The role of research and training in family planning programmes.

PIP: The slow progress of family planning in Egypt is not due to the insufficiency of human and material resources. The problem lies in the distribution, management, and improvement of these resources. Research and personnel training are critical to directing efforts along the right course and towards the right objectives. The Population Council (USA), at the end of 1972, identified all findings of major significance from international research on family planning programs. Of the 322 studies, not 1 was carried out in Egypt or was based on 2ndary data from Egypt. Since 1972, though, Egyptian social and medical scientists have become actively involved in demographic themes and human reproduction. These are mainly personal iniatives, often limited by a scarcity of funds. Findings of population studies are not as transferable from 1 population to another. Also, there is a diversity of research needs. Many Muslims believe that their religion outlaws birth control. Religious objection appears the most widely shared reason for nonuse. This objection suggests a series of questions on what can be done to influence religious attitudes relating to contraception. A permanent and adequately managed institution for training in family planning and related aspects of maternal education has not been set up in Egypt. Training requirements of different levels and categories of personnel must be carefully identified. The impact of training on the quality of performance must be monitored. Training should not be limited to conventional groups of trainees. Al-Azhar's Islamic Centre for Population Studies and Research was built 5 years ago with initial aid from the United Nations Fund for Population Activities. It was an attempt to create an intellectual focus on population issues, concerning how the quality of life and Islamic standards of its quality affect each other. During the 1st 5 years, the Centre devoted itself to research activities. 44 studies were conducted.^ieng

Laparoscopy on patients with previous lower abdominal surgery: a new technique.

During the period June 1979--May 1981, 1582 diagnostic and operative laparoscopic procedures were performed at Al-Azhar University Endoscopy Unit and during field visits to several hospitals in Egypt, Sudan and Mauritania. Ninety-nine of these had had previous lower abdominal surgery. Laparoscopy was performed on 93 of these patients using a modified technique of laparoscopy. The modified technique involves direct visualization of the previous peritoneal scar with the scope before its careful puncturing with the trocar and cannula. The paper describes the technique, findings, complications, limitations of the procedure and its application.

Laparoscopic ventrosuspension: a new technique.

During 42 months of study, 150 cases of laparoscopic ventrosuspension were performed at Al-Azhar University hospitals. In 98 patients (65.33%), the primary complaint was infertility. Retroversion of the uterus was the only abnormality detected during laparoscopic examinations. The remaining 52 patients (34.66%) had retroversion of the uterus concomitant with other conditions requiring surgery. Ventrosuspension was performed via the laparoscope by applying Falope rings (KLI, Newtown, Pennsylvania USA) to the round ligaments. These patients were followed up for 6-30 months. Pregnancy occurred in 29 infertile patients and improvement of backache, deep dyspareunia, congestive dysmenorrhea and leukorrhea occurred in 81.25%, 89.25%, 68.18% and 56.66%, respectively. The technique is simple and safe; it reduces the length of hospitalization and can be performed concomitant with other surgical procedures.

Menstrual pattern and blood loss with U-coil inert progesterone-releasing IUDs.

Menstrual blood loss (MBL) was estimated before and after insertion of the U-coil progesterone-releasing device in 37 patients. The same procedure was carried out in 39 cases fitted with an inert U-coil IUD of the same size and shape. Blood loss was estimated by the atomic abosorption technique during the preinsertion cycle and at the 1st, 3rd, 6th, 9th, and 12th postinsertion cycles. MBL was significantly reduced in patients fitted with a progesterone-releasing U-coil compared to those fitted with an inert U-coil who showed a significant increase in MBL. The cycle length was prolonged with the progesterone U-coil, and was reduced with inert U-coil devices. The duration of flow was significantly reduced with the progesterone U-coil and significantly prolonged with the inert device. The incidence of intermenstrual spotting was higher with the progesterone U-coil than with the inert U-coil. The hemoglobin level was significantly increased with the progesterone U-coil while it was significantly reduced with inert U-coil devices.

Diagnostic laparoscopy for infertile patients as a training program.

