How barefoot? (Letter to the editor)
It was good to read Professor Backett's and Dr. England's viewpoint concerning the need to consider the global convergence of interests in medical training. In both western nations and developing countries there has been a recognition of the potential of the physician's assistant/medical auxiliary although the extent of effective incorporation into medical care systems differs. The next stage is to explore the possibilities of more self care, particularly in the western countries where, despite good standards of general education, disproportionate numbers of medical personnel are practicing. As it has been shown that individuals who receive a small amount of training can care for a wide range of diseases, the following recommendations are made to further facilitate self help: 1) safe drugs with clear instructions need to become widely available via slot machines; and 2) adult education and secondary school courses in self care should be established. The preferred approach would be to have the general practitioner as the head of any teaching program. It is hoped that both the physician and the health authorities will consider self help as a stimulating new way to provide primary and personal care.
Effects of oral contraceptive steroids on pituitary prolactin secretion.
An investigation based on the association of amenorrhea-galactorrhea syndrome with the use of oral contraceptives (OC) involved the evaluation of serum prolactin (PRL) levels during 19 treatment cycles with synthetic estrogens and progestins in 16 premenopausal subjects. 10 subjects received sequential OCs during the estrogen segments of the treatment cycle (days 7-16) while 6 received combination OCs between days 9-20. The epidosic nature of PRL release necessitated the use of the transverse mean for quantitative comparison of OC users with normal untreated subjects. Significant increases in prolactin concentrations were exhibited in both sequential (p less than .001) and combination (p less than .05) pill users as compared to normals. Subjects on sequential pills had a significantly greater (p less than .01) mean serum level than those on combination OCs. These data suggest that the pill's estrogen component has a positive effect on pituitary prolactins ecretion, although it is likely that this association occurs only in individuals with preexisting hypothalamic pituitary abnormalities. Further investigation regarding this association is needed.
Abortogenic activity of antiserum to alpha-foetoprotein.
100 pregant mice (day 9-20 of gestation) were injected with .5-2.0 ml of specific anti-alpha-foetoprotein (anti-AFP), with non-immune rabbi t serum or with buffered saline to demonstrate the abortogenic activity of rabbit antiserum to murine AFP. Anti-AFP was produced by immunization with antigen fractions derived from amniotic fluid and had a specific antibody concentration of .424-532 mg/ml. Mice were examined at 6, 12, 18 and 24 hours after injection and autopsied at 24 hours. Litter size and fetal dimensions were determined and fetuses examined for gross morphological changes. Histological sections of fetal and maternal tissue were prepared. Passage of aborted fetuses usually occurred 16-20 hours after injection. 68% of animals treated with specific anti-AFP exhibited a physiological response. Partial and complete abortions both occurred in the latter 2/3 of gestation. The greater the fetal mass the more anti-AFP was tested to whole mouse serum and to 3 mouse protein antigens similar to AFP. These antisera caused neither partial nor complete abortion in any animal tested. Anti-AFP was absorbed with pregnant uterine tissue extracts or purified AFP fractions and tested with blocking experiments. Absorbed anti serum injected into pregnant mice was essentially without effect. The mechanism of action of anti-AFP is unknown but it is suggested that resp onse may be in terms of anaphylactoid contractions of uterine smooth muscle or that AFP may suppress allogenic and mitogenic induced lymphocyte transformations and is instrumental in maintaining pregnancies.
Comparative glycolytic metabolism in the normal and in the copper treated human endometrium.
Endometrial biopsies were taken from 7 regularly menstruating women and from 11 different women wearers of an IUD of the copper releasing type (Cu-T<200>), first during the secretory half of the menstrual cycle ( 20 plus or minus 1 day) and then in the same women during the proliferative phase (10 plus or minus 1 day) of the next menstrual period. The untreated endometrium produced significantly more lactate during the secretory (2.6 mcmoles/mg DNA) than during the proliferative phase (1.62 mcmoles/mg DNA). This tendency towards anaerobic glycolysis was also reflected in the observed decrease in oxygen uptake during the secretory phase. Carbon-14-glucose conversion to carbon-14-glycogen was 4 times higher during the 2nd half of the menstrual cycle (.83 mcmoles of glucose converted/mg DNA hrbc-1e <-1> During the proliferative phase, the presence of a copper IUD induced a significant decrease in the conversion of glucose to glycogen and to lactate and also a decrease in oxygen uptake and in the utilization of endogenous substrates. However, the conversion of glucose to carbon dioxide-14 was significantly increased. The same pattern of changes was produced by the Cu-T<200> during the luteal phase, but in this case the conversion of glucose to carbon dioxide-14 was also significantly reduced (p is less than .005). (AUTHOR'S MODIFIED)
Oestrogen synthesis during delayed implantation in the rat.
A study was based on the hypothesis that Tamoxifen could have a direct effect on the ovary and may owe part of its antifertility action to an ability to inhibit synthesis and/or secretion of estradiol by the ovary. In vitro studies were done in which ovarian tissue from normal pregnant or Tamoxifen-dosed (.1mg/kg) pregnant rats were incubated with radioactive estrogen precursors and their incorporation into the steroid measured. No difference between the 2 groups was seen on day 2. However, normal rats exhibited a considerably higher plasma level of estradiol on day 3 than Tamoxifen-dosed animals. Estradiol plasma levels coincided with previous observations. These results support the hypothesis that Tamoxifen affects the ovary through inhibition of estradiol synthesis. The effect of the selected dose of Tamoxifen administered on Day 2 wears off by Day 4 allowing a delayed estrogen sur ge and delayed implantation in dosed animals.
Conization and the minipill. (Letter to the editor)
The incorporation of a cervical cancer screening laboratory in a family planning clinic has led to a realization regarding the (progesterone-only) minipill which I have not previously seen recorded. Some 300 postconization cervical smears screened have been characterized by the scanty nature or even complete absence of endocervical cells and mucus despite the smears having been taken in the usual manner from the region of the cervical os. As the chief mode of action of the minipill depends on its effect on endocervical mucus it would seem apparent that this type of oral contraception would lose its efficacy if a large proportion of the gland-bearing, mucus-producing epithelium of the endocervix were removed by conization. The abortion law in South Africa does not permit therapeutic termination of pregnancy in cases of contraceptive failure and it is therefore unjustifiable to embark on a clinical trial of this theoretical consideration. It has therefore been decided in this family planning program to regard previous conization quite empirically as a contraindication to the use of the minipill. It would be interesting to know whether any of your readers have had experience of minipill failures in patients who have undergone cervical conization.(FULL TEXT)
Last week Mrs. Castle announced (British Medical Journal, p. 293) that the Government had accepted the recommendations made by the House of Commons select committee which had been examining the Abortion (Amendment) Bill. She added that Parliament would be given a chance to reestablish the select committee in the coming session - opening up a prospect of a repetition of all the familiar arguments on the topic. The real priorities have been plain ever since the Lance Committee reported. Wider availability of reliable contraceptive advice and facilities could help to reduce the numbers of unwanted pregnancies (currently estimated at 200,000/year in Britain). There is still inadequate provision for early termination of pregnancy within the National Health Service (NHS) in many parts of the country. More use of outpatient procedures, supported by sympathetic and effective counseling services, could eliminate the circumstances in which women have to shop around for weeks in order to arrange a termination, so introducing unnecessary medical hazards and psychological stresses. Almost all the objectionable practices occur in the private sector, which exists mainly because of deficiencies in the NHS. Very few women pay for their abortions as a matter of choice. Changes in the law rarely correct abuses, and they would not be needed if all parts of the country had the same facilities as those freely available in units which have given the problem its proper priority. (FULL TEXT)
Population and development at Bucharest and after.
The Bucharest World Population Conference marked a great step forward in concern for population matters. Developmentalists, i.e., thinkers who stress the need for socioeconomic development to precede fertility control, and the populationists, i.e., those who feel that fertility decline is necessary as a precedent for any social development, had a useful dialogue at the Conference. Economic development programs and family planning programs combined are both important to the overall progress of a society. The developmentalist view was stressed at the Conference during the first week of meetings. It was important for African and Latin American nations to be able to point out their emphasis on economic development. After doing that, they could find it easier to accept restrictive population policies where necessary. The final Plan adopted by the Bucharest Conference stressed development and population control. Many international happenings since Bucharest have recognized the importance of population policies. Broad population principles must now be adjusted to the individual situation of individual nations. Increased interational aid for national population programs must be made available. Populationists have been made to realize the importance of development also.
Effect of estradiol at mating on conception in ewes. (Abstract only)
In other experiments, the administration of 30 mcg of estradiol-17beta to ewes at the time of mating improved sperm transport to the oviducts. In the present study, 8 ewes in each of 4 groups were injected sc at the time of natural mating with none, 30, 150, or 750 mcg of estradiol-17beta. The ewes were killed 3 days later and ova examined. 8 other ewes in each of 4 groups were treated with doses of estradiol-17beta and killed 25 days later. Of the 8 ewes per group treated with 0, 30, 150, or 750 mcg of estradiol-17beta and killed at 3 days, the number of ewes with cleaving ova was 8, 8, 7, and 7. Mean numbers of accessory sperm cells in the zonae pellucidae were 41, 73, 40, and 6 (p less than .01). Of 8 ewes per group killed at 25 days, the number with embryos was 8, 7, 7, and 5. The dosage of 750 mcg of estradiol affected sperm transport adversely as indicated by decreased numbers of accessory sperm cells in the zonae pellucidae. This dosage caused some 3-day ova to appear flattened and the zonae pellucidae to be wrinkled. However, the results indicated that a dose of about 30 mcg of estradiol that might be used to improve sperm transport was not detrimental to ovum fertilization or to embryo survival to 25 days.(FULL TEXT)
Serum immunoglobulins and C-reactive protein in patients using intrauterine contraceptive devices.
Serum immunoglobulins (IgA, IgG, and IgM) and C-reactive protein were analyzed in patients using IUDs. 20 women, aged 16-40, with the Saf-T-Coil, the standard Dalkon Shield (containing copper ions), or a non-copper-containing Dalkon Shield were included in the study. Blood samples were obtained at the time of IUD insertion, and 4 and 12 weeks postinsertion. C-reactive protein was assayed by immunodiffusion on cellulose acetate and by the Mancini technique, which is quantitative and employs radial immunodiffusion on agar gel. No marked amount of C-reactive protein was detected in any of the samples. Although the mean differences in immunoglobulin levels may either increase (IgA), decrease (IgG), or not change (IgM) from 4 weeks to 12 weeks, the overall effect from insertion to 12 weeks was an increase in levels, dominated by the increase from insertion to 4 weeks.
Adult hamsters received varying amounts of testosterone via subdermal Silastic capsules (Berndtson, W., et al., Journal of Endocrinology 62: 125-135, 1974) to determine whether this steroid was capable of inhibiting and/or supporting spermatogenesis. Silastic capsules ranging from 100 to 4800 sq mm were implanted (5 hamsters per surface area) for 40 days prior to determining testicular and accessory sex gland weights and the relative number of germ cells at Stage 7 of the cycle of the seminiferous epithelium (Clermont, Y., Revue of Canadian Biology 13: 208-245, 1954). Testes from control hamsters averaged 298 + or -93 mg while those receiving 200 and 4800 sq mm testosterone capsules averaged 792 + or or -99 mg, respectively. The relative number of Type A spermatogonia, preleptotene and pachytene spermatocytes and Step 7 spermatids averaged .99, 25.7, 25, and 95.2 in control hamsters; .85, 7.4, 4.3, and 0 in hamsters receiving 200 sq mm capsules; and .94 24.9, 24. 1, and 93.4 in hamsters receiving 4800 sq mm capsules, respectively. The inhibitory effects of testosterone on spermatogenesis were achieved without inducing alterations in accessory sex gland weights or plasma testosterone concentrations. In contrast, capsules supporting spermatogenesis quantitatively induced accessory sex gland hypertrophy and elevated plasma testosterone concentrations about tenfold above control values (i.e., 7 ng/ml plasma). The results support the concept that testosterone is capable of inhibiting spermiogenesis withough altering circulating levels of testosterone and that spermatogenesis may be supported quantitatively through Step 7 of spermiogenesis providing that circulating levels of testosterone are maintained about tenfold above normal.(FULL TEXT)
In vitro estrone-estradiol-17beta interconversion in the cornea, len s, iris, and retina of the rabbit eye was investigated. The eyes of 10 female rabbits were enucleated and the cornea, lens, iris, and retina were removed and incubated with radioactive estrone or estradiol-17beta, chromatographed and the metabolites were characterized. Interconversion by the action of 17beta-hydroxysteroid dehydrogenase decreased in the sequence cornea, iris, retina, and lens. Estradiol-17alpha was also formed from estrone in a smaller yield. The cornea appears to be an active-metabolizing tissue. The role of estrogens and progestogens in these tissues is briefly discussed.
