Noting that hypertension is said to be an extremely rare complicatio n of contraceptive pill use, the author reports this case of a 19-year-old girl given Orthonovin (norethisterone 2 mg and mestranol .1 mg). Her weight rose from 66.6 kg to 71.2 kg and her blood pressure from 115/70 to 200/100 mm of mercury in 2 years. She was changed to Norinyl-1 (norethisterone 1 mg and mestranol .05 mg) and her wieght fell to 66.6 kg and her blood pressure to 130/80. Chlorothiazide and Slow-K were given for 6 days only because of side-effects. She now takes Minovlar (norethisterone 1 mg and ethinyl estradiol .05 mg). Her weight is 66.6 kg and her blood pressure 130/75. A similar case has also been treated at Guy's Hospital. The condition may be more common than hitherto expected.
A suction-curet apparatus for endometrial biopsy.
A suction-curet apparatus for endometrial biopsy is described. The primary application of the apparatus is in the determination of ovulation in cases of infertility. An electric motor suction apparatus is employed instead of suction by syringe. The curved tube cannula is preferred to the straight instrument, and can usually be inserted without dilation of the cervix. The method can also be used for diagnosis of adenocarcinoma of the uterus, hyperplasia of the endometrium, the study of indocrinopathic amenorrhea, and for obtaining fertilized ovum at very early stages of implantation.
Statistics are presented for death from abortion during the 1st half of this century. Abortion is defined as the termination of intrauterine pregnancy prior to the 28th week regardless of cause. Data include changes made over the years in 1) determining primary cause of death; 2) mortality rates; 3) other causes of death from abortion. There has been a steady decrease in mortality from abortion from about 150 to 30 per million reproductive age women. Deaths from septic abortion outnumber deaths from nonseptic abortion deaths. Improved contraceptive methods, more skillful abortionists and better therapeutic drugs account for these changes. Mortality from abortion has been higher among blacks than whites but has declined faster among whites that blacks. Regional differences affect abortion mortality rates, but on the whole the death rate is on the decrease. For comparative purposes, some data is included for Switzerland, Germany, and England.
The chemical profile of dimethisterone is presented. Dimethisterone (6alpha, 21-dimethylethisterone. 6 alpha, 21-dimethyl-17alpha-ethynyltestosterone. 17beta-hydroxy-6alpha-methyl-1 7-(1-propynyl)-androst-4-en-3-one) is a white crystalline powder that is soluble in ethanol, chloroform, and acetone, but not in water. The hydrated form of the drug melts at 103-113 degrees, while the anhydrous form melts at 137-139 degrees. The ultraviolet spectrum of dimethisterone in methanol shows a maximum at 242 mmc. A colorimetric assay has been developed on the basis of the reaction of dimethisterone with sulfuric acid to form a chromogenic substance absorbing at 490 mmc.
Endometrial leukocytes in patients using intrauterine contraceptive devices.
Leukocyte infiltration of the endometrium was studied in women wearing a stainless steel ring intrauterine device (IUD). Adequate specimens from endometrial washings were obtained from 36 women wearing the IUD and 11 control subjects. The mean leukocyte count in IUD-patients was 40, compared to 14 in control subjects (p=.01). Counts under 20 were found in 3 of the IUD-patients (8.3%) and in 10 of the con trol subjects (90%). The differences were independent of the phase of the cycle. The observed inflammation is not the classical endometriosis, and is most likely harmless. The results suggest that the IUD exerts its contraceptive effect by creating an intrauterine environment that is toxic to sperm or the ova.
Some psychiatric aspects of birth control.
As it is the right of every couple to control their family size, physicians and psychiatrists need to be involved in the process of finding an efficient, simple and acceptable means of contraception and making it available to patients as a "mental hygiene measure." 400 married women, 253 Roman Catholics, 112 Jews, 30 Protestants, 5 Greek Orthodox, ranging in age from 16 to 50, the majority supported by welfare, and seeking contraceptive help at a birth control center in New York were studied. Each patient was personally interviewed and a diaphragm was prescribed. Patients were followed for a period varying from 6 months to 3 years at 6 month intervals. The method proved 100% successful in that any failure reported was due to a lack of cooperation by 1 of the partners. Only 10 husbands objected to the diaphragm. Women who had consistently experienced orgasm reported themselves as happier since using the diaphragm. Of the 400 women improved contraception was responsible for a return of or improvement in orgasms in 28% ofthe cases with the general effect of better health and mood and a more positive outlook towards life. Even without a return of orgasm, the women described themselves as more comfortable and content now that the fear of unwanted pregnancy was removed. The use of the diaphragm clearly eliminates worry and tension and consequently the relationship between husband and wife benefits as does the home atmosphere for the children. Birth control is an important addition to a psychiatrist's tools, for it relieves anxiety so that energy otherwise wasted may be used in psychotherapy. Psychiatrists should become involved in the further study of birth control for as a "mental hygiene measure" it is 1 of the most positive. (AUTHOR'S MODIFIED)
On design for experiment and research in fertility control.
A comprehensive and intensive design for experiment and research in fertility control is proposed. The design of the research is based on the assumption that fertility behavior is basically dependent upon the social milieu and that changes in fertility behavior necessarily involve social change. Consequently, changes in fertility behavior cannot be ac hieved by efforts to change attitudes, values, or motivation except in the context of changes in the social order. The proposal involves the following 5 key elements: 1) a fertility control program set up in accordance with the principles of experimental design; 2) a sampling scheme which proposes that a national probability sample be obtained of the study area; 3) the definition of the dependent variable proposes that the dependent variable be the birthrate, general and age specific, and if possible a conception rate along with a measure of the use of various methods of contraception; 4) "control independent variables"; and 5) "experimental independent variables." The results of the experiment would indicate the way in which contraceptive behavior was in fluenced by the varying "dosages" which considered cultural simultaneously with personal and sociological factors. The experiment would provide action programs with information on the most efficient way to bring about fertility control, with maximum result per unit of cost as measured by time, money, and human effort. The general design of the experiment is a broad outline of a major project requiring about 10 years of intensive effort. If this is not possible, the proposal is divisible into a number of parts, but the total design is not necessarily impossible nor impractical. Governments already coping with the fertility control problem could develop an experiment of the type proposed without much expenditure beyond their current effort. A comprehensive experimental program has greater potential of yielding significant results than the current unintegrated, uncoordinated, and non-additive action and research programs.
Medicine and world population.
In interpreting population growth in developed countries, the best answer can be achieved by determining the relative importance of birth and death rates and by accounting for significant factors of the behavior of the 2 rates. Examining 3 periods, before 1770, from 1770-1838, and after 1838 in England and Wales, reveals that in the 1st period birth and death rates were high, in the 2nd period mortality declined, and in the 3rd period, with national statistics available for confirmation for the 1st time, births exceeded deaths. This latter situation has continued until the present. The birthrate remained high until it began a decrease in about 1870. Mortality remained fairly constant until it began a decrease in about 1880. This decline in mortality appears to explain the initial population increase in the late 18th century and the continued population increase after 1870 despite a declining birthrate. The reasons for the decrease in mortality from the 5 diseases or groups of diseases (tuberculosis; typhus, typhoid, and continued fever; scarlet fever; cholera, dysentery and diarrhea; and smallpox) after 1838 were a rising standard of living, changes in the hygiene standards, and a positive trend in the relationship between the infectious agent and the human host. Therapy only had a minor effect on decreasing mortality. It can be said that the progress in the health field since the 18th century has been caused by a rising standard of living from about 1770, sanitary measures from about 1878, and treatment from about 1925. Now that there is an interpretation for the population increase in developed countries, it becomes necessary to deal with the present-day problem of controlling this increase. It appears that this problem can best be resolved by spending time and effort in the native villages bringing about a recognition of the need to limit family size.
Statistical evaluation of contraceptive methods: use-effectiveness and extended use-effectiveness.
Use-effectiveness relates to the experience of a human population with contraception while exposed to the risk of unintended pregnancy. In 1959 a new term, extended use-effectiveness, was applied to the evaluation of the experience of couples who had adopted contraception and had remained exposed to the risk of unintended pregnancy whether or not they continued their contraceptive practice. In studies of use-effectiveness, pregnancy rates tend to decline with duration of use. In studies of extended use-effectiveness, pregnancy rates can be expected to increase for a time as couples abandon contraception and then to decline gradually. A study was done in which each woman was classified by: 1) use effectiveness of all contraception, 2) use-effectiveness of 1st method, 3) extended use-effectiveness of all contraception, and 4) extended use-effectiveness of 1st method. 12 examples of contraceptive experience and a follow-up record are given. By such a study, a coherent framework for evaluation the use-effectiveness, in both senses, contraception as well as continuation is provided.
Population: more than family planning.
Family planning programs often have the limited objectives of promoting voluntary control to attain a desired number of children. It is unlikely that such programs will be able to achieve fertility control or population control, let alone its own limited objectives. If fertility control is to be achieved, family planning programs must recognize abortion as supplementary to contraception; must have as an objective inducing couples to desire replacement levels of fertility; and may have to consider abandoning voluntarism in favor of sanctions and incentives. Although family planning programs should be expanded, they should also be evaluated, and a determination made if other approaches to fertility reduction should be tried. Comprehensive population policies and programs need to be developed which take into account various aspects of population dynamics. (AUTHOR'S MODIFIED)
[Experiences in intrauterine contraception with the DANA SuperIUD]
Clinical experience with the DANA Super IUD in 172 women for at leas t 6 months (2751 use-months observed) is described. Indications include d recent induced or spontaneous abortion, and contraindications or intolerance of hormonal contraception. Insertion, performed on an outpatient basis, is best done immediately before or after the 2nd menstruation after abortion. Spotting occurred in 2/3 of the patients during the first few days after insertion; later side effects included endometritis, adnexitis, pelvic pain, breakthrough bleeding, and hypermenorrhea. The device was removed in 3 cases, and expelled in 6 others. 2 pregnancies occurred in spite of the IUD. The DANA Super IUD is highly effective, has a low rate of side effects, and is very economical.(AUTHOR'S, MODIFIED)
Fertility and economic behavior of families in the Philippines.
Socioeconomic influences on fertility and the interrelated effects of parents' fertility behavior upon their economic activity and welfare in the Philippines are analyzed in order to derive a formula for predicting direct and indirect consequences of various population policies upon fertility levels thereby assuring a more accurate cost-eff ectiveness measurement of a particular policy. A model, which utilizes variables generated from the National Demographic Survey of the Philippines conducted in May 1968, is employed to interpret available data in 5 areas of family activity: marriage, fertility, labor force participation, income, and migration. Primary emphasis is placed on the investigation of fertility determinants. A linear structure of equations representing fertility-related decisions on the timing of marriage, the number of years married, family size, and the use of birth control measures are analyzed by use of statistical methods appropriate to the model. The age at marriage is significantly influenced by the degree of schooling of the woman and her participation in the labor force prior to marriage. The actual decision concerning the timing of marriage is very important because the length of marriage variable deter mines the total number of births for families in all age groups. The use of any birth control method, including the more effective ones, was unpelated to longer open birth intervals. However, knowledge of birth control may be linked with a more rapid birthrate in the younger ages. The interactions between family fertility behavior and labor force participation and income of the women and their husbands are next explored. The significance of recent rural to urban migration patterns is also briefly examined. A concluding section on the policy implications of research findings emphasizes that knowledge of birth control methods is much more widespread than their use.
Studies on male infertility: 6. Clinical observation on male infertility.
Results of clinical observations of male infertility cases seen in S eoul, Korea, National University's Department of Urology between January 1955 and December 1969 are presented. 920 infertile men were seen, repr esenting 3.2% of 36,071 urological outpatients, and 3.9% of 30,125 male outpatients seen during this 15-year period. The number of male inferti lity cases has increased from 10 (1.09%) cases in 1955 to 166 (18.04%) cases in 1969. Primary sterility was found in 78% of the 920 infertile cases in 1969. Primary sterility was found in 22%. The ages of the infertile men ranged from 24 to 61 years (mean=35); the ages of their sp ouses ranged from 24 to 49 years (mean=32). Infertile marital life ranged from 1 to 40 years (mean=7). The duration of infertility cases seen between 1955 and 1959 was 10 years, between 1960 and 1964, 8 years; and between 1965 and 1969, 6 years. There was no close correlation between incidence of infertility and occupation (290 cases were white-collar workers and 414 were physical laborers). Etiological classifications indicate that 40% of the male infertility cases were due to faulty spermatogenesis, 21% due to faulty transportation, 14% due to faulty seminal composition, .5% due to faulty ejaculation, and 24% from unknown causes. In 840 cases where semen was analyzed, 51% had azoospermia, 34% had oligospermia, and 7% had normospermia. In 41 cases analysis revealed normal semen, however, no children have been conceived in 3 years. Testicular biopsies of azoospermias revealed 30% hypospermatogenesis, 27% germinal aplasia, 20% germinal cell arrest, 11% efferent duct occlusion, 9% peritubular fibrosis, and 3% normospermatogenesis. There was no significant difference in average frequency of sexual intercourse between fertile and infertile couples. Medical treatment combined with various drugs (e.g., testosterone, vitamedine) for 3-12 months was most effective in oligospermia (52 out of 101 cases) and azoospermia (13 out of 126 cases). In 22 cases of bilateral epididymal obstruction treated by epidiymovasostomy, viable sperm appeared in the ejaculates of 9. Vasovasostomy performed on 85 previously vasectomized men yielded successful results in 62 of 71 azoospermia cases in which the semen could be repeatedly examined. (AUTHOR'S MODIFIED)
3-month-old female hamsters were checked during the 2 weeks prior to experimentation for vaginal cyclicity. Those showing 3 consecutive cycles were implanted with a 450 micron diameter ball of progesterone or cholesterol on the tip of a 30 gauge needle. Ether was used as anesthesia and implantation was performed between 40-64 hours after ovulation. All implants were midline. The animals were divided into 2 groups; 1 group was ovariectomized on the next expected day of ovulation and the other was checked for vaginal cycles during the 4 weeks postimplantation. Ovulation was checked by counting tubal ova after ovariectomy. Progesterone implants in the preoptic-anterior hypothalamus, just below and slightly posterior to the anterior commissure and above the suprachiasmatic nucleus (frontal sections) suppress ovulation. Implants in the arcuate, ventromedian, or mammillary nuclei did not suppress ovulation. However, progesterone implants in the mammillary region did affect the period of the estrous cycle; it was not uncommon to observe 5 or 6 days between ovulations based on vaginal cytology. Cholesterol did not suppress ovulation when implanted in the preotpic, anterior hypothalamic, suprachiasmatic, ventromedian, arcuate, or mammillary regions. The same size implants do not disturb ovulation or estrous cycles when placed subcutaneously. To have an effect subcutaneously a 2-mm ball of progesterone must be used. Since progesterone is normally present in the hamster and subcutaneous injection of 25 mcg of progesterone inhibits ovulation (American Zoologist 8: 753, 1968), it is proposed that the preoptic-anterior hypothalamus is important as a negative feedback center for control of ovulation by progesterone.(FULL TEXT)
The physical and chemical properties of a crystalline material, derived from corpus luteum extract and possessing progestin activity, were analyzed. Compound A, the main constituent of the mixture, is composed of C21 H34 02, melts at 128 degrees, and is physiologically inactive. Compound B is composed of C21 H30 02, melts at 128 degrees, and has the characteristic physiological properties of progestin. Doses of .5-1 mg Compound B cause progestational proliferation in the castrated rabbit. Its potency is tentatively designated as 1 rabbit unit/mg. Compound C is also physiologically active, melts at 120-121 degrees, and is considered an isomorphic modification of Compound B. It is suggested that the name progestin be retained for Compound B because of its physiological action.
The effect of progestin and progesterone on ovulation in the rabbit.
The ability of exogenous progestin derived from the corpora lutea of sows or progesterone to inhibit ovulation was studied in the rabbit. The animals received either 3 rabbit units of progestin or 1-5 mg of progesterone after which attempts at mating were made, most of which were unsuccessful. In those animals in which mating was achieved there was no indication of ovulation in any of the animals 18 hours after mating. The administration of a minimal ovulating dose of pregnancy urine extract immediately after the refusal of mating resulted in ovulation in 7 of 9 animals. It was concluded that progestin inhibits ovulation by interfering with the postcoital release of pituitary gonado tropin hormone.
The size of uterine cavities was measured by using the planimeter-hysterogram technique. Factors affecting this size were considered. The measured size of uterine cavities was correlated with the occurrence of side effects from subsequent insertion of Lippes loops. Subjects were 45 normal multiparous women. Hysterograms were done with Diagunal as the contrast medium. Visualization of the cervical canal was obtained by using a short-tipped Jarcho's uterine cannula to inject the dye. This device also prevented leakage of the dye into the vagina. The procedure was carried out under fluoroscopy, followed by 3 films in the anterior-posterior position. A film with the cannula in place served to determine measurements. The uterine cavity was considered as a plane since the anterior and posterior walls were almost in contact. A compensatory polar planimeter was used for measurements. Of the 45 women, 32 (71%) had uterine areas between 6-8 square cm. Neither age of patients nor parity was correlated with the size of the uterine cavity. The surface area of the individual, calculated from height, and weight with the Dubois chart had no influence on the size of the uterine cavity. The distance between the fundus and the uterine os varied from 2.9 to 6.4 cm, with most 4-6 cm. The distance between the 2 cornua was 2-3.1 cm. The width of the Lippes loops inserted after the tests was 27.5 mm. 30 of the 45 women had the distance between the cornua less than 27.5 mm. The Lippes loops were 25 mm long. All the subjects had uterine cavities longer than 25 mm. Follow-up studies for 2 years revealed that 60% of the patients had vaginal bleeding immediately after insertion of the Lippes loops and 40% had inc reased bleeding with subsequent menstrual periods. In these 40%, the ut erine area was 6 square cm or less in 55.5% of them. Of those with no s uch complaints only 3.7% had uterine areas of less than 6 square cm. In 30%, pain had followed the Lippes loop insertion. Of these, 60% had uterine cavity areas of 6 square cm or less. In those not having pain only 10% had measurements of 6 square cm or less. Removals of IUDs were made in 40% of these women because of these symptoms. Pregnancy occurred in 12 women within 1 year after removal of the IUDs. There were no expulsions. It is suggested that the frequency of vaginal bleeding and pain is related to the disparity between the size of the uterine cavity and that of the IUD, particularly the width of Lippes loops at present commonly in use (27.5 mm). Newer devices should reduce this width but could increase the length. Fewer side effects and greater acceptability would thereby be promoted.
Fertility after removal of the intrauterine ring.
In order to answer questions most often asked by women using or considering use of the (IUR) intrauterine ring, 305 women who had requested removal of an IUR in order to become pregnant were followed for 18 months. 32.1% of these women conceived in the 1st month after removal; after 18 months, 93.1% had conceived. This figure is comparable to the results of a study by the World Health Organization. The failure of 6.9% of the sample to conceive cannot be attributed definitively to the IUR, as many of these women may have conceived after the follow-up period, and cases of sterility may have resulted from factors unrelated to the IUR. Younger women (mean age = 23.8 years) conceived sooner after removal than older women (mean age = 37.3 years). However, this difference was significant only after 18 months, and conception rates decrease with increasing age in women with no history of IUR use. Because the postremoval fertility rate was much higher for women who had worn the device for 1-18 months than for those who had worn it for 19-36 months, the IUR should be left in place for 2 years, removed for 1-2 months, and then reinserted if continued contraception is desired. The IUR may postpone conception, but it does not cause permanent infertility. Furthermore, in this sample, most women who became pregnant while the IUR was in place had normal labor. The IUR does not seem to cause malformations in pregnancies that occur while the device is in place or in pregnancies after removal.
Metabolic effects of steroid contraceptives.
Literature on the metabolic effects of steroid contraceptive agents is reviewed. Oral contraceptives (OC) do not seem to produce marked changes in tissue levels of carbohydrates. Abnormal glucose tolerance tests have been reported by some investigators, though the greatest changes appear to occur in women with a pre-diabetic condition or a family history of diabetes. The effect of OCs on glucose tolerance seem to be dose-related, and OCs containing mestranol have a greater effect than ethinylestradiol. The pre-diabetic changes induced by OCs are considerably milder than those occurring during pregnancy. OCs have frequently been found to produce considerable effects on the major lipid constituents of blood. It seems likely that all high-dose OCs produce increase in serum non-estrified fatty acids, triglycerides, phospholipids, cholesterol, and lipoproteins. In some women, it appears that changes in blood lipids are spontaneously reversed after 6-12 months. Lipid changes may be involved in weight gain in OC users, though there is no evidence that such changes contribute to a tendency to atherosclerosis. It appears that the degree of lipid changes are proportional to the estrogenicity of the compound taken. The decrease in plasma alpha-amino nitrogen during OC use probably indicates an equilibrium shift in proteins and circulating amino acids, which may be due to an increase in tissue mass and weight gain. OCs also cause an increase in the catabolism of tryptophan, and it is suggested that abnormal tryptophan metabolism is associated with emotional depression. Abnormal tryptophan metabolism, induced by OCs, may aggravate rheumatoid arthritis. OCs increase blood circulating factors VII, IX, X and fibrinogen, though low-dose progestogen preparations do not seem to affect the blood clotting mechanism. It is not yet possible to establish a clinical correlation between particular blood clotting factors and the incidence of thromboembolism. Little change in hemoglobin levels occurs among OC users, though serum iron and iron-binding capacity are considerably increased. The blood plasma of many OC users is normocalcaemic, but also hypophosphataemic and hypomagnesaemic, the latter leading to muscular convulsions over the long-term. Low plasma magnesium levels also enhance blood clotting. Most combined and sequential OCs suppress the release of luteinizing hor mone, but have little effect on other pituitary trophic hormones. Acne and hirsutism may be diminished by the decrease in androgen excretion among women taking OCs. Estrogens increase the level of plasma corticosteriod-binding globulins, thus increasing plasma blood cortisol. Most OCs reduce or eliminate the mid-cycle peak of urinary pregnanediol and reduce estrogen excretion. OCs reportedly increase levels of insulin and growth hormone. Estrogen-dependent effects of OCs on thyroxine-binding globulin produce alterations in thyroid function tests. Estrogen also seem to be responsible for changes in BSP retention, thymal turgidity, and, occasionally, serum alkaline phosphatase and transaminase. Severe cases of jaundice, though rare, have been reported for OC users. OC use must be discontinued in cases of liver infection.
[Contraceptive advice for the young]
Contraceptive counseling of youth is part of sex education in the br oadest sense. Because of the acceleration of physical development and changing sociological situations, the physician is increasingly confront ed with the problem. He is a witness of the process of development and must place himself helpfully at the disposal of his patients. The techniques of contraception, therefore, form only part of the physician's advice. Counseling the young must be done with special care to avoid damage. It is the physician's duty to provide contraceptive advice and counseling to young and unmarried individuals who seek it.(AUTHORS', MODIFIED)
Basic science and human reproduction.
There have been recent developments in 3 areas of biomedical research in the field of fertility control. The knowledge of cellular science has been applied to studies on the ovary and the ovum. Much has to be done to identify the controlling factors initiating the synthesis of RNA in the oocyte. Such knowledge is essential to controlling the ovarian process. There is still much to learn about the action of LH in triggering ovulation. Collagenase is being studied as a possible suppressant to RNA, and thus a suppressant to ovualtion. Cellular research is also investigating capacitation of spermatozoa and the mechanism by which the spermatozoa actually fertilizes the ovum. A recent advance, allowing further study of capacitation and fertilization has been the development of a procedure to fertilize mammalian eggs in v itro. A 2nd area of research has been in early embryonic development and in the passage of embryos from the oviduct into the uterus. Estrogens, anti-estrogens, and diphenylindenes are known substances which may interfere with ovum transport or implantation. Suppression of the release of LH may in turn affect estrogen levels and thus suppress implantation. A 3rd area of biomedical research is in developing a male contraceptive which would block spermatogenesis. Experiments have been conducted with alpha-chlorohydrin which may prove to be an alkylating agent. High doses of various hormones, such as estrogens and androgens will also suppress spermatogenesis, probably by suppressing LH and thereby reducing the endocrine support for spermatogenesis. It is hoped that an artificial androgen could be developed which would suppress LH, but maintain libido.
