Extra-relational sex among Hispanic women and their condom-related behaviours and attitudes

Limited data are available concerning sexual behaviour of Hispanic women. A total of 318 Hispanic women were surveyed concerning extra-relational sex and their condom-related attitudes. Fifteen per cent of the sample had a secondary sex partner (apart from the first partner) during the three months preceding the survey. Of these women, 77 and 53% used condoms with their secondary and primary partners, respectively. Among women in monogamous relationships, condom use was low (17%), and nearly two-thirds (61%) of those with a high-risk partner did not use condoms. The most common concerns about condom use among these Hispanic women were a reduction in pleasurable sensations and embarrassment associated with buying condoms. Women with concurrent partners as compared to those with a single partner felt more at risk for HIV and STDs, were less likely to believe condoms have side effects or are unacceptable to their male partners and were more able to use condoms in long-term relations. In conclusion, extra-relational sex among Hispanic women may be higher than previously reported, although more favourable attitudes to condom use are seen among women with concurrent than those with a single partner. HIV/STD programmes in the Hispanic community should tailor to the sexual behaviour of their participants.

Previous cesarean section. A contraindication to vaginal hysterectomy?

OBJECTIVE

To compare surgical outcomes of vaginal hysterectomy between women who have had one or more cesarean deliveries and those who have not.

STUDY DESIGN

A retrospective, chart review study was performed on women undergoing vaginal hysterectomy during a four-year period. Of 275 women who met the study criteria, 104 had a history of previous cesarean deliveries, and 171 did not. The groups were compared for indications for surgery, operative time, length of hospitalization and surgical complications.

RESULTS

Previous cesarean delivery did not affect hemoglobin loss, hospital stay or operative time among women undergoing vaginal hysterectomy. The complication rate (either operative or postoperative) was 12.3% among women without a history of cesarean section, 6.8% among those with one, 3.7% among those with two and 11.1% among those with three or more (chi 2 = 2.8, P = .4). The odds for surgical complications were not significantly different between women with one or more prior cesarean deliveries as compared to those without after adjustment for possible confounders.

CONCLUSION

Surgical complications with vaginal hysterectomy do not appear to be higher among women with a prior cesarean section as compared to those without a history of such operation.

Condom use among sterilized and nonsterilized Hispanic women

BACKGROUND

Women who use sterilization for contraception are at risk for various sexually transmitted diseases, unless they use a barrier method. Use of condoms is significantly lower among sterilized women than among hormonal-contraceptive users. Among Hispanics, women's perception of risk and the influence of male partners are strong correlates of dual-method use. Limited data are available concerning use of condoms among sterilized women, in particular among Hispanics.

GOALS

Past and future use of condoms was examined and compared among 224 sterilized women and 104 hormonal-contraceptive users of Hispanic origin, and the reasons for use or nonuse of condoms were examined.

STUDY DESIGN

Cross-sectional survey.

RESULTS

As compared with hormonal-contraceptive users, sterilized women were significantly less likely to have used condoms in the 3 months before the study or to have plans to use them in the future (P < 0.001). Despite similarities between various HIV-related characteristics of sterilized and nonsterilized women, the former group had significantly lower perceptions of being at risk for both HIV and other sexually transmitted diseases. Sterilized women were also more likely to have used condoms for the purposes of dual protection from pregnancy. The strongest correlates of consistent condom use by both sterilized and nonsterilized Hispanic women were their perceived susceptibility to disease, male partners' positive opinion about condoms, and the women's ability to use condoms in long-term relationships. Furthermore, the practice of concealing the use of a contraceptive from a male partner was not uncommon, although this characteristic was not related to increased dual-method use.

CONCLUSIONS

Sterilized women may be at a higher risk of disease than hormonal-contraceptive users. Among Hispanics, women's perception of risk and male partners' influences predict whether the women protect themselves from pregnancy and disease simultaneously.

A qualitative study of perceptions, attitudes, and experiences of long-term levonorgestrel implant users

The present study examined the perceptions, attitudes, and experiences of long-term contraceptive implant users. Group interviews were conducted to obtain qualitative in-depth attitude and opinion data from 31 women who had used the implant for a minimum of four years. Results indicated that many women had experienced side effects with implant use, in particular during the first year. The primary motivations for continuing the use of implant were: women's strong desire for a long-term, reversible, and convenient method that offered effective protection from pregnancy, a strong need for control over one's life, and general dissatisfaction with alternative methods. Exposure to negative media reports, and peer commentaries did not influence implant's continued use. However, intensive educational counseling prior to insertion played a significant role in the long-term use of implant. Findings from this study indicate that women are willing to accept side effects as the price to be paid for an effective and convenient contraceptive method, and for gaining control over their lives. Furthermore, women appear to be less influenced by opposing social climate, in the absence of negative personal experiences. Our findings underscore the importance of educational counseling prior to implant insertion.

Planned condom use among women undergoing tubal sterilization

BACKGROUND AND OBJECTIVES

Women who are undergoing tubal sterilization are at risk for various sexually transmitted diseases (STDs) if they do not use a barrier method of contraception. There is a paucity of data concerning dual use of condoms among sterilized women.

GOAL

Planned use of condoms for protection against STDs was examined among 2,782 women undergoing surgical sterilization from 1991 to 1996.

STUDY DESIGN

Cross-sectional survey.

RESULTS

Planned condom use increased significantly over the 6-year study period. Of women who were using condoms before sterilization (n = 646), nearly half indicated no plans to do so after becoming sterilized. Thus, 11% of the total sample experienced an increased risk for exposure to human immunodeficiency virus or other STDs. Condom abandonment was significantly higher among Hispanic and married women. Multiple regression analysis was used to examine the association between condom use and various characteristics. Factors associated with future condom use were younger age, black ethnicity, being unmarried, previous STD, not having a steady partner, higher number of previous sexual partners, having used condoms for disease prevention in the past, and lack of partner involvement in the decision to undergo sterilization.

