Intrauterine release of oestriol in castrated rhesus monkeys induces local but not peripheral oestrogenic effects: a possible approach for the treatment and prevention of Asherman's syndrome.

Two types of oestrogen-medicated intrauterine devices (IUD) were studied in ovariectomized rhesus monkeys. An oestradiol (E2) fibre-wrapped IUD that released E2 at a rate of 3.57 micrograms/cm/day, or an oestriol (E3) fibre-wrapped IUD that releases E3 at a rate of 6.4 micrograms/cm/day, was inserted in eight animals and left in place for 4 weeks. Serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), E2 and E3 were determined by radioimmunoassay for 1 week before the IUD insertion, during the time the IUD was in place, and for 3 weeks after its removal. Uterine histology was performed at the time of IUD insertion and removal by light and transmission electron microscopy. Both E2 and E3 IUDs induced similar histological changes in the uterus, i.e. four- to five-fold increase in endometrial thickness, a shift of the gland/stroma ratio from 1:4 to 1:1, transformation to a marked pseudostratified epithelium with pronounced coiling of the glands, appearance of subnuclear and luminal secretion and, finally, change from spindle-dense stromal cells to plump eosinophilic cells. Oestradiol fibre-wrapped IUDs produced circulating E2 levels of 150-200 pg/ml during the entire 4 weeks. FSH and LH levels were decreased to an average of 55% and 65% from a castration baseline (P less than 0.001 and P less than 0.05, respectively). Oestriol fibre-wrapped IUDs produced circulating E3 levels of 100-250 pg/ml. However, FSH and LH levels were not altered in this group. The specific local oestrogenic effect of E3-IUDs without affecting the pituitary secretion of gonadotrophins, suggests their possible application in cases in which an exclusively oestrogenic effect at the uterine level, such as in Asherman's syndrome, is desired.

Management of breech presentations in developing country hospitals.

PIP: This paper reports the results of an analysis of singleton breech presentations, alive at the onset of labor and with no congenital anomalies. There is no significant benefit from abdominal delivery for small or very small babies because developing country hospitals lack the neonatal care facilities to care for the low birth weight babies. For babies over 2500 grams, vaginally delivered babies are more than twice as likely to die before their mothers are discharged from the hospital. Parous women are more likely than are primipara to safely deliver breeches vaginally. In developing countries the possibility of maternal morbidity is at once greater and more serious because of fewer resources to provide adequate care. In deciding whether to deliver a breech abdominally or vaginally physicians should ask the following questions: 1) Are neonatal care facilities adequate for the small baby delivered alive? 2) What is the mother's parity and what are her future reproductive plans? 3) Will future deliveries occur at home or in a hospital? 4) Will she consider tubaligation at the time of cesarean section? 5) What is the hospital's record of maternal morbidity and mortality for cesarean sections? and 6) What is the physician's skill in delivering breeches vaginally and in performing cesarean sections?^ieng

The use of prostacyclin analogue-containing suture for the prevention of postoperative venous thrombosis in the rat.

The ability of prostacyclin analogue incorporated into a controlled-release suture to prevent postoperative venous thrombosis was investigated. Thirteen rats underwent bilateral transection and anastomosis of the common femoral vein. In each animal, polycaprolactone suture containing 0.25 micrograms/cm of the prostacyclin analogue Iloprost (Schering Ag, Berlin, West Germany) was used to perform the anastomosis on one vessel. Similar suture without prostacyclin analogue was used on the contralateral vessel, which served as a control. Functional patency and luminal surface morphology were assessed 24 hours postoperatively. All anastomoses performed using suture containing prostacyclin analogue were patent. Among controls, five anastomoses were patent and eight were occluded. This difference was highly significant (p less than 0.005). All anastomoses performed with prostacyclin analogue-containing suture exhibited a uniform absence of thrombosis. In contrast, eight control veins exhibited a dense, well-organized fibrinous clot that filled the entire lumen, effectively sealing off the vessel. These results suggest that the prostacyclin analogue released from the suture was highly effective in inhibiting thrombus formation without adversely affecting the vessel's ability to achieve hemostasis.

Chemical sterilization with an IUD.

