Related editorial, page 127. Related editorial, page 127. Editor’s Note:The American Journal of Obstetrics and Gynecology (AJOG) rarely prints previously published work. However, when provided with the opportunity to republish Dr Jack Lippes’ original manuscript describing the evolution of the Lippes loop intrauterine device (IUD), we accepted. This manuscript forms the foundation for a subsequent large body of work related to the IUD over the intervening decades; indeed, since 1965, nearly 500 manuscripts on this topic have been published in AJOG, including a 1965 case series by Dr Lippes. We take advantage of this look into the past to pivot into the present. Dr Jeffrey Peipert, Deputy Editor for AJOG, discusses the evolution and current status of the IUD in women’s health care in the accompanying editorial in this month’s issue, “Lippes loop and the first IUDs: lessons from a bygone era.” On our website (www.ajog.org), we have compiled all AJOG manuscripts published about the IUD in the past 5 years. Topics range from its role in preventing pregnancy to effectiveness in treating gynecologic conditions and beyond. This curated collection can be accessed at https://www.ajog.org/iud. There is a plethora of nineteenth-century medical literature describing intracervical and intrauterine pessaries with a major impetus toward straightening a flexed or displaced uterus. The most significant outcome of these studies was the recognition that they might also be contraceptive. A variety of substances was used to make them, including natural products such as wood, wool and ivory, as well as metal such as silver, gold and platinum; some were adorned with diamonds. Then as now, controversy flared in Europe and in the United States over the safety and effectiveness of these devices. In the twentieth century, the medical profession continued to alternately praise and condemn intrauterine devices (IUDs). Grafenberg presented data on silk and/or silver rings in 1928, 1929 and 1930, his last presentation being at the Seventh International Birth Control Conference in Zurich, 1930. He reported on 600 patients fitted with the silver ring and observed that only 1.6 percent had become pregnant. Only 5 years, later the Berlin Gynaecologic Society condemned intrauterine contraception as a careless procedure. Grafenberg, who was Jewish, was incarcerated in a Berlin jail until Margaret Sanger raised a ransom to free him. He emigrated to the United States where he established a private practice in New York City. A library search revealed that doctors who protested intrauterine contraception were not the physicians with the greatest experience using IUDs but only those individuals who occasionally removed a device. Their opposition to IUDs was based on typical “I had a case” reasoning. For all practical purposes, intrauterine contraception stagnated in western society for the next 30 years. In spite of negative case reports, Japanese physicians continued to use a modification of the Grafenberg ring designed by Ota. Atsumi Ishihama of the Iwata Medical College in Morioka, Japan, inserted rings in his private practice and for years carefully followed the use of these devices throughout Japan. In 1959, more articles on intrauterine contraception were available in the Japanese medical literature than in the rest of the world. Western medicine did not renew interest in this subject until the same year, when the editors of the American Journal of Obstetrics and Gynecology invited W. Oppenheimer to write a review of his 28 years experience with IUDs. Oppenheimer and Ishihama claimed the method to be both safe and effective. Furthermore, using an IUD was inexpensive and required little motivation. The single act of having an IUD inserted provided years of protection. A new concept of sociological significance was introduced. By having an IUD inserted, the responsible act of parenthood became an act of deliberation. To become pregnant a woman had to make a decision to have the IUD removed and then see a physician to have this done. The reports by Ishihama and Oppenheimer aroused the curiosity of many gynaecologists. In the twentieth century, as in the nineteenth century, inventors strove to meet the major IUD requirements: (1) design, (2) size, (3) material and (4) the inserter. My thoughts were then focused on clinical evaluation and the innovation of new designs for intrauterine contraceptive devices. In my private practice I began inserting handmade Oppenheimer rings. Ota rings imported from Japan were tried. It was found that the small lentil-shaped polyethylene (PE) disc in the centre of the Ota ring necessitated considerable dilatation of the cervix, which was painful for the patient and difficult for the operator. Excising the lentil-shaped disc from the centre of the ring made insertion easier, but expulsions occurred more frequently. Removal of the ring was accomplished with Grafenberg’s instrument, which resembled a crochet hook. Success depended upon the operator’s sense of touch. I soon learned that inserting IUDs was easier than removing them. Frequently, it was difficult to feel the device, much less remove it. Thus, the second modification was to tie a linear PE thread to the Ota ring, so that the device could be easily withdrawn when desired. (see Fig.1.) Creating a cervical appendage was contrary to Grafenberg’s tenet against connecting the uterine cavity with the vagina because that might increase infection. Grafenberg was correct, for in 1930, only a multifilamented thread was available, and from the Dalkon shield experience we know that a multifilament thread conveys bacteria from the vagina to the uterine cavity by capillary action. Fortunately, the single strand of PE does not do this. Patients became fond of the PE thread because it provided them with palpable reassurance that protection continued. With experience, more design changes evolved. It was noticed that round devices rotated, winding the thread into the cervix or uterine cavity in a manner similar to rolling up a window shade, and thereby eliminating the easy means of removal. In the summer of 1960, a colleague questioned whether it was wise to do this type of clinical research in a private office. It was an intelligent question. A planned parenthood clinic was the right place to evaluate a new contraceptive. When approached, both the Medical Committee and the Governing Board of the Buffalo Planned Parenthood Clinic considered IUDs outside the realm of standard medical practice and were reluctant to grant permission for “such radical research;” after all, it was a time when gynaecological textbooks proclaimed that IUDs should be mentioned only in condemnation. I wrote a letter to Alan Guttmacher, then president of the Planned Parenthood Federation of America, asking for his advice and help. The letter was referred to Christopher Tietze, who encouraged me to continue IUD evaluation and offered his help. He came to Buffalo and persuaded the Buffalo Planned Parenthood Clinic to grant permission to investigate intrauterine contraception. Tietze provided credibility and encouragement for continuing these studies. The letter was also referred to Hans Lehfeldt, who had worked with Grafenberg in Berlin and who, in 