During a 3-year period, 2650 cases of diagnostic laparoscopy were performed on selected infertility patients in a training program on gynecologic laparoscopy at hospitals in Egypt, the Sudan and Saudi Arabia. All cases were attended by the senior author. Most of the procedures were performed by physicians who either had never performed the procedure or had not had significant experience with it. This report presents the laparoscopic findings, complications and problems encountered. It shows that with emphasis on equipment care and handling, careful patient selection and observation of simple precautions during and after the operation, the procedure can be safely included in the training program of residents in obstetrics and gynecology.

Contraception during lactation.

PIP: Breastfeeding is often crucial to infant health in developing countries, and should be encouraged. It is well known that although lactation provides some protection against pregnancy, it is not a substitute for effective contraception. 588 lactating mothers were observed at the Al Azhar University, Cairo, Egypt, and divided into 5 groups, according to the type of contraception administered: 1) combined oral contraception (OC), 2) progestin-only contraception, 3) 3 different types of IUDs, 4) sulpiride; and 5) the rhythm method for the control group. Results from the observations showed that: 1) combined OCs decreased the volume of milk produced and shortened the duration of lactation in 1/3 of women; 2) progestin-only contraception increased the production of milk and extended the duration of lactation; 3) IUDs did not influence lactation patterns; 4) sulpiride significantly increased milk production but its contraceptive efficacy declined sharply after the 4th month postpartum; 5) 1.3% of women in the control group began menstruating at 6 weeks postpartum, 22.3% within 6 months, and 60.2% within 1 year; ovulation was detected in 18% of menstruating women at 3 months postpartum. When side effects of each method were investigated it was concluded that IUDs are the ideal contraceptive method for use during lactation, with the addition of a lactation stimulant when needed.^ieng

Lactation pattern in Egyptian women using the Progestasert system.

PIP: 80 Egyptian women, aged 22-35 and with parity 1-6, were inserted immediately after delivery with Progestasert, an IUD releasing a small amount (65 mcg) of progesterone daily. A group of women not using contraception was used as control. The total expulsion rate was 52.5%, and occurred between the 7th and the 10th day postpartum; the devices were reinserted in all cases. The rate of return of menstruation was significantly higher in Progestasert users than in controls; 25% menstruated after 6 weeks, 71.2% by 6 months, and 82.5% by 12 months. Breakthrough bleeding occurred in 27.2% of cases, scanty menstruation in 27.2%, and menorrhagia in 10.6%. The incidence of return of ovulation was significantly higher in the control group, 42.7% compared to 7.5% in Progestasert users; there were 2 uterine pregnancies, or a failure rate of 2.5%. The amount of milk and total protein and glucose content of milk were significantly higher in Progestasert users. The high rate of expulsion was attributed to the increase in volume of the uterine cavity, and the reduced volume of menstrual bleeding to the progesterone released by the device. The incidence of menorrhagia reported with Progestasert is much lower than that reported with other IUD types.^ieng

Contraception during lactation.

Seven hundred and seventy-two lactating mothers were studied from delivery for 1 year to select the best contraceptive method (oral drug, injected drug, or IUD) which did not affect lactation. Ten groups of mothers were studied, including 234 control subjects. The injectable progestational contraceptives caused an improvement in the amount of milk and its protein concentration, whereas the IUCDs did not influence the lactation pattern. Sulpiride was an ineffective contraceptive but a potent lactation stimulant. The side effects of each method (effects on milk yield, protein content and prolactin concentrations) were also noted; it was concluded that IUCDs are the ideal contraceptive method during lactation, with the use of a lactation stimulant when indicated.

Some biochemical effects of long term oral contraceptive therapy on Egyptian females living in rural areas.

PIP: The serum activity of glutamic oxaloacetic transaminase, glutamic pyruvic transaminase and alkaline phosphatase, serum nilirubin (total, direct and indirect), serum proteins (total, albumin, alpha 1, alpha 2, beta and gamma globulins), serum glycoproteins (glyco-albumin, alpha 1, alpha 2, beta and glycoglobulins) and serum lipoproteins (alpha,pre beta, beta and chylomicrons) were studied in 131 Egyptian females receiving either 1 of 2 types of oral contraceptives. These parameters were evaluated before and after 6 and 12 months of continuous use of either 1) mg lynestrenol + 0.05 mg ethinyl estradiol) or (0.5 mg lynestrenol). All these biochemical entities remained within normal limits except serum albumin which showed a significant decrease from the pretreatment level. This decrease could be attributed to a decreased rate of albumin synthesis. Since the liver is the main organ for albumin synthesis, the reduction in albumin might indicate a possible deleterious effect of the hormones on the liver. The determination of the albumin level in the serum may serve as an index to the effect of contraceptive hormones on the liver. Tables for the mean and standard deviation values of studied parameters for group 1 and group 2 before and after 6 and 12 months of continuous use of the combined pill and the minipill are included.^ieng

Clinical evaluation of U-coil progesterone releasing device versus inert U-coil IUD.

