Sexually transmitted diseases: global importance.

The worldwide incidence of sexually transmitted diseases (STDs) including the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) continues to increase and represents a major public health problem especially in the developing world causing infertility and ectopic pregnancy. Prevention of the spread of STDs, along with early detection and appropriate therapy has the potential to minimize the reproductive tract damage of these infections and simultaneously improve the health of women in all areas of the world.

Hysteroscopic sterilization.

Despite the numerous painstaking evaluative trials that were conducted for more than two decades, hysteroscopic sterilization techniques remain more of a concept than a reality. However, it is likely that transcervical methods will continue to attract the investigator who is interested in simple, inexpensive outpatient office or female sterilization procedures in the clinic. Regardless, the cost of clinical trials, required follow-up, and preclinical toxicologic evaluations may continue to inhibit further research in this area.

PIP: Hysteroscopic sterilization remains more of a concept than a practical reality despite an approach which seemed to offer minimal intervention, low cost, potential reversibility, a high effectiveness rate, and a low rate of complication. Clinical experience has, however, been lacking on the approach's effectiveness and rate of complication. The initial enthusiasm for hysteroscopic operations was based in part on a set of circumstances which have made hysteroscopy increasingly popular worldwide for diagnostic and surgical interventions. It is simple, requires minimal if any anesthesia, is adaptable to the outpatient setting, and has an operative risk substantially lower than that of laparotomy. This paper surveys the destructive and occlusive methods of hysteroscopic sterilization, problems common to hysteroscopic sterilization operations, and the future.

Innovative community-based postgraduate training for obstetrics and gynecology in west Africa.

OBJECTIVE: To describe a unique international effort to develop a training program in West Africa that would be of similar quality to any other in the world (but with sensitivity to cross-cultural needs) and would retain physicians in West Africa to improve women's health in that part of the world. METHODS: Step-by-step formulation of a program included initial trainee recruitment, the inclusion of foreign guest faculty, and the establishment of institutional libraries. This was followed by a phase of curriculum development, recruitment of West African faculty, and organization of an innovative, community-based fourth year. RESULTS: Between ten and 12 postgraduates will have completed the program by January 1996, and will be placed in Ghana. More than 60% of Ghanaian postgraduates have passed the relevant regional examinations, compared with less than 25% of candidates from other countries. Nine Ghanaian specialists have returned to Ghana to become faculty members in the program. Over 20 published peer-reviewed articles have resulted from this program since 1989. The number of residents being trained has increased from three to 28. Seven new residents joined the program in 1994. An early reduction in maternal mortality from 9.9 deaths per 1000 births in 1991 to 4.2 deaths per 1000 births in 1992 was noted when senior postgraduates took over labor and delivery at the teaching hospital in Accra, Ghana, where approximately 10,000 deliveries occur per year. CONCLUSION: Specialty training in obstetrics and gynecology that is specifically aimed at meeting the needs of West Africa has been initiated successfully. Long-range success will require support from regional governments and continued long-term commitments from the international community of obstetricians and gynecologists.

Infertility: a global perspective. The role of pelvic infection.

PIP: The results of an examination of 5800 couples in 33 World Health Organization centers in 25 countries have provided the most comprehensive information on infertility in both developed and developing countries. Prior infection and bilateral tubal blockages were frequently traced as the cause of infertility. In the African sample; up to 64% of female patients had prior infection as the cause of infertility. A gynecological history of sexually transmitted disease, pelvic inflammatory disease (PID) and infection-related pregnancy complications of normal childbirth and abortion were directly related to infertility. 49% of the African couples and 11-15% of other patients in other parts of the world had infectious tubal disease. Westrom's study found that after PID 6-60% of patients became infertile. The factors affecting the infertility were the number and severity of infections, and the age when initial infection occurred. Between 1960 and 1980, in Sweden and the US, infertility doubled. Cates in the US has estimated that after 3 PID infections more than 50% of patients will be infertile. Ectopic pregnancy is another outcome of pelvic infection and sexually transmitted disease. Common PID infections are caused by Chlamydia trachomatis and Neisseria gonorrhea. These infections can cause tubal obstruction or pelvic adhesions and destructive tubal damage. After an ectopic pregnancy, 50% of patients are infertile and 10% have subsequent ectopic pregnancies. Some infertility may be treated. Microsurgery can be performed for tubal disease. Hysteroscopy can be used to treat intrauterine adhesions (Asherman's syndrome). Success has been better with hysteroscopy. Tubal microsurgery had led to conceptions in only 30-30% of patients, and a very high percentage of tubal pregnancies. The most successful results have come from tubal reanastomosis for reversal of tubal sterilization. The most promising results have come from "in vitro" fertilization and other methods of assisted reproduction. However, there must be a more simplified technology, improved results, and reduced costs before large numbers worldwide can benefit. The best approach is prevention and early detection of infection, and risk assessment. Culturally sensitive education programs will generally alert the population to precursor conditions of infertility.^ieng

Study and treatment of gestational trophoblastic diseases at the John I. Brewer Trophoblastic Disease Center, 1962-1990.

From 1962 through 1989, 5063 patients were referred to the John I. Brewer Trophoblastic Disease Center of the Northwestern University Medical School. Among these were 564 patients treated with chemotherapy for gestational trophoblastic tumors (choriocarcinoma and invasive mole). The overall cure rate was 94%, 100% for 323 patients without evidence of metastases and 85% for 241 patients with metastatic disease. Four factors were determined to significantly influence treatment response: (1) clinicopathologic diagnosis of choriocarcinoma, (2) metastases to sites other than the lung or vagina, (3) number of metastases, and (4) previous failed chemotherapy.