Age and infertility

Direct evidence on age patterns of infecundity and sterility cannot be obtained from contemporary populations because such large fractions of couples use contraception or have been sterilized. Instead, historical data are exploited to yield upper bounds applicable to contemporary populations on the proportions sterile at each age. Examination of recent changes in sexual behavior that may increase infecundity indicates that sexually transmitted infections, the prime candidate for hypothesized rises in infertility, are unlikely to have added to infecundity to any great extent. These results imply that a woman in a monogamous union faces only moderate increases in the probability of becoming sterile (or infecund) until her late thirties. Nevertheless, it appears that recent changes in reproductive behavior were guaranteed to result in the perception that infecundity is on the rise.

Primary and secondary infertility in sub-Saharan Africa

BACKGROUND

No previous study has provided national estimates of the prevalence of primary and secondary infertility in sizeable areas of sub-Saharan Africa.

METHODS

Primary infertility is measured by the proportion childless among women who entered their first marriage at least 7 years before date of censoring. Secondary infertility is measured by the 'subsequently infertile estimator' from parous ever-married women. Exposure begins at the age of the woman at the birth of her first child, and exposure ends when the woman is of an age, which is 5 years lower than her age at censoring. These last 5 years are used to determine her status as infertile or fertile at the last observation 5 years before censoring. A woman is considered infertile at last observation if she has had no livebirths during the last 5 years before censoring, otherwise she is considered fertile. A woman who has not given birth at age a or later is defined as being 'infertile subsequent to age a'. The index of the proportion subsequently infertile at age a is estimated as the number of women infertile subsequent to age a, divided by the total number of women observed at that age. Infertility is estimated for women age 20-44.

RESULTS

Primary infertility is relatively low and it exceeds 3% in less than a third of the 28 African countries analysed. In contrast, elevated levels of secondary infertility prevail in most countries. Secondary infertility for women age 20-44 ranges from 5% in Togo to 23% in Central African Republic.

CONCLUSIONS

It is feasible to gauge national levels of primary and secondary infertility from population based surveys including a birth history. The prevalence of infertility of pathological origin is so high in sub-Saharan Africa that infertility is not merely an individual concern, it is a public health problem.

Codeine increases pain thresholds to copper vapor laser stimuli in extensive but not poor metabolizers of sparteine

The analgesic efficacy and kinetics of a single oral dose of 75 mg codeine was investigated in 12 extensive metabolizers and 12 poor metabolizers of sparteine in a double-blind, placebo-controlled crossover study. The cosegregation of the O-demethylation of codeine to morphine with the sparteine oxidation polymorphism was confirmed. Hence morphine could not be detected in the plasma of any of the poor metabolizers, whereas detectable morphine plasma levels were found in 10 of 12 extensive metabolizers. Pain thresholds to laser stimuli were determined before drug intake and 90, 150, and 210 minutes after drug intake. Codeine significantly increased the pricking pain thresholds in the extensive metabolizers (p less than 0.05), whereas there were no significant changes in the poor metabolizers. No change in pain thresholds occurred with placebo in any of the two phenotypes. In the extensive metabolizers there was a significant positive correlation between the increase in pain threshold and plasma concentration of codeine. The study supports the hypothesis that morphine formation is essential for achievement of analgesia during codeine treatment.

Female circumcision and obstetric complications

OBJECTIVES

To examine whether complications at delivery are associated with female circumcision.

METHOD

One thousand eight hundred and fifty-one women seeking family planning or antenatal care in three south-west Nigerian hospitals were interviewed and had a medical exam. The prevalence of complications at delivery for uncircumcised women and circumcised women with type 1 (partial or total removal of the clitoris) or type 2 (partial or total removal of the clitoris and part or all of the labia minora) were determined. Associations between self-reported complications at delivery and clinic-reported type of circumcision were analyzed using bivariate and multivariate logistic regression.

RESULT

Forty-five percent were circumcised; 71% had type 1 and 24% had type 2. Circumcised women had significantly higher risks of tearing and stillbirths when all pregnancies were analyzed.

CONCLUSION

Circumcised women experienced more obstetric complications, while there was no significant difference between women with type 1 and type 2.

The association between female genital cutting and correlates of sexual and gynaecological morbidity in Edo State, Nigeria

OBJECTIVE

To examine the association between female genital cutting and frequency of sexual and gynaecological symptoms among a cohort of cut versus uncut women in Edo State of Nigeria.

