Factors related to infertility in the United States, 1965-1976

Although the overall rate of infertility among American women of reproductive age remained fairly constant between 1965 and 1976, the percentage of young black women who were infertile increased very sharply. In 1976, 18% of black women of reproductive age were infertile, whereas only 9% of white women of the same age were infertile. With use of national data bases, the relationships between sexual activity, complications of pregnancy, sexually transmitted diseases, pelvic inflammatory disease, use of contraception, and infertility were examined. Available evidence shows a strong association between sexually transmitted diseases, pelvic inflammatory disease, and infertility trends. Our projections indicate that sexually transmitted diseases operating through pelvic infections account for much of the race differential in infertility as well as for one-half to one-third of the increase. In 1976 5-8% of 20-29-year-old black women were estimated to suffer infertility attributable to sexually transmitted diseases. Among white women the estimated incidence of infertility caused by sexually transmitted diseases was 0.7-1%.

Genital infections in women undergoing therapeutic abortion

We studied the prevalence of genital infections and the frequency of infectious complications in 170 women who requested an abortion in Antwerp, Belgium, where termination of pregnancy is still illegal. Chlamydia were isolated in 12% of these women, compared to a 0.6% isolation rate for N. gonorrhoeae. After the abortion 5.5% developed PID and 3% endometritis. There was a strong correlation between an infection with C. trachomatis before abortion and the appearance of infectious complications after the aspiration curettage. No such relationship was found with any other micro-organism. Depending on the prevalence of C. trachomatis in a given population, screening followed by selective treatment or prophylactic use of antimicrobial medication for all women is indicated to prevent post-abortum infections.

Factors predicting abnormal hysterosalpingographic findings in patients treated for acute pelvic inflammatory disease

One hundred forty-six consecutive inpatients with acute pelvic inflammatory disease (PID) were randomly treated either with the combination of doxycycline and metronidazole or with the combination of penicillin G/amoxicillin and metronidazole. Forty-three women underwent hysterosalpingography (HSG) 6 months after the treatment, and a multivariate statistical analysis was used to study the effect of 11 different variables (parity, history of previous abortion, history of previous PID, use of an intrauterine contraceptive device (IUD), use of oral contraceptives, presence of adnexal mass, results of cervical cultures for Neisseria gonorrhoeae, and Chlamydia trachomatis, presence of serum antichlamydial antibodies, penicillin-metronidazole treatment, and doxycyclin-metronidazole treatment) on the hysterosalpingographic findings. Abnormal HSG was most likely to occur in women who had antichlamydial antibodies present in the serum, an adnexal mass detected on the initial bimanual examination, or had an IUD (positive associations) and least likely to occur in women who had been treated with the combination of doxycycline and metronidazole (negative association).

Primary tubal infertility in relation to the use of an intrauterine device

Women who use an intrauterine device (IUD) are at increased risk of acute pelvic inflammatory disease, but the relation of the IUD to subsequent infertility is not established. We interviewed 159 nulligravid women with tubal infertility to determine their prior use of an IUD. Their responses were compared with those of a matched group who conceived their first child at the time the infertile women started trying to become pregnant. The risk of primary tubal infertility in women who had ever used an IUD was 2.6 times that in women who had never used one (95 per cent confidence interval, 1.3 to 5.2). The observed difference between cases and controls was not uniform for different types of IUD. The relative risk associated with use of a Dalkon Shield was 6.8 (1.8 to 25.2), and that associated with use of either a Lippes Loop or Saf-T Coil IUD was 3.2 (0.9 to 12.0). The smallest elevation in risk was found among users of copper-containing IUDs (relative risk, 1.9 [0.9 to 4.0] for all women who had ever used a copper-containing IUD). The relative risk for women who used only a copper-containing IUD was 1.3 (0.6 to 3.0). We conclude that use of the Dalkon Shield (and possibly of plastic IUDs other than those that contain copper) can lead to infertility in nulligravid women.

Role of sexual behavior in the development of pelvic inflammatory disease

The role of sexual behavior in the development of pelvic inflammatory disease (PID) is not well understood. In general the literature is limited and flawed in the methods used to assess sexual behavior. Good evidence suggests that PID in Western society is a sexually transmitted disease. For number of partners, frequency of intercourse, time of intercourse and sexual life-style the evidence suggests that those variables have a significant role in the development of PID. It is important to assess PID in the context of all its risk factors, including sexual behavior, race, prior history of PID and IUD use.

