A number of steroids have been demonstrated to be inhibitors of DNA repair replication in normal human lymphocytes. Diethylstilbestrol (DES) has proven to be one of the best DNA repair inhibitors of the hormone analogs which were examined, with 50% inhibition being produced between 10 and 20 mcM. Estradiol was also found to be inhibitory. In the case of progesterone and its derivatives, progesterone proved to be the most effective inhibitor, producing 50% inhibition of the repair process at about 5 mcM. The 11-keto and the 11-dehyro derivatives were much less effective as inhibitors, as was medroxyprogesterone. In contrast to the estrogen and progesterone derivatives, testosterone and its derivatives were generally much poorer inhibitors of repair. 17alpha-ethinyl derivatives were also tested and were effective inhibitors. Because the alkylating agents and X-rays used in tumor therapy cause chemical alterations in cellular DNA of a type which can be repaired by the excision repair inhibitory steroids, it is suggested that repair inhibitory steroids may be useful in conjunction with treatment involving alkylating agents or X-rays.(AUTHORS', MODIFIED)
Experiments were performed to determine the mechanism for the effect s of mercuric chloride on the reproductive system of the hamster. Tissue levels of mercury were determined in animals which were treated with daily sc doses of saline, 1 mg of mercuric chloride, or 1 mg of mercuric chloride and 50 mg of N-acetyl-DL-penicillamine (NAP) throughout 1 4-day estrous cycle. The relations between concentations of mercury in several organs were found to be kidney>liver>anterior pituitary>ovary> blood>uterus>hypthalamus>cerebral cortex. Animals which were injected with mercuric chloride and NAP had significantly less (p less than .001) mercury than animals treated with mercuric chloride alone in all tisses except the cerebral cortex. Tissues from a nimals that were injected daily with 12 mcCi of mercuric chloride-203 an d 1 mg of mercuric chloride were prepared for radioautography. In the ovary, mercury was more concentrated in the corpora lutea than the folli cles of interstitium. Mercury was also found lining the sinusoids of the pituitary and in some of the neurons of the arcuate nucleus of the hypothalamus. It has been suggested that the neurons in the region of the arcuate nucleus and median eminence synthesize and store the gonadotropin-releasing hormones of FSH-RH, LH-RH, and PIF, which are released by the neural stimuli originating in the anterior hypothalamus. Mercury may have interfered with the synthesis and release of FSH-RH, LH-RH, and PIF from these neutrons. The possibility exists that other releasing hormones also may be affected by damage to the arcuate region of the hypothalamus. When hamsters were given a tota l of 3 or 4 mg of mercuric chloride during the 1st cycle, 60% of the animals did not ovulate by Day 1 of the 3rd cycle.(AUTHORS', MODIFIED)
Photoperiodic regulation of the estrous cycle of the rat: role of the pineal gland.
A 20-hour daily photoperiod was used in an attempt to modify predict ably the estrous cycles of rats exposed to this environment for 20 days. Predicted changes in the cycle were based on the theoretical phase relationships of 2 component rhythms which interact to generate a characteristic pineal HIOMT pattern during the estrous cycle. Whereas control rats from a 14/10 Light:Dark (L:D) photoperiod normally show vaginal cornification about 50% of the time, rats on exotic, 20-hour schedule (L:D,1.4/1) showed variations in cornification from 46% to 68% of the time, depending on the phase relationship between the 2 component rhythms. Rats pinealectomized and placed in this environment at selected times showed cornification about 57% of the time but no longer exhibited the relationship between vaginal cornification and phase. These experiments indicated that the pineal gland may affect the regularity of 4- and 5-day estrous cycles of the rat by modulating the magnitude and duration of action of the hypothalamic-hypophyseal axis, but not its timing.(AUTHORS', MODIFIED)
Electrosurgery untangled: with emphasis on advances in laparoscopic tubal sterilization.
Electrosurgery, particularly as applied in laparoscopic tubal sterilization, is discussed. In order to use electricity efficiently in the human body, a high-frequency current is required. The current has both nonsurgical and surgical uses. 3 types of current within the high-frequency spectrum are employed surgically. These can be identified by the wave patterns they display on an oscilloscope: coagulating, cutting, and blended. The classic method of using the various for ms of current produced by all types of generators for tubal fulguration is the unipolar system. The isolated unipolar system is not ground-seeking and will not function if a break occurs in the circuit. With a bipolar system, both electrodes and switch are carried on the hand instrument and no ground plate is needed. The introduction of the bipolar principle can be considered a technical advance for tubal coagulation. With the use of a bipolar forceps, the laparoscopist can avoid most of the electrical accidents formerly associated with laparoscopic tubal fulguration.
The histochemical activity of the enzymes delta-5-3-beta-hydroxysteroid dehydrogenase (3-beta-HSD) and 17-beta-hydroxysteroid dehydrogenase (17-beta-HSD) was studied in the ovaries of aged golden hamsters. These enzymes are operative in progesterone synthesis (3-beta-HSD) and 17-beta-estradiol-estrone interc onversion (17-beta-HSD). Blood levels of circulating progesterone were determined in the same animals. Data from the old animals were compared to measurements of these parameters from young hamsters. The pattern of 3-beta-HSD activity was similar in young and old animals, appearing in follicles and copora lutea at appropriate times of their function and in interstitium at all times. The 17-beta-HSD activity was found in follicular granulosa cells during the cycle and the first half of pregnancy of young and old animals, but was also found in corpora lutea in later pregnancy. The ovaries from old animals differed from those from young animals mainly in the degree of development of various components. There was much individual variability, but often old ones had fewer large follicles, fewer ovulations, and more corpora lutea atretica. Interstitum with 3-beta-HSD was less abundant and replaced by pigment or condensed inactive stroma. Circulating progesterone was not significantly lower than normal in old hamsters; and on certain days, some even had exceptionally high levels compared to young. Old hamsters carried fetuses to term but did not deliver them apparently because their corpora lutea continued to secrete progesterone. The fact that many old hamsters resorb conceptuses or fail to have implantations does not appear to be primarily related to lack of progesterone or deficiency of ovarian steroid dehydrogenases. (AUTHORS' MODIFIED)
The effect of large doses of estrogens post coitum in 2000 women.
The effect of large doses of estrogens given to 2000 women is reported. In 1418 cases (71%) ethinyl estradiol (Lynoral) was used. In 524 cases (26%) diethylstilbestrol (Stilbestrol) was given. For the remaining 58 women (3%) the estrogen administered was not recorded. At first, lower doses had been used and several pregnancies occurred. Later 5 mg of ethinyl estradiol or 50 mg of diethylstilbestrol were given for 5 consecutive days, beginning within 48 hours after coitus. In some cases the drugs were given later. The incidence of pregnancy was reduced to a low level. With the higher doses and early use, no pregnancies have followed. Implantation of the ovum is thought to have been prevented. Nausea and vomiting were reduced by antiemetics. Recently, only ethinyl estradiol has been used. The method is recommended only in emergencies, or unexpected intercourse. Also, improved contraceptive counseling is considered to be indicated.
[Oral contraceptives and female ecology]
This review covers principal effects, side effects, and management of oral contraceptives, including how to adapt the prescription to the individual, and drug interactions. The principal effects are blocking ovulation and rendering cervical mucus inhospitable to sperm depending on whether combined, sequential or minipills are used. The author's criteria for side effects are: 1) higher incidence in treated than in control populations; 2) altered current or future life of the individual ; 3) important effects on life and health of offspring; 4) irreversible or difficult to reverse. Therefore one significant pill side effect is amenorrhea lasting 6 months or more after stopping, sometimes associated with galactorrhea, hirsutism and acne. This condition occurs more often in nulliparous women, after depot progestagens or combined pills. Amenorrhea has little relation to duration of use and can easily be treated with clomiphene. The second consequence is spontaneous abortion due to nonteratologic effects of the pills, when pregnancy ensues within 6 months after stopping. A third group of sequelae is benign lesions e. g., polypoid cervical hyperplasia and breast fibrosis. Thromboembolism is 3-9 times more likely in pill users, expecially after surgery; or, similarly, in women given estrogens to prevent lactation expecially after surgical or traumatic delivery. Pill prescriptions indicated for amenorrhea are increased estrogens; for metorrhagia increased progestagen activity. Complications requiring discontinuation such as diabetes, jaundice, migraine or paralysis are listed. The types of drug interactions discussed were absorption e.g., folic acid; serum binding proteins e.g., transcortin; liver enzyme induction e.g., by phenobarbital; inhibition of liver enzymes e.g., by carbon tetrachloride.
A comparative clinical study of treatment with hormones or a combination of hormones and cyclophosphamide for metastasizing breast cancer is reported. 36 patients received diethylstilbestrol dipropionate (10 mg 3 times daily) or Norandrostenolone decanoate (Retabolil, 50 mg twice weekly). 37 patients received similar hormone treatment and cyclophosphamide. Patients receiving the combined therapy lived an average of 4.7 months longer, but this difference was not statistically significant. It appears that combined therapy is more effective than hormone therapy alone, at least for premenopausal women. A significantly higher survival rate was seen in patients in whom a remission of metastases occurred; patients with skin, lymph node, and/or bone metastases also live significantly longer. (AUTHOR'S MODIFIED)
Microscopic examination of endometrial carcinoma in 36 patients, before and after treatment with chlormadinone acetate, is reported. Significant response to treatment was observed in 13 of 26 cases of differentiated carcinoma, but in only 3 of 10 undifferentiated cases. First effects of treatment became visible within 3 days of beginning treatment, and remained visible for 5-7 months in some cases. Hormone-sensitive endometrial carcinomas undergo structural changes corresponding to the transformation of the normal endometrium in the postovulatory phase of the cycle. High-dosage gestagen therapy seems to inhibit proliferation in hormone-sensitive endometrial carcinomas; this inhibition is apparently secondary to the processes of synthesis which the hormone induces in the tumor cell. (AUTHOR'S MODIFIED)
[Effect of chlormadinone acetate on the activity of various liver enzymes in newborn rabbits]
Effects of daily injections of chlormadinone acetate (.05 mg) on new born rabbits were studied. Animals were killed on the 2nd, 3d, 4th, and 6th days of life, 24 hours after the last injection. No effect on the activity of LDH, ICDH, G6PDH, and GDH in the liver was noted, but GOT and GPT showed a higher activity on the 4th day of life, compared with control animals. These findings are interpreted as evidence of steroid-caused enzyme induction.(AUTHOR'S, MODIFIED)
Population laws of the Philippines.
Laws that directly and indirectly affect population control in the Philippines are explained. The presentation is divided into 4 major sections: 1) Laws dealing directly with birth, 2) Law on family planning education and services, 3) Family law affecting population, and 4) Laws on economic matters related to the family. The first section on birth laws describes laws regulating: 1) The importation, manufacture, sale or dispensation of contraceptives, and drugs producing abortion; 2) Dissemination of birth control information; 3) Abortion (its classification as a felony under the Philippines Revised Penal Code); 4) Sterilization, and 5) Infanticide. The second section on family planning education describes some of the measures to institute the population education programs. The third section provides information on the following aspects of population-connected family law: 1) Minimum marriage age, 2) Polygamy and bigamy, 3) General marriage laws, 4) Annulment, 5) Divorce, and 6) Paternity and filiation, The last major section, which is the lengthiest, furnishes legal information on the following aspects of family economic matters: 1) Maternity benefits, 2) Child care and allowances, 3) Immigration, 4) Taxation, 5) The government service insurance system, 6) Laws on descent and distribution of property, 7) Social Security, 8) Workmen's compensation, 9) Medicare, 10) Land tenure and 11) Zoning and housing. Brief concluding sections give some general observations as well as propose improvements in laws affecting population. It is noted that the recent laws enacting a Population Commission and providing for the regulation of contraceptive sale and dispensation indicates a radical change of the Philippine Government's attitude toward family planning from one of indifference to one of outright encouragement. However, major problems include the influence of religious values and the absence of any immediate alleviation of problems stemming from high population growth.