Rhythm: a hazardous contraceptive method.
The acceptance, applicability, use-effectiveness, and future practicality of the rhythm method of birth control was assessed in 10 family planning centers in Colombia. The acceptance rate ranged from 0% to 40%, for an average of 14.1%. The percentage of women using the rhythm method dropped from 21% to 8.8%, while acceptance of the intrauterine device rose from 8.4% to 27.5% of all methods used. The use of the basal body temperature chart was extremely difficult to teach, and husbands were often uncooperative in abstaining during the fertile period. Follow-up efforts were considerably more expensive for the rhythm method than for other methods. The lowest failure rate for the method among the centers was 36.2%. It is concluded that it is virtually impossible, if not hazardous, to implement a mass family planning program based on the rhythm method.
Irregular menses -- overripeness and fetal anomalies.
The possible association of irregular menstrual periods and overripeness of the ovum with fetal anomalies is discussed. Fetal anomalies occur most frequently among women who are 15 years of age and those who are over 35. It has been reported that the possibility of a normal conceptus decreases from 92% to 42% if ovulation occurs on Day 15, or later, of the cycle. Suppression of luteinizing hormone release for 48 hours in rats resulted in normal ovulatory rates, a decreased fertilization rate, increased embryonic anomalies, and a reduction in th e number of implantation sites. Embryonic abnormalities in aged rats increased with an increase in the frequency of irregular cycles. The similarities in the conditions associated with fetal anomalies between rats and humans should not be disregarded.
Sperm motility and survival in relation to glucose concentration: an in vitro study.
The effect of glucose on human sperm motility and viability was studied in vitro. At low concentrations of glucose, sperm motility was markedly depressed, but increased proportionately with increased glucose concentrations, reaching a plateau at 20-30 mg/ml of glucose in buffered solution. The results support the proposition that cervical mucus must contain at least 200 mg/100 ml of glucose during the fertile period. A hostile cervical environment may reflect a deficiency in glucose content in cervical mucus.
[Activity of the pregnancy interruption commissions in Berlin]
The channels through which an application for interruption of pregna ncy passes are briefly described. After pregnancy is diagnosed, the application is reviewed by 2 experts, usually gynecologists, who must make their recommendations with a view to the patient's present and future health status. The uniform judgement of the indications for an interruption of pregnancy has not yet been achieved in Berlin: the percentage of applications approved varied between 52.3% and 83% in various districts of the city in 1968. (For Berlin generally, 1508 of 2073 applications were approved, or 75.7%.) The author recommends that members of the commissions avail themselves of all therapeutic possibilities to encourage the applicant to bear the child.(AUTHOR'S, MODIFIED)
The effect of medroxyprogesterone acetate upon the duration and char acteristics of human gestation and labor was studied. 200 pregnant women (36-38 weeks gestation) were randomly assigned to a group receiving 20 mg 4 times/day or to a group receiving only the tablet base. This double-blind study failed to reveal any effect upon the duration of pregnancy or the characteristics of pregnancy, labor or fetal conditions.
Oral contraceptives and thromboembolism.
Reports quoted confirm previous investigations regarding the association between the use of oral contraceptives and deep-vein thrombosis and pulmonary embolism. 1 study showed that the use of oral contraceptives increased the risk of thrombosis 3 times; another study showed that 38% of women with venous thrombosis who were admitted to a hospital had been taking oral contraceptives while only 8% of controls had been using these drugs. An investigation by the Committee on Safety of Drugs suggested a relationship between oral contraceptives and death from pulmonary embolism. Such deaths were estimated to occur in 3 of every 100,000 users per year. Findings suggest it is the estrogen which is responsible; sequential types may, therefore, be more dangerous as they contain more estrogen. Chlomadinone acetate used without estrogens may be safer. Use of estrogens for other than contraceptive purposes, particularly if given in high dosage or for long periods, may also carry a risk. Thromboembolic disease in 1 of ever 2000 women per year of those taking oral contraceptives has been estimated and requires more attention.
Family planning programme in Punjab.
Since the reorganization of the state of Punjab, India, in 1966, the government has undertaken an aggressive program of family planning, conc entrating on the promotion of both male and female sterilization and IUD insertion. It is estimated that by 1967 about 50% of the eligible couples were using some form of contraceptive. 2 intensive campaigns in 1966 and 1967, for 37 and 45 days, respectively, were launched to enlist people in birth control programs. Approximately 1/2 of the year's IUD insertions and 3/4 of the sterilizations were done during these brief periods. In the period 1961-1967 the national growth rate decreased from 23.13 to 20.88 per thousand. Currently, family planning services in Punjab are available on a "cafeteria" basis, with all contraceptive methods presented to the prospective user so that he can make a personal choice with the aid of medical or paramedical personnel. There are also government sponsored family planning camps for loop insertions, vasectomy, and tubectomy. Leave and financial incentives are provided to persons undergoing sterilization or loop insertion. Charts, graphs, and other illustrative material are included.
Oral contraceptives and gastrointestinal disorders.
4 case histories of gastrointestinal abnormalities which developed in association with the use of oral contraceptives are presented. These were all cases of mesenteric vascular disease, confirmed through operative diagnosis. 2 cases exhibited massive bowel infarction necessitating resectioning.
MINI-TAB: a packaged cross-tabulation program for processing survey data on small computers.
MINI-TAB is a packaged computer program which cross-tabulates and makes charts out of files of data. The program can be used on a variety of electronic computers, even machines with a minimum of core storage. MINI-TAB performs 3 functions: 1) it regroups, recodes, and selects data for charts; 2) it computes frequencies and percentages for cells, rows, and columns; and 3) it calculates statistical associations. To use the program the user merely changes the instruction card in the program. Co des in the program will set up the table with indications for the width of data fields. Control cards indicate horizontal and vertical lines in the table.
Participation in United Nations Interregional Seminar on Demographic Aspects of Manpower.
This report informally describes a seminar on the relation between demography and manpower organized by the Population Division of the United Nations. This United Nations Interregional Seminar on Demographic Aspects of Manpower discussed relationships between population growth and needs in the labor force. Statistical methods for projecting population and manpower figures were discussed. Fertility control programs, a controversial area, were mentioned.
In 1969 the world's population increased by 71,000,000 with only 6.9% of these births in Europe but with 63.4% in Asia. The problems of overpopulation are evident in the extent of malnutrition, pollution, and overcrowded cities throughout the world. Even where family planning projects have been attempted, they have for the most part been unsuccessful because there first must be improvement in education and living standards and the establishment of adequate maternal and child welfare services before family planning can be accepted. In Britain a committee of senior civil servants has been set up to study the problem of population growth. The select committee on science and technology of Parliament appointed a subcommittee on the subject. Hopefully these beginnings will lead to a needed permanent committee on population and the environment.
In a study on fertility control and small families, it was found tha t data were unavailable to test the hypothesis that a feeling that children interfere with personal freedom motivates fertility control and small families. Only among couples who have remained childless does the desire to avoid restriction of personal freedom seem to have been a motivating factor. An alternative hypothesis was proven: Among couples with children, a feeling of restriction develops from the difficulties and hardships experienced. Women seem to feel more restricted by children in all socioeconomic groups than do men. The feeling of restriction increases with unsuccessful fertility, number of children, and low socioeconomic status. Having 3 or more children correlated highly with feelings of personal restriction. It is speculated that the feeling of restriction experienced by couples of high socioeconomic status relates to different values regarding family building and not to economic difficulties. The factors that were experienced (lack of success with family planning, actual number of children, or the objective difficulties related to economics) were less important to the couples' feelings than was the subjective interpretation of the experiences.
[Genetics of fertility and sterility.) (Domestic animals]
Fertility can be affected by genotype, environment, ovum or sperm function, congenital defects of the reproductive system, endocrine function, sexual function, and hereditary predisposition to certain disorders. Genetic traits affecting fertility are generally polygenic, but selection for fertility should be possible in species subject to art ificial insemination. Instead, it is probable that universal artificial insemination (to the extent that some bulls have 50,000-250,000 descendants and the male/female ratio is 1:1000-3000 in cattle) has decreased fertility. Environmental factors affecting fertility include photoperiod, breeding time, physical hygienic and climatic conditions, feeding and stress. Hormonal stess such as oxytocic stress from mechanical milking and adrenal stess from crowding may affect fertility. Hormonal function is selected for in egg-laying hens and probably in dairy cattle. Immunogenetic factors may act at the level of different parts of the male reproductive tract, decapacitation factor, blood group antigens, sex-linked antigens. Maternal-fetal incompatibility may account for 45% of embryonic loss in swine, 30% in c attle. For example, dairy cattle are known to reproduce more successfully if they are homozygous for serum beta-globulins. Morphologic of functional defects, some of which have been characterized as recessive autosomal, have been documented in several strains of cattle. Methods of choosing males for sperm donors must be improved and based on rigorous scientific principles rather than on traditional customs.
Report of Near East/South Asia/Far East workshop on literacy/population/ family planning education.
In order to encourage and implement the use of population/family planning information in literacy programs in the developing world, a workshop was held in India in 1970 with attending personnel from Afghanistan, India, Iran, the Philippines, Thailand, and Turkey. The objectives of the workshop were to share experiences in preparing and using teaching and reading materials; to explore common needs which could serve as a basis for joint planning and resource pooling; to assist in the design and planning of demonstration projects for developing materials and introducing population/family planning information into adult literacy and family planning education programs; and to assist in the identification of the technical assistance and supporting services needed to achieve these objectives. It was felt by the participants that these objectives were met.
A study of environmental factors in carcinoma of the cervix.
Epidermoid cancers rarely occur in sites not exposed to exogenous factors of irritation. To study the role of environmental factors in the production of cervical cancer, a clinical-statistical study was carried out jointly in the United States and India. A review is given of the incidence of cervical cancer as encountered in various population groups including: Jews, Fijis, Moslems, Negroes, low-income groups, marital status groups, and prostitutes. This study was an attempt to determine by personal interview whether factors that could explain variations in the incidence of cervical cancer among the different population groups could also explain variations within each group and vice versa. The major associations which this study suggests or confirms are marital status, age at 1st marriage, age at 1st coitus, number of marriages, and circumcision status of the partner. However, statistical associations do not by themselves necessarily establish the etiological significance of the associated factors. The present results are compatible with the concept that those population groups having a late age at 1st coitus and 1st marriage and low remarriage rate, whose men are circumscribed, have a lower rate of carcinoma of the cervix. Carcinogenesis represents the effect of many factors some of which may be endogenous and some exogenous.
A study on ovulation inhibition by Quinestrol: one dose a month.
The efficacy and safety of Quinestrol in a single-dose-a-month regimen for inhibition of ovulation was studied. 10 women received 2 mg Quinestrol on Day 1 of the first treatment cycle and 2 mg Quinestrol plus 50 mg medroxyprogesterone (Provera) on Day 22. During treatment Cycles 2, 3, and 4, 2 mg Quinestrol plus 50 mg Provera were received on Day 22, and in Cycle 5 no medication was received. Basal body temperature, urinary pregnanediol and urinary follicle-stimulating hormo ne determinations, vaginal cytology, and endometrial biopsies were performed during each cycle. The single 2 mg dose inhibited ovulation in 60% and delayed ovulation in 35% of a series of 40 cycles. The human safety laboratory studies did not reveal any abnormalities, and the side effects were mild in nature. It was concluded that this regimen might prove adequate for more effective inhibition of ovulation with larger do ses of Quinestrol.
Edward Foote's Medical Common Sense: an early American comment on birth control.
The 1864 edition of Edward Foote's Medical Common Sense is remarkabl e because it candidly supported birth control. The hazards of multiple pregnancy to maternal health were mentioned, but Malthusian concerns wer e primary. Folk methods of birth control were denounced. The methods t hat were currently in use--the glans condom, the regular condom, and the cervical diaphragm--were discussed. Because of his unorthodox views, Foote was convicted under the Comstock law in 1876. He continued to advocate birth control up to his death in 1906.
Prevention of pregnancy in the rabbit by the sc implantation of a silastic tube containing estrogen but not by similar implantations containing progesterone or ethinyl estradiol is reported. 10-14 days after implantation rabbits were mated and laparotomies done 2 days after to determine if ovulation had occurred. When ovulation had not taken pl ace, rabbits were artificially inseminated 12-14 days later and also injected iv with 50-90 I.U. of human chorionic gonadotropin (HCG) to induce ovulation. Animals were killed at 2, 6, or 12 days after mating or insemination. At autopsy the silastic tubes were removed and the rate of absorption of the compound calculated. The rates of absorption varied for different animals but were not correlated with day of removal. Tubes containing progesterone or ethinyl estradiol had not prevented ovulation. Ovulation had failed in 3 of 11 rabbits treated with estrogen. The average number of corpora lutea was reduced in those treated uith estrogen; 5.67 plus or minus .74 in 18 estrogen-treated animals, 12.7 plus or minus .64 in 20 treated with progestin, and 10.30 plus or minus .90 in 10 controls. Also the proportion of eggs recovered and of embyros obtained to corpora lutea was less in the estrogen-treated rabbits (28% compared with 90-91% in the other animals). The proportion of eggs fertilized was not affected. Failure of implantation was increased in estrogen-treated rabbits but not in the others. In estrogen-treated rabbits disturbance of egg transport seemed to increase the number of degenerated but fertilized eggs. The use of such procedures for contraception is recommended for further investigation.
An experiment was conducted to determine whether the luteolytic effect of the IUD inserted into the uterine horn contralaterad to the ovary containing the corpus luteum is exerted through systemic channels such as the general circulation of through a direct pathway to the opposite side such as the uterine lumen or the intercornual tissues. IU D was inserted in the uterine horn on Day 1 of the estrous cycle. Early regression of the CL occurred, as indicated by weight of CL on Day 10. Removal of the ipsilateral uterine horn or surgical separation of the 2 uterine horns from each other interfered with the luteolytic action of the IUD located contralaterad to the CL. Suturing the broad ligament from the unilaterally hysterectomized side to the uterine-intact side seemed to restore partially the luteolytic properties of the IUD. Sever ance and ligation of the uterine horn caudad to the IUD apparently did not interfere with the luteolytic action of the IUD, whether the IUD was contralaterad or ipsilaterad to the CL.(AUTHOR'S, MODIFIED)
The work of the Contraceptive Testing Centre of the Government of India.
The work carried out by the Contraceptive Testing Unit, a team of In dian Government research workers, is discussed. Colposcopy is described as it is used in detecting changes on the vaginal and cervical mucosa. 2 kinds of contraceptives are investigated by the Unit: oral and local. Biological testing of oral contraceptives is carried out for the Unit, which is chiefly concerned with developing substances capable of preventing fertilization or implantation. In studying local contraceptives, it must be determined whether the contraceptive meets 3 main requirements: effectiveness, harmlessness, and acceptability. For evaluation of these criteria, the local contraceptive studied by the Government Testing Unit must be submitted to laboratory tests, clinical tests, clinical trial, and a field trial. As changes in the cells and cellular architecture of the surface epithelium can be detected by magnified observation with the colposcope, it is possible to note the slightest changes in the cervical and vaginal mucosa, occurring after the "10 minutes test," the "Cap Test," and long-term use of the contraceptive.(AUTHOR'S, MODIFIED)
1 of the main measures taken to create an equilibrium between the natural resources and the expected economic growth and the population gr owth in Egypt was the establishment of family planning clinics. 8 of the clinics were established in 1955. In 1956, there were 12 family planning clinics in Egypt. Assistance is given in the clinics in 1) raising the standard of living through limiting the number of children; 2) spacing the number of children so the mother and children will be healthier; 3) treating sterility cases in order to help the childless family to get children; 4) evaluating the efficiency of the various methods of birth control anc selecting the most suitable methods to be used in various cases; and 5) collecting information about the number of children each family tends to have and the reason for such tendencies. The personnel at the clinic includes a doctor, social worker, and nurse. Suitable drugs and instruments used are given for half their cost price. (AUTHOR'S, MODIFIED)
Discovering the degree of commitment to family planning in a Calcutta City Project.
2 sections of Calcutta, each with about 10,000 residents, were selected to study changing family planning attitudes, behavior, and fertility over a 3-year period beginning in June 1964. 1500 couples from Center 1 were exposed to an action program on family planning; 1500 couples from Center 2 served as a control group. Data were collected at 6-month intervals to measure the impact of the action program. KAP data were collected on a limited sample basis from an extra block as a means of cross-checking data from the original survey and of obtaining data on attitudes, knowledge, practice, and sources of procurement. The data are presented in 20 tables broadly classified as general tables and attitude tables. The general tables are presented by 3 variables: age of husband, age of wife, and education and occupation of husband. The attitude tables are grouped into 4 subcategories: 1) acquaintance with family planning methods by education and occupational level of husband, sources of knowledge of husband and wife; 2) adoption of family planning by education and occupation of husband and by education, occupation, and willingness type of both spouses; 3) nature of steps adopted by education and occupation of husband and sources of procurement, types of methods adopted by education and occupation, and reasons for not adopting steps; and 4) desire for additional children by age of husband and wife and desire for additional children by surviving number of children.
The recent U.S. Senate hearings on oral contraception have engendered statements of opinion from both The American College of Obstetricians and Gynecologists and the Board of Directors of the American Fertility Society. Both have endorsed the Second Report on Oral Contraceptives of the Advisory Committee on Obstetrics and Gynecology to the U.S. Food and Drug Administration (FDA), which gives tacit approval for the continued prescription of oral contraceptives. Confusion regarding oral contraceptive usage stems from the difficulty involved in assessing and interpreting numerous variables. Such evaluation is necessarily influenced by the moral, ethical, social, political, economic, and medical attitudes of the assessor, as well as the user. Inasmuch as we do not have a legal definition of "safety," our actions are modulated by the collective opinions of responsible agencies - in this case the FDA. Presently there is no consensus on what comprises adequate toxicity evaluation of pharmacologic agents in general. The unqualified assumption that observations in the laboratory animal are uniformly applicable to the human is not justified. Furthermore, in interpretation of human data, hereditary and social factors must be considered. It is generally acknowledged that associated serious side effects of contraceptive pill usage occur infrequently. Causal relationships are difficult to establish, but the possibility of such relationships cannot be dismissed summarily. Since these agents are so utterly effective as contraceptives, any potential hazard must be weighed against the medical and social risks of an undesired pregnancy, as well as the risk of daily activity. The public has a right to accurate, unbiased information. Overreaction to some preliminary findings does not serve the best interests of either the public or science. Careful, responsible reporting and interpretation of data within the context of a given study are to be encouraged. There must be continued efforts to establish reasonable guidelines for the use of all pharmacologic agents, including the "pill". Physicians are accepting increasing responsibility for society's needs. Contraception is no exception. It is clear that every effort must be made to make periodic physical examinations, with cytologic studies, available to all. A careful review should always be undertaken to uncover potential contraindications to any contraceptive practice. Such comprehensive care necessarily includes helping the couple in their selection of the contraceptive modality most appropriate to their individual circumstances. Within such limitation, the oral contraceptives are a reliable therapeutic method and may yet prove to be the most valuable contribution to the welfare of society in the past decade. (FULL TEXT)
It has been shown that the X and Y chromosomes associate at meiotic prophase in the human male, but there has been speculation on whether it is the long or the short arm of the Y chromosome which associates with the X. Definitive evidence is presented that the latter takes place during the first meitoic prophase. Diakinetic cells were prepared according to the technique of Evans et al., stained with quinacrine dihydrochloride, and viewed with a Leitz microscope fitted with an HBO 200 light source and a Ploem vertical illuminator. 50 cells were selected from a normal male which showed differential fluoresecence. The X-Y bivalent was examined under ultraviolet light and under phase contrast. It was determined that where the X and Y chromosomes were associated, the more highly fluorescent region (the distal ends of the long arm fluoresce with the quinacrine stain) was at 1 end of the sex bivalent and not in an interstitial position. In cases were the chromosomes were lying free, the Y chromosome had a highly fluorescent a rea and a less fluorescent area which mirrored the staining distribution of the Y chromosome during mitosis. It was concluded that the short arm s, centromere, and proximal parts of the long arm are in the less fluore scent part of the chromosome as they are in the mitotic Y chromosome.
The Y chromosome in human spermatozoa.
Attempts have been made to distinguish between spermatozoa of mammal s containing either an X or a Y chromosome. It has been determined that the distal end of the long arm of the Y chromosome in mitotic and meiotic metaphase nuclei of human cells displays a fluorescence more brilliant than that shown by the other chromosomes when stained with either quinacrine or quinacrine mustard. When human spermatozoa were stained with quinacrine or quinacrine mustard, slides prepared, and viewed uith fluorescent illumination from a Zeiss photomicroscope using exciter filters for transmission ranges between 330 and 500 mn, some sperm showed a fluorescent body (F-body) which was brighter than the bulk of the fluorescent material. It is believed that the F-body represents the Y chromosome because: 1) In mitotic and meiotic metaphases, part of the Y chromosome fluoresces more than any other chromosome as does the F-body; 2) In interphase nuclei of normal XY males there is only 1 strongly fluorescent spot of chromatin, while in nuclei from XYY males there are 2 spots, and the nuclei of normal XX females exhibit no such spots. The frequency with which F-bodies are seen in sperm approaches that expected from the segregation of the Y chromosome at meiosis. It is presumed sperm lacking an F-body lack a Y chromosome and therefore may be X-bearing sperm.
The author reviews the history of the Bermuda Health Department's ef forts to promote population control among the island's black population. Political, social, and moral resistance by the black population to birth control is described, and lines of opposition from other sectors of the population during the initial efforts are reviewed. Social conditions that tend to promote illegitimacy are descr ibed, and legislative efforts (particularly that which required caring for illegitimate children) to reduce the illegitimacy rate are noted. Birthrates and illegitimacy rates are given for the years 1938, 1940, 1950, 1954, and 1955 along with corresponding public events. Public health nurse visits during the early phases of the program resulted in only 50 new patients a year. From 1954-1955 new cases increased from 200 to 650. This latter increase was accompanied by a reduction of births from 27 per 1000 to 25 per 1000 population though illegitimate births increased slightly.
A cheap and harmless oral contraceptive is needed to check world population growth. One substance, m-Xylohydroquinone or 2:6 dimethyl hydroquinone, has proven satisfactory in tests. It has no toxic effects, is not an abortifacient, and does not cause permanent sterility. For rural, illiterate India it is unsatisfactory because this substance must be taken on Days 16 and 21 of the menstrual cycle. Women in these areas cannot count and have no sense of time. A substitute compound has been developed at the Calcutta Bacertiological Institute, 2:6 diethylhydroquinone. This needs administering only after the menstrual period stops. Tests by several international laboratories indicate that this compound is at least a somewhat satisfactory oral contraceptive.
Community education in family planning.
Community education in terms of family planning in the case of India is examined. Having no children or having less than the accepted norm may well be a social stigma; therefore, there may be socal pressure on a woman to not consider the services of a family planning clinic. If the pressure could be made to work positively than the whole trend may reverse itself. The motivational trends should be understood by the family planning worker fully so that suitable methods of health education for family planning may be chosen. A group discussion method may work well in terms of changing attitudes and motivations. Another factor that may help the success of family planning would be providing sex education to children. Community programs of family planning should not only offer services but should also educate the public as to the availability of the services.
Progress and problems of family planning in the United Arab Republic.