1960, was chairman of the research subcommittee of the National Medical Advisory Committee for the Planned Parenthood Federation of America. Lehfeldt wrote to me explaining that the use of an IUD in the United States could be considered malpractice. This reply reflected the attitude of the medical profession of that day. Shortly thereafter, I visited Hans Lehfeldt and, while driving around New York City, he told me that IUDs were much better than most physicians believed and that my investigations with new designs should be vigorously pursued. “Forget about the letter I wrote on behalf of the Planned Parenthood Medical Advisory Committee.” Later that afternoon, he took me to the office of Herbert Hall who had been an associate of Grafenberg in his Manhattan office. He dismissed his secretary for the day and the three of us retreated to his consultation room. When Herbert Hall carefully closed the door behind him, I felt as though I was entering some kind of subversive conspiracy. Furtively, Hall described how he and Grafenberg had inserted a stainless-steel modification of the Grafenberg ring into a number of celebrities from New York and Hollywood. Patients were sworn to secrecy and Hall was on call 24 hours a day. He was reluctant to publish his excellent results for fear that his colleagues might disgrace him for what they considered a repudiated medical practice. A few months later he did publish his long experience with the stainless ring, which was then named the “Hall-Stone ring.” I returned to Buffalo, refreshed, encouraged and with a newly found enthusiasm for the task before me. My attention was focused on how to prevent rotation of the IUD with disappearance of the useful removal thread. A departure from the geometry of the ring was essential. Perhaps, if the IUD closely fitted the contours of the uterine cavity, rotation might be prevented or at least minimized. Concurrently, other changes had to be incorporated in the design to reduce the incidence of expulsions. If one assumes that the uterus expels an IUD in a manner similar to the way one expels a noodle or spaghetti from the mouth, then the IUD must similarly be deflected or straightened before the uterus expels it. However, this is not always the case. The uterus can and does expel an IUD en masse. Nevertheless, to inhibit expulsions, it seemed logical to maximize the work the uterus must do to expel an IUD. Because it requires more energy to straighten a “U” turn than anything smaller, a design that placed as many “U” turns as possible on the PE noodle (the IUD) could improve uterine retention. Obviously, the gist of this concept was further defined by uterine anatomy. The double “S” was designed to reduce expulsions and, simultaneously, to accommodate the IUD to the triangular, or some might say trapezoidal, shape of the uterine cavity. (See Fig. 2.) Measurements of the uterine cavity dictated the dimensions of the loop. Since the internal os of the cervix is 4 mm, the outside diameter (o.d.) of the inserter is also 4 mm. The inside diameter (i.d.) of the inserter barrel is 3.4 mm. For the loop to fit into the barrel of the inserter, its cross-sectional diameter had to be even smaller. In cross-section, loop D is 2.7 by 2.0 mm, while loop A is 2.4 by 2.0 mm. (See Fig. 3.) According to Dickinson, the inside diameter of the uterine fundus varies between 25 and 35 mm while the inside diameter of the lower uterine segment is approximately 6 mm. A double S or loop shape had to be confined with this trapezoid. (See Fig. 4.) The Population Council had awarded a grant to make steel moulds for the loop. Funds were sufficient to cut one or possibly two moulds. It seemed important to select the right size from the start. A loop which was 22.2 mm across the top bar appeared safer. The smaller device would fit within a uterine cavity with a fundus which measured either 25 or 35 mm. This 22.2 mm loop was at first called “loop I,” and later was labelled “loop A.” By 6 months it was observed that loop A had a cumulative expulsion rate of 14.6 per 100 women-years (hwy) and a pregnancy rate of 4.8/hwy. These rates were unacceptably high. Would a larger loop reduce the expulsion and pregnancy rates? Using the remaining funds in the Population Council grant, a second and larger loop was made. It had the largest diameters which I thought could reasonably fit the uterine cavity, and was called “loop II” but later was labelled “loop D.” Loop D was 30 mm across the top bar and narrowed to 16.7 mm at the bottom. As already mentioned, the cross-sectional diameter was, and remains, 2.0 by 2.7 mm. With loop D, expulsion rates were reduced to 5.6/hwy at 6 months and were only 7.7/hwy at 12 months. Pregnancy rates dropped from 4.8/hwy for loop A to 1.0/hwy for loop D. These initial observations were for the first 6-12 months only. In successive years these rates improved. To provide the physician flexibility in selecting the right size for the individual patient, two intermediate sizes were subsequently made, i.e. loop B and loop C. The results were intermediate as well. Figure 5 depicts the four sizes of loops. The advent of thermoplastics permitted the development of new IUDs. With linear geometric configuration, devices constructed of the right plastic could be straightened to fit into a hollow tube, ejected from the tube and resume the shape in which it was moulded. This characteristic of memory for low-density PE was excellent. Other materials were tried and discarded, e.g. polypropylene, but was found to be too stiff. PE had many advantages and a favourable history. The United States Food and Drug Administration considered PE non-toxic when they approved it for packaging food. Chest surgeons had moulded it into many shapes and placed the devices in the thorax to collapse tuberculous lungs. Ishihama had reported on 973 personal cases and 18,594 from 149 Japanese hospitals using the Ota ring, many of which were partially made of PE. Although one or two cases of uterine carcinoma had been reported, none could be attributed to PE devices, and observation which remains true to this day. The best material proved to be low-density PE. It could easily be altered by winding or twisting a strand: after heating and cooling the strand retained a new shape. To convey the idea of the loop from paper to plastic, thin sheets of PE were cut into strips with a paper cutter. Such strips were wound on a wooden jig to form a double S or loop. The plastic was tied to the jig with string. These forms were baked in an oven at 300 degrees F. When cooled to room temperature they hardened in the designed shape. After obtaining favourable data with handmade loops of the dimensions described above, steel moulds were cut for mass production. Money for this was provided by a grant from the Population Council. The inserter for the loop also had special requirements. At first round tubing was used; however, with round tubing the plane of egress of the loop could not be controlled or predicted. When an elliptical barrel was utilized as an inserter for a loop with an elliptic cross-section, control of the exit plane was obtained. (See Fig. 3.) An indicator or flange was placed 4.4 mm from the tip of the inserter barrel. This indicated