Singapore: Family planning in an urban environment.
The history of the development and growth of family planning activities in Singapore from the mid-1930's to the end of 1972 is described. A major portion of the historical narrative is given over to the efforts of the IPPF affiliate, the Singapore Family Planning Association (FPA) as the sole major organization conducting family planning activities in Singapore in the first 20 years following the end of World War 2; although the FPA was a recipient of a government grant that reached $100,000 annually by 1959. The inadequacy of the FPA program, coupled with the growing realization of the high cost of providing schools, health services and housing to a rapidly expanding population led to the formal commitment to family planning by the ruling People's Action Party in 1959. Due to the need to educate the public on family planning and to consider political factors, the start of the Government family planning program was delayed until 1966. Although some data on the results of the highly successful Government family planning program is provided, the main thrust of the historical account after 1966 is the description of the gradual formulation of family planning policy through the interplay of political interests. Thus, a description is given of the decision reached through political consensus to make abortion complementary to the main family planning methods of contraception and sterilization due to popular opposition and to the fear that there would be an increased dependence on abortion instead of contraception for controlling family size. The adoption of disincentives in housing and in maternity medical care to further discourage large families is also described.
The pharmacology of estrogens was discussed. Anatomical and physiological considerations, biosynthesis and other chemical aspects of estrogens, metabolism and excretion of estrogens, estrogen binding and estrogen receptors, biochemical actions of estrogens on their target organs, therapeutic uses of estrogens, toxicity of estrogens, pharmacological preparations of estrogen and antiestrogens were the topics included. Placental estrogens appear to arise primarily from dehydroepiandrosterone and dehydroepiandrosterone sulfate. The adrenal cortex appears to be the principal site of biosynthesis of these androgenic precursors to estrogens. The liver seems to be the most important organ as far as the biotransformations of estrogens are concerned.
Effects of hysterectomy and other factors on luteal function.
The effects on luteal function of hysterectomy, IUDs, toxic agents, local uterine luteolytic action, uterine and ovarian transplantation, oxytocin, prostaglandins, and uterine luteolytic agents are discussed. The physiological condition of the uterus controls the function of the corpus luteum in several species. Premature luteal regression or prolonged maintenance can be caused by 1) presence of an IUD, 2) toxic agents in the uterus, 3) exogenous oxytocin, and 4) partial hysterectomy. Hysterectomy prolongs luteal function in the ewe and pig, and in these species in which hysterectomy delays luteal regression, the endometrium seems essential for inducing luteolysis. Local luteolytic action between a uterine horn and its adjacent ovary occurs in some species. The action of exogenous oxytocin, progesterone, or estrogen may be mediated through the uterus.
Severe pelvic sepsis and the Majzlin spring. (Letter to the editor)
While we were in the process of preparing a manuscript describing our experience with 3 patients wearing a Majzlin spring who subsequently developed bilateral tuboovarian abscesses, 2 such reports appeared. Rather than clutter the literature with our very similar cases, we would instead simply express our complete agreement with the authors who made the "decision not only to avoid future use of Majzlin springs but to remove springs from all women who still harbor them." The wisdom of this seemingly aggressive approach is seen from a study of the details of the published cases and our own experience. 1st, the spring was in place for from 11 to 30 months prior to the onset of signs and symptoms suggestive of acute infection. Thus, the lack of symptoms in a patient is no guarantee that she will not subsequently develop severe pelvic sepsis. 2nd, the occurrence of severe sepsis was associated with removal in only 1/3 of the cases. 2/3 of the patients developed their infections "spontaneously." Therefore, since it is difficult to pinpoint those patients who will ultimately develop severe infection, and since the exercise of extreme care in removal will prevent at most about 1/3 of such infections, it seems wise to remove all these devices before sepsis develops in a certain, though admittedly small, number of patients. Removal of any Majzlin spring is potentially hazardous. Risk of infection should be diminished if all removals are done with antibiotic coverage, e.g., a 5-day course of oral tetracycline with removal on 2nd day, and if moderately difficult and difficult extraction s are performed after cervical dilatation under anesthesia. The guidelines, as described, are presently adhered to at this institution.(FULL TEXT)
Localization of the inhibitory actions of estrogen and nicotine on release of luteinizing hormone (LH) was studied in rats. Blood was obtained from ovariectomized rats through atrial cannulas at 10-minute intervals for plasma LH radioimmunoassay. Estradiol benzoate or 17beta-estradiol inhibited the pulsatile discharge and depressed the LH concentration. Progesterone or prolactin had no effect on the discharge or concentration of LH. However, nicotine tartrate caused a marked depression in LH at a dosage which blocks the proestrous rise of LH. Injections of estradiol benzoate, 17beta-estradiol, and nicotine gave si milar results in rats, exhibiting pulsatile LH release after being subjected to partial or total deafferentation of the mecdial basal hypothalamus 4-6 weeks prior to ovariectomy, as in nondeafferented ovariectomized animals. 17beta-estradiol had a partial inhibitory effect on pituitary LH release in response to an injection of LH releasing hormone (RH). These results indicate that the inhibitory effects of estrogen and nicotine on LH release are exerted via blockage of LH-RH release from the medial basal hypothalamus.
Family planning clinics in 1970.
A survey of clinics was undertaken in 1970 by the Institute for Social Studies in Medical Care as part of a study of birth control services in 52 areas of England and Wales. The survey showed that slightly over half the clinics had been running for less than 5 years. In 1970 the greater part of the task of providing this service was still being carried out by voluntary organizations: the Brook Advisory Centres, the International Planned Parenthood Federation, a few local organizations and, most of all, the Family Planning Association (FPA). 3/4 of the clinics were being run by the FPA, 1/5 by local authorities and the remaining 4% by these other organizations. Parallel to this survey of family planning services, in the same 52 areas, a survey of women was carried out by Margaret Bone to find out, among other things, how they used the services and what they thought about them. It was found that, omitting those women known to be sterile, 30% of the married women did not know of a family planning clinic and 26% thought that a visit to a clinic would be difficult to arrange. 91% of clinics advertised in some way through posters, leaflets, or less frequently, through the local press. Almost all the clinics had a telephone. The telephone number might not always have been easy to find in the directory, however, since it was sometimes under the name of the organization running the clinic, sometimes under the hospital or local authority on whose premises the clinics was held, and sometime under the council authority on whose premises the clinic was held, and sometimes under health department. 43% of the clinics received calls only during clinic sessions. The difficulty of arranging babysitting was shown to be one of the most serious obstacles to visiting a family planning clinic. Only about 1/10 of local authority clinics had evening hours whereas 4/5 of FPA clinics did. Very few had special youth advisory sessions.
A random sample of 1000 women in Sri Lanka who had used oral contraceptives continuously for more than 4 years was studied. In addition, 100 cases were examined in detail. When oral contraceptives were introduced in 1960 women were initially fearful of complications, either as reported in the press or by the family doctor. Education by individual house-to-house visits changed the picture completely. By 1968-1970 49% of women attending the birth control clinics preferred the pill and there was a marked drop in diaphragm and jelly, the most popular method of the pre-pill period. The intrauterine device is also a popular method. 93.2% of the women had income of less than Rs. 300/month. About 51.7% were aged 25-35 years and used the pill mostly for limitation, while 38.2% were under 25 years and used it to space pregnancies. 64.5% had 4 or more children and used it mostly to limit families. Nausea and vomiting, which were troublesome to some women in the 1st cycles, were minimal by the 6th. No cases of malignancy of breasts or cervix or embolism occurred in this series. No dysfunction of liver was noted and the 2 cases with high blood sugar levels gave a history of a prediabetic condition. The failure rate was 4.9%, due to omissions of pills. Amenorrhea after discontinuation has not been a problem; of 10 women who discontinued to become pregnant, all conceived within 4 months after stopping the pills. In the series of 100 cases studied intensively, 41 discontinued after more than 50 cycles; reasons included: regime is too exacting, side effects, nervous of complications, husband against method for prolonged use, and unable to come for pills regularly because of overwork. All chose other methods of contraception. It is concluded that oral contraceptives are very acceptable even among poorly educated women in rural areas and that distribution can be undertaken by properly-trained paramedical personnel such as midwives, nurses, and public health educators.
Experience with laparoscopic tubal sterilisation in Nepal.
A report of 168 cases of laparoscopic sterilization performed in Nepal from November 1971 to September 1972 is presented. Local anesthesia and a single-puncture technique was used. Age of patients varied from 21 to 48 years with the average being 32.4 years. The average total pregnancies was 5 and the average number of living children was 4, with an average of 2.4 male children. 73 of the women (43%) were using some family planning method. Most were sterilized between 6-7 days of the menstrual period. 8 were sterilized with 5-7 days of evacuation without being discharged from the hospital, and 15 were operated on 40-50 days following childbirth but were not staying with their husbands. The operation is not done immediately after childbirth because the uterus is big and vascular and chance of bleeding is increased. Operative complications included: 10 cases of bleeding no ne serious; 1 perforation of the fundus which was self-healing; 2 cases of failed laparoscopy, 1 because of a tubo-ovarian mass; 1 involvement of the bowel; 2 pregnancies in which the woman had lied about her menstrual period; 5 cases of amenorrhea; and 2 with previous operations. the procedure takes 20-25 minutes. The author groups sterilizations and does at least 10 procedures in 1 day, which makes set up and sterilization of instruments more economical. Laparoscopic sterilization can be easily introduced in less developed countries.
Questions are presented concerning the field of medical ethics. The physician has tended to be involved with the practical, with what can actually be accomplished, with those things that are known, and from which he feels that he should be able to adduce the future. The ethicist has tended to look toward the ideal, to consider the meaning of life, the importance of the sanctity of life, the ultimate meaning of man's existence, and the role of the individual in the world. Both the physician and the ethicist are concerned with improved medical care for the patient, administered ethically. Subjects which are areas of interest to the ethicist include: 1) informed consent; 2) organ transplantation; 3) abortion and contraception; 4) drug research; 5) reproductive research; and 6) the "right" to medical care. Physicians and ethicists are interested in a number of problems where there is a need for careful consideration of the rights, duties, responsibilities and needs of the patient, the physician, and society. A group of problems which require a good medical knowledge in addition to some unde rstanding of ethics include: 1) assessing the competency of physicians; 2) malpractice suits; 3) continuing medical education for practicing physicians; 4) unnecessary surgery; 5) excessive fees; 6) needless hospitalization and laboratory tests; and 7) excessive prescribing of antibiotics and tranquilizers. Physicians and ethicists should meet regularly to discuss points of common interest.
Other considerations of norgestrel in fertility control.
Recent developments in the use of norgestrel in regulating human fer tility are discussed. These include: 1) various combinations of norgest rel and ethinyl estradiol; 2) use of cyclic d-norgestrel; 3) luteal phase administration of progestogens; 4) postcoital preparations; 5) long-acting injectables; 6) use of norgestrel in devices and implants; and 7) male contraceptive use.
Adult education and family planning in the Philippines.
The integration of family planning in adult education programs in the Philippines reflects both the diversity and similarity of agencies and institutions implementing the national population program. Agencies representing the government and the private and religious sectors show the diversity while the provision of integrated family planning services, combining information, education, motivation, and clinical services, by agencies involved shows the similarities. 12 projects involved in family planning education for adults are described: 1) Adult and Community Education Division, Bureau of Public Schools; 2) Adult and Community Educators, National Organization of the Philippines; 3) Institute of Maternal and Child Health; 4) Adult and Community Education Division, Population Project 1; 5) Adultand Community Education Division, Population Project 2; 6) Commission on Population, Asian Social Institute Project; 7) Commission on Population, Department of Local Government and Community Development Project; 8) Commission on Population, Province of Laguna Project; 9) Commission on Population, Responsible Parenthood Project; 10) Commission on Population, Silliman University Medical Center Project; 11) Commission on Population, Tulungan Family Planning and Mother Craft Project; and 12) World Neighbors.