Zipper has more than adequately demonstrated that quinacrine, when placed in the uterine cavity, has a sclerosing effect on the tubal ostia, resulting in chemical sterilization of the fallopian tubes. His technique involves the use of 3 monthly instillations of 250 mg of pellets into the uterine cavity. With the hope of reducing the total dosage and making it a 1-insertion technique, quinacrine has been mixed with polyethylene oxide and place on the arms of various IUDs. It is hoped that the material is directed at the tubal ostia. Studies to date have occurred in women awaiting hysterectomy with careful pathologic examination of the intramural portion of the tube. The results thus far are most encouraging and once the best vector is identified, it is hoped that this will become an acceptable means of female sterilization.

Endometriosis and the development of tuboperitoneal fistulas after tubal ligation.

The present study details gross and histologic findings of 79 previously ligated fallopian tubes from 3 groups of patients. Of 20 oviducts removed after documented sterilization failure (group I), 6 revealed a process compatible with endometriosis. Four of nine previously ligated fallopian tubes removed at the Johns Hopkins Hospital (group II) were successfully injected with India ink. In two patients histologic examination demonstrated the India ink in epithelium-lined spaces that lay beyond the muscle of the tubal wall extending from the tubal lumen to the serosal surface. Fifty oviducts were studied in twenty-five patients requesting reversal of their sterilizations (group III). A higher percentage of fistulas was demonstrated in patients with less than 4 cm of remaining proximal tubal segment. Furthermore, most of these fistulas were demonstrated in patients for whom 3 years had elapsed since the original sterilization procedure. Patients sterilzed by laparoscopic cautery methods were observed to have a higher percentage of fistula formation and histologic documentation of endometriosis at the sterilization site as compared with patients sterilized by other methods. Our observations suggest that ligation of the oviduct within 4 cm of the uterine cornu may predispose to the development of endometriosis and subsequent fistula formation in the tip of the ligated oviduct.

PIP: Gross and histological findings of 79 previously removed fallopian tubes from 3 groups of patients are reported. Of 20 tubes removed after documented sterilization failure (Group 1), 6 showed endometriosis. 4 of 9 previously ligated tubes (Group 2), were injected with ink; 2 patients showed ink in epithelium-lined spaces beyond the muscle of the tubal wall from the tubal lumen to the serosal surface. Group 3 was 50 oviducts from 25 patients requesting reversal of sterilizations. In this group a higher percentage of fistulas was demonstrated in those with less than 4 cm of tube remaining in the proximal segment. Also, most of these fistulas were in patients 3 years or more away from the original procedure. Laparoscopic cautery sterilizations had higher percentages of fistula formation and endometriosis at sterilization site than sterilizations by other methods. Therefore, ligation of the fallopian tube within 4 cm of the uterine cornu may predispose development of endometriosis and subsequent fistula formation at the tip of the ligated tube.

Technical failures in tubal ring sterilization: Incidence, perceived reasons, outcome, and risk factors.

Six centers participated in comparative studies of female sterilization conducted by the international Fertility Research Program. The incidence of technical failures (or failed attempts) was compared between patients sterilized with the tubal ring and those sterilized with other tubal occlusion techniques. The tubal ring was associated with a higher failure rate than electrocoagulation, the Rocket clip, or the modified Pomeroy technique. Of 1,035 tubal ring sterilizations, there were 38 technical failures. Reasons given by the operators for the failures, by frequency of occurrence, were surgical complications, conditions preexisting in the patients, and problems with the instruments. Most of these failures were remedied by changing to other techniques. In two patients, the procedure was completed by changing the approach from laparoscopy to laparotomy. In five others, sterilization was not completed. Case-control analysis was performed and three risk factors were delineated: obesity, prior use of an intrauterine contraceptive device and previous abdominal operations.

PIP: 6 centers participated in comparative studies of female sterilization conducted by the International Fertility Research Program. The incidence of technical failures (or failed attempts) was compared between patients sterilized with the tubal ring and those sterilized with other tubal occlusion techniques. The tubal ring was associated with a higher failure rate than electrocoagulation, the rocket clip, or the modified Pomeroy method. Of 1035 tubal ring sterilizations there were 38 technical failures. Reasons given by the operators for failures by frequency of occurrence were surgical complications, conditions preexisting in the patients, and problems with the instruments. Most of these failures were remedied by changing to other techniques. In 2 patients, the procedure was completed by changing the approach from laparoscopy to laparotomy. In 5 others, sterilization was not completed. Case-control analysis was performed and 3 risk factors were delineated--obesity, prior use of an IUD, and previous abdominal surgery.