DESIGN

Cross sectional study.

SETTING

Women attending family planning and antenatal clinics at three hospitals in Edo State, South-south Nigeria.

POPULATION

1836 healthy premenopausal women.

METHODS

The sample included 1836 women. Information about type of female genital cutting was based on medical exams while a structured questionnaire was used to elicit information on the women's sociodemographic characteristics, their ages of first menstruation (menarche), first intercourse, marriage and pregnancy, sexual history and experiences of symptoms of reproductive tract infections. Associations between female genital cutting and these correlates of sexual and gynaecologic morbidity were analysed using univariate and multivariate logistic regression and Cox models.

MAIN OUTCOME MEASURES

Frequency of self-reported orgasm achieved during sexual intercourse and symptoms of reproductive tract infections.

RESULTS

Forty-five percent were circumcised and 71% had type 1, while 24% had type 2 female genital cutting. No significant differences between cut and uncut women were observed in the frequency of reports of sexual intercourse in the preceding week or month, the frequency of reports of early arousal during intercourse and the proportions reporting experience of orgasm during intercourse. There was also no difference between cut and uncut women in their reported ages of menarche, first intercourse or first marriage in the multivariate models controlling for the effects of socio-economic factors. In contrast, cut women were 1.25 times more likely to get pregnant at a given age than uncut women. Uncut women were significantly more likely to report that the clitoris is the most sexually sensitive part of their body (OR = 0.35, 95% CI = 0.26-0.47), while cut women were more likely to report that their breasts are their most sexually sensitive body parts (OR = 1.91; 95% CI = 1.51-2.42). Cut women were significantly more likely than uncut women to report having lower abdominal pain (OR = 1.54, 95% CI = 1.11-2.14), yellow bad-smelling vaginal discharge (OR = 2.81, 95% CI = 1.54-5.09), white vaginal discharge (OR = 1.65, 95% CI = 1.09-2.49) and genital ulcers (OR = 4.38, 95% CI 1.13-17.00).

CONCLUSION

Female genital cutting in this group of women did not attenuate sexual feelings. However, female genital cutting may predispose women to adverse sexuality outcomes including early pregnancy and reproductive tract infections. Therefore, female genital cutting cannot be justified by arguments that suggest that it reduces sexual activity in women and prevents adverse outcomes of sexuality.

Secular trend in age at menarche in China: a case study of two rural counties in Anhui Province

There is increasing evidence that age at menarche has decreased in Europe and the United States during the last century and in Japan over the last several decades. Data from a community-based survey conducted in two rural counties of Anhui Province in China indicate a similar, downward secular trend in age at menarche for Chinese women. The present study shows the mean age at menarche decreased by 2.8 years, from 16.5 to 13.7, over an approximate 40-year time interval. This rapid decrease in age at menarche may partly be due to better nutrition and living standards reflected by the improved socioeconomic standards experienced in China over the past few decades. To test this hypothesis, a number of determinants of age at menarche were assessed; year of birth, literacy status, county of residence, amount of physical labour, general health status, pesticide exposure before age at menarche, and drinking water source were all found to be associated with age at menarche.

Pain control after dental surgery: a double-blind, randomised trial of lornoxicam versus morphine

Lornoxicam is a new non-steroidal anti-inflammatory drug of the oxicam class. This randomised, double-blind, placebo controlled trial compared the analgesic efficacy and tolerability of intramuscular (IM) injections of lornoxicam (4, 8, 16 and 20 mg) with morphine (10 and 20 mg) and placebo in 252 patients with mainly moderate to severe pain following surgical removal of an impacted mandibular third molar. Patients treated with lornoxicam or morphine experienced a significantly greater cumulative pain relief over the 4-h post-injection period (TOTPAR0-4) than placebo recipients. This effect appeared to be dose-dependent, with patients in the lornoxicam 4 mg or morphine 10 mg groups recording significantly lower TOTPAR0-4 scores than patients in the higher dosage groups of these drugs. No significant difference was detected between the morphine 20 mg group and the lornoxicam 8, 16 and 20 mg groups. Lornoxicam was well tolerated at all doses and was associated with a significantly lower incidence of adverse events than morphine 10 or 20 mg. Thus, the analgesic efficacy of IM lornoxicam at doses > or = 4 mg is superior to placebo, and doses > or = 8 mg are at least as effective as IM morphine 20 mg. Furthermore, lornoxicam possesses a more favourable tolerability profile than morphine and thus represents an attractive alternative for the treatment of moderate to severe acute pain.