CONCLUSIONS

Use of condoms among sterilized women appears to be on the rise, women at higher risk for disease are more likely than others to be using condoms, and only a small group of women experience an increased risk for exposure to disease as a result of selecting this permanent method of contraception.

Factors associated with unintended pregnancy

This research was designed to identify determinants of unintended pregnancy among women attending family practice or family planning clinics. Survey data were collected from 95 women who were categorized according to whether or not they had experienced an unintended pregnancy. Women reporting unintended pregnancy were younger, reported earlier sexual debut and a greater number of sexual partners than those not having experienced an unintended pregnancy. Those who had avoided unintended pregnancy displayed higher levels of preventive sexual self-efficacy, had more confidence in their ability to use contraceptive methods, perceived more negative consequences associated with having children in the near future, and believed pregnancy among unmarried women to be less acceptable than did women who had had unintended pregnancies.

Differential expression of uterine progesterone receptor forms A and B during the menstrual cycle

Recent studies suggest that the progesterone receptor isoforms (PR-A and PR-B) activate genes differentially and that PR-A may act as a repressor of PR-B function. Hence, the absolute and relative expression of the two isoforms will determine the response to progesterone. We have measured their relative expression in the uterus of cycling women who underwent endometrial biopsy. PR isoforms were identified on blots of SDS-PAGE gels by reaction with the AB-52 antibody after immunoprecipitation from endometrial extract. Both isoforms were highest in the peri-ovulatory phase, but levels of PR-A were always higher than those of PR-B. The ratio of PR-A to PR-B changed during the menstrual cycle. Between days 2 and 8, PR-B is almost undetectable and the A:B ratio is >10:1. From days 9 to 13, the ratio is about 5:1, and it is about 2:1 between days 14 and 16. Thereafter, PR-B dwindles rapidly and is virtually undetectable at the end of the cycle. In various hypoestrogenic environments, PR-B expression was reduced. However, exogenous estrogens in the follicular phase in the form of oral contraceptives, enhanced PR-B expression. These data support the possibility that progesterone acts through cycle-specific PR isoforms.

Third-generation oral contraceptives and thromboembolism risk

Recently, observational studies have suggested an increased risk of nonfatal venous thromboembolic complications in women using oral contraceptives (OCs) containing the third-generation progestins, gestodene and desogestrel. Because of the observational, rather than randomized, nature of these trials, the clinical relevance of these findings is difficult to interpret. Each study included one or more potential sources of bias. In particular, cases came almost exclusively from hospitalized patients with nonfatal venous thromboembolism, which represents only a minority of patients diagnosed with this condition according to current clinical practice. In the absence of a sound biologic rationale to explain the increased risk with third-generation OCs, and considering the potential sources of bias within the current studies, an alternative view argues against causality. Oral contraceptives remain safe and effective. Clearly, additional research is needed to determine the relationship between thromboembolic disease and the use of third-generation OCs. In the interim, women should be informed thoroughly with objective data on all risks associated with the use of OCs.

Consistency of condom use among users of injectable contraceptives

Use of condoms for protection against sexually transmitted diseases (STDs) was examined over a nine-month period among 536 women from 17 clinics in southeastern Texas who had selected the injectable depot-medroxyprogesterone acetate (DMPA) as a contraceptive. Among women who were using condoms prior to receiving DMPA, nearly half said they never or rarely did so after initiating DMPA use; only 18% of all women in the study used condoms consistently while relying on DMPA. Factors associated with consistent condom use were being black (odds ratio of 2.0), being unmarried (odds ratio of 2.2), having a history of STD infection (odds ratio of 1.8), having previously used condoms (odds ratio of 2.7) and having no interest in future childbearing (odds ratio of 1.8). Our data suggest that the majority of users of injectables may not be protected from exposure to the human immunodeficiency virus and other STDs.

Insulin-like growth factor binding proteins in peritoneal fluid of women with minimal and mild endometriosis

This prospective cohort study was carried out in a university-based infertility clinic to determine the profile of insulin-like growth factor binding proteins (IGFBPs) in patients with mild endometriosis and no obvious mechanical factor contributing to infertility. A total of 26 patients with minimal and mild endometriosis and 10 controls contributed peritoneal fluid at surgery. The variety, expression and levels of IGFBPs were determined by radio-immunoassay and Western ligand blots (WLBs) with quantitation by laser densitometer. A 27 kDa species was significantly lower and 31 kDa species tended to be lower in patients with endometriosis as determined by quantitative laser densitometer. The levels of IGFBP-3 detected by radioimmunoassay and by WLB were correlated in the control group and in the patients with endometriosis in the follicular phase but not in patients with endometriosis in the luteal phase. The level of 27 kDa species seen on WLBs did not appear to correspond to IGFBP-1 determined by radioimmunoassay and IGFBP-3 levels in luteal phase endometriosis patients also departed from values determined by radioimmunoassay. These discrepancies suggest a complex system to control levels of IGF in the peritoneum involving multiple binding proteins and proteases. The IGFBPs of patients with endometriosis may contribute to reproductive dysfunction and be able to serve as markers.

Experiences of injectable contraceptive users in an urban setting

OBJECTIVE

To examine method-related experiences and acceptability of depot medroxyprogesterone acetate (DMPA) among women using this contraceptive for the first time.

METHODS

Five hundred thirty-six women who received an injection of DMPA from any of seventeen clinical settings in southeast Texas, United States, were followed for 1 year. At each follow-up visit, patients were asked about their experiences with DMPA during the past 3 months and their plans to use this method in the future.