the horizontal or frontal plane of the uterus. During insertion the indicator stops the tip of the inserter at the internal os of the cervix, making certain that the loop enters the inferior end of the internal os of the uterine cavity and rises to the fundus when the operator pushes on the plunger. This minimized the risk of perforating the uterus. Notwithstanding the significance of the loop, other IUDs have appeared which introduced the concept that the IUD could act as carrier to deliver a pharmacological agent into the uterine cavity to produce a local effect, improving contraceptive effectiveness. The realization that the obstacles in creating the loop could be overcome is homage to all the researchers who have contributed to the field of contraception. In these endeavours, I acknowledge with gratitude the help of Mr. Paul Bronnenkant, a good friend, a World War II test pilot, an engineer, president of Hallmark Plastics and founder of Finishing Enterprises Inc. (FEI). His gracious wife, Helen, sacrificed a cookie pan, which was ruined when the first loops were made. Both Helen and Paul are gone but are fondly remembered. Their sons, Lance and Bruce, now preside over FEI where IUDs and other medical devices continue to be manufactured. Lippes loop and the first IUDs: lessons from a bygone eraAmerican Journal of Obstetrics & GynecologyVol. 219Issue 2PreviewAt morning report, a resident presented the case of a 39-year-old para 2 who has used her levonorgestrel-containing intrauterine device (IUD) for 8 years, with no unintended pregnancies. She was being scheduled to go to the operating room for removal and replacement of her device (IUD strings could not be visualized for removal, and she does not tolerate pelvic examinations). I questioned whether the IUD really needed to be replaced…it was at that point that I felt old. Full-Text PDF

Objectives: Determine the long-term risk of hysterectomy and ectopic pregnancy in women using the quinacrine hydrochloride pellet system of permanent contraception (QS) relative to the comparable risk in women using Copper T intrauterine device (IUD) or tubal ligation surgery (TL) for long-term or permanent contraception. Methods: This was a retrospective cohort study, conducted in the Northern Vietnamese provinces of Ha Nam, Nam Dinh, Ninh Binh and Thai Binh. Women who had their first QS procedure, last IUD insertion or TL between 1989 and 1996 were interviewed regarding post-procedure health outcomes approximately 16 years post exposure. Results: A 95% response rate resulted in 21,040 completed interviews. Overall incidence rates were low for both outcomes (91/100,000 women years of follow-up and 22/100,000 women years of follow-up for hysterectomy and ectopic pregnancy, respectively). After accounting for variations in baseline characteristics between women choosing QS vs. the other two contraceptive methods, no significant excess hazard of either hysterectomy or ectopic pregnancy was associated with QS. Conclusions: No significant excess long-term risk of hysterectomy or ectopic pregnancy was found among a large group of women using QS vs. IUD or TL for contraception after an average 16 years of follow-up.

A rat carcinogenicity bioassay (CaBio) of quinacrine was reanalyzed to investigate its mode of tumor induction. Quinacrine’s effects in the rat uterus when administered as a slurry in methylcellulose were contrasted with the human clinical experience which uses a solid form of the drug, to determine the relevance of the tumors produced in the rat to safe clinical use of quinacrine for permanent contraception (QS). A review was performed of the study report, dose feasibility studies, and clinical evaluations of women who had undergone the QS procedure. The top three doses of quinacrine in the CaBio exceeded the maximum tolerated dose, and produced chronic damage, including inflammation, resulting in reproductive tract tumors. Chronic inflammation was significantly correlated with the tumors; there was no evidence of treatment-related tumors in animals without chronic inflammation or other reproductive system toxicity. Because such permanent uterine damage and chronic toxicity have not been observed in humans under therapeutic conditions, we conclude that this mode of action for tumor production will not occur at clinically relevant doses in women who choose quinacrine for permanent contraception.

Dr. Jaime Zipper, the Chilean inventor of the quinacrine method of nonsurgical permanent contraception, was aware that when chest surgeons injected quinacrine into the pleural cavity to treat and prevent reoccurrence of pleural effusion, it resulted in the formation of fibrous adhesions between the lung and costal pleura. Zipper thought that a similar scarring effect could occur in the fallopian tubes if quinacrine was instilled into the uterine cavity. A series of refinements of the methodology culminated in the use of a modified Copper T intrauterine device inserter tube as a delivery system to introduce seven quinacrine pellets into the uterus. This approach with quinacrine sterilization (QS) was introduced into clinical practice in several countries, and a national clinical trial of over 50,000 women was conducted in Vietnam. However, in 1993, the World Health Organization raised concerns that quinacrine might be carcinogenic. This resulted in abandonment of QS in Vietnam and other countries. Subsequent epidemiologic data from extensive human studies do not support an increase in cancer risk. This paper reviews the history, limitations and clinical potential of QS.

Quinacrine has been widely used in treatment of parasitic diseases such as malaria and giardiasis, and in the treatment of autoimmune diseases. Quinacrine has also been used as an effective substitute for surgical contraception by causing occlusion of the fallopian tube. This minimally invasive treatment protocol involves intrauterine insertion of the drug in the form of pellets and has been studied in humans in a number of countries, including the United States. Despite its development in the 1970s, the cellular and molecular events induced by quinacrine in the human fallopian tube have not been described. Here we describe a plausible mechanism for quinacrine action in the fallopian tube. This is manifested as an acute pro-inflammatory response in the uterus and fallopian tube, characterized by loss of epithelial cell adhesion. This response relies on properties of gated channels found on the surface of epithelial cells in the reproductive tract. While the uterus returns to normal, the inflammatory response affects the uterotubal junction and transmural segment of the human fallopian tube, and initiates formation of mature collagen in the lumen of the fallopian tube, resulting in its permanent occlusion. The response within the fallopian tube appears similar to the protective mechanisms that have evolved in women to minimize the likelihood of systemic infection from Neisseria gonorrhoeae, and to some extent from Chlamydia trachomatis. This review could assist in development of experimental models used in investigating the mechanisms of fibrotic responses in humans as well as development of techniques for permanent non-surgical female contraception.