The rapid population growth in the United Arab Republic (URA) is bec ause of 1) the large rural population (57%), 2) the agricultural economy , 3) high illiteracy, 4) high infant and child mortality, and 5) the hig h incidence of divorce and polygamy. There are an estimated 2,000,000 women of fertile age with 2-3 children. The goal of the governmental family planning program is to reach 1,000,000 women by 1970, reducing the rate from 2.54% in 1968 to 2.1%. IUDs and oral contraceptives are manufactured within the country. Acceptance of both is low in rural areas. Problems associated with the family planning program in the UAR include inaccuracy of statistics, interagency staff distribution, poor location of new centers, bureaucratic demands, need for more village centers or mobile units to reach rural areas, fixed working hours that are inconvenient for acceptors, lack of social workers, lack of availability of contraceptives, inadequate communication and motivational efforts, lack of sufficient full-time personnel, welfare advantages given to large families, and lack of centralized industries.
Rhythm of sexual desire in women.
Literature on the rhythm of sexual desire in women is reviewed and a preliminary study is presented. A major difficulty in past studies has been the woman's seeming ignorance of her own physiology. Although there is general agreement that peaks of sexual desire do occur, there is little agreement on when they occur. In a study of 30 women, sexual desire was apparently strongest during the postmenstrual and early ovulatory periods. The rhythm method of birth control, therefore is a source of sexual frustration for many women.
Chemical nature of the urinary "pregnancy test" with iodine.
This study evlauated the claim that the addition of iodine to the warmed urine of pregnant women produces a red pigment which is extractable with amyl alcohol and is diagnostic of pregnancy. Under optimal conditions 163 of 168 urine specimens of pregnant patients gave a positive test. However, 86 of 142 random urine samples from nonpregnant women or males also gave positive tests. The red pigment found when pregnancy urine reacts with iodine results from a reaction between uric acid, iodine, and tryptophan; uric acid is oxidized by iodine and the unstable intermediate reacts with tryptophan. Most urines of pregnant women have enough tryptophan to give a positive test. However, a positive test is an indication of hypertryptophanuria and not a specific test for pregnancy.
Motivation for and problems in establishing an evaluation mechanism in the State of West Bengal.
The government of India was presented with a plan by West Bengal, in 1967, to establish an evaluation program of the Family Planning efforts. The main objections of the government to the first plan was its cost and the need for highly qualified personnel. In July 1968 the plan was resubmitted to the government with proper modifications. It was not acted upon favorably. A third proposal was submitted in 1969. Action was being awaited at the time of this article. Problems complicating the development of an evaluation mechanism for West Bengal include the largeness of the country, the need for expertise, and the cost of an evaluation program.
Organization and motivation for evaluation.
One of the main difficulties in implementing an evaluation program of family planning programs is to get it accepted. Organization and motivation become very important in that case. Misunderstandings over the meaning of the term evaluation, the relationship between management and evaluation, and the relationship between internal and external program evaluation present problems with the acceptance of evaluation. The role of the advisor in establishing an evaluation program then is to help alleviate these problems; namely, to help analysts and managers understand the objective, the role, the purpose, etc. of the evaluation program. In order to accomplish this task, the advisor has to have a working knowledge of the program with its strengths and weaknesses, and a knowledge of installing a system for program evaluation.
Total cesarean and puerperal hysterectomy: a report of 205 cases.
A series of 205 total hysterectomies performed at cesarean section or in the puerperal period is reported. Although this total was collected during a 7-year period, 1949-1956, it represents the material from approximately 50,000 deliveries, a section rate of 3.72% of which 45% are repeat procedures. There were no surgical complications in 180 patients, 16 were in shock, there was hemorrhage in 4, afibrinogenemia in 4, and spinal shock in 1. Postoperative complications were observed in 59 patients, most of which were of a mild nature. There was 1 bladder injury, a vesicovaginal fistula which responded to treatment. There were 30 stillbirths, 10 of which occurred in conjunction with rupt ured uteri, 18 from abruptio placentae, 1 from erythroblastosis, and 1 from a neglected transverse lie, a rate of 14.6%. 3 maternal deaths occurred and are considered incidental to the procedure. 1 death followed long-standing peritonitis associated with uterine rupture; 1 patient with eclampsia, abruptio placentae, and lower nephron nephrosis died on Postoperative Day 20 of cerebral thrombosis; the third patient died at home on Postoperative Day 19 of a pulmonary embolus. Operative experience has shown that there is no reason to leave the cervix in situ. It is concluded that whenever hysterectomy at the time of cesarean section or in the puerperium is indicated, a total abdominal hy sterectomy can and should be performed.(AUTHOR'S, MODIFIED)
Inhibitory effects of steroids on gonadotrophin secretion in the male rat.
In assessing the capacity of a large number of steroids to inhibit gonadal function in male rats, it has been observed that the endocrine component of the testis appears to be inhibited more readily than is spermatogenesis. The compound is administered by the oral or parenteral route in 30-day-old male rats for 30 days. This method enables the inve stigators to distinguish between the inhibition of spermatogenic and endocrine functions of the testes and, by extrapolation, between the extent of inhibition of the FSH and ICSH secretory capacities of the hypophysis. Some of the compounds which appear to inhibit ICSH at a lower dose level than is required for inhibition of FSH are 17alpha-ethi nyl-5(10)-estraenolone, 17alpha-ethinyl-19-nortestosterone, 17alpha-ethi nyl-19-nortestosterone enanthate, 17alpha-ethinyl estradiol-3-methyl ether, 9alpha-bromo-11-ketoprogesterone, and 17alpha-2-methallyl-19-nortestosterone. Compounds whose androgenic activity are such that differentiation between ICSH and FSH inhibition c annot be made by this method although their inhibitory effect on total gonadotropin can be shown include testosterone propionate, methyl testosterone, methyl-19-nortestosterone, 17alpha-ethyl-19-nortestosteron e, and progesterone. In applying the findings to the female, it is suggested that the effectiveness of a compound in suppressing ovulation is not so much a factor of total gonadotropin inhibition as it is of an upset of the ICSH (or LH) and FSH balance. The FSH-LH ratio must be disturbed to a degree that follicular maturation and rupture are unable to progress normally. This would explain the observation that some relatively poor gonadotropin inhibitors, such as progesterone, have been observed to suppress ovulation.(AUTHOR'S, MODIFIED)
5- and 10-year results of 460 patients treated for breast cancer at the Johns Hopkins hospital during 1951-1956 are reported. Follow-up was obtained in all but 1 patient. 274 were Caucasian, 186 non-Caucasian, and the median age was 52 years. Radical mastectomy was done in 370 cases, simple mastectomy in 54 cases, and a modified radical operation in 8. The other 28 had only biopsy. Operative mortality was 1%. About 40% had negative axillary nodes, 47% positive nodes, 13% unknown. The 5-year crude survival rate for radical mastectomy was 62.3% and the 10-year crude rate 48.7%. The prognosis for Negro women was worse, even when compared to stage of disease. Compared with earlier reports, the Johns Hopkins figures were 20% better in the survival of patients with localized disease but only 10% better in patients with regional node involvement. World-wide survival rates are similar regardless of differences in type of treatment, which leads investigators to believe that factors of intrinsic malignancy of the tumor vs. intrinsic resistance of the host may be more important in the final outcome than differences in treatment. Studies are needed to assess the value of adj uvant therapy including castration, preoperative or postoperative radiation, and chemotherapy.
Relation of various epidemiologic factors to cervical cancer as determined by a screening program.
This study attempted to elucidate the etiology of cervical cancer by examining its association with a number of factors in a relatively unselected group of women. In 1963, a cytologic screening program was undertaken in Washington County, Maryland. The irrigation smear method was used. The final study group of 4341 was 46% of all white women aged 30-45 years enumerated in the census. Of the 4290 satisfactory smears, 46 were positive or suspicious. Subsequent investigation confirmed 31 cases of which 28 were at Stage 0 and 3 were invasive carcinoma of the cervix. Of 15 with suspicious cytologic findings 6 had confirmed findings, all of which were at Stage 0. Women who were never married had no confirmed cases. Currently-married women had lower rates than women whose marriages had been disrupted. Those who were married at age 16 or earlier had higher rates of cervical cancer as did those from lower socioeconomic levels. Having had multiple sex partners was associated with an increased risk of developing cervical cancer. Smokers had slightly higher rates than nonsmokers. Trichomonas vaginali s infestation was associated with higher rates. Findings indicate that trichomoniasis and cervical cancer are both associated with sexual activity.
Endometrial morphology and polyethylene intrauterine devices: a study of 200 endometrial biopsies.
209 consecutive endometrial biopsies were taken from patients at the Contraceptive Service of the Margaret Sanger Research Bureau in New York City. Patients had used polyethylene IUDs from 1 day to 105 months. IUDs used were Lippes loops B, C, and D (147 biopsies), Margulies coil 5 (28), Birnberg bow 3 and 5 (21), and more than 1 type (13). 96 of the patients were asympotomatic; 112 had IUDs removed because of abnormal or excessive bleeding, pelvic pain, persistent vaginal discharge, or anothe r symptom related to the presence of the device. The mean ages for asymptomatic and sympotomatic patients, respectively, were 32.3 and 32.0. The mean periods of use for the asymptomatic and symptomatic groups were 30.1 and 20.7 months, respectively. Since 9 of the biopsies yielded insufficient tissue for examination, the observations were based on 200 biopsies from 199 women. The 3 classes of endometrial biopsies were normal, minor changes, and significant lesions. 29% of the 106 biopsies from symptomatic patients and 40% of the 93 biopsies from asymptomatic patients were interpreted as normal. Minor changes were either local and superficial endometrial reactions of minor degree or asynchrony by 7 days or more from the stated day of the cycle (arbitrary 28-day basis) on which biopsy was obtained. 45% of the biopsies in symptomatic patients and 50% of those in asymptomatic patients showed minor changes. Among the minor changes in both asymptomatic and symptomatic patients, the ratio of minor-stromal-reaction biopsies to as ynchronous biopsies was 1:2. Biopsies designated as having significant lesion were those showing a diffuse inflammatory process or another intrinsic endometrial abnormality. Among 107 biopsies from symptomatic patients 25.2% had significant lesions. Among Lippes loop users 28% and 12.5%, respectively, of symptomatic and asymptomatic women showed significant lesions. Lesions were absent in the 28 women using Margulies coils. The number of patients using the bow was too small to provide relevant data. The main type of lesion found among Lippes loop users was endometritis, chronic or acute. 2 of the total of 13 biopsies having chronic endometrit is also had squamous metaplasia of the surface epithelium covering fundic endometrium, suggesting that long-term study of women using polyethylene IUDs is a good idea.
Projected world population and food production potentials.
During the past 200 years a technological revolution throughout the world has continuously improved the levels of living in rich countries, but in poor ones its principal effect has been to multiply human misery by causing a rise of human population at rates higher than ever before experienced. The rate of population growth was about .5% a year until 1900 and nearly 1% to 1950. Now rates are about 2% a year and in some countries 2.5-3%. At this rate the world's population now doubles in about 30 years. This growth and the lag in economic and social development are interrelated. For the next 20 years it is necessary to bring about an unprecedented increase in world food supplies because no likely reduction in population growth in poor countries will be adequate. Moreover a marked improvement in human diets, especially for infants and children, may be essential to lower birthrates because the availability of contraceptive devices may be unimportant until the desired number of living children is secured. Although the population p roblem has been created by lowering death rates, an essential element in overcoming the problem is to lower infant and child death rates still further. Increased production in developed countries cannot be adequate to supply poor countries 20 years hence. Although the cultivable area of the world is over 2 times as much as actually cultivated, the cost of bringing such lands into production is not economical. Most are in the tropics and methods of cultivating food crops in these areas on an intensive scale have not been developed. Long-term programs, capital assistance, and technical assistance will be needed on a large scale. Industry, universities, and research laboratories must cooperate. Some achievements have been made. Mexican wheat varieties in Pakistan and India and new rice varieties from the Philippines are promising. Other fertilizer-responsive crops have been planted in India. Availability of capital and introduction of new technology are needed. However, overall foreign aid effort to date has been too little and sometimes too late.
Relationship of family planning to pediatrics and child health.
This article starts from the premise that there are good reasons as to why family planning and child health services should be closely related to each other, in the end helping prolong the life of the infants, promote optimum levels of growth, and better the quality of par ental care. The points discussed in those terms are: 1) greater intervals between pregnancies reduces the chance of infant and child mortality, 2) family planning helps better the quality of family life and the health of the existing children by keeping the number of children low and the intervals between them optimum, 3) infant and child mortality reduction is a prerequisite in many underdeveloped countries for couples to adopt family planning, 4) family planning education and services should be a part of school programs, 5) large family size and overcrowding are associated with children's diseases, 6) children of large families are smaller in size, 7) maternal care in large families is less adequate than that in smaller families, 8) because of less maternal supervision, accidents in childhood may be more in the large families. The authors feel that family planning and child care services should be brought together for the foregoing reasons. The ways of doing this may include special health programs for school children, dissemination of family planning information in day care centers, head start programs, and diagnostic, counseling, and treatment centers for handicapped children, etc.
Contraceptive methods applied in family planning clinics in Egypt.
To avoid the use of criminal abortion as a means of family limitation in Egypt, 12 family planning clinics were established in various communities. The mechanical methods used were diaphragm and jelly, cervical cap and condom. Chemical methods included jellies, creams, suppositories, and foam tablets. In addition combination methods such as diaphragms with jelly, sponge with either 10% salt solution or a contraceptive or medicated tampon were used as well as physiological methods. Diaphragm and jelly was the most satisfactory method used and the most accepted. Because of the popularity of the method, a diaphragm suitable for use by the Egyptian women in a tropical climate is being produced locally with resulting economic advantages for the Egyptians.
Brief talk on the work of the Family Planning Association of Great Britain.
The Family Planning Association of Great Britain (FPA) receives no h elp from the British treasury but, since 1956, the government has at least recognized the good work done by the Association. The recognition has meant that information could be aired through the public media. The FPA works to establish clinics throughout Britain, sometimes using Public Health facilities if available. 235 clinics are currently in operation and more are needed. The London headquarters of FPA runs a pregnancy diagnostic center, a section on male subfertility, and research to test new contraceptives.
How are we doing in family planning in India?
The proposed family planning goal of the government of India is to r educe the birth rate from 41 to 25 per 1000 by 1975-1976 and to 22 by 1978-1979. The author describes 3 ways in which this could be done: 1) concentrating all efforts in the first year; 2) concentrating all effort s in the last year; and 3) making efforts to reduce the birth rate linea rly. The total population at the end of 1975-1976 would be respectively 559,000,000, 644,000,000, and 600,000,000. The total number of births to be prevented from 1966-1967 to 1975-1976 would be 85,300,000; 10,200,000; 49,200,000.
Pseudopregnancy: treatment of periodic psychiatric illness: a pilot study.
Although the use of oral contraceptives has been implicated in the onset of depressive episodes, pregnancy has been noted to be associated with a lower risk of developing periodic depression. It was considered worthwhile to pursue a small pilot study to evaluate the potential gain or risk of treatment with Enovid, an agent that at high dosage produces a pseudopregnant state. Patients were selected who had a history of periodic psychiatric illness or postpartum depression. Initial psychiatric evaluation and medical studies were done. The drug regimen used was 10 mg Enovid for 1 week, with weekly increments of 10 mg until 40 mg were reached. The drug was then discontinued and a placebo given for 2 weeks. Patients were observed for another month. Psychotherapy, occupational, and recreational therapies were continued during the treatment period. Of the 4 patients studied, 1 improved moderately, 1 slightly, and 2 remained unchanged. Clinical use should be deferred until further data are accumulated.
Low-oestrogen oral contraceptives.
The authors wrote in response to an account by Dr. E. Grant of sympt oms occurring in patients taking low-estrogen oral contraceptives (OCs). They reported a study of 60 patients enrolled in a "side effects" study of Ortho-Noven 2 mg (norethisterone 1 mg plus mestranol 100 mcg) later changed to Ortho-Novin 1/50 (norethisterone 1 mg plus mestranol 50 mcg). After 363 cycles on the low dosage, 29 patients reported markedly reduced vaginal bleeding (8 had pseudoamenorrhea), 7 had slight breakthrough bleeding and 4 had premenstrual pain for the first time. It was felt that these side effects differed from those reported by Dr. Grant because she used 5 quite different formulations representing a variety of estrogen/progestogen combinations whereas in this study the ratio of estrogen to progestogen remained the same. In this study no patient found the side effects sufficient to stop taking OCs.
Industrial pressure and the population problem the FDA and the pill.
Contrary to expert testimony before the Nelson Committee, Enovid was not approved by the Food and Drug Administration because of "industrial pressure." In 1959 neither G.D. Searle and Company nor the FDA wanted to become associated in the public mind with contraceptives. Both were unduly careful. Enovid had been in use for treatment of endometriosis and hypermenorrhea for 3 years before the company applied to market it as a contraceptive. The application was accompanied with data on 897 women who had taken the drug through 10,427 cycles. At the time, estrogens and progesterone were not considered dangerous drugs. Outside authorities were consulted before the FDA granted a "no objection" status to Enovid.
Reaction of unmarried girls to pregnancy.
An article by Claman, Williams, and Wogan in the Canadian Medical As sociation Journal reports their study of 316 unwed clinic patients at Vancouver General Hospital. 85% were between 16-25 years old, most under 20. Their reactions to the pregnancy were 1) fear of parental rejection; 2) fear of financial hardship; and 3) immediate thought of marriage. Most rejected marriage as an alternative, an enlightened response compared with former times. Most received supportive help from parents. Few chose abortion. More than 1/3 had been pregnant before. The authors concluded that once a young girl becomes pregnant out of wedlock, she is likely to do so again.
Administrative evaluation: an overview.
This paper focuses on the administrative aspect of evaluation of family planning programs such as assessing the organization of family planning clinics rather than measuring the economic effects of a family planning program. In a sense, administrative evaluation is more limited and more focused that overall family planning program evaluation. The exact questions that are being asked will determined the nature of the evaluative process. The author defines the administrative evaluation as evaluation of the action oriented, operational aspects of a program. As well as being program oriented, administrative evaluation is also task and activity oriented. It operates on a set of basic assumptions such as improvement in program operations leads to better utilization of services which may then have an effect on knowledge of, attitude toward and practice of the services. The characteristics of a useful evaluation, according to this article, are simplicity, practicality, uti lity, inexpensiveness, promptness, acceptability. Another part of the paper focuses on family planning administration and its evaluation in terms of answering questions such as determining who comes and who continues.
Estimating fertility without good vital statistics.
In discussing how to estimate fertility in the absence of good vital statistics, this paper elaborates on 5 different methods of fertility estimation. The first one, the reverse survival method, requires a life table describing the mortality situation at the time of the census. With this method it is possible to estimate fertility measures from basic census age data. The second method is called the "own children technique" based on census of survey data on own children who live with their mothers. The third method, the Brass technique, is a way of estim ating fertility from reports on childbearing in the past. Fertility rates are computed by using the census or survey data on children ever born and births by age of mother in 1 year preceding the census or survey. The Pregnancy History Analysis, the fourth method suggested, is based on a battery of interview questions serving as a substitute for vital statistics registration. The Population Growth Estimation (PGE) study, the fifth method considered, requires that the vital events be recorded by 2 independent investigators in sample areas. The article elaborates on the specifics of use of these methods and suggests that the Brass technique not be used on populations whose fertility has changed drastically in the recent past. The Pregnancy History Analysis approach works well if a good sample design is developed. The PGE, on the other hand, may require too much time and expense.
Sex-age pattern of population mobility in the U.A.R. with some international comparisons.
Egyptian census information collected since 1907 provides basic data on population mobility in the country over a long period of time. The general population is almost equally balanced between males and females. Males migrate slightly more than females do. Only in the depression period of 1927-1937 did female exceed male migration. The distance of migration affects the sex composition of the migrants; males migrate longer distances. This is also true in other countries. Age composition of major urban areas is similar in the countryside. The proportion of children under 15 in Cairo in the 1960 census was exactly the same as in the country as a whole. Young adult males do seem to migrate more than other age-sex groups. Economic prosperity tends to encourage migration for both males and females. Rural-to-urban migration seems to be fairly permanent, except when hard economic times hit. Retired people do not seem to return to the countryside.
The natural history of untreated breast cancer.
This report on breast cancer between the years 1805 and 1933 was obtained primarily from the early Middlesex (London) Hospital Cancer Cha rity records. Of 356 cases cared for in the hospital during this period, records were adequate for 250. Almost all were advanced cases o n admission. All died in the hospital. Autosies confirmed the diagnoses in all cases. Histopathological material was still available for 86. In these the incidence of tumors of low-grade malignancy was identical with that found in present-day cases. None had been treated with surgery or radiotherapy. At 3 years 44% were alive, at 5 years 18%, and at 10 years 4%. All had died by 19 years although 9 patients lived over 10 years. The median survival was 2.7 years. The prognosis was less favorable for young women. Those histologically graded 1 and 2 lived longer than those graded 3. No case of spontaneous regression was observed. A long, drawn-out distressing illness was suffered by many.
Deladroxate for the prevention of ovulation.
The article presents a study assessing the effects of a monthly injection of dihydroxyprogesterone acetophenide (Deladroxate) combined with either 10, 20, or 30 mg of estradiol ethanate in 3 groups of 10 women. Ovulation was entirely inhibited during the interval between shots. A high degree of side effects was observed, e.g., breast tenderness, heavy or prolonged menstrual flow, premenstrual fluid retention, and decreased libido. These side effects have been minimized by using dosages with less estrogen and more progestogen without depriving the drug of its antiovulatory effect.(JPS JPS)
The testes and accessory glands of 4 pubescent and 6 adult monkeys were examined in histologic sections stained with periodic acid Schiff reagent at various times from 17 hours to 7 months after a single sc injection of 1 ml cadmium chloride (9.12 g/l). In pubescent testis removed 17 hours or 8 days after injection, the diameter of the seminiferous tubules had decreased, and the spermatogonia had ceased spermatogenesis, the germinative cells on the periphery were necrotic, but the Sertoli cells were intact. 3 months later some tubules showed necrotic spermatogonia. In adults, 3 weeks after injection, the seminal vesicles, epididymal epithelium and prostate were atrophied. 3 months later the accessory structures had recovered, by 6-7 months approaching controls. During this time, the Sertoli cells were thriving, spermatogenesis was apparent, but newly formed sex cells were degenerating. Some Leydig cells had a large nuclei with prominent nucleoli.
Oral contraceptives have been suspected of playing a causative role in occlusive vascular disease. Women with hypertension, migraine, or va scular disease are thought to be especially at risk. The increased incidence of strokes in young women using the pill has been noted. Although meaningful morbidity data are lacking, complacency is not justified. Many women receiving the pills do not have adequate medical supervision. Observation of those accepting the risk should be careful and continuous. Alternate methods should receive greater attention. Despite unanswered questions, social, economic, and geopolitical factors still warrant this form of population control.
Oral contraception and thromboembolic disease.
Results of 2 case-controlled, retrospective studies on the risk of thromboembolic disease among oral contraceptive users are summarized and evaluated. The British Committee on Safety of Drugs found that risk of death from thromboembolism is 1.5 per 100,000 women annually for previously healthy pill users aged 20-34, compared with .2 for nonusers, and 3.9 for users aged 35-44 compared with . 5 for nonusers of same age g roup. The British Medical Research Council concluded that hospitalization for deep vein thrombosis would be required annually for 1 in 2000 married healthy pill users compared to 1 in 20,000 nonusers. The author recommended that women with predispositions to thromboembolism, such as hypertension or diabetes, not be given oral contraceptives. The risks should be weighed against risk of death from of death from smoking, pregnancy, cancer, and accidents.
Reproduction in goats subsequent to removal of intrauterine spirals.
An experiment was conducted in which female goats were fitted with intrauterine polyethylene spirals in 1 or both uterine horns. Their fertility was tested with the devices in place and after removal and compared with control goats' fertility. The estrous cycle in goats fitted with IUDs was reduced; the cycle returned to normal following removal of the IUD. This is evidence that no permanent endocrine changes are induced by IUDs. Following removal of the spirals, overall fertility of the IUD-fitted goats was 71%, compared to 100% for the control group. This difference was not statistically significant. No uterine pathological changes were induced by the spirals. It would seem that the contraceptive effect of IUDs lasts only while the device is in place.
