This paper describes the evaluation of a new method of natural family planning (NFP) in Liberia. The Modified Mucus Method (MMM) was developed to address the need for a simple method of charting for poor and illiterate women. The acceptance, use, and cost-effectiveness of the MMM were compared with standard NFP methods, the sympto-thermal and ovulation method (ST/OM), used in the same population. The personal discontinuation rate of MMM users was 27.3 per 100 women per year compared with 3.2 among ST/OM users. Unplanned pregnancy rates were low for both MMM and ST/OM, 6.6 and 1.5 respectively. The cost per couple year protection (CYP) for MMM was $55.80 and for ST/OM $56.10. There were differences in characteristics between MMM and ST/OM clients. The MMM clients were more likely to have attended school and to have used a family planning method previously, and were less likely to be housewives. We conclude that the MMM in Liberia was provided to an inappropriate sample of women, educated and middle-class rather than poor and illiterate. The MMM users were dissatisfied and discontinued at the rate of 44 per 100 women entering per year. This is an unfair evaluation of the MMM because of the unsuitable study population. It is our opinion that the MMM needs more study to become part of the inventory of birth spacing methods.
Bone HealthCalcium Isotope TracingCalcium ResorptionAccelerator Mass Spectrometry
Bone loss occurs in young women who experience amenorrhea or ovulatory disturbances. The purpose of this study was to determine whether bone loss could be prevented by simulating a more normal hormonal pattern, using treatment with cyclic medroxyprogesterone, with or without calcium supplementation, in physically active women with disturbed menstruation.
This study was a 1-year randomized, double-blind, placebo-controlled trial. Women who were stratified by menstrual cycle disturbance were randomized into four groups. The outcome variable was the change in spinal bone density measured by dual energy techniques.
A large metropolitan area. Sixty-one healthy, normal-weight physically active premenopausal women aged 21 to 45 years who experienced amenorrhea, oligomenorrhea, anovulation, or short luteal phase cycles completed the study. Therapies were cyclic medroxyprogesterone (10 mg/day for 10 days per month) and calcium carbonate (1,000 mg/day of calcium) (A) (n = 16) cyclic medroxyprogesterone plus calcium carbonate; (B) (n = 16) cyclic medroxyprogesterone with calcium placebo; (C) (n = 15) placebo medroxyprogesterone with active calcium; or (D) (n = 14) both medroxyprogesterone and calcium placebos. The initial bone density (mean = 1.12 g/cm2) did not differ by group (P = 0.85). The 1-year bone density change was strongly related to treatment with medroxyprogesterone (P = 0.0001) and weakly to calcium (P = 0.072) treatment. Bone density increased significantly (+1.7% +/- 0.5%, +/- SEM, P = 0.004) in the medroxyprogesterone-treated groups (A and B), did not change in the calcium-treated group (C) (-0.7% +/- 0.6%, P = 0.28), and decreased on both placebos (D) (-2.0% +/- 0.6%, P = 0.005). Cyclic medroxyprogesterone increased spinal bone density in physically active women experiencing amenorrhea or ovulatory disturbances. POTENTIAL Amenorrhea, oligomenorrhea, anovulation, and short luteal phase cycles are common in premenopausal women and associated with spinal bone loss occurring at a stage of life when bone density would normally be stable or increasing. This controlled trial shows a significant gain in bone in women in the cyclic medroxyprogesterone intervention group, whereas those subjects in the placebo group lost bone. Calcium supplementation appeared to be helpful but did not reach statistical significance. The implications of these findings for the prevention of osteoporosis warrant further investigation.
To determine whether the use of luteal phase support improves pregnancy rate (PR) in infertility. A meta-analysis of randomized trials of luteal phase support. Search of the National Library of Medicine MEDLINE data base from 1971 using the words luteal, pregnancy, human, and comparative. Bibliography of relevant articles, reviews, and abstracts of scientific meetings were hand searched. All randomized controlled trials of luteal phase support in infertility were included. Luteal phase support for recurrent abortion and nonrandomized trials were excluded. The common odds ratio was calculated for each intervention using the Mantel-Haentzel test. Homogeneity of treatment effect was evaluated using the Breslow-Day test. Pregnancy per cycle, rate of spontaneous abortion, and ovarian hyperstimulation syndrome rate. Eighteen trials met the above criteria. Human chorionic gonadotropin improved PRs in IVF when GnRH agonist (GnRH-a) was used (n = 151) and was superior to P (n = 352). Its benefit in all IVF cycles, however, was not established because of significant heterogeneity of treatment effect. Progesterone improved the PR in all IVF cycles (n = 457). No significant reduction in spontaneous abortion was noted with luteal support (n = 200). Ovarian hyperstimulation syndrome occurred in 5% of patients with hCG. Combination of data from trials of luteal support with other infertility therapies was not possible because of the differences in patient populations. The meta-analysis supports the routine use of hCG in IVF cycles using a GnRH-a. Progesterone was also beneficial for luteal phase support in IVF. For other infertility therapy, however, further research is needed to evaluate the role of luteal phase support.
Fehring RJ et al., 1994·J Obstet Gynecol Neonatal Nurs
To determine the use effectiveness of the Creighton model ovulation method in avoiding and achieving pregnancy. Prospective, descriptive. A natural family planning clinic at a university nursing center. Records and charts from 242 couples who were taught the Creighton model. The sample represented 1,793 months of use of the model. Creighton model demographic forms and logbook. At 12 months of use, the Creighton model was 98.8% method effective and 98.0% use effective in avoiding pregnancy. It was 24.4% use effective in achieving pregnancy. The continuation rate for the sample at 12 months of use was 78.0%. The Creighton model is an effective method of family planning when used to avoid or achieve pregnancy. However, its effectiveness depends on its being taught by qualified teachers. The effectiveness rate of the Creighton model is based on the assumption that if couples knowingly use the female partner's days of fertility for genital intercourse, they are using the method to achieve pregnancy.