An evaluation of the TCu 380Ag and the Multiload Cu375

The TCu 380Ag (Outokumpu Oy, Pori, Finland) and the Multiload Cu375 (Multilan, Organon, Oss, The Netherlands) were evaluated in 1477 women in a multicenter clinical trial. The intrauterine devices showed similar, low-event rates. Cumulative life-table pregnancy rates were less than 1.0, and continuation rates were approximately 90 per 100 women at 1 year after insertion. The risk of subsequent hospitalization or pelvic infection was low.

Association of actinomyces and intrauterine contraceptive devices

We analyzed the clinicopathologic aspects of 19 cases of actinomycosis associated with intrauterine devices (IUDs) seen and treated at hospitals affiliated with the State University of New York at Buffalo between 1972 and 1982. Clinical manifestations included the following: (1) asymptomatic IUD-associated Actinomyces colonization, (2) endocervicitis, (3) endometritis, (4) endometritis with salpingitis and/or tuboovarian abscesses and (5) abdominopelvic abscesses. No consistent relationship was found between the total peripheral lymphocyte count and/or degree of histologic lymphocytic reaction and the clinical picture. Abnormal uterine bleeding and/or discharge, pain, fever and abdominopelvic masses were among the symptoms and signs encountered. Patients with endocervicitis and/or endometritis responded to removal of the IUD, dilatation and curettage and antibiotic therapy for two to four weeks. Those who developed abscesses were treated successfully with surgical drainage and added antibiotic treatment.

Laparoscopic sterilization in a free-standing clinic: a report of 1,092 cases

The five-year experience of 1,092 laparoscopic tubal sterilizations performed in a free-standing clinic in the U.S. with no anesthesiologist under local anesthesia is reviewed. The current technique of the Hasson "open" method and bipolar cauterization is felt to minimize major mishaps and is acceptably comfortable to the patient.

[Prevention of Chlamydia trachomatis infections in women]

Over the past several years, the incidence of chronic salpingitis has increased relentlessly, with its accompanying pelvic pain, ectopic pregnancies, and tubal sterility. Chlamydia are a frequent etiologic agent. Preventing these infections is difficult, nevertheless proper care will be given by recalling four key words: avoidance, diagnosis, education, and treatment. It is important to discourage early sexual activity and multiple sexual partners, to encourage the use of condoms, and avoid the use of an intrauterine device in adolescents. Atypical presentations of salpingitis must be recognized and treated effectively, thus preventing the spread of infection. Education on venereal diseases should be presented in secondary schools, during military service, and other similar groups, but especially during physician visits for contraception.

Diagnosis of pelvic actinomycosis by fine needle aspiration. A case report

A case of pelvic abscess caused by Actinomyces in a patient wearing an intrauterine contraceptive device is presented. The diagnosis was established preoperatively by transvaginal fine needle aspiration. The cytologic, surgical and histologic findings are discussed.

The role of severe adnexal disease in tubal reconstructive surgery

Fifty two consecutive women underwent microsurgical reconstruction of the tubes. Thirty one percent conceived and 19% delivered live infants. Medical history suggestive of pelvic infection was obtained in 44% of the women. Fifty four percent had extensive, coarse and fibrous adhesions. Tubal reconstruction in these patients did not yield any pregnancies. Severity of the adnexal disease should be evaluated before attempted tubal reconstructive surgery. Women with severe adnexal damage should be referred to in vitro fertilization.

Potential risks, benefits of progestins in birth control pills outlined

Progestins in oral contraceptives (OCs) produce potential complications, as well as noncontraceptive benefits, according to Robert A. Hatcher, MD, MPH, professor of gynecology and obstetrics, Emory University Medical School. Hatcher told CTU that lowering the progestin content in an OC may decrease complications, but could also decrease the benefits experienced by women. "The extent to which that will happen remains to be seen," he said. Hatcher cited the following potential complications of progestins in OC: hypertension; decreased levels of high density lipoproteins; acne; oily skin; headaches between pill cycles; dilated leg veins; pelvic congestion syndrome; thrombosis of superficial leg veins; gallstones; Monilia vaginitis; cholestatic jaundice; and depression, fatigue, and decreased libido. Progestins, according to Hatcher, also produce these noncontraceptive benefits: protection against PID; decreased dysmenorrhea; decreased menstrual blood loss, decreased iron deficiency anemia; protection against endometrial cancer; protection against fibrocystic breast disease, and fibroadenomas of the breast; decreased bleeding from fibroids; decreased growth of fibroids. When ovulation is suppressed, Hatcher emphasized, additional benefits that may occur include the following: decreased risk of functional ovarian cysts; elimination of mittleschmerz pain; decreased rick of ovarian cancer; protection against endometriosis.

