Successful pregnancy in a 42-year-old woman with imminent ovarian failure following ovulation induction with ethinyl estradiol without gonadotropins and in vitro fertilization.

PURPOSE: To describe the methodology used to induce ovulation in a 41-year-old woman with imminent ovarian failure and tubal factor so that in vitro fertilization-embryo transfer (IVF-ET) could be performed. METHODS: Ethinyl estradiol was used to suppress elevated serum follicle stimulating hormone (FSH) levels, thus theoretically allowing restoration of down-regulated FSH receptors and response to endogenous gonadotropins. RESULTS: One oocyte was retrieved and fertilized and one embryo was transferred. The patient conceived and is presently in her last trimester. CONCLUSION: Successful pregnancy following IVF-ET is possible in women with imminent ovarian failure - even in women older than age 40.

Outpatient pelvic laparotomy.

A population of generally healthy women underwent a variety of reproductive operations by pelvic laparotomy at an ambulatory surgical center. The techniques and safety of this approach are described. Of the 373 women, one experienced a major complication (ureteral injury), which was treated in the surgicenter. The patient recovered in the hospital, with no late adverse outcome. Two other women were hospitalized for intravenous fluid therapy because of persistent nausea and vomiting. No patients required blood transfusion or reoperation. Four women had minor complications that were treated outside the hospital. The rate of hospitalization was 0.8%; of major complications, 0.3%; of minor complications, 1.6%; and of total complications, 1.9%. In this population, 98% of the patients had no complication, and 99% did not need hospital care. Thus, outpatient pelvic laparotomy was found to be safe and cost effective.

[Contraception and pelvic infection in women]. / Contraception et infection pelvienne chez la femme.

PIP: Although sexually transmitted diseases are a major public health problem at the international level, the relationship between contraception and pelvic infection is seldom examined. Numerous STDs are more difficult to diagnose, more frequent, and more serious in women than in men. Differential diagnosis between pelvic infection and other intraabdominal syndromes has been a concern for practitioners for years, and many pelvic infections are probably never diagnosed. Lower abdominal pain and sensitivity as well as fever, leucocytosis, accelerated sedimentation rate, inflammatory annexial mass evident on sonography, and microorganisms in the pouch of Douglass and presence of leucocytes in the peritoneal fluid are diagnostic criteria. Apart from errors in treatment resulting from errors in diagnosis, pelvic infections are often inadequately treated, especially in the initial phase before symptoms are confirmed. The exact incidence of pelvic infections in the US is unknown, but pelvic inflammatory disease (PID) accounted for over 200,000 hospitalizations per year between 1970-75. PID carries grave risks of subsequent ectopic pregnancy, chronic pelvic pain, and infertility which is more likely as the number of acute episodes increases. The female genital tract has diverse microenvironments propitious for growth of microorganisms of different types, aerobic and anaerobic. Each anatomic site has specific features conditioning bacterial growth. Histological modifications during the menstrual cycle and pregnancy affect the microbial flora. Except in the case of gonorrhea, it is not known how many female lower genital tract infections spread to the upper tract. Since 1970, several studies have domonstrated a growing diversity of cervical and vaginal flora in asymptomatic subjects. The principal risk factors for PID have been well described in the literature. All contraceptive methods except the IUD provide some degree of protection against PID. Even among IUD users the risk of PID is probably not greater than among women with a comparable risk of exposure to STDs. The protective effect of condoms has been recognized since the era of Casanova, but it is difficult to quantify. Studies describing the protective effects of spermicides used one against pelvic infection are very rare, and protective effects have usually been demonstrated only in vitro. Surfactants such as nonoxynol probably have viricidal properties against herpes simplex. Condoms and diaphragms have been seen to exercise a protective effect independent of spermicide, with relative risks of .6 and .4 compared to nonouse of contraception. There is as yet no consensus on changes in risk of PID during oral contraceptive (OC) use, but several studies have shown OCs to have a protective effect. Risks of PID in IUD users apparently stem from contamination during insertion or of the thread during prolonged use, but both possibilities remain controversial. The use of women not using contraception as controls in studies of relative risks of PId may not be appropriate because their sexual behavior and risks of exposure to STDs may differ. At the moment of ovulation, when the mucus is most receptive, IUDs do not place any barrier in the way of ascension of sperm and bacteria to the upper genital tract.^ieng

The Fitz-Hugh-Curtis syndrome revisited. Changing perspectives after half a century.