RESULTS

Amenorrhea, irregular bleeding, and weight gain were the conditions reported most frequently. Reports of amenorrhea, weight gain, and acne or skin problems increased over time, but complaints of longer periods decreased (P < .001). Two pregnancies occurred during the study period. However, of these, one existed before the first injection. Depot medroxyprogesterone acetate's continuation rate at 1 year was 28.6%. Heavier and more frequent bleeding, increased cramping, amenorrhea, weight gain, headaches, depression, and nervousness were more frequent complaints of women who discontinued DMPA (P < .05), whereas lighter and less frequent bleeding were reported more often by those who continued to use this method (P <.05). Women who discontinued use of DMPA were more likely to be married and have a concern about injectable contraceptives than those who continued to use this method.

CONCLUSION

Intolerable side effects and changes in menstrual pattern are the most frequently indicated reasons for discontinuing DMPA use. Our results suggest that DMPA's 1-year continuation rate may be lower than previously reported.

Sperm transport and survival post-application of a new spermicide contraceptive. Advantage 24 Study Group

The present study was undertaken to evaluate the effectiveness of Advantage 24 to inhibit sperm transport and survival when applied at 24 hours, 12 hours, and 15-30 minutes prior to a single act of intercourse. Conceptrol, applied at 15-30 minutes before intercourse, was employed as the comparative spermicide. One-hundred-thirty-nine women, aged 22 to 45 years, were enrolled into the study and 111 completed the trial. The ability of the spermicides to immobilize sperm was assessed by postcoital testing (PCT) and by examining the proportion of sperm immobilization failure (SIF) rates. SIF was a postcoital test result with > or = 10 sperm with progressive motility (either sluggish or rapid) per x 400 power field. Conceptrol and Advantage 24 used at 15-30 minutes were similar with respect to their ability to inactivate sperm (0% and 2% SIF, respectively, p = 0.5). At longer intervals between spermicidal application and intercourse, less inhibition of sperm motility was noted (9% and 14% SIF for 12 and 24 hours, respectively). The present study indicates that Advantage 24 is an effective agent to immobilize sperm. The action of Advantage 24 may decrease if it is applied earlier than 15-30 minutes before intercourse.

Comparison of spermicides on vulvar, vaginal, and cervical mucosa

The objective of this study was to compare the tolerability of Advantage 24 to two other spermicides containing non-oxynol-9 (N-9). These spermicides were Today Sponge (Sponge) and Conceptrol. In order to examine the incidence of complaints and the clinical observation of vaginal ulceration and irritation of the three spermicides, a randomized, open label, three period cross-over trial was conducted. Thirty-three women, ages 18-45, with a normal vaginal environment based on physical exam, Pap smear, vaginal wet prep, colposcopy, and serum N-9 were randomized into four treatment groups. Each treatment was for seven consecutive days with a 21-day washout. Data obtained were studied by one-way analysis of variance, chi-square, and Kruskal-Wallis test. No vulvar or vaginal abnormality was observed from either spermicide. Subjects had fewer and less severe cervical lesions by colposcopy during treatment with Advantage 24 than with Conceptrol or Sponge (p < 0.01). Comparison of the incidence of abnormal gynecological findings, serum N-9 levels, and the incidence of adverse events before and after treatment with the three study drugs indicate that most subjects had normal examinations pre- and post-treatment. Pap smear and colposcopy changes from normal to abnormal accounted for about 50% of all gynecological findings during the Conceptrol and Sponge treatments, but less than 20% during treatment with Advantage 24. All serum N-9 levels were below the level of detection (< 1.9 microgram/ml). Advantage 24 is better tolerated than Conceptrol or the Sponge. Furthermore, the cervical mucosa appears to be less resilient to spermicides than vulvo-vaginal mucosa.

A cross-sectional survey of condom use in conjunction with other contraceptive methods

A cross-sectional survey of 3,136 women attending family planning clinics in Texas was conducted to examine past use of and future plans for use of condoms by partners during sexual intercourse for disease prevention in conjunction with other contraceptive methods. Following the receipt of clinical services, including counseling about family planning and disease prevention, both contraceptive and planned condom use reporting increased for the majority of subjects. However 22% of the sample indicated that they intended to reduce condom use in the future and instead use a contraceptive which protects from pregnancy but not from disease. Condom use was indicated more frequently for those who reported at least one risk factor for HIV, but 17% of those at risk indicated lower future condom use than past use. This suggests that without changes in risk behavior, these women will be at increased risk of HIV or another sexually transmitted disease.

Characteristics of injectable contraceptive users in a low-income population in Texas

Among 600 women at 17 family planning clinics in Texas who expressed interest in using the hormonal injectable depot medroxyprogesterone acetate (DMPA), 536 (89%) actually received the injectable. Thirty percent of the DMPA recipients were younger than 21 and 77% were not married. The average numbers of pregnancies and births were 1.9 and 1.2 per woman; one-third of the women had had at least one abortion. The majority of women receiving DMPA (66%) were using it to space births. Their main sources of information about the method were friends (42%) and health care providers (37%), and the most commonly reported reason for its use was dissatisfaction with previous contraceptive methods.

Aggressive angiomyxoma of the pelvis and perineum. A case report

BACKGROUND

Aggressive angiomyxoma of the female perineum and pelvis is a slowly growing neoplasm occurring almost exclusively in women of reproductive age. The tumor is characterized by its locally infiltrative behavior. The high recurrence rate has been attributed to incomplete surgical excision.

CASE

A case of a huge, recurrent, aggressive angiomyxoma of the perineum and pelvis was treated.

CONCLUSION

Correct preoperative diagnosis and assessment of simultaneous perineal and pelvic involvement indicate a combined abdominoperineal surgical approach to achieve wide, tumor-free margins.