By 1973, the birth rate in Taiwan will have been reduced from 36 per 1000 in 1963 to about 24 per 1000. The purpose of the policy of continuing the reduction as fast as possible is primarily economic, i.e., raising the standard of living and making increased savings possible. While industrialization, urbanization, and economic growth work for this policy, the increasing fecundability of the population and the significant increase in the number of young women of marriageable ag e are working against it. The achievement in Taiwan to date has primarily been reached by the full-time home visitors. There are advantages to having family planning and the regular Provincial Institute of Maternal and Child Health (MCH) programs work closely; help can be gotten from the experienced MCH personnel. However, when the MCH program is still weak, the family planning program should go ahead without having to wait for the advancement of the MCH program. A major educational effort is needed to reach young people and thereby change th e ideal family norm from 4 to as near 2 as possible. Nutritional education within the MCH program will have to be improved and strengthened also.
Septic abortion: current management.
The management of septic abortion continues to improve. Trends of i mportance are: 1) earlier and improved diagnosis, and 2) prompt and aggressive treatment. Initial treatment must be based upon a clinical diagnosis. A delay in treatment while awaiting laboratory confirmation could permit irreversible toxic processes to become established. Metabolic disorganization resulting from the circulating bacterial toxins can lead to the rapid onset of septic shock and renal failure. Early evacuation of the uterus, along with the rapid administration of p harmacologic doses of proven antibiotics (chloramphenicol, penicillin) and steroids (Solu-Cortef, Solu-Medrol), will give the patient the greatest possible advantage. Total abdominal hysterectomy with bilateral salpingo-oophrectomy in cases of early treatment failure, or in cases of welchii infection, has contributed significantly to the saving of lives.(FULL TEXT)
A novel, practical synthesis of 18-norsteroids.
18-norsteroids were synthesized from hecogenin derivatives by decarboxylation of a 12-keto-18-oic acid. 3beta-acetoxy-20beta-hydroxy-5alpha-pregnane-12-one, a hecogenin derivative, was treated with lead acetate and iodine in cyclohexane, yie lding a gamma-lactone as the main product. The lactone, when treated with dilute NaOH in methanol gave the 18-nor-3beta-acetoxy-20beta-hydroxy-5alpha-pregnane-12-one. The rings structure was verified as 13beta,14alpha trans, by comparison of the IR spectrum with that of a pure sample.
Stroke, sickle cell trait, and oral contraceptives.
A case report of a woman who developed a positive sickle cell test a nd an A-S pattern with less than 2% hemoglobin F (hemoglobin electrophoresis) while taking the oral contraceptive Ovulen (1 mg ethynodiol diacetate and .1 mg mestranol) is presented. Since 8.5% of American Negroes have sickle cell trait, it is suggested that a sickle cell test and a hemoglobin electrophoresis be performed before prescribing an oral contraceptive for a Negro patient. An alternative contraceptive method is suggested if sickling or hemoglobin S is found.
Contraceptive pill and thyroid nodule.
A case report of a 30-year-old twice gravid female who developed a h yperfunctional, thyroid-stimulating hormone-dependent thyroid nodule whi le taking an oral contraceptive agent is presented. While the drug was maintained, the nodule grew larger; but when the drug was discontinued, the goiter decreased in size and then disappeared. The association of an oral contraceptive drug and a nodular goiter may be coincidental, but a causal relationship involving thyroid-stimulating hormone should not be ruled out. Careful examination of all women taking oral contraceptive steroids and frequent radioactive thyroidal scans may bring to light a number of such cases that perhaps are being overlooked.
The statement of H.H. Suter (Letters, May 15) that "abortion, culling, (and) termination" will cover population control concerns only one side of the ledger. The other side - a new worry - is the generation of selected individuals. One can visualize the use of somatic cells or cultured somatic cells for the replication of larger numbers of "superior" beings. Several techniques that could make this feasible will be available in the near future. It is now possible to maintain or preserve the genetic pattern of somatic cells - how perfectly isn't known - of an individual long after his death. From an ethical and "moral" viewpoint perhaps we should take steps to insure that an individual's genetic pattern is not replicated as an individual and dies with him.(FULL TEXT)
Failures in natural conception control and their causes.
This summarizes case histories of 59 women who became pregnant while using the Ogino-Knaus method of biological birth control (rhythm system) . There were 2 actual failures, 23 women erroneously had intercourse during the conception period, 13 kept insufficient menstrual records before starting (less than 4 months), and 14 women used the method without any menstrual record at all. 2 women used the method immediately after childbirth before the menstrual cycle had reestablished itself. There was 1 irregularly menstruating woman, 1 with inflammation of the cervix, and 3 with pregnancies due to mental shock, change of climate, or marked variation in physical habits. Records of 11,222 intercourses from 265 women during the sterile period show no conceptions, confirming this method is practical and reliable when used correctly. However, adequate menstrual records must be kept before beginning. Although the menstrual cycle may be temporarily upset by sickness, physical or mental shock, unusual exertion, great change of climate or altitude, or other distrubances, it usually returns to accustomed regularity after the disturbance is past.
Anastomosis of the vas deferens to correct post vasectomy sterility.
It is emphasized that anastomosis of the vas deferens has been succe ssful in a sufficient number of cases to justify its more frequent perfo rmance. In 6 cases operated on by the author, normal sperm counts were later found in 5. Also, in 1 case with tuberculous epididymitis, a normal sperm count followed resection of the diseases tissue. Vasectomi es of these patients had been done from 3 to 13 years previously. In 1 successful case, a previous unsuccessful operation had been done elsewhe re to correct the condition. An intraluminal splinting silkworm suture was used in each case. This was removed after 4-6 days. Minimal dissection and gentleness was used in handling tissues. Mattress-type sutures were placed to retain approximation of vas ends with minimal tension. Very fine silk sutures were used at the anostomoses with care taken to avoid penetrating the lumens. The operation is recommended in selected cases.
Chlormadinone, a potent synthetic oral progestin: evaluation of 1002 cycles.
A clinical evaluation of chlormadinone acetate, a synthetic steroid preparation with marked and selective progestational effect on the endom etrium, is presented. Like progesterone it demonstrates no estrogenic activity; in fact, it is a potent antiestrogen and requires either endogenous or exogenous estrogenic priming of the endoemtrium to produce secretory effect. It does not show androgenic properties that might predispose either the patient or her female female to masculinization. 279 patients were followed for 1002 menstrual cycles. 143 received various dosages either alone or in combination with mestranol for either primary or secondary sterility lasting from 1 to 10 years; 90% had sterility of 2 years or more. These women were treated for 451 cycles. Withdrawal bleeding occurred within 7 days of cessation of therapy in 79.5% of cycles; in all but 5 of the remaining cases bleeding occurred within 14 days. The oral contraceptive group consisted of 130 women who took 80 mcg mestranol daily from Cycle Day 5 to 19 followed by 2 mg chlo rmadinone and 80 mcg mestranol taken from Day 20 to 24. 15 patients rec eived a hemogram, a clotting profile, routine urinanalysis, and a battery of liver, thyroid, and adrenal function tests as well as endomet rial biopsy at 3-6 month intervals. In 98.7% of all cycles withdrawal bleeding occurred within 7 days; in 4 cycles there was pregnancy and in 2 patients failed to follow the regimen properly. 8 patients experienced prolonged menstrual flows and 1 markedly diminished flows. No adverse effects were found in any of the laboratory examinations. 6 patients were selected for special study while on chlormadinone therapy. In 3 with secondary amenorrhea investigators found secretory endometrium; in 3 with normal menstrual cycles, regressive glandular changes with pseudodecidualization was found. Undesirable side effects included breakthrough bleeding, some nausea (although less with chlormadinone alone than when combined with estrogen), mastalgia, and dysmenorrhea. No cases of thrombophlebitis or pulmonary embolism were observed. Doses of 2-4 mg proved adequate to stimulate normal secretory endometrium with predictable withdrawal bleeding.
Population growth: challenge to endocrinology.
The basic population problem is the decreasing quality of life of human numbers. The rate of growth of 2% per year is unprecedented and largely due to decelerating death rates in countries with low living standards and high growth rates (up to 3%). These countries are trying to increase economic growth but need to invest a 9% increase in capital just to maintain their 3% annual growth. The problem is augmented for them because over 40% of their numbers are children dependent for health care, education and consumer items. The economists debate whether famine will come soon or whether we will find barely enough food eventually; the poor countries can discuss whether their next doubling will occur within 60 years rather than 25. These countries cannot wait for economic, medical and educational development to slow their population growth. Although all couples are free to plan or limit their families, many of them, e.g. 80-85% of the people in Africa and South American have no national family planning programs. Over 9% of the effective contraception in Asia is due to IUDs and sterilization. In many countries pills have not been used, but studies have shown poor continuation rates, e.g. 41% after 1 year. The reason is probably that hormonal contraception needs a better technology, an acute challenge to endocrinologists.
Low-dose progestagens as contraceptive agents.
The low dose progestogens available for use as contraceptive agents are identified, and the evidence of their possible mode of action is discussed. The relative acceptability and clinical effectiveness is also indicated. Progestational agents fall into 2 groups: 17-acetoxy progestogens (chlormadinone acetate 500 mcg and megestrol acetate 500 mcg) and 19-norsteroids (norgestrel, 50-75 mcg, norethisterone acetate, 300 mcg, norethisterone 500 mcg, and ethynodiol diacetate 250-500 mcg). The effect of the progestational agents on the hypothalamo-pituitary-ovarian mechanisms can be interpreted from leutinizing hormones (LH) levels. 17-acetoxy progestogens disturb LH excretion and the dose of these drugs which inhibits ovulation is very close to the dose exerting local contraceptive action. In 19-norsteroids administration, the LH midcycle surge is still present but long-term use may distort the LH peak rather than suppress it. 19-norsteroids seem to effect the ovarian function, although the corpus luteum appears normal. Evidence for an ovarian effect produced with chlormadionone acetate is less convincing. An effect of these progestogens on the endometrium appears to be absent, however, this assertion is without the support of electron microscopy study. Cervical mucus is a major site of action of the 17-acetoxy group although this may be unrelated to contraceptive effectiveness. The data on the effect of 19-norsteroids on cervical mucus is conflicting. Animal studies with low dose progestogens have shown unusual findings to be absent, although breast nodules were found in the beagle. The disadvantages of the low dose progestagens are in the irregular bleeding and the use effectiveness rate of 9/100 woman-years and method failure of 6/100 woman-years.
A technique of vasectomy for sterilization.
A technique used in 160 vasectomies is described and illustrated. After injection of novocain, short incisions are made, the vas is graspe d with a hook, freed from surrounding tissues, and 1 or 2 inches excised. The proximal end is ligated with dermal sutures and buried in the surrounding fascia; the distal end is ligated with catgut and anchored outside the fascia using a dermal suture. Patients reported for sperm checks until semen was spermatozoa-free. In 2 cases efforts were made to reestablish patency. In 1, done 7 years and 8 months after vasectomy, the outcome seemed successful. In the other, done 7 years after, the outcome was not.
The clinical effectiveness of the rhythm method of contraception.
Of 551 women referred to the rhythm clinic at the Free Hospital for Women in Brookline, Massachusetts, 409 used the method for 1 month or longer. They were observed for 7267 months or 605.6 woman-years. 224 participated for less than 1 year, but these patients contributed only 1134 months or 15.6% of the aggregate exposure to the risk of pregnancy. The number of accidental pregnancies recorded during this period was 57. In addition, 209 women discontinued participation without further contact with the clinic. To determine if additional accidental pregnancies were concealed in this group, a trained social worker contacted a selected sample of 69 women and found 10 (14.5%) who were accidentally pregnant when they withdrew from the clinic. If this ratio is applied to the 209 nonreturning patients, the estimated concealed pregnancies is 30, for a total number of accidental pregnancies of 87. This gives a rate of 14.4 pregnancies per 100 woman-years of exposure or 1 unwanted conception for 8 years' reliance on the method. This is much higher than the rates for diaphragm-and-jelly or condom (6 or 7 per 100 years of exposure). For those for whom pregnancy would be dangerous, this method is considered inadequate.
Steroids. 12. Aromatization experiments in the progesterone series.
Aromatization experiments in the progesterone series are presented. Mineral oil vapor phase aromatization was employed in converting 1,4,16- pregnatriene-3,20-dione, prepared from allopregnane-3,20-dione, into 3-hydroxy-17-acetyl-1,3,5,16-estratetraene. Reactions discussed included its transformation into the aromatic analogs of the corpus luteum hormone progesterone, and the adrenal hormone 17alpha-hydroxyprogesterone. Progesterone or 16-dehydroprogesterone on tri- or dibromination, respectively, followed by collidine dehydrobromination, lead to the same 1,4,6,16-pregnatetraene-3,20-dione which undergoes the dienone-phenol rearrangement. Hydrogenation of the rearrangement product yields the aromatic progesterone analog 1-methyl-3 -hydroxy-17-acetyl-1,3,5-estratriene.
Some effects of progesterone and related compounds upon reproduction and early development in mammals are described. The efforts were largel y directed toward studies designed to induce progesterone effects at critical stages during the follicular phase of the cycle. In humans, ovulation-time studies were based on the examination of the temperature curves, endometrial biopsies, and vaginal smears taken during control cycles. In the experimental cycles, positive diagnosis for ovulation time was possible in 27% of the temperature curves, 18% of the endometrial biopsies, and 6% of the vaginal smears. The incidence of ovulation time practically coincides with the incidence of mature corpora as revealed by laparotomy. Pregnanediol excretion studies suggest that progesterone taken orally may be excreted in the feces or that if it is absorbed via the enterohepatic circulation, a liver-produc ed metabolite other than pregnanediol is produced, which may or may not be the "effective" ovulation inhibitor. Follow-up studies revealed a rapid return to normal ovulation cycles following progesterone discontinuation. The effects of 19-nor-17-ethinyl testosterone and 17-ethinyl estraeneolone were examined in a limited number of humans. Their effects appear to be more potent and more promising than progesterone. The nonsteroidal substances, cirantin and metarylohydroquinone, were studied in rabbits and in rats. No marked antifertility action was observed in rabbits at dosages the same as or larger than those found effective with 15 active steroids, but both were effective in the rat. The deductions made from these studies are that 1) a number and variety of substances capable of preventing fertility in experimental animals are demonstrable, 2) certain substances having ovulation-inhibiting effects in experimental animals exhibit entirely comparable effects in the human female, and 3) effective substances may be taken by mouth or administered parenterally.
Religious factors in the population problem.
The Roman Catholic Church has often been singled out as the sole religious opponent of efforts to reduce birth rates. Other major religions do not officially condemn contraceptives. Moslems have official permission to practice contraception but their birthrates are uniformly among the highest in the world. The disparity between official doctrine and actual behavior exaggerates the importance of Catholic doctrine. The influence of religion as exerted through promulgated doctrines is not as important as fold beliefs. Desired family size is nearly always larger in undeveloped countries. To achieve replacement levels birth rates in most underdeveloped nations need to be reduced 50%; contraceptive control without changes in motivation cannot bring about such a change. Reductions in infant and c hild mortality, urbanization, industrialization, and associated economic factors as well as religion relate to these inducements. Recent Catholic thought tends to stress that family size must be determined by the family in its own circumstances and not by social or political agencies or even by the Church. However, the Church does promote the moral desirability of large families when within the means of the couple. Spacing, as a form of planning, has religious sanction because it helps safeguard the health of the mother. Folk beliefs, religious or otherwise, are a significant point at which religious variables become r elevant in predicting ways motivation to control fertility can be increased. A pronatalist factor in Islam stems from a strong belief in the active providence of Allah. Any question of restricting the number of offspring tends to appear as lacking in piety. In the popular minds of Hindus and Buddhists the conscious endeavor to prevent conception, other than by abstinence, has often been interpreted as injury to life and as interference in natural and morally inviolable cosmic processes. Communists adhere to the Marxian assertion that overpopulation per se can never exist in a socialist state and that inequity in resources is a consequence of capitalistic production. However late marriage and sanctions against having more than 2 children are used in China. Russia maintains that population growth is within the scope of governmental authority. The Catholic insistence upon the voluntary nature of family-size decisions is considered favorable. In all cultures the voluntary approach is considered the best.
Oral contraceptives and urokinase activity.
The effect of oral contraceptives (OCs) on the excretion of urokinase and the patterns of urokinase excretion in normal women during the menstrual cycle were studied. Urokinase activity was determined on morning specimens by the Von Kaulla method. The results indicated an increase in urokinase activity as a result of OC use. The mean optical density of urokinase activity in urine of users was .886 as compared with .372 for nonusers. There was wide variation in urokinase activity among normal women within the same menstrual cycle phase and only a slight change (increasing toward the end of the cycle) in any given individual throughout the cycle.
The effect of ethinyl estradiol, medroxyprogesterone acetate, and 3 oral contraceptive preparations (Enovid E, Enovid, Provest) on experimen tal allergic encephalomyelitis (EAE) was studies. .005 mg/day ethinyl estradiol prevented the development of EAE in rats immunized with .2 mg of 10% rat cord in Freund's adjuvant. 8 of 10 controls showed histologic EAE at sacrifice 3 weeks postimmunization; in 6 it was severe. 2 of 9 ethinyl estradiol-treated rats showed histologic EAE, and in only 1 was it severe (p greater than .01). Clinical disease was inhibited, and the treated gained while the controls lost weight. 1 mg medroxyprogesterone acetate did not inhibit EAE in rats immunized with 10% rat cord. 14 of 17 treated showed histologic lesions (11 were severe), which was comparable with the untreated controls. 21 of 31 controls showed clinical disease, whereas all 17 treated rats showed clinical disease, indicating medroxyprogesterone acetate exacerbated EAE. The 3 combination OCs all inhibited EAE at 3 weeks in rats immunized with 10% rat cord. When kept for 6 weeks, Enovid E and Enovid groups remained disease-free, whereas 8 of 11 treated with Provest showed disease. Since EAE mimics multiple sclerosis (MS) clinically and pathologically, the question of whether women with MS should be given OCs arises frequently. It was suggested that those OCs with the highest estrogen-to-progestin ratio be favored in patients with MS.
Inhibition of HCG-induced ovulation by anti-HCG serum in immature mice pre-treated with PMSG.
The minimum time in which ovulatory gonadotrophin must be present in the circulating blood of the mouse to be effective was determined. Mice received a subcutaneous priming injection of pregnanct mare's serum gona dotrophin (PMSG) followed by a single subcutaneous or intravenous inject ion of human chorionic gonadotrophin (HCG) 54-56 hours later. Rabbit anti-HCG and -PMSG were injected at various times after the injection of the ovulating hormones HCG and PMSG. The mice were sacrificed 20-24 hours later for the examination of tubal ova. Ovulation was completely blocked when the hormone and its antiserum were administered simultaneously by intravenous injection. All mice ovulated normally when the injection of antiserum was delayed for 2 hours. It was concluded that a 2-hour existence in the circulating blood is sufficient for the ovulatory gonadotrophin to induce maximum ovulation and that irreversible changes occur in the mature follicles during this period.
The General Assembly of the International Union against the Venereal Diseases and Treponematoses was held in Budapest in June 1969. Papers dealt with the following topics: 1) changing patterns of sexual behavior and their relation to venereal disease (VD); 2) the need to diagnose and treat VD in routine gynecological examinations; and 3) venereology training. Many countries expressed an interest in the social, educational, and public health aspects of VD. There is a need for the more developed countries to aid less developed countries in venereology training. The modern factors of urbanization and migration of labor are causing a breakdown in the family unit and an increase in VD. "Repeaters" must be studied. Basic biological research is needed. It was mentioned that the increasing use of IUDs and pills, rather than the older barrier contraceptives, is causing a rise in the incidence of VD. All medical and social indications are that VD will continue to rise. Greater financial support for international work in this area is needed.
Recurrent polyneuropathy with pregnancy and oral contraceptives.
This is a case report of a 26-year-old patient with recurrent symmetrical polyneuropathy with 3 consecutive pregnancies and while taking oral contraceptives. She was admitted to the hospital complaining of numbness of hands and feet and progressive weakness of all limbs. Similar symptoms had occurred during 3 previous pregnancies and had progressed to quadraplegia with areflexia. The pregnancies ended in normal deliveries. In the first pregnancy symptoms disappeared in 2 months; in the subsequent ones symptoms appeared earlier and required 6 months to disappear. After the third pregnancy she received for 9 months a chlormadinone acetate and mestranol contraceptive, then ethynodrel diacetate and mestranol. 2 months later symptoms began and progressed in 1 month to complete quadriplegia. She stopped the contraceptive as soon as symptoms began. There was no pregnancy, no cranial nerve involvement, nor muscle atrophy. Distal hypalgesia and decreased position and vibration senses were noted. Nerve conduction velocity was diminished. Muscle biopsy was normal. Nerve biopsy showed degeneration of the myelin sheath with relative preservation of axons. Laboratory tests were normal except for elevated spinal fluid protein. Recovery was slower than previously. After 2 years slight foot-drop was present. There seemed to be a relation between female hormones and the recurrent disorder. The possibility that immunopathologic factors were involved was considered.
Effect of an oral contraceptive agent on blood pressure response to renin. (34640).
This study attempted to determine why an occasional patient develops hypertension that appears to be related to the use of oral contraceptives. Changes in the renin-angiotension-aldosterone system have been blamed. Renin, an enzyme from the kidney, acts on renin substrate, a plasma protein, to release angiotensin, a powerful vasoconstrictor and stimulator of aldosterone secretion. The concentration of renin substrate has been shown to be increased by estrogen. In this study 20 Holtzman albino female rats were treated with norethynodrel with mestranol (Enovid R), given in their diet at .1 mg/kg/day. 20 other rats received 1 mg/kg/day. There were 20 controls. After 3 weeks of therapy, cannula were placed in the femoral arteries and jugular veins. Angiotensin, .12, .25, and .50 mg/kg, was administered iv and blood pressure response recorded in 10 animals from each group. Blood pressure response to renin was determined on the remaining animals. (Amounts of renin giving a response approximately equal to the 3 dosages of angiotensin were used.) Rats given 1 mg/kg/day of Enovid had a significant decrease in blood pressure (p less than .01) to the .5 mcg angiotensin. The .1 mg of Enovid had no effect on blood pressure. All doses of renin produced an increase in blood pre ssure response in rats treated with 1 mg/kg/day of Enovid (p less than .01). Those treated with .1 mg/kg/day had slightly decreased blood pressure response. Angiotensin responsiveness was shown to be decreased when renin was increased. Data indicate that renin-substrate is rate-limiting in vivo in blood pressure response to exogenous renin. However, renin levels may not give a true guide to angiotensin production. As angiotensin responsiveness can be reduced by oral contraceptive agents, determination of angiotensin levels and responsiveness is necessary before the role of changes in the renin-angiotensin system in the genesis of oral contraceptive hypertension can be evaluated.
Contraceptives and hypertension.
Though described in 1962 the hypertensive effect of oral contraceptives was not given much attention until 1967. Since then an increasing number of single and multiple case records have been reported, particularly in an accelerated malignant form. The blood pressure rise may begin weeks or months after beginning such therapy, usually falling by 4 months after therapy is stopped. Estrogen is blamed. Failure of plasma renin to be suppressed has been thought to indicate susceptibility. Estrogens are known to increase the protein substrate upon which the enzyme renin acts to produce the pressor substance angiotensin. The increased angiotensin should suppress the release of additional renin. Failure to do so results in a rise in renin levels and more angiotensin with hypertension. Development of a diagnostic procedure for the early recognition of susceptible patients is suggested. Also the need to occasionally measure the blood pressure of patients taking oral contraceptives is emphasized.
Bacteriological study on the users of intrauterine contraceptive devices.