1.3 million sterilizations in 1974; rise of 43% over 1973.
An estimated 1.3 million vasectomies and tubal sterilizations were p erformed in the U.S. in 1974, an increase of about 43% over the previous year, according to a report from the Association for Voluntary Sterilization (AVS). Almost 1/2 of those sterilized were women; AVS figures indicate than in 1970 4 times as many men were sterilized as women. The AVS data include procedures performed on men and women of all ages, whether or not contraceptive in intent. AVS surveyed 166 sterilization clinics, including those sponsored by Planned Parenthood and by public and private hospitals, as well as by the military. Usable responses were received from 67% of the clinics; the Navy and Air Force provided exact data, while the Army provided estimates. In addition, AVS received an estimate of the number of vasectomies and tubal sterilizations performed by doctors in private practice from IMS America, Ltd., a firm that collects data from 1500 randomly selected physicians for the "National Disease and Therapeutic Index." 96% of the female and 92% of the male sterilizations were performed by private doctors. About 3% of all sterilizations were performed in clinics, where twice as many vasectomies as female operations were performed. About the same number of men and women were sterilized in military facilities (39,500) as in civilian clinics (42,500), AVS found. According to AVS, between 1970 and 1974 tubal ligations and vasectomies were performed on some 5.3 million men and women.(FULL TEXT)
Adolescent pregnancy: review of the literature.
The literature on adolescent pregnancy lacks an adequate theoretical base, its concepts are indefinite, and its terminology loose. Although numerous empirical studies have been done, few are linked to any theoretical framework, have adequate design, or have adequate samples. 1 approach to the problem of unmarried motherhood is to challenge the definition of illegitimacy. A cross-cultural study identified 6 preventive measures societies have used: 1) penalizing the parents, 2) forced marriages, 3) early marriage, 4) legalized abortion, 5) birth control, and 6) sex education. The 1st 3 have never worked, the latter 3 have never been fully tried. Proponents of the psychological view claim unwed motherhood is a reaction to early parent-child dysfunctioning. Sociologically-oriented authors claim it is the result of poverty and cultural factors. Still other authors blame pathology and stress. Illegitimacy has also been studied from a demographic and e cological perspective. Medical studies have shown that the unwed mother and her child have traditionally been at risk but the risk comes from environmental conditions rather than marital status. The pregnant teen-ager presents a nutritional risk to herself and her child and she is also less likely to seek or maintain prenatal care. Studies which have defined this problem in terms of costs to society have generally been filled with class and racial bias. These studies indicate an unwed mother receives welfare benefits for an average of 2 1/2 years. What they tend to ignore is that the cost to society of illegitimacy in the lower socioeconomic class is likely incidental to the general financial cost deriving from the poverty. Studies which focus on relation of adol escent pregnancy to truncated education and poverty are not of sufficien t methodological design to distinguish which are the antecedent, which the consequent variables. Adolescent pregnancy is both a personal problem and a public issue. It cannot be explained by a single theoretical perspective. Development of suitable study frameworks is a research challenge.
Local and systemic effects of intrauterine devices. (Letter to the editor)
Dr. Oster and Mr. Salgo, in their most comprehensive review, "The Copper Intrauterine Device and Its Mode of Action," recognize the hazard of uterine perforation and subsequent expulsion into the peritoneal cavity by polyethylene and copper IUDs. There have been few studies on the effects of an "abdominal IUD," but severe complications have been re ported. Our laboratory recorded both local and systemic effects of poly ethylene rod or copper wire aseptically implanted in the mouse peritonea l cavity. 21 days after implantation of copper wire or polyethylene rod (5 mm long) in the peritoneal cavity of adult female Swiss Webster mice, peritoneal fluid and tail blood were withdrawn and stained, and cellualr distributions were tabulated by methods previously described. Female mouse peritoneal fluid may indicate physiologic alterations within the abdominal cavity, often in a manner seen in women. No change in the leu kocyte distribution in tail blood was found in either experimental group as compared with controls, but severe rouleau formation of erythrocytes in all copper-implanted animals indicates that intraabdominal copper does produce some systemic effects. However, cellular distributions in peritoneal fluid indicate that abdominal foreign bodies may not alter the equilibira within the peritoneal cavity. Possibly, this low response by peritoneal fluid to abdominal inflammation is characteristic of the mouse.(FULL TEXT)
Should social workers be involved in family planning?
A Domiciliary Family Planning service functioniong in the Haringey borough of London is discussed. Haringey is an area with a large immigrant population, most of whom are in the lower socioeconomic classes. The service, free to the clients, is run by 1 doctor and 2 nurses. In addition to providing family planning advice and supplies at the home, or referring clients to family planning clinics, the Domiciliary service acts as a pregnancy advisory service and arranges abortions where desired. The service operates under disadvantages becau se lower class individuals are ignorant, fearful, and prudish where sex is concerned. The families referred for this service really do want family planning help; most have been reluctant to attend family planning clinics. Many self referrals occur now. The pill, IUD, and sterilization are the family planning methods chosen most often. A couple's relationship, attitude toward life, and value they place on chi ldren will influence whether they practice birth control effectively. Social workers are often reluctant to involve themselves with family planning through lack of training and reticence. There is a real need for social workers to become involved. The practice of family planning could help their clients with other problems as well.
The unanswerable questions in voluntary sterilization--the physician's dilemma.
There are presently a variety of methods for performing vasectomies. The medical literature on vasectomy does not facilitate evaluation of vasectomy methods. The literature lacks uniformity in content and in reporting of methodology. Establishing a standardized criteria for conducting and reporting research and a standardized terminology would facilitate comparison of various vasectomy procedures. Comparison of methods as to safety, efficacy, reversibility, and complications is needed.
Population and the Seventh Special Session: a report.
The debate and documents of the United Nations Seventh Special Session held in Bucharest, September 1-16, 1975, devoted to issues of economic development and international economic cooperation are discussed with particular attention to the condiseration given to population as a factor in development. The debate had only a very limited discussion on population. The Third World nations emphasized their reluctance to accept birth control as part of a remedy for poverty. They argue that distribution of wealth and the health of thier societies are more relevant as factors in thier development than population control. However, the resolution adopted by the General Assembly stressing improved health care acknowledges the legitimacy of family planning as a health measure. This lack of attention to population during the Special Session can be related to 3 factors: 1) there was a desire to focus on areas of broadest agreement; 2) the absence of population as a distinct issue in the World Population Plan of Action; and 3) the feeling among developing countries that they were owed transfer of wealth as reparations for centuries of colonial exploitation. Ther was also a preference for national self-reliance over international action.
The family planning nurse practitioner: concepts and results of training .
The 12-week training program for family planning nurse practitioners set up by the Obstetrics and Gynecology Dept. of New Jersey Medical School, Planned Parenthood-World Population, and Planned Parenthood-Essex County is described. Each class of 10 nurses spends 1/3 of the time in didactic and 2/3 of the time in clinical experience. Both free-standing and hospital-based clinics are used to give the students a variety of delivery settings and varied techniques. The program has trained 80 students since inception in 1972 and 30 more are in training. 31 had baccalaureate or higher degrees, 45 were graduates of hosptial or diploma schools of nursing, and 4 were graduates of 2-year associate degree programs. Median age was 35.8 years and over 20% were from minority groups. Evaluation of the nurses after they had gone back to their agencies showed that all but 5 had added patient management to their functions after training, acceptance by patients and physicians has been enthusiastic., and no medical catastrophes due to poor nurse practitioner judgment have been reported. Acceptance by other nurses appears to be a problem in some instances, although many graduates report good reception. The need is unequivocally present and the well-trained nurse practitioner can improve and expand services in many diverse situations. A need exists for eventual standardization and accreditation of training programs and national certification of the various nurse practitioner categories.
Human milk, nutrition, and the world resource crisis.
In less developed countries, protein-calorie malnutrition of early childhood is widespread. Severe syndromes, such as kwashiorkor and marasmus, are found in 1-7% of young children in some populations. Many more are affected by less severe manifestations. It has been estimated that there are 10-20 million young children with severe syndromes, most of whom will die without treatment. Conversely, infantile obesity is becoming a problem in more affluent populations. Recently, the pattern of malnutrition has altered in many developing countries due to urbanization and a decline in breast-feeding. Nutritional marasmus with diarrhea in the 1st year of life is more common. Human milk, as compared with cow's milk, contains a more abundant supply of nutriments most needed for the rapid growth and development of the central nervous system. Much illness in early childhood is related to infection which occurs more easily in those with malnutrition and aggravates that condition. Breast-feeding is known to have a contraceptive effect. Appropriate child spacing is thus aided. Human milk must be considered a resource priority in national development policy and in international planning for health. As an emergency measure in famine relief, attention should be given to providing food for lactating women rather than to distributing formulas.
Interpreting trends in the incidence and mortality of endometrial cancer.
Current data show no increase in the incidence or mortality of endometrial cancer during the period 1947-1971. In 1947, the National Survey age-adjusted incidence rates for white females were 21.1 cases/100,000 population and in 1970 the rate was 20.4/100,000. A rise in incidence has been shown in the menopausal years with the peak incidence in the late 60s. Recent screening programs have detected some early asymptomatic cases of endometrial hypenplasia, carcinoma in situ, and early invasive lesions which apparently increase the incidence of endometrial carcinoma. More frequent hysterectomies, done for benign disease, have reduced the number of potential cancer victims. The highest rates for cervical cancer and the lowest rates for endometrial cancer are found in the poorly developed regions. Many cancer cases recorded as uterus have not differentiated those of cervical from those of corpus origin. This has confused the statistics. In some of these cases, the recorded histology has been adequate to differentiate. Adenocarcinomas were regarded as endometrial and epidermoid cancers as from the cervix. Overall there has been a marked decrease in the crude mortality rate for all uterine cancers from 20/100,000 population in 1950 to 10/100,000 in 1971. This study does not lend support to the hypothesis linking endometrial carcinoma and exogenous estrogens.
Current bibliographic index of mammalian reproduction, 81.
This listing of articles published in late 1974 and 1975 is divided into: behavior, biochemistry-metabolism, assay and analysis, male reproduction, female reproduction, gametes, nidation, pregnancy wastage, contraception, genetics, anatomy, physiology, and endocrinology. Author affiliation is included wherever possible.
A new Birth Control Trust pamphlet states that oral contraceptives (OCs) should be available to the public without a prescription. OC use should be supervised by doctors and nurses in women with conditions whic h increase risks associated with pill use. A less radical reform would involve distribution of OCs by nurses, midwives, and health care personn el who would be under a doctor's supervision. The pamphlet incites debate which will most likely occur following the introduction of a program in the United Kingdom allowing nurses to dispense OCs. The ultimate goal is to increase availability of contraception, but the pamp hlet fears that inclusion of nurses among the authorized dispensers may have a reverse effect of interfering with complete freedom of access. A major fear that a presently unsuspected hazard may emerge in 5 or 10 yea rs may be sufficient to ensure caution in decision-making. Questions regarding these possibilities should continue to be asked.
Liver disease caused by medicinal agents.
