Results of the insertion of hysteroscopic sterilization devices in a brazilian public hospital / Resultados da inserção de dispositivos de esterilização histeroscópica em um hospital público brasileiro

Abstract Objective To evaluate the insertion of the hysteroscopic intratubal sterilization device for female sterilization concerning the technique and the feasibility. Methods Retrospective study with data collection of medical records of 904 patients who underwent device insertion between January and September 2016 in a public hospital in Rio de Janeiro (Brazil) with data analysis and descriptive statistics. Results In 85.8% of the cases, the uterine cavity was normal, and themost commonlydescribed findings upon hysteroscopy were synechiae (9.5%). The procedure lasted an average of 3.56minutes (range: 1 to 10minutes), and the pain was considered inexistent or mild in 58,6% of the cases, mild or moderate in 32,8%, and severe or agonizing in less than 1% (0.8%) of the cases, based on a verbal scale ranging from 0 to 10. The rate of successful insertions was of 85.0%, and successful tubal placement was achieved in 99.5% of the cases. There were no severe complications related to the procedure, but transient vasovagal reactions occurred in 5 women (0.6%). Conclusion Female sterilization performed by hysteroscopy is a safe, feasible, fast, and well-tolerated procedure. The rates of successful insertions and tubal placements were high. There were few and mild adverse effects during the procedure, and there were no severe complications on the short term.

Resumo Objetivo Avaliar a inserção de dispositivo intratubário de esterilização histeroscópica com relação à viabilidade e à técnica. Métodos Estudo retrospectivo com coleta de dados de prontuários das pacientes submetidas à inserção do dispositivo entre janeiro e setembro de 2016 emumhospital público do Rio de Janeiro, comanálise dos dados e realização de estatísticas descritivas. Resultados Foram incluídos 904 casos no estudo. Em 85,8% dos casos, a cavidade uterina estava normal, e os achados mais comumente descritos à histeroscopia foram as sinequias (9,5%). O tempomédio do procedimento foi de 3,56minutos (gama: de 1 a 10 minutos); a dor foi considerada de ausente a leve em 58,6% dos casos, de leve a moderada em32,8% dos casos, e de forte à pior dor possível emmenos de 1% dos casos (0,8%). A taxa de inserções bem-sucedidas foi de 85,0%, e a colocação tubária foi bemsucedida em 99,5% dos casos. Não foram identificadas complicações graves, mas reações vasovagais transitórias ocorreram em 5 mulheres (0,6%). Conclusão A esterilização feminina por histeroscopia é um procedimento seguro, viável, rápido, e bem tolerado. As taxas de inserção bem-sucedida e de colocação tubária foram altas. Houve poucos e leves efeitos colaterais durante o procedimento, e não foram observadas complicações graves no curto prazo.

When Doctors Don't Tie: Hierarchical Medicalization, Reproduction, and Sterilization in Brazil.

Drawing on ethnographic fieldwork among black women, medical personnel, and activists in Brazil, this article highlights the implications of hierarchical medicalization. I show that the prioritization of particular forms of medicalized contraception for women located differentially in society enables different relations, political positions, and mobility. Denial of a tubal ligation in favor of modern reversible contraceptives, in a context of inequitable distribution, can perpetuate social stratification. This work contributes to literature exploring the complexity of medicalization and its relationship with society via reproduction.

The Rise of Female Sterilization: A Closer Look at Colombia.