This study was undertaken because of reports that IUDs might lead to pelvic inflammatory disease. Bacteriological examinations were carried out on 180 women wearing IUDs for periods of 3 months to 13 years. Also 60 non-IUD users were studied. Cultures were incubated at 37 degrees C. on 6 different media by both aerobic and anaerobic methods. Incidence of positive endometrial cultures among the controls was 3.33%; among the IUD users, 6.67%. Bacteria in all cases were few. Corynebacteria, anaerobic bacteria, and Gaffkya tetragena were found. Highest incidence was found in women using the IUD less than 1 year. All users for over 5 years had sterile uteri. Also 23 uteri removed because of cervical erosion or myomata were sterile. The incidence of bacterial growth was higher in the secretory phase than in the proliferative phase of the menstrual cycle. It is therefore recommended that insertions or removals should not be done during the secretory phase.
Interference with reproduction in water buffalo by intra-uterine devices.
A study was conducted on the effect of IUDs on ovulation, estrous cy cle length, and pituitary gonadotropic activity in Surti buffalo heifers . 36 heifers were divided into 4 groups. Group 1 received sham operations. In Groups 2, 3, and 4, a plastic coil IUD was fitted in the uterine horn on the same side as that on which ovulation occurred (ipsilateral), in the opposite side (contralateral), and in both the uterine horns (bilateral) 72 hours after the exhibition of heat. The control heifers had an average cycle length of 21.1 days, whereas the ipsilateral, contralateral, and bilateral groups showed an average cycle length of 10.95, 11.6, and 11.53 days, respectively. Heifers were slaughtered after the onset of heat in post-IUD-insertion cycles. 8 heifers in Group 1 ovulated, 1 in Group 2 ovulated, 1 in Group 3 ovulated, and 3 in Group 4 ovulated. No significant differences were found among the 4 groups in other ovarian characters studied. Among treatment groups, neither LH or FSH activity was statistically different . The fact that the IUD when present in 1 horn also affected the adjacent ovary of the opposite horn to induce shorter cycles may be due to the transmission of some unknown uterine factor from the IUD horn to the non-IUD horn as has been reported for the rat and mouse.(AUTHORS', MODIFIED)
Assessing the demographic effect of a family planning programme.
The problems of measuring the consequences of family planning, often called "evaluation," are many. Evaluation of a family planning program includes studying the success it has had in preventing unwanted births, its effects on the well-being of the family, the way the program is handled and the measurement of the demographic consequences such as the reduction of the birthrate. The present paper is concerned with the measurement of births averted, which is one way an evaluation can be made. For a valid evaluation of a family planning program there has to be accurate records of the characteristics of acceptors, the techniques used, and the length of time a method is used. Also, there have to be sophisticated methods to analyze the data collected. One of the problems of assessing the effects of a program is that women who come to such clinics do not constitute a random sample in terms of the timing of their entry and in terms of their level of risk. These women also usually have higher fertility rates than the average of the population in general. One way of trying to overcome such problems would be the usage of matched pairs in the study design. The author states that he has been engaged in research into the possibility of using computer simu lation experiments to answer these questions. At present the author is applying these methods to the evaluation of the program in Mauritius.
Barrier methods of contraception.
There is a definite place in modern contraception for barrier methods. Contraception should be suited to the psychological, physiological, and anatomical needs of each couple and reassessed at different stages of their emotional and reproductive life. Barrier methods, both mechanical and spermicidal, should be freed from prejudices and taboos. Both mechanical and spermicidal types used together offer maximum protection. They do not interfere with the body's endocrine system. Theoretical effectiveness for barrier methods is high; use-effectiveness may not be as high. Barrier methods include condoms for males and caps of various kinds for women. Each method is reviewed, including indications and contraindications.
Fate of spermatozoa in cases of obstructive azoospermia and after ligation of vas deferens in man.
Epididymal secretions and biopsies were studied in 100 cases of azoospermia and in 5 cases of oligozoospermia. Testicular biopsy findings were normal in all of the azoospermic patients. In 7 cases, vasoligation had been done 3-10 years previously. Epididymal fluid and biopsy tissues were obtained at the time of surgery done to correct the condition. Spermiophage cells in epididymal fluid were examined unstained and with several staining techniques. Also, a phase-contrast microscope was used. There were 46 biopsy studies in the azoospermic group and 5 in the oliogospermic group. These biopsy studies showed that the phagocytosis of spermztozoa was chiefly intraluminal. Extravasation of spermatozoa into the interstitial tissues was rare. The lining epithelium of the epididymal tubules contained yellow or brown pigment similar to that found in the macrophages. It was thought that the epithelial cells lining the epididymal tubules showed phagocytic activity. These findings may be related to the development of autoantibodies against spermatozoa.
The return from investment in population control in less developed countries.
The fundamental economic problem in less developed countries is how to raise real per capita product. An analytical model is developed for assessing the impact of demographic investment compared with that of capital investment. The measures for assessing demographic investment include the return per year, the rate of return on the initial investment, the total lifetime return for the investment, the return in 1 year for preventing 1 birth, and the total return over all years for preventing 1 birth. A simulation study based on the model is presented using data from Chile. The calculations show that a modest program of demographic investment in 1960-1964 would have resulted in high rates of return.
The cervical gland is as important in the reproductive process as the uterus, the fallopian tubes, or the ovary. The anatomical, biochemical, immunochemical, and biophysical physiology of the cervical mucus and glandular epithelium must be described in response to stimuli. Estrogens, progestogens, antibiotics, and corticosteroids affect the functioning of the cervix factor.
This is a report on the study of continuation rates of oral contraception in the Singapore National Program. Clinic records of a sample of 2962 women accepting oral contraception during 1967-68 are following to the end of December in 1969. Results revealed that: 1) 39% of the acceptors were continuing with the pill at the cut-off date; 2) 56% of discontinuers had alternative method of contraception, mainly the condom; 3) there was a positive correlation between continuation rates and age; 4) women with no formal education and the ones with secondary education had higher continuation rates; 5) Malays had the highest continuation rates, then came the Chinese, and then the Indians and Pakistanis; and 6) for women with duration since the termination of their last pregnancy of more than 12 months, there was a higher continuation rate.
Data compiled at Santiago, Chile, for the years 1960-1969 indicate that as the number of women using contraception increased, the sex ratio of stillbirths changed from 1.097 in 1960 to .884 in 1969. There was no change in the sex ratio of live births. Data from the second report of the British Perinatal Mortality Survey showed that the sex ratio for stillbirths was 1.250 with a large variance influenced by birth order, age of the mother, and different causes of death. Malformations were the only factor group with a female preponderance. In Santiago the increase in anencephaly and malformations among stillbirths may partly explain the inversion observed.
Family planning courses for clinic staff.
The Population Planning General Directorate of Turkey has establishe d a policy that every gynecologist and general practitioner working in government health institutes should be trained in family planning services. The Ankara Maternity Hospital was initially chosen as a training center; there are 21 centers now. Gynecologists receive priority training. They then start training the general practitioners and assistant health workers in their district. Since 1965, 973 doctors and 5625 assistant health workers have received training.
Family planning in Iran: a systems approach to program organization and administration.
The development and the progress of Iran's national family planning program are described. 1 of the major problems facing the program is overcoming or modifying traditional attitudes and practices. The methods for evaluating the program must be improved. Rural midwives will become increasingly important to the program. Success in the IUD program, especially in rural areas, depends upon special training for female medical professionals. More KAP studies are needed in different ethnic groups. The Iranian family planning program has received much support from the government, but more staff who would be exclusively devoted to the program are needed.
Fertility and economic activity of women in Guatemala City, 1964.
The relationship between economic activity and natality in Guatemala City was studied. The data used were obtained from the official 5% sample of the 1964 Guatemala census of population. It was determined that the economically active women, especially domestic servants, had lower cumulative fertility than inactive women. This was partly because a larger proportion of them had never married and were childless, but there was a substantial differentiation even among the ever-marrieds. Analysis showed that age, marital status, and educational attainment were more strongly associated with fertility than was activity status. There was, however, a significant association between activity status and fertility. Live-in domestic had lower fertility than those who lived out and most employers preferred single or childless women as domestics. The findings in this study support those carried out previously in other Latin American cities.
Women's magazines and public opinion.
630 women who entered the offices of 6 obstetricians in Ohio were asked to fill out a questionnaire which attempted to determine if magazine articles have influenced public use or opinion of oral contraceptives. The articles mentioned are not objective but editorial ones that have appeared in the Ladies Home Journal and they mention the fact that doctors have lost faith in the pill and that the birth control pills are in trouble. Results revealed that 54.9% of the women changed their opinion concerning the adverse effects of the pill after reading t he articles mentioned. Of the women 13.6% stopped taking the pill solely on the basis of the information in the article, and 48.6% sought medical advice.
The Near East South Asia (NESA) countries are the focus of this study of cost effectiveness of alternative strategies for dissemination of oral contraceptives. The study resulted in the contention that since the effect of administrative variables on continuation rates is not known, data collection on the costs associated with them is not fruitful at this point in time; also, published sources in the United States generally do not contain cost analyses. The analysis suggested that the factors that have an effect on continuation rates are 1) indices of a woman's motivation to avoid conception, 2) the cost of pills, 3) the availability of pills. Findings were contradictory in the area of effects of side effects on continuation rates. Quality and frequency of contacts with family planning workers did not seem to have an effect on continuation.
Mortality level, desired family size, and population increase: further variations on a basic model.
An earlier paper reported a series of computer-simulation models relating mortality level to fertility behavior and to rates of natural increase. It was assumed that couples made use of a perfect means of birth control, that they wanted to be highly certain of having at least 1 son survive to the father's sixty-fifth birthday and that all women were biologically capable of having the same number of children. It was also assumed that each woman bore her first child at age 18 and that her husband was 21 years old. Subsequent children were assumed at 2 1/2 year intervals until the couple wanted no more children or a maximum of 12 children had been born. The event of a male birth is a random variable with a mean of .513. This paper presents a similar model but assumes women to be of variable fecundity. The results are similar. The authors also compare models which assume parents want at least 2 surviving children regardless of sex. At high levels of mortality, these rates of natural increase are quite similar. When mortality is at intermediate to medium-low levels, the 2-surviving-children model shows a lower rate of natural increase than the surviving-son model. At very low levels of mortality, such as now experienced by most advanced nations, the 2-surviving-children model manifests a higher rate of natur al increase than the surviving-son model. Results indicate that a lessening of the preference for sons in the less developed nations might speed the tempo of their demographic transition.
This paper reviews the history of pregnancy tests and details the procedures for biological pregnancy tests and immunoassays. Present methods are based on determining human chorionic gonadotrophin (HCG) in urine with results expressed in international units (I.U.). In pregnancy urinary and serum levels of HCG rise within 48 hours after implantation of the fertilized ovum and peak between Days 50 and 90 following onset of the last menstrual period. Urine levels and serum levels reach 50-120 I.U./ml. During second and third trimester they diminish to 10-20 I.U./ml and after delivery fall to normal by the tenth postpartum day. 30 to 40 days from the last menstrual period levels are .5-2 I.U./ml. Less sensitive tests may be negative at first, positive later. Biological assays of HCG are accurate but time-consuming, expensive, and subject to technical error. Hemagglutination and latex particle agglutination tests are rapid, sensitive, inexpensive, and easy to use. Indirect agglutination tests use an antiserum from immunized rabbits which is neutralized if mixed with pregnant woman's urine. Lack of agglutination implies a positive pregnancy test. Hemagglutination te sts using red blood cells as carriers for HCG are the most sensitive tests available and can detect .7 to 1 I.U./ml. As test tube tests they require incubation of 2 hours. The Gravindex and Pregnosticon slide tests can be done in minutes but are not as sensitive. They use latex particles as HCG carriers. Occasional false positive results occur. The direct 1-stage agglutination test on a slide uses latex particles se nsitized or coated with an antibody to HCG; agglutination indicates positive pregnancy test. It can be used with either serum or urine. Albumin or blood in urine may give false positive as can some cancers and persistent corpus luteal cysts. False negative may occur with low specific gravity urine, ectopic pregnancies, and threatened abortion. Rapid slide methods may then fail and more sensitive test-tube tests are indicated. In threatened abortion negative test usually indicates an un successful outcome. High titers after the first 90 days may indicate trophoblastic disease, twins, or polyhydraminas. When trophoblastic tumor is diagnosed, rising or falling titer over a 3-year period may be used as a guide to therapy.
Incidence of pregnancy during lactation in 500 cases.
A study was conducted at the Catholic Maternity Institute, Santa Fe, New Mexico, in the spring of 1953 to determine the exact time and occurrence of pregnancy during the lactating period. Among the 500 pregnancies studied, there were 46 cases in which a pregnancy occurred during lactation, an incidence of 9.2%. 28 cases, or 60.87%, occurred after the ninth month of breast feeding, and 18 cases, or 39.13%, occurred within 4 to 8 months, with very few cases occurring in the earlier months. In 40 cases out of the 46, or 86.96%, pregnancy occurred during the last few months of breast feeding, or when the process of weaning takes place. Among 454 cases, or 91.8%, of the 500 pregnancies studied, the interval between the end of breast feeding and the next conception was, for the most part, extremely short. In 185 cases, or 40.76%, the interval was less than 2 months. A total of 246 cases, or 54.20%, had an interval of less than 4 months; 102 cases, or 22.47%, had an interval of 5 to 9 months; 51 cases, or 11.23% had an interval of 10 to 14 months; and 55 cases, or 12.1% had an interval of 15 to 39 months. It is concluded that breast feeding does protect the mother from pregnancy for approximately 9 months or more if no additional supplementary or complementary formula is used. Efforts should be made to encourage breast feeding, and mothers should be induced to continue breast feeding as long as possible.
Motivation for family planning, with special reference to field studies.
Different ways to explore the underlying reasons motivating a person toward or away from family planning are discussed, with particular reference to an epidemiological study of village people near Ludhiana, Punjab, India. Motivational studies made in Indianapolis and Puerto Rico are also highlighted. At least 3 conditions must be met in motivating for family planning. People must know there is such a thing as family planning. They must be familiar with the effective methods. They must have access to family planning materials. In order to study factors that play a large role in motivation, a conceptual framework must be developed that is broad enough to include many factors that may or may not be important. The best place for carrying out these investigations is in the field through the diagnostic discipline of epidemiology. Epidemiologists consider the phenomenon to be studied from the point of view of host, agent, and environment. In family planning studies, the host is the person whose motivation is to be studied. The agent is the immediate cause of the phenomenon--here, the actual method of family planning and the method of offering contraception. The environment can be divided into 3 areas--physical, biological, and social. The physical environment includes those factors such as heat and humidity, which can affect certain methods of contraception. The biological environment, which does not greatly affect motivation, includes such things as nutrition and venereal disease. The social environment includes a variety of customs, beliefs, and values, such as the attitude toward children and sex, relationships between the sexes, inheritance laws, religious values, and so forth. The mechanics of a program making family planning acceptable to the rural people of India still needs to be developed. Consideration of the factors which affect motivation should precede, not follow, the creation of such a program.
Fertility control with oral medication.
Following the demonstration of the ovulation-inhibiting effectiveness of several oral progestational 19-nor steroids in animals and in a group of selected patients, a field trial was undertaken in Pue rto Rico with the use of 1 of these compounds, norethynodrel. The study was conducted over a peroid of 16 months, and it was determined that the ingestion of 10 mg of norethynodrel, supplemented by varying amounts of estrogen, on a prescribed Day 5 through Day 24 regime, resulted in a normal distribution of lengths of menstrual cycles. When the regime was altered, the menstrual cycles were shortened or lengthened. No conception occurred when the medication schedule was followed faithfully. No pathological endometrial changes were observed. Studies of urinary excretion of steroids indicated a decrease in 17-hydroxycorticosteroids and, to a questionable extent, of 17-ketosteroids. No significant differences in hemoglobin level were noted during or after medication as compared with those of untreated women. 18% of the patients ceased medication because of side effects. The administration of a magnesium aluminum glycinate antacid led to the reported disappearance of untoward reactions in 82% of the subjects who took the antacid. The pregnancy rate was 13 per 100 marriage years due to pill omission. The fact that 14 women who had discontinued medication after 1-17 cycles became pregnant within 1-3 months thereafter suggests that the drug does not interfere with subsequent fertility.
Sterilization of male rhesus monkeys by iron salts.
A single injection directly into the testis of ferrous sulphate or ferric chloride caused total destruction of the testis of adult rhesus monkeys. Germinal and endocrine portions were equally affected. The damage was considered to be due to toxic properties common to other heavy metallic ions. The iron salts were used at .08 mmole/kg body weight in 3 ml sterile distilled water into each testis. Histochemically the injected iron was found localized in the tunica propria of the tubules and in the interstitium. It accumulated in the mitochondrial and supernatant fractions in equal amounts. Typical castration changes were evoked in the seminal vesicles and prostate.
Contraception with intrauterine devices: 1959-1966.
The recent history (1959-1966) of the development of IUDs is reviewed. A research program involving 22,403 women is described: 2 out of 3 women were under 30 years of age and there was an average of 3.3 live births per mother. A rate of 2.8 unintended pregnancies per 100 first insertions was reported for the first year of use by the end of the third year there were 57.3 pregnancies per 100 women. Expulsion rate declined with age and parity and after the first year of use. Bleeding and pain were the most important medical reasons for removal. At the end of 3 years, 3 out of 5 women were still wearing the loop. The Lippes loop D is compared with spiral, bow, and steel ring in terms of performance. Pelvic inflammatory disease (PID) was reported in 606 cases. 1 out of 23 unintended pregnancies was ectopic. 85% of 242 who had the IUD removed for a planned pregnancy conceived after an average period of 2.8 months. The larger Lippes loop remained the IUD most suitable for general use among those tested.
Oral contraceptives and thromboembolism.
Recent independent studies undertaken in Britain have demonstrated s tatistically for the first time the increased risk of thromboembolic dis ease among women taking oral contraceptives. The Royal College of General Practitioners study suggests that the risk is increased about 6-fold by pregnancy and about 3-fold by oral contraceptives. The Statistical Research Unit of the M.R.C. listed 29 women with deep-vein thrombosis or pulmonary embolism of whom 14 had been taking oral contraceptives. Of 36 controls with other conditions only 3 were using the pill. The Committee on Safety of Drugs study reports 378 deaths in married women aged 15-44 during 1966; in 261 thromboembolic disease was mentioned on the death certificate. Coronary thrombosis was not associated but cerebral thrombosis and pulmonary embolism were possibly related to use of oral contraceptives. Deaths attributable to oral contraceptive use were approximately 3 per 100,000 users per year. In England and Wales the annual death rate for full-term pregnancies is 12 per 100,000 population. Death rate following abortions for unwanted pregnancies is higher. Advantages of oral contraceptives are, for many women, greater than the risks of iatrogenic morbidity or mortality. However, safer contraceptives must be sought as well as means of discovering which women may be at greatest risk from thromboembolism.
Effectiveness of family planning in Taiwan: a methodology for program evaluation.
This paper presents tentative statistical evidence on the assocation between regional birth rates and family planning program activity in Taiwan, with a different approach to evaluation of program effectiveness. In 1966 and 1967 the national program appeared to have a significant effect on birth rates. Most of the analysis in this paper deals with these years. The Taiwan program appears to have had an initial effect on birth rates larger than can be accounted for by IUD acceptance alone. This fact is attributed to the dissemination of knowledge about traditional forms of contraception. Because of diminishing marginal productivity, heavy reliance on 1 type of contraceptive and/or 1 type or family planning field worker is not advisable. In Taiwan, the Village Health Education Nurses (VHEN), and the Pre Pregnancy Health Workers (PPHW) perform different duties, seek to reach different populations, disseminate different services, and are likely to reinforce, not compete with, one another in promoting the program's broader objectives.
Lactation and child spacing as observed among 2,102 rural Filipino mothers.
The relationship of breastfeeding to the interval of pregnancy was studied in 2102 rural Filipino women. Breastfeeding for 7-12 months resulted in a pregnancy interval of 24-35 months in 51.2% of the women. However, this interval was observed in only 30% of the women when the child was artificially fed. The actual difference between the 2 groups was more than twice the standard error. The results show that breastfeeding for 7-12 months, or more, may prolong the interval between pregnancies.
The fertile period in practice.
500 women using the fertile period procedure of conception control w ere studied over a 5-year period. Each was required to present a writte n record of the beginning dates of the last 6 menstruations and each received a thorough pelvic examination. The careful weeding out of women with some systemic or pelvic condition which could affect the fertile period is credited with the author's gratifying success with this method. Such conditions included advanced pulmonary tuberculosis, fibroid uterus, ovarian carcinoma, cervical carcinoma, occluded fallopian tubes, large ovarian cysts, uterine polyps, and pernicious anemia. During this study not a single pregnancy resulted from cohabitation outside the fertile period, 12 women became pregnant during the fertile period even though they used alternate contraception, and 27 women used the procedure to space pregnancies properly. In 1 case the system was used for relief of supposed sterility. To be successful the patient must furnish a list, written down at the time, of the last 6 or 8 menstruation dates, and the doctor must determine cycle variation from the longest and shortest cycles in the list. If no pelvic abnormalities are found, furnish the patient with an individual calendar that is as nearly foolproof as possible. The rest of the method rests on patient motivation.
The time of fertility and sterility during the human menstrual cycle.
In a study of 278 cases rectal basal body temperatures were used to determine time of ovulation and periods of fertility and sterility. 51 previously sterile women became pregnant through intercourse at the fertile period. The fertility period ranged from the 10th to the 19th day of the menstrual cycle with fertility the highest on Days 12, 13, and 14. In 23 pregnancies time of conception was pinpointed by temperature-determined ovulation data; absolute gestation time ranged from 252 to 285 days with the average for girls 269 days, and the average time for boys, 267.5 days. Ovulation was, in some cases, accompanied by clinical signs such as a slight low abdominal pain or cramp and a clear vaginal discharge. Experience has led to the conclusion that a fairly typical curve indicates normal ovarian activity while an abnormal configuration indicates some abnormality of reproductive balance. Lack of a postovulatory high temperature phase is characteristic of low progestin secretion and forewarns of habitual abortion tendency. A woman with an irregular curve should be advised not to depend upon this method for contraception. Low grade infections, anemias (even of mild degree), and convalescence from pregnancy, abortion, or serious illness upsets the curve's regularity. Liver and iron supplements and rest will reestablish a normal basal body temperature curve.
Total hysterectomy at time of cesarean section and in the early puerperium.
A review of studies on tubal ligation and on uterine cancer is prese nted, and clinical experience in performing total hysterectomy at the time of cesarean section and in early puerperium is reported. A total of 74 total hysterectomies were done since 1951 at the University Hospital at the University of Maryland School of Medicine and the Sinai Hospital, Baltimore, Maryland. The operation was carried out for the purpose of sterilization or as indicated for disease. There was no mortality in the series. The gross morbidity rate was 22.9%. The average hospital stay postoperative for all patients was 8.28 days and for patients with complications, 11.45 days. Evidence indicates that the uterus is not prophylactic removal of both ovaries in women after the age of 40 should be done at the same time. A follow-up of 40 patients (54%) revealed good results psychologically, anatomically, and functionally. While tubal ligation or tubectomy does not guarantee sterilization, nor is it free of mortality and morbidity, total hysterectomy at the time of cesarean section and in the puerperium assures sterility and is a prevention against developing disease and/or malignancy in the removed genital organs.
Attitude towards sterilisation both male and female.
An attitude study was done on 200 male and female attendants of the Family Planning Department of the Medical College Hospital in Calcutta to determine their knowledge of, reliance on, and preference for different contraceptive methods (including sterilization), their opinions on family size, and the sources of their information on contraception. Personal interviews were combined with comprehensive questionnaires to collect the information. Some of the results of the study showed that 1) the main sources of information on sterilization were neighbors, medical personnel, friends, and relatives; 2) 72% of the people questioned had requested sterilization to limit family size; 3) a lthough the request came from those with 4-6 children, 90% of these believed in sterilization after 3 children; 4) 90% of those questioned thought sterilization to be reliable, the rest thought it harmful; 5) although 96% males and 70% females knew that vasectomy was easier, most opted for tubal ligations; and 6) 80% of both sexes knew of condoms and 20% knew or used other contraceptive methods.