To define relation between mood and concentrations of progesterone and cortisol during perinatal period to test hypothesis that rapid physiological withdrawal of steroid hormones after delivery is associated with depression. Prospective study of primiparous women from two weeks before expected date of delivery to 35 days postpartum. Antenatal clinic in university hospital, obstetric inpatient unit, patients' homes. 120 of 156 primiparous women interviewed. Remainder excluded because of major marital, socioeconomic, or medical problems or because caesarean section required. Concentrations of progesterone and cortisol in saliva samples; women's moods assessed by various scores for depression. Changes in salivary progesterone and cortisol concentrations were similar to those already characterised for plasma. Peak mean score for maternity blues (5.3 on Stein scale) was on day five postpartum (P < 0.02 compared with mean scores on other postpartum days). High postpartum scores for maternity blues were associated with high antenatal progesterone concentrations on day before delivery (P < 0.05), with high rate of rise of antenatal progesterone concentrations (P < 0.05), with decreasing progesterone concentrations from day of delivery to day of peak blues score (P > or = 0.01), and with low progesterone concentrations on day of peak blues score (P < 0.01). Seventy eight women were designated as having maternity blues (peak score > or = 8 on Stein scale) while 39 had no blues. Women with blues had significantly higher antenatal progesterone concentrations and lower postnatal concentrations than women without blues (geometric mean one day before delivery 3860 pmol/l v 3210 pmol/l respectively, P = 0.03; ten days postpartum 88 pmol/l v 114 pmol/l, P = 0.048). Cortisol concentrations were not significantly associated with mood. Maternal mood in the days immediately after delivery is related to withdrawal of naturally occurring progesterone.
To characterize ampullary endosalpingeal findings in women with occlusive or nonocclusive salpingitis isthmica nodosa. Prospective case study. Obstetrics and Gynecology Department of a University Hospital. Twenty women (38 tubes) with occlusive or nonocclusive salpingitis isthmica nodosa were studied. Salpingoscopy was performed during diagnostic laparoscopy in 20 women (38 tubes) with hysterosalpingographic evidence of salpingitis isthmica nodosa. Salpingoscopic findings were recorded and the patients were managed accordingly. Of the 38 tubes 10 appeared radiographically and laparoscopically normal. Two tubes were occluded distally. Of the 26 tubes with occlusive or nonocclusive salpingitis isthmica nodosa, 5 (19.2%) showed varying degrees of endosalpingeal abnormality. Patients with abnormal salpingoscopy were regarded as having bipolar tubal disease and were referred for assisted conception. The remaining patients were scheduled for microsurgical tubal reconstruction. One in five patients with proximal tubal disease may have ampullary endosalpingeal damage of varying degrees. However, the significance of this finding in relation to subsequent management strategies and fertility outcome is yet to be characterized.
To determine the relationship between some reproductive variables and infertility caused by tubal obstruction. A retrospective, case-control study. A tertiary care university hospital that is a referral center for infertility patients. Subjects were interviewed between March 1990 and December 1991. Cases were 215 consecutively recruited infertile women with either evidence of tubal obstruction found at laparoscopy or hydrosalpinx diagnosed by hysterosalpingography. Women with a history of surgical sterilization were excluded. Controls, selected in the same hospital, were women in the puerperium who had no history of infertility. Two controls were matched by age at the time of tubal obstruction diagnosis to each case. History of pelvic surgery and use of alcohol were significantly associated with the risk of infertility caused by tubal obstruction. The use of barrier, oral, and medroxyprogesterone acetate (MPA) contraceptives was associated with a protective effect. When only women with secondary infertility were analyzed, history of pelvic surgery and number of lifetime sexual partners were significant risk factors, and the previous use of oral contraceptives was the only protective factor. History of pelvic surgery was the most important risk factor for tubal infertility. All precautions must be taken to avoid infection and adhesion formation when pelvic surgery is performed. In addition, women can be protected from tubal infertility by using barrier, oral, or MPA contraceptive methods.
Fertility AwarenessOvulation MethodCervical Mucus and TemperatureReturn of Fertility Detection
Natural family planning (NFP) methods can be effective if taught well and practised by well-motivated couples. Midwives should be able to give couples an understanding of the basic principles of the methods. The observable signs of the fertile cycle are changes in basal body temperature, in the consistency of cervical mucus and in the texture and position of the cervix. Practised properly the ovulation method can have a failure rate of as little as 2.2 pregnancies per 100 woman-years. The ovulation method is a suitable method for mothers who have breastfed to detect the onset of ovulation.
To establish age-stratified reference values for salivary luteal P levels. One hundred thirty-six regularly menstruating women (18 to 48 years of age), screened for weight, exercise, and steroid medication use, collected daily saliva samples for one complete menstrual cycle. Luteal P levels were measured by 3H-RIA, and data were aligned by day of next menstrual onset. Means (+/- 1 SD range) and percentiles, calculated using both untransformed and log transformed data, were calculated for each luteal day and for indices of luteal P production. Reference values for salivary daily luteal P levels and indices of luteal P are presented for three age groups (18 to 24 years, 25 to 39 years, and 40 to 48 years). The age-stratified reference values presented here can be used, without collateral clinical procedures, to assess salivary luteal P levels. Salivary monitoring is ideally suited for research and long-term clinical observation, but the characteristics of salivary P data may limit the usefulness of these values for individual diagnosis.