This companion article offers an alternative interpretation for the quinacrine-induced uterine tumors observed in a 2-year bioassay in rats (CaBio, Cancel et al., 2010), and provides additional data from two new experiments that support a different interpretation and analysis. Our major premise is that the design of the Cancel et al. bioassay was flawed, particularly regarding dose selection that allowed for misinterpretation of carcinogenic activity. We feel the totality of the information provided herein dictates that the doses (70/70, 70/250 and 70/350 mg/kg quinacrine) causing uterine tumors in their study clearly exceeded the maximum tolerated dose (MTD) typically administered in chronic cancer studies. Our new data support this conclusion and serve to explain the development of lesions, especially the uterine tumors, they have reported. We argue that the rat uterus is not a valid surrogate for the human fallopian tube. Further, we maintain that quinacrine is not genotoxic in vivo, as suggested in their paper. In summary, we believe that quinacrine is not carcinogenic in rats at doses that do not exceed the MTD.

Objective: To evaluate the safety of nonsurgical quinacrine sterilization for HIV-positive (HIV+) women.Design: An open trial of quinacrine sterilization was carried out in women infected with HIV and women who were HIV negative (HIV-). Comparison of the results with the two groups provided an assessment of the safety and effectiveness of quinacrine sterilization for HIV+ women.Setting: University Medical School outpatient services.Patient(s): A total of 258 women who desired sterilization were offered quinacrine sterilization as a means of limiting family size. Sixty-four were HIV+, and 194 were HIV- Women who were HIV+ had CD4 counts >200 and were otherwise healthy.Intervention(s): A modified Copper T intrauterine device inserter was used to place 252 mg of quinacrine, divided into seven pellets (36 mg each) into the uterine cavity. Three insertions of this formulation were performed, I month apart. Viral load and CD8 and CD4 lymphocytes were measured both before and after quinacrine sterilization and at follow-up visits. Pregnancies and adverse events were recorded carefully. A decrement life table was made to statistically analyze results.Result(s) and Main Outcome Measure(S): No serious adverse event occurred in any patient in this study. Adverse effects related to quinacrine sterilization were abdominal cramping, vulvar itching, nausea, and vaginal bleeding. Vaginal bleeding was the only short-term side effect noted to occur more frequently in HIV-infected women after quinacrine sterilization. Among HIV+ women, 35.9% had complaints of increased bleeding, whereas only 8.2% of those who were HIV- had such complaints, which probably were insertion related. Viral load and the CD4+ and CD8+ lymphocyte measures displayed no statistically significant difference after quinacrine sterilization.Conclusion(s): Quinacrine sterilization is a safe method for the sterilization of HIV-infected women and has no short-term effect on the pathology of the disease. (Fertil Steril (R) 2009;92:108-15. (C)2009 by American Society for Reproductive Medicine.)

AimUsing sonography, the bicornate and septate uterus as causes of failure of quinacrine sterilization (QS) are explored. Whether QS can be effectively performed on women with a bicornate or septate uterus is a question answered by a presentation of three such cases.MethodsThree cases presented were part of a prospective nonrandomized study of QS in 205 women requesting sterilization at the Family Planning Clinic, School of Medicine of the Federal University of Minas Gerais, Belo Horizonte, Brazil. Sonography was performed on all patients before, during and after QS. Quinacrine was packaged as seven pellets in a modified Copper-T IUD inserter (Sipharm, Sisseln, Switzerland). Each woman received the first transcervical insertion of 252 mg of quinacrine during the follicular phase of the menstrual cycle, usually immediately after menses. One month later, a second insertion was similarly performed. Patients were advised to use an alternate method of birth control for 12 weeks to allow time for scarring of the oviducts. A blood pregnancy test was done before the QS procedure.ResultsThe diagnosis of a septate or bicornuate uterus was made by sonography in three of the 205 patients in the study. It was obvious that quinacrine had to be inserted into the two horns of such an anomalous uterus if the dissolved drug was to enter both fallopian tubes. Quinacrine dissolved into “lakes of quinacrine,” and sonographically could be seen at the top of the uterine fundus. For this clinical trial of 205 patients, there were 546 woman-years of follow-up, and the Pearl index was 0.73 per 100 woman-years (95% confidence limits: 0.02, 1.4).ConclusionsThe bicornate or septate uterus can be a cause of failure of QS if undetected. Advantages of sonography prior to, during and after QS are apparent in the three patients with septate uteri. Sonography is advantageous when performing QS by demonstrating an anomaly of the uterus, which required separate insertions of quinacrine into each horn of a septate uterus and helping to direct quinacrine into each horn of these anomalous uteri.

OBJECTIVE:To review the significance of a United States Food and Drug Administration (FDA) approved Phase I clinical trial of a new use for an old drug, quinacrine. To discover whether ultrasound may have utility in quinacrine sterilization (QS).METHOD:This clinical trial began on 16 September 2000 at the Women's and Children's Hospital of Buffalo (WCHOB) in Buffalo, New York. Ten patients volunteered to have QS. These subjects were carefully followed with regularly scheduled examinations, including extensive laboratory blood tests. In addition, each patient had a trans-abdominal ultrasound examination six weeks or later past the date of the second insertion of quinacrine. The trial was completed on 30 April 2003.RESULTS:Laboratory results fell within normal limits, thus providing additional evidence to affirm the lack of toxic effects of QS. With ultrasound, we were able to see scars in both oviducts on all of our patients. One patient with a small scar as seen on ultrasound became pregnant.CONCLUSION:QS was found to be safe and effective. Ultrasound holds the promise of reducing the failure rate.