The Fitz-Hugh-Curtis syndrome is an extrapelvic manifestation of pelvic inflammatory disease. Classically it consists of adhesions between the liver capsule and the diaphragm or the anterior peritoneal surface. Two recent changes have been made in the assessment of this syndrome. One, the syndrome was originally thought to be caused solely by Neisseria gonorrhoeae. Recent studies using tissue cultures and serum antibody titers have documented a major etiologic role for Chlamydia trachomatis as well. Two, the condition has recently been reported to exist in men, whereas previously it was believed to be limited to sexually active women in their reproductive years.

Surface changes in intrauterine contraceptive devices after variable use.

Four used intrauterine contraceptive devices and two new control devices were studied by scanning electron microscopy. All intrauterine contraceptive devices were found to have surface deposits that differed not only from site to site on a given device but between devices. A finding of this study not previously described in the literature was the observation of a euhedral crystal rosette of an apatite mineral group [Ca5(PO4)3(F,Cl,OH)] on the Lippes Loop that had been in situ for 15 years.

PIP: Scanning electron microscopy was used to study 4 used contraceptive devices and 2 new control devices. A Lippes Loop No. 1 (in situ 15 years), a Saf-T-Coil No. 1 (in situ 8 years), a Cu-7 No. 2 (in situ 4 years), and a Cu-T No. 1 (in situ 6-1/2 years) were placed in 2.5% glutaraldehyde in Millonig's buffer immediately after their removal. Unused IUDs -- the Cu-7 No. 1 and the Lippes Loop No. 2 -- also were placed in glutaraldehyde immediately after removal from their sterile envelopes. After suitable fixation, all specimens were prepared for scanning electron microscopy according to standard techniques. Samples were mounted on aluminum studs and vacuum evaporated with gold-palladium in a ratio of 60:40. A MEOL JSM 50A scanning electron microscope was used. Photographs were taken with Polaroid P/N 55 film. The intrauterine portion of 1 of the 2 strings of the Lippes Loop No. 1 demonstrated an irregular distribution of plaquelike encrustation with a smooth string surface visible underneath the plaque. In contrast, part of the intravaginal portion of the 2nd string was so heavily encrusted that the underlying surface was not visiable at any point. The body of the Lippes Loop showed 2 different encrustation morphologic characteristicss. These were seen on both sides of the clearly visible molding mark that bisects the IUD. 1 pattern had the appearance of a continuous mud-cracked encrustation. On a more superior portion of the IUD body several rounded masses appeared to project from the surface. The dissimilarity of the Saf-T-Coil to the Lippes Loop No. 1 centered around the absence of euhedral crystalline forms and the presence of "bulbous nodules" surrounded by plaquelike encrustation that appeared fibrous at times and granular at others. In some areas a netlike matrix was visible, suggesting that the nodules represented filled-in areas of a fibrous network. On other areas of the IUD the superficial encrustations had broken off revealing an underlying and more regular granular base of plaque on the IUD surface. An observation not seen on any other device examined was the presence of spaghetti-like structures projecting from a coherent base of the plaquelike encrustation on the intrauterine portion of string of this device. The observations of the Cu-7 No. 1 were characterized by thick and dense encrustation; "bulbous nodules" were absent. The surface of the IUD body and its string had plaque-like encrustations with a more textured appearance. There were 2 notable features to the encrustation of the Cu-T, No. 1: the thick and contiguous nature of the encrustation; and a series of symmetrical cracks in an underlying base coating seen at a higher magnification.

