PID seen in these patients was less than that observed in the control group. It was also less than that in the general population or that following legal induced abortion. The expulsion rate of 1% per 100 woman-years in our patients is the lowest ever reported. It probably is related to the low motility of the uterus and expansion of the cervix during ovulation; the latter facilitates insertion during ovulation.

Diagnosis of pelvic actinomycosis by fine needle aspiration. A case report.

A case of pelvic abscess caused by Actinomyces in a patient wearing an intrauterine contraceptive device is presented. The diagnosis was established preoperatively by transvaginal fine needle aspiration. The cytologic, surgical and histologic findings are discussed.

PIP: This report presents a case of pelvic actinomycotic infection that was accurately diagnosed preoperatively by means of fine needle aspiration. The patient was a 40-year-old black female, gravida 6, para 6, who presented to the emergency room complaining of intermittent, crampy lower abdominal pain of approximately 1 month's duration. She also complained of a recent onset of urinary frequency and urgency without dysuria as well as a change in bowel habits, with recent constipation. Review of the patient's medical history was notable for the placement of a Dalkon Shield IUD 10 years before without subsequent removal, a history of irregular menses in the past year, and treatment for gonorrhea 10 years previously. The patient's last menstrual period was 2 weeks prior to admission. She denied fever and night sweats but had lost 20 pounds in the past 2-3 months. Vital signs were normal. Pelvic examination revealed a firm, fixed uterus, approximately the size of a 14-week pregnancy, and an associated mass extending to the left and inferiorly into the rectovaginal septum. An intravenous pyelogram showed left hydronephrosis and hydroureter, with compression of the ureter at the level of the sacrum. Sigmoidoscopy revealed extrinsic compression of the rectum at 12 cm, the some mucosal edema. A CT scan of the pelvis disclosed an 8 cm mass in continuity with the uterus extending into the lower pelvis, with possible focal erosion of the sacrum. The clinical impression was advanced cervical carcinoma. Transvaginal fine needle aspiration was performed using a 21-gauge spinal needle and a Franzen needle guide. Following a diagnosis of actinomycotic abscess, the patient was placed on tetracycline, due to her penicillin allergy, and taken to surgery. The abdomen was opened and revealed a slightly enlarged uterus. The uterus and cervix were adherent to the left pelvic wall and posteriorly to the rectum by firm, friable tissue. The left fallopian tube and ovary were adherent to this . With some difficulty the uterus was freed, and a total hysterectomy and bilateral salpingo-oophorectomy were performed. The postoperative course was unremarkable, and the patient was discharged on tetracycline. A morphologic diagnosis of actinomycotic infection with abscess formation was made. Sections of the left parametrium revealed multiple microabscesses and sinus tracts surrounded by abundant granulation tissue. Some of the abscesses contained actinomycotic organisms. Chronic endometritis and cervicitis as well as acute and chronic left salpingitis were documented.