Quinacrine sterilization has been studied for over 20 years, ever since Dr. Jaime Zipper realized that it had the potential for sclerosing the mucosa of the human oviductal lumen (1Zipper J. Cole L.P. Goldsmith A. Wheeler R. Rivera M. Quinacrine hydrochloride pellets preliminary data on a nonsurgical method of female sterilization.Int J Gynaecol Obstet. 1980; 18: 275-279PubMed Google Scholar). He took the technique from chest surgeons, who had safely and effectively used quinacrine to produce pleural adhesions to prevent the recurrence of pleural effusions. For his epochal contribution to the field of family planning, Dr. Zipper was honored by the American Fertility Society in 1970, when he delivered the Samuel L. Siegler Lecture, “Human Fertility Control by Transvaginal Application of Quinacrine on the Fallopian Tube” (2Zipper J.A. Stachetti E. Medel M. Human fertility control by transvaginal application of quinacrine on the fallopian tube.Fertil Steril. 1970; 21: 581-589Crossref PubMed Scopus (64) Google Scholar). The method he developed consists of using a modified inserter for a copper T intrauterine device (IUD) to insert 252 mg of quinacrine pellets into the uterine cavity on two occasions, spaced 1 month apart. Medical professionals who are qualified to insert an IUD can easily deliver quinacrine into the uterus. In 1993, strong evidence for the safety of quinacrine-induced tubal sclerosis was provided when Dr. Do Trong Hieu reported on over 31,000 Vietnamese women who had undergone quinacrine sterilization (3Hieu D.T. Tan T.T. Tan D.N. Nguyet P.T. Than P. Vinh D.Q. 31,781 cases of non-surgical female sterilisation with quinacrine pellets in Vietnam.Lancet. 1993; 342: 213-217Abstract PubMed Scopus (106) Google Scholar). There were no deaths, and serious adverse events were estimated at 1/50th that of laparoscopic sterilization. Unfortunately, his clinical trial was cut short when the World Health Organization, Special Programme, Research Development and Research Training in Human Reproduction complained that toxicology data “was not adequate to justify large scale field studies” (Francis T.C. Webb, M.D., letter to Ms. Demers, 9 December 1993). In response to the study’s termination, editors of the Lancet challenged WHO to explain its negative position on quinacrine sterilization, calling WHO’s action “reprehensible” (4Death of a study: WHO, what, and why.Lancet. 1994; 343: 987-988Abstract PubMed Scopus (17) Google Scholar). WHO countered that “further clinical research is not justified until various toxicological issues have been resolved on intrauterine Quinacrine” (5Benagiano G. Quinacrine family-planning method.Lancet. 1994; 343 ([letter]): 1425Abstract PubMed Scopus (6) Google Scholar). In 1942, the Winthrop Corporation published a 40-page bibliography that listed 171 reference on the toxicology of quinacrine, also including some data from clinical trials (6Winthrop Chemical Company, IncLibrary. Annotated bibliography: chemistry and pharmacology of atabrine dihydrochloride (quinacrine hydrochloride). [Winthrop Chemical Company], New York1942Google Scholar). This document cannot be found in Index Medicus. Before there was an Internet or an Index Medicus, the United States Army kept its own medical index, where, after much searching, one could find the Winthrop list. Perhaps the difficulty in finding this document explains why WHO and some feminist groups have maintained that toxicology studies have not been done and thus clinical trials of quinacrine sterilization should not start. The fundamental purpose for doing a toxicologic study is to predict what a particular drug will do when it is taken by humans. However, when you are in possession of both preclinical toxicologic animal studies and human studies, human data are more valuable and hold priority. The Winthrop list contained studies on animals—including rabbits, guinea pigs, dogs, cats, monkeys, canaries, sparrows, turkeys, and chickens—as well as on humans. These toxicology studies predicted the safety of quinacrine. Indeed, quinacrine has been in use for over 70 years. It has been prescribed to cure and prevent malaria for more than 100 million people, including the 3 million American soldiers who took it daily while serving in the South Pacific during World War II. After treating these veterans for over 50 years, no Veterans Administration Hospital has reported any long-term serious side effects or any increase in cancer among the personnel who served in the South Pacific and took quinacrine daily as compared with those who served in Europe and did not take quinacrine. Currently, quinacrine is used to treat rheumatoid arthritis, lupus, tapeworm, amebiasis, and Giardia infection. Until 1985, one could pick up a textbook of pediatric infectious disease and find that quinacrine was preferred over metronidazole (Flagyl), as the more effective, less costly treatment for Giardia infection in children (7Mandel G.L. Bennet J.E. Dolin R. Principles and practice of infectious diseases. Vol. 2. Churchill Livingstone, New York, Edinburg1985: 2891Google Scholar). For unknown reasons, the American manufacturer withdrew quinacrine from the market; today metronidazole is used in spite of its higher price and carcinogenic potential. Both animal and human observations overwhelmingly affirm the safety of quinacrine. Little doubt remains about systemic toxicity and quinacrine. What question is left? When it is inserted into the uterine cavity on two occasions, can quinacrine produce a new toxicologic problem, perhaps a cancer of the uterus? This issue has three unambiguous answers. 1.Many of the 100 million people who took quinacrine daily for many years were women living in areas where malaria was (and perhaps still is) endemic. With chronic exposure to quinacrine, the drug is absorbed and carried in the bloodstream to the uterus every day it is ingested. It is known from animal studies that repeated doses of quinacrine greatly increase the tissue levels of quinacrine (8Shannon J.A. Barle Jr, D.P. Brodie B.B. Taggart J.V. Berbner R.W. The pharmacological basis for the rational use of atabrine in the treatment of malaria.J Pharmacol Exp Ther. 1944; 31: 307-330Google Scholar). Such levels apparently rise for up to 30 days. Considering that this intense exposure continued for many years, surely the uterine exposure to quinacrine was of an order of magnitude greater than that experienced by the patient who receives two insertions of quinacrine, a month apart. Did this constant, chronic, cumulative level of exposure to quinacrine produce an increase of cancers of the uterus? No such report exists.2.The uterus is known only to produce three cancers. Cancer of the cervix we now consider a sexually transmitted disease (STD) related to the papilloma virus. Cancer of the endometrium usually occurs after or around the time of menopause; in women of reproductive age it is found in conjunction with a functioning ovarian tumor where estrogen is produced unopposed by progesterone. Uterine sarcoma, a very rare malignancy representing 1% to 3% of uterine cancers, occurs at a mean age of 55 years and is associated with obesity, hypertension, and diabetes. None of the factors associated with uterine cancers can be related to quinacrine.3.Data are already available on women who have undergone quinacrine sterilization. For over 20 years, Dr. Zipper has followed more than 1500 women who had quinacrine sterilization. No excess risk of cervical cancer was found when these women were compared with a control group who were not exposed to quinacrine (9Dabancens A. Sokal D.C. Pruyas M. Rivera M. Zipper J. Prevalence and standardized incidence rates of preclinical cervical pathology among 1,061 women sterilized with transcervical quinacrine hydrochloride pellets.Fertil Steril. 