Characteristics and experiences of American women electing for early removal of contraceptive implants

The study describes the experiences of 430 women who had Norplant(R) contraceptive implants removed prior to the five years of method effectiveness. Each subject was surveyed when the implants were inserted and again at the time of removal. Descriptive data are presented concerning perceptions of the method before insertion and after removal, reactions to the contraceptive and experiences associated with the removal procedure. Subjects' use of Norplant implants ranged from 14 days to 40 months, with a mean of 13.3 and median of 13 months. Over 95% reported changes in menstrual bleeding patterns and 95% experienced other non-bleeding related side effects. Non-bleeding side effects were the most frequently indicated reasons for removal, followed by bleeding changes. The mean removal time was 34 minutes with a median of 25 minutes. Over 48% reported experiencing significant pain during the removal procedure, and 27% stated that the pain was greater than expected. Despite electing for early removal of implants,the majority of women surveyed indicated satisfaction with all aspects of the method save its effect on their overall health. Although method-related side effects were intolerable for most subjects, their overall perception of the method was generally satisfactory.

Epidemiology of endometriosis among parous women

OBJECTIVE

To report the prevalence of endometriosis and its associated risk factors among multiparous women, and to determine the relationship between the location and depth of this disease and certain medical and behavioral characteristics.

METHODS

Over a 6-year period, 3384 multiparous women underwent laparoscopy for tubal sterilization. Endometriosis was detected in 126 patients (3.7%), who were consequently evaluated for severity of the disease. To conduct a case-control study, 504 patients with no evidence of endometriosis were randomly selected from a group of women who underwent sterilization. Information obtained through physical examination and a self-administered questionnaire was studied by multivariate logistic regression analysis.

RESULTS

Most endometriosis lesions were minimal. Factors associated with an increased risk for endometriosis included: advanced age (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.1-3.7), Asian race (OR 8.6, 95% CI 1.4-20.1), long cycle length (OR 1.8, 95% CI 1.1-2.7), one live birth (OR 2.2, 95% CI 1.1-4.3), long duration of intrauterine device use (OR 3.0, 95% CI 1.1-8.1), and long duration of uninterrupted menstrual cycles (OR 2.9, 95% CI 1.3-6.4). Present oral contraceptive use was protective for disease (OR 0.5, 95% CI 0.2-0.9). The role of these factors varied among different disease locations (ovary, uterus and tubes, posterior broad ligaments and cul-de-sac), and depth (superficial or deep).

CONCLUSIONS

The prevalence of endometriosis is relatively low among multiparous women, and certain menstrual and reproductive characteristics are associated with its development. Furthermore, the relationship between various factors and endometriosis appears to be site and depth specific. Our findings suggest that asymptomatic endometriosis may be clinically important.

Leukaemia inhibitory factor in human endometrium during the menstrual cycle: cellular origin and action on production of glandular epithelial cell prostaglandin in vitro

Leukaemia inhibitory factor (LIF) is a pleiotrophic cytokine which plays an obligatory role in mouse implantation. To investigate its potential role in the regulation of uterine function in the human, LIF secretion by isolated human endometrial glandular epithelial and stromal cells in primary culture was determined. Endometrial cells secreted a detectable amount of LIF protein during the first 48 h of culture. In the follicular and late-luteal phases, LIF secretion by both cell types was low. At every stage of the menstrual cycle, the epithelial cells secreted significantly more LIF than did stromal cells. Glandular epithelial cells of the mid-luteal phase, at the expected time of implantation in the human, secreted significantly more LIF than at other stages of the cycle. Stromal cells showed a similar, but nonsignificant, LIF secretion pattern. It could be concluded that endometrial LIF expression was dependent on cell type and stage of the menstrual cycle, and might thus play a role in human implantation. Oestradiol-17 beta stimulated both prostaglandin (PG) F and E release by the epithelial cells in both follicular and luteal phases. PGE release during the luteal phase was greater than in the follicular phase. However, addition of recombinant human LIF did not change either PGF or PGE release in either follicular or luteal phases, in the presence or absence of oestradiol.

Characteristics of teens tested for HIV in a metropolitan area

PURPOSE

This article describes the status of HIV infection in an adolescent population attending publicly supported HIV testing clinics in Houston.

METHODS

Records were reviewed of 4017 teenagers receiving HIV counseling and testing services over a period of three years (January 1990 to December 1992). We analyzed demographic characteristics, risk exposure groups, results of HIV antibody testing, and post-test counseling return rates.

RESULTS

An overall seroprevalence rate of 10.2 per 1000 was observed, with the majority of cases seen among black females. Forty-nine percent of teens with the virus failed to acknowledge a risk factor, but of those who did, male-to-male sexual contact was the most frequently reported. None who tested positive reported injected drug use. The majority of teens tested never returned to obtain their test results and post-test counseling.

CONCLUSIONS

In order to reinforce preventive behavior, institutional and other barriers should be examined and priority given to contacting both seropositive and high-risk clients who have sought testing. Interventions that encourage condom use or address sexual behavior may be more beneficial to teens than those that simply focus on drug use.

Emergency contraception alters progesterone-associated endometrial protein in serum and uterine luminal fluid

OBJECTIVE

To evaluate the effect of high-dose oral contraceptives on serum and uterine luminal fluid progesterone-associated endometrial protein in the luteal phase.

METHODS

Five ovulatory women participated in the study. In a control cycle, serum and uterine lavage samples were collected on luteal day 11. In the next cycle, on luteal day 9, the participants were given two 50-micrograms ethinyl estradiol-norgestrel tablets, repeated 12 hours later. Serum and uterine lavage samples were collected 48 hours (luteal day 11) after the last dose and analyzed by two-dimensional polyacrylamide gel electrophoresis and radioimmunoassays of the serum.