The epidemiology of HIV-1 infection in northern Tanzania: results from a community-based study

We conducted a community-based study to determine the predictors of HIV-1 among women aged 20-44 years (N = 1,418) and their regular male partners (N = 566) from randomly selected households in Moshi, Tanzania. The weighted prevalence of HIV-1 was 10.3% in women and 7% in men. The highest risk of HIV-1 was in subjects whose partners were HIV-1 seropositive in both women (adjusted odds ratio (AOR) = 26.63; 95% confidence interval (CI): 10.74-66.02) and men (AOR = 22.25; 95%CI: 7.06-70.15). Herpes simplex virus type 2 (HSV-2) and Mycoplasma genitalium were also significantly associated with HIV-1. Women with male partners >or=12 years older than themselves had increased risk of HIV-1 (AOR = 1.99; 95%CI: 1.01-7.85). Other predictors of HIV-1 were history of infertility and the number of sex partners in the last three years in women and the age at time of circumcision and history of past sexually transmitted diseases (STDs) in male partners. These findings show that HIV-1/STDs were major public health problems among women and their long-term partners in this population. HIV-1 prevention efforts should include promotion of couple's HIV-1 counseling and testing services, control of HSV-2, promotion of safer sexual practices and strategies to reduce the age difference between women and their partners.

Efficacy and tolerability of lornoxicam versus tramadol in postoperative pain

This randomized double-blind study compared the analgesic efficacy and tolerability of intramuscular lornoxicam and tramadol in 76 patients with moderate to unbearable pain following arthroscopic reconstruction of the anterior cruciate ligament using the patella bone-tendon-bone technique. Patients receiving a single dose of lornoxicam 16 mg experienced significantly greater total pain relief than patients receiving tramadol 100 mg over the following 8 hours. Lornoxicam had greater analgesic efficacy than tramadol in patients with moderate baseline pain but was of equivalent efficacy in those with severe/unbearable baseline pain. Fewer patients in the lornoxicam group required rescue medication (58% vs. 77%, respectively). Patients' global impression of efficacy showed lornoxicam to be superior to tramadol with 82% and 49% of patients, respectively, rating treatment as good, very good, or excellent. Following multiple-dose administration of lornoxicam (8 mg tid) or tramadol (100 mg tid) for 3 days, efficacy profiles similar to those following a single dose were obtained. Thus, slightly fewer patients in the lornoxicam group required rescue medication, and patients' global impression of efficacy again favored lornoxicam. Adverse events were reported by 38 of the 76 patients and were mainly mild to moderate in severity. Significantly fewer patients reported one or more adverse events with lornoxicam than with tramadol (14 vs. 24, respectively). Thus, intramuscular lornoxicam offers a useful alternative to tramadol for the treatment of moderate to severe postoperative pain.

Fertility and son preference in Korea

In Korea, total fertility declined from 6.0 in 1960 to 1.6 in 1990, in spite of a strong preference for male offspring. This paper addresses the notion that son preference hinders fertility decline, and examines the effects of patriarchal relations and modernization on fertility using the 1991 Korea National Fertility and Family Health Survey. It was found that women who have a son are less likely to have another child, and that women with a son who do progress to have another child, take longer to conceive the subsequent child. This pattern prevailed for women of parity one, two, and three, and became more pronounced with higher parity. A multivariate analysis showed that preference for male offspring, patriarchy, and modernization are all strong predictors of second, third, and fourth conceptions.

Divorce in Ethiopia: the impact of early marriage and childlessness

Forty-five per cent of first marriages in Ethiopia end in divorce within 30 years, and two-thirds of women who divorce do so within the first 5 years of marriage. This paper looks at two factors that may have an impact on the risk of divorce in Ethiopia: early age of first marriage, and childlessness within the first marriage. Data used were from the 1990 National Family and Fertility Survey conducted by the Government of Ethiopia. A total of 8757 women of reproductive age (15-49) were analysed. Life table analysis was used to determine the median age at first marriage, first birth and the median duration of marriage. Cox models were analysed to determine the differentials of divorce. The results of this analysis showed that both early age at marriage and childlessness have a significant impact on the risk of divorce. An inverse relationship was found between age at marriage and risk of divorce. Having a child within the first marriage also significantly reduced the risk of divorce. In addition, several cultural and socioeconomic variables were significant predictors of divorce.