Intrauterine devices and pelvic inflammatory disease

There is convincing clinical evidence that PID is more common in IUD users than in users of other contraceptive methods. There appears to be a smaller but significant increase when IUDs are compared with sexually active noncontraceptive users. However, the incidence of PID severe enough to warrant hospitalization is only of the order of 1 to 2 per 1,000 women per year. The question which remains is whether beyond this low figure of moderate and severe disease there is a much higher incidence of subclinical PID which may result in complications for IUD users. Development of a marker such as C-Reactive protein or the split complement component C3d to detect mild PID would prove invaluable in the elucidation of several crucial problems in the clinical management of women using IUDs.

A comparative evaluation of three IUDs

Private practice clinical experience with the insertion of 3 types of IUDs (Lippes loop, Dalkon shield, Cu 7) is evaluated. Life table analyses indicated similar pregnancy rates for the 3 IUDs. Lower expulsion rates were experienced with the Dalkon shield. Higher removal rates were experienced for pelvic inflammatory disease and pain and/or bleeding with the Cu 7. In part, the higher Cu 7 removal rates reflect a change to more liberal indications for IUD removal.

Evaluation, therapy, and outcome in 493 infertile couples

From 1973 through 1979, 493 infertile couples were evaluated for their infertility problem, allowing for a minimum follow-up of 1 year and a maximum follow-up of 7 years. Accurate records were kept on margin-punched cards for easy review and updating. Ovulation defects; male factor problems, and tubal disease accounted for 60% of the diagnosed causes of infertility. No diagnosis was made in 25% of the patients studied. Therapy began as soon as indicated and continued concurrently as the diagnostic evaluation progressed. Among the 493 infertile couples, 257 (52%) patients had a successful outcome; 90% of this group conceived by 1 year after the initial visit. One hundred thirty-seven patients underwent both hysterosalpingography and laparoscopy during their diagnostic evaluation. The interpretation of the hysterosalpingogram was wrong in about one third of the cases. Of 37 (7.5%) undiagnosed patients who underwent complete evaluation, including visualization of the pelvis by either laparoscopy or laparotomy, only 12 eventually conceived, 11 by the end of 1 year from the initial visit.

Patterns of adnexal inflammatory damage: Chlamydia, the intrauterine device, and history of pelvic inflammatory disease

In a study of 204 consecutive infertile couples, 58 women with adnexal abnormalities consistent with prior pelvic infection were identified. The status of those 58 subjects with respect to prior pelvic infection, prior intrauterine device use, and serologic evidence of past chlamydial infection was correlated with the types of adnexal abnormalities identified. Women with serologic evidence of past chlamydial infection were more likely to exhibit severe adhesions and hydrosalpinx formation, and hydrosalpinx formation was related to a history of clinically detected pelvic infection.

Comparison between OM-GA Cu and Copper-T IUCDs

OM-GA Cu and Copper-T IUCDs were compared in a randomized prospective clinical trial in two-hundred women and followed up for two years. Dysmenorrhea and dyspareunia were more frequent with the Copper-T. Menometrorrhagiae, vaginal discharge and pelvic inflammatory disease were similar with both IUCDs. Two-year pregnancy rate for the OM-GA Cu was 5.4% and 3.2% for the Copper-T. Expulsion rate was 11.9% for the OM-GA Cu and 5.3% for the Copper-T. The OM-GA Cu users had less dysmenorrhea and dyspareunia but a higher expulsion rate compared to the Copper-T.

Surgical treatment for salpingo-oophoritis patients

In the past, the established methods of surgical treatment for salpingo-oophoritis were extraperitoneal drainage of a pelvic abscess or total abdominal and bilateral salpingo-oophorectomy. Increasing awareness of the role of anaerobic bacteria and changes in antibiotic-prescription patterns have modified the clinical response of some patients. In patients with a unilateral tuboovarian abscess, unilateral removal of the adnexa suffices.