"Uterine Isolation" has been discussed, in one form or another, since the early 1940's by such notable American theologians as Fr. John C. Ford, SJ, Fr. Gerald Kelly, SJ; Fr. Francis J. Connell, C.SS.R.; Fr. L. Bender; Fr. John R. Connery; SJ, Fr. Edwin F. Healy, SJ; and Fr. Thomas J. O'Donnell, SJ.l The term "uterine isolation" originated with Fr. O'Donnell. O'Donnell, who is personally convinced of the validity of the arguments for the solid probability of the "uterine isolation" view, was also responsible for having this deleted from the "Ethical and Religious Directives for Catholic Health Facilities" which were published and approved by the bishops in 1971." 'Isolation of the uterus' or 'uterine isolation' " he says, "had taken root in the medical-moral community and, either through misunderstanding or deception, was being used as a presumably morally acceptable semantic for various forms of clearly contraceptive sterilization."l O'Donnell states that the following three points need to be understood by Catholic hospital administration and staff with regard to the term "uterine isolation procedure":
1. Hysterectomy in the presence of a uterus which has been so damaged or weakened by multiple cesarean sections that it is judged to be incapable (because of the damage within the uterus itself) of safely supporting another pregnancy is, with solid probability, not a contraceptive sterilization and is permitted . . . 2. In this case, and only in this case, the isolation of such a uterus at its tubal adnexa, instead of its extirpation, if clinically indicated, is, with solid probability, not a contraceptive sterilization and thus may be permitted and practiced; unless, of course, this is disapproVed by the bishop of the diocese who might well foresee greater harm in the danger of misunderstanding and morally unwarranted extension of the procedure as a semantic to conceal directly contraceptive sterilizations. 3. If, after further study and investigation, there would be a sufficient consensus of theological opinion or a decision by the Congregation for the Doctrine of the Faith that either of the procedures described above (either the hysterectomy in this case or the isolation procedure) is indeed a direct sterilization (such as to discount the solid probability that it is not), then neither of the procedures could be done within the context of Catholic teaching. The sale moral defense of either procedure is the solid probability of the moral opinion that it is not a directly contraceptive sterilization (emphasis applied). I wish to emphasize the need for further study and investigation of this issue because the experience with "uterine isolation" is compelling and proves that the practice is nothing but direct contraceptive sterilization. It is also a practice with inappropriate medical justification . . . a practice which, in the 1990's, cannot be justified on medical moral grounds. One of the most important questions that needs to be asked with regard to "uterine isolation" is "What are we isolating the uterus from?" It is clear that the uterus is not being isolated from either the sperm or the ovum since they present no potential of risk. It is equally clear that the isolation of the uterus, so proposed, is not isolating the uterus from any known disease condition. the only possible thing that this procedure could be isolating the uterus from is a pregnancy . Thus, it seems equally clear that the primary intent of such a "uterine isolation" is contraceptive sterilization. Furthermore, the actual application of "uterine isolation" policies in Catholic hospitals suggests that it is direct contraceptive sterilization.
To (1) review the events leading to peritoneal adhesion formation; (2) review traditional adhesion prevention adjuvants; (3) overview studies for adhesion prevention barriers including a perspective for their use; and (4) look toward the future of adhesion prevention. A great deal of effort has been dedicated to reduce adhesion formation because of the morbidity associated with adhesions and the associated economic burden, which considering only hospital costs and surgeons' fees, was $1,180 million in the United States. To understand the role of adhesion barriers in gynecological surgery, an appreciation of the cellular cascade and temporal nature of peritoneal repair is necessary. Evidence indicates that areas denuded of peritoneum will heal satisfactorily and that suturing of the peritoneum may increase adhesion formation. Physical barriers, including both mechanical and viscous solutions, are widely used to prevent adhesion formation by limiting tissue apposition during the critical stages of mesothelial repair. Clinical studies do not support the use of intraperitoneal, dextran for adhesion prevention. Theoretical considerations of peritoneal fluid dynamics indicate that crystalloid instillates should not prevent adhesion formation because of their short intraperitoneal residence. This prediction is consistent with clinical observation. The availability of Interceed (Johnson and Johnson Medical, Inc., Arlington, TX) and Gore-Tex Surgical Membrane (W.L. Gore, Flagstaff, Arizona) barriers provides substantial progress in postsurgical adhesion prevention. Although many investigators are incorporating adhesion prevention barriers into their routine clinical situations, physician acceptance is constrained by technical difficulties.
To evaluate further the safety and efficacy of selective ostial salpingography combined with transcervical wire recanalization for the diagnosis and treatment of proximal tubal obstruction. Prospective study. Division of Reproductive Endocrinology and Department of Radiology at Harbor-University of California Los Angeles (UCLA) Medical Center, a tertiary care academic institution. Twenty-eight infertile patients diagnosed with proximal tubal obstruction by hysterosalpingogram (HSG) or by chromopertubation at laparoscopy (total of 46 obstructed tubes). After antibiotic prophylaxis and IV analgesia a conventional HSG was performed. If proximal tubal obstruction was confirmed, selective salpingography was done under fluoroscopic guidance. If proximal tubal obstruction was still present, wire recanalization using a new prototype cannula was then performed. If recanalization was successful, contrast media was injected to confirm tubal patency. Proximal tubal patency, complete tubal patency, pregnancies. Eleven of 46 tubes (23.9%) were patent by HSG. Ostial salpingography of the remaining 35 tubes revealed 6 patent tubes (13%). Nine of the 29 obstructed tubes (31%) had successful wire recanalization, and 8 of these were patent distally. There were 4 intrauterine pregnancies (IUPs) and 1 ectopic pregnancy after recanalization and 2 IUPs after ostial salpingography. Selective salpingography should be considered at the time of an HSG showing proximal tubal obstruction. If indicated, wire recanalization can also be attempted. Selective ostial salpingography combined with wire recanalization is a safe and effective procedure for the diagnosis and treatment of PTO.