IPPF world survey: (1) factors affecting the work of family planning associations.
This report is based on questionnaires answered by 43 family planning associations in 42 countries. Most of the questions concerned the year 1964, which is considered the end of a chapter in family planning: It was the year before the loop and the year before the world woke up to the implications of family planning. The questionnaire and report cover 4 broad areas: 1) sources of income, 2) types of publicity, 3) clinic structure and personnel, including the usefulness of mobile vans, and 4) family planning methods available at clinics (their advantages and disadvantages, the type of patient, and methods of recruitment). Among the findings is that the amount of help an association is likely to get from outside sources varies directly with the status it holds in its own country. IPPF was the greatest source of outside training. Associations were particularly interested in training that emphasized the IUD and health and sex education. In publicity, religious and political factors were the most important influences. In addition, the amount and type of publicity depended upon money and on multiple-language problems, illiteracy, and the availability of the mass media. Most patients came from urban areas and belonged in the middle of the socioeconomic stratum. Figures showed that many new patients accepted foam tablets and vaginal foam, but that oral contraceptives and IUDs seemed to be the wave of the future.
Prolonged lactation and family spacing in Rwanda.
A study of the effect of lactation on conception and the return of m enstruation is described. 50 nonlactating and 318 lactating Rwandese women were studied through medical records and by interview. 9 months after delivery, 74% of the nonlactating women and 7.6% of the lactating women became pregnant. A conception rate of 74% for the lactating group did not occur until almost 2 years after delivery. Conception rates for the 2 groups approximated each other at 6 months in the nonlactating group (68%) and at 21 months in the lactating group (67.4%). In the lactating group, menstruation reappeared in 20.9% of the women at 6 months, 48.6% at 12 months, 75% at 24 months, and 5.4% remained amenorrheic after 4 years. It is presumed that the contraceptive effect of lactation had largely disappeared at 27 months after delivery.
Uterotrophic action of an intrauterine contraceptive device in rhesus monkeys.
Results from an experiment with either Margulies spiral or Lippes loop IUDs indicate that they have no effect on the uterine weight of intact or ovariectomized rhesus monkeys. Biochemical and histologic measurements show a mild, transitory trauma to the primate uterus on insertion; it is not long-lasting. In ovariectomized monkeys with or without IUDs, estrogen therapy will cause the same degree of weight gain in the uterus. These findings contrast with earlier work on rats.
Bibliography on vasectomy and its reversal in man and animals.
This is a bibliography of books, articles, and bibliographies dealin g with vasectomy, or vasoligation, in man and animals. Categories covered are: 1) immunological aspects in man; 2) surgical or spontaneous reversal in man; 3) general and miscellaneous material dealing with vasectomy in man; 4) techniques in animals, and 5) effects in animals. There are no notations for the entries.
"Come and Go" aspiration abortion.
Today, termination of first-trimester pregnancy (therapeutic abortion) is becoming the most common surgical procedure performed on women. Significant reflections of this revolution are observed in the recent decline, not only in the numbers of septic incomplete abortions but also in maternal mortality due to abortion. "Come-and-Go" aspiration abortions performed by trained personnel in hospital environs, adjacent to facilities prepared for surgical emergencies, show no increase in morbidity compared with admissions to the hospital for presurgical preparation and observation for 12-24 hours after abortion. The outpatient abortion is not only safe, efficient, effective, and minimally embarrassing to the patient, but also offers: 1) abbreviated clerical admissions procedures; 2) elimination of needless enemas, douches, and vulvar shaving; 3) minimal use of hospital personnel who can then attend acutely ill patients or those recovering from major operations; 4) anonymity by surgical scheduling through identification number or attending physicians; and 5) short convalescence at home with maximum privacy and minimum regimentation. (FULL TEXT)
The rhythm of reproduction in mammalia.
The rhythm of reproduction in mammalia is a function of the critical unit--a phase in the development of every vertebrate embryo, during which it resembles the embryo of any other vertebrate in a corresponding stage but with certain special class features. The development of mammae could only occur after development to the critical stage--that the yolk sac became a negative quantity and the allantoic placenta was formed. Birth would thus take place at the critical stage or the organism would postpone birth by passing to the allantoic placenta. It was suggested that the ovulation period became almost equal to this critical unit (that is, birth). An impending ovulation triggers birth. In further prolongation of the reproductive stages there is a correspondence between length of gestation and a certain number of critical units. Lactation may keep up the rhythm of the gestation in corresponding to 1 or more gestation lengths. Lactation, gestation, ovulation and critical units are all connected and conform with the rhythm of reproduction in mammalia controlled by the rhythm of ovulation.
The "safe period" as a birth control measure: A study and evaluation of available data.
Although conception can occur at any time of the cycle, evidence shows an association of maximum sexual desire and well-being with a minimum chance of conception during the premenstrual week and a secondary period of sexual desire postmenstrually, the time of greatest fertility. The premenstrual week is the relatively low pregnancy risk p eriod with a 1 out of 10 chance of pregnancy. Few adequate records show women with known "safe periods." The most fertile period, however, is during the week or 10 days following menstruation with ovulation occurring between the 14th and 19th days from the beginning of the cycle. Studies have suggested that coitus may free the ovum earlier. Co nception does occur during menstruation in 13% of cases partly because menstrual blood is a favorable medium for sperm motility. Passage of the ovum via rhythmic tubal contractions which vary according to the time of the month occurs subsequent to ovulation up to the 22nd day. That conception can occcur at any time suggests that either human sperma tozoa or ova or both survive longer than those of lower animals.
Characteristics of the normal menstrual cycle.
Previous studies which have shown that the lengths of apparently normal menstrual cycles vary widely and that absolute regularity in the individual patient is exceptional have not eliminated anovulatory cycles, patients with subtle endocrine disturbances, and such lesser disturbances as travel, monor illnesses, or alterations of working hours. Variable schedules make data based on nurses especially suspect. In this study 109 women were carefully selected and all cycles showing late hours, restless sleep, travel, febrile illnesses, and other disrupting factors were eliminated. Of the 524 recorded cycles, 500 or 95.4% were ovulatory, 13 or 2.5% were anovulatory, and 11, or 2.1% were indeterminate. All 58 biopsies from cycles with ovulatory temperature patterns revealed progestational endometriums. Of the 500 ovulatory cyc les, 0 were shorter than 19 days; 1 was longer than 60 days; 3.2% were 19-22 days; 21.4% were 23-25 days; 53.6% were 26-29 days; 17.8% were 30-36 days, and 4% were longer than 36 days. More than 1/2 were 26-29 days and 92.8% fell within the 23-26 day interval. Comparison with the data of others shows that when anovulatory cycles are eliminated, short cycles (less than 19 days) apparently disappear from the curve. Studies with a larger number of mature women have fewer anovulatory cycles. In 79.6% of the women the estrogenic phase was 10-16 days long. In 1.9% it was less than 10 days in length but in 15.6% it was 17-25 days and in 2.9% longer than 25 days. Except for 1 progestation rise which was only 5 days long, the progestational phase was 8-19 days long. 69.5% showed progestational phases of 11-14 days, 94.0% of 10-16 days, 1.8% less than 10 days, and 4.3%, 17-19 days. This confirms the belief that the unusual length of the ovulatory cycles results from a longer estrogen phase. In 68.4% of patients bleeding was 3-5 days in duration and in 95.4%, 3-7 days. The mean temperature differential between pre- and pos tovulatory phases is often relatively small (.2-.5 degrees F). In 78.9% the rise was .6-.9 degrees F. This emphasizes the value of recording the temperature in degrees Fahrenheit on a relatively large scale rather than using a small scale or degrees Centrigrade.
Judging fertility control methods and approaches.
An outline is presented of certain considerations in applying fertility control methods. Primary criteria in evaluating these methods are effectiveness, safety, patient acceptance, convenience, and cost. Fertility control objectives and the urgency required in treatment influence standards of acceptability under the stated criteria. In emergency cases, high risks are usually acceptable and, perhaps, advisable. Individual patients choosing to practice fertility control should have contraceptive services made available through private medical practice or clinics and regulated by a doctor's prescription. In cases of large-scale population control programs, particular attention should be given to public health and epidemiological procedures, to providing suitable services for all levels of society, to making available information and materials at reasonable cost, and to the risks, inconveniences, and financial problems according to the degre e of urgency.
Pharmacognosy (drug sources) is reviewed from 1953-1956. This article covers steroid precursors, hypotensive alkaloids, rauwolfia and veratrum, radioactive tracer techniques in alkaloid biogenesis, Duboisia species, cardioactive drugs, antimitotics, and anthroquinones. Good possibilities exist for cortisone synthesis from sarmentogenin, a steroi d sapogenin from Strophanthus sarmentosus. Pregnane derivatives can be synthesized by introducing an 11-oxygen function into hecogenin and diosgenin. Surveys have been launched of the genera Dioscorea, Agave, Yucca, and 56 others for steroid precursors. Dioscorea composita from Vera Cruz yields 3.3-6.9% sapogenin, almost exculusively diosgenin.
Histochemical observations on the endometrium: 1. Normal endometrium.
Human endometria (15 proliferative, 39 luteal, 6 early pregnancy) taken from hysterectomies were examined histochemically for ribonucleoprotein, alkaline and acid phosphatase, glycogen, glycoprotein, nonspecific esterase, 5-nucleotidase and ferric iron. Rib onucleoprotein increased in glandular epithelium in proliferative phase, disappeared during luteal phase, but appeared in clumps before menstruation. Alkaline phosphatase also peaked in late proliferative phase in epithelium, and in endothelium of spiral atterioles; it decreas ed in luteal phase, but appeared in gland secretions. Acid phosphatase was evenly distributed but low in proliferative phase, and increased to a peak at the end of the cycle. Glycogen also rapidly increased during luteal phase, appearing as granules in epithilium, in proliferative phase, and in glandular secretions of pregnancy. Menstrual and pregnancy endometrium had high acid phosphatase and glycogen. Results were discussed in terms of growth or differentiation, estrogen or progesterone control, and events during implantation.
The effect of therapeutic doses of nitrofurantoin (furadantin) upon spermatogenesis in man.
Furadantin (N-(5-nitro-2-furfurylidene)-1-amino-hydantoin) was ingested at 10 mg daily in 4 divided doses by 36 male volunteers for 14 days. Total sperm counts were taken at about 4-week intervals, and testicular biopsies taken at 2-4 week intervals from 25 subjects, and analyzed by the chalkley quantitative method. 18 men showed no differences in sperm counts or testicular biopsies. 5 had a negligible decreased in sperm count only. 5 showed depressed sperm counts 5-8 weeks after starting furadantin, and recovery 9-12 weeks later, but no change in testicular histology. Of 8 others with depressed sperm counts, 7 had spermatogenic arrest, with polynuclear cells in some cases. Intolerance appeared in some of the men in the form of nausea and headache. These results are difficult to interpret because the dose was considerably lower than the dose which inhibited spermatogenesis in rats, because 10 of the sperm counts and 13 of 25 of the biopsies were subfertile, and because sperm counts from 19 men were of doubtful reliability.
Population growth and economic development in India from 1956-86.
This paper mainly reviews and interprets a monograph with the same title by Coale and Hoover. In 1954, under the Auspices of the World Bank, the Office of Population Research of Princeton University undertook a study of the relation between population change and economic developments in areas with low income. This study bases its population projections on estimates of future mortality rates by age and sex and on estimates of future fertility by age of the mother. In terms of fertility the authors contend that the future course in India appears uncertain. No downward trend seems to have occured in India as a whole as far as the fertility rates are concerned. Depending on the specific assumptions of fertility trends in the future (it will remain unchanged, it will decline after a decade, it will decline immediately, etc.), the growth patterns will differ. The paper also analyzes the possible effects of these differential growth patterns on the age distribution, and other aspects of economic growth. The basic conclusion of the study is that lower fertility will lead to an improved national economy.
Use of Enovid and other agents for improved development of the inadequate luteal phase.
A discussion was held on the proper use of Enovid and related compounds. The particular phase described of application of the new progestins is their use in the so-called phase or secretory hypoplasia, the patient is required to collect her overnight urine for 10 days in order for pregnanediol determinations to be carried out. In the author's experience, there has been a pregnancy rate in the vicinity of 20% with luteal phase therapy with norethisterone. Women so treated had had reasonable indication of progestational defects. Doses of 10 mg/day are given and subsequently alternated. Using the injectable 17alpha-hyd roxyprogesterone caproate, the pregnancy rate was slightly less. When Enovid was used, the pregnancy rate was similar to that with norethisterone. When 17-acetoxyprogesterone was used in a dosage of 120 mg/day, a very low pregnancy rate was obtained. Enovid is probably a helpful prophylactic for the habitual abortor, but when it is given, the patient must have repeated pregnancy tests and examinations to determine if she is still pregnant. It is concluded that in the more common indications, the indications, the synthetic compounds are far superior to progesterone itself.
Prevention of pregnancy by intra-uterine silkworm contraceptive gut coil.
Experience with the IUD silkworm gut coil is reported. Of the 1500 rings the author has inserted, he has never seen any complication cause by the ring. Much depends upon the absolute asepsis when administering the method. A silver wire is fastened to the ring, which shows in the X-ray. All women who are basically healthy, not suffering from inflammation of any kind or from genital tuberculosis, abnormal bleeding caused by fibroids or polyps, endometriosis or glandular hyperplasia, or gonorrhea, are suitable subjects for the method. Sounding of the uterus before inserting the ring for the first time is strongly advised. There has been a 2.4% failure rate in the 1500 insertions. The effectiveness of the ring does not decrease by habitual wearing. There is no reason to assume that the ring can be responsible for a carcinoma, because the same percentage of carcinoma cases occurs in non-ring-wearing women. The author has not seen any malformation of the fetus in any patients who have worn the ring, become pregnant, and carried to term.
Steroid compounds with progestational activity.
The chemical structure, assays, and clinical use of 5 synthetic steroids with progestational activity, norethindrone (Norlutin), norethynodrel, norethandrolone (Nilevar), medroxyprogesterone acetate (Provera), and 17 alpha-hydroxyprogesterone caproate (Delalutin), are discussed. When compared with progesterone, medroxyprogesterone acetate , (MPA, Provera) was most strongly positive on the test of Clauberg, McGinty, decidua, maintaining pregnancy, stimulation of the seminal vesicle, and inducing masculinization of all 5 compounds. It is also a potent gonadotropic inhibitor and may thus be used in the long-term treatment of endometriosis. Clinically, Norethynodrel and Norethindrone are more effective than progesterone in the treatment of dysfunctional bleeding, dysmenorrhea, endometriosis, as contraceptives, and in the treatment of endometrial hyperplasia. Norethynodrel is less effective than progesterone during pregnancy while norethindrone is ineffective. MPA, Depo-MPA, and 17 alpha-hydroxyprogesterone caproate are as effective or more so than progesterone in treating dysfunctional bleeding, endometriosis, endometrial hyperplasia, and during pregnancy. Except for the treatment of endometrial hyperplasia, MPA was the most effective. MPA could be used in the treatment of dysmenorrhea. Depo-MP A and 17 alpha-hydroxy progesterone caproate have been successfully used in the treatment of endometrial cancer.
Oral-contraceptive feminization of a normal male infant: report of a case.
A case report is presented of gynecomastia in a male infant, breastfed while the mother was taking 2.5 mg of norethynodrel plus ethinyl estradiol 3-methyl ether (Enovid). Near the end of the 3rd week, postpartum, a noticeable increase in the child's breast size was noted which again increased when the dosage of Enovid was mistakenly increased to 5 mg daily. Upon discontinuation of nursing, the child's breasts returned to normal and have not since changed pathologically. It is assumed that an estrogenic substance was passed to the child through the mother's milk. The possibility of gynecomastia in breastfed infants should be added to the list of side effects of oral contraceptives.
Testis hormone physiology: a quantitative study of inhibition and recovery of spermatogenesis.
By employing a quantitative method of analysis, the inhibition and recovery of spermatogenesis was studied in 300 male rats. Diethylcarbamylmethyl-2, 4-dinitropyrrole (ORF 1616) was used to induce inhibition. The doses ranged from 50 to 500 mg/kg body weight, and the observation periods extended from 6 hours to 6 months. Testes were secu red, fixed, and prepared at appropriate times. A single dose of 500 mg/kg caused a series of cytological changes, beginning as early as 6 hours following treatment. Initially, changes occurred in the pachytene and resting spermatocytes. Following this, damage appeared in steps 1-14 spermatids. By Day 4, pachytene spermatocytes in stages 7-14 and steps 1-14 spermatids had disappeared. Steps 15-19 spermatids progressed to full maturation and release. Type A spermatogonia in stages 9-11 underwent more subtle, yet more persistent, damage. The compound continued to exert this effect for approximately 1 week after its administration. A single 500 mg/kg dose caused complete infertility for approximately 21 days after treatment. Fertility returned approximately 49 days after the single treatment had been given. It was determined that the administration of the drug for 6 months maintains inhibition of spermatogenesis by arresting spermatocytic development at stage 7. Recovery occurs progressively after withdrawal of treatment.
A-norsteroid (H241), estradiol cyclopentylpropionate (ECP), a derivative of diphenyl-dihydronaphthalene (U-11100A), and estrone were fed to rabbits 1, 2, and 3 days after insemination in order to test antifertility activities. When examined 6 days after mating, estrone, H241, and ECP in the dose of .5 or 1 mg per rabbit, induced 98-100%, 90- 100%, and 83-97% degeneration of ova, respectively. The results of administration of U-11100A were inconsistent; 5 to 10 mg per rabbit induced 82-97% degeneration of ova. Feeding of ECP .5 mg per rabbit once on Day 1 or Day 3 was less effective than feeding 3 times on Days 1, 2, and 3. Except for estrone and ECP, feeding these compounds on Day s 6, 7, and 8 at the time of implantation had no effect on implantation. Feeding the compounds 3 times before insemination did not inhibit ovulation or fertilization and did not indicate their antifertility activity. When the animals were fed on Day 1 and examined on Day 2, a certain percentage of ova was found in the uterus sooner than expected, although the morphology (not necessarily the physiology) of the ova recovered from the tube or the uterus was normal. When hamsters were fed with these compounds (with the exception of U-11100A) 3 times on Days 1, 2, and 3 after mating, and examined on Days 12-13, a high percentage of embryonic degeneration was observed at a dose level of 1 mg per hamster, indicating that a much higher dose level is required for the hamsters than for the rabbits. It is concluded that natural estrogen or any other compounds that have the activity of causing retention of ova in the tube, expulsion of ova, and fast transportation of ova into the uterus, would be effective as an antifertility agent if administered soon after mating.(AUTHORS', MODIFIED)
A psychoanalytic study of contraception.
This study tries to highlight the unconscious meaning of contraception and how it mobilizes anxieties and conflicts in people. This objective is emphasized through case studies dealing with the fitting of a diaphragm, the relationship of contraception with the size of genitalia, the contraceptive device as an organ of the body, coital significance of contraceptives, how one may gain adult status through the use of contraceptives, anxiety, doubt, and frustration as they are related to contraception, and the misuse of contraceptives. The latter may be result from psychologically hidden motives such as aggressive impulses towards the partner or unconscious wished to become pregnant.
Child mortality in Turkey has been decreasing so that the expectancy of life at birth is now about 54 years. There has been a decline in the birthrate, which began before 1960 partly due to a real decrease in fertility and to a shortage of women in the childbearing ages. There are regional differences in fertility due mainly to differences in socio economic and literacy indices. It is estimated that about 11% of the couples of childbearing age are using modern forms of contraception. IUDs are more highly accepted in urban rather than in rural areas. The family planning goals are to increase the number of couples practicing family planning by 5% so that 2,000,000 couples will be practicing by 19 72.
The A.I.D. population and family planning program - goals, scope, and progress.
Assistance to developing countries in fields of family planning and population by the Agency for International Development Aid increased from $2,100,000 in 1965 to $34,500 0,000 in 1968. AID's policy is to help countries who request aid and to fund only those programs where participation is voluntary. AID provides assistance in: provision of commodities, such as contraceptives; establishing and equipping facilities; equipment for transportation and education; and meeting research and evaluation needs. It also has provi ded support for university associated Population Centers which are involved in research and training in population programs. The goal of the AID population and family planning program is to improve the health, well being and economic status of people in developing countries by improving conditions of human reproduction.
Calendar rhythm and menstrual cycle range.
2316 women (15-44 years), contributing a minimum of 10 cycles for a total of 30,655 cycles were evaluated to assess their individual cycle variations and to determine what percentage were suitable for contraception by the calendar method. 30% experienced a cycle range of 8 days or less which is considered the limit of cycle variation for successful use of the calendar method. Cycle range varied with age, the youngest group showing the largest number of long cycles, and each succeeding group showing a larger percentage of cycles of 8 days or less peaking in the 30-34 year age group and then declining. Even regular women can expect an occasional random long cycle, and the longer the period of observation the more liklihood that this will be noted.
Specifications for a national system for family planning improvement.
Simultaneously with the launching of a national family planning program, each nation needs to establish an effective long-range and integrated program of evaluation and review. A system of providing feedback for improvement of family planning, described as a Rapid Feedba ck for Family Planning Improvement (R.F.F.P.I.) System, should possess c ertain characteristics: 1) it should interfere as little as possible with the family planning action program; 2) it should cost as little as possible 3) it should be as simple as possible; 4) it should be practical; 5) it should give results fast; and 6) the various components of the system must be integrated. The system proposed is comprised of 4 components: 1) demographic analysis; 2) national family planning sample inventory; 3) national evaluation of family planning services; and 4) special studies. It is believed that in many nations, much more money is being spent now on family planning research than would be required to set up a national R.F.F.P.I. system. Because this money is being spent in an unsystematic way on isolated KAP surveys that are uncoordinated and unrepresentative either of the national population or of the family planning action being undertaken, the results tend to be irrelevant for the problems being encountered and do not provide a clear picture of where the program stands, what its unresolved problems are, and what progress is being made, if any. In many countries, essential components of a R.F.F.P.I. system exist. They need only to be organized, integrated, and forced to face up to the task of providing feedback for improvement.
Clinical experience with basal temperature rhythm.
364 patients were instructed in the use of basal body temperature charts to limit family size. 107 couples claimed to understand the instruction after the 1st visit, 1 required a 2nd instruction, and 1 never was sure they comprehended the method. Follow-up showed almost 1/2 the group used the method for only 9.3 months. 47 couples continued it for an average of 15.2 months. Before attending the clinic the total group had an unplanned conception rate of 28 pregnancies/100 woman-years. Periodic continence with basal temperatures as a guide resulted in 8 unplanned pregnancies or about 8/100 woman-years. The low number of biphasic charts with abrupt rises in temperature (26%) contrasts sharply with the 80% reported by Marshall. Since sharp transitions obviously make interpretation easier, the high percentage of charts with a gradual rise may have contributed to the high drop-out rate.
Demulen: hastily approved drug.
The writer criticizes the acceptance of Demulen as an oral contraceptive on the evidence presented by the Federal Drug Administration (FDA) and the granting of a new drug application (NDA) to G. D. Searle Company. The cited British study included 987 women of whom only 112 were treated with Demulen for 24 or more cycles. A later American study involved only 82 patients treated for 4 cycles. FDA guidelines require a minimum of 200-300 patients for demonstrating the efficacy of an oral contraceptive and required clinical tests must be conducted by a U.S. company and by qualified U.S. investigators. The results of laboratory studies were not given in the British data. Demul en contains 1 mg ethynodiol diacetate and 50 mg ethinyl estradiol. Data from Ovulen, containing mestranol, were used to indicate presumed effectiveness of Demulen. Ethinyl estradiol, a principal metabolite of mestranol, is almost twice as effective; therefore half the dose was presumed to be adequate. The Searle advertising was criticised as misleading by suggesting that Demulen contains only half the estrogen content of other oral contraceptives. Therefore the reviewing medical specialists were unable to approve Demulen and the NDA was sent to the Director of the Bureau of Drugs.