Adult education and family planning in Singapore.
Although the growth rate in Singapore dropped sharply from 2.3% in 1966 to 1.7% in 1969, it has risen again in the past 2 years. This rise is attributed to 1) the great increase in women of reproductive age and 2) the large average desired family (3.6 children) and high average completed family size (4.3 children). To counteract this, families must be convinced of the desirability of the 2-child family. Sustained educational publicity is considered the best means, particularly among young adults and older couples who already have 2 or more children. The adult education program in Singapore is divided into 2 main groups: activities through mass media channels and face-to-face contact. Mass media channels include radio, television, cinemas, press, magazines and bulletins, exhibitions, and publicity material. Face-to-face education include talks, seminars, forums, symposia, and debates, which are carried out in groups, and individual contact, such as home visits by clinic staff and postpartum programs in hospitals. Activities are planned and implemented by the information, education and communications unit of the Singapore Family Planning and Population Board (SFPPB). Face-to-face contace education is planned and carried out by the clinical services unit. The SFPPB has established liason with government agencies, businessses, unions, and the like, which provides a basis for continuing family planning and population education.
Population policy and development planning are related in a complex way. The relationship is not a simple cause-effect relationship. There are 4 differenct types of population policy, related to each other but emphasizing different factors: economic, political, social, and demographic. Population policy must be broader than mere demographic policy; it must include development aspects. Demographic statistics in all the African countries are given. Some African countries have an enunciated antinatalist population policy, some support or assist family planning programs, and some take a pronatalist position. The demographi c situation is different in different African nations, but all are still relatively underpopulated. Family planning programs in Africa should become a part of a movement for broad social and economic change. African leaders should place a greater emphasis on quality, not quantity, population. Western industrialized nations have the responsibility of explaining their motives for encouraging family planning programs in less developed areas.
The Korean National Family Planning Program.
In 1962 the Korean government initiated a family planning program under the Ministry of Health and Social Affairs. Laws prohibiting importation of contraceptives were repealed and local manufacture of contraceptives was facilitated. In 1973 abortion was legalized. The program goal was to reduce the national growth rate from 2.9% in the 1955-1960 period to 2.5% in 1966 and 2% in 1971. Targets have been fairly well achieved. Most services are provided by government-sponsored health centers, private doctors, and family planning field workers. Urban clinics offer services in all the provincial capitals and Seoul. Some contraceptives are available commer cially also. Since May 1964, the IUD program has been the major method used. The national program supports many information, education, and communications activities. Local Mothers' Clubs function as centers of family planning information. Population education materials have been d eveloped for use in the schools. The program conducts training and research. Foreign assistance has been available to help with most aspects of the program. The target of reducing national growth to 1.3% by 1981 will be harder to achieve than previous targets.
Recent trends in ideal family size.
Recent opinion studies in Korea indicate that the average ideal number of children has fallen to 3.7, down from 3.9 of past surveys. The change is most noticeable among younger and urban women. Urban women wanted 3.3-3.4 children while rural women continued to want about 4 children. The 1971 survey showed that 56% of respondents would choose 3 children, whereas only 38% did so in a 1967 poll. In Korea there is still a strong son preference. Women who want 3 children want 2 sons and 1 daughter. The majority of women under 30 thought this was the ideal arrangement of children. Demographic education for young people will be necessary in order to spread the government's campaign of "stop at two."
[Thermogenic potency of mammary cancers. II. Variations during hormonal tests]
Changes in the specific thermogenic potency elicited by ethinyl estr adiol, norethisterone, fluoxymesterone, and testosterone acetate were studied in 12 patients with breast cancer, and compared with variations of uptake rate of radioactive phosphorus. The results suggest a test of hormone sensitivity, the value of which seems to be confirmed by the effects of normone therapy applied in some of the studied cases. These investigations also demonstrate the importance of circulatory phenomena in the thermopathology of breast cancer.(AUTHOR'S, MODIFIED)
[Gestagens following radiotherapy of primary carcinoma of the uterine body]
Results of follow-up currettages after radiotherapy and 1 year's lyn estrenol (5 mg 3 times daily) treatment in 30 patients with inoperable carcinoma of the uterine body are reported. Local recurrence was observed in 6 cases (4 of which may be remains of the primary lesion); distant metastases were not seen. Subjective improvement was reported by most patients. No side effects of lynestrenol therapy were observed, and treatment has been continued. Dose-dependance and the mode of action are discussed. Prolonged lynestrenol treatment with higher doses is recommended.(AUTHOR'S, MODIFIED)
Effects of different oral contraceptives (combined and mini pill) on lipid metabolism.
The effects on serum lipids of low dose Volidan (megestrol acetate and ethinyl estradiol) and the continous use of megestrol acetate, a minipill, were studied. 39 women from India, aged 20-40 years, were treated with Volidan from 3 to 29 months and 34 women were given continuous doses of minipills, .5 mg daily. 21 subjects took both types of regimen consecutively. Lipid studies were carried out at 3 and 6 month intervals. Total cholesterol, triglycerides, esterified and free fatty acids were evaluated. Significant increases in total cholesterol, triglycerides, and esterified fatty acids were found after use of the combined pills as compared with controls (p less than .00l). The minipill showed increase only in triglycerides (p less than .01) but this increase was less marked. In minipill users the esterified and free fatty acids were decreased in relation to the controls (p less than .01). 1/3 of those taking continuous gestagen therapy after the combined drug therapy showed a lowering in cholesterol values. This difference was considered significant (p less than .02). There was no direct correlation between the duration of contraceptive therapy and serum lipid values. However, a gradual return to basal lipemic state was noted after exposure to the hyperlipemic effects of the steroidal contraceptive therapy. The estrogenic component is thought to be responsible for the changes in lipid metabolism. Other have reported that estrogens have no effect on serum lipids and lipoprotein patterns in individuals whose diet lacked proteins. These subjects came from a low socioeconomic group whose diet is known for protein deficiency.
This report updates a list published in 1973 by the International Planned Parenthood Federation/Western Hemisphere Region of training facilities in demography, family planning and reproductive physiology in the region. The list under demography includes a training facility in Great Britain as well. Each listing appears in a regional and country breakdown, gives detail on type and length of course or courses, sponsoring agency, organization or office, preliminary preparation or degree requires, type of work or area for which an individual will be trained in the course or program, availability of fellowships or scholarships, per diem or travel expenses, and degree or certificate awarded on completion of the course. The name and address of the responsible person to obtain further information or the office is given. In cases where the course or study is possible in Spanish in the U.S., it is so noted. Some listings in the U.S. and Canada mention that the courses are oriented especially for persons from or planning to work in developing countries. In some cases financial assistance is available from outside organizations, such as U.S. Agency for International Development, United Nations, and Development Associates, Inc. 2 listings of organizations which provide fellowships for some of the programs listed earlier in the document, appear under a final section on Fellowship Programs.
New cancers arising in 1563 patients with carcinoma of the cervix treated by irradiation.
This reports 1563 consecutive cases of primary invasive cancer of th e cervix treated between 1932 and 1970. All received radium or external radiation or both. 69 patients (4.4%) were lost to follow-up. Of the patients 829 (53%) were white and 734 (47%) were nonwhite. New cancers were found in 30; these cancers arose in different organs and were of different cell types from the original. Ages of 1st diagnosis of cervical cancer in these cases ranged from 33 to 70, with a mean of 49.6 years. Time elapsed between diagnoses of the original and secondary cancers ranged from 4 to 31 years, with a mean of 14 years. Age of patient when the 2nd primary cancer developed ranged from 43 to 82 years, with a mean of 63.3 years. No significant difference was noted in the number of secondary cancers observed and the number expected. Results suggest that the incidence of new cancers in an irradiated population with previous cervical cancer does not differ from that in the general population.
Androgen dependence of breast cancers.
This is a criticism of an article by Flax and others of June 2, p. 1204. Several replicate incubations of cultures of tumor slices should have been made and incubation periods longer than 24 hours should have been done to be sure they were not dealing with dying tissues. Equating sensitivity to dependence is not justified. Acquiring testosterone dependence by the adaptative mechanism in contrast to initial dependence was not shown. Clinical response of 14 patients with testosterone dependent tumors to antiandrogen measures was not adequately verified. While organ culture of human breast cancers may be a valuable method the conclusions expressed in the previous article are not considered valid. A reply by Falx and others follows. It was stated that all initial cultures were set up in duplicate. With techniques used triplicates were not needed. The 1st 24 hours was considered best although cultures would survive longer. In-vitro independent tumors did not need hormones to show maintenance of histological appearance and enzyme activity. Also 8 patients with such tumors have received antihormone treatments without any objective remission. In-vitro testosterone dependence was demonstrated for 14 breast cancers but not in over 100 other breast cancers where androgen therapy had not been given. This was a preliminary report. However, measurable reduction in size of all lesions was maintained for at least 3 months without any use of radiotherapy or cytotoxic drugs. Antiandrogen measures were therefore successful in 6 patients. In-vitro studies suggest that at least 6 different kinds of behavior regarding prolactin, estrogen, or androgen dependence may occur in different tumors.
Taiwan population studies summaries.
Taiwan's active family planning program has helped reduce the population growth rate from 3% to less than 2% in ten years. It is now working to halve this present rate of growth. In order to meet the demand for information on how Taiwan has achieved such an effective program, activities have been continually documented in reports, article s, reference volumes, chartbooks and readers. Over 100 studies have been undertaken between 1962 and 1973 by the research unit in Taichung. These studies range from action oriented operations research activities to large scale sample surveys. The summaries of these studies are generally brief and include a simple description, a summary of findings and a list of references. They are intended for those both within and outside of Taiwan who want to be informed on the kind of research being conducted and its results, who want to use this volume as a reference as well as for those who are doing research elsewhere and want to know what Taiwan has done. It is also helpful for the Taiwan program for it provides a reference of what work has been carried out to date.
Indices of population reproductivity for all Japan in 1965-1970.
Indices on population reproductivity for all of Japan for each year from 1965 to 1970 are presented. Included are standardized vital rates, reproduction rates for female, and intrinsic vital rates and stable popu lations for female. Additionally, references are made in some tables to indices for the preceding years selected from the data already presented in reports numbered 155, 157, 161 and 178 of this Research Series.
Some epidemiologic variables in prostatic carcinoma in California.
In an epidemiologic investigation for prostatic carcinoma in which control patients underwent an extensive evaluation to insure that they had no latent cancers, a questionnaire was given to 221 patients with histologically confirmed prostate cancer. Information on sexual activity was obtained by personal interview. Family members were investigated in both cancer and control groups. The ratio of familial prostate cancer in the cancer group was consistently higher than in the controls (p less than .01). Of the 221 prostatic cancer patients 12 had prostatic cancer in the family but only 2 of the controls did. Of the 210 cancer patients from whom satisfactory data were obtained, 50 families showed 74 extraprostatic tumors while 56 control families showed 72 extraprostatic tumors. This was not considered significant. 186 cancer patients had been married while 192 control patients had been. Factors found statistically significant included: familially associated prostatic cancers, past history of veneral disease, coital frequency, number of sexual partners before marriage, and the use of contraceptive agents. While these genetic factors and activities may pr edispose patients to cancer of the prostate, they may also serve as a marker for a high risk group. Findings by others suggest the possibility of a sexually transmitted virus in the causation of prostatic cancer. Socioeconomic status, occupations, and religions all had similar rates. Environmentally-related variables strongly support the potential viral etiology for prostatic cancer.