Redwine DB, 1994·The Journal of the American Association of Gynecologic Laparoscopists
To determine the accuracy of postoperative recall of preoperative pain, this prospective, longitudinal study was conducted by a general gynecologist in private practice at a referral center. Before excision of endometriosis at laparoscopy or laparotomy and again at 6 to 18 months after surgery, 168 patients completed a 5-point scale assessing 11 symptoms that may be related to endometriosis. For 6 of the 11 symptoms, over 50% of patients had exact recall of pain level. For 10 symptoms, over 80% recalled their preoperative pain level within +/-1 point. Patients requiring reoperation were most likely to recall preoperative pain levels accurately. Those not requiring reoperation tended to inflate slightly their remote assessment of preoperative pain, indicating that successfully treated patients tend to forget how much they formerly hurt.
An introduction to and some new anatomical and physiological aspects of the cervix and vagina are presented and also an explanation of the biosynthesis and molecular structure of mucus.
PregnancyInfection ScreeningPuerperal EndometritisC-Reactive Protein in Pregnancy
Silent intrauterine infection as cause of preterm labour should be recognised early by measuring C-reactive protein (CRP) levels in the maternal serum. Ensuing antibiotic therapy may not only cause gestational prolongation, but also has a positive effect on pathology during the puerperal period. Consequently, we examined the rate of infectious puerperal complications of 181 patients who suffered from so-called idiopathic preterm labour. 84 patients showed normal CRP-levels at the onset of tocolysis (< 5 mg/l); an elevated level was found in 97 patients (> 5 mg/l). Patients with elevated CRP-levels and supplemented antibiotic therapy during pregnancy (n = 51) showed significantly fewer symptoms of postpartal endometritis than women with similarly elevated CRP-levels but without antibiotics (n = 46). This effect was not produced when preterm labour was associated with normal CRP-levels. Patients with premature contractions and elevated CRP-values at the onset of tocolysis seem to benefit from the antibiotic therapy during pregnancy because they show reduced infectious complications throughout the puerperal period.
Bone HealthProgesterone and Bone RemodelingBone Metabolism
Diagnostic and Statistical Manual of Mental Disorders - 4th Edition, 1994·Personal Disord
We examined the latent structure underlying the criteria for DSM-IV-TR (American Psychiatric Association, 2000, Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.) personality disorders in a large nationally representative sample of U.S. adults. Personality disorder symptom data were collected using a structured diagnostic interview from approximately 35,000 adults assessed over two waves of data collection in the National Epidemiologic Survey on Alcohol and Related Conditions. Our analyses suggested that a seven-factor solution provided the best fit for the data, and these factors were marked primarily by one or at most two personality disorder criteria sets. A series of regression analyses that used external validators tapping Axis I psychopathology, treatment for mental health problems, functioning scores, interpersonal conflict, and suicidal ideation and behavior provided support for the seven-factor solution. We discuss these findings in the context of previous studies that have examined the structure underlying the personality disorder criteria as well as the current proposals for DSM-5 personality disorders.
Perimenopause/MenopauseMenstrual Cycle Effects on BoneMenstrual DisturbancesBone Metabolism
To determine whether cyclic medroxyprogesterone treatment given without estrogen causes adverse symptoms in postmenopausal women. This was a placebo-controlled, double-blind, crossover trial of 10 days/month of medroxyprogesterone and placebo treatments given during 2 consecutive months in random order. Participants recorded their physiologic and emotional experiences on a 0-4 scale using a daily diary form. Eleven postmenopausal women aged 43-63 completed the study. The subjects were not taking hormones. Height, weight, and serum estradiol concentration were measured once. In each woman, the sum of scores for the 10 days of medroxyprogesterone was compared to the sum of scores for the 10 days of placebo using nonparametric tests. No significant differences in scores were found between the 10 days on medroxyprogesterone and the 10 days on placebo. The median and range for the composite scores for premenstrual-like symptoms were 26 (20-67) during medroxyprogesterone and 25 (19-40) during placebo (P = .39). Medroxyprogesterone given alone does not cause adverse symptoms in postmenopausal women. Therefore, medroxyprogesterone therapy, by itself, cannot explain the side effects reported by postmenopausal women taking combined hormones.
The primary objective of this prospective study was to test whether preterm birth prevention education plus increased clinic visits and selected prophylactic interventions reduce preterm birth. Eight West Los Angeles prenatal county clinics, comparable with respect to selected demographics, were randomized to be either experimental or control clinics. High-risk patients in all clinics were identified with a risk scoring system derived from a similar population. High-risk patients (N = 1774) in experimental clinics were offered a program of education and more frequent visits and were randomized to receive various secondary intervention protocols in addition to the basic interventions of education and more frequent visits. Control clinic patients (N = 880) received standard county care. Preterm birth rates were 19% lower among the experimental high-risk patients (7.4% vs 9.1%), and differences were significant (p < 0.05) when preterm risk was taken into account. There was no evidence to suggest that the secondary interventions provided added benefit over the primary intervention protocol of preterm birth prevention education and increased visits. The 19% reduction in preterm birth rate observed in the experimental clinics suggest an overall program benefit from a protocol that offered education, more frequent visits, and greater attention given to patients while the selected interventions were applied.
NaProTECHNOLOGYDevelopment and HistoryBillings Ovulation MethodNatural Family Planning
The following is an address presented to a summit meeting on natural family planning sponsored by the Pontifical Councilfor the Family in December, 1992
I am honored and privileged to have this opportunity to be with all of you at this summit meeting on natural family planning. I wish to thank Alfonso Cardinal Lopez Trujillo for his invitation and all ofthe members ofthe Pontifical Council for their generosity and hospitality.
