Focus in this discussion of IUDs is on types of IUD, fitting and insertion of IUDs, IUD management, physiology of IUDs, IUD pathology and management, and future development of IUDs. Several clinical trials are now underway in the effort to develop an IUD which will be able to lower the rate of pregnancies, expulsions, pain, bleeding, infections and other complications associated with IUD use. The use of proper techniques for insertion and placement of IUDs reduces the risk of uterine perforation, expulsion, pregnancy menstrual bleeding, pain and pelvic inflammatory disease. The device should be placed as high as possible in the endometrial cavity without perforating the uterine wall. In the absence of contraindications, IUDs can be used in adolescent females. The correct model should be selected and adapted individually to the sometimes underdeveloped uterine cavity. Side effects and complications of IUDs include uterine pain, dysfunctional uterine bleeding, expulsions, perforations, pelvic inflammatory disease, accidental intrauterine pregnancy and ectopic pregnancy. Novel approaches for future IUD improvement include medicated IUDs, medicated IUDs with compounds to reduce bleeding, IUDs designed to reduce expulsion after early postpartum and postabortion insertion, improved fit of IUD size and configuration to a given uterus, better insertion techniques and instrumentation, and application of biodegradables and polymeric delivery system.
This study was conducted to analyze risk factors for dyspermia in infertile subjects in a population of men attending outpatient services for infertility in Milan, Northern Italy. Between September 1989 and November 1990 we conducted a case-control study on risk factors for dyspermia. Cases included infertile men with a diagnosis of unexplained dyspermia consecutively observed for the first time during the study period at the Outpatient Service for Infertility of the First Obstetric and Gynecologic Clinic of the University of Milan. Specific work-up was done to exclude the major known or potential causes of dyspermia and infertility in patients and their partners. Two control groups were selected. The first included normospermic men of infertile couples with negative work-up for any disease that might affect fertility, observed in the same outpatient service where cases had been identified. The second control group included fertile men of unknown semen quality who were the partners of women who gave birth at term (> 37 w gestation) to health infants in randomly selected days at the same clinic. In comparison with those who have never smoked, current smokers were at increased risk of dyspermia versus both normospermic men of infertile couples and fertile men of unknown semen quality, and the risk increased with number of cigarettes smoked per day and duration of smoking. The risk of dyspermia increased with the number of cups of coffee drunk per day compared with men drinking no or one cup per day. Likewise, alcohol drinkers were at increased risk and the risk increased with number of drinks/d.(ABSTRACT TRUNCATED AT 250 WORDS)
The peritubular zone of the rat testis has an extensive extracellular matrix (ECM). Fibronectin (FN) is distributed primarily in the basal lamina of the seminiferous tubule boundary tissue and is synthesized by peritubular myoid cells. Several extracellular changes are mediated by growth factors and these changes occur at the time of hormone mediated testicular development, particularly in the peritubular zone. The effects of serum or dibutyryl cyclic AMP (cAMP) on FN production by the mesenchymal peritubular myoid cells were evaluated. Rats of various ages (10, 15, 20, 40 and 80 days) were employed for immunofluorescent localization of rat testicular FN in frozen sections. In all age groups tested, FN was primarily present in a broad layer around each seminiferous tubule, and blood vessel, and in variable distribution throughout the interstitial stroma. By day 20 there was no clear distinction in FN staining between the peritubular zone and the interstitial tissue. This indicates an involvement of FN in the ECM developments which occur in the peritubular zone of the testis at this time. The peritubular myoid cells were isolated from 20-22 day old rat testis and cultured on glass coverslips. These cells were grown to confluence with 10% fetal calf serum (FCS) in medium until day 4 and then subcultured to have secondary monocultures maintained with or without serum. By means of immunofluorescence and cytochemistry using avidin-biotin peroxidase complex it was observed that peritubular myoid cells were positive for FN and most of the FN was localized in the perinuclear region. Subcultured peritubular myoid cells maintained for 4 days in medium containing FCS developed an extensive interconnecting FN matrix. In the presence of 0.5 mM cAMP in culture, FN became localized along the filamentous process of peritubular myoid cells and more prominently in the areas of triangulated multi-cell aggregates as well as on the surface of the contracted small spherical cells. The addition of cAMP in the presence of FCS, also caused a noticeable change in the staining pattern; FN was detected along the filamentous process developing into a complex network of cells encased in an extensive matrix. It would appear that the translocation of FN in the cytoplasmic extensions of peritubular myoid cells may be a direct consequence of morphological changes associated with metabolic regulation of cAMP. This may also be related to the puberty associated development of in vivo changes in the ECM produced by peritubular myoid cells.