It has been claimed that the Dalkon shield is a superior IUD because of its low pregnancy and expulsion rates. The basis for this statement was the comparison of event rates obtained with the Dalkon shield and other IUDs in studies conducted in different clinics by different investigators. A randomized comparative study utilizing the Dalkon shield, the Copper T (TCu 300), and a modified Lippes loop (silicone-shell loop) was conducted utilizing 776 multiparous women attending 1 clinic. Insertions were performed by the same group of physicians. As expected with randomization the mean age, gravidity, and parity of women assigned each of the devices was similar. Life table analysis of the 1st segment net cumulative termination rates at 12 and 18 months revealed no significant differences in events except a lower expulsion rate for the stiff shell loop. The results of this study thus revealed a similarity of performance among these 3 IUDs, 2 of which had been previously reported to have superior performance to other IUDs, on the basis of nonrandomized comparisons. It is concluded that it is not possible to accurately compare IUD performance by comparing event rates of investigations performed at different times in different populations with different personnel. Previous multiclinic studies of the same IUD have shown significantly different event rates among different clinics. Thus, most previously reported differences in event rates among most types of IUDs are probably related more to differences among clinics tha n to differences in design of the IUD itself. Differences among clinics include differences in age, gravidity, and parity of the patients; timing of insertion in relation to last pregnancy; physicians technique of insertion; the patients cultural acceptance of side effects; and the amount of staff encouragement to tolerate these side effects. In order to minimize this variability, the only valid way to compare performance of various IUDs is to conduct a randomized comparative study in the same clinic or groups of clinics during the same period of time. The results of such a study involving 3 very differently designed IUDs, including th e Dalkon shield, revealed similar event and continuation rates. It has not yet been demonstrated that any specific type of IUD has a superior p erformance to others in multiparous women.(FULL TEXT)
Regional Economic Commissions: Economic Commission for Asia and the Far East. (ECAFE).
Lengthy excerpts are provided of the U.N. Economic and Social Council resolution that established and defined the terms of reference of the Economic Commission for Asia and the Far East at its 4th session (and amended thereafter), and of other resolutions adopted between 1963 and 1970 on population and social and economic policies and programs needed in the ECAFE region. The recommendations of the Asian Population Conference of December 1963 on National Policy and Action, international cooperation, economic and social policy and planning relevant to population problems, family planning, urbanization, internal migration and population distribution, and the adoption and recommendations by ECAFE of these in a Committee of the Whole are given in substantial detail. The resolutions are addressed to ECAFE members and associate members, ECAFE's Executive Secretary, other U.N. organs, Specialized Agencies and U.N. Administrators. Among them is the decision to establi sh the Asian Population Conference as a statutory organ to be convened every 10 years in connection with the decennial population and related censuses. Other resolutions call for regional cooperation, exchange of information, technical assistance, and the establishment or expansion of training facilities and institutions. Concern is evident in several resolutions over the continued high rates of population growth rates in the region and their adverse effect on the economic and social welfare o f the population.
Regional Economic Commissions: Economic Commission for Latin America (ECLA).
Lengthy excerpts are provided of the texts of a resolution of the Economic and Social Council of the U.N. establishing the Economic Commission for Latin America (ECLA), and others adopted between 1961 and 1973 by ECLA on its recommendations and decisions on population and demographic studies, censuses, technical assistance, expansion of the programs of the Latin American Demographic Centre (CELADE), as well as others on programs and services of the ECLA Secretariat. Some of the recommendation are of a very broad nature, e.g., participation of Latin American countries in the Second United Nations Development Decade, the International Development Strategy, participation in and programs of the region in the 1974 World Population Conference. Excerpted resolutions are arranged in 5 topical categories. Dates of adoption of the resolutions and how adopted, unanimously in almost all cases, are indicated in footnotes.
The effect of clomiphene citrate given in vivo upon the in vitro uptake of labeled estradiol (tritiated-E2) was investigated in a 60-year-old patient with breast cancer who had had a mastectomy 10 months earlier followed by radiotherapy. Multiple subcutaneous metastatic nodules and enlargement of the liver were present but bone metastases could not be shown. A biopsy from a subcutaneous nodule, taken prior to present treatment, showed 86 fmol estradiol binding sites per mg of cytoplasmic protein with a dissociation constant of the estradiol-estradiol binding protein interaction of 2.8 X 10 <-10> M. The patient was treated with 200 mg clomiphene citrate daily. Subjective symptoms improved and a reduction of skin nodule size and of liver enlargement followed. The serum enzymes alkaline phosphatase, nucleotidase, and phosphohexoseisomerase were diminished. A 2nd biopsy taken at Day 26 of treatment with clomiphene citrate showed complete inhibition of labeled estradiol tritiated-E2 uptake by the cytosol protein. This finding is thought to show the absence of free binding sites after clomiphene citrate therapy. Microscopic studies of biopsy material were unchanged. These results are thought to be the first to record human in vivo inhibition of trititated-E2 uptake for EBP by an antiestrogen compound, although similar in vitro observations have been made in human tumor specimens. There is thought to be a potential value of antiestrogenic agents, alone or with inhibitors of prolactin secretion, to replace endocrine ablations and to predict the response to endocrine therapy.
The hormonal basis for pregnancy termination after accelerated lactation in the rat. (Abstract only)
Rats that have been mated in the postpartum estrus may terminate their pregnancy if allowed to suckle a large litter following implantation of embryos from the postpartum pregnancy. Either all embryos are absorbed or no more than normal. The size of the suckling litter must be at least 9. The accelerated lactation must be begun prior to Day 10 of pregnancy and must continue at least 2 days. The primary cause for pregnancy termination was determined to be an insufficient level of progesterone. A small amount of estrogen was also shown. Administration of luteinizing hormone (LH) after accelerated lactation prevented pregnancy termination. In experiments, the enzyme 20 alpha-hydroxy-steroid dehydrogenase (20 alpha-OH-SDH) was shown to be only slightly increased by Day 10, more by Day 11, and 3 times the control level by Day 12. The effects of LH and progesterone administration on 20 alpha-OH-SDH were tested. Each had the same effect suggesting indirect activity of LH. Plasma progesterone concentration was shown to be decreased prior to the time at which increase in 20 alpha-OH-SDH activity was detected, therefore the decrease was not considered due to this enzyme. However, the later increase of the enzym e may cause irreversible decline in progesterone secretion and lead to pregnancy termination. The ability to maintain concurrent pregnancy and lactation by hormone administration has potential applicability in anima l husbandry.
The contraceptive WL-33 requires the woman to take a daily tablet co ntaining 50 mcg of d-norgestrel and 50 mcg of ethinyl estradiol for 11 d ays and then a daily tablet containing 125 mcg of d-norgestrel and 50 mc g of ethinyl estradiol for the next 10 days, followed by a tablet-free i nterval of 7 days. This oral contraceptive regimen was followed for a t otal of 1112 cycles by 178 women. 95 of the women had previously taken another preparation and 70 had begun this regimen at 4-6 weeks after par turition. No pregnancies occurred during the study. The cycle control was excellent. Subjective complaints were few. Side effects were less than with other methods. Increased menstrual bleeding occurred in only 2 patients. Amenorrhea was noted in .4% of cycles, but not after the 3rd cycle. Breakthrough bleeding was present in .5% and spotting in 5.6% of cycles. More patients lost weight than gained weight. Biopsies showed cyclic endometrial changes but less than have been reported with larger doses. The total cyclic dose of Ovran is 10,500 mcg of d-norgestrel while with WL-33 it is only 1800 mcg.
The team concept in health care delivery.
Family planning is a useful measure in ensuring optimum health for children and adults, society and a whole nation. Provided the religious, economic and health aspects in which spacing, timing and quality of life are considered, a family or nation can grow according to its wishes. The purpose of family planning must be appreciated at both the family and national levels and must take into account overall national development as seen through economic development. Technical skills, intellectual capacity and physical energy, required for operation of industry, are attainable by citizens who are healthy and productive. The team concept of health care delivery aims to achieve the national quality of which family planning is a part.
The Meeting on Evaluation of Educational Materials Used in Family Planning Programmes, organized by ESCAP, was held at Bangkok, January 7-11, 1974. In attendance were senior officials responsible for the communications component of their national family planning programs, researchers, and representatives of several specialized agencies. The 2 main aims were 1) to discuss and review the status of pre-testing and evaluation of educational materials in selected ESCAP countries and 2) to suggest a set of simple and convenient, yet theoretically sound, guidelines for pre-testing and evaluation that could be adopted by national family planning programs. It was strongly felt that the field staff could be more directly and actively involved both in the production and design of educational materials, in their pre-testing, an d in their evaluation. Such data as obtained by the field staff could then be collected by a central research unit which should work closely with both field units and the central policymaking body. Horizontal and vertical feedback could be handled by agencies at the national level which would undertake clearinghouse functions. The participants also considered the draft of a simplified guide to pre-testing and evaluation prepared at the request of ESCAP, analyzing it and making suggestions for improvement. The final document is included as an insert. Also inc luded are 7 selected papers from the conference on pre-testing and evaluation of educational materials in family planning programs in general and specifically in Singapore, Korea, the Philippines, India, Iran, and Indonesia.
A simplified guide for pre-testing and evaluating family planning educational material has been prepared with the idea that fieldworkers can become key data gatherers, especially in non-urban areas. Pre-testing is a tool which essentially measures the suitability and potential effectiveness of educational materials, while evaluation measures the actual effectiveness of such materials after fullscale production, distribution, and utilizat on in the field. The purpose of the guide is to provide basic knowledge of research, especially related to pre-testing and evaluation, and basic tools to serve as a guide in pre-testing and evaluating educational materials and in bridging the gap between producer and target audience. It is also hoped that the guide will encourage the inclusion of pre-testing and evaluation in all family planning communications systems. 2 sample pre-test questionnaires and a sample evaluation form are included.
Physiological studies on the LH- and FSH-releasing hormone, its analogue s, and antisera.
Literature on the effects of luteinizing hormone-release hormone (LH-RH) and its analogs and antisera is reviewed. LH-RH is a polypeptide isolated from the porcine hypothalamus with a structure of (pyro) Glu-His-Trp-Ser-Tyr-Gly-Leu-Arg-Pro-Gly-NH2. In rats, LH-RH increases the production of LH and follicle stimulating hormone (FSH), stimulates spermatogenesis and follicular development, and induces ovulation. LH-RH stimulates ovulation and the release of LH and FSH in sheep, rabbits, and hamsters. LH-RH stimulates LH release in pigs and cattle, induces LH release and ovulation in some species of fish, cand causes premature ovulation in chickens. The induced increases in serum LH and FSH in monkeys is not as great as that in humans. The administration of sex steroids amplifies the pituitary response to LH-RH. Estrogens inhibit the rise in FSH, though it can augment the rise of LH in response to LH-RH, whereas dihydrotestosterone has the inverse effect. The half-life of LH-RH is about 6 minutes in the rate and 4 minutes in humans. In both animals and humans, LH-RH appears to stimulate fertility. In rabbits, immunization with LH-RH caused severe testicular atrophy in rats. In rats, the administration of antisera against LH-RH suppressed the preovulatory surge of LH and FSH, and blocked ovulation. Several synthesized analogs of LH-RH, such as desHis2desGly10-LH-RH-ethylamide, blocked the in vivo response to LH-RH in rats, and inhibited ovulation in rats and rabbits. The results to data emphasize the possibility of developing effective polypeptide contraceptive agents.
Endocrine control of spermatogenesis.
Literature on the endocrine control of spermatogenesis is reviewed. The control of spermatogenesis may begin with the stimulation of testosterone production in the Leydig cells by ICSH. Testosterone, or its metabolites, are then transported into the seminiferous tubules and the Sertoli cells. There, testosterone possibly interacts with the germinal cells to initiate a wave of spermatogenesis. There is a possible direct action of testosterone on spermatocytes to promote meiotic division. As a result of follicle stimulating hormone (FSH) binding and stimulation of adenylate cyclase, cyclic AMP (cAMP) is produced, which in turn activates cAMP-dependent protein kinase. cAMP, or another FSH "messenger", then increases RNA and protein synthesis by a variety of mechanisms. This increased synthetic activity increases androgen receptor protein activity, permitting a complex formation betwe en testosterone and the receptor protein. The progression of spermatoge nesis is thus determined by a direct interaction of the hormone receptor complex with germinal cells, or an indirect interaction through a "message" generated as a result of events in the Sertoli cells controlled by this complex.