I have been asked to discuss with you what has become known as the Creighton Model Natural Family Planning System. This system obtained its name from my personal association, in its early days of development, with Creighton University School of Medicine in Omaha, Nebraska. This discussion will be, by its very nature, a summary of work that has been done and work that is currently ongoing.
The Creighton Model is referred to as a "model" as opposed to a "method" because it is an integrated education, research and service oriented system which meets the demands of the allied health and medical professions in the field of natural family planning. This system was specifically built to accomplish accountability and competency through a strong professional infra-structure. At the same time, it has been built within the context of a Catholic ethical and moral service delivery framework. It uses a standardized modification of the Billings' Ovulation Method in accomplishing these goals.
I personally became involved in natural family planning with a research project I did as a senior medical student in 1968. As I investigated the salivary albumin concentrations in women during the course of their menstrual cycles, I was looking for a reported decrease in albumin around the time of ovulation. Unfortunately, a project which I had no doubt would solve the problems related to natural family planning (sic), proved to be not a very good idea. . .
NaProTECHNOLOGYOvulation MonitoringUltrasoundClassification Systems
We assessed the relationship between dietary restraint and menstrual cycle characteristics in 27 ovulatory women, previous participants in a longitudinal study of spinal cancellous bone mineral density (BMD). Subjects completed the restraint scale of the Three Factor Eating Questionnaire, recorded basal temperature and exercise for at least three menstrual cycles, and completed a 3-d food record. Cycle lengths of women in the upper and lower tertiles of scores for restraint were similar [27.8 +/- 1.0 (mean +/- SE) vs 27.6 +/- 0.8 d], but luteal phase length was shorter in the former group (8.6 +/- 0.9 vs 10.8 +/- 0.5 d, P < 0.05). Age, body mass index, percent body fat, waist-hip ratio, reported energy intake, and activity were similar between groups. Because the previous longitudinal study found associations between ovulatory disturbances and bone loss, we assessed spinal BMD using dual-energy x-ray absorptiometry (DXA) and quantitative computed tomography (QCT). BMD of women in upper and lower restraint tertiles, respectively, DXA, 1.15 +/- 0.05 vs 1.20 +/- 0.06 g/cm2; and QCT, 140 +/- 7 vs 133 +/- 7 mg/cm3. Additional prospective studies, however, appear warranted. In conclusion, this study's results provide evidence that high dietary restraint is associated with a shortened luteal phase length.
Schöpf J et al., 1994·Eur Arch Psychiatry Clin Neurosci
A group of 119 patients suffering from a severe psychiatric postpartum disorder who were admitted for the first time in their life to a psychiatric hospital has been investigated. The onset of illness occurred within 3 months following delivery. The patients represented 92% of the total sample fulfilling the inclusion criteria. A follow-up investigation was performed after a mean of 21 years (range 2-35 years). Of the patients 66% had nonpuerperal psychotic episodes in later life. The diagnosis, taking into account the long-term course, was affective psychosis in 57%, schizoaffective psychosis in 18%, schizophreniform psychosis in 12%, brief reactive psychosis in 4% and schizophrenia in 9%. A bipolar psychosis was found in 31%. The relation of unipolar to bipolar psychoses corresponded to that in a control group of affectively ill women without puerperal onset. The frequency of a manic syndrome in bipolar psychoses at the index episode was the same as in nonpuerperal episodes, which does not suggest a mania-provoking pathoplastic effect of the puerperium. The comparison with female nonpuerperal controls matched for age and diagnosis revealed evidence of a better long-term course in the index patients. The risk of a puerperal relapse for further pregnancies was 35%. The global morbidity risk for functional psychoses in first-degree relatives was 11%, with affective psychoses representing the majority of secondary cases (6.8%). The index patients showed a nonsignificant lower morbidity risk in relatives than a control group of psychotically ill women without puerperal onset. The major aetiological factor found for postpartum psychoses is the relation of these disorders to functional psychoses. There is strong evidence that the postpartum period tends to provoke affective psychoses and other nonschizophrenic psychoses, but not, or only to a lesser degree, narrowly defined schizophrenias. The liability to puerperal decompensations suggests some common pathophysiological mechanism, the nature of which remains unknown.
AndrologyBioassay AssessmentVaricocele and Sperm FunctionSperm Function Testing
The sperm function of fertile men (control), infertility patients (experimental), and men with varicocele were compared. The bioassays used were the follicular fluid-induced acrosome reaction, the binding to the zona pellucida, and the penetration of zona-free hamster oocytes. The percentage (mean +/- SEM) of reacted spermatozoa was 35 +/- 3 in the control, 22 +/- 1 in the experimental, and 22 +/- 3 in the varicocele. The minimum value of acrosome reaction in control men was 20%. The mean number of zona-bound spermatozoa was 250 +/- 30 in the control, 160 +/- 28 in the experimental, and 196 +/- 44 in the varicocele. The minimum number of zona bound spermatozoa in control men was 50. The mean number of hamster oocytes penetrated was 50 +/- 8 in the control, 19 +/- 3% in the experimental, and 10 +/- 3 in the varicocele. The minimum number of oocytes penetrated in control men was 6%. In the experimental group, 22 men had a normal sperm function, 58 had 1 or 2 bioassays below the minimum (relative dysfunction), and 10 had all bioassay below the minimum (abnormal sperm function). The results of these bioassays could help to reclassify the infertile men in several subgroups.