Dietary outcome in obese patients treated with a gastroplasty program

Dietary intake was recorded on 7-d food registers by 18 patients for 2 y after horizontal gastroplasty (GP) for morbid obesity. The aim was to evaluate diet compliance and nutritional safety. In accordance with prescriptions, frequency of meals increased and amounts of food decreased. Contrary to intentions, qualitative improvements were minor and transient resulting in a lasting fractional increase of patients with inadequate intakes of a wide range of nutrients. Protein malnutrition could not be detected from measurements of serum-albumin, plasma-prealbumin, or plasma retinol-binding globulin. Calcium was not included in the vitamin-mineral supplement and serum-Ca decreased. Despite thorough instruction, close follow-up, and gastrosurgery, there were no major qualitative dietary improvements. The study showed that bad compliance with an intended qualitative improvement of diet adds to the risks of being on a severely energy-restricted GP diet and increases the necessity for broad long-term supplements.

Infertility in a community and clinic-based sample of couples in Moshi, Northern Tanzania

BACKGROUND

Previous research on the aetiology of infertility in sub-Saharan Africa was generally clinic based and it is not known whether findings from this work are representative of the general population. A better understanding of the medical causes of infertility is crucial for reducing the incidence of infertility and for improving the clinical management.

OBJECTIVE

To determine the type and aetiology of infertility in a community and clinic-based sample.

DESIGN

Couples identified as infertile in a representative cross-sectional survey from a community-based sample of 2019 women aged 20-44 years and couples seeking care for infertility at a tertiary health facility.

SETTING

The community-based sample was drawn from Moshi Urban District and the clinic-based sample from patients seeking care at Kilimanjaro Christian Medical Centre (KCMC) in 2002 and 2003.

PARTICIPANTS

Sixty six couples identified as infertile in the community-based sample and 112 couples seeking care for infertility.

RESULTS

The percentage of primary infertility was 37.1% and secondary infertility was 62.9%. Female only factor infertility was identified in 65.9% of the couples, male only factor in 6.8%, male and female factors in 15.2% and unexplained infertility in 12.1%.

CONCLUSION

The type and aetiology of infertility were the same in the community and clinic-based sample suggesting that the couples seeking infertility health care were representative of the general infertile population. Tubal factor infertility was the commonest cause.

Short-term fluctuations in death by cause, temperature, and income in the United States, 1930-1985

Disclosures that this decade has had the five hottest years ever recorded globally raise concern that extreme temperatures might be associated with higher mortality. An analysis of fluctuations in annual case-specific deaths, seasonal temperatures, and annual income per capita in Massachusetts, Michigan, Washington, Utah, North Carolina, and Mississippi, 1930 to 1985, suggests that, on the contrary, a temperature increase throughout the year was associated with fewer deaths from all causes combined, including deaths from infectious diseases, heart diseases, cerebrovascular diseases, pneumonia, and influenza. An average temperature increase of one degree Fahrenheit was associated with a more than 2 per cent decline in deaths from pneumonia and influenza. The only category of deaths showing no significant association was death from malignant neoplasms. Compared to spring, summer, and fall temperature fluctuations, unusually cold winter temperatures had the strongest fatal effects, but only in North Carolina and Mississippi. The greatest cumulative temperature effects on mortality were found in the same two states. Controlling for annual fluctuations in income per capita did not influence the relationship between temperature and mortality. There was evidence suggesting that the level of wealth ameliorated the fatal effects of extreme temperatures. In conclusion, unusually warm weather was followed by fewer deaths; unusually cold weather, by more deaths.

From lineage to conjugality: the social context of fertility decisions among the Pare of northern Tanzania

This paper is a case study of the linkages between selected characteristics of the social organization in a particular ethnic group and reproductive values and behavior. Specifically, it examines factors that might be responsible for the acceptance of contraception and an expressed desire for a relatively small number of children among the Pare of Northern Tanzania. It is hypothesized that with the increasing shift towards wage labor and diminishing dependence on land and lineage relations, there is a growing reliance on the conjugal bond and the development of a partnership marriage in which husbands and wives perceive their interests as mutual. This facilitates communication, particularly about family planning. Research methodology consisted of a two-pronged approach and combined an intensive ethnographic study of the households in the Ugwengo District of the Pare mountains with individual surveys administered to a sample of 512 women and in-depth interviews conducted with 20 women regarding the value of children and contraceptive and birth histories.

