Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women.

BACKGROUND: Previous studies of intrauterine devices (IUDs), many of which are no longer in use, suggested that they might cause tubal infertility. The concern that IUDs that contain copper--currently the most commonly used type--may increase the risk of infertility in nulligravid women has limited the use of this highly effective method of birth control. METHODS: We conducted a case-control study of 1895 women recruited between 1997 and 1999. We enrolled 358 women with primary infertility who had tubal occlusion documented by hysterosalpingography, as well as 953 women with primary infertility who did not have tubal occlusion (infertile controls) and 584 primigravid women (pregnant controls). We collected information on the women's past use of contraceptives, including copper IUDs, previous sexual relationships, and history of genital tract infections. Each woman's blood was tested for antibodies to Chlamydia trachomatis. We used stratified analyses and logistic regression to assess the association between the previous use of a copper IUD and tubal occlusion. RESULTS: In analyses involving the women with tubal occlusion and the infertile controls, the odds ratio for tubal occlusion associated with the previous use of a copper IUD was 1.0 (95 percent confidence interval, 0.6 to 1.7). When the primigravid women served as the controls, the corresponding odds ratio was 0.9 (95 percent confidence interval, 0.5 to 1.6). Tubal infertility was not associated with the duration of IUD use, the reason for the removal of the IUD, or the presence or absence of gynecologic problems related to its use. The presence of antibodies to chlamydia was associated with infertility. CONCLUSIONS: The previous use of a copper IUD is not associated with an increased risk of tubal occlusion among nulligravid women whereas infection with C. trachomatis is.

[Manual intrauterine aspiration om the treatment of molar pregnancy]. / Aspiración manual endouterina para el tratamiento del embarazo molar.

Thirty six cases of molar pregnancy treated by Manual Vacuum Aspiration (MVA) were reviewed in the Instituto Nacional de Perinatología from January 1st to october 31, 1997. Molar pregnancy rate was 2.3 per 1000 pregnancies. Sixty percent of the cases occurred in women aged 20-30 years old. Previous molar pregnancy was the most frequent risk factor found, it was present in 44.5% of the cases. The mean gestational age was 12.6 weeks. Peridural blocking was used for anesthesia de 86.1% of the cases, in the remainder general anesthesia was used. MVA was performed by different surgeons, following the technique that has been previously reported. Twelve women received sharp curettage immediately after MVA. There were tree women with bleeding complications (1000 cc or more), one case needed blood transfusion. In two cases the evacuation was incomplete. Seven cases became persistent trophoblastic disease. The histopathologic report was consistent with complete molar pregnancy la more than 90% of the cases. Oral contraceptives were selected by 66.7% of the women after the evacuation. It was concluded that MVA is a safe and effective method for the evacuation of molar pregnancy.

[Obstetric decisions concerning adolescents vs. adults]. / La resolución obstétrica de las adolescentes en comparación con la de las adultas.

Information relative to the frequency of vaginal delivery and cesarean section in adolescent population is limited and contradictory. Some publications refer that cesarean section is practiced more frequently in adolescents than in adults, because teenagers have a biological immaturity and a less medical control during pregnancy; but others show that frequency of cesarean section and vaginal delivery is very similar in adolescents as in adults. The reason of this contradiction is the fact that all studies compare general populations, with or without sistemic pathologies, and with or without obstetric antecedents. Therefore, the authors of this paper consider that if they compare adolescent and adult populations in their first pregnancy and without sistemic pathologies, the frequency of cesarean section and vaginal delivery should be the same in the two groups of women. To confirm their hypothesis, the authors collected original data from 121 adolescent women in their first pregnancy, seventeen years old or younger, without sistemic pathology, attended in the Instituto Nacional de Perinatología, and they compared them with original data collected from 121 adult women also in their first pregnancy, between 20 to 27 years old, without sistemic pathology, attended in the same institution and during the same period. The authors concluded that there were not statistical differences between the two groups in relation to the number of prenatal care visits; the weeks of pregnancy at the time of delivery; the indications of the different obstetric procedures to resolve the delivery; and in the perinatal mortality. Nevertheless, there were differences with high statistical significance between the number of vaginal deliveries and the number of cesarean sections; in fact, the cesarean section was performed more frequently in adult women. The authors considered that in the population of adolescents they studied, the age by itself was not a risk factor; furthermore, it is necessary to perform other studies to confirm and to explain why the cesarean section was performed more frequently in the adult population.