General OB/GYNMeconium AspirationAmniotic Fluid Complications
To determine prospectively the incidence of several pulmonary diagnoses among infants born through clear or meconium-stained amniotic fluid (AF) managed by a selective approach to tracheal intubation. All live births greater than 36 weeks' gestation occurring between January 1990 and December 1992 were included. Diagnostic criteria for several respiratory disorders were determined prospectively and monitored. Infants with light meconium and vigorous infants with moderate to thick meconium were selectively not suctioned. A control group of infants with clear AF matched for gestational age and year of birth was randomly selected for comparison. The incidence and severity of respiratory disease were compared between the groups. Of 4938 live births, 799 (16%) had meconium-stained AF (light, 334; moderate to thick, 465). Compared to 211 infants with moderate to thick meconium selectively not suctioned, 196 suctioned infants had significantly greater rates of abnormal fetal heart rate (FHR) patterns, fetal acidosis, low Apgar scores at 5 minutes, need for resuscitation, and neonatal intensive care unit admission. Meconium aspiration syndrome was significantly more common in suctioned infants as compared to those selectively not suctioned, those with light meconium, and those with clear fluid (11 versus 3 versus 0 versus 0%; P < .01). The need for ventilator or oxygen support was similar between infants with clear fluid, lightly stained fluid, and moderate to thick fluid who were selectively not suctioned, but was significantly greater among suctioned infants (P < .01). We conclude that a selective approach to tracheal intubation and suction of infants with meconium-stained AF was not associated with increased pulmonary morbidity or mortality. Postnatal management of neonates at greatest risk of meconium aspiration syndrome does not necessarily prevent adverse pulmonary outcome.
Annual report (Jahrbuch) of the Deutsches IVF-Register (DIR) for treatment year 1993. DIR is the German national IVF/ICSI registry, founded 1982 — the oldest continuously operating ART registry. Voluntary professional-society database with high de-facto coverage of German fertility centres. Reports cycles, transfers, pregnancies and clinical outcomes by treatment type (IVF, ICSI, frozen embryo transfer, donor). German-language registry document. Used as a Phase B historical-archive source for the ART Registry Comparison study (cross-registry classification by reporting completeness on 7 framework dimensions).
Since 1989 an international multicenter prospective study to evaluate the effectiveness and acceptability of natural family planning (NFP) methods in Europe has been conducted by the NFP Research Center at the University of Düsseldorf in collaboration with the European Zone of the International Federation for Family Life Promotion (IFFLP). Fourteen NFP-organizations from nine European countries participate in the study. Cycle data from women in the fertile age group are transferred to a special standard computer sheet by the respective organizations and forwarded at three-monthly intervals to the study center for analyses. To date, 10,045 cycles from 900 women aged between 19 and 54 years have been analyzed. This paper presents the pregnancy rate for the women aged between 19 and 45 years of age, who contributed 9284 cycles. In the analyses the cycles were subdivided into two categories consequent to sexual practices group I (NFP only--4277 cycles) use only NFP to avoid a pregnancy; group II (FA/mix--5007 cycles) where barrier methods or coitus interruptus during the fertile phase, at least in some cycles, were used to avoid a pregnancy. The women used different clinical indicators such as basal body temperature (BBT), cervical mucus, calculations, cyclical cervical changes or combinations of these to determine the beginning and the end of the fertile phase necessitating a further division into four subgroups, A, B, C, D, and different efficiency rates for each of these groups. In group A (symptothermal method, double check) 15 unintended pregnancies (UIP) occurred in 7404 cycles, giving a pregnancy rate of 2.4 Pearl Index (PI); in group B (muco-thermal method) there were 12 UIP in 1352 cycles with a pregnancy rate of 10.6 (PI); in group C (mucus to detect the beginning and mucus and BBT to determine the end of the fertile phase) there was one UIP in 434 cycles, and in group D (mucus method only) there was one IUP in 70 cycles. The numbers in group C and D are too small to calculate a pregnancy rate (PI). No pregnancy was observed in women over 40 years of age. Our conclusion from these preliminary results is that in the continent of Europe, the symptothermal method when used with periodic abstinence (NFP only = group I) and fertility awareness with the use of barriers during the fertile phase (FA/mix = group II) are effective methods of family planning.(ABSTRACT TRUNCATED AT 400 WORDS)
To compare the effect of fertility drugs and IVF on the outcome of triplet pregnancies. Prospective clinical study. A single university medical center. One hundred six consecutive triplet pregnancies treated from 1984 through 1992. The frequency of pregnancy loss, livebirths, and antenatal and neonatal complications was compared in spontaneous, clomiphene citrate (CC), menotropins, and IVF triplet pregnancies. Eighty-one of the 106 (76.4%) triplet pregnancies progressed beyond 25 weeks, comprising 6 of 7 (85.7%) spontaneous pregnancies, 13 of 16 (81.2%) CC induced, 44 of 56 (78.6%) menotropin induced, and 18 of 27 (66.6%) IVF gestations. There were no significant differences in the stillbirth and neonatal mortality rates according to the mode of conception. The mean gestational ages and the mean birth weights were similar in the four groups. The frequency of premature contractions, premature rupture of membranes, cesarean section, and neonatal complications were similar in the ovulation induction and IVF pregnancies. Triplet pregnancies after ovulation induction and IVF have a similar outcome.
good of all, and above all, for the protection of the weak."2I submit that, no matter how appealing a marketplace model may seem for the NHS, it is a business model.As such the destruction of either purchaser or provider is eventually certain, with the barbarisation of the survivor.It is not too late for consortiums of purchasers and consortiums of providers to join forces and become one NHS again.