On the causation of pelvic inflammatory disease.

PIP: The classic descriptive model of pelvic inflammatory disease (PID) omits any direct statement that sexual intercourse leads to the development of the lower genital or cervical infection which ultimately leads to upper genital or tubal infection. Despite this, clinicians treating patients with PID frequently, either implicity or explicitly, link its onset to sexual activity. In the past decade numerous authors have commented on the strong association between the widespread changes in sexual attitudes and behavior (without describing them in detail) and the enormous rise in sexually transmitted diseases and PID. With the advent of the case control study, the epidemiologist viewed sexual activity as only 1 of many risk factors for the development of PID. Yet, the clinician often maintanied that this relationship was too obvious to require case control studies to prove the point. The sum, the classic hypothesis on the pathogenesis of PID has remained virtually unchanged for nearly 8 decades in spite of its limitations, such as the failure to consider the endogenous and exogenous risk factors for the development of PID in a given patient. Possibly the greatest defect of the classic theory is its failure to address the precise mechanisms by which the infectious agents that cause PID travel from the lower to the upper genital tract. Existing literature suggests that 3 mechanisms may be operative. The 1st mechanism is that motile trichomonads are capable of ascending from the vagina to the level of the fallopian tubes and may carry with them a variety of infectious agents. The 2nd suspected mechanism for transport of microorganisms to the fallopian tubes is by attachment to sperm. If this occurs, then clearly spermatozoa may serve as vectors of pelvic infection. Abundant evidence exists to support the concept that sperm intimately associate with a variety of infectious agents, many of which are unrecognized as pathogens in the female. The 3rd suspected mechanism for transport of bacteria from the lower to the upper genital tract in the female appears to be that of passive transport. The literalture lacks reference to bacteria per se gaining entrance to the uterus but contains abundant references to the transport of particular matter and sperm. The current orientation of most American textbooks and much of the literature in regard to the pathogenesis of PID is oversimplified. More attention must be devoted to the mechanisms by which infectious agents arrive at the fallopian tubes.^ieng

The etiology of pelvic inflammatory disease.

PIP: The etiology of pelvic inflammatory disease (PID) is speculated upon based on reported incidence and epidemiological studies. In Western society, the incidence of PID (annual) is 1% among women aged 15-34 years and 2% in the high risk group of women aged 15-24 years. The annual incidence in the US is higher, at least 2% among fecund sexually active women aged 13-44 years. The medical consequences of PID are infertility, ectopic pregnancy, and chronic pelvic pain. Causative agents include Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma hominis and various other aerobic and anaerobic microorganisms; however, the natural genital flora of females is so varied that determining actual causative agents is difficult. some case-control studies have determined risk factors for PID; these include particularly current or prior use of IUD, prior pelvic surgery, sexual activity (including number of partners), race, and prior PID acute infection. PID is not a sexually transmitted disease, but rather is classified as sexually derived. Use of barrier methods and oral contraceptives protects against PID. IUD use greatly increases the risk of PID, probably because of the avenue the device provides for organisms to ascend from the lower to the upper genital tract. The role of males in PID etiology is currently the subject of much discussion. It is theorized that the mechanical action of penis insertion in intercourse helps to move causative agents to the upper genital region; also, semen may carry vaginal flora through the cervical opening into the uterus and tubes. Menstruation and PID are closely associated, perhaps because the cervix dilates during bleedings. Research areas include: determination of role of sexual activity (and number of partners) in PID etiology; evaluation of events of menstruation that are predisposing; evaluation of relationship between bacteriosperma and lower and upper genital infections; relationship of particular contraceptive methods to PID incidence; and breakdown of risk factors.^ieng

Clinical experience with the prevention of Rh-isoimmunization: a historical comparative analysis.