Early incidence rates of precancerous cervical lesions in women using contraceptives.
This describes the continuation of a study of the occurrence of early cervical neoplasia in relation to method of contraception used by women attending Planned Parenthood of New York City. An earlier paper indicated a small but significant excess in rates of carcinoma in situ for steroid users compared with diaphragm users. This report estimates incidence rates of carcinoma in situ and lesser precancerous cervical lesions in steroid, diaphragm, and IUD users who were initially proved free of cervical neoplasm. No statistically significant difference was found though these variations are not inconsistent with previous findings. It is suggested this may be due to a protective effect of the diaphragm, a causal effect of steroids, or to some unknown factors in the makeup, behavior, or habits of women who chose the diaphragm. This study emphasizes rates after prolonged use. Women for this study were taken from the entire population attending all the centers. Gynecologic examinations were given at initial visit and once yearly thereafter. Cytology specimens were obtained at each visit. Women whose findings were normal on the first 2 visits and who returned for further examination were accepted for determining incidence rates. A variety of commercial combination-type oral contraceptives were used. None of these women developed invasive carcinoma, none had clinically visible abnormalities of the cervix. When cytology reports indicated, Schiller's iodine test was done followed by biopsy. Comparable control patients were selected. There were 5,778 steroid users, 1015 diaphragm users, and 911 IUD users compared with the controls and each other (selected from a total of 78,098 women who had been examined at least once). Steroids were used mostly by younger women, the diaphragm by older women. Within the 3 years of study no increase in the incidence of precancerous lesions was shown by any contraceptive method but possible longer term effects are not known.
Estrogen-dependent twenty-four-hour periodicity in pituitary LH release in the female hamster.
This investigation defines some of the relationships of estrogen and progesterone to pituitary LH in the ovariectomized hamster and presents evidence of 24-hour periodicity in the release of LH. All of the hamsters were ovariectomized 3 or more weeks before the experiments. At 72 hours before other treatment, estrogen (E) was given as estradiol benzoate, 50 mcg, subcutaneously in oil. Progesterone (P) was similarly given at 25 mg. Sodium phenobarbitol, 100 mg/kg body weight, was given sc in some experiments and luteinizing hormone-releasing hormone (LH-RH), 40 ng in .2 ml saline, was given iv after a blood sample was taken. A second blood sample was taken 10 minutes later. Serum was assayed for LH by radioimmunoassy. When pituitaries were collected they were also examined immediately by radioimmunoassay. P alone or in combination with E had no effect on the pituitary content on concentration of LH. E alone depressed morning levels of serum LH to 40% of controls. Correlated with a lower concentration of pituitary LH and E-treated animals was an increase of LH serum levels in the afternoon. In combination with P the E further depressed serum LH to values similar to those found in diestrus. P alone did not affect serum LH. Pituitary responsiveness to exogenous LH-RH was diminished by a combination of E and P but not by either alone. Phenobarbital inhibited LH release by action on the central nervous system. Observations indicated that in the hamster there is a 24-hour periodicity in the central nervous system activities causing the preovulatory release of LH. This LH release mechanism is enhanced by estrogen and is inhibited by progesterone. The inhibitory effect of progesterone is, at least partly, on the pituitary.
The effect of exogenous gonadotropins on the ovum and the developing follicle.
An attempt was made to achieve earlier development of the follicles and maturation of their ova in normally menstruating women by administration of exogenous follicle-stimulating-hormone-like gonadotropin (Pergonal) at a certain time in the cycle. Subjects were 14 women with uterine myomata who were to have hysterectomies. All had normal ovulatory patterns and had had previous successful pregnancies. All were operated on in their proliferative phase on Day 11 of their cycles. Of the 14 patients, 12 received 2 ampoules a day of Pergonal-500 for 2 consecutive days corresponding to 150 IU of follicle stimulating hormone. In 2 cases, 3 ampoules of Pergonal were given daily. At the time of operation, follicular fluid was removed with a pipette and the ova studied. Another 22 patients having hysterectomies for myomata served as controls. In each of the patients who received Pergonal there were 4-12 mature follicles per ovary. Of 47 ova collected from treated patients, 44 were in the dictyate stage with a germinal vesicle. From the control patients, 63 ova were collected, with all being in the dictyate stage. Results indicate that Pergonal shortens the time needed for follicular maturation. Early maturation of follicles was achieved without evident abnormalities. The early maturation may have been due to the small amount of luteinizing hormone activity in the Pergonal. This investigation may be of value in indicating the treatment of infertile women with damaged tubes. The method could be used for the collection of ova and subsequent fertilization in vitro.
Immunological factors in sterility: the role of antispermatozoal antibodies in male sterility.
The role of antispermatozoal antibodies in male sterility is discussed. It was shown by the capillary spermagglutination test and the indirect immunofluorescent technique that 26.3% of male partners of infertile couples had autoantibodies against spermatozoa. Oligoazoospermia, hypocinesia, and pathological changes of the genital tract were more frequent in patients with circulating antoantibodies than in subjects without (52% vs. 40.8%, 44% vs. 1.4% and 48% vs. 15.4%, respectively). The pathogenic role of detectable antispermatozoal antibodies in sterile male subjects has not been sufficiently clarified. They may play an important role in the automaintenance of the disease or only represent a simple epiphenomenon.
Binding of progesterone and R 5020, a highly potent progestin, to human endometrium and myometrium.
A progestin receptor was demonstrated in human endometrium and myometrium supernatant fluid by specific binding and density gradient fractionation. Tissue from 3 women given estrogens before hysterectomy were homogenized in 10% glycerol containing 10 mM tris-HC1, 12 mM thioglycerol, 1.5 mM EDTA, pH 7.4, centrifuged at 105,00 x g for 1 hour. Progestagen was found by incubating cytosol for 1 hour at 4 degrees C with R 5020 (17,21-dimethyl-19-nor-pregna-4,9-diene-3,20-dione) 50 Ci/mM, and fractionation by centrifugation on 5%-20% sucrose density gradients in the same buffer. Endometrial cytosol bound R 5020 specifically in the 7-8 S zone. This binding could be suppressed by including unlabeled R 5020 or progesterone, but label then was recovered in the 4-5 S region. Labeled progesterone and cortisol both exhibited 4-5 S peaks. Myometrial cytosol behaved similarly; R 5020, R 2323, norgestrel, and progesterone each suppressed binding by 7-8 S in favor of 4-5 S binding. Equilibrium dialysis yielded intrinsic dissociation constants of .45 and .6 for endometrium and myometrium, representing 1.4 and 1.1 nM binding sites in a cytosol concentration of 1 mg protein/ml. The specific 7-8 S receptor was purified of 4-5 S contamination by precipitating with 40% ammonium sulfate; the receptor would bind labeled R 5020 or progesterone, or be displaced by excess unlabeled progestagen. The properties of this receptor resemble those found in mouse, rat, rabbit, and guinea pig uterus.
Efficacy of different phosphorus supplements for sows during gestation and lactation.
This study was undertaken to compare dicalcium, Curacao, and soft ph sophates as supplemental feeding during gestation and lactation. In Exp eriment 1, 37 crossbred sows at 11 months of age were mated and each of 4 groups given an experimental diet. The basal diet was a 16% crude pro tein-fortified corn-soybean meal containing .34% of phosphorus and .72% of calcium. The test diets were fortified with either dicalcium, Curaca o, or soft phosphate to provide .52% of phosphorus. Limestone was given to maintain .72% of calcium. Animals were confined in a concrete feedin g area and fed 1.8 kg of diet per head per day until Day 94 of gestation . At that time the diet was increased to 2.3 kg/day. On Day 109 of gestation animals were moved to farrowing crates until 10 days postpartu m and then to wooden units until weening at 8 weeks. Sows were sacrific ed after 8 weeks lactation, or if they developed posterior paralysis. In this experiment, the different phosphate sources were without observed influence on the livability or performance of pigs up to 8 weeks of age (p less than .05). Gilts receiving no supplemental phosphorus had significantly lower bone ash and phosphorus than did those receiving either of the supplements. Posterior paralysis was observed in 5 of 9 sows fed the unsupplemented diet, in 3 of 9 fed the soft supplemented diet, and in 2 of 10 fed the Curacao phosphate supplement. None fed dicalcium phosphate developed paralysis. The paralysis usually occurred after 6 weeks of lactation and was often accompanied by a fractured femur. In Experiment 2, 70 sows were bred at 10 months of age and fed 1.8 kg of the experimental diets. During 36 days of lactation, phosphorus digestibility, retention, and balance were shown to be lower for those fed only the basal diet. Bone ash, bone phosphorus, and bone strength were lower in those fed the unsupplemented diet. Results of these studies indicate the need for supplemental phosphorus in sow feeding. When feeding dicalcium phosphate or Curacao phosphate the use of over .5% phosphorus in the sow's diet is unnecessary during gestation and lactation.
Complication of laparoscopy during early pregnancy. (Letter to the editor)
I note that in the 3 cases of accidental insufflation of gas into the uterine cavity reported by Drs. M.B. Barnett and D.T.Y. Liu (February 23, p. 328) "the pressure was continuously monitored and never allowed to exceed 30 mm Hg." This level would seem to me to be excessive. Many of the hazards of laparoscopy are associated with induction of the pneumoperitoneum. These can involve injecting gas into many areas such as bowel, subperitoneal tissues, the uterus itself, and other tissues, and it is my experience that in all such cases the readings of induction pressure were higher than normal, which I take to be between 10 and 12 mm Hg. In fact if the reading is higher than 14 mm Hg I always remove the Verres's needle and reinsert it. It is a common finding that the fundus of the uterus has a small nick in it, particularly when sterilization is carried out after termination at more than 12 weeks' pregnancy. I would suggest that if such dangers are to be avoided pressures should be continuously monitored and never allowed to rise above 14-16 mm Hg, the higher level being associated with inspiration, particularly if the patient is on an insufflator.(FULL TEXT)
Metabolic side-effects of oral contraceptives.
A variety of metabolic effects of oral contraceptives is described. Changes in serum lipid and lipoprotein levels, carbohydrate and intermed iary metabolism, metabolism of vitamins, tryptophan metabolism, serum pr oteins, blood coagulation and fibrinolysis, blood pressure, liver functi on, and mineral metabolism are discussed. These biochemical disturbance s are unnecessary for the antifertility effect of oral contraceptives. While the estrogen component of combined oral contraceptives appears to be responsible for most of the metabolic changes, the progestogen is also important. Differences between the metabolic profile of pregnancy and that observed during oral contraceptive medication emphasize that contraceptive steroids and natural gonadal hormones do not necessarily have identical biological actions. The relation of the metabolic changes to the severe side-effects of oral contraceptives, such as thromboemobolic disease and hypertension, is not clear. The former are found in the majority of users whereas the latter are rare. This suggests that severe clinical side effects may occur only in subjects whose natural homeostatic mechanisms are deficient because of preexisting organ system dysfunction.
Data requirements for unified development planning.
A unified approach to development planning seeks to remedy the serious imbalances created by sectoral approaches to development. It tries to achieve this by treating society as an integrated organic system and by recognizing that an activity in 1 sector will have corresponding influences on others sectors as well as on the whole. Development planning is a design for an organized national effort to progress from the present socioeconomic level to a desired future status of change with growth in all sectors of the polity. Its objective is to guide and accelerate existing developmental factors and to initiate new ones as necessary to achieve a better society with improved levels of living. The following are among the areas that need to be involved in unified development planning and a review of their interrelationships is provided: general data; demographic data; production data; income distribution; employment; education; skills and mobility; family; housing; health, nutrition and water; environment; social welfare and security; social stability; satisfaction and happiness; communication; popular participation; and government administrative capacity. Realistic development can only be achieved within a nation's own socioeconomic and political context in which both the feasibilities and the available alternatives are carefully considered. Developing Asian countries need Asian methodologies and Asian planning systems. Asian planners need to look inward to think through their own special problems in a new and open minded may in order to arrive at workable solutions within the context of their own natural resources.