Records for 1000 patients attending a special clinic for treatment in mid- and late-1967 were analyzed. Those using oral contraceptives were 11.8% of the total, more than twice the national percentage of pill users in England, Wales, and Scotland. 15% of the gonorrhea patients used oral contraceptives. The figures are too small to be statistically significant. It does seem that oral contraceptives are used more by the selected group of gonorrhea patients than by the 1000-patient group as a whole. 2 explanations for this are proposed: 1) patients taking the pill are more promiscuous naturally and run a greater risk of contracting gonorrhea; or 2) gonorrhea is easier to diagnose in women who are taking contraceptive pills.
A model is presented in this paper that helps convert demographic goals into family planning targets and quotas, using data already available or data which can be inferred or estimated. A good quality population census is all that is necessary to use this model for any nation in the world. The steps of going through the model are: 1) making a projection of the female population by age for each single calendar year of the projection period, 2) estimating the female population of each age exposed to sex relations during each calendar year of the projection period, 3) estimating the fecund population of each age that is exposed to sex relations during each calendar year of the projection period and 4) estimating the number of nonpregnant fecund and sexually active women at each age during each calendar year of the projection period. The article explains the mathematical formulas that are proposed and also has graphs to explain the functions. Pakistan is used as an example in estimating family planning targets and quotas.
The prospects for hormonal sterilization.
Any contraceptive method acts by producing temporary sterility. Var iations in the time of spontaneous ovulation and variations in the length of the cycle render the date of ovulation relatively unpredictabl e. The safe period, therefore, varies. Hormonal sterilization deals with methods that render the woman sterile for the duration of at least 1 menstrual cycle. This anovulatory cycle is 1 method. No corpus luteum forms although bleeding occurs cyclically. Most cycles during lactation are sterile. Other women sometimes have anovulatory cycles. Prolactin injections have been shown to temporarily suppress ovarian cyclic activity in mice and rats. Prolactin may produce anovulatory cycles in women and thus provide a method of hormonal sterilization. 4 mg progesterone daily inhibits estrus. Studies with estrone show that it has a depressant effect on ovarian response to follicle stimulating hormone. Large doses of estradiol benzoate used to treat dysmenorrhea have altered menstrual rhythm. Injection of gonadotrophic antisera for prevention of ovulation is a possibility. Daily injections of estrone, begun on day of mating, usually have resulted in retention of ova in the fallopian tubes of mice and rabbits. All of these ova showed signs of degeneration by Day 4. Fertilized human ova may be tube locked by an excess of estrone or degeneration of the fertilized ovum may inhibit further development. The potentialities of hormonal sterilization are great. Extensive investigation for humans is warranted.
A joint inquiry was conducted by the Medicine Research Unit and the General Register Office of Great Britain into social and biological fact ors in infant mortality. It was found that 60% of all single, legitimat e births in 1950 in England Wales occurred in nursing homes or hospitals. There were differential hospital births according to groups. Women more likely to have delivery in the hospital were: 1) from London and the South East; 2) in the highest social class; 3) having first babies; 4) younger mothers; and 5) had not previously lost a baby in childbirth. Of the "high-risk" groups considered vulnerable to perinatal mortality, 2 had a higher than average hospital delivery rate--older women expecting first children and women expecting multiple births. The other 2 "high-risk" groups--women over 40 and women who had previously lost children--had less than the average of hospital deliveries.
Factors contributing to patient attendance in the clinics.
Based on observations in Hyderabad, India, family planning clinics, established in 1950, 9 factors which influence patient attendance are discussed. 1) Location. A quiet area, with great privacy, will help draw patients better than a clinic in a busy general hospital's outpatient department. 2) Working hours. The quiet hours of the afternooon seems to be the best time for women to attend. 3) Personality of the doctor and health visitor. Tact, patience, and an interest in the several problems, other than family planning, that concern the patient help gain client confidence. 4) Role of social work ers. With their enthusiasm and conviction, social workers can greatly in crease clinic attendance. 5) Intensive propaganda. There should be a s eparate, fulltime unit devoted to education and information. A van should visit each locality at least once a month. 6) Social strata of the people. Propaganda should be concentrated among the lower middle classes, which are the most viable group when it comes to family planning. Family limitation should be directed at the poorer classes, and family planning clinics should be set aside 1 day a week for performing vasectomies. 7) Impact of contraceptive failures. Only reliable methods should be taught. Failures are bound to be exaggerated. Doctors should make sure the woman is suited to the particular method he recommends. 8) Follow-up. There should be a systematic plan for follow-up visits to induce women to attend the clinic regularly and use the contraceptive method consistently. Follow-up visits will also help in making statistical surveys. 9) Group talks to women in postnatal wards and clinics. Women at this stage are very receptive to the idea of family planning. Systematic visits by a health worker should induce them to come to the clinic within 3 months of delivery.
Tolerance of intrauterine contraceptive devices.
Intrauterine device tolerance was studied in 355 women using Lippes loop and 91 women using stainless steel Hall Inhiband. 94% of the devices were well-tolerated. Commonest side effects were menorrhagia, which responded well to iron and vitamn-C therapy, and heavy bleeding. 46% the Lippes loop users required iron and vitamin-C compared with 42% of the Inhiband users. 21% of those with Inhibands and 37% of those wit h loop required some medication for bleeding. The pregnancy rate was 6 per 100 woman years with the Inhiband and 1.1 per 100 woman years with the loop. 12% found the Inhiband contraceptive unsatisfactory and 11% found the loop unsatisfactory.
A joint inquiry was conducted by the Medicine Research Unit and the General Register Office of Great Britain into social and biological fact ors in infant mortality. An historical study was made of the mortality of children fathered legitimately by men in 8 different occupations: 1) professional workers; 2) farmers; 3) teachers; 4) clerical workers; 5) textile workers; 6) miners; 7) farm workers; and 8) building laborers. Infant mortality rates were compared in the following 5 periods: 1911, 1921, 1930-32, 1939, and 1949-50. It was found that the postneonatal (w ithin the first year of life after the first 4 weeks) death rate correlated more closely with the father's occupation. Infant mortality in general for the 8 occupational groups, or for these 8 groups reorganized into the standard 5 social classes, declined by the same proportion over the last 40 years. This was true for both neonatal (within the first 4 weeks of life) and postneonatal deaths, although these 2 types of death are attributable to different causes. 3 causes were offered for this similarity in proportion of death rate declines: 1) there may be a delay before a personal increase in the family living standard is reflected in a rise in expenditure for health care; 2) people moving from one social or occupational group during the testing may have complicated the data; and 3) we still have not discovered the reasons for infant mortality differentials between social classes.
Clinical tests of chemical contraceptives.
The author reports on the clinical tests performed at the Margaret Sanger Research Bureau to determine the effectiveness and safety of newly developed chemical contraceptives (spermicides). Conditions under which a new product will be accepted for study are presented. To determine that a product is harmless, it is first tested in single doses and later in a 21-day test. Tests for the effectiveness of creams and jellies determine the spermicidal value through such means as the Brown and Gamble test and the Sander and Cramer test. The occlusive and adhesive properties of the product on the cervical os and on a rubber diaphragm are also tested. In addition to the previous tests, vaginal suppositories and foam tablets are also tested for their melting rate. A further test, used on all agents submitted, is a postcoital test asses sing spermatozoic activity several hours postcoitus in a volunteer who is planning a pregnancy. Once a product is shown to be harmless and sufficiently effective in laboratory and clinical trials, it is then tested for the equivalent of 75 woman-years of exposure.
Promotion of family planning through public health centers.
The use of midwives in promoting family planning methods in Japan is reported. Midwives' homes are the site of group guidance meetings. The midwives and staff meet monthly with leaders of the program for health education, technical study in practical guidance, and the exchange of ideas. 150 group guidance meetings have been held with 4750 women attending. This has resulted in a diffusion of birth control information to 62% of the women in Suginami ward. It is hoped that the women will overcome their needs to see a midwife and go directly to the directors of the program.
Development programmes and planned parenthood in Asian countries.
An overview of socioeconomic development programs and family planning programs in Asian countries is presented. Underdevelopment in East Asia is characterized by a very low standard of living, an unmechanized agriculture, widespread illiteracy and lack of education, lack of physical and intellectual communication, high birthrates and death rates and an increasing population, and insufficient resources to achieve new political and economic order. Political independence, national development programs, and international aid have combined to counter the state of underdevelopment. Per capita cereal production for the area has increased from 1948-1951 levels of 82% of pre-World War 2 levels to 88% in 1953-1954. Per capita consumption of food and certain goods has increased though it remains at an unsatisfactory level. The lack of capital, the dynamics and effects of population density, and the importance of technological production contribute to the problem. Birthrates and death rates have generally declined in Asia, though medical facilites remain inadequate for the 1954 population. The appropriateness and objectives of family planning programs for the area are outlined and discussed. The use of trained and semitrained social workers in educating the public to birth control and the selection of contraceptive methods that do not offend the public mores are discussed. It was concluded that though not all Asian countries presently perceive a need for family planning programs, they likely will, and data from existing programs will be most useful in developing cooperation between developing nations.
The writer reviews the literature in psychology on testing involving the relationship between family size and intelligence level. A complicating factor is that fertility differentials among educated groups have decreased recently. There has always been a negative correlation between intelligence test scores of children and the number of their siblings. The question is found to be more complex that originally thought. Number of years between siblings is a complicating factor. The exact effects of heredity and environment, parental motivation and contact with parents are other factors to consider. On the basis of early data, several writers had predicted a drop in the intellectual level of the population. This conclusion is doubtful and needs more corroboration. Testing the relationship between intelligence and family size presents certain methodological problems: 1) incomplete families are included in the sampling; 2) selective factors, such as several children from one family, may skew the test data; and 3) mean family size can be defined in different ways. There is growing interest and a need for a carefully designed test to measure this relationship. A battery of aptitude tests, not one single test, should be used. Subjects should be measured until their families are complete. Ages of parents at birth of first and last child should be recorded. Information on occupation, income and education levels is important.
Present day demographic trends.
Demographic trends in India as a whole are discussed. Past data, although insufficient, indicate that the rate of population growth maint ained a steady upward trend after 1921. The author discussed the broad mortality and fertility trends and the way they may have been affected by economic and social changes in the country. Estimates of future death rates are given. There are certain cultural trends that may tend to reduce the number of children: the taboo on sex relations while the infant is young and the extended period of lactation, which may have an effect on spacing because of the longer time it takes to resume menstruation. Nonremarriage of widows is another factor which may lower the birthrate. However, the author contends that the largest reduction in birthrate must be expected from a planned family planning effort.
6alpha-methyl-17alpha-hydroxyprogesterone and its 17-acetate (Provera), propionate caproate, phenylacetate and beta-cyclopentylpropionate esters were synthesized. 17alpha-hydroxyprog esterone-bisethylene acetal treated with peracetic acid gave a mixture of 5alpha,6alpha and 5beta-epoxide. The alpha epoxide was refluxed with methylMgBr2 to yield the bisethylene acetal of 5alpha, 17alpha-dihydroxy -6beta-methylpregnane-3,20-dione. This hydrolyzed and dehydrated to 6be ta-methyl-17alpha-hydroxyprogesterone, then epimerized to the 7alpha product. The 17-acetate (Provera) and other esters were prepared. In the McPhail assay, Provera was 50-60 times more potent than progesterone sc, and 100-300 times more so than ethisterone orally. Provera was 10-20 times more active an ovulation inhibitor than progesterone in rabbits, and 25-100 times more active in maintaining pregnancy in rats ovariectomized on Day 8.
Evaluation of a new contraceptive cream-jel based on long-term usage.
In the Post-Partum Clinic of the Sinai Hospital in Baltimore, Maryland, a 3-year study of a new spermicidal vaginal cream-jel, Immolin, was conducted. The study adhered to the criteria of the Council on Pharmacy and Chemistry for testing chemical contraceptive agents, which require that each case reported be observed at least 12 months and that a minimum of 75 patient-years of experience be reported. In this study 176 women used the product as the sole contraceptive for 12-35 months, a total of 279.5 patient-years. The women were all postpartum patients of the clinic, ranged from 15-45 year s old, were predominantly Negro, and were visited by a social worker and questioned about the use of this method every third month after the initial contact. At the end of the study 141 patients were still using the product, indicating a high rate of acceptability. In the total of 3354 patient-months of use, 7 pregnancies ascribed to patient failure and 9 pregnancies ascribed to method failure occurred. By the Pearl formula this is a pregnancy rate of 5.7 per 100 years of exposure, calculating both patient and method failures, and 3.2 per 100 years of exposure when only method failure is considered. The mode of action of the product is inhibition of sperm migration by causing a physical alteration in the cream-jel immediately upon contact with semen so that the spermatozoa are arrested and killed.
During 1920 to 1930, there was 1 therapeutic abortion in 52 obstetric admissions done in Johns Hopkins Hospital; this figure became 1 in 870 during the decade of 1950-1960. It is not correct to think that a therapeutic abortion carries no more danger than an ordinary curettage for incomplete abortion. It is true that an abortion performed before the sixth week of pregnancy may be done with safety through the vagina. The figures from Denmark show that therapeutic abortion carries a maternal mortality of 2 per 1000 and that in 3.2% of the cases there are serious consequences. Infertility results in 15-20% of the cases. Diabetes, heart disease, etc. are no longer considered to be indications of abortion. However, the author concludes that therapeutic abortion is against all the ethical and moral codes of the medical profession.
Fertility control agents as a possible solution to the world population problem.
While the "demographic revolution" - the transition from high death rate and birth rate to low death rate and birth rate - occurred in the industrialized nations, completion of the revolution with family planning methods alone may be implausible or too slow in arriving in the underdeveloped countries. Moreover, even if couples throughout the world become proficient in family planning, the world population's desire for children may prevent the avoidance of disaster. The author raises the possibility that, in the future, fertility control agents will be used by governments as supplements to family planning measures used voluntarily by couples. An example of a fertility control agent would be a compound raising the threshold requirement of some substance involved in the implantation of blastocysts. Such a compound may be available for field testing within 5-15 years. A fertility control agent must have less than 100% effectiveness and should reduce the fertility of everyone equally. Moreover, it should be easily and unobtrusively a part of the intake of everyone in the population, harmless, inexpensive, easily reversible, unassociated with family planning of couples, and unrelated to the sexual activity of individuals. Economic sanctions directed at couples bearing more than a predetermined number of children have been proposed, but associated problems involve welfare of the children born in spite of the sanctions and discrimination against economic groups. Raising the legal age of marriage or denying requirements of married life (housing, etc.) to people below a certain age are inconsistent with the more attractive concept of allowing marriage at an age consistent with cultural and biological desires. Policies allowing couples to have only a certain number of children might be unworkable, unduely harsh, or objectionable in method. When the population growth is seriously affecting the welfare of the population and voluntary means are inadequate, then gover nmental action becomes morally and politically justifiable.
Does IUD turn blastula into a blob?
An experiment was designed to test the hypothesis that IUD devices cause either premature expulsion or degeneration of the fertilized ova. Artificial resin sphere ovas and rabbit eggs were transferred to 14 IUD monkeys and 12 control animals who had been caged with fertile males at least 3 days before transference of the substitute eggs. At 72 hours, only 1 transferred egg was recovered from the IUD group and all resin spheres and 36% of the rabbit eggs were recovered from the control abnormal, and 2 of 8 were recovered from the IUD group, 1 of which was degenerate and unfertilized and the other was a degenerated mass of more than 20 blastomeres. It is concluded that since no evidence indicated eggs were expelled from the uterus, the presence of an IUD causes fertilized eggs to degenerate.
Although the need for new, effective contraceptive agents is widely proclaimed, few realize the practical problems involved in such an effort. The logistics in terms of time and money are outlined for the development of 3 types of contraceptives: a new female contraceptive, consisting of a once a month pill with abortifacient or luteolytic properties; a male contraceptive pill; and a ubiquitious agent, such as an additive to drinking water. The strict safety requirements of the Food and Drug Administration (FDA), including animal toxicity studies on animals whose metabolic systems may not be similar to man's, require that about 10 years be spent in the development of a drug when studies go well. Added to this is the enormous expenditures that pharmaceutical companies must make in the development of a drug (essentially all modern prescription drugs were developed by pharmaceutical companies). Tables are presented outling cost and time data for the female and male contraceptive pill. Of the two, the first is considered more likely, since more is known about the reproductive biology of women and women have a deeper interest in effective contraception. Practical problems relating to the development and use of a universal agent are raised, such as side effects and the effect on small children. Given the premise that pharmaceutical companies should remain involved in the effort to develop a new male or female contraceptive and that this should be done under rules and regulations of the FDA, 4 recommendations are made: 1) the FDA should grant "conditional approval" to drugs which have been successful in well-planned, moderate-sized clinical studies of a length that would disclose conspicuous toxicity; 2) there should be a procedure for appealing decisions of the FDA which have turned down proposals for the initiation or continuation of clinical studies; 3) revision should be made in the patent granted drugs when very long-term premarketing investigation is required; and 4) part of the cost of developing a new contraceptive should be borne by the government.
Rhythm, calendar rhythm: general considerations.
The factors involved in calculating the "safe periods" for the rhyth m method of contraception are detailed. The functional life-span of the egg is 12-24 hours after release from the ovary while the spermatozoon maintains its capacity to fertilize for probably not more than 48 hours after ejaculation. The problem comes with ascertaining the time of ovulation. Since ovulation occurs roughly 14 days before menstruation, the woman is forced to count backwards to ascertain the safe period. Since some women, especially as they grow older have more anovulatory periods which are shorter than true menstrual periods, the rhythm becomes less regular. Computation of infertile days is possible only if the menstrual data of at least 1 year are available, but most clinics op erate with only 3 month's records from the woman. Details of figuring "safe periods" for menstrual cycles of various lenghts are explained. For a 28-day cycle the fertile phase starts on Day 10 and ends on Day 17, including 2 extra days on each end to compensate for possible extended life of spermatozoa or egg. A study of 409 patients in the author's clinic showed a mean pregnancy rate of 14.4 + or - 1.5 per 100 woman years, compared to 80 per 100 expected with no contraception.
Recent advances in contraceptive techniques.
Oral contraceptives and intrauterine devices have been shown to be m ore effective than older techniques of contraception. The author discus ses progestin-estrogen compounds. Side effects have reduced acceptibili ty but tend to disappear after the third month. Newer compounds like ethynodiol diacetate, 2 mg, with mestranol have reduced side effects. Reported effects on lactation have varied, depression being more marked in those who had not previously lactated for long periods. Uterine fibromyomas have increased in size with use of these drugs. Thromboembolic disease may be induced in susceptible women. A carcinogenic effect has not been shown. When the oral contraceptive is withdrawn ovulation occurs and the child-bearing function is restored. Recent modifications of intrauterine devices have improved this method. Polyethylene devices can be introduced without an anesthetic, are immediately effective, and make no further demands on the patient. Side effects tend to diminish with time. Approximately 10% of patients do not tolerate the device. Pregnancy may occur in .5% with the device in place but the infant is not damaged. Intrauterine devices are considered the best method of population control for the less developed countries.
The first Symposium on Family Planning in Uruguay was held in 1963. Doctors, midwives, nurses, schoolteachers, journalists, religious minist ers, social workers, as well as representatives of university and executive authorities were invited to attend, and consensus views on birth control and sex education were established. In July 1964 cooperat ion between the Clinic of Gynecology 'C' the Dept. of Psychology of the Faculty of Humanities, and the Educational Institutes for normal and high school teachers, led to the first course in sex education and family planning being inaugurated at the university and high school level. Since then several forums for sex education have opened up: schools, social clubs, religious organizations, radio and television. At the beginning, resistance was encouraged not from parents but from school authorities. This was gradually overcome and a program of sex education at school levels involving both parents and high school students, is currently being considered by the Council of Primary and Secondary Education. The lectures sponsored by the Uruguay Association for Family Planning and Investigation into Human Reproduction (AUPFIRH) are now frequent, cover a wider geographic area, and are beginning to combat some of the resistanfe of public organizations. The AUPFIRH, as its name implies, has also promoted and undertaken research, and elaboration of a theory of sexuality which differs from the classic psychoanalytic concept of the sexual instinct. The AUPFIRH established numerous Family Planning Dispensaries and a Laboratory for the Investigation of Human Reproduction which were recognized and made 'official' by the Ministry of Public Health on June 21, 1967. Their essential task is to undertake research using programs aimed against induced abortion and for treatment for sterility and infertility, as well as for sex education and premarital advice. The first Latin American Course on Sex Education and Family Planning was scheduled for October 1969 and proposed classes for school children, courses for parents, information for parents on child development and adolescent personality, and information for teenage groups on problems of human relationships. The AUPFIRH further envisages a 4 stage goals: 1) making people aware of the tremendously important problem of sexuality and family planning; 2) undertaking research into theories and methods of sex education and birth control; 3) implementation of research findings with close collabortion with all types of education institutions; and 4) communication and publication of experiences thus acquired.
[Problems of demographic data collecting in Arab countries of the Middle East]
12 Middle Eastern Arab countries can be divided into 5 northern countries with demographic data from census or survey and 7 southern countries primarily in the Arabian peninsula (Bahrien excepted) with no data. Obstacles include lack of information on tribes, migrations, and even nomadic status, large areas with sparse population, low socioeconom ic and literacy levels, and cumbersome registration systems. The author computed the index of regularity of age and sex, age distribution by sex, and crude birth-, death, and infant mortality rates to estimate the validity of existing data in each country. These estimates showed that for birthrates registration was about 100% complete for Kuwait and Jordan, 80% for Libya, 60% for Syria, 40% for Iraq. For mortality the registration was so poor that it is only about 30%-40% complete, even in Kuwait and Libya. Data on infant mortality are also poor and have apparently worsened in the 1960s compared with the 1950s. Bias probably exists in birth place, marital status, education, and profession. The author suggested that in southern countries a census should proceed over several years in steps: 1) lists of towns and tribes, 2) simple head count, and 3) complete census. valid vital statistics are urgently needed for national economic planning.
Uterine contractility in women using intrauterine devices.
Recordings were made of uterine contractions at the various stages o f the utero-ovarian cycle in women wearing IUDs. Patients were 35 multiparous women with normal cycles who were using Margulies spirals or Lippes loops. Intrauterine pressure readings were made with an open-end polyethylene catheter. To estimate the stage of the cycle, hormonal evaluation of cytologic smears, day of cycle, and endometrial biopsies were considered. Recording sessions were 90 minutes to 4 hours. In 5 cases the IUD was inserted during the recording session. Uterine contractility was not immediately increased in any of these patients. Alterations found during the first week of use were seen only while the patient had postinsertion bleeding. These changes were independent of the stage of the menstrual cycle. For patients using IUDs from 2 to 48 months, a change in the frequency of uterine contractions with increased intensity and greater frequency was found. This change in the pattern of contractility might be a factor in the contraceptive effect of IUDs. However a hormonal imbalance in the utero-ovarian cycle was thought to be an explanation of contraceptive action.
Studies in female sterilization in Uttar Pradesh.
Family planning work was started in Uttar Pradesh, India, by the State Red Cross Society in 1952. It was soon discovered that the people who most needed family planning would not afford or use correctly the av ailable chemical and mechanical contraceptives. Postpartum sterilizatio n was felt to be the ideal method of contraception for this class of people. Hospitals performed the operations free of charge. In 1952 studies were done to determine demand for and attitudes toward sterilization. From studies of opinions about sterilization, of actual sterilization cases, and of follow-ups after the operation, it was evident that sterilization has no ill effects on the health, reproductive organs, or sex life of the individuals. All the women polled indicated they would not consider sterilization until they had at least 4 living children. It is still evident that with increased propaganda and public education and with improved operative facilities in the hospitals, poor people who have had all the children they want will take advantage of the opportunity for sterilization.