The deleterious effects of numerous drugs on the liver are discussed . In regards to steroid contraceptives, jaundice occurs in a small proportion of users. However, the incidence of hepatic dysfunction may involve as many as 50% of oral contraceptive (0C) users. A personal or family history of jaundice of pregnancy increases the risk of jaundice in OC users. Hepatic adenoma may be produced or potentiated by OCs. However, a definite association between OCs and focal nodular hyperplasia of the liver has yet to be established. The development of the Budd-Chiari syndrome in OC users is likely due to the known thrombogenic effects of contraceptive steroids. The basic treatment for hepatocellular jaundice includes termination of therapy, and a diet high in calories (3000/day), moderately high in protein (70-100 gm/day), and high in carbohydrates (400-500 gm/day).
Quingestanol acetate (.3 mg daily) was given to 13 women from the 2nd week postpartum for a total of 111 cycles. In addition to clinical follow-up, serial night urine pregnanediol levels were studied in 8 women for 45 cycles. 1 pregnancy (5th treatment cycle) was observed. Irregular bleeding during the first 3 cycles constituted the only major side effect. Vaginal bleeding occurred for 7/28 days when cycles during treatment had regularized. Ovulatory cycles were observed in 6/8 patients in whom urinary pregnanediol was studied during the 4th-6th cycles, and in the 7th and 10th cycles, respectively, in the other 2 patients. Of the 45 cycles studied, ovulatory secretion patterns were seen in 21, while 11 were anovulatory, and severe luteal insufficiency w as seen in 13.(AUTHOR'S, MODIFIED)
Conception and contraception in the lactating mother.
There is a belief that the nursing mother is protected against conce ption, therefore, mothers in primitive societies nurse their child for as long a period as possible. Lactation in the majority of women has been shown to confer protection for at least 9 months. Postpartum amenorrhea has continued into the amenorrhea of the next pregnancy in 5.4% of the women in a group studied. Should conception occur in the postpartum period, it is a disaster for the nursing child because with the birth of the newborn the first child loses his protein source of nourishment in favor of the new child. The protein deficiency disease, known as kwashiorkor, which literally means number 2, may result. The taboo agianst sexual relations while lactating is in vogue in many parts of the world. The duration of amenorrhea in lactating women is variable. The average is about 12 months. Pregnancy may occur by the 6th month in 1% of nursing women and more frequently after that time. At 12 months the probability has been shown to be less than 20%. The 1st postpartum menstruation may be anovulatory in 85% of cases. Oral contraceptives may have a tendency to suppress lactation. Since the duration of amenorrhea in nursing mothers varies, breast-feeding is not a reliable method of birth control. However, it is an important factor of population control in underdeveloped areas.
Human seminal plasma and sperm survival and transport: a brief review.
During the emission and ejaculation, the accessory genital glands discharge their secretions in a specific sequence. The first portion of the ejaculate is mainly prostate fulid. Later portions are mainly of vesicular origin. Most spermatozoa appear in the first portion but some are in all portions. Acid phosphatases are secreted from the prostate and fructose is present in seminal vesicle fluid. Spermatozoa in the second half of the ejaculate have poorer survival and motility than those of the first portion. The addition of 4% albumin overcame this difference. Vesicular fluid was shown to contain 1 or more factors deleterious to sperm motility and survival. Prostate fluid has a stimulatory effect on spermatozoa. Patients with biochemical signs of prostatic dysfunction have semen samples of poor sperm motility and viability. In man, the seminal prostaglandins (PGs) are secreted from the seminal vesicles. They do not alter sperm motility but do increase uterine motility. Several differnt PGs with different effects on uterine muscle have been identified. The large amounts of PGs present in human seminal fluid and the effects on uterine motility indicate that they may play an important role in human reproduction. PGs may be vital for survival and migration of spermatozoa in the female genital tract.
Age at 1st birth, race, key to child expectations; poor maternal health to postpartum sterilization.
Analysis of data from the 1972 National Natality Survey (NNS) and the 1973 National Survey of Family Growth (NSFG) indicates that race, age at time of first birth, and education have considerable impact on a woman's lifetime fertility expectations. One in every 500 women having a live birth in 1972 were included in the NNS canvas, while the NSFG probability sample interviewed 9,8000 ever-married women under the age of 45. Total number of births expected increases consistently with age. Women under age 20 expected an average of 2.8 children in the NNS and 2.4 children in the NSFG, while women aged 40 to 44 expected 4.8 and 3.5 children respectively. Women giving birth before age 18 expected a total of 3.4 (NNS) and 3.8 (NSFG) children, while women giving first birth after age 30 and over expected 2.9 and 2.1 children. Black women expected an average of 3.4 (NNS) and 3.5 (NSFG) children in their lifetimes, while white women expected a total of 3.0 births (NNS and NSFG). Data from both surveys indicate that education is inversely rela ted to fertility expectations; women with more education expect fewer children. Poor maternal health nonprivat maternal care, and previous miscarriage or abortion are related to hagher birth expectations. Maternal health factors were found to be significantly related to postpa rtum sterilization. 12.6% of women with underlying medical conditions were sterilized immediately after delivery, as were 12.1% of the women experiencing one previous stillbirth or miscarriage, and 15 of those experiencing 2 or more fetal losses. Only 7% of the women without histories of medicinal problems or fetal loss chose postpartum sterilization.
Data on a new entity which inhibits the release of luteinizing hormone (LH), designated as factor C-LHIH, are presented. In vitro assays were carried out with pituitary glands from female rats. Factor C-LHIH and follicle stimulating hormone releasing hormone (FSHRH) initially fractionated together. FSHRH obscured C-LHIH, and FSH assays guided fractionation. Factor C-LHIH and FSHRH were separated and purified by Sephadex and high pressure liquied chromatography. The resulting fractions of C-LHIH inhibited LH-release at 100-500 ng and did not inhibit thyrotropin releasing hormone-thyroid stimulating hormone response.
The establishment of a community health clinic: a case study in a Lebanese suburb.
Analysis of motivational differences between family planners and nonplanners in a Beirut, Lebanon suburb in terms of social stratification indicates that the family planners tended to be recent in-migrants, younger but with large families, and relatively unestablished within the socio-economic hierarchy of the community. Their perception of social isolation freed the newcommers from community pressures regarding the controversial decision to accept contraception. Composition of social networks proved to be equally important; 65% of all friendship linkages among family planners were formed with other family planners. These informal associations provide support and recognition, and may be an important element in the family planning decision. Substitutes may be found in nonmobile communities; voluntary groups, such as Korean mothers' clubs or the Colombian Profamilia organization, are forming and providing information which can lead to the practice of modern contraception. Offering alternatives to traditionally ascribed social networks, these associations create a context in which individual choices can be sanctioned and reinforced.
Health and family planning Saturation project for Korea. No 489 11 580 649.
Phase I of an USAID project for development and testing of a lowcost family planning delivery system in Korea will include field staff recruitment and selection of 3 rural populations of approximately 6,500 each within on geographic region. Following a village meeting for explanation of the distribution system and family planning discussion, all households in the 3 treatment areas will be mapped and registered, and married women 15 to 49 years of age will be interviewed. Contraceptive kits will be packaged in Korea and will include 3 cycles o f condoms and pills. Clinic backup services will be established for treatment of women unable to accept the contraceptive package, and for those experiencing side effects from the pill. Evaluation criteria, such as cost per acceptor and percent increase in number of acceptors, will be developed prior to program implementation and used to determine if the project should continue. Contraceptive resupply depots will be established within each village. Phase 2 of the project will consist of delivery system design and implementation on the island of Cheju-do following a benchmark survey of 15% of all married women aged 15 to 49 from a total population of 4000,000. Phase 2 will include a cross-sectional survey of 12,000 married women aged 15 to 49, a detailed cost effectiveness analysis, and a comparison of all project fertility data with that of the Korean Fertility Survey of 1978.
Previously we showed that norethisterone was covalently bound to proteins after incubation with liver microsomes (Archives of Pharmacology Suppl. 285: R38, 1974). Now we examined the conditions necessary to cause this binding. We incubated 14,15-tritiated-norethisterone in presence of rat liver microsomes. Up to 1.5 nmol/mg microsomal protein was bound covalently to the microsomal protein. The binding was a time-consuming process, was dependent on microsomal protein concentration, oxygen, and HADPH, and was inhibited by carbon monoxide. If albumin was added to the microsomal incubation, norethisterone was also covalently bound to this protein. After trypsin digestion of both proteins, radioactive labeled peptides were obtained. Glutathione, cysteine, cysteine-methylester, and N-acetyl-cysteine diminished the binding of norethisterone to microsomal protein as well as to albumin, whereas other amino acids were ineffective. After microsomal incubations of norethisterone, norethisterone-4, 5-epoxide was identified by Cook et al. (Drug Metabolism and Disposition 2: 58, 1974). We synthesized 14,15-tritiated-norethisterone-4, 5,-epoxide and incubated it with microsomes and albumin. With norethisterone epoxide, the amount of steroid covalently bound to microsomal protein was 10 times higher than with norethisterone itself. Albumin bound the epoxide also without microsomes. Cofactors were not necessary for the protein binding of norethisterone epoxide. In agreement with norethisterone incubations glutathione also inhibited the protein binding of norethisterone epoxide. Our results favor the the concept that norethisterone has to be transformed to norethisterone-4, 5-epoxide by microsomal enzymes of the liver before its reaction with proteins. Sulfhydryl groups might be involved in this binding reaction. (FULL TEXT)
The demographic potential of the United States.
Even though birthrates in the United States have fallen to replaceme nt levels, family planning programs should not become complacent. The large number of babies born between 1946 and 1957 are now passing through the prime ages of childbearing. There will be an increase of 34% in women of reproductive age during 1970-2000 and between 1970 and 1 985 these fertile-age women will be concentrated in ages where age-speci fic birthrates are highest. In addition, there is the strong possibility that current low birthrates are due to delayed childbearing. Inflation, high unemployment, and uncertainty over the economy may be frightening off many young couples. Future birthrates may be strongly influenced by economic conditions. This hypothesis of postponement is especially important because the present level of childbearing is much below what women report as their ideal family size in public opinion surveys. Instead of having unwanted children today many millions of Americans may be practicing unwanted contraception and will go back to having children when given an opportunity by the economy or public opinion. High birthrates are still found among black, Spanish-speaking, and American Indian populations. Racial genocide charges against family planning programs make good politics but poor demography. The evidence is that minority women want to practice contraception and bring their family sizes down to those already enjoyed by more affluent white women. Even with lowered birthrates in the future, the black population has 3 times the potential for reproduction that the white population does. By the year 2000 most fertile-age white women will be in the older age brackets while black women will still have concentrations in prime childbearing ages. This is also the time for family planning services to evaluate the use-effectiveness of the va rious programs. Education, efficient utilization of resources, and evaluation of alternative ways of delivering information, motivation, and service are needed.
Problems in the identification of program effects.
Assessment of demographic impact of family planning programs in the U.S. is not totally impossible but serious problems exist and a reasonable goal is estimation rather than accurate measurement. It is more difficult to evaluate any medical program in the U.S. because; there is not a theoretical vacuum of services; it is harder to identify new factors clearly; and this country permits a narrower range in which change can occur. A table presents a 6-link chain from program effort through 1) birth control practice, 2) prevention of unwanted pregnancies among clients, 3) lower fertility in population, 4) improved personal health, 5) improved family welfare, and 6) improved macro-economy. For each step endogenous determinants, contextual constraints, level factors (how much change is really taking place), and time relationships are listed. Every one affects the evaluation. Coupled with evaluative difficulties is the question of purpose. If the objective of the program is to make family planning available to all who want it, this can be assessed. Frequency of failure as evidenced by pregnancies among clients, can be assessed. Also, total population trends can be analyzed without attempting to define the relative contribution of an arbitrarily defined segment of services utilized by the population and existing within a complex of direct and indirect social variables operating in a constantly fluid matrix.
Progress towards a male oral contraceptive.