Marital decision making as applied to family planning.
Couple decision making concerning family planning is discussed. The literature and research in the field of couple decision making is reviewed. In any decision concerning family planning, there are 3 factors to consider: 1) the motivation, personality, and previous experience of each partner; 2) the couple interaction in decision making, which is based on considerations of power and affection; and 3) the ability of the partners to perceive and communicate their differences to each other. A decision making model for use by family planning counselors is proposed.
Regulation of the human menstrual cycle.
Methodological and investigative advances in the field of reproducti ve endocrinology have produced new information regarding the regulation of the menstrual cycle. The synthesis and release of gonadotropins by the pituitary gland is regulated by an single neurohormone or by 2 humoral factors. The mechanism of and experiments with this factor are described. Steroids can modify the process. The pituitary system reacts with the ovarian system. Cycles are charted for LH and FSH conce ntrations in the blood serum during normal menstrual cycles. These are charted against basal temperature cycles and progesterone concentration, urinary estrogen, and pregnanediol excretion through the cycle. Further research should examine temporal and physiological relationships between ovarian steroids and the gonadotropins which regulate their formation.
International Fertility Research Program/ Carolina Population Center: introductory address.
Organization of the International Fertility Research Program is desc ribed and study options in female sterilization are detailed. All 3 divisions of IFRP (field studies, data processing, and design and analysis) are involved in evaluation of all new and on-going studies. To date data collection instruments have been developed for studies of pregnancy termination, menstrual regulation, female sterilization, IUDs, systemic contraceptives, and conventional contraceptives. These instruments record patient identification, patient characteristics, method of fertility regulation used, and follow-up. Instruction manuals are available for each instrument. Help is also available for those wishing to set up surveillance studies, straight studies, and comparative studies. Plans call for more regional programs with IFRP merely acting as a consultant. Such studies are especially needed in the field of female sterilization. Information needs to be gathered to compare operative methods, patient categories, and type of occlusive method used. A disciplined network of Trial Centers using standard research tools could significantly advance the usefulness of female sterilization in Southeast Asia.
The frequency and reasons for women abandoning family planning program were studies in 84 clinics in Mexico in terms of the ages, the number of children, the educational level, the method or methods utilized during her attendance at the clinic, the total number of months attended, and birth control measures employed after terminating the program. Women who used oral contraceptives were more inclined toward terminating the program than those who were using an IUD or a trimestral injection. Younger women with less children were more inclined to quit than women with more children. The majority of women who used the pills and the injections abandoned contraceptive measures within a short time after their last visit to the clinic, and the frequency of pregnancy was significant. The ones who had used the IUD, however, tended to continue with the same method and usually kept the same IUD. Among women who were using the IUD, the most common reasons for quitting the program were: no problems with the method ( so no reasons to go back), the necessity to leave town, and the lack of time. None of these reasons were directly related to the use of the method.
At the Institute for Reproduction in Bombay, India, 1339 IUD insertions were performed in the 6 years from 1965 to 1970. 49 pregnancies with the IUD in place resulted, which equals a 3.6% failure rate. 92% of these pregnancies occurred within 2 years of insertion. A high percentage of abortion occurred with these pregnancies. In 5 cases of full term delivery and 1 of abortion, the IUD remained in the uterus. The attending doctor must be sure the IUD has been expelled. Ectopic pregnancy is possible with an IUD; this possibility must be ruled out whenever there is any case of irregular bleeding or abdominal pain.
As family planning programs have achieved limited success in many developing countries, it becomes necessary to determine why excessive time, money, and talent have achieved so little. Population research has been blocked by too narrow investigation, selection of the individual or married couple as the prime target rather than an interactive social group or community. Cultural or social anthropological studies which place fertility and family planning behavior in a sociocultural context are needed. The usefulness of such study is demonstrated by M. Mamdani's book, "The Myth of Population Control: Family, Caste and Class in an Indian Village (1972)". It is an evaluation of the Khanna project conducted in a Punjab village from 1956 to 1960 by a team of Indians and Americans. The project included a family planning action research program. The study reveals that for various social and economic reasons the villagers generally were actually not proponents of small families although a knowledge, attitude s, and practice survey had disclosed that nearly 90% of the villagers fa vored contraception and 2/3 of them claimed an ideal family to be 2 boys and 1 girl. The anthropological approach can be further studied in the papers of W. Bleek, J.R. van Renselaar, and D.G. Jongmans. In these works fertility behavior is described and analyzed against the background and in the framework of the sociocultural system of the societies in which the fieldwork was conducted. Symposium participants had difficulty reconciling their belief that anthropological studies were able to provide highly suggestive findings to family planning organizations with the lack of anthropological studies about birth control in the social science literature. This situation has been brought about by the fact that executives of family planning boards, agencies and programs have been slow to ask antrhopologists to participate in their efforts in addition to the fact that anthropologists have frequently criticized the superficiality and anivety of large scale surveys but have not made a positive contribution to replace the methodology they criticize.
Family planning, response and perception among villagers in Bangladesh.
Among the residents of 2 villages in Bangladesh, there was positive response to the government's family planning program only among the parents of large familiies, married couples who had already attained or gone beyond the prevailing norm of marriage fertility. This study's profile is totally consistent with the previously reported results of national research among IUD and vasectomy clients. It was evident that to these villagers family planning meant prevention of more births rather than spacing of children. After contact with the most highly motivated villagers was established, the family planning assistance workers reached a threshold they were unable to cross, and the family planning workers never even seriously attempted to convince the newlyweds or young married couples to adopt contraceptive methods. The desire for children is possibly stronger among poor families but children as a support for old age is a more significant value to the villagers. The findings reveal that there appears to be a marked preference among the more educated and the better situated for the IUD. The vasectomy is generally the choice of the illiterate and poor men. Findings in both villages suggest that husbands actually make the finally decision about contraceptive use. Generally, conventional contraceptives such as condoms and foam are disliked. When villagers learned about the oral contraceptive in the later phase of the family planning program, they were interested but cost prohibited its use.
Contraceptive practices in Finland in 1971.
The main purpose of a study of contraceptive practices of Finnish adults aged 18 to 54 was to describe, explain and interpret patterns of sexual behavior and contraceptive practices considering sociological, psychological and medical factors. Social and demographic background variables break down the incidences of ever-used and currently used methods of contraception into categories of exposure to conception and the level of effectiveness of the currently used contraceptive. Data have indicated that there is near universal use of contraceptive methods, there are social differentials in the types of contraception used and most frequently used contraceptives are the condom, the pill and coitus interruptus. Less reliable methods are used in the lowest income group and among those who want no more children. Of the latter group in which effective contraception is needed, 34% of the less educated and 17% of the better-educated considerably risk unwanted pregnancy. The proportion of couples using no method at all or an unreliable one is 35% in the lowest income group and 18% in the highest. The study suggests that if conception is to occur by choice rather than by chance, guidance and services for effective contraception are still needed.
Urban population growth: implications for India and South Asia.
In India more than 1/2 the total urban population is concentrated in the 6 cities with populations of 1 million or more. Densities in some areas of these cities reach 100,000-500,000 people per square mile. In Calcutta an estimated 600,000 people live on the pavement because they are too poor to afford shelter. Large cities in developing areas tend to draw migrants not only from rural areas but also from smaller towns. These people are disproportionately single, better educated, with higher occupational level. The smaller town is the poorer because they have left. Cities also draw the hopeless and the landless and, in addition, have high fertility rates. All Asian countries have a large dependency ratio. A drop in dependency ratio would help offset the high proportion of gross national product (GNP) which has to be reinvested just to keep per capita income at a constant level. In India this largely demographi c investment exceeds 1% of the GNP. Because of the improved infant survival rates combined with high birthrates between 1955-1965, the labor force will increase very rapidly between 1970-1980 in South Asia. This problem of finding employment will be aggravated in urban centers due to migration. As the number of frustrated rural dwellers come to the cities hoping for work and finding none, they become a force threatening stability. Industries must be decentralized to revitalize rural areas. Housing schemes and vigorous birth control projects must be put into force to eliminate slum conditions and squatters. In Asia industrailization and urbanization are in the early stages; if housing is as bad as it is today, what will it be like when industrialization becomes advanced? The money now spent aimlessly on wandering beggars needs to be funneled into health and welfare systems to raise their level. Education and transportation are critically strained by Asia's urbanization. According to Kingsley Davis, even if Asia had 100% effective family planning so that each couple had only the children desired, there would still be a population crisis because of the social structure which motivates couples to have large families. More education for women seems to be the answer. Women with primary education tend to have 6.6 children; with middle school education, 5.0; high school, 4.6; and those with some university, 2.0.
The effects of cyproterone acetate and ethinyl estradiol on testosterone metabolism by enlarged human prostate glands in vivo were studied. Tritiated testosterone (10 mcCi) was infused into 15 men approximately 20 minutes before prostatectomy. Cyproterone acetate 20 mcg was added to the infusate for 5 patients and ethinyl estradiol 15 mcg for another 5. The reamining 5 received testosterone alone. Excised prostate glands were frozen and sections taken for histology. Remaining tissues were extracted by acetone and radioactive compounds were separated by thin-layer chromatogrpahy. Identification was by coch romatography with authentic compounds, recrystallization to constant radioactivity, and preparation of derivatives. Major metabolities from prostates of men receiving testosterone alone were 5alpha-dihydrotestosterone (16%-35% of total radioactivity) and androste nedione (11%-16% of total radioactivity). A similar pattern of metabolities was seen in prostates from men receiving testosterone plus cyproterone acetate, but testosterone plus ethinyl estradiol gave very much lower amounts of both 5-alpha-dihydrotestosterone and androstenedione. Ethinyl estradiol, but not cyproterone acetate, significantly reduced the rate of radioactivity uptake by the prostate gland in most patients.(AUTHORS' MODIFIED)
Endocrinological effects of oral contraceptives.
The effect of oral contraceptives on the hypothalamus, the pituitary the gonads, the thyroid, and the adrenal is described. The chief endocr inological effect of oral contraceptives is exercised on the feedback mechanism of the gonadal steorids to the hypothalamus. There is good but not conclusive evidence that oral contraceptives suppress ovulation by inhibiting the release or formation of luteinizing-releasing hormone (LRH) in the hypothalamus. There is very little evidence of spillover effect on other pituitary hormones and none of direct effects on the pituitary tissue itself. When oral contraceptives are withdrawn, pituitary activity resumes promptly except for a few patients in whom the whole mechanism may remain quiescent for a long timey It has been shown that the release of gonadotropins in patients being treated with oral contraceptives is variable and dose-dependent. The effects on other endocrine systems are slight and appear to be the result of metabo lic alterations brought about by the oral contraceptives, mainly the estrogenic component, rather than by direct effects on the endrocine glands.
"Delayed marriage and planned birth": Translation of a Chinese birth control manual.
A popular Chinese book on planned birth compiled by the Planned Birth Leadership Group of Kwangtung Provincial Revolutionary Committee has been translated. Delayed marriage is advocated. It is recommended that men marry at about age 25 or 26 and women marry at about 23 or 24. This benefits the parents' health, enabling them to work and study unworried and enables the children to receive good care and education. Planned birth has the advantages of: 1) giving people more time and energy for reading and studying and participating in political activity; 2) promoting revolution, promoting production and work, and allowing the people to be prepared for war; 3) elevating the people's health; 4) helping to achieve higher education for future generations; and 5) being beneficial to the rational arrangement of individual and family life. The mechanics of pregnancy and contraception are explained and discussed. The condom, oral contraceptive pills, and the contraceptive ring, and the contraceptive flower are described. Abortion, vasectomy, and tubal ligation are described and discussed as well.
The role of the International Labour Organisation in family planning and population programmes.