[Norplant: a 3-year experience of the National Institute of Perinatology in Mexico]. / Norplant: experiencia de tres años en el Instituto Nacional de Perinatología.

We present the experience from Instituto Nacional de Perinatología (INPer) with the use of subdermal contraceptive implants Norplant from 1995 to 1997. The purpose was to Know the sociodemographic characteristics and evaluate contraceptive efficacy, adverse effects and tolerance on the users of Norplant. We carried out a prospective, observational trial in the Family Planning Clinic, during the period january 1o, 1995 through december 31, 1997. Women with desire of long term hormonal contraception, and without contraindications for the use of progestins were eligible for the study. The follow up consisted in visits every 6 months, and in some cases we obtain the information by telephonic interviews. One hundred an two women were included in the study; the median age of the subjects was 21.6 years, the median number of pregnancies were 2.0. In 53% of the subjects an obstetric risk factor was present such as adolescence (25.5%), social (8.8%), and others. Seventy-four women were followed up, and accumulated 1,064 months of observation. (Average 14.4 months). Menstrual irregulaties (83%), and headache (30%) were the most frequent adverse effects. The continuity rate was 81%, and during the study no pregnancy was observed. The principal causes for the extraction of the implants were menstrual irregulaties and headache. The contraceptive subdermal implants Norplant, constitutes and excellent choice because of its high efficacy, safety and good tolerance.

[Manual intrauterine aspiration in the treatment of incomplete abortion]. / Aspiración manual endouterina para el tratamiento del aborto incompleto.

Manual vacuum aspiration (MVA) is a method proposed for uterine evacuation in cases of incomplete abortion, using a syringe of plastic material to produce negative pressure. With this technique, we treated 122 cases of different types of abortion at The Instituto Nacional de Perinatología, and results obtained were compared with those of 126 women treated with standard dilation and curettage (D&C). The sociodemographic characteristics of the two groups were similar. Molar pregnancy and blind ova were more frequent in cases treated with MVA. Types of anesthesia used were similar in both groups with the exception of 10 cases of MVA, that received paracervical block. Four surgical complications occurred, one of hemorrhage in each group and two cases of incomplete evacuation in the MVA group. Histopathological examinations using morphometric techniques showed similar proportions, of fetal parts, villi, decidua, myometrial cells and blood clots for both groups. It was concluded that MVA is as effective and safe as D&C, it is easy to perform, and is not associated with important complications. It can be used as an advantageous option for the evacuation of molar pregnancy.

[Endometrial aspiration biopsy]. / Biopsia endometrial por aspiración.

The factuality and diagnostic accuracy of aspiration endometrial biopsy with Karman's cannula, as compared with the curetted sample with Novak's cannula, were evaluated. Two hundred and thirty endometrial biopsies, were taken, as part of the study in women with fertility problems, at the Assisted Reproduction Clinic and Sterility Clinic, Instituto Nacional de Perinatología. The samples taken with Karman's cannula, Group I (n = 115); and with Novak's cannula, Group II (n = 115), were compared: procedure's time, pain intensity, quantity and quality of samples, macro and microscopically. In 92.2% of group I, tissue adequate for diagnosis, was obtained, as compared with 84.4% in Group II; likewise, the sample was better quantitatively and qualitatively, in Group I; and required time was less than one minute in 90% in Group I, an 83% in Group II. With the use of Karman's cannula, 20% of the patients had no pain, and 0.9% with the use of Novak's cannula. So, it can be concluded that endometrial aspiration with Karman's is reasonable and reliable in the functional histological diagnosis; it permits the obtention of adequate samples, in quantity and quality, and offering as advantages less pain and more security for the patients.