A renewed interest in producing infertility via the male has led to research concerning the mechanism of action of an ideal oral contraceptive (OC) for him. 2 ways of achieving this could be through uninterrupted production of motile spermatozoa which are incapable of fertilization or of spermatozoa which are nonmotile. Safety, rapidity of action, predictability, and reversibility are major factors involved in a successful male OC. Recent investigations on the mouse and rat have involved antifertility alkylating chemicals which operate via the epididymis such as alpha-chlorohydrin. Since alpha-chlorohydrin is rapidly metabolized with a high degree of dehalogenation, only a small fraction of the given dose can reach the epididymis. It has been speculated that it is converted in vivo to another alkylating chemical, glycidol. After substerilizing doses of alpha-chlorohydrin no evidence has thus far been found of mutagenicity in rats or mice. Experimental evidence concerning the steroidal approach to fertility control via the epididymis has shown that doses of cyproterone actate completely inhibit the functions of other accessory glands. Other steroids tested have included testosterone compounds, estrogens, and nonsteroidal compounds with antispermatogenic actions. Prospects of a male contraceptive depend upon the results of current work with the chlorohydrin group as seen in satisfactory evaluation of their toxicity in animal species and upon their effectiveness and safety in man. No nonsteroidal chemicals have been tried as a contraceptive in humans. The molecular simplicity and specific action of alpha-chlorohydrins has shown possibilities for success. A combination of the rapid chlorohydrin type of activity with the delayed but longer-term steroid action could be a possibility.
Sperm transport from the vagina to the fallopian tubes in women.
Clinical and in vitro studies in humans show the importance of sperm motility in passage through the cervix. However, passage of inert particles has also been shown. Human sperm transport under optimal assessable conditions was studied in normal fertile women who had requested surgical sterilization. All were restricted from coitus for 11-14 days preoperatively. Studies were done within 36 hours of the estradiol preovulatory peak. Surgical excision of both fallopian tubes was done before insemination or at predetermined times following insemination with fresh ejaculates. Cervical insemination was not done. After excision, tubes were divided into 3 segments. These segments were opened separately, rinsed into test tubes, and prepared for histologic study. Cervical mucus was removed. An endometrial cavity washing was then done, followed by dilatation and curettage. Rinses of tubal segments, endometrial washings, and curettage washings were centrifuged and the sediment examined for spermatozoa. Cervical mucus was assessed for the presence of motile sperm. No sperm were found in tubes removed before insemination or in those removed 2 minutes after insemination. Sperm were present in the oviducts 5 minutes following insemination in the 2 subjects studied at that interval. The sperm were found in all 3 segments of the oviducts. Numbers found at 5, 10, and 15 minutes after insemination increased with the time intervals (ps less than .05 to less than .01). Increases in sperm numbers did not occur after 15 minutes. None was found in 1 subject studied at 48 hours. Sperm were not found in endometrial washings until 90 minutes after insemination. They were no longer present by 48 hours. Numbers of sperm in cervical mucus remained the same after 15 minutes following insemination. The increase in endometrial sperm numbers with increasing time following insemination suggested a reservoir function of the cervical mucus.
The need for capacitation of human sperm: functional and ultrastructural observations.
The study of human sperm capacitation requires the use of an in vitro fertilization system. The problem of authenticating fertilization of human oocytes in culture could not be done with a light microscope. With ultrastructural study by electron microscopy, all fertilizing criteria were observed in specimens fixed 24 hours after insemination. To demonstrate need for capacitation, sperm ability to penetrate through the zona pellucida needs to be shown to be greatly increased as a result of a given treatment, and sperm traversing the zona pellucida should be observed to have undergone the acrosome reaction. Exogenous gonadotropins in the fertilization environment increased sperm penetrating ability in a statistically significant manner. Hormonally induced enhancement of sperm penetrating ability was the 1st functional evidence of the need for capacitation of human sperm. The effect was thought to be mediated by gonadotropin-stimulated corona cells. The morphological evidence of human sperm capacitation was obtained from the ultrastructural study of oocytes matured and fertilized in vitro. Immature oocytes were 1st primed with 17beta-estradiol then cultured for 40-44 hours in the presence of 17alpha-hydroxyprogesterone, the basic medium being Ham's F10. Under these conditions 44.2% of 154 oocytes did mature in culture. About 1/5 of these underwent monospermic fertilization. In such specimens 2 types of sperm were observed in contact with the zona pellucida, or nearby. The type passing through the zona pellucida had 1st undergone the acrosome reaction. Most sperm seen outside the zona had also undergone the acrosomal reaction. Some were deeply imbedded between corona cells. Further experiments with zona-pellucida-free oocytes showed that the zona is the essential site of block to polyspermy which is a lethal condition in humans. The lack of acrosome reaction and lack of capacitation did not interfere with the fusion of human gametes when the zona pellucida no longer prevented their immediate contact. Complete control over oocyte maturation in vitro needs to be solved.
Contraception and sperm transport in domestic animals.
In work with domestic animals, fertilization failure can often be avoided by use of excessive numbers of spermatozoa or by their surgical introduction near the uterotubal junction. The vaginal environment is relatively unimportant, except in cases of acute inflammation. The cervix is a potential barrier and is the main reservoir in the cow, sheep, and goat. In the pig and horse the ejaculate enters the uterus directly. The uterotubal junction and the fallopian tubes are also hazards. Passage through the cervix is rapid in the cow and ewe. The uterine glands and the uterotubal junction also act as reservoirs for spermatozoa in the cow and ewe and as the main reservoir in species with uterine insemination, as in the sow and horse. Several thousand spermatozoa in the tubes seem to be necessary for fertilization. Malnutrition may affect the production of spermatozoa in the male. After drought conditions, poor conception rates can be expected with artificial insemination. Stress reduces the number of spermatozoa which reach the upper part of the uterine horns. For the ewe the annual rhythm of breeding activity is associated with a corresponding rhythm of pituitary gonadotropin output and ovarian activity. Sperm transport failure is involved in the subfertility of ewes grazed on estrogenic pastures. A small daily dose of estrogen given in the diestrous period also impairs sperm transport. The cervix seems to act as the barrier. The pattern for subsequent fertility seems to be established within 2 hours after insemination by the number of spermatozoa present in the caudal third of the cervix. Many spermatozoa may be found in the uterus after 2 hours but few or none in the tubes. In ewes, the number of spermatozoa recoverable from the tubes at 24 hours is correlated with the number in the uterus. In experimental techniques the only accurate method for the study of sperm migration is fixation of the tract in situ immediately after slaughter and serial resectioning with subsequent counting of spermatozoa. This method is not suitable for quantitative experimentation. Flushing experiments are less accurate but valuable for comparative work.
Physiopathology of sperm transport in the human female.
The cervical mucus protrudes from the exterior os and makes contact with the ejaculate which coagulates within 1 minute, trapping most spermatozoa. The cervical mucus is immediately invaded by the sperm. Fibrinolytic enzymes of the seminal plasma cause liquefaction of the coagulum within 5-15 minutes. The spermatozoa do not attain full motility until liquefaction of the coagulum. Each ejaculation contains 200-400 million spermatozoa. The 1st fraction of the ejaculate contains the highest concentration of spermatozoa. The number of sperm is an important factor for fertility. The endocervical mucosa secretes the bulk of the mucus in the lumen of the canal. Several functions have been ascribed to cervical secretions. Sperm penetrability of human cervical mucus begins 8-5 days before ovulation, increases to the time of ovulation, and decreases abruptly 1 or 2 days after ovulation. Individual variations are common. Sperm penetration into cervical mucus is correlated with NaCl content and crystallization pattern of the mucus. When crystallization was higher than 80% migration occurred and spermatozoa survival was more than 24 hours. Sperm migration through the cervical mucus is facilitated by the morphology of the sperm head. Where sperm concentration is dense, spermatozoa beat synchronously in phase. In a normal semen sample 4-20% of spermatozoa have abnormal forms. Fertility may be impaired when abnormal forms exceed 20% as abnormal forms fail to penetrate cervical mucus. A filtering effect by the cervical mucus is thought to occur. Vaginal content in women is usually acid, pH 3-4, and detrimental to spermatozoa. The optimal pH for sperm ascent in the cervical mucus is 7-8.5. Sperm motility is reduced when pH falls below 6.5. Many pathological conditions of the cervix interfere with sperm migration and result in infertility. Some microbial agents promote head-to-head agglutination of spermatozoa. Antimicrobial therapy has improved pregnancy rates in some of these patients. Sperm and seminal fluid may be antigenic, producing sperm-agglutinating antibodies in the female and infertility. Immunoglobulins have been found in cervical mucus. Cervical and vaginal infections may stimulate local production of antibodies that react with spermatozoa. Antibodies against spermatozoa have been detected in the blood of infertile patients with cervicovaginal schisostomiasis.
A comparison of the uptake of selenium (Se) 75 selenite, Se 75 selen omethionine and Se 75 methionine by tissues of ewes and lambs is presented. Included in the study were 3 lactating ewes with lambs at foot and 3 lambs which had been weaned on to fodder low in selenium and were recovering from white muscle disease with Se therapy. Isotope entry into milk was rapid and was greater when Se 75 was administered as selenoamino acid than as selenite. Alkaline dialysis demonstrated that greater amounts of activity derived from selenite were bound to plasma proteins than to the protein of milk, particularly in samples taken some hours after administration. Small amounts of Se 75 selenomethionine were incorporated as selenoamino acids into the proteins of liver, kidney, pancreas, milk and plasma. Selenomethionine and selenocystine were identified chromatographically in enzyme digests of defatted liver and kidney of the ewes. Some differences were seen in the distribution of labelled compounds in organs from the ewes and lambs. Recent findings of an association between selenium and glutathione peroxidase are discussed in relation to the incorporation of selenium into protein.
A comparison of the Dalkon shield and Gravigard (copper-7) intra-uterine devices in Southampton.
A comparison of the Dalkon shield and Gravigard IUD in 909 patients attending a single clinic in which a single staff did all insertions is described. Among the 501 fitted with a Dalkon shield continuation rates after 1 year was 70.4%, removals for bleeding/pain were were 1.1% at 6 months and 1.7% at 12 months, and the pregnancy rate was 1.2% at 12 months. The rates for the Gravigard were 70.% continuation rate, 1.2% removals for pain/bleeding at 6 months and 1.7% at 12 months, and pregnancy rate of 1.2% at 12 months. There is not a high incident of removal during the early months with either device but among low parity women the marginally higher rates of the Dalkon shield are accentuated. The chance of pregnancy is greater with the Dalkon shield. With both the chance is greatest during the 1st 6 months; after 1 year the chance is small. The clinic advised additional contraception during the "unsafe" period, which may have influenced results. Expulsion rates were 1% for the shield and 1.9% for the Gravigard at 12 months and 1.1% for the shield and 2.2% for the Gravigard at 18 months. However, the refitted Gravigards had a high retention rate, which suggests the original fitting might have been faulty.
Hysterectomy-induced maternal behavior during pregnancy in the rat.
A series of studies made an attempt to verify short-latency maternal behavior after hysterectomy between the 10th and 19th day of pregnancy a nd to determine the role of the ovaries in the onset of maternal behavio r starting at 0, 24, 48, or 72 hours after surgery. Rat pups stayed with the females overnight; testing was repeated daily with new pups until maternal behavior was exhibited. Latencies for the onset of maternal behavior were shorter after hysterectomy on the 10th and 16th days of pregnancy than in intact pregnant females at the same stages of pregnancy. The later the termination of pregnancy the shorter the latencies. When hysterectomy included ovariectomy during pregnancy shor t-latency maternal behavior was absent. Testing during the last 40 hours of pregnancy revealed that nest building began at 34 hours prepart um and retrieving at 28 hours prepartum. The survey concluded that the rise in estrogen production following hysterectomy during pregnancy probably induces the rapid onset of maternal behavior. It is suggested that continued low-level secretion of estrogen throughout the second half of pregnancy may gradually and cumulatively increase the maternal responsiveness.