The International Labour Organisation (ILO) has been concerned with labor and population on 2 levels: 1) furthering research to determine the interaction between population growth, employment, social security, and minimum standards of living and 2) educating and providing services to workers and their families through trade unions; social, health and welfare organizations; social security organizations, and rural cooperatives. The ILO has helped intensify family planning efforts in countries which already have programs, and have initiated model family planning services in countries which do not have a formal population policy. The ILO's position on family planning is that it falls within the scope of an enlightened labor welfare policy, and that an intensive family planning program is both feasible and very desireable among workers' families. ILO has conducted several seminars on population and labor in conjunction with other international agencies in India, Thailand, and Malaysia. ILO activity in family planning education has also been furthered with the publication of literature useful in workers' education programs. Courses in Indian trade union centers have been geared to interest rural workers with small landholdings in family planning. The ILO has held seminars for organizations of employers in Colombo (1972) and has planned 2 more in Djakarta and Seoul. Financial support for all population activities has been provided by the UNFPA, and it is expected, with the creation of the ILO Labour and Population Team in the regional offices in Bangkok, that population activities will be intensified.
Some aspects of planning and implementation of the family planning programme in Sri Lanka.
7 years of experience in the Sri Lanka family palnning program has revealed that the involvement of obstetricians and gynecologists can bring good results. The services should originiate in the antenatal, postnatal, and child welfare clinics as well as the family planning clinics. In Sri Lanka, family planning efforts have been implemented by the Family Planning Association from 1953 and by the Ministry of Health from 1965. The 5 year plan reveals that provisions have been made for the establishment of family planning clinics as part of the Maternal and Child Welfare services throughout the island. All family planning programs require the cooperation of obstetricians and gynecologists, pediatricians, and other family planning workers. The family planning programs should be concentrated at the 23 major hospitals, for the hospitals are now operating with a minimum of facilities and personnel. Regardless of the number of children she has, every mother should be instructed in family planning, and all parents should be advised to base their family size on their income level. Additionally, parents should b e counseled concerning spacing of pregnancies and sterilization after achieving the required number of children in a family. A family planning program can achieve effective results only if the obstetrician speaks individually to the mother regarding the need for family planning.
The amount of estradiol benzoate with progesterone required to induce lordosis in ovariectomized hamsters was determined to compare the responsiveness of hamsters to estradiol benzoate with that of rats and guinea pigs. In addition, the uptake and metabolism of tritiated estradiol in ovariectomized rats, guinea pigs, and hamsters was examined in an attempt to correlate species differences in behavioral sensitivity to estradiol with possible differences in neural affinity for the steroid. A dose of nearly 90 mg/kg was required to induce lordosis in 100% of the hamsters compared with the 2-5 mcg/kg which is effective in rats and guinea pigs. In all 3 species, highest uptake of estradiol was in the uterus and anterior pituitary gland. In the rat and guinea pig brains, the hypothalamus took up more estradiol than either the cortex or midbrain. In the hamster, there were no consistent differences in brain uptake. The affinity of the uterus, anterior pituitary, and hypothalamus of rats and guinea pigs for estradiol was greater than that of hamsters. In all 3 species, estrone was the principal metabolite of estradiol found in the tissues. The authors suggest that the higher the endogenous levels of a steroid, the less sensitive the animal is to that steroid.
Intracranial venous thrombosis complicating oral contraception.
A case report of cerebral venous thrombosis in a woman using Norinyl -l is presented. Specific histologic changes in the vessel walls are described, and some of the problems of diagnosis and management are discussed. 4 days after the onset of a severe headache, the 22-year-old woman who had been taking oral contraceptives for less than 3 weeks had a convulsion, followed by right hemiparesis. Other focal neurologic signs and evidence of raised intracranial pressure appeared, and she became comatose on the 7th day. A left craniotomy revealed extensive cerebral venous thromobis. The patient died the next day. On postportem examination, extensive thrombosis of the superior sagittal sinus and draining cerebral veins and multiple areas of cerebral hemorrhage and hemorrhagic infarction were seen. Some of the superficial cerebral veins showed focal necrosis of their walls, and the lateral lacunae of the superior sagittal sinus contained proliferating endothelial cells. These findings are possibly related to the contraceptive intake. It is noted that although the risk of cerebral venous thrombosis developing in a young woman on oral contraceptives is extremely small, it should be considered in the differential diagnosis of such a patient presenting with severe headache or focal neurologic deficit.(AUTHOR'S MODIFIED)
Endometrial reaction with long use of intrauterine contraceptive devices (7-9 years).
Endometrial reactions after IUD insertion for a long period ranging from 7 to 9 years were studied in cases selected from family planning clinics in Cairo. 71 endometrial biopsies were taken from the women who were wearing Lippes loops C. Chronic endometritis was present in 54.95% of the cases. Stromal hemorrhage was found in 45.07% of the cases, and cystic glandular hyperplasia was present in 23.84%. Stromal fibrosis, w hich was found in 12.12% of the cases, was marked and generalized. The general incidence of abnormal findings with the long-term use of the device was 65%. It is concluded that the presence of an IUD for several years may lead through its mechanical and possible local hormonal action to various pathological changes indicating endometrial irritation and activity. It is advised that women wearing the IUD be subjected to periodic pelvic examinations with routine Papanicolaou's smear and even endometrial biopsy if needed. Removal of the device with a time of rest is recommended to avoid long-term use with its possible untoward endometrial changes.
Cervical cancer in Yugoslavia: 2. Epidemiologic factors of possible etiologic significance.
To investigate the possible role of a genital herpes virus in the pathogenesis of cervical cancer, epidemiological factors were sought in a case-control study of cervical cancer among Moslems and non-Moslems in Yugoslavia. Women who developed cervical cancer were more likely to manifest behavorial characteristics such as smoking, drinking of alcohol , and diminished religiosity. The cases were significantly shorter, lighter, and less endomorphic than controls similar in age, marital status, religion, and urban/rural residence. They also had somewhat higher systolic and diastolic blood pressures at 2 different readings. Parents of cases tended to be older, especially 40 years, than parents of controls at the time of the patients' births. Multiple marriages and early initiation of coitus were more common among the cases. However, coital frequency was consistently lower among Moslem and non-Moslem cases than controls, both at the onset of coital practice and later cases tended to have more normal menstrual histories than controls, with relatively fewer long, heavy, painful, or irregular cycles. Absences from home and extramarital sexual experiences were significantly more common among the first husbands of the cases. An unexpected finding was the twofold or threefold greater mortality, especially at young ages, of first husbands of cases as compared with those of controls. The cases tended to experience more frequent and longer widowhoods beginning at earlier ages than controls. For most of the variables studied, case-con trol differences among the Moslem women closely resembled those among the non-Moslems. The results of this investigation are consistent with the venereal hypothesis of cervical carcinogenesis, but suggest the need for further investigations of the role of steroid hormones in this disease.(AUTHORS' MODIFIED)
Statistical evaluation of IUD (loop) acceptors and of pregnancies and births in Korea has indicated that a concentration of loop acceptors is between ages 30-39 and that rural but not urban acceptors are more likely to have used other contraceptive methods such as the condom. Upon interview, 51% of rural and 36% of urban acceptors still had their first loop in situ while 15% had had a reinsertion. Side effects of which pain and bleeding are most frequent, have been reported by 42% of acceptors, 2/3 persisting up to 1 month. Loop removals, more common in urban than in rural areas, occurred in 40% of acceptors. Expulsion accounted for 16% of acceptors. Side effects, removals, expulsion and the needs for treatment, consultation and reassurance usually occur within the first two months following insertion. 21% of acceptors reported pregnancy following acceptance; 3% occurred with the IUD in situ while 18% occurred following removal or expulsion. Pregnancy was more common among young and low parous women. Higher discontinuation an d removal rates occurred in urban acceptors while they aborted 53% of first pregnancies following acceptance as compared with 27% in rural acceptors. Continuation with the loop at 1, 2 and 3 years is 57%, 38% and 25% respectively with a lower urban than rural continuation rate. Lower rates were also found in younger women with lower parity than in older higher parous women and among better educated acceptors. Recommendations include measures to promote acceptance of IUDs at lower ages, measures to encourage loop acceptance and continuity by urban women and measures to reduce termination of IUDs. Efficient operation of IUD programs depend upon standard procedures and the above recommendations.
A pilot training program in laparoscopy in a community hospital.
A pilot training program in laparoscopy was begun in July 1971 in a 300-bed community hospital. First, the senior residents in obstetrics and gynecology were trained in the use of the laparoscope; they in turn trained attending physicians. When the program began, only 4 physicians were familiar with the technique; after 9 months, 21 attending physicians were skilled enough to do the procedure independently. The procedures were initially performed on an inpatient basis, but by September 1971 a staging area had been developed to perform the procedures on an outpatient basis. The average hospital stay on an outpatient basis was 8 hours. Of the first 220 laparoscopic procedures, 179 were tubal sterilizations and 41 diagnostic laparoscopies. Each group is discussed separately. The physicians found certain steps which facilitated the procedure and lowered the incidence of complications. The use of Semm's vacuum cannula to manipulate the uterus and inject indigo-carmine in infertility work-up was found profitable. The use of 2 towel forceps to grasp the para-umbilical skill facilitates the introduction of the pneumoperitoneum needle and the trocar for the laparoscope. The Touhy needle reduced the difficulties in introducing the pneumoperitoneum. Connecting the cannula to the automatic pressure regulator was the simplest and most accurate method to ensure the intraperitoneal location. To avoid burns of the bowel, the electric current should not be connected before grasping the tube and finding that the area to be fulgerated is free from adjacent structures. Electrocoagulation followed by cutting with scissors was preferable to tubal electrocoagulation and partial resection by Palmer biopsy forceps. The authors feel that diagnostic laparoscopy has its place in everyday gynecologic practice and that tubal sterilizations are an essential procedure in family planning projects in community hospitals and developing countries. They hope their pilot laparoscopy training program will encourage the establishment of other programs.
This discussion assesses the current status of operative laparoscopy, reviews some of the problems, and evaluates developments. The 2 major types of instruments are the 1-puncture and the 2-puncture l aparoscopes. The 2-puncture method enables the operator to visualize a larger area of the operative field. The single puncture decreases the possibility of complications. The success of the procedure depends upon the skill of the operator. To meet the demand for physician education, training programs are being established throughout the world. Operative procedures may be for diagnostic or for therapeutic purposes. Biopsies of ovaries, tumor implants, or liver biopsies have been accomplished. Peritoneal fluid can be aspirated for bacterial culture or acytologic examination. Ovarian cysts may be drained. Aspiration of ovarian follicular fluid has been done on an investigational basis. Hysterosalpingogram can be done under direct vision. A special manipulating instrument can bring the ovary and tubes into better position. The greatest use of the 1 puncture technique has been for tubal sterilization. Bowel burns are a hazard. The recently developed bipolar coagulating forceps prevent the coagulation of any tissue other than that lying between the 2-prong terminals of the instrument and eliminates the need for a grounding plate. Excision of a section of tube is done by some but coagulation only is preferred as less likely to be complicated by bleeding. A recent technique of using a polyp snare through the second puncture seems to avoid bleeding. Dilation and curettage along with the sterilization procedure are advocated to avoid the possibility of a luteal phase pregnancy. Lysis of peritoneal adhesions may be done in an infertility investigation. Fulguration of endometriosal implants in cases of endometriosis may avoid laparotomy. Uterine suspension by laparoscopy has been of value and removal of intrauterine devices that have perforated the uterus is possible. (The IUD may be withdrawn through the trocar of the instrument or through the sheath of the telescope.) Most procedures can be done on an outpatient basis and associated morbidity is low.
Laboratory test results altered by "the pill."