[Levonorgestrel releasing subcutaneous implants. 1st year's experience]. / Implantes subdérmicos liberadores de levonorgestrel. Primer año de experiencia.

This multicentric study was done in order to know the contraceptive efficacy and side effects of subdermal implants liberating levonorgestrel, in Mexican women. Results analysis, at one year, of 246 women, at four medical centers of Mexican Institute of Social Security (IMSS), showed that this contraceptive is highly efficacious, as there were no pregnancies in 2326 months of observation. The main side effects were: menstrual disorders in 34.8% of women; soreness in implantation site in 3.6%; headache in 13.4% and nausea, dizziness and vomiting in 11.6%. The most frequent causes for implant retirement were menstrual cycle alterations, and soreness at implantation site, with 7.3 and 3.5 respectively. The continuity rate at one year was 84.3, which was higher to what has been seen at the Institution with other temporal contraceptive methods, so the implants may be considered as one more alternative in family planning methods.

[Levonorgestrel-releasing subcutaneous implants. First year's experience]. / Implantes subdérmicos liberadores de levonorgestrel. Primer año de experiencia.

This multicentric study was done in order to know the anticonceptive efficacy and side effects of subdermic implants liberating levonorgestrel, in Mexican women. Results analysis, at one year, of 246 women, at four medical centers of Mexican Institute of Social Security (IMSS), showed that this anticonceptive is highly efficacious, as there were no pregnancies in 2326 months of observation. The main side effects were: menstrual disorders in 34.8% of women; soreness in implantation site in 3.6%; headache in 13.4% and nausea, dizziness and vomiting in 11.6%. The most frequent causes for implant retirement were menstrual cycle alterations, and soreness at implantation site, with 7.3 and 3.5 respectively. The continuity rate at one year was 84.3, which was higher to what has been seen at the Institution with other temporal anticonceptive methods, so the implants may be considered as one more alternative in family planning methods.

[Oral contraceptives and metabolic changes]. / Anticonceptivos orales y alteraciones metabólicas.

PIP: Sufficient evidence has accumulated to relate oral contraceptives (OCs) to various cardiovascular diseases in which metabolic alterations play a role. Although epidemiological studies have shown OC users to be at greater risk of venous thrombosis than nonusers, blood coagulation studies of OC users have yielded conflicting results due to variations in the methodologies used, the factors studied, the different formulations and doses of OCs, and the duration of use. Moreover, no satisfactory method exists of measuring coagulability in its totality, which is the sum of the effects of individual variations in coagulation factors, fibrinolysis, and platelet function. Numerous studies have shown that OC users have increased levels of several coagulation factors, which are believed to indicate hypercoagulability and increased risk of thrombosis, but the pathogenesis of venous thrombosis is complex. Accompanying changes in the fibrinolytic system can be interpreted as attempts to equilibrate the hypercoagulability induced by OCs. Further, there is no proof that in vitro changes are related to thrombosis in vivo. The alterations appear to be dose-related, produced primarily by estrogens, unrelated to duration of use, and to disappear a few months after termination of OC use. OC users have been shown repeatedly to have elevated levels of glucose and insulin, which are especially pronounced in glucose tolerance tests. The changes vary in intensity according to the dose and progestational components and the existence of other risk factors for diabetes. Deterioration of glucose tolerance appears related to duration of OC use, but serum insulin levels maintain the same initial elevations. The estrogens have been shown to have few effects on carbohydrate metabolism in the lower doses currently used. Norgestrel has the most marked effects on glucose and insulin levels, ethynodiol diacetate has moderate effects, and norethindrone has the least effect. The combination of .15 mg levonorgestrel and 30 mcg ethinyl estradiol has no effect on oral glucose tolerance and little effect on insulin secretion. It is hypothesized that OCs affect carbohydrate metabolism by decreasing the number and affinity of insulin receptors in target tissues. The mechanisms by which OCs produce undesirable effects on the cardiovascular system are not completely understood, but are believed to be related to alterations in lipid metabolism. The majority of laboratory studies have shown that OC users had elevated levels of cholesterol, triglycerides, and the (LDL) fractions, and a diminution of the high density lipoprotein (HDL) fraction, which has antiatherogenic properties. The changes are atherogenic in nature and produce a lipid profile similar to that of men and postmenopausal women, who are at greater risk of thrombotic cardiovascular disease that premenopausal women who are protected by estrogens. .^ieng

[Oral contraceptives and cardiovascular diseases morbidity]. / Anticonceptivos orales y morbilidad de enfermedades cardiovasculares.