1995; 64: 444-446PubMed Google Scholar). Nor was any increase in endometrial cancer found over those same 20 years (10Dabancens A. Pruyas M. Zipper J. Rivera M. Velasco V. Intrauterine quinacrine and risk of endometrial cancer.J Gynecol Obstet Biol Reprod. 1998; 6: 21-26Google Scholar). In general, quinacrine sterilization patients showed no excess risk of cancer compared with a control group who were not exposed to quinacrine (9Dabancens A. Sokal D.C. Pruyas M. Rivera M. Zipper J. Prevalence and standardized incidence rates of preclinical cervical pathology among 1,061 women sterilized with transcervical quinacrine hydrochloride pellets.Fertil Steril. 1995; 64: 444-446PubMed Google Scholar, 10Dabancens A. Pruyas M. Zipper J. Rivera M. Velasco V. Intrauterine quinacrine and risk of endometrial cancer.J Gynecol Obstet Biol Reprod. 1998; 6: 21-26Google Scholar, 11Sokal D.C. Dabancens A. Guzman-Serani R. Zipper J. Cancer risk among women sterilized with transcervical quinacrine in Chile an update through 1996.Fertil Steril. 2000; 74: 169-171Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar). Further evidence will require decades of postmarketing surveillance of many thousands of quinacrine sterilization acceptors, as was done for oral contraceptives. Because laparoscopic sterilization is the most popular method of limiting family size today, it is important and revealing to compare the safety of quinacrine sterilization with laparoscopic sterilization. With laparoscopic sterilization, serious complications from inadvertent trauma are associated with the use of the trocar, including perforations of bowel and bladder. Perforation of major blood vessels has led to hemorrhage and death. When cautery is used, the bowel and bladder have been accidentally burned. The dangers of a gas embolus from the pneumoperitoneum required for laparoscopy or the dangers of general anesthesia are well known. None of these complications are associated with quinacrine. In a survey of American laparoscopists, Phillips (12Phillips J.M. Membership surveys and complication reports. American Association of Gynecologic Laparoscopists, Santa Fe Springs, CA1988Google Scholar) found 3 deaths per 100,000 laparoscopic sterilizations. Chamberlain (13Chamberlain G. Brown J.C. Gynecological laparoscopy report on the confidential enquiry into gynecological laparoscopy. Royal College of Obstetricians and Gynecologists, London1978Google Scholar), surveying laparoscopists in England, reported 10 deaths per 100,000 laparoscopic sterilizations. Because medical malpractice lawsuits are far more common in the United States than in the United Kingdom, the 10 deaths per 100,000 report from England may be closer to reality. In a review of 100,000 documented cases of quinacrine sterilization, Kessel (14Kessel E. 100,000 quinacrine sterilizations.Adv Contracept. 1996; 12: 69-76Crossref PubMed Scopus (43) Google Scholar) reported no deaths and no events attributable to quinacrine that required surgery. One patient in the Vietnamese trial of 31,781 women (3Hieu D.T. Tan T.T. Tan D.N. Nguyet P.T. Than P. Vinh D.Q. 31,781 cases of non-surgical female sterilisation with quinacrine pellets in Vietnam.Lancet. 1993; 342: 213-217Abstract PubMed Scopus (106) Google Scholar) underwent a hysterectomy for heavy bleeding diagnosed as “hemorrhagic endometritis” 1 year after a third insertion of quinacrine (DT Hieu, personal communication, September 2001). Two other patients needed to have the cervical canal sounded to relieve hematometra. There also were rare reports of allergic reactions to quinacrine. What a remarkable safety record! Women with some medical conditions may find that surgery and/or general anesthesia is dangerous and even contraindicated. Heart disease, chronic obstructive pulmonary disease, obesity, smoking, and diabetes come to mind. Quinacrine sterilization offers sick patients a safe option and offers all women another choice. With the evidence enumerated above, it was not surprising that the U.S. Food and Drug Administration granted approval for a Phase 1 clinical trial to be carried out at the Children’s Hospital of Buffalo in Buffalo, New York. Furthermore, the investigation review board of the Children’s Hospital of Buffalo unanimously approved of this clinical trial twice, once in 2000 and again in 2001. What we do not know is what the effectiveness would be in an American environment. Gynecologists must keep in mind that transcervical chemical sterilization is still in its infancy. Improvements will come once physicians begin to use this technology. The situation is the same as when laparoscopic sterilization was introduced. As the years went by, clinical researchers found various ways to interrupt the fallopian tubes with rings and clips. They discerned differences in effectiveness between unipolar and bipolar cauterization and improvements in reducing pregnancy rates when more points of the oviduct were cauterized (15Peterson H.B. Xia Z. Wilcox L.S. Tylor L.R. Trussell J. Pregnancy after tubal sterilization with bipolar electrocoagulation. U.S. Collaborative Review of Sterilization Working Group.Obstet Gynecol. 1999; 94: 163-167Crossref PubMed Scopus (44) Google Scholar). Likewise, we can expect clinicians to discover new ways to reduce failures and improve the quality of quinacrine sterilization. One example already comes to mind. Dr. Hieu recognized that the placement of quinacrine at the very top of the uterine fundus was essential in keeping the pregnancy rate low; variations in practice accounted for some of the differences between the lower and higher pregnancy rates in various provinces in Vietnam (3Hieu D.T. Tan T.T. Tan D.N. Nguyet P.T. Than P. Vinh D.Q. 31,781 cases of non-surgical female sterilisation with quinacrine pellets in Vietnam.Lancet. 1993; 342: 213-217Abstract PubMed Scopus (106) Google Scholar). More recent evidence by Bairagi et al. (16Bairagi N.R. Mullick B.C. Kessel E. Mumford S.D. Comparison of the efficacy of intrauterine diclofenac and ibuprofen pellets as adjuvants to quinacrine nonsurgical female sterilization.Adv Contracept. 