The diverse and extragenital effects of oral contraceptives (OCAs) are reflected in alterations of laboratory test results. One of the variables that needs to be considered in the evaluation of laboratory test results is the effect of drug therapy. Protein metabolism is affected by the steroids by increasing the utilization of plasma amino acids and increasing hepatic synthesis of many proteins having a transport function in the blood. Changes in the renin-angiotensin system have also been noted. OCAs activate the system and lead to increased levels of angiotensin 2 and aldosterone. Laboratory abnormalities due to altered hepatic function include impairment of sulfobromophthalein clearance and elevations of levels of serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase, alkaline phosphatase, leucine aminopeptidase, 5 nucleotidase, and bilirubin. In addition, protein-bound cortisol is increased possibly because of a decrease in the efficiency of metabolism. OCAs also increase thyroid-bi nding globulin and the actual thyroxine content of the plasma. The ability of individuals to handle a glucose load is noted in all women to some extent. There is some confusion of the effects of OCAs on blood lipid constituents. A dose-related estrogenic effect is the elevation of serum triglyceride levels. Concomitant changes have been reported in the pre-beta-lipoprotein fraction. In most cases the increased triglyceride levels are within the normal range except in women with preexisting hypertriglyceridemia. Changes have also been noted in the hematopoietic and hematologic systems.
Fertility control policy, social policy and population policy in an industrialized country.
The recent history of political and social policies of fertility control in the United States is recounted. Surveys in 1941, 1955, and 1960 showed that contraception was widespread, but the poor tended to be less successful because they used less effective methods and initiated contraception later. Contraception was first mentioned in public press in 1955, first prescribed in municipal hospitals in 1958, first provided in Foreign Assistance in 1963. Some states repealed restrictive laws ag ainst disseminating contraceptive information in 1965. The Supreme Court ruled that married couples are free to use contraception in 1965, extended this right to unmarried in 1972, and in 1973 overturned state abortion restrictions for first trimester. Funds were allocated by Congress for family planning under the Economic Opportunity, Social Security, Foreign Assistance and Population Research Acts. Within the U.S. 3.5-4 million poor and marginally poor women have benefited by services in over 3000 clinics. The author calculated that expenditures for family planning rose from .02% in 1968 to .14% in 1972 of all U.S. social welfare expenditures. Since 1972, the administration has not expanded services, so that rural poor and adolescents remain without contraception. Thus experience shows that efforts to reduce fertility complement other social and economic welfare programs. The polar views that only compulsory population control, or only economic assistance without providing family planning, will solve the population problem are refuted by this analysis.
Population and development: is a consensus possible?
The debate concerning population growth and economic development cen ters on whether efforts should be specifically directed at reducing popu lation growth or on general economic and social development. Arguments supporting the former include 1) the position that unrestrained population growth is the principal cause of social problems; 2) the position that there is a demand for fertility control and thus provision of services is needed; 3) the human rights position that it is a fundamental right to determine family size, to have good health, and for women to control their own bodies; and 4) the population-programs-plus-d evelopment position. Positions against the need for special population programs include 1) the pronatalist position; 2) the revolutionary position; 3) the anticolonial and genocide position; 4) the position that the developed countries overconsume resources, which is more detrimental than the population growth; 5) the position that the problem is one of underemployment and that a proper economy can provide employment regardless of population size; 6) the position that the problem is one of distribution of the population, not of its size; 7) the position that fertility will decline when mortality declines and that provision of social security will lead to fertility declines; 8) the status-of-women position; 9) the religious-doctrine position; 10) the medical-risk-of-contraception position; 11) the holistic-development position; and 12) the social-justice position. A consensus position on population plus development programs which would include elements of the other positions seems to be the most logical means of formulating a program for action that would be acceptable to a majority of countries.
The book "China's Population Struggle: Demographic Decisions of the People's Republic, 1949-1969," by H. Yuan Tien, is reviewed separately by Aird, Borrie, and Salaff. The reviews are followed by a reply by Tien. The stated purpose of the book was to examine all factors which influenced size, growth, or distriubtion of China's population between 1949-1969. Aird, in his lengthy review, finds the book superficial, misleading, and ingenuous. His greatest criticism is that there is no room in Tien's analytical framework for a consideration of economic influences on such matters as population growth, food, land, and employment opportunities. He is aghast at Tien's failure to link changes in official attitudes toward birth control, first against, then for, to the bounty of the Leap Forward and the subsequent food crisis. Borrie, on the other hand, is complimentary. He considers the book an important contribution to our knowledge of Chinese population, but does regret the lack of critical comment or appraisal. Salaff is not sure the book merits detailed consideration. "The absence of a well-structur ed framework, along with a lack of conclusive analysis and in-depth substantiation of most of the topics. . .relegate the book to a relatively superficial place," she writes. She is particularly concerned by the lack of data more recent than 1962 and by the presentation of policy statements divorced from their implementation. The greater part of Tien's rebuttal is aimed at Aird, whose "rhetoric and phraseology" he finds "repugnant, misleading, and full of ethnocentrism. " He defends the book's organization as following the sequence of events and says he often referred to the influence of economic events and conditions upon population growth and movement. He considers Aird a prisoner of Cold War philosophy. Tien defends himself against Salaff by attributing the lack of very recent data both to its general unavailability and the absence of known changes in China's population policy since the early 1960s. Tien suspects Salaff has not read the book thoroughly, as she misconstrues the book's aim and distorts some of its contents. While Salaff criticizes Tien for dealing only with 3 birth control techniques (sterilization, pill, and abortion), Tien maintains he was concerned with methods that were controversial, not with methods per se.
At the International Conference on the Physician and Population Change held in Stockholm shortly after the Population Conference at Bucharest, several speakers spoke of fertility control as a basic human right which doctors must do all they can to help their patients achieve. Mankind is already suffering from the ills of overpopulation. It was agreed that programs of fertility control must be adapted specifically to the needs of each community. Many speakers were critical of the poor response doctors had made so far in most countries to their patients' demands for fertility control. It was noted that if healthy and humane control of fertility is to be achieved, it is now the medical profession who must change more than their patients or communities. Involvement of lay people in carrying out family planning was advised. Many of the speakers spoke of induced abortion as a part of family planning. Help will be sought from the medical profession in the immediate future, and the conference laid down some guidelines in "A Strategy for Action".
Beyond the demographic transition.
In the past 30 years there has been a decline of death rates in deve loping countries and a rise and subsequent decline in birth rates in some developed countries. The developed countries appear to have gone beyond the demographic transition and to have entered an era in which fertility fluctuates mainly in response to influences other than those that reduced birth rates during the preceding 3 centuries. The principal features of the rise and decline in fertility since the lows of the 1930s were reached are reviewed. It is concluded that improved effectiveness of fertility control within marriage may have facilitated the movement toward younger marriage, younger childbearing, and higher proportions marrying and having children, but that improvements in technology alone are not sufficient to account for these trends. The postwar movement toward younger marriage and childbearing was probably also influenced by improved economic conditions and by the assumption of greater responsibility by national goevernments for many of the costs associated with parenthood. Couples now respond to varying social and economic conditions more by changing the ages at which they marry and have children than by changing the total number of children they have. Countries in Eastern Europe went through the demographic transition late r than did the countries of Western Europe. It may be that the trend toward earlier childbearing is occurring later in Italy, Portugal, and Spain than in the countries of Northern and Western Europe. Further comparative studies are recommended to gain further information on recent trends in fertility.
Report on the use of the Dalkon Shield intrauterine device.
Experience with the Dalkon shield in 274 women (most 26-30 years old ; 13 nulliparous) through 3738 woman-months over a 27-month period (Apri l 1971-July 1973) is reported. 12 women were fitted with the small shield, all others with the standard size. Socioeconomic conditions were the most common indications. 82.9% had normal pelvic examinations. A few had an enlarged uterus, lacerated cervix, or cervical erosion. Use varied from 1 to 27 months. Most of the insertio ns were performed after the first, second, or third menstruation following delivery or abortion. 48 women had previously used a different IUD. After the Dalkon shield insertion, patients were examined at 1, 6, 12, and 24 months. 51 patients were lost to follow-up . 197 continued over the whole period; the continuation rate for 12 months was 77.1%. Of 13 pregnancies with the device in situ, 5 aborted spontaneously. No infections were noted in these cases. No pregnancies followed unnoticed expulsions. Expulsions occurred in 4 cases. During the 27-month period, there were 60 removals, 44 for medical reasons, i.e., 70% for bleeding or pain and 3.3% because of infections. In 16 patients, removal was for a desired pregnancy. There were no perforations or tubal pregnancies. An important factor in minimizing the removal rate is proper selection of patients, with particular care relating to the personality of each woman.
Laparoscopy in the community hospital: set-up, performance, control.
A report on laparoscopy as performed at St. Luke's Hospital, a community hospital of 225 beds in Davenport, Iowa, is presented. Betwee n June 1, 1970 and August 31, 1973, a total of 2303 laparoscopic procedu res were performed on 2286 patients by 4 gynecologists. Of these, 285 were diagnostic laparoscopic operations while 2018 were primarily for the purpose of tubal sterilization. Of the total cases, 1249 were performed by the author. The admission procedures, preparation and anesthesia, operating room scheduling, and other events leading up to the operation are described. The double puncture technique of tubal sterilization is used in the hospital, in general, the single-puncture technique being used only by the author. Of the 2018 tubal sterilizations performed, there have been 4 luteal phase pregnancies. In addition to the luteal phase pregnancies, there have been 3 pregnancies occurring after the procedure. These 3 were all operated by the same surgeon, and all were done by the double-puncture technique. In the first half of the series, there were 5 laparotomies performed for control of bleeding. In the second half of the cases, there have been no laparotomies performed because of bleeding. The total major complication rate was .84%. The most serious complications occurred as a result of the use of the electrosurgical apparatus.
The development of endoscopic procedures in general is discussed as a vital part of the history of laparoscopy. The first recorded report of an attempt to visualize the interior of a body cavity was made in 1805 by Bozzani of Frankfurt, who constructed a cumbersome instrument using a candle as the light source. The period of visual instrumentation utilizing light directed from the outside through a system of mirrors ended in 1867 when Bruck examined the mouth using a loop of platinum wire heated to brilliance by an electric current. 10 years later Nitze, using the same wire source for illumination, added lenses to magnify the area to be examined. This lens system is the forerunner of all modern endoscopes. In 1889 Boisseau de Rocher separated the ocular part from the sheath, a principle upon which almost all modern endoscopes are based. Ott was the first to introduce endoscopic inspection of the abdominal cavity in 1901. Kelling, from 1901 to 1910, introduced closed cavity endoscopy. Development continued in a slow and small way until 1952, when Fourestier, Gladu, and Valmiere developed a new apparatus that revolutionized endoscopic techniques. They developed a method of transmitting an intense light along a quartz rod from the proximal to the distal end of the telescope. This removed the dangers resulting from electrical faults and heat and intensified the light to a degree that photos could be taken. Still, there was little interest in laparoscopy until Steptoe, in 1967, published the first book on the subject in the English language. Since then, and with the publication in the U.S. by Fear and by Cohen and the improvement of lighting techniques utilizing fiber optics, the use of laparoscopy has snowballed. In 1973 there were approximately 500,000 laparoscopies performed in the U.S.
Pearl-Reed type stochastic models for population growth.
The question of fitting a mathematical model to the U.S. population growth is examined. A fairly general class of models is investigated wi th particular emphasis on the problem of specifying the stochastic compo nent of the model. The first step taken was fitting a straight line. In order to remove the significant pattern in the residual-fit plot, the data was transformed. The modeling implications of the data analysis were than investigated. Very large variations in the estimated values of y(infinity) for the 3 models obtained were noted. There was close agreement between the estimated limiting population for the logistic model after 1910 and the value of 197 million obtained by Pearl and Reed despite the fact that they used a different fitting procedure. The estimates of y(infinity) provided by the logistic model were consistenlty too low. Although a stochastic model was found which provided an adequate description of the population growth in the United States, the investigators were unable to estimate the parameters in the model sufficiently well to provide useful forecasts.
Sexuality and birth control: impact of outreach programming.
The development of a program of family planning assistance and sex c ounseling