Clinical experience with prevention of Rh-immunization is reviewed. The pathogenesis of hemolytic disease and the chemistry of prophylaxis is explained. The factors which effect antigenic expression are delineated. The clinical indications for prevention of AMIS are reviewed. International data pertaining to Rhesonativ are presented from postpartum trials and antepartum trials. A protocol for antepartum administration of anti-Rh immunoglobulin is given.

[Health risks of intrauterine contraception (author's transl)]. / Les risques inherents a la contraception intrauterine.

PIP: Uterine perforation, intrauterine and ectopic pregnancy, pelvic infection, and fertility problems after removal of the IUD are among recognized or potential health risks of IUD use. The frequency of uterine perforation varies according to type of IUD, with estimates of cervical and uterine perforation respectively ranging from 0 in 4122 Saf-T-Coil insertions to 1.5 and .3/1000 insertions of the Copper T. Data on perforations and their treatment and sequelae are however incomplete and unsatisfactory. The structure of the IUD, the rigidity of the applicator, the size and position of the uterus and the time of insertion relative to delivery or abortion, and the physician's technique and experience are all related to the incidence of perforation. Reported pregnancy rates/100 woman years vary from 5.3 for the Lippes Loop A to 1.6 for the Copper 7 Gravigard among nulliparous users. Disparities result from inherent fecundity differences in the populations studied, the age-parity composition of the population, sociocultural factors related to timing and frequency of coitus, and methods of data analysis. Spontaneous abortion rates for intrauterine pregnancies with IUDs range from 23.5-52.9% depending on whether the device is in place, but rates do not differ greatly from those of diaphragm users if the IUD is removed, even during pregnancy. The IUD does not seem to increase the risk of congenital anomaly. Although evidence and opinion on the question are divided, the use of an IUD apparently does not by itself increase the risk of ectopic pregnancy. Later fertility does not seem to be affected: 80-90% of women discontinuing IUD use to become pregnant do so within 1 year. Pregnancy rates appear to be comparable to those of women discontinuing diaphragm use. Although evidence of a greater risk of pelvic inflammatory disease among IUD users has been observed, the extent of the added risk if any is unclear because of diagnostic and methodological problems. In comparison to other reversible methods of contraception, the rates of failure, and of mortality resulting from use of the IUD or indirectly from failure of the IUD, are low. Patients should however be carefully screened and informed of the risks and symptoms.^ieng

Utilization of Rh prophylaxis.

PIP: The elimination of Rh hemolytic disease of the newborn infant is now possible as a result of the development of Rh-immune globulin (RhIG). The extent to which Rh hemolytic disease of the newborn will be eliminated depends on the extent of utilization of anti-Rh prophylaxis in all potential candidates. Between 1970-79 the incidence rate of the hemolytic disease of the newborn declined from 40.5%-14.3/10,000 births. Appropriate surveillance allows health agencies to monitor trends in incidence, to evaluate the effectiveness of their efforts toward prevention, and to detect any deficiencies in the use of preventive measures. With regard to RH hemolytic disease, surveillance involves collecting and reporting the following information: the number of sensitized pregnant women; the number of infants with Rh hemolytic disease, the number of associated fetal and infant deaths; and Rh-immune globulin utilization rates among eligible Rh-negative women. At this time no central data collection agency incorporates all of these requirements for the entire population. Following a literature review, this article summarizes utilization data derived from a variety of sources. It also presents the methodology for individual hospitals and health care institutions to calculate their own internal utilization rates of Rh prophylaxis. The status of various data from state health departments as provided to the Center for Disease Control (CDC) is presented in a table. The Connecticut State Health department has surpassed other states in the completeness of its data collection system and its ability to implement a working surveillance program. The results of the 10 year effort in Connecticut can be summarized as follows: the percentage of Rh-negative women delivering who were already sensitized dropped from 4.5% in 1970 to 1.2% in 1979; the utilization rate of prophylaxis for eligible women has risen from 93.3% in 1970 to 99.5% in 1979; and perinatal deaths due to Rh disease have decreased from 32 in 1970 to 6 in 1979. The Illinois Department of Public Health began monitoring Rh hemolytic disease incidence, Rh incompatible pregnancies, and immune globulin use in 1970. The program instituted in 1968 by the Massachusetts Department of Public Health was unique in that the state recognized at the onset the high cost of obtaining RhIG and decided to manufacture and distribute the biologic material. A survey of blood banks in the US determined that in the 12-month period ending March 31, 1974 a total of 212 patients were reported to have received Rh-incompatible transfusions. Slightly more than half of the women who received Rh positive blood were treated with RhIG. Once the racial composition of any population group is known, the number of women for whom RhIG is indicated after term deliveries or abortion can be estimated on the expected number of Rh-incompatible pregnancies for each racial group.^ieng