The constant infusion of [3H]equilin sulfate ([3H]EqS) was used to estimate the MCR of equilin sulfate (EqS) and to measure the conversion of this estrogen to equilin (Eq), equilenin (Eqn), equilenin sulfate (EqnS), 17 beta-dihydroequilin (17 beta-Eq), 17 beta-dihydroequilin sulfate (17 beta-EqS), 17 beta-dihydroequilenin (17 beta-Eqn), and 17 beta-dihydroequilenin sulfate (17 beta-EqnS) in normal postmenopausal women and men. Infusion of [3H]EqS was started in five postmenopausal women and two men 30 min after a priming dose and continued at a constant rate of 12-15 microCi/h for 3 h. Blood samples were taken 15 min before the end of infusion, at the end of the infusion, and 15 min after the end of infusion. Unconjugated and sulfate-conjugated Eq, Eqn, 17 beta-Eq, and 17 beta-Eqn were isolated from plasma. The mean MCR of EqS was calculated to be 280 +/- 24 L/day or 170 +/- 18 L/day.m2. The mean conversion ratios for precursor EqS to product 17 beta-EqS, EqnS, 17 beta-EqnS, 17 beta-Eq, Eq, Eqn, and 17 beta-Eqn were 0.300, 0.190, 0.100, 0.020, 0.016, 0.008, and 0.004 respectively. In both the sulfate-conjugated and unconjugated forms, 17 beta-Eq was the most abundant metabolite formed. 17 beta-Eq estrogen is a potent uterotropic agent and has a much higher affinity for estrogen receptors than Eq. Its formation may be of importance in the overall biological activity of EqS present in conjugated equine estrogen preparations.
Redwine DB, 1993·The Journal of the American Association of Gynecologic Laparoscopists
To determine if laparoscopic excision of endometriosis by electrosurgery is more rapid than by sharp dissection, a retrospective comparative study was made of operative times for the two procedures. Median operating times for laparoscopic electro-excision of endometriosis were 26% to 49% faster than excision by sharp dissection. A chi2 analysis of the frequency counts of surgical intervals, and disease stage revealed this difference to be statistically significant and not due to acquired experience or differences in extent of disease in the two groups. The reduction in operating time achieved with monopolar electro-excision seems primarily associated with a more rapid cutting action with simultaneous coagulation of bleeders.
Menstrual CycleDietary InfluencesLignans and Hormonal EffectsNutritional Interventions
Lignans are a group of phytochemicals shown to have weakly estrogenic and antiestrogenic properties. Two specific lignans, enterodiol and enterolactone, are absorbed after formation in the intestinal tract from plant precursors particularly abundant in fiber-rich food and are excreted in the urine. We evaluated the effect of the ingestion of flax seed powder, known to produce high concentrations of urinary lignans, on the menstrual cycle in 18 normally cycling women, using a balanced randomized cross-over design. Each subject consumed her usual omnivorous, low fiber (control) diet for 3 cycles and her usual diet supplemented with flax seed for another 3 cycles. The second and third flax cycles were compared to the second and third control cycles. Three anovulatory cycles occurred during the 36 control cycles, compared to none during the 36 flax seed cycles. Compared to the ovulatory control cycles, the ovulatory flax cycles were consistently associated with longer luteal phase (LP) lengths (mean +/- SEM, 12.6 +/- 0.4 vs. 11.4 +/- 0.4 days; P = 0.002). There were no significant differences between flax and control cycles for concentrations of either estradiol or estrone during the early follicular phase, midfollicular phase, or LP. Although flax seed ingestion had no significant effect on LP progesterone concentrations, the LP progesterone/estradiol ratios were significantly higher during the flax cycles. Midfollicular phase testosterone concentrations were slightly higher during flax cycles. Flax seed ingestion had no effect on early follicular phase concentrations of DHEA-S, PRL, or sex hormone-binding globulin. Our data suggest a significant specific role for lignans in the relationship between diet and sex steroid action, and possibly between diet and the risk of breast and other hormonally dependent cancers.
PregnancyCervical Length AssessmentTransvaginal Cervical MeasurementPrediction and Risk Stratification
To establish a nomogram for the length of the uterocervical canal and to determine whether this can be used to predict preterm delivery. Cervical length was measured by transvaginal ultrasonography in 32 women (21 primigravid, 11 multigravid) with threatened preterm delivery, and in 177 normal singleton pregnancies between 18-37 weeks' gestation. Regression analysis was used to create the nomogram. Student t test was used to compare the groups. A linear relationship was found between cervical length and gestational age (r = -0.4, P < .001). Comparison of cervical length on admission in the patients with threatened preterm delivery showed that 11 preterm deliveries occurred in women who had a mean cervical length of 23.2 mm (range 17-29), whereas 21 term deliveries occurred in women with a mean cervical length of 31.7 mm (range 21-42). The difference was significant (P < .001). A cervical length of less than 20 mm on admission had a positive predictive value of 100%. These patients had preterm delivery despite tocolytic therapy during hospitalization. The risk of preterm delivery is high in women whose cervical length on admission is less than 30 mm, and strict management is required for those with a cervical length of less than 20 mm.
Body LiteracyInstitutional ProgramsCatholic HealthcareNFP Integration
A recent survey conducted by the American Academy of Natural Family Planning (AANFP) found that over 55% of Catholic hospitals surveyed either provide or would like to provide some form of Natural Family Planning (NFP) services. In addition, over 60% of the respondents felt that NFP should be part of the mission of a Catholic hospital.