Objective In the 1970s, OCPs and IUDs were the most popular contraceptive methods in Colombia. According to data from the most recent Demographic and Health Survey (DHS), sterilization has become the most common form of birth control in Colombia. This study aims to examine the characteristics of Colombian women desiring long-acting contraception. Methods This study uses the 2005 and 2010 Colombian DHS dataset. Women who choose long-acting contraception were divided into those using female sterilization and those using long-acting reversible contraception (LARC). A multivariate logistic regression model was used to compare demographic and social determinants of contraceptive choice among reproductive age women seeking long-acting contraception between the years 2005 and 2010. Results Among women using a long-acting contraceptive method in 2010, compared to 2005, women were significantly more likely to be sterilized (1.14 OR, 95% CI 1.09-1.18) and less likely to use LARC (0.88 OR, 95% CI 0.85-0.92). Of women seeking long-acting contraception, those exposed to a family planning provider were less likely to undergo sterilization (0.54 OR, 95% CI 0.51-0.58) and more likely to use LARC (1.84 OR, 95% CI 1.73-1.96). When compared to all contraceptive users, younger women and women with less than two children were more likely to use LARC than sterilization. Conclusion Between 2005 and 2010, an increase in the proportion of contracepting women being sterilized in Colombia occurred. Our findings suggest that exposure to a family planning provider and appropriate contraceptive counseling appears to be key determinants of long-acting contraceptive choice. To improve use of long-acting, effective contraception, efforts should be made to increase access to family planning providers.

Avaliação das concentrações de zinco no aparelho reprodutor feminino por ativação neutrônica instrumental / Assessment of zinc concentration in the female reproductive system by instrumental neutron activation

A esterilização feminina não cirúrgica por meio da aplicação intracervical de pastilhas de cloridrato de quinacrina foi considerada um método contraceptivo definitivo de baixo custo, seguro e eficaz. O zinco, presente no útero e nas tubas uterinas, inibe a ação da quinacrina. A adição de cobre aumenta a eficácia da quinacrina, reduzindo o risco de gravidez devido às falhas de obstrução das tubas uterinas. O cobre neutraliza o efeito deletério do zinco, aumentando a eficácia do método. Para obter o mapeamento da concentração de zinco no aparelho reprodutor feminino, amostras de útero e de tubas uterinas foram analisadas por ativação neutrônica instrumental. Os resultados obtidos são apresentados neste trabalho.

Nonsurgical female sterilization through the transcervical insertion of quinacrine pellets was considered a definitive, low-cost, safe and effective contraceptive method. The zinc, present in both uterus and Fallopian tubes, inhibit the action of quinacrine. The addition of copper increases the efficacy of quinacrine, thus reducing the risk of pregnancy due to the failure to obstruct the Fallopian tubes. The copper neutralized the deleterious effect of the zinc and so the treatment efficacy is increased. In order to obtain a mapping to study the zinc concentration in the female reproductive system, samples of both uterus and Fallopian tubes were analyzed by neutron activation. The results are here reported.

25 years of quinacrine sterilization experience in Chile: review of 2,592 cases.

OBJECTIVES: To assess short-term side effects, long-term risks and efficacy of quinacrine sterilization (QS) in Chile. METHODS: Review experience of 2,592 cases sterilized with 2 or 3 transcervical insertions of 252 mg quinacrine as pellets since 1977; review the Chilean pre-clinical experience and epidemiological studies on cervical, endometrial and other cancers. RESULTS: Among 2,592 women who underwent QS, the total number of pregnancies was 119 (4.6%); 59 (49.5%) were carried to term with no birth defects related to QS. Nine cases were ectopic pregnancies. The ectopic pregnancy risk per 1,000 woman-years was 0.41, similar to that for surgical sterilization. The cumulative life-table pregnancy rates per 100 women at 10 years varied from 5.2 to 6.9. Mild and transient side effects were reported in 13.5% of quinacrine intrauterine insertions and pelvic inflammatory disease was diagnosed in 4 cases (0.15%). Long-term follow-up of quinacrine-sterilized patients shows no increased risk of cervical, endometrial or other cancer. CONCLUSIONS: QS efficacy at 10 years is comparable to widely accepted tubal clip and single point bipolar electrocoagulation laparoscopic procedures. QS has a low risk of serious, immediate side effects. No long-term risks have been identified after 25 years of use.

Quinacrine sterilization: a retrospective.