PIP: A case control study was conducted in Mexican Institute of Social Security hospitals in the Valley of Mexico to determine the relationship between oral contraceptive (OC) use and nonrheumatic cardiovascular disease in Mexican women. The study involved Mexican women between 20-44 years of age residing in the metropolitan Mexico City area and married or in stable union. 28 women hospitalized with confirmed diagnoses of ischemic heart disease, 22 with cerebrovascular accidents, 70 with pulmonary embolism or venous thrombosis, 33 with hypertensive cardiopathy, and 55 with other nonrheumatic heart diseases comprised the 201 cases. The 606 controls were women hospitalized with noncardiovascular acute illnesses who met the same requirements for inclusion or exclusion as the cases. Over 98% of the women in the study had been pregnant at some time. OC users were younger and better educated than nonusers. 30% of OC users and 26% of nonusers were smokers. The relative risk of nonrheumatic cardiovascular disease was 1.22 for past users of OCs, who included women using OCs until 1 month prior to the interview. The relative risk for women using OCs within 30 days of the interview (current users) was 1.24. The relative risk according to the estrogen dose was 1.79 for users receiving 40 mcg or less, but paradoxically doses of over 40 mcg decreased the risk to .75. The risk was 1.35 after 1 year of use of OCs, .96 from 12-18 months of use, and 1.34 after 48 months of use. The relative risk was .95 for ever users of OCs aged 20-29 years, 1.38 for those aged 30-39, and 1.48 for those 40-44. Among current users the relative risks were 1.19 for those aged 20-29, .84 for those aged 30-39, and 3.83 for those aged 40-44. The relative risks for ever users and current users respectively were 1.65 and 2.01 for ischemic heart disease and cerebral vascular accidents; 1.40 and 1.43 for pulmonary embolism and venous thrombosis; .85 and .71 for hypertensive cardiopathy; and 1.09 and 1.91 for other cardiovascular diseases. Users and nonusers of OCs had the same access to medical services. Observed differences in the ages and educational levels of users and nonusers were not a source of bias because cases and controls were paired by age and education. The results demonstrated that Mexican women in the Valley of Mexico who use OCs have a statistically significant elevated risk of developing nonrheumatic cardiovascular disease. In declining order of risk are cerebral vascular accident, ischemic heart disease, and pulmonary embolism and venous thrombosis. The risk is present from the 1st days of OC use and in use of OCs containing less than 40 mcg of estrogen. The risk increases with the age of users but not with smoking.^ieng

[Cardiovascular diseases and oral contraception. Study of cases and controls]. / Enfermedades cardiovasculares y anticoncepción oral. Estudio de casos y controles.

PIP: Data on 146 Mexican women aged 20-44 years who were residents of the Mexico City metropolitan area, married or in stable union, and who suffered from nonrheumatic cardiovascular disease, and on 387 controls matched for age, parity, and education were used to study the possible association of nonrheumatic cardiovascular diseases and the use of oral contraceptives (OCs). The women were hospitalized at Mexican Institute of Social Security hospitals between 1979 and 1982. 20 cases had ischemic heart disease, 15 had cerebrovascular accidents, 50 had pulmonary embolism or venous thrombosis, 27 had hypertensive cardiopathy, and 41 had other conditions, primarily arrhythmia, cardiomyopathies, and pericarditis. Among OC users and controls respectively, 1.3% and 2.3% had never been pregnant. 35.0% and 18.6% were aged 20-29 years, 50.0% and 49.0% were 30-39, and 15.0% and 32.4% were 40-44. 25.0% of users and 22.8% of nonusers currently smoked. 60.0% of users and 76.5% of nonusers had primary education or less. The relative risk for nonrheumatic cardiovascular disease was 1.00 for 58 women who had never used OCs, 1.49 for 88 ever-users of OCs, and 1.40 for 26 current users. The relative risk for 10 women using pills with an estrogen dose of 40 mcg or less was 1.60, compared to 1.06 for 11 women with an estrogen dose over 40 mcg. The relative risk was 1.60 for 52 patients using OCs for 12 months or less, 1.13 for 22 patients using them for 13-48 months, and 1.87 for 14 patients using them for over 48 months. Relative risk increased by age and was over 3 times as high for women aged 40-44. The relative risk was 1.55 for 13 OC users who had never smoked, .44 for 2 users who had previously smoked, and 1.51 for 11 users who currently smoked. Considering smoking only, relative risk was 1.00 for 80 women who never smoked, 1.61 for 66 who previously smoked, and 1.45 for 47 who currently smoked. The risk was significantly increased in OC users for ischemic heart disease, cerebrovascular accidents, venous thrombosis, and pulmonary thromboembolism.^ieng