250 sexually active, unmarried female adolescents were studied at the Kings County Hospital Center in Brooklyn, New York. The adolescents were divided into the following groups: 1) 100 primigravidas choosing to deliver; 2) 100 primigravidas choosing abortion; and 3) 50 girls who were sexually active but never pregnant. The study covered personal characteristics, sexual and contraceptive knowledge and history, future personal and contraceptive plans, and attitudes towards out-of-wedlock p regnancy. The ethnic composition of the 3 groups did not differ from the obstetric patients in the hospital. Almost 1/3 of the girls choosing to deliver had not finished elementary school. Less than 1/3 lived with both parents. More than 1/2 the girls had never used contraceptives and less than 10% were using them at the time they conceived. The preferred contraceptive method was orals. The 3 groups did not differ as to the age at which they started dating and having intercourse. The girls, their parents, and their partners do not consider out-of-wedlock pregnancy a stigma. The adolescents exhibited ambivalence toward the use of contraception and impracticality as to their future personal plans.
Serum lipids during oestradiol-valerate/norgestrel treatment of menopausal women.
Serum lipids during estradiol-valerate/norgestrel treatment of 33 menopausal women are reported. The women aged 38-56 years, all with menopausal complaints, were treated after randomization during 3 cycles with either estradiol-valerate/norgestrel sequential therapy or a placebo and then during 3 cycles with the opposite drug. Cholesterol, triglycerides, glycerol, free fatty acids and lipoprotein electrophoresis were studied before treatment, after each cycle and 4 weeks after the intake of the last tablet. Markedly lower triglyceride levels were seen during the treatment period than during the placebo period. A correlation analysis revealed a positive correlation between the difference in mean triglyceride value during the placebo and treatment period and the mean value during the placebo period (r equals .84, p less than .01). The triglyceride levels were lower after 8 weeks of treatment than after 4 weeks (p. less than .01). It is not known whether the decrease was due to the natural estrogen or to the gestagen. 4 weeks after the discontinuation of treatment the levels corresponded to pretreatment levels. No marked changes occurred in the other paratmeters.
The effects of progestagens, antiphlogistics and metabolic inhibitors of lung histology and enzymology in rats subjected to papain aerosol were studied. Chronic exposure to 10% aerosols of papain or trypsin caused marked increases in lung weights and lung beta-glucuronidase and arylsulfatase activities. Lung beta-glucuronidase tended to be lower in rats which received progesterone injections in addition to papain aerosol in comparison with aerosal treatment only (15 days, p less than .05 and 36 days, p less than .01). Microscopically, distruction of alveolar walls was demonstrated as a decrease in the number of air spaces touching a line of known length. Pregnenes, progesterone and medroxyprogesterone acetate, but not norethindrone, partially prevented the papain-induced breakdown of alveolar septa and elevation of beta-glucuronidase. Paramethasone completely inhibited the rise in lung weight and beta-glucuronidase activity but did not prevent alveolar wall destruction. Indomethacin gave little or no protection. Cyclophosphami de and aprotinin gave limited prophylaxis against both histological and enzymatic changes. These results support the view that papain-induced emphysema in rats may serve as a model for the evaluation of drugs of potential utility in the therapy of human emphysema.
Some findings on the influence of infant mortality in a rural environment in India.
The relationship between infant mortality and fertility was studied based on individual data drawn from the 1969-1970 Demographic Survey of Varanasi (rural). The 2591 eligible couples interviewed presented 6024 complete birth intervals. The data show that individual experience of child loss has some effect on fertility due to the physiological effect of lactation. No significant effect on infant mortality on birth interval independent of lactation was established. An analysis of couples' subsequent reproductive behavior after the third birth does not show any substantial effect of infant mortality on fertility. Infant deaths at different parities were found to be influenced by the experience of previous infant deaths and consequently the small differences observed may not be due to replacement effect. Thus, the interrelationship between lactation and birth interval is the principal mechanism on which a decline in fertility as a result of a decline in ch ild mortality depends.
Influence of infant mortality on fertility in African countries.
Date for 20 African countries have been used in an effort to study, via additive regression model, the influence, either individually or in combination, of infant mortality rate, gross national product, and newspaper circulation on fertility. Newspaper circulation had the highest association with fertility. As the per capita gross national product or newspaper circulation increased, the birthrate decreased. 63% of the variation present in birthrate had been explained by these 3 variables, although an addition of x1, here standing for infant mortality rate, did not help much in explaining the variation present in the birthrate. The standard error of the estimate is lowest if all 3 independent variables are used, as opposed to using any 2 independent variables.(AUTHOR'S, MODIFIED)
Meperidine and combination oral contraceptives. (Letter to the editor)
The interaction between meperidine and combination oral contraceptives cited in an article by Stambaugh and Wainer "is hardly accepted as fact." His own reference book considers the reaction the least significant of several because documentation is poor, potential harm to the patient is slight, and incidence of interaction is low. In discussing the clinical significance of the interaction his book stated it was based on "preliminary information from urinary excretion data."
Meperidine and combination oral contraceptives. (Letter to the editor)
In response to a letter from P.D. Hansten charging that the authors overstated the significance of the reaction between meperidine and combi nation oral contraceptives in a previous article, Stambaugh and Wainer reply there is more need for investigation of clinical significance of various drug interactions. Physicians and pharmacists in clinical practice do not usually investigate proposed interactions in depth but rely on various texts. The listing in Hansten's text prompted further investigations by the authors. Hansten's text was a pioneer in the field but work still needs to be done on significance of drug interactions.
Data was collected from 2 hospitals in Calcutta, India, in order to study the effect of maternal age and parity on infant birth weight. In general, low birth weights are more common in India than elsewhere. Females had a higher proportion of low birth weights, but the curves for birth weight occurrence were similar for both female and male babies. There is a U-shaped variation for birth weights, with first and late pregnancies producing more underweight infants and third babies having a minimum of low birth weights. Young mothers had an increasing proportio n of low birth weight babies with increasing parity. The U-shaped curve was typical for women over 30. Improperly spaced pregnancies seem to be the reason for production of low birth weight infants.
Poor IE&C is major bar to program acceptance.
A recent book by D.J. Bogue, Twenty-five communications obstacles to the success of family planning programs, is briefly discussed. Among the problem areas cited are: 1) concerns about the effects of the various female methods and of vasectomy on health, sexuality, and appearance; 2) rumors; 3) pressure for children; 4) the equation of contraception with promiscuity; 5) lack of awareness of services; 6) insufficient emphasis on spacing rather than terminating childbearing; 7 ) neglect of immediate and intermediate benefits of family planning, including improved relationship between husband and wife, better financial situation, and reduced burden on women; 8) low status of women; and 9) narrow focus of family planning. People should be informed of the support for family planning among those holding similar religious and moral views.
International Women's Year: Population and the Mexico Conference.
2 major documents came out of the World Conference of the International Women's Year, which was held in Mexico City June 9-July 2, 1975: the Declaration of Mexico on the Equality of Women and their Contribution to Development and Peace; and the World Plan of Action for the Implementation of the Objectives of the International Women's Year. Sections from these 2 documents dealing specifically with population dynamics are excerpted, calling for: 1) the integration of women into all aspects of economic life; 2) a reassessment of sex roles, including changing the male sex role to include a greater part in and responsibility for family life; 3) provision of child care facilities; 4) the development of cooperatives and small-scale industries to extend the range of economic roles for women; 5) equal educational opportunities, including special training programs for women in rural areas; 6) legislation setting a minimum age at marriage, helping women, particularly, to continue their education; 7) the right to family planning; 8) recognition by governments of the population processes whereby the status of women influences childbearing patterns; 9) special rural development programs to lessen single-sex migration, resulting in a sex imbalance in both urban and rural population; and 10) more accurate data collection on women in the labor force.
Estrogenic and antiestrogenic properties of E-492, a nonsteroidal compound.
Estrogenic and antiestrogenic properties of E-492, a nonsteroidal compound (3 methyl-4'-(beta-pyrrolidinoethoxy)-2,3-diphenyl propiophenone), were assessed on the basis of ponderal, histologic, and biochemical changes in the uterus, cervix, and vagina of ovariectomized adult rats. This compound was studied at its maximum effective antifertility dose of .5 mg/kg/day for 5 days. Estradiol-dipropionate (EDP) was studied at a dose of 1 mcg/kg/day. EDP and E-492 separately increased the weight of the 3 genital accessories. Histologically, the organs presented an infantile condition characterized by atrophic epithelia, compact stroma, and inconspicious muscularis. The uterine glycogen level was raised by EDP (p less than .01) but not by E-492 (p greater than .05). Lactic acid was increased by EDP in all target organs (p less than .01) and by E-492 in the uterus and vagina (p less than .01) but not in the cervix (p greater than .05). Combined therapy antagonized EDP effect at the uterine and vaginal levels. Alkaline phosphatase was enhanced by EDP in all 3 organs (p less than .01) and by E-492 in the uterus and cervix (p less than .01). These results indicate that on the basis of changes in weight and histology, E-492 has both estrogenic and antiestrogenic potencies.
Ovulation and gonadotropin-releasing activity of D-Leu6, des-Gly NH2 10, Pro-ethylamide 9 -GnRH (38715) (2) were investigated in rats, rabbits and sheep. When given to the diestrous or proestrous rat, 2 was 47 and 59 times, respectively, more effective than pGlu-His-Trp-Ser-Tyr-Gly -Leu-Arg-Pro-Gly-NG2 (GnRH) in causing ovulation. The analog increased the number of ova shed at the higher dose levels in the diestrous rat (p less than .05) but neither peptide affected the number of ova recovered from proestrus rats. Generally, serum luteinizing hormone and follicle stimulating levels were related to the dose of the peptide. The integrated luteinizing hormone (LH) release was 1.9 times greater for the analog and the time of increase and maximum serum concentrations of LH were delayed after injection of the analog. The analog was at least 50 times more active than GnRH in releasing LH in both the midluteal and anestrous ewe. It appears that the intense ovulation-inducing activity of 2 can be accounted for by the intrinsic LH-releasing activity of the nonapeptide rather than by a prolonged release stimulus.
Abdominal hysterectomy for surgical sterilization in the mentally retard ed. (Letter to the editor)
In reviewing Wheeless' article "Abdominal hysterectomy for surgical sterilization in the mentally retarded: a review of parental opinion" (August 1, 1975), 2 points are made. First, hysterectomy is a reasonable means of fertility control for mental retardates because of personal hygiene and reduction of emotional outbursts, behavior problems, and seizure activity in epileptics. Second, the prohibition of the use of Federal funds for the sterilization of mentally incompetent persons is unfortunate because it will cause hardship to the families of retardates who find it difficult to avoid pregnancy. 2 groups should be concerned with the present restrictions: 1) physicians who provide patient care; and 2) third parties who fund patient care.
Hormonal contraception or therapy and altered immunity. (Letter to the editor)
Comments are made concerning a study on the sensitivity of women receiving hormonal contraceptives to D.N.C.B. and on studies of the effects of estrogen in the treatment of patients with prostatic cancer. In view of recent studies on the effect of estrogens in a variety of compounds on the changes in protein synthesis and immunological factors, it might be significant to compare the D.N.C.B. skin reactivity of the 5 women in the study receiving pills of "estrogenic predominance" to the 41 women taking pills of "progestogenic predominance" and to the 2 takin g pills without predominance. Questions were raised concerning the dosage necessary to reach the critical point at which a reduction in cellular responsiveness may be predisposing to impaired host resistance. Preliminary studies in which a better clinical response and increased survival in patients after cryotherapy of prostatic tumor when hormonal therapy was absent suggests a possible dual suppressive effect of estrogen--on the concentration of autoantigen and on the immunologica l responsiveness of the host to the tumor.
Some effects of an oral contraceptive (OC) on dietary carbohydrate-lipid interrelationships in the baboon are reported. 6 male and 6 female mature baboons received the following dietary regimen in gm/kg for 7 weeks: sucrose or glucose 750, calcium caseinate 180, dried yeast 50, salts 20 and added vitamins. The diets were given either with or without the OC. Blood was obtained before each diet and after 21 and 49 days. Triglyceride levels were markedly raised when the diets contained sucrose or glucose plus the OC but not when OCs were given with the normal laboratory diet. A marked fall in serum cholester ol was seen on the glucose diet but did not occur when the OC accompanied the glucose diet. Sucrose plus OCs resulted in an increase in serum cholesterol in male baboons, whereas with sucrose alone no such rise was seen. It is concluded that the addition of the OC to a high-carbohydrate diet in baboons seems to produce some serum lipid levels that are greater than those found with diet alone.