PIP: 76 patients were randomly selected to be fitted with U-Coil intrauterine device. The inert U-Coil device was inserted in 39 patients and the progesterone releasing U-coil device was inserted in 37 patients. Patients fitted with both types of device were followed up for 12 postinserton months. The main side effects of the device were expulsion, removal for pelvic pain and bleeding and dysmenorrhea. No expulsion in those women fitted with inert U-coil device was reported. Expulsion of the progesterone U-coil device occurred in 3 patients (8.1%). Removal for bleeding and pain in women fitted with inert U-coil was necessary in 2 patients (5.1%). In patients fitter with progesterone U-coil, removal for bleeding and pain was necessary in 1 patient (2.2%). Pelvic pain was reported in 10 patients (25.6%) fitted with inert U-coil device, while it was reported in 1o patients (35.1%) fitted with progesterone U-coil device. Dysmenorrhea occurred in 29 patients (74.4%) fitted with inert U-coil device compared to 19 patients (59.5%) fitted with progesterone U-coil device. All removals of inert U-coil device th removal for bleeding and pain was only 1 case with uterus in anteverted position and in 1 expulsion the uterus was in midosition.^ieng

Status of fertility control in Egypt.

PIP: The concern for fertility control is not alien to the cultural and religious heritage of Egypt. Historically, Egyptian interest in fertility dates to the Pharoahs. Contraceptive recipes written at least 15-18 centuries B.C. have been found. Romans may have borrowed some of the more effective methods from Egypt when it became part of the Roman Empire as evidenced by the decline in size of aristocratic Roman families at the beginning of the Christian era. Muslim conquerors of Egypt encouraged fertility control. In the 9th century differences of opinion about the legality of contraception appeared among the interpreters of Islamic law. Some methods found in the writings of Muslim doctors as al-Razi and Avicenna still survive in the folk medicine of Egypt. In modern times use of barrier methods of contraception were encouraged by family planning organizations in Egypt. The medical profession was not deeply involved since these methods did not require much medical assistance. In 1936 a religiouss verdict declared contraception to be a lawful act of Islam. National programs in family planning in the 1960's encouraged the use of the Lippes Loop IUD. The medical problem of blood loss associated with the IUD caused anxiety because of the high incidence of anemia in the female Egyptian population. There was also a cultural limitation on the wide use of the IUD. "Spotting" due to the IUD resulted in females being ritually unclean and therefore unfit to pray or observe the Islamic fast. The Pill, initially favored caused complications due to its effect on breast milk which is the universal source of nutrition for infants in Egypt. Replacement of the Pill by depo-provera injections during the post partum period of lactation is a practical solution. Permanent sterilization is limited to females and only performed when medically indicated. Abortion is illegal and permitted only as a therapeutic measure.^ieng

Population and human health.

PIP: The nature, proportions, causes, effects and cures of the Egyptian population crisis are analyzed. If the world population growth rate of 2% continues by the year 2000 a population of 6.5 billion can be expected. By 2115 the world population will have doubled. The greatest increase in population is made by developing countries, e.g. Egypt's population will double in 25 years, Turkey's in 26 years, and Algeria's in 21 years. National health goals become increasingly difficult to achieve under these conditions. For overpopulated countries the options of migration, resource transfer, and fertility control have both positive and negative effects. For Egypt, migration of medical manpower is a major factor responsible for low health standards. Technology transferred from developed countries to assist overpopulated developing countries to increase production of all resources is a slow procedure. Fertility control will slow population growth, reduce maternal morbidity, create smaller families which may result in better psychological family health and therefore better level of job performance. It will also permit women to participate in the work force more easily and earn independent incomes. The effects of health improvement have also been positive and negative in Egypt. The Egyptian population is still growing at a rate .3% higher than the world rate. This situation has resulted from a decline in the death rate rather than in an increase in fertility. The death rate dropped from 32.9 in 1937 to 26.8 in 1947 to 15.8 in 1967. Fertility is close to 5.5 which is no higher than the world average. The drop in death rattes is due to better sanitation, extension of medical services, immunization campaigns, expansiion of health education and greater availability of foo. Reduction of morbidity coupled with health improvement is hoped to foster increased acceptance of fertility control, increased population attention to and acceptance of fertility counseling and increased funding for research in contraceptives responsive to the biosocial needs of the population. Effective fertility control is limited by the unavailability of contraceptive methods satisfying all areas of acceptability, the need to expand national programs and the need to include social and economic factors in fertility control programs.^ieng