OBJECTIVE: To trace development of quinacrine sterilization (QS). METHODS: Review of published reports. RESULTS: The high prevalence of septic abortion among high parity women in Santiago, Chile, motivated Zipper to find a safe, inexpensive method of non-surgical female sterilization. Various cytotoxic drugs were tried in rats. Because quinacrine was already accepted for intrapleural injection it was chosen for the first clinical trial. A slurry consisting of quinacrine and xylocaine was instilled into the uterine cavity with a transcervical syringe. Reasonable efficacy was noted and a limited scar of the intramural tube demonstrated. However, a side effect of cortical excitation and reports of 3 deaths ended this approach. Zipper and Wheeler hypothesized that the difficulty was due to rapid absorption of quinacrine under pressure and designed a pellet form that dissolves slowly and could be delivered transcervically using a modified IUD inserter. A standard protocol of 252 mg in seven 36 mg pellets placed at the uterine fundus on two occasions a month apart has now been widely used with considerable evidence for safety and efficacy. Indeed, protection is greater than 98% at 2 years of use. CONCLUSION: QS is ready for widespread use, especially where surgical sterilization is not safely available or when women are poor candidates for surgery or have such a fear of surgery that they will not seek surgical sterilization.

Quinacrine female nonsurgical sterilization (QS): endometrial assessment by vaginal ultrasonography in 128 women.

OBJECTIVE: Investigate effectiveness, safety and endometrial pattern after QS. METHOD: This study began in March 1999 and ended March 18, 2003; 128 women received transcervical insertions of quinacrine. Follow-up visits with ultrasound were scheduled at 1, 3, 6, 12-month intervals. RESULTS: Two pregnancies occurred, one at 25 months, the other at 37. Adverse events (AE) were: yellow vaginal discharge, headache, mild abdominal pain, vaginal pruritus, nausea and transient decrease in endometrial thickness. One patient had allergic reaction. A third insertion was done in case of vaginal bleeding (16.4%). One year after QS 10% still had amenorrhea, which may be the results of the fact that 73% of our patients had received DMPH. Once inside the uterus, the dissolved quinacrine could be seen within seconds, via ultrasound as a "Lake of Quinacrine" which stays for up to two hours. Frequently, a transverse vaginal ultrasonographic view of the uterine cavity showed plug-like echogenic points at the cornua. CONCLUSION: Quinacrine sterilization is safe and effective. The echogenic points need to be more thoroughly studied in order to affirm whether ultrasonography may identify the blockage of the tubes. Since early pregnancy is due to imperfect tubal closure, the use of ultrasound may prevent failure. However, pregnancy due to later recanalization cannot be avoided.

Pregnancy rates among Chilean women who had non-surgical sterilization with quinacrine pellets between 1977 and 1989.

We describe cumulative pregnancy probabilities among women who underwent quinacrine pellet sterilization in Chile between 1977 and 1989 (N = 1492). We interviewed the women or relatives in 1991-93 and 1994-96, and reviewed hospital records. Mean follow-up was 9.6 years (median 9 years). We recorded 120 pregnancies, including 40 that went to term or near-term. There were nine adverse outcomes in eight infants: one fetal death at 18 weeks gestation; three infants born prematurely; one stillbirth (placental infarct); and four infants with birth defects. There was no clustering of any particular kind of birth defect. For two insertions, the 10-year cumulative pregnancy probability was 8.9 (95% confidence interval 3. 7, 14.1). For 3 insertions, the 10-year rate was 7.0 (4.4, 9.5). For women who were under 35 years at insertion, the 10-year rate was 10. 7 (7.4, 14.1). For women who were 35 or older at insertion, the 10-year rate was 3.1 (0.6, 5.7). The pregnancy rate varied little for 2 vs. three insertions, but the rate did vary significantly by age, with women who received quinacrine at 35 years or older 0.3 (0. 2, 0.5) times as likely to become pregnant as younger women. The 10-year cumulative ectopic pregnancy probabilities for women with two and three insertions of quinacrine were 0.9 (<0.1, 2.6) and 0.5 (<0.1, 1.2), respectively. Pregnancy rates after quinacrine insertion are higher than after surgical sterilization, but ectopic pregnancy rates appear similar.