Pathogenesis of microglandular hyperplasia of the cervix uteri.
22 cases of microglandular hyperplasia of the cervix, occurring over a 10-year period, are reviewed. 15 of the patients had been using oral contraceptives, 33% of whom had been taking them for less than 6 months. 1 patient presented with clear-cell carcinoma of the cervix associated with in utero exposure to stilbestrol. Histologic examination of deeper sections between these 2 types of lesions of the cervix are discussed.
The setting for pregnancy in women seen for elective abortion. (Abstract only)
All women having an elective early abortion between January 1 and June 30, 1971, who were living in the vicinity of Rochester, New York (Monroe County), were seen 4-8 weeks after the abortion. Using a semi-open-ended interview technique, information was obtained on the medical and psychological sequelae and an attempt was made to learn about psychosocial events at the time of conception. Interviews were conducted by obstetrician-gynecologists trained in psychosomatic medicine. 262 women (97% of original sample) were followed up. The ages ranged from 13 through 45. Patients were derived from both private and division services and had an ethnic distribution compatible with this country. Most of these women were not using effective methods of contraception. The authors feel they could characterize a psychosocial setting from the majority of these pregnancies including loss, forming or breaking relationships, other life changes, and exacerbation of chronic depression. In the under 25 age group, loss was found to be the major setting in 35%, forming or breaking a relationship in 25%, and depression in 20%. In women aged 35 or over, depression was found in 45%, loss in 20%, and life change in 15%. (FULL TEXT)
Diaphragms: a new look at the old standby.
This instructive article defines the meaning of diaphragm, describes its fitting, use, practice and care and discusses its pros and cons. Advantages to use of the diaphragm unclude a 98% effectiveness rate (when used consistently and with spermicide), and a nearly 100% safety rate. One disadvantage as reported by Masters and Johnson is that it may be displaced during intercourse because the vaginal barrel expands during sexual excitement. Danger of displacement is increased by repeated intercourse in the female-superior position. Sexual spontaneity need not be disturbed because the diaphragm may be inserted and left in place several hours before and after intercourse and during repeated intercourse. A woman's preparation for sexual intercourse depends upon the maturity and freedom of the people involved.
NMPC-PIEO: in the service of the population effort.
The message of family planning is being disseminated in the Philippines through leaflets, brochures, training manuals, posters, radio and TV jingles, and short films. Most of the materials have been produced by the Population Information Education Office (PIEO) of the National Media Production Center (NMPC). Since its start in 1970 the PIEO has been revising the materials according to the feedback and trying to answer the reactions. Most of the materials are in Filipino and in the major dialects. It is estimated that film messages reach 40% of the population, while radio covers 75% to 80%. PIEO has been phasing out some of its responsibilities under the information program; the Commission on Population (POPCOM) pinpoints needs and coordinates efforts in the information program, but production will probably always be a function of PIEO/NMPC.
Population planning and health care - Chinese communist style.
The Chinese approach to family planning is characterized by a centralized system for policymaking with a decentralized system for policy implementation. China is the only country where the official population program aims at promoting late marriages, birth spacing, and small families. There is a firm political commitment of manpower and resources. The health model calls for a nationwide network of paramedical services at the rural village or urban neighborhood level. Statistics show a demographic transition with late marriage and widespread use of contraception. The Chinese model was designed for a country with low income and scarcity of trained personnel. The approaches include: 1) free or low-cost, accessible services; 2) income compensation during surgical procedures; 3) mobile units for service and training; 4) encouragement of local initiative; 5) using parttime paramedics; 6) annual targets at local and national levels; and 7) having married women with status participate in motivational and educational work and distribute contraceptives.
The optimum growth rate for population.
The theory of optimum population concerned with the stationary plateau of population considers limitations of unaugmentable land and economics of scale and maximizes per capita output and consumption. In the usual version of the growth model the slower the rate of exponential growth, the higher the level of steady-state consumption. The present analysis considers differentiated periods of life, work and retirement and investment in capital goods and derives the conditions for an optimum intermediate population growth rate. The analysis proves by serendipity theorem that under laisse faire private saving would suffice to support this growth-rate state if necessitated by biological and cultural factors. (AUTHOR'S MODIFIED)
Research on the consequences of adolescent pregnancy and childbearing.
In this request for proposal (RFP) we are requesting research on the social, psychological, and economic consequences of adolescent fertility as they may be measured with available data. Proposals that include the collection of original data would not be responsive to the requirements of the RFP. Consequences may refer to the woman involved, the child, the man or father, the families of those involved, or society in general. Clarification of the determinants of adolescent pregnancy and childbearing will be sought through other requests for proposals. Proposals are sought from a variety of disciplines: sociology, demography, psychology, anthropology, and others concerned with human development and family and social welfare. The RFP was issued on January 15, 1976. The closing date for receipt of proposals submitted under the RFP will be March 5, 1976. Only those sources which have been technically evaluated as qualified will be requested to submit proposals. Copies of the RFP may be obtained by sending a written request to Mack Bell, Contracting Officer, Contracts Management Section, Office of Grants and Contracts, National Institute of Child Health and Development, Landow Building, Room C-625, Bethesda, Maryland 20014. (FULL TEXT)
The total number of condoms distributed by both the free distribution clinics and the Nirodh subsidized program were as follows in these fiscal years: 59,215 in 1968-1969; 98,350 in 1969-1970; 132,933 in 1970-1971; 162,810 in 1971-1972; 161,303 in 1972-1973; and 208,722 in 1973-1974. The "Nirodh" Publicity Budget spent in millions Rs. 2.49 in fiscal 1969-1970, Rs. 4.66 in fiscal 1970-1971, Rs. 4.85 in fiscal 1971- 1972, Rs. 5.28 in fiscal 1972-1973, and 2.36 in fiscal 1973-1974.
Family planning clinics play a major role in VD screening.
Incidence of gonorrhea in the United States increased 21/2 times between 1965 and 1974. Because this desease if often asymptomatic in women, many health care services now test routinely for gonorrhea. From June 1974 to June 1975, family planning facilities tested 29%, or 2 1/2 million, of the 8.9 million women checked in gonorrhea screening programs. Among all facilities, 4.2% of the tests were positive while 2.5% of the family planning screening programs. Family planning services tested three times as many women as did venereal disease clinics. Among all family planning facilities, health department clinics accounted for half the total tests while private groups accounted for 870;000 tests. Community health centers performed 700,000 tests, more than a third of which occured in family planning clinics. Community clinics tested six times as many women as community prenatal/ob-gyn clinics, however, more than twice as many gonorrhea tests were performed in hospital family planning clinics. Venereal disease clinics accounted for the highest rate of positive tests (19%); health department cancer screening clinics had the lowest rate (1.0%). Among hospital outpatients, the positive test rate was 2.2% in cancer screening clinics, 3.0% in family planning clinics, 3.5% in prenatal/ob-gyn clinics, and 4.6% in combination and other clinics.
Antisterility activity of d-alpha-tocopheryl hydroquinone (ATHQ) in the vitamin E-deficient male hamster and rat was investigated. Male hamsters were reared from weaning on vitamin E-deficient diets, 1 high and 1 low in added fats, for 90-100 days prior to surgical ablation of 1 testis. The testes were much reduced in weight and showed advanced degenerative changes. The same diet plus oral supplements of 10 mg of d-alpha-tocopheryl acetate or 25 mg of ATHQ/day for 20-30 days resulted in marked increases in testis weight and remarkable repair of the germinal epithelium. In rats similarly treated, 10 mg of ATHQ/day protected aganist testicular degeneration but was ineffective in repair of testis injury. Both hamsters and rats revealed evidence of ATHQ or some biologically active product storage, with effectiveness lasting several months. It is concluded that ATHQ has antisterility activity in the vitamin E-deficient male hamster and rat approximating 1/5 that of d-alpha-tocopherol.
Antisterility and antivitamin K activity of d-alpha-tocopheryl hydroquinone (ATHQ) were investigated in the vitamin E-deficient female rat. 58 and 22 vitamin E-deficient rats received oral supplements of ATHQ and of d-alpha-tocopheryl acetate, respectively, over Days 5-8 of gestation. The results suggested a minimal protective dose of approximately 50 mg ATHQ, which, if distributed over the 1st 10 days of gestation, would represent about 5 mg/day. After Day 10, vitamin E had little or no effect upon the course of gestation. In another study, 125 mg ATHQ/kg/day during early gestation in vitamin E-deficient rats caused excessive uterovaginal bleeding, intrauterine hemorrhage, and retarded development and death of fetuses. 330 mg ATHQ/kg/day given to male rats caused the testis, epididymis and related fat body to be prone to hemorrhage. Menaquinone prevented hemorrhage in both sexes, therefore the observed phenomena were attributed to an induced deficiency of vitamin K through unknown actions of ATHQ.
Biometric models of fertility.
Biometric models of fertility are reviewed. Models are employed to describe fertility and estimate its parameters, to indicate variables for which data are essential, to predict the effects of continuation or changes in these parameters and to carry out pseudo-experiments in an area where experiments on actual populations are difficult or impossible to undertake. Models require rigorous and exact definitions of variables, their form and dependencies. The development of a model can encourage greater precision in thinking. A model can help one examine in detail the full range of effects implicit in the theory of fertility it represents. The many uses of reproductive models in fertility research are illustrated.
Independence of oral contraceptive-induced changes in glucose tolerance and plasma cortisol levels.
Plasma glucose and cortisol concentrations were measured in 25 young healthy women (13 of which were using oral contraceptives) following a 50 gm oral glucose load. Plasma glucose levels for oral contraceptive (OC) users were higher than those for controls at 60 minutes (.01 is greater than p which is greater than .001), 90 minutes (.1 is greater than p which is greater than .05) and 120 minutes (p is greater than .001) but returned to fasting levels by 180 minutes. Cortisol concentrations measured before and 60 minutes after the glucose load were 419 and 328 nM/1 for controls and 901 and 826 nM/1 for OC users. The responses to the glucose test and the cortisol concentrations were i ndependent of the estrogen taken or the duration of OC use. No significant correlation between glucose tolerance and cortisol concentrations for either the controls or OC users was seen (p is greater than .05).
Oral contraceptives and reduced risk of benign breast diseases.
Oral contraceptives (OCs) and reduced risk of benign breast diseases is evaluated from a 1970 questionnaire on OC use mailed to 97254 married women 25-49 years of age in Greater Boston. 69% responded and during the subsequent 30 months, 1072 of the women were hospitalized for breast disease. The rate of hospitalization for fibrocystic disease was similar for nonusers and for OC users of 1-12 months duration. Users for 13-24 months and 25 or more months had rates only 70 and 35%, respectively, of those of nonusers. Analysis of these results suggest that the use of OCs appears to lower risk of fibrocystic breast disease and fibroadenoma.
Ectopic pregnancy and the I.U.D.
IUDs should not necessarily be implicated in causation of ectopic pregnancy. There may be a relationship between pelvic inflammatory disease and ectopic pregnancy. Pelvic inflammatory disease is often asymptomatic and women often do not consult a physician until other problems, e.g., ectopic pregnancy, occur. Previously published research has indicated the risk of ascending subclinical infection in IUD users. Indirectly, IUDs might contribute to ectopic pregnancy through pelvic inflammatory disease causation. There is a need for strict asepsis when inserting IUDs.
Norway to assist India's family planning programme.
In December 1974, an agreement was signed between Norway and India whereby Norway pledged 50 million Norwegian kroners over the next 4 years to assist the Indian postpartum and family planning program. The assistance will be provided through the Norwegian Agency for Development. This assistance follows a 1971 grant of 8 million N. kroners and a 6.5 million N. kroner-grant during 1973-1974.
Organization and management of the division of population control and family planning.