Assessment of analgesia in human chronic pain. Randomized double-blind crossover study of once daily repro-dose morphine versus MST continus

OBJECTIVE

This study evaluated Repro-Dose morphine (RDM; Reliadol from Nycomed Pharma), a new once daily controlled-release morphine formulation, against twice daily MST Continuous (MST) at steady state in patients with chronic opioid responsive pain.

METHODS

A randomized double-blind two-way crossover design was used to evaluate the efficacy and adverse effects of RDM once daily or MST twice daily, at the same total daily doses, in patients with chronic stable pain (dose range 20-120 mg per day). During the RDM limb of the study active drug was administered in the evening and placebo in the morning. Dextromoramide was provided as escape analgesia throughout the study. Following a 5-day screening period, during which stability of oral opioid dose was verified, patients underwent two 5-day treatment periods, (one MST, one RDM) in random sequence. Pain scores, escape analgesia requirements and side-effects were compared using data from days 3, 4 and 5 of each treatment period. Any events or medication changes occurring during the study period thought liable to influence analgesia were regarded as protocol violations. Overall assessment and period preference was assessed by direct questioning. RDM treatment was regarded as successful if the amount of escape medication required during the RDM period was equal to or less than that required during the MST period.

RESULTS

Forty-seven patients were included in the study, of whom 40 completed both periods [the intention to treat (ITT) population], 31 in strict accordance with the protocol [the per protocol (PP) population]. Results were similar for both populations. There was no significant difference in pain scores or incidence of adverse events occurring during the MST and RDM periods. For the ITT population, requirements for escape medication during the RDM period were less than, equal to or greater than those recorded during the MST period for 14, 15, and 11 patients, respectively. Twenty-nine of 40 patients (72.5%) were therefore RDM treatment successes (95% confidence interval 56.1-85.4%). The percentage of patients preferring RDM (45%) combined with those with no preference (32.5%) was significantly higher than those preferring MST (22.5%; P = 0. 0003).

CONCLUSIONS

Oral morphine administered as RDM once daily is at least as effective and well tolerated as MST twice daily, with over 70% of patients in this double-blind crossover study reporting that RDM was equal or superior to MST.

Fertility differentials among the Ijo in southern Nigeria: does urban residence make a difference?

The paper tests some of the conflicting hypotheses regarding the effects of urban living and education on fertility by examining the fertility levels of women migrants--some educated, others not--to various urban centers in one Nigerian ethnic group. Of particular interest are the conditions under which the urban residents live and the concept of 'urban' is examined in this West African context. Research methodology consisted of a two-pronged approach and combined an intensive ethnographic study of the families in the rural home community and in one urban center with a demographic survey administered to a larger sample of the rural residents and urban migrants. Analysis indicates that the effect of education on fertility is more powerful than urban or rural residence. The importance of utilizing culturally appropriate categories in demographic research is discussed.

Postinfarction rupture of left ventricular free wall repaired with a glued-on pericardial patch. Case report

In a 68-year-old man admitted in deep shock, prompt echocardiographic diagnosis of postinfarction left ventricular free wall rupture was followed by probably life-saving pericardiocentesis. At emergency surgery a 2 cm linear tear in the anterolateral wall of the left ventricle was successfully repaired with a glued-on pericardial patch, without infarctectomy or placement of sutures in the infarcted area.

The age pattern of fecundability: an analysis of French Canadian and Hutterite birth histories

This paper analyzes the age pattern of effective fecundability from populations with no evidence of deliberate fertility control using a new convolution model of fecundability. The analysis is based on a sample of Hutterite birth histories from the mid-20th century, and birth histories of French Canadians from the 17th and 18th centuries. The main findings are as follows: 1) the level of effective fecundability is higher among the French Canadians compared to the Hutterites; 2) effective fecundability peaks at age 20 for the Hutterites, and in the early to mid-20s for the French Canadians; 3) Hutterite effective fecundability declines almost linearly from age 20 to 45, and French Canadian effective fecundability declines slowly from its peak to the early 30s, and more rapidly at older ages; and 4) the duration of postpartum amenorrhea is longer for the French Canadians than for the Hutterites. Because of the shorter periods of postpartum amenorrhea the Hutterites have about the same average number of children as the French Canadians, even though the French Canadians have higher effective fecundability.