Tubo-ovarian abscess after tubal ligation.

Tubo-ovarian abscess usually results from ascending infection of the lower genital tract. In a few cases it can occur as a result of direct contamination at the time of tubal sterilization. We describe a case that presented seven years after post partum tubal sterilization, showing both acute and chronic components.

PIP: This paper presents the case of a 32-year-old woman who developed a tubo-ovarian abscess 7 years following tubal ligation via minilaparotomy. Symptoms experienced included pain, which was exacerbated by walking, and mild deep dyspareunia. Abdominal and pelvic examinations revealed pain in the left iliac fossa, cervical excitation tenderness, and an ill-defined left adnexal mass. Sonographic evaluation of the pelvis showed an irregularly shaped, cystic mass (8.0 x 4.5 x 5.3 cm) with thickened internal septations and solid parts. A left tubo-ovarian multilobulated complex mass adherent to the omentum and the pelvic side was found upon laparotomy. There was pus in the Pouch of Douglas, and the uterus was 10 weeks in size with symmetrical enlargement. The previously ligated right fallopian tube and the ovary were unremarkable. Management includes left adnexectomy, omental biopsy, and 5-day course of antibiotics against Staphylococcus aureus, which was cultured from the purulent material in the Pouch of Douglas. Tubo-ovarian abscess should be considered in diagnosing patients presenting symptoms of pelvic inflammatory disease.

Model minilap training program to go international.

PIP: Female sterilization is the method of family planning most preferred by women in the Dominican Republic. For the past 20 years, minilaparotomy has been successfully performed under local anesthesia by hundreds of trained general practitioners throughout the country. As such, minilaparotomy has become an important family planning option for Dominican women. Given this success with the procedure in the Dominican Republic, AVSC and its partners in the country plan to share their knowledge and expertise with the world by offering international training in the delivery of the method. The senior director of AVSC's technical resources worldwide believes the program has succeeded because of its focus upon meeting clients' needs and its strong commitment to the technique by all who are involved. AVSC continues to be a catalyst for positive change in the Dominican Republic.^ieng

Sterilization for family planning in a Third World country.

Outpatient laparoscopy procedures have made sterilization possible for millions of women in developing countries. This report describes the experience of a team of doctors, nurses, and support staff that performed 107 laparoscopic tubal sterilizations during on eight-day sojourn in a remote north-central area of Nicaragua. Minimal analgesia (oral ibuprofen) and anesthesia (1% lidocaine) were used since most of the patients walked to and from the hospital-some up to 15 miles. Because the Nicaraguan government's support for birth-control programs is unreliable and because illegal abortion is the leading cause of maternal mortality in Nicaragua, this safe, minimally invasive surgical method is the favored means of birth control.

PIP: During an 8-day visit to Jalapa, Nicaragua, in 1996, a Short-Term Volunteers in Mission team from Minnesota, US, performed 107 outpatient laparoscopic sterilizations and 14 vasectomies in this remote town near the Honduran border. Standard medical procedures were modified to adapt to the inadequate medical facilities and large patient load. The mean age of female sterilization acceptors was 28.92 years; they had an average of 4.4 living children. 75% lived in or near the town and walked a total of 1 hour or less to and from the hospital; another 20% walked an average of 4 hours round trip. Because of the women's need to walk home after the procedure, local anesthesia (1% lidocaine) was administered in conjunction with oral ibuprofen. More than 75% of acceptors experienced mild or no intraoperative pain and were sent home right after the procedure; 20% reported moderate pain and 3% severe pain, but in all cases the pain dissipated within 10-45 minutes. The length of time from admission to discharge averaged 45 minutes (range, 25-75 minutes). Civil war, overpopulation, and severe poverty limit the ability of government-sponsored programs to deliver family planning services consistently. Thus, sterilization is an ideal method of fertility control for appropriate candidates.