1995; 11: 303-308Crossref PubMed Scopus (16) Google Scholar), Sarin (17Sarin A.R. Quinacrine sterilization experience among women at high risk for surgery.Adv Contracept. 1999; 15: 175-178Crossref PubMed Scopus (14) Google Scholar), and Soroodi-Maghaddam (18Soroodi-Maghaddam S. Preliminary report on a clinical trial of quinacrine pellet method for nonsurgical female sterilization in Iran.Int Fam Plann Perspect. 1996; 22: 122-123Crossref Scopus (4) Google Scholar) using the Hieu insertion technique has reported pregnancy rates of 0 to 1.7% at the 2-year mark. At this time there is a trade-off between safety and effectiveness. However, the choice should at all times be left to the well-informed woman. Although the failure rate with quinacrine sterilization at this early stage of development is still higher than with surgical sterilization, many women may choose it because it is a safer method. Some physicians compare quinacrine sterilization to the copper T IUD (ParaGard T 380A, Ortho-McNeil, Raritan, NJ). From the combined data collected by the Population Council and WHO, we recognize that the continuation rate of the T 380A is only 23% at 3 years and only 5% at 10 years (19ParaGard T. 380A intrauterine copper contraceptive.in: Physician’s Desk Reference. Medical Economics Company, Montvale, NJ2001: 2385Google Scholar). Sterilization is the only method of limiting family size where the continuation rate approaches 100%. The difference in cost for quinacrine is enormous, and it behooves physicians, health insurance companies, HMOs, and the government to take interest. When quinacrine was manufactured by SIPHARM, the cost in Asia for the inserter and quinacrine pellets was less than US$1.00 per sterilization. In the United States, because we are not allowed to import this product, each quinacrine pellet must be individually prepared by a compound pharmacists. The cost in the United States for 14 pellets (i.e., two packs of seven pellets each with two inserters) is $140.00; add the U.S. physician’s charges, and the total might be $500. Compare that to the expense of surgical sterilization (laparoscopic), which may run anywhere from $3000.00 to $5000.00, not counting treatment of complications from general anesthesia and surgery. With approximately 600,000 annual sterilizations in this country, the savings with quinacrine sterilization could reach $2 billion per year. Most critical of all is informed consent. No physician would dream of carrying out any procedure without the patient being completely informed, the patient must sign a detailed, but easily understandable, written and/or oral informed consent. Sterilization is not a procedure to be taken lightly. All precautions against coercion must be taken seriously and all healthcare providers must follow the respected conventions accepted worldwide, namely the Belmont Report, and the International Harmonic and Helsinki conventions. A patient considering quinacrine sterilization would be given an honest explanation of the advantages and the disadvantages of this method. Rigorously detailed information would be provided and all alternative methods would be explained so that the patient’s free choice is truly an informed choice. The patient would take the written informed consent home and read it at her leisure, discuss it with her relatives, friends, and advisers as she wishes. After a reasonable amount of time, say 2 weeks to 1 month (or more if she chooses), she can make a free choice without coercion or incentives. Benagiano has denied the “polarization of opinions” (20Benagiano G. Non-surgical female sterilization with quinacrine an update.Contraception. 2001; 63: 239-245Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar) over quinacrine sterilization. I agree that concentration on extremes does not contribute constructively to a scientific debate on quinacrine sterilization, and I encourage letting scientific facts and scientific reasoning be the final arbiters. Why can’t well-informed American women be given an option with quinacrine? Should the American Society for Reproductive Medicine take a position on this issue? Many American women desiring a permanent method of limiting family size have difficulty obtaining surgical sterilization because of cost, fear of surgery, or a current illness that increases the risks of an operation and general anesthesia. Quinacrine is the leading candidate for nonsurgical female sterilization. Additional trials are needed in U.S. settings.

N-Acylethanolamines (NAEs) are an important family of lipid-signaling molecules. Arachidonylethanolamide (anandamide) (AEA), palmitoylethanolamide (PEA), and oleoylethanolamide (OEA) are co-produced from similar phospholipid precursors when neurons are stimulated. AEA is an endogenous agonist (endocannabinoid) for cannabinoid receptors. It binds with higher affinity to type CB1 than to type CB2 cannabinoid receptors. PEA does not bind to CB1, while the hypothesis that it reacts with putative CB2-like receptors has been questioned. OEA does not activate currently known cannabinoid receptors, but it mimics the effects of AEA and cannabinoids in reducing the fertilizing capacity of sea urchin sperm. OEA and PEA also act as entourage compounds by inhibiting the hydrolysis of AEA by fatty acid amide hydrolase. Cannabinoid receptors and/or AEA are present in mammalian reproductive organs including the testis, epididymis, prostate, ovary, uterus, sperm, preimplantation embryo and placenta, as well as prostatic and mammary carcinomas. We now report that analysis by high-performance liquid chromatography/mass spectrometry (HPLC/MS) shows the presence of AEA, PEA, and OEA in human seminal plasma, mid-cycle oviductal fluid, follicular fluid, amniotic fluid, milk, and fluids from malignant ovarian cysts. Previous studies showed that AEA-signaling via cannabinoid receptors regulates capacitation and fertilizing potential of human sperm, early embryonic development and blastocyst implantation into the uterine mucosa of rodents, as well as proliferation of human mammary and prostatic carcinomas. Current results imply that NAEs also may modulate follicular maturation and ovulation, normal and pathological ovarian function, placental and fetal physiology, lactation, infant physiology, and behavior. Collectively, these findings suggest that NAEs in human reproductive fluids may help regulate multiple physiological and pathological processes in the reproductive system, and imply that exogenous cannabinoids delivered by marijuana smoke might impact these processes. This study has potential medical and public policy ramifications because of the incidence of marijuana abuse by adolescents and adults in our society, previously documented reproductive effects of marijuana, and the ongoing debate about medicinal use of marijuana and cannabinoids.

