Dimensional and architectural disproportion between the intrauterine device and the uterine cavity. A casue of bleeding.

PIP: Hysterograms were performed on 172 women fitted with 30 mm Lippes Loops to determine uterine dimensions. Uteri classifications were: normal; triangular, divided into 1) small triangle, 30 mm. loop was too large; 2) medium triangle, device fits snugly, less severe bleeding at 7 months; 3) large triangle, device too small, mild bleeding at 10 months and formal conical cavity, divided into 1) narrow fundus, too small for device, leading to traumatic bleeding; 2) medium, device fits snugly causes intermenstrual bleeding; 3) large, loop covers only a portion of uterine cavity, bleeding less severe later. Ideally the IUD should fit snugly against the various borders of the uterine cavity, exerting light and equal pressure. Congenital anomalies and devices incorrectly positioned caused intermenstrual bleeding.^ieng

A simple technic of hysterography for evaluating side effects and mode of action of intrauterine devices. A study of 100 cases.

PIP: This paper describes the use of a simple technique of hysterography to evaluate the side effects and mode of action of IUD. The technic utilizes 2 x-ray films per patient of the lower abdomen: a flat film to determine the presence or absence of the device, and a hysterogram; diluted water-soluble contrast medium was used, allowing visualization of the device and the endometrial cavity in a single x-ray exploration. The technic was performed on 100 women fitted with Lippes loop; 74 of these experienced side effects while 22 patients with no complaints were used as controls; 1 had an asymptomatic uterine peforation with the loop lying in the pelvis and 3 were pregnant (2 had a double uterus). In the control group, the hysterograms were performed 3-6 months after loop insertion while in the study group, the hysterogram were done 3-190 days after insertion, with the exception of true expulsion cases where a device similar to that ejected was reinserted just before taking x-ray. 44 patients were found to have bilateral cornual spasm. Incomplete fundal coverage of the device was associated with an increase in the incidence of side effects, mainly bleeding. Out of 23 cases of clinically suspected expulsion, the device was found in situ in 12 cases. In 10 cases, the IUD position was reversed with the thread withdrawn into the uterine cavity. In the remaining 2, the loop was found in the abdominal cavity. Congenital uterine abnormality was also found in 4 out of 10 cases with true expulsion. The incidence of side effects can be minimized by constructing IUDs which would fit properly into the endometrial cavity. Hysterography is a useful diagnostic tool for determining the incidence of side effects and possible mode of action of IUDs; it can also provide an index of the probable efficiency of the device after insertion.^ieng

Copper levels in women using intrauterine devices or oral contraceptives.

PIP: A study was undertaken to explore the role of the copper IUD (Cu-200) in contraception and to lower its side effects. Endometrial and plasma concentrations of copper were determined spectrographically in the late proliferative and late secretory phases in 15 women wearing the copper IUD, in 6 short-term Lippes loop users, in 23 long-term Lippes loop users, in 17 patients on oral contraception, and in 32 women who were not using contraception,y The last group of women served as controls. The findings showed a decrease in the endometrial copper level in the secretory phase but no change in the plasma concentration of copper in the control group. Both Cu-200 and Lippes loops produced a rise in endometrial copper which was significant during the secretory phase. The possibility of a local foreign body reaction is noted. Combined steroid pills caused variable degrees of increase of endometrial and plasma copper in both phases. Endometrial copper levels were elevated in both phases of the cycle, while plasma copper showed a probably significant rise in the proliferative phase only. The change in plasma copper may be explained by changes occurring in hormonal pattern during pill therapy.^ieng

Influence of the copper IUD and the Lippes loop on sperm migration in the human cervical mucus.

PIP: 30 women (24-34 years; parity 3-6) randomly selected from the family planning clinic at Al-Azhar University Hospital, Cairo, were divided into 3 groups: 1) 10 normal fertile; 2) 10 women fitted with T-Cu-200 for 2-20 months; and 3) 10 women fitted with Lippes loop for 2-8 years. On the 13th-15th day of the cycle cervical mucus was sample and tested for sperm penetration, motility, turbidity, Spinnbarkeit, and ferning. Sperm penetration tests used the sperm migration meter of Kremer and turbidity and clarity were assessed by the naked eye. Sperm penetration and motility were greatly impaired with Cu-device users, while with Lippes loop the findings approached that of the normal control women. Turbidity results were significant (p less than .01) for Cu-device users. Diminished Spinnbarkeit and positive ferning were also observed in the presence of the Cu device. The impaired sperm penetration and immobilization with the use of the Cu-devices as opposed to Lippes loop suggests a local lethal effect of the increased copper on cervical mucus rather than a local foreign body reaction.^ieng

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.

Minilaparotomy for female sterilization: a feasibility study of a new technique.