[Closure of the skin with cyanoacrylate in surgical wounds after tubal sterilization]. / Cierre de la piel con cianocrilato en las heridas quirúrgicas después de la obstrucción tubaria bilateral.

Close of skin with cyanocrilate in surgical wounds after tubary sterilization. The objective was to determine the use of cyanocrillate in surgical wounds coalescence, to decrease the time employed when closing the skin, as well as to aid the healing process. This is an observation, prospective, length, comparison, study. Since March, 1995, the Gyneceum-Obstetrics "Luis Castelazo Ayala" Hospital has carried out this research, forming two groups as follows. Group A: Tubary sterilization (OBT) was practiced to 36 patients applying a superficial coat of cyanocrilate. Group B included 31 patients whose skin was sutured with catgut 00. In Group A. the average time for skin closure is 14.5 seconds, in wounds with a length of 2 to 6 cm. In Group B the average time is 3.9 minutes, in wounds with a length of 1 to 4 cm. 4 cases of group A reported pain for the first 12 hours (11.1%), pruritus in wound in 3 cases (8.3%), partial dehiscence of wound, 1 case (2.7%). While in Group B the result are: Pain in 10 cases (32.2%), pruritus in 3 cases (9.6%), partial dehiscence of wound in 3 cases (9.6%), 1 case with poor edges coaptation (3.2%), and reaction to suture in 2 cases (6.4%). Not even an infection condition occurred. Cyanocrilate used in selected cases is an inexpensive, fast, easy to use efficient method, with little morbidity and likely to improve the aesthetic of surgical scar.

PIP: 100 women undergoing bilateral tubal sterilization at a hospital in Mexico City between March and September 1995 participated in a prospective study of the use of the contact adhesive cyanoacrylate for closure of the surgical wound. Cyanoacrylate was used for the patients in group A, while in group B the skin was sutured with catgut 00. The remainder of the procedure was similar in both groups. The 36 patients in group A and 31 in group B who attended follow-ups at 12 hours, 7 days, and 40 days were included in the study. Patients in group A ranged in age from 20 to 36 and averaged 31.7 years, while those group B ranged from 18 to 35 and averaged 27.5 years. Group A patients had 2.8 and group B 3.1 children on average. The wounds in group A ranged from 2 to 6 cm and averaged 3.1 cm, while those in group B ranged from 1 to 4 cm and averaged 2.5 cm in length. The time for wound closure ranged from 4 to 30 seconds and averaged 14.5 seconds in group A, and from 1 to 7 minutes with an average of 3.9 minutes in group B. 4 patients in group A had pain (11.1%), 3 had pruritus (8.3%), and 1 each had (2.7%) poorly joined borders, partial dehiscence of the wound, and bleeding. 10 patients in group B had pain (32.2%), 3 each (9.6%) had pruritus and partial dehiscence of the wound, 1 had poorly joined borders (3.2%), and 2 had reactions at the site of the sutures (6.4%). It was concluded that, in appropriately selected cases, cyanoacrylate is inexpensive, rapid, easy to use, and efficient, with few side effects.

Risk factors for tubal sterilization regret, detectable before surgery.

Brazil has one of the highest prevalence rates of female surgical sterilization in the world. At the same time there is an increased demand for sterilization reversal. In order to understand which women tend to later request reversal of the procedure, a case-control study was carried out comparing 216 women who requested reversal with sterilized women who did not, paired by year of surgery. The relative risk of requesting reversal for women sterilized before age 25 was 18 times that of women sterilized after age 29. The elevated risk remained even after controlling for a number of variables present at the time of surgery. Multiple regression analysis showed that request for reversal was associated with younger age, less information about the procedure, and fewer contraceptive methods known before sterilization. These results support the recommendation that women should be fully informed about the tubal ligation procedure and have access to other contraceptive options before being sterilized.

FHI quinacrine studies.