[Comparative clinical study of 5 barrier methods]. / Estudio clínico comparativo de cinco métodos de barrera.

PIP: The effectiveness and acceptability of 5 barrier methods of contraception were investigated in 171 males and 407 women. They chose the use of ovules with 0.4 mg phenylmercuric acetate; foaming tablets with mephengol; 60 mg ovules with nonoxynol 9, 5.8%; and polymeric sponges with nonoxynol 9 at different concentrations. Anticonceptive effectiveness was evaluated by the Pearl's Index; the lowest rating (6.0) was for the preservative. In decreasing order came mephengol tablets (33.4), phenylmercuric ovules (33.0), nonoxynol ovules (60.7), and polymeric sponges (52.8-120.0). In general the acceptability was low. Discontinuation of spermaticides was due to unreliability; dissatisfaction was the reason for discontinuation of the preservatives and sponges. There were no important side effects. Some couples using foaming tablets reported a sensation of heat as the tablet was dissolving and 2 users reported a bad vaginal odor. After favorable initial acceptance of these methods, final acceptance was low, possibly due to the association with intercourse and direct manipulation of the genitals. (author's)^ieng

[Application of intrauterine devices preceded by measurement of the endometrial cavity using a Hollister sound]. / Estudio sobre la aplicación de dispositivos intrauterinos previa medición de la cavidad endometrial con la sonda Hollister.

PIP: The frequency of IUD expulsion, pregnancy, and removal was studied in 694 users. Those IUD types examined were the Lippes Loop D, Copper T-device, the 220C, and the T releasing 65 mcg of progesterone. A comparison was done as to the length of the uterine cavity, measured by a Hollister device which tends to be very accurate. Other authors have described certain length limits in the uterine cavity beyond which the number of pregnancies, expulsions, and removals are greater, but this was not confirmed in the present study. The only statistically significant difference was reduced frequency of such events in those women using the Copper T as compared with the Lippes Loop, independent of uterine cavity length. (author's modified)^ieng

Estudio sobre la aplicacion de dispositivos intrauterinos previa medicion de la cavidad endometrial con la sonda Hollister. / Implantation of intrauterine devices with previous measurement of the endometrial cavity using a Hollister catheter

Se efectuo un estudio comparativo entre la frecuencia de los eventos expulsion, embarazo y retiros por razones medicas en 694 usuarias portadoras de dispositivos intrauterinos asa de Lippes D, Tcu 220C y T liberadora de 65 mcg. de progesterona en relacion con la longitud de la cavidad uterina, medida con la sonda de Hollister, la cual permite una medicion mas exacta de esta dimension del utero. A pesar de que otros autores han descrito ciertos limites de longitud de la cavidad uterina, fuera de los cuales las tasas de embarazos, expulsion y retiro son mayores, esto no pudo confirmarse en nuestro estudio. La unica diferencia con significacion estadistica encontrada fue una menor frecuencia de los eventos mencionados en las mujeres portadoras de T, comparadas con el grupo que uso asa de Lippes, independientemente de la longitud de la cavidad uterina