RESULTS

Progesterone-associated endometrial protein levels were lower in sera from treated compared with control cycles. Analysis of serum levels of this protein by two-dimensional polyacrylamide gel electrophoresis did not reveal bands corresponding to the known size and charge characteristics (27 kd and pI of 4.9) in either control or treatment samples. On the other hand, in uterine lavage samples, a complete suppression of the 27-kd, pI-4.9 species was evident after treatment.

CONCLUSION

High-dose ethinyl estradiol-norgestrel emergency contraception effectively suppresses progesterone-associated endometrial protein in the midluteal uterus, potentially altering the endometrial environment unfavorably and affecting the survival of the early embryo.

HIV exposure in the city of Houston

Demographic characteristics and risk factor data for 76,672 clients were studied to characterize the distribution of infection with human immunodeficiency virus (HIV) and the use of counseling and testing facilities in Houston, Tex. The number of clients who received free, voluntary HIV counseling and testing services between January 1990 and December 1992 doubled, while the seroprevalence rate declined from 6.1% to 2.9%. Rates were highest for white males, clients attending freestanding HIV testing sites, and those reporting male-to-male sexual contact. The number of females testing positive had increased by 67% over time and consisted almost entirely of blacks. Only 57% of clients who were tested returned for test results and received posttest counseling. Among those who were HIV negative, high-risk behaviors were frequently reported. Behavioral change must be reinforced, and priority must be given to contacting both seropositive and high-risk clients who seek testing.

The attitudes of clinic staff as factors in women's selection of Norplant implants for their contraception

Medical and counseling staff at 13 family planning clinics in Texas, U.S.A., were surveyed regarding their opinions and level of information about the contraceptive Norplant. These responses were used to assess the relationships between clinicians' information and attitudes about the contraceptive and the use of that method by their patients. No differences were associated with respondents' clinical responsibilities or with their type of professional training. However, significant variations in the numbers of patients receiving Norplant from individual providers, and in the proportion receiving the method from certain clinics, were associated with responses to some attitudinal questions. These findings suggest that the opinions about Norplant held by personnel staffing family planning clinics influence the method selection of their patients.

High doses of oral contraceptives do not alter endometrial alpha 1 and alpha v beta 3 integrins in the late implantation window

OBJECTIVE

To assess the effects of an emergency contraceptive agent on the distribution of integrin heterodimers during that part of the implantation window.

DESIGN

Prospective, case-controlled study in a university-based Population Program. In the first ovulatory control cycle after the detection of LH surge, patients had endometrial sampling 11 days after the surge. In the next cycle the procedure was repeated 2 days after the administration of a postcoital contraceptive agent on day 9 after LH surge (100 g ethinyl E2 and 2 mg norgestrel).

MAIN OUTCOME MEASURES

The effects of postcoital contraceptives on the expression of integrin heterodimers (alpha 1 and alpha v beta 3 subunits) reported to be unique to secretory phase was determined.

RESULTS

All six specimens were consistent histologically with days 24 and 25 of the menstrual cycle by light microscopy. Using immunohistochemistry, strong membrane staining of endometrial glandular cells and superficial epithelium for both alpha 1 subunit and vitronectin (alpha v beta 3) receptor was observed in treatment and controls. No diminution of intensity or distribution was observed relative to pretreatment controls.

CONCLUSIONS

There is no apparent change in the level of these two integrins in the human endometrium when high-dose oral contraceptives are given in the later stages of the implantation window. This suggests that the high doses of steroids used in emergency contraceptives may exert their effect through more complex mechanisms than endometrial cell surface changes.

One-year experience with subdermal contraceptive implants in the United States

Women who received Norplant contraceptive implants from any of fifteen clinical settings in southeast Texas, U.S.A., were followed for one year to determine their reactions to the method. Of 1,385 who enrolled to receive Norplant implants, 1,253 had implants inserted. Side effects were reported by 78% of those receiving implants and 70% described changes in bleeding patterns. Spotting or irregular bleeding, weight gain and headaches were the conditions reported most frequently. Nine pregnancies were reported during the study period. Six of these, however, existed before the implants were inserted. At the one year anniversary, 143 of women receiving implants had had them removed. Those who discontinued method use were less satisfied, reported more side effects and were more likely to have planned to have another child, thus using the method for spacing, or to have had a change in their marital status while they were using the contraceptive. Providers should counsel patients to focus attention on plans for the future in selecting their contraceptive method. In addition, we recommend, as does the product's distributor, that providers confirm that patients are not pregnant prior to inserting implants.

Planned condom use by women with Norplant implants

This research examines the use of condoms to protect from disease women who selected hormonal implants for contraception. After receiving contraceptive implants, subjects were surveyed regarding their past use of condoms and their plans for using them to inhibit the transmission of HIV and other sexually transmitted diseases in the future. Twenty-one percent of women in the sample had used condoms in the past, but did not plan to use them once they have the implants. While decreasing their risk for unplanned pregnancy, they and/or their partners can be expected to experience an increased risk of exposure to sexually transmitted disease. Contraceptive providers must emphasize to their patients the need for protection from disease, in addition to pregnancy, when prescribing contraceptive methods.