Female sterilization via a minilaparotomy incision was performed on 30 patients at Al-Azhar University Teaching Hospital in Cairo, Egypt. A uterine sound fed through a Foley catheter was used as a uterine elevator. A 2 cm suprapubic transverse laparotomy was performed and sterilization was accomplished by fimbriectomy. Twenty patients received general anesthesia and 10 patients initially received local anesthesia. Surgical time ranged from 7 to 15 min, and the average duration of hospitalization was 8 hours. Blood loss was small, and no patient was transfused. One patient had a wound infection. This pilot study indicates that this procedure is relatively simple, safe and inexpensive.

Physiologic studies of menstrual blood loss. II. Physiologic variables affecting the magnitude of menstrual blood loss.

The effect of marital status, age, parity, age at menarche, maternal size, arterial blood pressure, position and size of the uterus and hematologic parameters on the magnitude of menstrual blood loss was investigated in 745 randomly selected women in normal physiologic condition, aged 14-49 years, from a city population (Cairo). Menstrual blood loss was found to be related to parity, weight and body surface area and systolic and pulse pressure and to depend mainly upon the hematologic indices reflecting the state of iron balance and anemia in the body.

Physiologic studies of menstrual blood loss. I. Range and consistency of menstrual blood loss in and iron requirements of menstruating Egyptian women.

Two physiologic studies of menstrual blood loss in Egyptian women are presented below. In the first, an attempt was made to establish the normal range of menstrual blood loss of Egyptian women, to test their individual consistency in the amount of menstrual blood loss and to determine the iron requirements needed to compensate for iron loss and prevent iron deficiency anemia in menstruating Egyptian women. In the second, physiologic and other variables affecting the magnitude of menstrual blood loss in Egyptian women were investigated.

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.

The benefit of lactation amenorrhea as a contraceptive.

A group of 148 lactating women who delivered normally at El-Galaa Hospital, Cairo, were followed up monthly for 1 year to study the pattern of lactation amenorrhea, the return of menstruation and ovulation, and the incidence of pregnancy. By the end of the sixth week postpartum, only 1.3 percent of the women had begun menstruating; the percentage gradually increased to 60.2 percent by the end of the first year. The amount of blood loss and the duration of menstruation increased gradually until the fourth postpartum menstrual period. Ovulation had occurred in 58.1 percent and pregnancy in 26.1 percent of all cases at the end of the 12th postpartum month. Among menstruating, lactating mothers, ovulation occurred in 86.5 percent and pregnancy in 32.6 percent, while in amenorrheic, lactating mothers only 6.1 percent had become pregnant at 1 year postpartum.

Medicated intrauterine devices to improve bleeding events.

In an attempt to find an IUD that will cause a minimum amount of blood loss, while continuing to be effective and easily retained, we are studying 4 medicated IUDs: a copper-bearing Lipps Loop, a Copper-T-200, a progesterone-releasing U-coil, and a tranexamic-acid-releasing Lippes Loop. Inert devices of the same shape and size are used as controls. This is a comparison of the findings on menstrual blood loss and loss and changes in bleeding patterns for patients using the plain and copper-bearing Lippes Loops. Preliminary results for the progesterone-bearing U-coil and the tranexamic-acid-releasing Lippes Loop are also given, but studies of these devices are not yet complete.

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.

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.

Fibrinolytic activity of menstrual blood in normal and menorrhagic women and in women wearing the Lippes Loop and the Cu-T (200).

Assessment was made of the fibrinolytic activity in menstrual and peripheral blood of 30 normally menstruating and 30 menorrhagic patients and of 30 women wearing Lippes Loops and 15 wearing CU-T (200)s. Assessment was performed by measuring the area of lysis on heated and unheated fibrin plates. Also, histochemical identification of fibrin fibrils in the menstrual endometrium was performed by Mallory's phosphotungstic acid hematoxylin method. Results in the normally menstruating group were compared to those of the menorrhagic women, and together these were compared with results in the groups of women wearing intrauterine devices. The fibrinolytic activity in menstrual blood was significantly increased in menorrhagic patients compared to that in normally menstruating patients, but no significant difference was detected in the plasma of either group. The histochemical study of the normally menstruating endometrium revealed dense intravascular and extravascular deposits of fibrin. Less dense intravascular fibrin deposits, but no extravascular ones, were present in the menorrhagic patients. The increase in the fibrinolytic activity of menstrual blood and the decrease in the density of fibrin deposits in the menstrual endometrium of the menorrhagic women were thus associated and were probably involved in the excessive menstrual loss. The fibrinolytic activity of menstrual blood in women wearing Lippes Loops was higher than that in women with Cu-T (200)s and was associated with decreased density of fibrin fibrils in the menstruating endometrium. This may explain the increased blood loss associated with the use of the Lippes Loop.

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

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