On April 11, 1975 a presidential order was issued outlining the duties assigned to the Division of Population Control and Family Planning of the Ministry of Health of the government of the People's Republic of Bangladesh. These duties include responsibility to determine policy on population control and family planning, to prepare projects, and to coordinate and evaluate all related activities. Additionally, the Division was instructed to carry out research and training activities related to the population effort, to perform a variety of motivational and service delivery efforts, and to accept responsibility for the activities of the government maternal and child health centers. Organizational and managerial requirements are considered in this report within the general framework of governmental policy and anticipated governmental directives concerning the organization and functions of the Division. In addition the responsibilites of the Division, the remaining 9 sections of the report concentrate on the following areas: 1) new management concepts; 2) Central Office of the Directorate; 3) district program organization; 4) national family planning and maternal and child health logistics system; 5) program policies and the role of women; 6) training; 7) pilot Thanas; 8) the need for patience, timing, and a step by step approach to implementation; and 9) sequence of implementing activities. It is recommended that initial priority be on the development of the organizational capability required for the task of family planning services delivery. As this is established, the maternal and child health component can be strengthened and its coverage extended. Full and successful implementation is expected to require from 3 to 5 years.
Family planning fees for anaesthetists. (Letter to the editor)
The author disagrees with those anesthetists who complain to the Central Committee for Hospital Medical Services of their discontent with the differential between surgical and anesthetic fees in hospital family planning services. These physicians believe that the anesthetic fee is for comprehensive service while the surgical fee is only for the actual operation. Failure to quote a paragraph of HSC(IS) which states that payment for surgery or for the insertion of IUDs will be on a per case basis covering all necessary responsibilities associated with the particular type of clinical practice results in mininterpretation of other paragraphs. Complaints of these physicians concerning anasthetic fees are unjustified according to the author.
1910 laparoscopic sterilizations performed 1970-1973 were compared with 531 tubal ligations via laparotomy performed during the same period. Complication rate for the ligations was 6 times higher. The high rate (3.8%) of common postoperative infection remained constant during the period while the use of Dextran 70 reduced the incidence of deep venous thrombosis associated with tubal ligation. Unsuccessful laparoscopy, usually due to obesity or pelvic adhesions, accounted for more than 2/3 of this method's complications. During the study period unsuccessful sterilizations decreased from 6.6% to 1.5% and the number of laparotomies that needed to be performed because of bleeding also decreased. There were none in 1973. This is presumably due to increasing operator skill. Rare and more serious complications included bowel and bladder damage, cardiac arrest, burns, hernias, and anesthetic complications. Their incidence was .4% for laparoscopy and .6% for tubal ligation. 1/2 of the serious complications associated with laparoscopy were burns caused by the cautery current. The 1 death in the series occurred 48 hours after the patient returned home following suction abortion and laparoscopic sterilization. Precise cause of death was not known. Pregnancy rate following laparoscopy was 2.2%, following tubal ligation .4%; highest rate for laparoscopy was 7.0% in 1970 when the technique was being learned, the lowest 2.3% in 1973. In 1973 a woman undergoing tubal ligation stayed in the hospital an average of 8 days, for laparoscopy 3 days. Outpatient procedures were begun in 1974. Letters to the British Medical Journal, in which this report was published, suggested clips as a substitute for cautery and changes in tubal ligation technique to reduce hospital stay.
Spaced births mean healthier mothers and children.
Family planning emphasis should be shifted from limitation to spacing, which mothers seem to desire. Contraception in order to lengthen the interval between births should be presented to mothers in terms of the growth and future well-being of their children. In societies where there is a taboo against grandmothers becoming pregnant, family planning advice should be offered to mothers whose oldest daughters are pregnant. Studies indicate a positive relationship between short birth intervals and greater infant mortality and malnutrition. Physical and intellectual growth rates are also related to the length of time between births. The consensus is that a 3-year birth interval is optimal. Firstborn children will suffer the most when birth intervals are too short.
The syllabus of the course in family planning nursing contains the aim of the course; the preface; and general information such as entry requirements, length of the course, and teaching time and clinical experience. Course units, record of competence, design of the course, and library services are described. The objective of skills, knowledge, and attitudes of course units 1, 2, and 3 are presented.
Seminar on the cultural consequences of population change.
A summary of the seminar on the cultural consequences of population change is presented. Attending the seminar were more than 30 human scientists from 12 countries. The bulk of the seminar was taken up with country papers on Ghana, Nigeria, Kenya, Malawi, Philippines, Indonesia, Mexico, Venezuela, Bangladesh, India, and Sri Lanka. There was also a discussion of seminar goals and on the Draft World Plan of Action.
Changes of natural fertility and contraceptive equivalents.
In underdeveloped countries fertility is reduced by prolonged lactation and by malnutrition, which delays the onset of menstruation and lengthens postpartum amenorrhea. The Perrin-Sheps model of human reproduction as a renewal process is used to quantify the increases in natural fertility that might occur if prolonged breastfeeding were exchanged for bottle feeding, under 3 different levels of nutrition. The same model is used to assess the amount of contraception needed to counteract these enhancements of natural fertility. The models show that if a social group which has been practicing breastfeeding under nutritional circumstances poor enough to protract amenorrhea lengths toward a year suddenly abandons its nursing practices before a serious start on birth control, an appreciable rise in fertility will result. (AUTHOR'S MODIFIED)
Study on the diffusion of menstrual regulation at the family planning clinic.
In order to meet the growing demand for induced abortion, the 13 Planned Parenthood Federation of Korea (PPFK) clinics began offering menstrual regulation in February 1974. Questionnaires were distributed at all 13 clinics during the October 1974--January 1975 period. The survey indicated demographic characteristics of acceptors. Knowledge about menstrual regulation came mostly from other people, with only 15% recruitment from mass media advertising. The majority of menstrual regulation recruits had already experienced induced abortion. Following the procedure, a high proportion indicated interest in use of contraception. Husbands have much influence in whether their wives will use menstrual regulation. It was recommended that publicity for the procedure be given army personnel and industrial workers Doctors vary in their attitudes toward and skill in performing menstrual regulation. It is hoped that the questionnaire results will help PPFK officials improve provision of menstrual regulation service.
[350 requests for abortion. The events in the preceding 24 months]
200 case histories from the Psychiatric Policlinic of the University of Lausanne and 150 private cases of women who had consulted for an abortion request were compared with 100 controls, as to whether these women had undergone a trauma such as surgery, death or separation in their immediate family within the last 24 months. The controls were 100 cases from the Policlinic, born after 1940, consulting for other reasons, excluding oligophrenia and endogenous or organic psychoses. 12 8 (64%) of the clinic requests, 85 (57%) of the private requests, and 26 (26%) of the control patients has suffered such a trauma in the last 2 years (p less than .001). The groups showed no significant differences in age, although there were fewer minors, fewer married women and fewer financially independent women in the affected group. The 137 women without trauma were proportionally much more fertile (92 living children, p less than .01, and 244 pregnancies, p less than .05) than the 231 affected women (83 living children and 312 pregnancies). The women with trauma in their history had used contraception less consistently than those free of trauma. Slightly more of those with trauma were granted approval for abortion. A majority were diagnosed as charachter disorders, compared to a quarter of the controls. These results suggest that physicians aware of such loss, separation or trauma in a patient should take particular care to provide effective contraception.
Africa and its population growth.
The economic growth; Africa - the continent; population growth; some views from Bucharest; family planning; and outlook for Africa are discussed in this bulletin. A table depicts the population of Africa, Europe, and Asia in 1650, 1850, and 1900. A 2nd table shows Africa's population in 1975 by country. Family planning in separate countries is discussed by the regions of Northern Africa, Western Africa, Eastern Africa, Middle Africa, and Southern Africa. Under Northern Africa, Algeria, Egypt, Morocco, and Tunisia are included. Dahomey, Gambia, Ghana, Liberia, Mali, Nigeria, and other Western Africa Francophone nations are discussed under the heading of Western Africa. The Eastern Africa discussion includes: Ethiopia, Kenya, Malawi, Mauritius, and Tanzania; and Middle Africa includes Gabon and Zaire. Botswana and the Republic of South Africa are discussed under the heading of Southern Africa.
The changing world population. (chart)
A chart summarizing knowledge of changes in the population of the world and of various countries over recorded history and prehistory, particularly in relation to current changes and those occurring over the last 100 years, is presented. There are several sections, entitled: 1) the growth of world population; 2) the demographic transitions; 3) equilibrium, disequilibrium, and age structure; 4) age-specific mortality and resources; 7) population policy and control; 8) research; 9) projections; and 10) population and development.
Bangladesh Association for Voluntary Sterilization: a profile-training programme.
The Bangladesh Association for Voluntary Sterilization (BAVS) was formed in 1974 and is providing leadership and service facilities in voluntary sterilization. The booklet describes the general information; the National Executive Committee of BAVS; information, education, and communication activities; the sterilization service; and training of the Association. Detailed listings of times and subject in a 1-week course in vasectomy training and a 3-week comprehensive course are included.
Can timing intercourse alter sex ratio?
Results of a study involving 1318 pregnancies whose conception was monitored for basal body temperature (BBT) and insemination suggest that the timing of insemination can effect the sex ratio. The probability of having a boy was 68.3% when insemination was 6-9 days before a BBT shift. The probability of having a boy was 43.5% when insemination occurred on the day of the shift and 53.4% when insemination occurred the day after the shift.
[Temperature measurements and tubal histology findings in laparoscopic sterilization]
Temperatures generated by laparoscopic equipment during tubal sterilization were measured continually in 32 Fallopian tubes. Thermal damage to the tubes caused by varying energies and coagulation durations was examined microscopically. Energies of 20-30 watts produce temperatures of about 100 degrees C at the point of coagulation. The best histologic results were obtained when coagulation took 60 seconds at 30 watts (effective coagulation time of 50 seconds). Instrument temperature returns to normal 1-2 minutes after coagulation. At higher energies, sparking occurs consistently, tubal temperatures up to 600 degrees C are observed, and instrumental temperature remains high for 3-4 minutes. To avoid burns and to obtain good histologic results during laparoscopic tubal sterilization, energies of 30 watts should be used with a 60-second coagulation time. (AUTHOR'S MODIFIED)
Cortisol metabolism after oral contraceptives: total plasma cortisol and free cortisol index.
A study to determine whether the free cortisol index (FCI) could give a suitable measure of true adrenocortical status and to establish a baseline against which changes in adrenocortical status could be measured without discontinuing contraceptive medication involved 43 healthy women taking combined estrogen/progestogen and progesterone-only oral contraceptives (OCs). For at least 6 months plasma concentrations of cortisol, cortisol resin uptake ratio (cortisol RUR), and FCI were measured. As compared with control subjects among women taking the combined pill elevated cortisol RUR values were seen in the morning and afternoon but little change in FCI was noted. Essentially normal levels of cortisol, cortisol RUR, and FCI at both times of day were observed in progesterone-only pill users. Diurnal variations of total cortisol and FCI remained unimpaired in women taking both types of OC. The FCI measurements indicated that there was an insignificant increase in metabolically active cortisol in women taking either the progesterone-only or the combined type of OC.