The surface ultrastructure of the tails of various IUDs (Multiload, Copper 7, Copper T-Device, Nova-T, FDI, Lippes Loop, and Dalkon Shield) was studied with the scanning electron microscope. The parts of the IUD tail exposed to the vaginal, cervical, and uterine milieu showed strikingly different surface characteristics. The surface ultrastructure of these 3 parts is influenced by the duration of use, nature of microbiological contaminants, pregnancy with the IUD in situ, and pelvic inflammatory disease (PID). Duration of use and PID alter the surface ultrastructure most drastically. In comparing tails of the different IUDs, the IUDs with relatively smooth tails became less rapidly contaminated during the 1st few months of use. The surface ultrastructure of the IUD tail was formed through a coat of material which consists of cellular debris, dead bacteria, mucus, etc. The thickness of the coat was found to be largely dependent on the duration of IUD use. The thicker the coat, the more likely bacteria were found on the intrauterine part of the tail. The possible significance of these findings with respect to the development of PID is discussed.
To evaluate the use-effectiveness and safety of IUD insertion immediately after menstrual regulation (MR) for delayed menses, a Lippes Loop D (LLD) intrauterine device was inserted in each of 100 consecutive clients at the University College Hospital, Ibadan, immediately after menstrual regulation. Pertinent event rates after 12 months of use were compared with those of 100 consecutive women who had the LLD inserted during menstruation. The cumulative net expulsion rate after 12 months of use was 8% for the study group and 4% for the controls. The overall rate of removals was 15% for the study group and 16% for the control group. None of the observed differences was statistically significant. The continuation rates at 12 months were comparable for both groups (78% and 80%, respectively). There were no accidental pregnancies during the study period. The authors suggest that IUD insertion immediately after menstrual regulation is as effective and safe as intramenstrual insertion, provided prophylactic antibiotics are given.
The politics of contraception and family planning programmes have been at the centre of many heated debates. Population issues have always been a subject of controversy, and these were highlighted yet again at the International Conference on Population (ICP) which took place in Mexico City in August 1984, when 150 governments gathered to discuss issues relating to population and development and to review progress since the World Population Plan of Action (WPPA) was agreed in Bucharest in 1974. In Mexico it was shown time and time again that not only is the topic of fertility regulation complex and emotive, but also it is often used as an entry point for wider discussion on international issues such as the role of free market economies in development, and the impact of population issues on North-South debates.
The subtitle of this chapter relates not only to an article by Djerassi1 on the probable state of the art of contraceptive development by the year 1984, but even more to the intellectual nightmare so ably depicted by George Orwell in Nineteen Eighty-Four 2.
A combined oral contraceptive (OC, Restovar, Organon) containing 0.0375 mg ethinyl estradiol and 0.75 mg lynestrenol was investigated. Various clinical and laboratory variables were studied in 164 women over 1376 treatment cycles. No pregnancies occurred. In common with other low-dose combined preparations, Restovar also caused some intermenstrual bleeding but acceptability was good in the majority of women. The frequency of general complaints was low. The estrogen-sensitive proteins, ceruloplasmin and transcortin, increased in proportion to the estrogen content of the preparation. The estrogen-androgen-sensitive proteins, sex hormone binding globulin, and thyroxin binding globulin, increased to a rather high level. Free testosterone decreased significantly. The elevation of sex hormone binding globulin level was accompanied by a decrease in free testosterone. The strong increases in sex hormone binding globulin and thyroxin binding globulin indicate that the preparation has a very low androgenic activity. The latter was confirmed in 2 women with initially low sex hormone binding globulin levels who showed a marked improvement in hirsutism and acne during treatment; this improvement was correlated with an increase in sex hormone binding globulin and decreased free testosterone levels.
An international dataset of 21,610 IUD insertions revealed 41 uterine perforations occurring at the time of, or subsequent to, insertion. Dat were collected on standard forms. Perforations were classified as confirmed, probable, or possible, based on the clinician's judgement and subsequent management. The uterine perforation rate was estimated as between 1.9 and 3.6/1000 insertions. 13 of the total 41 perforations were reported from 2 of 72 cooperating clinics. In 1 clinic, this center-clustering phenomenon suggested an effect of a high risk device. In the other clinic, the effect of insertor (operator) inexperience was indicated. A case-control analysis delineated previous cesarean section as a host risk factor (P0.05, McNemar's chi square). Further investigation of this association by similar case-control studies is recommended.