The effects of a long-acting progestin on the hypothalamic-pituitary-ovarian axis in women with normal menstrual cycles

This study was performed to determine how a long-acting, slow-release preparation of norethindrone (NET) affects the hypothalamic-pituitary-ovarian axis of normal ovulatory women. Ten women were studied during the luteal phase of their menstrual cycle, and again at six and twelve weeks following intramuscular administration of 100 mg NET microencapsulated in poly-D,L-lactide-co-glycolide. Serial LH samples, serum E, P, and NET were followed by a GnRH stimulation test. Compared to luteal phase values, six and twelve weeks of treatment with NET inhibited serum E2 and P while mean serum LH remained unchanged and mean serum FSH increased significantly (p < 0.05). LH pulse frequency after NET treatment was twice the rate (p < 0.01) as that of the luteal phase, whereas LH pulse amplitude was decreased significantly (p < 0.05). Finally, although there was no significant change in pituitary LH secretion in response to GnRH, NET treatment augmented FSH responsiveness to GnRH at the times studied. Preserved pituitary responsiveness to GnRH in NET-treated patients suggests that inhibited ovarian function results in an increase in GnRH pulse frequency but not GnRH pulse amplitude. Since the progestational milieu is maintained in these patients by NET treatment, the decrease in serum E2 may be responsible for the increase in GnRH pulse frequency. The presence of a critical level of E2 may be necessary for progestins to affect the hypothalamic GnRH pulse generator.

Factors associated with the choice of Norplant by women attending subsidized clinics in the US

US women attending family planning clinics in Texas, were surveyed to determine which characteristics, experiences, behavior and specific needs were associated with the selection of the contraceptive Norplant. Race, ethnic origin, age and education were unrelated to choice of method. Increased numbers of previous pregnancies, familiarity with the method, dissatisfaction with previous methods, and sources of information about Norplant were associated with its selection. There was significant variation among the clinics in the proportion of patients to which they dispensed the method. Therefore, clinic selection may have influenced the outcomes of contraceptive decisions.

GnRH agonist exposure during the first trimester of pregnancy

OBJECTIVE

To evaluate pregnancy outcome in infertility patients with unrecognized exposure to a GnRH agonist in the first trimester.

METHODS

Five women were given GnRH agonist before controlled ovarian hyperstimulation for in vitro fertilization cycles. The medication was administered in a dose of 0.5 mg/day, with drug exposure beginning on cycle day 21. The duration of exposure in all patients was 14-21 days. Thus, all five women received the medication at 3-6 weeks' estimated gestational age by menstrual dating. Pregnancy tests were not performed before the first injection of the GnRH agonist.

RESULTS

Three of the five pregnancies progressed to term without complication, and normal healthy infants were delivered. Missed abortion occurred in one pregnancy, and another ended in induced abortion at 13 weeks because of trisomy 18.

CONCLUSIONS

This experience suggests that despite manipulation of the hypothalamic-pituitary-ovarian axis by administration of GnRH agonist in the first trimester of pregnancy, normal pregnancies can result. Pregnancies in these patients should not be terminated because of drug exposure alone.

Risk factors for infection with human immunodeficiency virus among low-income women undergoing voluntary sterilization

Data regarding risk for infection with human immunodeficiency virus (HIV) were collected from 486 women who presented in 1989 for tubal sterilization through a clinic operated by a medical school. This clinic was participating in a blind surveillance project administered by the local health department. The project was designed to estimate the prevalence of seropositivity for HIV among women seeking family planning services within the department's catchment area. The expectation was that the population of women choosing voluntary sterilization would be of relatively low risk for HIV infection. Surprisingly, however, when they were examined, nearly 25% of these women reported at least one identified risk factor for HIV infection. The rates for certain specific risk factors are no lower among these women than among the general population.

Characteristics and attitudes of early contraceptive implant acceptors in Texas

In 1991, shortly after Norplant became available in the United States, 678 women who had received the implant from 17 providers in Texas were surveyed. Forty-five percent of these women were under 21 years old. The majority (56%) had tried the implant because they were dissatisfied with their previous contraceptive method. Forty-four percent of the sample indicated that the implant was one of the first contraceptive methods they had used and that they had only recently decided to prevent unplanned pregnancy. The average number of children per woman was 1.2, and one-third of the sample had had at least one abortion. While 37% of the women said they wanted no more children, 63% said they were using the implant as a spacing method. The reasons for choosing the implant and concerns about it varied according to the user's age, educational level and race or ethnic group.

Hysterosalpingographic diagnosis of Crohn's disease. A case report

A woman presented with abdominal pain, weight loss and a pelvic mass. At the time of laparotomy she had a lower abdominal abscess from perforation of the ileum. Two years later she returned with a tender uterus and purulent cervical discharge. A hysterosalpingogram demonstrated an uteroileal fistula secondary to Crohn's disease, and the patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy.

Laparoscopic tubal sterilization under local anesthesia in women with cyanotic heart disease

Laparoscopic tubal sterilization under local anesthesia with intravenous sedation has been shown to be a safe procedure. However, the use of laparoscopy in patients with cyanotic cardiovascular disease is controversial and is generally contraindicated. Five women were referred with uncorrectable cyanotic heart disease and pulmonary hypertension. The mean preoperative arterial oxygen pressure was 56.2 +/- 5 mmHg (N = 5). After cardiology and cardiovascular anesthesia consultation and clearance, the patients underwent laparoscopic sterilization with Silastic rings under local anesthesia using direct trocar entry. Continuous hemodynamic monitoring and pulse oximetry were employed. The patients were kept in the intensive care unit or the hospital for 24 hours for monitoring, and all did well. This hospital for 24 hours for monitoring, and all did well. This small retrospective series demonstrates that laparoscopic sterilization under local anesthesia is a sterilization technique that may be suitable and safe for such patients when appropriate monitoring is performed. Tubal sterilization may be the contraceptive method of choice in women with heart disease when pregnancy is contraindicated.

