In developing countries with high levels of malnutrition and iron deficiency, the menstrual blood loss sometimes associated with IUD use can represent a serious maternal health concern. To identify the IUD models associated with the least amount of bleeding, 365 clients of the Mexican Institute of Social Security's Volunteer Family Planning Program participated in a 12-month comparative study of 11 IUDs. Menstrual blood loss was measured before IUD insertion; at 1, 3, 6, 9, and 12 months; and 1, 2, and 3 months after removal. Mean menstrual blood loss at baseline was 43.6 +or- 6.3 ml. The greatest increase in bleeding (above 80 mg) was recorded among acceptors of the Lippes Loop-D and Copper T-380 devices; the Copper T-200 and 220C and Multiload 250 were in an intermediate position (below 80 mg), while the Copper 7 induced little change. In contrast, users of the 5 progestogen-releasing IUDs experienced a decline in menstrual bleeding that was proportional to the amount of steroids released or the progestational potency. This reduction was greatest (96%) for the IUD that released 8 mcg/day of levonorgestrel. However, this category of IUDs is more costly and necessitates earlier removal; in addition, many women discontinue use of hormone-releasing IUDs precisely because of the associated amenorrhea. Recommended, therefore, is promotion of the Copper T-220C, which can remain in place for 10 years. In selected cases, short-term treatment with nonsteroidal anti-inflammatory agents can reduce IUD-associated hypermenorrhea and promote contraception continuation.
In Vietnam between 1989 and 1993, the modern contraceptive prevalence rate stopped at 38%. In 1984, the government implemented economic renovation (Doi Moi). This closed agricultural cooperatives which had supported commune health centers. Health workers received either low or no wages, resulting in low morale, absenteeism, and moving to the private sector or agriculture. Most women began using the IUD because it was low cost and easy to monitor, provided long-term protection against pregnancy, and there was a limited supply of oral contraceptives (OCs) and condoms. Condom use fell from 13% in 1984 to 1.4% in 1993. More than 80% of contraceptive users used the IUD. The IUD is not appropriate for many women because of health problems: 60-70% of pregnant women and 80% of parturient women have anemia, 40-60% of women have reproductive tract infections, and sexually transmitted diseases are rising. Vietnam's Prime Minister and the Communist Party are committed to expanding the range of the contraceptive method-mix and choice. Limited method choice is especially a problem in rural areas. It increases the abortion rate. About 38% of abortions supplant modern and traditional family planning methods. Improper counseling, insufficient knowledge, and low promotion of OCs account for the low use of OCs. Inferior quality, aversion by couples, and inaccessibility in most rural areas limit condom use. Women's fear and husband's objection outweigh the government's promotion of sterilization. Providers have limited comprehensive accurate and current knowledge of contraceptives. Health service facilities are concentrated in urban and semiurban areas. The quality of care in rural areas, where there is no clean water supply, is inferior. An annual target used to forecast contraceptive needs risks contraceptive stocks expiring during storage and/or disruptions in supply of users. Consecutive actions to eliminate constraints to use of other methods, developing a community level service delivery system to provide a wide range of methods, and developing specific service delivery systems for specific methods are optional strategies to expand method choice in Vietnam.
Researchers are developing vaccines to control fertility by inducing antibody and/or cell-mediated immune response against either a hormone or an antigen associated with gametes. The beta-human chorionic gonadotropin (hCG) vaccine, delivered with the tetanus toxoid vaccine, is reversible and causes only minimal side effects. It causes a large variability of antibody response. An improved version uses the beta-hCG linked with the alpha-subunit of another species (hetrospecies dimer). It is more immunogenic and produces antibodies at higher titres than does the beta-hCG-TT vaccine. It does not affect menstrual regularity. Researchers have formulated Praneem VILCI (vaccine-inducing local cell-mediated immunity) with purified extracts from Azardichta indica, an ancient Indian tree, to prevent pregnancy during the 1st 3 months. It is administered into the uterus and may be a feasible compatible approach with the hCG vaccine. Praneem VILCI does not affect ovarian function or sexual drive. The follicle-stimulating hormone vaccine has caused oligospermia and reduced fertilizing capacity of the sperm in monkeys. Contraceptive vaccines need to induce an effective and sustained immune response over a designated period in virtually all acceptors. Improved and more potent and safe adjuvants are probably needed to achieve such a response. Carriers with T cell epitopes with no suppressor T cell determinants can overcome variation in the immune response due to MCH-restriction in human populations with dissimilar immunogenetic background. Future vaccines may be polyvalent with various antigens prohibiting fertility at more than 1 point in the reproductive process. Contraceptive vaccines need to deliver multiple doses of the vaccine at 1 contact point. Biodegradable polymer microspheres can deliver antigens periodically. Live recombinant vaccines using engineered vectors can effect immunization with 1 or more doses. They would be cost effective and producible in large amounts, which would make them affordable for developing countries.
An intrauterine contraceptive device releasing 20 micrograms levonorgestrel daily has been studied for 15 years. The international clinical experience covers over 8000 woman years. Main characteristics of the levonorgestrel-releasing intrauterine device are its great effectiveness in preventing unplanned pregnancies and a reduction in menstrual bleeding and pain as well as a low infection rate.
HIV is in the semen and epididymal epithelia. A possible malfunction of the physiological barriers in the seminiferous epithelium may be an early response to HIV. Tight bonds between Sertoli cells serving as the blood-testis barrier may be the site of the breakdown that permits circulating HIV to penetrate the seminal compartment. Receptive partners of anogenital intercourse are more susceptible to HIV infection and progression to AIDS because some metabolites of semen extend to the vascular/lymphatic system. As couples move closer to stage IV of HIV infection, infertility is more likely. Condom use during all sexual encounters outside of long term monogamous relationships is advocated, even if other contraceptives are used. The US government requires strict quality controls on the manufacture of condoms to eliminate condom failure during correct use. HIV cannot penetrate an intact latex condom, thus it prevents the spread of HIV. Not everyone accepts condoms. Laboratory tests show that various spermicidal compounds destroy HIV and other sexually transmitted disease organisms. Yet, epidemiologic studies do not show that spermicides alone can protect against HIV transmission. Either intracellular location of HIV protects it from spermicides, or the toxicity of the spermicide causes genital ulcers which facilitate HIV transmission. An increase in condom sales in the US has occurred, particularly in the states with the highest AIDS rates (California and New York). Condoms made of lamb cecum are an option to men who are allergic to latex. Spermicides can also cause allergic reactions. Physicians should not prescribe the pill to prostitutes who reject condom use. Future research should examine HIV receptor on T lymphocyte, sperm, and brain neurons; local immunity against sperm antigen; development of locally enhanced immune response within the genital tract lumen; and purification/identification of immunosuppressive substances in seminal plasma.