Laparoscopic sterilization with room air insufflation: preliminary report.

Laparoscopic sterilizations can be safely performed using room air insufflation. In a series of 400 procedures, the rates of surgical complications were comparable to other laparoscopy studies in which high-pressure gas was used. The purported problems associated with room air insufflation were not encountered in this study.

PIP: This paper reexamines the use of room air as the insufflating medium for voluntary sterilizations. 400 sterilization procedures were performed at the Centro Medico in El Salvador. The 1st 100 sterilizations utilized a standard laparoscopy technique that familiarized the operating physician with the laprocator. The next 300 sterilizations utilized Hasson's open laparoscopy technique using the Hasson trocar and blunt cannula. In all the procedures, pneumoperitoneum by room air was used for insufflation. Air insufflation was achieved using the KLI insufflator which can deliver either gas under pressure or air with a pneumatic bulb. No surgical recovery period or follow up complications were observed in the standard laparoscopy series. Of the 300 open laparoscopy procedures, 1 case (0.3%) of mesosalpingial injury without bleeding was recorded as a surgical complication. Follow-up complications were 2 cases (0.7%) of urinary tract infections and 2 cases (0.7%) of incision inflammation that required medical treatment with only aspirin or penicillin. Reported sites of pain during standard laparoscopic procedures were pelvic (5%) and shoulders (2%). Benefits of use of room-air insufflation are universal availability, low cost, simplification of procedure, reduction of cost of backup equipment and reduction of performance time. The reported disadvantages of room air insufflation--pain, air embolism, infection or death--did not occur in this series.

Menstrual pattern changes in laparoscopic sterilization patients whose last pregnancy was terminated by therapeutic abortion. A two-year follow-up study.

Women were used as their own controls in the comparison of presterilization and poststerilization menstrual patterns. Five parameters were studied: regularity of cycle length, duration and amount of flow and incidence of dysmenorrhea and intermenstrual bleeding. Three parameters in the electrocoagulation group (regularity of cycle length and duration and amount of flow) and one parameter in the tubal ring group(duration of flow) showed significant changes after sterilization. However, by controlling for the effect of previous contraceptive methods used, no significant menstrual pattern changes following sterilization were discerned in either technique group.

PIP: Between 1973 and 1975, 2501 women were sterilized by laparoscopy at the Yonsei University College of Medicine in Seoul, Korea. The women were used as their own controls in a follow-up study of the changes in menstrual patterns following sterilization. Tables present the results of the study. In the electrocoagulation group, twice as many patients changed from regular to irregular cycles than the other way; there was no such difference among the tubal occlusion group. More patients in both groups experienced a decline in menstrual flow. The aging of the patients and the fact that some had had therapeutic abortions prior to or concurrent with the sterilization procedure did not have any effect on the observed changes in menstrual cycles. Changes in menstrual cycle length, duration, and amount seemed to be associated with the type of contraceptive used previously. Controlling for prior contraceptive usage caused the observed differences in menstrual cycles to disappear.

An epidemiologic study of risk factors associated with pregnancy following female sterilization.

Data on 14,700 female sterilization patients were collected by the International Fertility Research Program (IFRP) from 1972 to 1978 and analyzed to determine risk factors associated with the incidence of pregnancy following sterilization. With a case-control approach, it was found that younger patients (less than or equal to 34 years old) and those who did not lactate after sterilization had a higher risk of becoming pregnant. Patients who were sterilized in the early phases of a service program had a higher risk of pregnancy than those sterilized later. In the laparoscopic series, the relative risk of pregnancy was four times greater in patients who had the prototype spring clip than in patients who had the Falope ring. The relative risk increased to 7.0 when patients who had the prototype spring clip were compared to those who had the Falope ring, electrocoagulation, or the Rocket clip. Patients sterilized by electrocoagulation had a low pregnancy risk, but the risk of an ectopic pregnancy was significantly higher than for those sterilized with mechanical devices. In the culdoscopic series, the tantalum clip had an unacceptable pregnancy risk.