Although low-dose aspirin has been reported to reduce the incidence of preeclampsia among women at high risk for this complication, its efficacy and safety in healthy, nulliparous pregnant women are not known. We studied 3135 normotensive nulliparous women who were 13 to 26 weeks pregnant to determine whether treatment with aspirin reduced the incidence of preeclampsia. Of this group, 1570 women received 60 mg of aspirin per day and 1565 received placebo for the remainder of their pregnancies. We also evaluated the effect of aspirin on maternal and neonatal morbidity. Of the original group of 3135 women, 2985 (95 percent) were followed throughout pregnancy and the immediate puerperium. The incidence of preeclampsia was lower in the aspirin group (69 of 1485 women [4.6 percent]) than in the placebo group (94 of 1500 women [6.3 percent]) (relative risk, 0.7; 95 percent confidence interval, 0.6 to 1.0; P = 0.05), whereas the incidence of gestational hypertension was 6.7 and 5.9 percent, respectively. There were no significant differences in the infants' birth weight or in the incidence of fetal growth retardation, postpartum hemorrhage, or neonatal bleeding problems between the two groups. Subgroup analysis showed that preeclampsia occurred primarily in women whose initial systolic blood pressure was 120 to 134 mm Hg (incidence among such women, 5.6 percent in the aspirin group vs. 11.9 percent in the placebo group; P = 0.01). The incidence of abruptio placentae was greater among the women who received aspirin (11 women, vs. 2 in the placebo group; P = 0.01). Low-dose aspirin decreases the incidence of preeclampsia among nulliparous women, primarily through its effect in those who have elevated systolic blood pressure initially. This treatment does not decrease perinatal morbidity but increases the risk of abruptio placentae.
To examine and discuss the pathology, diagnosis, incidence, and patient profile of salpingitis isthmica nodosa and to question its natural history, propose management strategies, and identify areas of promising research. Over 50 studies were reviewed, evaluated, and compared to offer the clinician a foundation on which to generate treatment plans. Salpingitis isthmica nodosa is diagnosed by the pathological presence of isthmic diverticula and may be suggested by characteristic changes on hysterosalpingogram. Its incidence in healthy, fertile women ranges from 0.6% to 11%, but it is significantly more common in the setting of ectopic pregnancy and infertility. There are no studies, retrospective or prospective, that clearly dictate appropriate therapy. Given its progressive nature and probable deleterious effects on fertility, we propose that microtubal surgery be the definitive treatment for qualified women who have salpingitis isthmica nodosa.
The purpose of this study was to determine the relationship between C-reactive protein (CRP) levels and intraamniotic infection in 48 women presenting with preterm labor and intact membranes. Blood samples for CRP tests were obtained immediately before the performance of transabdominal amniocentesis. The prevalence of amniotic fluid cultures positive for organisms was 14.6%. In 16 women (33.3%) positive CRP levels were obtained. There were no significant differences in the prematurity rate or the prevalence of microbial invasion of the amniotic cavity between women with positive CRP levels and women with negative levels. The sensitivity, specificity, and positive and negative predictive values for the detection of amniotic infection were 71.5%, 73.2%, 31.3% and 93.8%, respectively. Based on these results, we suggest that in women with preterm labor and negative CRP levels, routine amniocentesis may not be essential to the initial workup.
To determine the magnitude of intraobserver variation in dating endometrial biopsies and its impact on clinical management. Blinded histopathologic interpretation of endometrial biopsy specimens 1 year apart by five pathologists. Large military tertiary care center. Endometrial biopsy specimens from 51 patients undergoing evaluation for potential luteal phase defects. None. Calculation of the magnitude of the individual and overall intraobserver variation in endometrial dating for the five pathologists and estimation of its potential impact on clinical management. The intraobserver variation was 0.69 +/- 0.05 days (means +/- SE). There was no significant difference in the magnitude of the variation for 1-day or 2-day dating ranges. The theoretical probability of altering clinical management by having the same pathologist redate a given specimen ranged from 15% to 28%. Histologic dating of endometrial biopsies is subject to a small but highly clinically significant intraobserver variability that may have a major impact on clinical management.
In spite of constant efforts by health and social workers, existing family planning measures are not used by a vast majority of eligible couples. This is because of the fear that the method may affect their health and happiness. Billings' ovulation method is based on the scientific observation that by noting the changes in cervical mucus, which is clear, slippery and copious in periovulatory period, it is possible to prevent pregnancy by avoiding intercourse during this period. As this method does not require the use of drugs or devices it was decided to promote this method in the urban areas and slums of Patna, Bihar where couples were not using other methods. This is not a comparative study of the cost-effectiveness of Billings' ovulation method versus other contraceptive measures at all. An analysis of 501 cases (267 in urban and 234 in slums) over a period of 2 1/2 years has been presented and it is gratifying to note that the couples from all religions and strata of the society (nearly 47% were slum dwellers) agreed to continue this method.
PregnancyInflammatory BiomarkersInfection DiagnosisC-Reactive Protein in Pregnancy
To evaluate clinical, microbiologic, and histologic findings associated with elevated C-reactive protein levels among women in preterm labor or with preterm premature rupture of the membranes (PROM). Obstetric data, serum C-reactive protein levels, and amniotic fluid (AF) and chorioamniotic membrane cultures and histology were obtained on 203 women presenting between 22-34 weeks' gestation in preterm labor or with PROM. Women with C-reactive protein greater than 1.5 mg/dL were more likely to deliver within 7 days of enrollment (54 of 68, 79%) than were women with normal C-reactive protein levels (45 of 135, 33%) (P < .001). The median C-reactive protein levels and association with rapid delivery did not differ between women with intact versus ruptured membranes. Elevated C-reactive protein levels were associated with a positive AF culture among women in preterm labor with intact membranes. To control for confounding by a long interval to delivery, only the group delivering within 7 days was considered for evaluation of C-reactive protein levels and placental and infant outcome. Among women delivering within 7 days, elevated C-reactive protein was associated with the development of clinical chorioamnionitis and with infant death before hospital discharge, but not with a positive membrane culture or histologic chorioamnionitis. Elevated C-reactive protein appears to be associated with AF infection, delivery within 7 days of admission, and infant death among women delivering preterm, but not with membrane infection or inflammation. Elevated C-reactive protein may be helpful in determining the need for AF culture and in targeting studies of antibiotic therapy among women in preterm labor or with preterm PROM.