[Spontaneous or induced abortion and the risk of Rh immunization]. / L'avortement spontane ou provoque et les risques d'immunisation contre le rhesus.

PIP: It has been well known for at least a decade that induced or spontaneous abortion can entail a risk of RH immunization in the mother. Anti-RH o (D) immunization prophylaxis after abortion is not always done, mostly because of its cost and because of the need of specialized personnel and equipment. The proportion of RH negative individuals is 15% among whites, 7.5% among black Americans, 4% among black Africans, and 0-1% among Orientals. The detection and quantification of fetal erythrocytes in the maternal circulation can be done by several methods. The standard dose used in the U.S. for anti-RH immunoglobulin after delivery is 300 mcg. After 1st trimester abortion it is 50 mcg; after 2nd trimester abortion the optimal dose has not yet been established, but it should be between 50 mcg and 200-300 mcg. Anti RH o (D) immune prophylaxis should be done also after menstrual regulation, even when pregnancy has not been ascertained; treatment must always be done as soon as possible after delivery or after abortion.^ieng

[Vaginal contraception. Pt. 1 (author's transl)]. / La contraception vaginale. Pt. 1.

PIP: Vaginal contraception is enjoying a revival among women who fear the side effects of the pill or of the IUD. Vaginal contraception by vaginal diaphragm or by cervical cap is totally reversible and never causes complications; there may be short term reversible side effects with the diaphragm, such as cystitis, uretritis, and hemorroids; no side effects are associated with the use of cervical caps. Vaginal contraception has the added advantage of exercising a notable prophylactic actions on the diffusion of verereal diseases and of other vaginal infections such as trichomoniasis and candidosis. It is also possible that vaginal contraception offers protection against cervical neoplasia. Failure rate of diaphragm use is an average 10/100 women years, and for the cervical cap it is about 7.6/100 women years, when both devices are properly used. Vaginal contraception needs to be used in conjunction with spermicidal agents. Spermicidal agents can be used alone and can be very effective; they are, however, not well accepted by most couples, who resent the interruption of the sexual act. Two experimental models of vaginal sponge are now under study; vaginal sponges can be left in place for some time, and insertion is very easy.^ieng

The Northwestern University multihospital twin study. I. A description of 588 twin pregnancies and associated pregnancy loss, 1971 to 1975.

Five hundred eighty-eight women who were delivered of twins at 13 hospitals affiliated with the Northwestern University Medical School or its outreach institutions between 1971 and 1975 were studied. Eighty-six of the infants did not survive the pregnancy, delivery, or the first week post partum. Maternal demographic and obstetric characteristics are outlined. Infants are categorized by birth order and by birth weight. The mean weight (and standard deviation) of first twins was 2,388 gm (+/- 742 gm) and that of second twins was 2.314 gm (+/- 766 gm). The rate of pregnancy wastage was highest in mothers who were under 20 years of age, who were of low parity, and who were delivered prior to the physiologic maturation of the fetus. The crude mortality rate of twin 1 was 6.1/100 versus 8.5/100 for twin 2. The causes of death in all infants over 2,000 gm are listed. All pregnancy losses are categorized into unavoidable deaths (26.6%), probably not avoidable deaths (59.4%), and possibly avoidable deaths (13.9%).