Lactation in Islam.

PIP: Preservation and promotion of breastfeeding in Islamic countries could be increased by stressing the religious importance of this practice as prescribed in Islamic religious teachings. The child's right to be breastfed is affirmed by the Quaran, the source of Islamic law and morality. Quranic verse 2:233 recommends a 2 year period of lactation. According to Islam a nursing mother is entitled to receive compensation from the father for nursing the child. The father, though, has the option to engage a paid or unpaid wet-nurse for the child, in which case the mother looses her right to be paid for nursing even is she volunteered to breastfeed. The mother's right to nurse a child without compensation is prior to a father's right to engage a wet-nurse. In another Islamic source the moral importance of breastfeeding is stressed. The mother receives the reward of a good deed for every single drop she gives her child. Islamic precepts on lactation influenced Arabian medicine. Avicenna's view that children should be breastfed for 2 years was approvingly quoted by European physicians in the 17th century. Major Arabian medical texts contain chapters on lactation, on tests for quality of breast milk, and on diets and drugs for improving lactation. Research at Al-Azhar University is directed toward finding a contraceptive that will not inhabit lactation and will not affect the quality of breast milk.^ieng

Effect of oral contraceptives on some biochemical aspects in bilharzial Egyptian females living in rural areas.

PIP: The serum activity of glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, and alkaline phosphatase; serum proteins (total, albumin, alpha-1, alpha-2, B and gamma globulins); glycoproteins (glycoalbumin, alpha-1, alpha-2, B and gamma glycoglobulins) and lipoproteins (alpha-, pre B, B and chylomicrons) were studied in 42 bilharzial Egyptian females with hepatic or hepatosplenic affections. These parameters were evaluated before and after 6 and 12 months of continuous use of either a combined pill (0.05 mg ethinyl estradiol + 1 mg lynestrenol) or a minipill (0.5 mg lynestrenol). All these biochemical entities remained within the normal limits except serum albumin and total serum proteins which showed significcant decreases after 6 and 12 months use of either contraceptive. The decrease of serum albumin could be attributed to a decreased rate of its synthesis. No significant increase in globulins was observed. Therefore a significant decrease in total proteins occurred. The decrease of serum albumin during the use of either contraceptive had previously been recorded by the authors in normal females living under the same socioeconomic status as the cases in this study. The same decrease in serum albumin had previously been recorded in non Egyptian females. The determination of albumin level in the serum may serve as an index to the effect of contraceptive hormones on the liver. In contradistinction to the finding in normal cases, alpha-1 glycoprotein failed to increase in response to the contraceptive hormones. This finding may indicate an inadequate response of the liver in bilharzial females to the effect of these hormones.^ieng

Hysterographic study of some side effects of the copper T 200 device.

PIP: A hysterographic study using the diluted dye technique (Urographin diluted to 15%) was carried out on 80 women to study the side effects that might result during the use of the T Cu 200 device in te 1st year of insertion. The hysterographic pictures showed the position and orientation of the device inside the uterine cavity and the side effects were related to the position of the device and size of the uterus in some cases. The women were divided into 4 groups according to their subjective symptoms; a control group with no complaints (37 cases), a group complaining of bleeding (27 cases), a group complaining of pain (11 cases) and a group who expelled the device (5 cases). The group complaining of bleeding were found to have a large sized uterine cavity. This was found to be statistically significant when compared to the control group. The other X-ray findings of orientation, anchorage or displacement of the device inside the uterine cavity were statistically insignificant when compared to the findings of the control group. The hysterographic findings in the group complaining of pain were statistically insignificant when compared to those in the control group. Cases of expulsion of the devices were found to have a large sized uterine cavity, a wide fundus and a diluted uterine isthmus. These findings were statistically significant when compared to thagt in the control group. Tables, charts and photographs illustrate the results of this study.^ieng

Selection of best parameters for ovulation detection in induction of ovulation with organic non-steroidal synthetic compounds.