Laparoscopic tubal sterilization under local anesthesia

Laparoscopic tubal sterilization has been performed under local anesthesia in the United States since 1971. Pilot studies suggested that local anesthesia was as adequate and as safe as general anesthesia. Since 1980, the senior author has performed more than 3000 outpatient laparoscopic tubal sterilizations with the silastic ring under local anesthesia. A retrospective descriptive study was conducted on 2827 cases. The technical failure rate was 0.14%. There were no unintended laparotomies due to complications. The mean operative time was 10.0 +/- 5.1 minutes. The mean anesthesia time was 23.3 +/- 6.9 minutes. The hospital cost for the patient was reduced by 68-85%. This study demonstrates that laparoscopic tubal sterilization can be performed adequately, safely, and quickly under local anesthesia.

Endometriosis in multiparous women

The incidence of endometriosis in the general population has been reported to range from 4% to 32%. A more realistic figure is probably 7.5%. An incidence of 7.4% was found in 42 of 566 multiparous women undergoing tubal sterilization at Baylor College of Medicine, Houston. Twelve of the 42 (29%) were less than five months postpartum. Hispanics had an incidence of endometriosis similar to that of whites and blacks. Indigent status had no bearing on the presence of endometriosis. A higher incidence of spontaneous abortion was found in patients with endometriosis, but the difference was not statistically significant.

Is vaginal birth after two or more cesarean sections safe?

Fifty-five patients with a history of two or more cesarean sections underwent a trial of labor. Forty-two had had previous uterine incisions of unknown type, 11 had had low cervical transverse incisions, and two had had low vertical incisions. Twenty-five women (45%) had successful vaginal deliveries, and 30 (55%) received oxytocin augmentation of labor. The incidence of vaginal delivery was significantly lower in patients who required oxytocin augmentation (30 versus 64%, P less than .01). Three of the 55 patients had scar separation detected at the time of delivery. Two patients underwent hysterectomy. There were no maternal or neonatal deaths. A history of multiple cesarean sections need not exclude the patient from the option of trial of labor.

Contraception: a risk factor for endometriosis

Endometriosis was detected in 42 cases out of 566 patients undergoing laparoscopic tubal sterilization. The presence of endometriosis was then correlated with previous contraception. Those patients using no contraception, or barrier contraception alone, were regarded as controls. Previous oral contraceptive use was associated with a lower incidence of endometriosis, although the difference was not significant. A significantly higher incidence (P less than .05) of endometriosis was present in former intrauterine device users, possibly because of retrograde flow of increased menses.

Multicenter clinical trials comparing cefotetan with moxalactam or cefoxitin as therapy for obstetric and gynecologic infections

The clinical efficacy and safety of cefotetan was assessed in two multicenter clinical trials involving 335 evaluable patients hospitalized with obstetric and gynecologic infections. In Study I, cefotetan was compared with moxalactam and in Study II, cefotetan was compared with cefoxitin. The clinical response rate in Study I was 67 of 70 patients for cefotetan (96 percent) and 33 of 34 patients (97 percent) for moxalactam. In Study II, the clinical response rate was 138 of 147 patients in the cefotetan group (94 percent) and 76 of 84 patients in the cefoxitin group (91 percent). For the patients with bacteriologic response data, 196 of 205 cefotetan patients (96 percent), 23 of 24 moxalactam patients (96 percent), and 70 of 75 cefoxitin patients (93 percent) had a satisfactory bacteriologic response. Cefotetan was well tolerated and produced no major adverse reactions. The mean amount of cefotetan given was lower than that of moxalactam or cefoxitin.

Results of noncomparative studies of cefotetan in the treatment of obstetric and gynecologic infections

In a multicenter trial involving 11 centers, 160 women were enrolled to evaluate the safety and effectiveness of 1 or 2 gm of cefotetan administered every 12 hours in the treatment of obstetric and gynecologic infections. The 133 evaluable patients generally were under 25 years of age, were nonwhite, and had hospital-acquired endometritis or pelvic inflammatory disease caused by both aerobic and anaerobic bacteria. Escherichia coli, Neisseria gonorrhoeae, group D streptococci, Bacteroides sp., and Peptococcus sp. were among the most frequently isolated pathogens. The patients were treated for a mean of 5.6 +/- 1.6 days and received a total dose of 19.27 gm. The signs and symptoms of infection were cleared or improved in 93% of the 133 patients evaluable for clinical response. Of the 116 evaluated bacteriologically, 95% had a satisfactory or presumed satisfactory response; only six patients (5%) were considered to be bacteriologic failures. Differences in the results of several clinical laboratory tests performed before and after treatment were statistically, but not clinically, significant (p less than 0.05). Safety was evaluated in the 158 patients who received cefotetan, and only four (3%) had adverse reactions considered related to the drug. Cefotetan was clearly effective and produced no untoward reactions in these women with obstetric and gynecologic infections caused by both aerobic and anaerobic organisms when administered at 1 or 2 gm every 12 hours.

Results of a randomized, multicenter, comparative trial of a single dose of cefotetan versus multiple doses of cefoxitin as prophylaxis in cesarean section

In a multicenter, open, randomized, comparative trial, 308 women undergoing cesarean section were given a single 1 gm dose of cefotetan or three 2 gm doses of cefoxitin after cord clamping to reduce the incidence of postoperative infectious morbidity. Of the 286 evaluable patients, 195 received cefotetan and 91 received cefoxitin. Most patients were in active labor and one third had ruptured membranes. Microorganisms cultured from the endocervix or intraoperatively from the endometrium or abdominal wall operative sites were comparable for the two groups. In this multicenter study, the difference between the percentage of patients receiving cefotetan who did not develop clinical signs and symptoms of infection (93%) and the percentage of patients receiving cefoxitin (85%) considered clinical successes was statistically significant (p = 0.02, chi 2). The bacteriologic response rate for patients taking cefotetan was also significantly higher than that for patients taking cefoxitin (93% versus 85%, p = 0.03). Isolates recovered from the endocervix, endometrium, or operative site were comparable for the two groups. Both drugs were well tolerated. In this evaluation, cefotetan administered in a single dose of 1 gm was more effective as a prophylactic agent than multiple 2 gm doses of cefoxitin in the reduction of infectious morbidity in this large series of patients undergoing cesarean section.