PIP: Scarcity of long-term funding has influenced Family Health International (FHI) to stop new animal studies on the safety of quinacrine pellets that are used in nonsurgical female sterilizations. These studies would have lasted 8 years and cost $8 million. FHI planned to examine quinacrine's potential toxicity, including life-time carcinogenicity in rodents. In the early 1980s, it sponsored toxicology studies but the US requirements for evaluating toxicity were different then. In 1994, a meeting of experts evaluated quinacrine research and FHI then decided to conduct short-term genetic toxicity tests on quinacrine. These tests proved that quinacrine causes genetic damage in vitro. FHI sent both the World Health Organization (WHO) and the US Agency for International Development (USAID) these results. FHI is presently conducting follow-up of two clinical studies in Chile (USAID-funded) and in Vietnam (Mellon Foundation-funded). A small cancer cluster promoted the follow-up study of 1492 women in Chile. One woman had developed the rare form of uterine cancer called uterine leiomyosarcoma. Data up to 1991 reveal that quinacrine did not increase the risk of cancer, but the sample size was too small to confirm quinacrine's safety relative to cancer. The Vietnamese government asked FHI to conduct a follow-up study that includes more than 2000 quinacrine acceptors and about 1500 controls. Ministry of Health providers had inserted the quinacrine pellets in the cases. Based on the findings of the original study, WHO recommended that Vietnamese officials suspend quinacrine sterilizations until more toxicologic evaluation of quinacrine could be performed.^ieng

Sterilization regret in the Dominican Republic: looking for quality-of-care issues.

This report approaches the concept of quality of care by looking at the covariates of sterilization regret in the Dominican Republic according to the results from the 1991 Demographic and Health Survey. The main variables observed are the women's satisfaction with sterilization, their decisionmaking process, sterilization experience, use of family planning, and socioeconomic characteristics. The more detailed measurement and analysis of the outcomes of care point to a need for improvement in the public program effort with regard to sterilization. Substantial proportions of women were sterilized who were younger than 30, who had three or fewer living children, and who had the operation before they had used any other method of contraception. Because a greater proportion of sterilization regret is observed among these groups, women must be enabled to make a free and informed decision about sterilization by means of programs that offer a more balanced choice of methods, as well as better counseling, education, and access to high-quality services.

PIP: A quality of care study examined the covariates of sterilization regret by analyzing data from the 1991 Demographic and Health Survey for the Dominican Republic. The leading contraceptive method was female sterilization (about 40% of women in union) followed by oral contraceptives (10%). Over time, an increasing number of younger women chose sterilization. In fact, 60% of all sterilized women underwent sterilization when they were younger than 30. Almost 40% of women in union who underwent sterilization when they were younger than 30 had no more than three living children. Sterilization was the first and only contraceptive method that 34% of sterilized women in union had ever used. 56% of them were younger than 30. 44% had fewer than four children. These women were more likely to report regret, dissatisfaction with their decision to undergo sterilization, and to not choose sterilization again than did all respondents (11% vs. 5%). Some variables significantly associated with dissatisfaction and regret were: age; no other modern family planning methods used; reasons for sterilization (recommended by medical/family planning worker and side effects/health concerns); a less than 6 month interval between last birth and sterilization; sterilization was first method used; family size less than four; sterilized at delivery; and sterilization was discussed with husband. These findings suggest a need for the family planning program to provide information about all contraceptive methods and their effective use, quality counseling, and access to high quality services to optimize levels of satisfaction among clients.

Multidisciplinary experience in the selection of patients for tubal sterilization.

Results of the use of a special protocol for evaluation of patients requiring tubal ligation is presented after applied by a multidisciplinary group. The authors conclude that the use of defined parameters of age, parity, marital union duration, number of children alive and the presence of maternal clinical pathology are useful to identify patients with smaller chances of regret after surgery.