PIP: Clomiphene, Tamoxifen and Epimesterol were used to determine the proper selection of the best parameter of ovulation detection in the absence of pregnancy. The trial consisted of 65 anovular infertile Egyptian women, ranging from 18-35 years of age, with at least 1 year of infertility, with different menstrual patterns varying from amenorrhea, oligohypomenorrhea to anovular menstruation. 6 parameters of ovulation detection were used: 1) basal body temperatures; 2) endometrial biopsy; 3) serial vaginal smears; 4) cervical mucus changes; 5) LH assay in morning urine; and 6) plasma progesterone by C.P.B. Clomiphene was tried on 25 patients as was Tamoxifen. Epimesterol was tried on 15 patients. The patients received the drugs for 174 courses. 41 had ovulation in 77 courses; 14 patients got pregnant; 4 of them aborted. It was occasionally difficult to decide on the basis of 1 test alone, whether a patient ovulated in a particular cycle because of the anti-estrogenic effect observed particularly with Tamoxifen and Clomiphene, but not with Epimesterol. The best parameter of ovulation detection in non-pregnant cases was hormonal assay. Due to the requirement of special equipment for such assay, endometrial biopsy at the onset of menstruation done parallel with BBT to avoid induction of abortion in early undiagnosed threatened abortion could be considered a fairly good parameter of ovulation detection.^ieng

Ovarian function during lactation.

PIP: The authors discuss the menstrual pattern during lactation, which lengthens the birth interval primarily by extending the period of postpartum amenorrhea. The length of postpartum amenorrhea varies greatly as it is influenced by such factors as breastfeeding practices (duration and extent of supplementry feeding); maternal constitution factors (e.g., maternal age and nutritional status); and pregnancy wastage and infant survival. Since full lactation prevents menstruation for a longer period of time than does partial lactation, supplementary feeding of suckling infants influences the return of menstruation. Also, increase in age and parity is frequently associated with longer periods of postpartum amenorrhea. It is difficult to determine if ovulation occurs during the 1st menstrual cycle after delivery or if it occurs regularly during subsequent menstrual cycles. It is assumed that the 1st 1 or 2 menstrual cycles following delivery are anovulatory, apparently in the cycle before menstruation. Thus about 1/2 of all nonlactating women are fertile before the 1st postpartum menstrual period. Ovulation is likely to precede menstruation in fully lactating women, but the longer menstruation is delayed by lactatioon, the more likely that the ust cycle will be ovulatory. The occurance of ovulation after return of menstruation is significantly higher than ovulation before the return of menstruation until 9th postpartum month during lactation. The incidence of pregnancy in fully lactating mothers is 1.3% by the 3rd postpartum month, increasing to 26% at the 12th postpartum month. The incidence of pregnancy before and after return of menstruation is significantly high. This is due to the high rate of ovulation after return of menstruation. When pregnancy rate in ovulating lactating mothers before and after return of menstruation is compared, no significant difference is detected. Also discussed are the ovulation inhibiting effects of progestational drugs (medroxyprogesterone acetate) used as a contraceptive during the postpartum period, as well as those of the nonhormonal drug, sulpiride, on the menstrual pattern during lactation. The authors' discussion refers to the results of other studies in the field.^ieng

Perinatal mortality in an Egyptian maternity hospital.

The factors affecting perinatal mortality during a period of 21 months were studied at Al-Galaa Teaching Hospital, using the International Fertility Research Program's Maternity Record 903 to collect the data. There were 6990 deliveries during the 21 months and 580 hospital perinatal deaths. Certain high-risk factors associated with perinatal mortality were identified including both biosocial and biomedical factors. The biosocial factors affecting perinatal mortality in this study are discussed, including maternal education, marital status, residence, hospital status as paying or non-paying patient, maternal age, registration status, outcome of last pregnancy, parity/family size, antenatal care, maternal hemoglobin, and the weight and sex of the baby.