Ejaculated mammalian sperm require several hours exposure to secretions in female reproductive tracts, or incubation in appropriate culture medium in vitro, before acquiring the capacity to fertilize eggs. Arachidonylethanolamide (AEA), also known as anandamide, is a novel lipid-signal molecule that is an endogenous agonist (endocannabinoid) for cannabinoid receptors. We now report that AEA is present in human seminal plasma, mid-cycle oviductal fluid, and follicular fluid analyzed by high-performance liquid chromatography/mass spectrometry. Sperm are sequentially exposed to these reproductive fluids as they move from the vagina to the site of fertilization in the oviduct. Specific binding of the potent cannabinoid agonist [H-3]CP-55,940 to human sperm was saturable (K-D 9.71 +/- 1.04 nM), suggesting that they express cannabinoid receptors. R-methanandamide [AM-356], a potent and metabolically stable AEA analog, and (-)Delta(9) tetrahydrocannabinol (THC), the major psychoactive constituent of Cannabis, modulated capacitation and fertilizing potential of human sperm in vitro. AM-356 elicited biphasic effects on the incidence of hyperactivated sperm motility (HA) between 1 and 6 hr of incubation: at (2.5 nM) it inhibited HA, while at (0.25 nM) it stimulated HA. Both AM-356 and THC inhibited morphological alterations over acrosomal caps between 2 and 6 hr (IC50 5.9 +/- 0.6 pM and 3.5 +/- 1.5 nM, respectively). Sperm fertilizing capacity, measured in the Hemizona Assay, was reduced 50% by (1 nM) AM-356. These findings suggest that AEA-signaling may regulate sperm functions required for fertilization in human reproductive tracts, and imply that smoking of marijuana could impact these processes. This study has potential medical and public policy ramifications because of the incidence of marijuana abuse by adults in our society, previously documented reproductive effects of marijuana, and the ongoing debate about medicinal use of marijuana and cannabinoids.

“Research on contraception still in the doldrums” (C. Holden, Reproductive Biology Special Issue, News, 21 June, p. [2172][1]) is an excellent review of the birth control field, with one glaring exception. It omits “sterilization,” specifically trancervical chemical sterilization using

Objective: There is currently no known comprehensive regulatory system which might explain such diverse events as inhibition of capacitation in semen, and suppression of sperm motility within the oviductal isthmus, and timed capacitation of sperm in the female reproductive tract. Arachidonylethanolamide (AEA), also known as anandamide, is an endogenous ligand for cannabinoid (marijuana-like) receptors. We have previously shown that AEA can block acrosome reactions (AR) and enhance sperm motility in sea urchins. AEA is also produced in the rodent testis and uterus. Is AEA present in human reproductive tract fluids? Does AEA or its analogs alter sperm function in the human? Design: Frozen human reproductive tract fluids were analyzed for AEA and similar compounds. The effect of a potent synthetic AEA analog, AM-356, was tested in three in vitro sperm function assays, using fresh semen from research donors. THC, the active substance in marijuana, was studied for acrosomal effects. AEA alone was also evaluated for its influence on hyperactivated motion. Materials/Methods: Frozen samples of human seminal plasma, mid-cycle oviductal fluid and follicular fluid from IVF were analyzed for AEA-like compounds by HPLC/MS. The presence of a cannabinoid receptor on human sperm was studied via radioligand binding assays. In vitro capacitation and analysis by CASA was used to assess human sperm motility and hyperactivation (HA). The influence of AM-356 on sperm/egg binding was followed using the Hemizona Assay. The incidence of completed AR, as well as newly-described intermediate modifications over the acrosomal cap, were determined by triple stain methods. Results: AEA is present within the three human reproductive fluids: seminal plasma (13.7 nM ± 3), oviductal fluid (10.5 nM ± 2), and follicular fluid (3.7 nM ± 1). Two other endocannabinoids, palmitylethanolamide and oleylethanolamide are also present. Human sperm contain a putative cannabinoid receptor (KD 9.7 nM for the specific analog). AM-356 inhibits (P < 0.01) alterations over the acrosomal cap (IC50 = 6 picomolar), without affecting the low rate of completed AR. THC (150 nM) likewise suppresses acrosomal modifications. Treatment with 1 nM AM-356 inhibits sperm/zona binding by 50% (P < 0.001), in theory by slowing capacitation. AM-356 elicits biphasic effects on sperm HA motility: 2.5 nM will inhibit HA while a lower concentration (0.25 nM) produces HA stimulation (P < 0.05). Preliminary data reveal that AEA can stimulate HA motility by 26-71%. Conclusions: The presence of endocannabinoids in seminal plasma, oviductal and follicular fluids may imply sequential exposure of sperm to these agents while moving from the male tract and up through the female reproductive tract. A presumptive modulatory role for endocannabinoids during sperm transport, capacitation and fertilization in vivo is suggested by concentration-dependent inhibition and stimulation of HA motility as well as the ability to inhibit acrosomal modifications and sperm preparation for zona binding. Such data also support the conclusion that smoking marijuana could impact these reproductive functions in the male and female. Supported by: SUNY-Buffalo (LB); NIDA grants # DA-03801 & DA-09158 (AM) and DA-12447 & DA-12431 (DP).