PIP: The International Fertility Research Program (IFRP) collected and analyzed data on 14,700 female sterilization patients from 1972-1978 to determine risk factors associated with the incidence of pregnancy following sterilization. It was found that younger patients (less than 34 years old) and those who did not lactate after sterilization had a higher risk of becombing pregnant. Using a case-control approach it was learned that patients who were sterilized in the early phases of a service program had a higher risk of pregnancy than those sterilized later. The relative risk of pregnancy was 4 times greater in the patients who had the prototype spring clip than in patients who had the Falope ring in the laparoscopic series. When patients who had the prototype spring clip were compared to those who had the Falope ring, the Rocket clip, or electrocoagulation the relative risk increased to 7. Patients sterilized by electrocoagulation had a low pregnancy risk, but the risk of an ectopic pregnancy was significantly higher than for those sterilized with mechanical devices. The tantalum clip had an unacceptable pregnancy risk in the culdoscopic series.

Suprapubic endoscopy for interval female sterilization.

PIP: Minilaparotomy delivery systems have been developed for rings and clips due to increased popularity and elimination of the hazards of electrocoagulation. The open laparoscopy technique eliminated the use of needle insufflation and blind introduction of a sharp trocar. Endoscopic sterilization combines the advantages of a minilaparotomy incision with intrapelvic tubal occlusion. Suprapubic endoscopic sterilization requires: 1) proper elevation of the uterus so the fundus is near the abdominal wall; 2) use of a trocar sleeve with blunt obtuator; and 3) employment of a Trendelenburg position of 35 degrees or greater. The suprapubic endoscopic approach eliminates the use of sharp trocars and needles, intraperitoneal electrical current, and the need for intra-abdominal insufflation.^ieng

The history of pregnancies that occur following female sterilization.

Data on 208 pregnancies occurring among 20,749 women following sterilization were collected by the International Fertility Research Program and the histories of these pregnancies from conception to termination were analyzed. In the laparoscopic series, the operator's failure to interrupt the tube by electrocoagulation or a tubal occlusion device was the major reason reported for sterilization failure. In the culdoscopic series, operator error or device deficiency were the major reasons for failure. About three quarters of pregnancies in this study were conceived within the first year following sterilization and were confirmed during the first trimester. The rate of ectopic pregnancy occurring in this series was higher than the rate reported for nonsterilized women and was especially high when electrocoagulation was used.

PIP: The International Fertility Research Program collected data on 208 pregnancies occurring among 20,749 women following sterilization. The histories of these pregnancies were analyzed from conception to termination. The operator's failure to interrupt the tube by electrocoagulation or a tubal occlusion device was the major reason for sterilization failure in the laparoscopic series. Operator error or device deficiency were the causes for failure in the culdoscopic series. Three quarters of pregnancies in this study were conceived within the first year following sterilization and were confirmed during the first trimester. The rate of ectopic pregnancy occurring in this series was higher than the rate for nonsterilized women. It was especially high when electrocoagulation was used. From 1972 to August 1978, the pregnancies were reported to the Program. More than half the pregnancies were diagnosed by a test alone or a pelvic examination. In 38%, the reasons for failures were not reported. 123 of the 159 failures were terminated; the remainder were being continued at last follow-up. 15.7% of pregnancies were confirmed during the second trimester; 3.8% were diagnosed beyond the 25th week.

Conception control by a single monthly injection.

PIP: 73 women of childbearing age and proven fertility were injected with dehydroxy-progesterone acetophenide, 150 mg and estradiol enanthate, 10 mg on Day 7, 8, or 9 of a new cycle and on Days 7-9 in succeeding cycles for a total of 929 cycles (1-24 cycles/patient). Patients missing 1 or more injections because of failure to menstruate were started as new patients and no patient was restarted more than 3 times. 69% received 1 series of injections; 24% received 2 series; and 7% received 3 series. There was a moderate prolongation of monthly bleeding. Cycles averaged 2 days shorter than before therapy. There was absolute pregnancy protection. Discontinuation was 45% for this study, most during the first 5 cycles, 1/2 of drug related discontinuation due to abnormal bleeding. Cytology smears, breast examinations and endometrial biopsies repeated before and during therapy were unremarkable.^ieng