PIP: 27% of reproductive-age women in Brazil have chosen surgical sterilization as their contraceptive method. Most of these women who have undergone tubal sterilization opted for cesarean surgery. However, given the young ages of many of these women, many regret having been sterilized. This paper summarizes the experience of a multidisciplinary group in evaluating women who apply for surgical sterilization at the Department of Tocogynecology, Faculdade de Ciencas Medicas, Universidade Estadual de Campinas in Sao Paulo. Detailed descriptions are presented of the medical and social characteristics of cases seen between June 1988 and July 1989. The authors conclude that the use of the defined parameters of age, parity, marital union duration, number of living children, and the presence of maternal clinical pathology are useful in identifying the patients who are least likely to regret undergoing surgical sterilization.

Show, no show and sterilization.

The study investigates the factors involved in the decision of a sample of women to break appointments for sterilizations at the Fertility Management Unit of the University of the West Indies. A case control study involved 50 women who did not show up (no-shows) and an equal number who did show up (shows) over the same period. The no-shows had spent a shorter time in their current union than the shows, and some had no children for their partners at the time the appointments were made. Marriage was the single most important event that would encourage the no-shows to consider sterilization in the future. As long as poor women see child bearing as a precondition for financial assistance from spouses, they will hesitate to give up this capability.

PIP: As part of a research program to identify the barriers to increasing the acceptance of sterilization in the West Indies, a study was undertaken to determine why an estimated 16% of annual registrants for sterilization failed to keep their appointments (no-shows). From 300 no-shows, a random sample of 50 was interviewed and matched for year of registration, age, parity, marital and economic status, and geographic area with a control sample of 50 sterilized women. The most important reason for considering sterilization for all of the women was the desire to have no more children. The no-shows exhibited a lack of self-motivation, citing friends and medical personnel as motivators, and in no case did motivation come from the partner. The no-shows cited partner-related reasons and fear as causing them to break the appointments. Many women were ready for sterilization but were unable to discuss the topic with their partners. Among the sterilized women, 2 regretted the procedure. Among the no-shows, there had been 8 pregnancies, 3 of which were terminated, and 7 women were attempting to become pregnant. Recent research in the Caribbean suggests that improving women's status plays a more important role in reducing fertility than that played by family planning programs. As long as childbearing is seen as a precondition for receiving financial assistance from a man, it will continue.

FHI's role in search for nonsurgical sterilization.

PIP: Nonsurgical female sterilization, through use of quinacrine hydrochloride pellets inserted into the uterus, has the potential to make low cost permanent contraception accessible to the millions of women in developing countries who desire no more children but do not live close to surgical facilities or cannot spend time away from their families. Family Health International (FHI) has been studying this agent in clinical trials in Chile since 1976. The efficacy rate for 2 100-minute pellets is 95-98% at 12 months. The predominant side effects, temporary and minor, are amenorrhea of 1-3 months' duration, lower back pain, heavier menstrual bleeding, and headache. In 1990, however, FHI withdrew its Investigational New Drug application to explore the agent's toxicity, teratogenicity, and carcinogenicity. In 1989, 8 cases of cancer in 6 different anatomical sites were identified among the 572 Chilean women who had received quinacrine in clinical trials in the preceding decade. A retrospective study of 1492 Chilean women who were sterilized with quinacrine in 1977-89 revealed 17 cancer cases. Small sample sizes and the lack of cancer incidence data in Chile make it impossible to draw conclusions on the drug's carcinogenicity, but FHI will monitor this group for another 5 years. Early preclinical studies in pregnant rats and monkeys have indicated high rates of fetal death but no evidence of chromosomal damage; however, these studies must be repeated to meet new requirements, including the evaluation of bacterial gene mutation, mammalian cell gene maturation, and in vitro cytogenetics. Another research site has been Vietnam, where 31,781 quinacrine pellet sterilizations were performed in 1989-92 at the request of the government. FHI researchers are collecting data on health related outcomes as well as acceptor satisfaction, provider counseling, and service delivery among 1800 of these women and will complete its study in 1994. If the toxicology study yields favorable results, clinical trials will be repeated in the US.^ieng

[Notes for a multidisciplinary study of female sterilization]. / Apuntes para un estudio multidisciplinario de la esterilizacion femenina.