Pelvic adhesions in intrauterine device users

A thorough inspection of the pelvis for adhesions was made at the time of laparoscopic tubal sterilization in 2131 patients. Contraceptive use was then compared in women with adhesions (cases) and those without adhesions (controls). Current or previous intrauterine device (IUD) use was not associated with a statistically significant increased incidence of adhesions (odds ratio = 0.98, 95% confidence limits 0.58-1.64). This risk was reduced to 0.62 for current IUD users. The IUDs removed at the time of laparoscopy included the Lippes Loop, Copper 7, and the Saf-T-Coil. These findings support the use of the IUD in the appropriate patient by demonstrating no increased risk for the development of adhesions in multiparous IUD users.

Trocar introduction performed during laparoscopy of the obese patient

Obesity, especially morbid obesity, is reported to be a relative contraindication to laparoscopy. A technique for trocar introduction and laparoscopy of the obese patient to eliminate this contraindication is described. The technique presented herein differs from the traditional method by: 1, primary trocar entry at a 90 degree angle to the horizontal plane, and 2, confirmation for intraperitoneal position of the instruments before creating the pneumoperitoneum. A retrospective study was done to compare demographic, medical and surgical data of obese and non-obese patients. No important differences were found and it was also found that obesity was not a relative contraindication to laparoscopy. Obesity was defined by a ponderal index of less than 11.7. No operative complications were found for the 344 obese patients studied and all laparoscopy procedures were completed as intended. These differences in technique can avoid the pitfalls commonly reported concerning laparoscopy of the obese patient.

Comparison of in vitro fertilization results in women with one or two ovaries

A study compared the in vitro fertilization results in women with one or two ovaries. Eighteen percent (23/125) of in vitro fertilization/embryo transfer cycles were in patients with one ovary. One-ovary patients averaged 4.2 follicles (greater than or equal to 10 mm) as compared to 7.9 in two-ovary patients, and significantly fewer ova were recovered from one-ovary patients (4.0 vs. 5.3). The total follicular volume was significantly less in one-ovary patients as compared to two-ovary patients, and the serum estradiol per follicle was less in one-ovary patients. However, the volume of the dominant follicle, the maximum serum estradiol levels, the number of ampules of Pergonal given and the ovum fertilization rate were not significantly different in one- and two-ovary patients. The mean number of embryos transferred was 3.9 +/- 1.9 in one-ovary patients and 4.5 +/- 1.8 in two-ovary patients (NS). Two pregnancies occurred in one-ovary patients (8.3% per laparoscopy) and 13 in two-ovary patients (12.9% per laparoscopy). The two one-ovary patients who achieved pregnancy behaved more like two-ovary patients in terms of peak serum estradiol levels and number of ova recovered.

Medical aspects of contraception

It is evident that choice of contraceptive has important medical implications, whether a mechanical or a hormonal method is elected. Each technology has unique benefits and risks, constraints, applicability, and inconvenience. Wise advice in a medical context must be based on thorough familiarity with the options available to each woman.

Residual embryos in failed embryo transfer

One hundred thirteen embryo transfers (ETs) were performed in an in vitro fertilization and ET program of which residual or extruded embryos were found in 17 transfers (15%). Residual or extruded embryos are those embryos found outside the uterine cavity, either at the cervical os, on the vaginal speculum, or remaining in the catheter after an ET. Patients were divided into two groups according to the method of inspection for residual embryos. In group I, microscopic visualization of the transfer catheter alone revealed that 9 of the 67 transfers (13.4%) had 17 residual embryos either at the catheter tip or adherent to mucus on the side of the catheter. In group II inspection of the catheter and cervical wash revealed that 8 of 46 ETs (17.4%) had 15 residual embryos that failed to be transferred during the initial attempt. Six of these 15 (40%) were found in the cervical wash medium. Thus, failure of the proper placement of embryos at the time of transfer may occur frequently. Evaluation of only the transfer catheter may result in a significant underestimation of the problem.

In vitro fertilization in couples with male factor infertility

The data from 83 consecutive in vitro fertilization-embryo transfer cycles were examined with emphasis on the presence of subfertile male parameters, including abnormal sperm density, motility, morphologic features, or an abnormal result in the sperm penetration assay (zona-free hamster ova penetration). There were 25 cycles (21 couples) in which there was a solitary or coexistent abnormal male factor. The presence of a male factor was associated with a lower fertilization rate and fewer embryos transferred. Statistically important reductions in the fertilization rate occurred with reduced sperm density and abnormal motility, but not with abnormal morphologic features. The parameter that was most significantly associated with human ova fertilizability was the ability to exceed two penetrations per egg in the sperm penetration assay.

Cefotetan in the treatment of obstetric and gynecologic infections

The efficacy, tolerance, and safety of cefotetan--a new 7-alpha-methoxy cephalosporin--was assessed in controlled and uncontrolled evaluations involving 131 evaluable patients hospitalized with obstetric and gynecologic infections. The 99% satisfactory clinical response rate obtained with this drug was equivalent to that obtained with either moxalactam or cefoxitin, yet the mean amount of cefotetan given was lower than that of the other two drugs. Cefotetan was well tolerated and produced no major adverse reactions. In this era of Diagnosis Related Groups and cost containment, the twice-daily dosage schedule of cefotetan is a decided cost benefit.