Serum follicle stimulating hormone (FSH) and luteinizing hormone (LH ) levels were measured (radioimmunoassay) in 10 women daily throughout a complete cycle. Contraceptive treatment included combined preparations (2 patients), a sequential preparation (1 patient), ethinyl estradiol sulfonate (a depot estrogen) (5 patients); 2 patients had normal, untreated biphasic menstrual cycles. In these last, serum LH and FSH patterns were characteristic of a biphasic cycle. Continuous low LH and FSH levels were seen in women on the combined contraceptive, while woman on the sequential preparation had constantly low FSH and multiple LH peaks. Women treated with the depot estrogen also had multiple LH peaks, which seemed to correlate with estrogen intake. (AUTHOR'S MODIFIED)
Traditionally, diagnosis of pregnancy is based on missed menstrual periods, nausea, and observation of the visible signs and symptoms of pregnancy. Scientific testing supplements these, but none currently available is suitable for use in rural areas. The immunologic slide tests are easier to transport, rapid to perform, and relatively inexpensive but less capable of early diagnosis than tube tests. The soft cannula vacuum aspiration of the uterine contents cannot usually be done by the time these tests first become positive. Radioimmunoassays (RIAs) are capable of very early diagnosis of pregnancy. The basis for most pregnancy tests involves the increase of chorionic gonadotropin (HCG) produced by the placenta. It is detected in the blood or urine. HCG production begins within 48 hours after implantation and reaches a peak at 50-90 days after the 1st day of the last menstrual period. A lower level is maintained throughout pregnancy and then ceases 3-10 days after delivery. Injection of the patient's blood or urine into test animals was the beginning of bioassays. In women with delayed menstruation, repeated doses of an estrogen-progestogen preparation during a 3-5 day period and then withdrawing the therapy will cause menstruation in nonpregnant patients but not in those who are pregnant. Because of the danger of producing fetal malformations if pregnancy is present, this test is no longer advised. Immunological tests are based on the capability of HCG to stimulate antibody production in test animals. In vitro tests can detect antibodies to HCG in the animals' blood. These antibodies are capable of neutralizing HCG in blood and urine samples from pregnant women. In addition to the tube test with red blood cells, a slide test has been devised with latex particles coated with HCG. Inhibition of agglutination suggests pregnancy. RIAs are based on the same principle as immunosasays. False-positive tests are rare. False-negative tests are more common. For family planning programs, false-negative tests are more important because necessary measures would be delayed, particularly if ectopic pregnancy or threatened abortion were present. These have low HCG levels. Pregnancy tests can also be of value for identifying HCG-producing tumors, as hydtidiform mole and choriocarcinoma which produce abnormally high levels of HCG; and in monitoring the response of these tumors to chemotherapy or as follow-up after surgery to detect recurrence. Testicular malignancy in men may be detected by pregnancy tests as some of these tumors secrete HCG. Bioassays are accurate but time-consuming and expensive. Hormonal tests are unreliable and possible unsafe. Immunoassays are accurate, convenient, and inexpensive. The most convenient pregnancy test is the Pregnosticon Dri-Dot test which is a slide method.
Reproductive motivation versus contraceptive technology: is recent American experience an exception?
Statistical evidence contradicts the premise that the age-specific fertility decline in the United States since the early 1960's is due primarily to modern contraceptive technology which prevented unwanted births and allowed realization of the ideal two-child family. Data coll ected from national surveys dating from the Depression through 1975 indicate that among white respondents, aged 21 to 24, ideal family size rose to an average of 3 children, and that until recently, the two child family has been preferred by less than 50% of all respondents. Reductio n of unwanted births within marriage must be considered in relation to trends toward rising age at marriage and an increase in marital dissolution. The percentage of currently married women, aged 20 to 24, dropped from 67% in 1960 to 58% in 1970. One study estimates that changing marital status accounted for 16% of the national birth decline between 1961 and 1968, and 14% between 1961 and 1973. United States vital statistics report an age-specific decline in actual married fertility of 28.9% during 1961-1970; change in parity distribution accou nts for 71% of this decline, while increased contraceptive effectiveness accounts for only 22%. Although ever-increasing use of the pill implies some net reduction in contraceptive psycho-social costs, data revealing decreasing public confidence in the pill's safety demonstrates a strong motivation to control fetility despite the risks involved. Tabulation o f six national surveys indicates a 50% increased among men and a 30% increase among women believing the pill to be unsafe between 1966 and 1974. The American experience demonstrates the importance of motivational factors in intentional fertility decline. High fertility in developing countries may reflect weak motivation rather than limited access to modern contraception. Effective birth control policy should include emphasis on reproductive incentives.
Four basic family size models are presented as a framework for the review of various micro-economic theories of fertility analysis. In the first two family decision-making situations, children are perceived as either by products of sexual activity, or as investment goods. In the second two situations, children are seen to yield direct utility; that is, children are considered consumer goods. The first group of models represent a choice between the "joys of marriage" and standard of living, while the second group represent the choice between children and other goods. Such distinctions between children as a means to an end, or as an end in themselves are artificial. Even in highly primitive cultures, children serve as by-products of sexual activity as well as providing direct utility as sources of future income and security. Family size decisions may involve choices between many, low-quality children and few high-quality children, or, many high-quality children and a low material standard of living, or, a few high-quality children and a higher material standard of living. Type of variables involved in each model, such as age at marriage, contraceptive availability, income or mortality, is dependent upon the problem being analysed. (AUTHOR'S MODIFIED)
For prevention of pregnancy after coitus, the ineffectiveness of douching is recognized because sperm can be out of reach of douches and spermicides too quickly. The nonsteroidal estrogen diethylstilbestrol (DES) has been used most often. Steroidal estrogens, e.g., ethinyl estradiol and conjugated estrogens, are also effective. Progestogens may also be effective. Hormone administration should begin as soon after coitus as possible but never later than 72 hours. Estrogens are given orally, usually for 5 consecutive days in doses of 50 mg/day. The ethinyl estradiol dose is 5 mg/day; conjugated estrogens, 20-25 mg/day; and estradiol benzoate, 30 mg/day for 5 days has been given by injection. These methods have been approved for emergency use only. Pregnancies have followed in not more than 2.4%. Some studies have reported no failures and others as low as .04%. The estrogen is thought to interfere with implantation of the blastocyst in the endometrium. A copper IUD might prevent pregnancy if inserted within 5 days after coitus. Folk methods, of which most depend on magic, are described. Douching has been used since ancient times with wide range of agents. When diaphragms or spermicides are also used, postcoital douching should not be done within 6 or 7 hours. When postcoital estrogens fail, the resulting pregnancy is ectopic in 10% of cases as compared with .5% of normal pregnancies. A high percentage of ectopic pregnancies also follow IUD or minipill failures. There is no likelihood that DES or other estrogens administered postcoitally will lead to genital cancer in female offspring if the treatment fails. A single case of acute pulmonary edema has been reported. Nausea and vomiting may occur, and menstrual patterns may be altered. Trials have shown that the progestogens d-norgestrel and quingestanol acetate are effective postcoital contraceptives. Combined estrogens and progestogens have been used successfully as postcoital contraceptives. Postcoital insertion of a copper IUD has been tried with apparent success. Further evaluation is recommended. Postcoital methods fill an important gap in fertility control services.
Family planning as a method of prevention.
New approaches, particularly prenatal diagnosis relating to the preventability of Down's Syndrome, raise fundamental issues for public health and social action. In considering primary prevention, the alternatives of prevention of conception and intervention after conception must be considered. A program of prevention of conception would have as its target women known to be a high risk in bearing a child with Down's Syndrome, those identified by genetic transmission and by maternal age. The influence of maternal age on total incidence is large, and, consequently, the incidence of Down's Syndrome would decrease automatically if older women prevented conception. Family planning and contraceptive advice needs to be fully available to older couples. The available form of intervention after conception is prenatal diagnostic screening. This program would be based on amniocentesis; laboratory culture of aspirated cells for identification of karyotypes; induced abortion; a comprehensive service to ensure that the population is covered in terms of information, access to screening, and obstetric services; and evaluation of the program in terms of efficacy and ethics. It is proposed that in the 1st phase prenatal screening be offered to all pregnant women aged 40 years and older. The program would require that every woman subjected to amniocentesis be fol lowed at least until delivery. No prediction can be made concerning the proportion of women who would accept the offer of the screening test and an induced abortion if it were positive. The rate of acceptance will be partially related to the vigor with which the program is explained and made accessible to the public. On the basis of this evaluation, it is concluded that where abortion laws allow, the possibilities of a prenatal screening program for Down's Syndrome should be explored without delay. The key to transforming the diagnostic procedure from a clinical measure for sporadic use into a public health measure for systematic use is to adapt it as a screening device.
Issues in the demographic evaluation of domestic family planning programs.
The most sophisticated evaluation of family planning work has been done overseas; in the U.S., where presumably there is more adequate vital statistics data, very little serious work has been done thus far. In the U.S. the norm for delivery of most health services, including family planning, is the physician in private practice. Family planning services generally are clinics with parttime physicians, varying numbers of fulltime persons, a variety of mixes of government and private funds, and differing standards for serving patients. Some utilize defined levels to establish income eligibility while others serve anyone who comes. Comparatively little is known about the delivery of services by physicians in private practice; therefore, family planning evaluation actually means evaluation of organized programs with diverse administrative controls, sponsorships, and institutional interests. Perhaps 2/3 of all programs funded under the Five-Year Plan of the U.S. Dept. of Health, Education and Welfare have been compiled in a computerized National Reporting System. These figures show that as of June 30, 1972, organized programs of some kind were operating in almost 2/3 of U.S. counties, run by nearly 3000 different agencies. During Fiscal Year 1971 about 1,058,000 new patients were enrolled; during 1972, an estimated 2,612,000. Median patient age was 23, 83% were below age 30, and median educational attainment was 12 years. 30% had no chil dren and median number of children for all patients was 1.8. Most of these patients are served by a small number of agencies in a few large metropolitan counties. Effectiveness varies from 0% of estimated need served to more than 100% in a few counties. For most of the 1960s officials felt there would be little interest among the poor in family planning; these figures prove this assumption wrong. Problems of evaluation include: these programs serve a subgroup for which adequate fertility data does not exist; it is difficult to define unwanted births averted; the programs have also substituted effective contraception for ineffective; and money has not been appropriated for adequate evaluation. There is great need for follow-up of patients who drop out of clinic programs. Do they become contraceptive droup-outs or do they switch to less effective contraception. These programs have served a sizable number of women; the problem is figuring out how to determine the effect.
Studies on sperm migration in the human female genital tract.
To define the distribution of spermatozoa in the genital tract several hours after intercourse in untreated women and in those using various contraceptive measures, the following groups were observed: 20 women who received no drug or IUD therapy during the study (Group 1), 5 women treated with megestrol acetate orally (Group 2), 5 women using the sequential pill method (Group 3), and 7 women wearing IUDs with copper (Group 4). All patients were instructed to have intercourse on the night prior to admission for surgery. The surgical procedure was laparotomy, aspiration of fluid from the pouch of Douglas, bilateral salpingectomy, ovarian biopsy, endometrial biopsy, and flushing of the endometrial cavity with 5 ml of saline. Each oviduct was flushed with 5 ml of Tryode solution. Fluids were examined for ova, centrifuged, and searched for spermatozoa by phase contrast microscopy. The number of spermatozoa from the control group varied markedly from 0 to 5000. The recovery was low in treated women when compared with controls, especially at the level of the oviducts and in the groups treated with megestrol acetate and with T-Cu IUDs. None of the treatments completely abolished sperm migration to the fallopian tubes. A correlation between the numbers of spermatozoa and the stage of the menstrual cycle was noted. During the follicular phase the median count for the endometrial cavity was 1397 spermatozoa and for each oviduct 138. During the luteal phase corresponding values were 7 and 1, respectively.
Included in this report of the Expert Group Meeting convened by the United Nations Economic and Social Commission for Asia and the Pacific in Bangkok, June 1974, are papers discussing the following topics: 1) social and psychological aspects of fertility issues and priorities; 2) review of social-psychological studies in Asian population; 3) social changes and changes in fertility motivation; 4) dimensions of the value of children in Asian societies; 5) perceptions and attitudes toward fertility control methods and services; 6) cross-cultural research design for social and psychological fertility studies; 7) methods for studying fertility decisions; 8) measurement of family composition preferences; 9) socio-psychological factors affecting family planning acceptance; 10) policy implications of theory and research on motivation and induced behavioral change for fertility and family planning. Research recommendations include those presented at the Technical Seminar on Social and Psychological Aspects of Fertility in Asia held at Choonchun, Korea in November 1973.
Moniliasis and vaginal diaphragms.
Question: Is there any evidence that a vaginal diaphragm can carry monilia and reinfect a patient? Answer: Since monilia forms spores the answer to both parts of the question is yes. If a patient is successfully treated for vaginal moniliasis it would seem sensible for her to obtain a new diaphragm. Old diaphragms could be sterilized by X-rays, ultraviolet light, or ethylene dioxide. It hardly seems worth the bother. (FULL TEXT)