PIP: This article attempts to reconstruct part of a study on female sterilization in Mexico. The research began with a demographic survey, which was continued with a regional psychologically-oriented survey and has been complemented with studies that apply qualitative analysis techniques and the redrawing of conceptual frameworks for reproduction-related topics and the regulation of fertility. The author attempts to bring together the features of several analytical perspectives for the study of female sterilization. He also argues that research needs to focus more on the social normativity of reproduction and sterilization, the way in which it is put into effect by institutional health programs, and family planning services. The paper also suggests the need to study health aspects of the women who have chosen this birth control method, who are estimated to total 25% of all married women of reproductive age in Mexico. (author's)^ieng

[Bilateral tubal occlusion by postpartum mini-laparotomy under local anesthesia and sedation]. / Oclusión tubaria bilateral por minilaparotomía post parto con sedación y anestesia local.

The first 1000 cases of tubal sterilization post-delivery by minilaparotomy with sedation and local anesthetic, were reviewed; these procedures were realized at the Hospital of Zona Francisco del Paso y Troncoso of the IMSS, in México City, during the period comprehended between December 1990 and October 1991. The greatest group of cases by age corresponded to the period between 20 to 29 years in 52.3%. 65% of the women had 3 or 4 children alive. The range of the diastolic blood pressure was between 70-80 mmHg in 66.3%. 19.7% with a value of hemoglobin less than 10 g. 2.3% of the patients with 100-120 kgs. of weight. The contraceptive method used previously with greatest frequency was the DIU in 40.6%. In all of the cases the indication was satisfied parenthood. In 100% of the cases the same drug was used for sedation, diazepam (oral) and chlorhydrate of nalbulfine, with simple lidocaine as a local anesthetic. Likewise in all the cases the Pomeroy technique was performed. The time between the childbirth and the surgery was less than 12 hours in 92.9% of the cases. And the time between the surgery and the recuperation reset was of 12-34 hours in 96%. In 0.8% of the cases the transoperatory complication of the surgery was the bleeding as a result of tearing of the mesosalpinx. The postoperatory complications after one week were the formation of hematoma and/or abscess at the site of the incision representing 0.5% of the cases. All these procedures are realized at a unit that was created especially for this kind of surgery and treatment.

PIP: The first 1000 postpartum tubal occlusions by minilaparotomy under sedation and local anesthesia performed at a Mexican Institute of Social Security hospital in Mexico City were retrospectively reviewed. The operations took place between December 1990 and October 1991. The youngest patient was 17 and five patients were under 20. 52.3% were aged 20-29, 31.9% were aged 30-34, and 13.8% were aged 35-40. 65% of the women had three or four live births and 16.8% had two. The diastolic blood pressure was between 81 and 90 for 12.1%, between 91 and 100 for 8.9%, and between 101 and 120 for 3.7%. 19.7% had hemoglobin levels below 10 g. 37 women with hemoglobin levels between 4 and 8 g were sterilized; all received transfusions before discharge. 66.7% of the women weighed between 50 and 70 kg, but 2.3% weighed 100-120 kg. 40.6% used IUDs, 16.8% oral contraceptives, and 14.2% injectable methods. 24.8% had never used a contraceptive method. The Pomeroy technique was used in all cases. All patients were given Lidocaine. The operation was performed within 12 hours of delivery in 92.8% of cases. 96.3% of the women were discharged within 24 hours. Bleeding, resulting from tearing of the mesosalpinx, occurred in 0.8% of cases. A hematoma or abscess at the site of the incision was observed in 0.5% at one week follow-up. The data indicate that bilateral tubal occlusion by postpartum minilaparotomy under local anesthesia and sedation, rather than general anesthesia, is a rapid and safe procedure, even for obese and hypertensive women.