The meaning of population policy.
Population policy may be defined as the taking of measures designed to adjust the population of the economy; in other words, measures designed to promote or reduce the population for the purpose of solving population problems. Population policy therefore comprises only measure s which promote or limit birth and emigration. In Japan, since there is at present little hope for emigration, there remains only the limiting of the birth rate, that is to say, birth control. Family planning is an essential feature of family life and should be practiced everywhere without regard to the population situation. In this sense, it has in itself nothing to do with population problems or population policy. The birthrate of Japan has in recent years fallen considerably, largely as a result of abortion and sterilization. If these are rejected as population policies we cannot at present expect any greater reduction in the birth rate. On the other hand, to permit abortions and sterilization is to destroy largely the ideal of family planning. The problem will not be solved until methods of contraception are so highly developed and widely spread that such drastic procedures are no longer necessary.
Studies in simple methods of contraception.
In order to study the effect and response to simple contraceptive me thods like foam tablets and the gel-alone method, 2 centers were establi shed in India, one at Badlapur, a small village near Bombay, and another one at Kalyan Camp, No. 2, a colony of displaced people mostly from Sindh. The clinical findings from 1954-1956 at Badlapur of the 84 cases studied showed that there were 28 vasectomies performed, 29 active users of foam tablets, 7 users of diaphragm and jelly, 7 who left the station, 7 pregnancies during irregular use of the method, 2 pregnancies during regular use of the method, and 4 planned pregnancies. It was determined at the Kalyan Camp No. 2 where the effect of Preceptin jelly was studied that the method failure was about 2%, whereas the patient failure rate was about 17%. It was concluded that the Preceptin Gel-alone method is acceptable.
Ten years of tubal sterilization by the Madlener method.
From 1945-1955, 734 women in Denmark were sterilized by the Madlener method. This method involves an abdominal incision, crushing and tying of the tubes. Since 1945 there has been a rising number of operations performed each year. Average age of the women was 33 years, with the 30-40 year old age group in the majority. Patients under 20 were recommended for sterilization by the Special Board for Sterilization of the Mentally Defective. The average number of living children among the patients was 4. Of the 734 operations, 2 deaths resulted, 1 patient delivered a child she had already been pregnant with at the time of the operation, and 1 more became pregnant following the operations. Few serious complications were reported. Only 3.9% of the patients who were followed-up indicated they regretted the operation. It is concluded tha t the operation is a harmless and safe method of sterilization.
The relationship of infant mortality rates in the first 2 years of life and both stillbirth rates and mother's age and parity are discussed on the basis of the single legitimate births in England and Wales in 1949 and 1950 amounting to 1,350,000. Maternal age and parity were found to be differentially related to stillbirth and to the chances of an infant dying during the postneonatal period. The stillbirth rate rose with maternal age and postneonatal mortality rose with maternal parity. The pattern of neonatal mortality (death in the first 4 weeks of life) was close to the pattern of stillbirths. There was a tendency for high neonatal mortality rate among children of young multiparae. Young mothers with many children have a high prematurity rate and their infants a high mortality risk during both neonatal and postneonatal periods.
Reports of a series of patients having elective vasectomy, a compari son of complications after the use of various techniques, and an explanation of the basic role of spermatic granuloma in the process of spontaneous recanalization are presented. 432 patients who underwent vasectomy were observed for a period of 5 months or longer. 417 of the patients were followed for more than 1 year. In 288 operations the vasa were divided, and the cut ends were doubly ligated with cotten; in 144 operations the vasa were divided and the cut ends were not ligated but were fulgurized with a needle electrode introduced 2 mm into the lumen of the vas. In 155 operations the cut ends of the vasa were dropped back into the wound after ligation or fulguration; in the other 277, the sheath was closed over the distal stump of the vas so that a barrier of fascia was placed between the cut ends. 1 patient requested reanastomosis during a subsequent marriage. Pain prevented only 1 man from returning to work promptly after operation. Spermatic granuloma arising from the cut end of the proximal vas occurred in 4.9% of the patients, and hematomas occurred in 1.9%. Spermatic granuloma may occur at the cut end of the vas or in the epididymis shortly after, or years after vasectomy. It is recommended that vasectomy be done through bilateral incisions, that both ends of the sectioned vas be fulgurized, and that the sheath of the vas be closed over the cut end of the distal vas. This technique should be employed in both elective and prophylactic vasectomy. Recanalization, or reanastomosis, occurs most frequently if the cut ends of the vas are ligated rather than fulgurized. It was noted that most psychological complications can be prevented if the patient and his wife both want the operation done, if they are fully informed of the steps in the procedure before it is done, and if they are assured that spermatogenesis continues and that reanasto mosis is possible.
Effect of the IUD and other contraceptive methods on lactation.
Lactation by 276 women using birth control methods was studied by mo nthly medical examinations for periods of longer than 1 year. All the women had nursed 1 or more children previously. 81 women were using IUDs; 103 were using long-acting gestogens, 500 mg medroxyprogesterone acetate (MPA) by injection every 6 months; 40 were using combined contraceptives, norethisterone acetate 1 mg and mestranol .08 mg for 14 days and chlormadinone 1.5 mg with mestranol .08 for 7 days; controls were 150 nursing women not using any contraceptive. The duration of lactation was compared with that following the previous pregnancy, as given in the history. Contraceptive therapy was begun about 1 month after childbirth. A study of neuroendocrine function was made on 8 lactating women from the MPA group using Guiloff's technique for measuring pituitary oxytocin and the Sica-Blanco method of study of the ejectolactic reflex. The lactation half-life, the time in which 50% stopped nursing was calculated for each group. The lactation period for the control group was similar to that given for previous pregnancies by the treated women (p = .10) at 6 months. Mothers using the IUD were able to nurse their children for longer periods, 7 months and 21 days compared to 4 months and 21 days for the control group. In the groups using combined and sequential therapy lactation was shorter than the control group. Study of the neuroendocrine component in the ejectolactic reflex as an index of oxytocin release showed no significant difference between the studied group of 8 women using IUDs and the control group. Analysis has shown inhibition of lactation only when the preparation used contained estrogen. This effect was most evident in sequential therapy where progestogen is given only in the last 7 days of the cycle. It is believed that estrogens act in conjunction with progesterone, also, to inhibit lactation.
A study in 1964 of 317 males and 314 females was conducted in Pakistan to determine knowledge, attitudes, and practice of family planning; a comparison of the results is presented. The median age of the subjects was 30.9 for men and 25.7 for women. 13% of the men and 2% of the women knew the correct mechanism of conception. 51% of the males and 42% of the females knew of temporary methods of contraception, while 30% of the females knew of no methods. The most common method known was the condom. The most important reason for having childeren was love and care for males, and God's will for women. Economic reasons were those most often given for not having children. Reasons given most often for family planning were mother's health, care and education of children, and freedom for parents. The mean ideal number of children was 3.6. 71% of the men and 78% of the women wanted to adopt family planning.
[IUD and pregnancy. Complications and management]
A case is described of a 32-year-old woman with an infected uterus and 3-month pregnancy diagnosed 3 months after insertion of a Lippes loop size B. The uterus was hard, painful, fixed, deviated to the right; the right cul-de-sac was tender; perimetritis was apparent to the left and rear; the IUD thread was in place, but short. X-ray showed the IUD on the left in the painful region. The IUD was removed. The patient stated that she had menstruated 10 days before and 20 days after insertion and asked for an abortion, but the authors refused and she carried pregnancy to term. The authors discussed how pregnancy might be saved when an IUD has to be removed because of infection.
Urinary pregnanediol estimations have provided a useful, but not totally accurate, estimation of progesterone production for many years. Initial studies of progesterone production centered about the sites of its production and the concentration of progesterone in the venous effluent, which taken together with the rate of blood flow, gave an approximate measure of production. In the follicular phase in humans, M ikhail found progesterone concentration to be .393-1.55 mcg/100 ml, and Aakvaag and Fylling found it as high as 8.1 mcg/100 ml in ovarian vein blood. In the luteal phase, the values rose to 14.8-110 mcg/ml of progesterone in ovarian vein blood. Because of different ovarian blood flow in each phase of the menstrual cycle and the lack of a known ovaria n blood flow rate, the estimated secretion for the ovary by this method in humans has a broad range. Very little progesterone, if any, comes from the testis, but most is secreted from the adrenal in man. Progeste rone has been identified in the adrenal venous effluent of 2 postmenopau sal women after excessive ACTH stimulation. Progesterone is also observed in high concentration in the uterine venous effluent in pregnancy, presumably representing placental production. Umbilical cord samples vary in progesterone concentration. Of the urinary and blood me thods of determining progesterone production, the urinary method is simp ler to carry out, but more precise physiological data can be derived fro m the blood method. In the male, where pregnanediol precursors contribute largely to the falsely high estimated urinary production, the contribution of pregnenolone production to progesterone production would be important. The clearance of progesterone takes place in the splanchnic and extrasplanchnic systems. From the present data, pregneno lone is not a significant prehormone for progesterone in the male. Pregnenolone and/or pregnenolone sulfate may be of more importance in the menstruating female and in pregnancy than in the male in their relat ive contribution to progesterone production.
Population review 1970: Bolivia.
This population review is based on a study made by the Department of Social Affairs of the Organization of American States and official Bolivian government statistics. The Bolivian crude birthrate is stable at 44/1000. The death rate declined from 21/1000 in 1960 to 19/1000 in 1970. However, both rates are higher than average for Latin American countries. In Bolivia, the infant mortality rate increased from 103/1000 live births in 1960 to 108/1000 in 1970. These are considered underestimations. The annual growth rate in 1970 is estimated as 24/1000 population. This includes migration. At these rates the population would double in 29 years. Urban dwellers are almost all wage workers at very low levels. However, among them knowledge of and access to contraceptives is increasing. In rural areas contraceptives are little known. There is much poverty so that even cheap contraceptives are a problem. Public health programs are rudimentary. There are no family health programs. Many of the medical supplies used for public health are donated by other countries, particularly Argentina. Hospitals are extremely poor. Private clinics are not well equipped. There are no family planning programs which have any impact. Abortion is practiced by physicians in clinics for anyone able to pay. Contraceptives have little place in a marriage. Some urban women use the pill; men do not favor the condom, particularly in rural areas. Physicians charge high fees for insertion of plastic spiral IUDs. The basic problem in Bolivia is population maldistribution. Technological development to promote internal migration to the better agricultural areas is beyond the resources of the country. Family planning will be resisted by a majority, but an urban minority practicing various methods will increase. Better medical services will cut the death rate and raise the natural increase rate. The country is already hard-pressed to provide subsistence for the existing population. Bolivia will be a major test for family planning programs.
Psychologic aspects of the basal body temperature method of regulating births.
410 couples out of 502 couples using the basal body temperature (BBT ) method for 2 1/4 years returned questionnaires between November 1966 and June 1967 assessing the psychological importance of abstinence from coitus in the method. 41% of the couples worried about the possibility of unplanned pregnancy, and this affected their attitude toward intercourse in 28% of the men and 38% of the women. A majority found abstinence difficult which had an effect upon themselves and relationship with spouse. 1/3 reported difficulty expressing love for spouse adequately during period of abstinence and experienced lack of spontaneity when intercourse was possible. 84% of the men and 80% of the women experienced a climax on some occasions without intercourse. Despite difficulties a majority found the BBT method satisfactory in general and thought it helped their marriage. However, they may not have had knowledge of any other contraceptive methods.
Immunologic infertility with special reference to altered biochemical status.
Male guinea pigs were injected with adjuvant plus saline or adjuvant plus spermatogenic antigen and sacrificed at weekly intervals up to 8 weeks. Levels of the enzymes leucine amino peptidase, alkaline phosphatase, alpha-amylase, lipase, and sorbitol dehydrogenase, were determined. Leucine amino peptidase and alkaline phosphatase levels were found to be sharply elevated in the immunized animals. Serological levels of alpha-amylase and lipase were also elevated. Sorbitol dehydrogenase levels fell without indicating a degree of cellular depletion. Periodic immunization of female guinea pigs with homologous testicular homogenate or sperm results in sterility of 1 year's duration. The presence of antibodies in the fluids and tissues of male and female patients classified as infertile has been shown. These antibody levels are of a low order of magnitude and wax and wane. In these cases, deficiency of inactivation systems in male or female could allow antigenic materials to go undergraded and thus incite antibody production. In animal experiments sterility can be induced by immunological methods. Problems of human fertility and sterility are being explored.
The effect of Enovid on the binding of thyroxine to plasma proteins in vitro.
The purpose of this investigation was to determine if Enovid (noreth ynodrel and mestranol) altered to binding of thyroxine to plasma proteins in vitro. The technique, using a column containing Sephadex G-25-40 which had been made into a slurry using a .15M, pH 7.4 trihydroxymethylamino methane (tris) buffer, is described. The distribution of the protein-bound thyroxine and the free throxine was followed using the radioisotopic tracer thyroxine labeled iodine-131. Enovid markedly increased the binding of the thyroxine to the plasma protein, the ratio increasing from 1l7 without Enovid to 6.0 at 200 mcg Enovid.
The new Food and Drug Administration (FDA) guidelines for evaluating contraceptives are blamed by some researchers for killing the initiative of a few drug firms undertaking long-term contraceptive research and development. Only government-sponsored work will follow. Required animal studies are causing the cost of contraceptive research and development to go up. Also more than 8 years would be required for introduction of a new agent to the public. The FDA is not considered by some researchers to be competent to monitor safety and effectiveness due to political, journalistic, and legislative pressures and lack of competent people to handle applications. More available government funds and private foundation funds are needed to further research. Widespread use of oral contraceptives makes evaluation for mutagenic effects imperative. Several assay methods are proposed. More studied related to delayed carcinogenic effects and to fill specific gaps in knowledge about oral contraceptives are also needed. Another researcher recommended use of less effective alternative methods of contraception with surgical interruption of unwanted pregnancies. At the beginning of oral contraceptive approval, pressures caused an irration approach to controlled studies; a more rational approach has been followed in recent years.
Psychological aspects of contraception.
The hypothesis that the frequency and severity of mood and behavior changes reported by women on the pill correlates to the severity of the women's psychopathology and personality problems was tested using 25 paid volunteers selected at random from the files of the Denver Planned Parenthood Clinic. All were taking the oral contraceptive Oracon (ethinyl estradiol and dimethisterone). Most were lower middle class, but all levels of education, IQ, and husband's occupation were represented. Most were white or Spanish-American; 8% were black. None was under the care of a psychiatrist, but 4 had seen one in the past. They had been on Oracon for a mean of 10 months. Each women submitted to a standardized psychiatric exam, with special attention on conflicts about femininity and motherhood, the marital relationship, and the couple's attitude toward contraception. The women were rated on their degree of disturbance in these areas. The Minnesota Multiphasic Personality Inventory, in shortened form, and the 16 Personality Factor Questionnaire, were also administered. To determine possible side effects of the pill, each woman, on 2 occasions, filled out a checklist stating the degree to which she was experiencing any of 121 symptoms or reactions that day. The women filled out the checklist once while they were on their estrogen pill and once while they were on their progesterone pill. The results strongly supported the hypothesis at the .05 level. The women with long-standing personality problems were the women who complained most about the side effects of the pill. Several symptoms, however, did not correspond with psychopathology: headaches, weight gain, and skin disorders. There were nonsignificant trends toward more somatic symptoms on the estrogen pill and more mood disturbances on progesterone.
Oral contraceptives and hypertension.
The occurrence of hypertension in patients taking oral contraceptives is discussed. A number of studies in which it was found that the blood pressure of some women rose while on oral contraceptive therapy are reviewed. In an attempt to find how many women would become hypertensive when given oral contraceptives, J.E.A. Tyson investigated 45 women given estrogen-progestogen preparations and found that 7 (15.5%) had a significant rise in blood pressure, mostly after the second cycle of drug usage. Treatment was stopped 1 or 2 months after the pressure rose, and in all cases the blood pressure returned to normal within 30 days. These findings have been contested by R.C. Goodlin and V. Waechter, who measured the blood pressure in 120 patients given 8 brands of oral contraceptives and matched these patients for age with 100 control subjects. They were unable to show any significant rise in blood pressure in the treated subjects. On the present evidence it is difficult to see why only some women show a sensitivity to oral contraceptives, manifested by a rise in blood pressure. It is suggested that a women who is found to be hypertensive and who is taking an oral contraceptive should stop taking the agent. Her blood pressure should be measured over a period of a month or 2 before considering the need for hypotensive therapy. A detailed clinical appraisal of the size of the risk of normotensive women developing hypertension and of hypertensive women having an exacerbation of their blood pressure when given oral contraceptives is needed.
Albumin metabolism in female rabbits treated with an oral oestrogen-progestogen contraceptive.
The effect of oral contraceptives on albumin metabolism in 11 female rabbits was studied. Labeled (iodine-131) albumin metabolism was studie d before and during a 50-day treatment with a combination of 1 mg ethynodiol diacetate and .1 mg mestranol (Ovulen). The concentration of serum albumin decreased from 45.9 gm/l to 37.2 gm/l (p less than .001). Plasma volume increased from 101 mg to 123 ml (p less than .001). The synthesis rate dropped from 1.13 gm/day to .86 gm/day ( less than .01) and the fractional catabolic rate dropped from 24.8%/day to 19.2%/day (p less than .01). The intravascular and the total mass to albumin did not change. It is fractional that the concentration of serum albumin regulates the fractional catabolic rate.
Family planning and eugenic movements in the mid-twentieth century.
The author reviews the history of the birth control and eugenics movements in Great Britain from the 1800s to the present and assesses their respective positions today. A major present-day development in the acceptance of birth control is the lack of opposition from the major world religions to its practice. Another important development is that modern countries which once viewed overpopulation and depopulation as different problems are now viewing both conditions in the same light. N azi government policies had brought great disrepute to the eugenics movement. The most important development in eugenics has been a revised standard of eugenic value. This standard focuses on the moral and social qualities of the healthy and happy family and favors the planned family and organized community. Some problems that are likely to occur in the future are depopulation scares, demographic pressures which may bring about compulsory measures impinging on the freedom of individuals to practice, or not practice, birth control, increased urban growth and the psychological effects on the children of overcrowded urban areas, the Roman Catholic Church and the practicality of the rhythm method of birth control, and the problems associated with differential fertility resulting from imported immigrant labor.
A survey of the pertinent literature on sexual sterilization for the past 25 years is presented. Emphasis is placed on the physical, psychia tric, and legal consequences in each of the 3 main types of indications for sterilization in the female and the male. Therapeutic sterilization for medical reasons is carried out to reduce maternal morbidity and mortality rates. Voluntary sterilization is to prevent pregnancy, usually for social and economic reasons. Statutory sterilization is done to prevent procreation of individuals who suffer from mental disease, epilepsy, heredofamilial degenerative diseases, and criminal sexual psychopathy. Reports on female sterilization relect the differing opinions held on the effects of sterilization. Almost all the vasectomies reported were carried out as statuatory sterilizations. Among the recommendations of the Committee of American Neurological Association in 1935 was 1 that called for voluntary rather than compulsorary sterilization. Opinions are diverse on the grounds for eugenic sterilizations. Evidence showing that intrauterine stress is more responsible for inborn anomalies than faulty heredity has accumulated. More precise information is needed in order to determine how pathological mutant genes occur and what exact chemical corrective measures should be undertaken.
Hypotheses for family planning derived from recent and current experience in Asia.
A list of general propositions concerning family planning as it is c urrently happening in Asia, based on a hasty 1-month tour of Singapore, India, and East Pakistan in February 1963, is presented primarily to promote evaluation and discussion. It is hypothesized that: 1) mass communication methods must be used to stimulate Asia's family planning programs; 2) family planning education can reach every village regardless of traditions, distance, or fatalism doctrine; 3) all population strata can comprehend the national population problem in collective terms; 4) communication and education should be directed toward promoting the ideal of companionate marriage; 5) the "organizer technique" of adult education training should be given wide experimentation and trial; 6) family planning programs should demand personal involvement and commitment; 7) the economic motive force in communication should be stressed; 8) the theory of "opinion leader" may not be too applicable in family planning communication; 9) personal contact in villages can be overdone; 10) there must be continuous striving for variety; 11) mother-in-law resistance must be overcome; and 12) shyness may prevent couples from purchasing contraceptive supplies from intimate acquaintances.
The National Committee on Maternal Health reported on 28 cases of pe rforation of the uterus in a total of 16,338 first insertions of IUDs after confinement, an incidence of 1.7 perforations per 1000 insertions. 20 of the perforations followed the insertion of a bow. 16 of these occurred in patients less than 12 weeks postpartum. With the bow there is a highly significant correlation between the perforation rate and the number of weeks postpartum, especially if no menses have occurred. The perforation rate after 12 weeks postpartum for the bow is 2 per 1000 insertions. This is less than the perforation rate of 3.23 per 1000 found in a collected series of 77,903 curettages. The high perforation rate for the early postpartum insertions indicates that softness and friability of the uterus is a greater factor in the etiolog y of the perforations than the type of introducer employed. Perforation s with other devices are difficult to determine because of the lack of accompanying symptoms and the presence of a tail protruding through the cervix. Care in examining the patient, judicious timing of insertion, the use of a tenaculum, traction to straighten flexion deformities of the uterus, sounding the uterus, and gentleness during the introduction and ejection of the device into the uterus should greatly reduce the incidence of uterine perforation.(AUTHORS', MODIFIED)
Pakistan's administrative approach for a family planning program.
This paper deals with the organization and administration of the Pakistani family planning pattern. The need for control of population growth in Pakistan is urgent. The urgency of the problem, recognized in the second 5-year plan implemented in 1960-1965, forced the Government of Pakistan to establish a family planning program. The program was entrusted to the National Family Planning Council, an autonomous agency with a full-time commissioner of family planning. The health minister is chairman of the Council, and the commissioner is its secretary. The commissioner is also joint secretary (the second highest rank in the civilian administration) to the Government of Pakistan in the new division of family planning in the Ministry of Health, Labour, and Social Welfare. The National Family Planning Council is responsible for policy and implementation of the family planning scheme, including coordination, assessment, and evaluation of activities, research, foreign aid, and consultation. The National Council has an evaluation unit for each province, with a technical staff to assess the progress and success of the program. Each unit has an administrator, medical officer, health educator, statistician, interviewers, and clerical staff . Performance is measured in terms of quantity, such as number of perso nnel on the job, IUD insertions, and amount of conventional contraceptives sold. The progress of the program is also followed through a continuous national-sample survey on knowledge, attitude, and practice of family planning. Fertility pattern studies reveal long-term use of various methods. The aim for the third 5-year plan 1966-1970 is to reduce the crude birthrate by 20%, from 50 to 40 per 1000. Goals were set for each district based on the number of fertile females in the population, available help, and local conditions. The benefits of an independent government agency are chiefly in expediting the start of a national family planning program. A plan was formulated, a budget prepared, and personnel recruited in about 3 months in Pakistan. Much government red tape, such as salary scales, civil service lists, and multiple approvals, was circumvented. (AUTHOR'S, MODIFIED)
The International Planned Parenthood Federation - its role in developing countries.
The International Planned Parenthood Federation (IPPF) is a union of autonomous family planning associations that feel that parents have the right to information and the means to plan the size and spacing of their children. The major objectives of IPPF are: 1) to stimulate the formation of family planning associations; 2) to provide information technical advice, training facilities, and financial assistance to member associations; 3) to make regional administrative arrangements; 4) to ensu rerepresentation on an international and regional level; 5) to persuade governments to provide family planning services; 6) to enlist support from the medical and intellectual community; 7) to stimulate public awareness of family planning; 8) to encourage research in new contraceptive and organizational techniques with proper evaluation; 9) to obtain financial support for the Federation and its associations. Because IPPF is a nongovernmental agency, it is often able to work in countries that are sensative to nationalistic pressures.