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HEALTHRIGHT. 1987 Feb; 6(2):37.The Medical Advisory Board of the Family Planning Association of New South Wales has developed 4 guidelines regarding the use of IUDs: 1) the IUD should not be the contraceptive of 1st choice in women under 25 years of age; 2) nulliparous women who request IUD information should be given a realistic assessment of the risks and sequelae of pelvic inflammatory disease (PID); 3) IUD use should be actively discouraged among women who are likely to be exposed to sexually transmitted diseases, are likely to be changing partners, have multiple sexual partners, or have a partner suspected of having multiple partners; and 4) women with a past history of probable PID should be discouraged from IUD use. The risk of PID is 4 times higher among IUD users than users of other contraceptive methods. Moreover, 25% of women who develop PID have some residual problem such as chronic pelvic pain, infertility, or ectopic pregnancy.
Geneva, Switzerland, World Health Organization, 1987. 91 p. (Technical Report Series 753)The mechanism of action, safety, and efficacy of IUDs were reviewed by a WHO Scientific Group in 1986. The Scientific Group concluded that the IUD should continue to be supported, in both developed and developing countries, as a safe, reliable method of fertility regulation. The newer copper-releasing devices are comparable to oral contraceptives in terms of safety and efficacy. When compared to women who use other reversible methods of contraception, IUD users have the lowest mortality resulting from deaths directly attributable to those methods or to the consequences of unwanted pregnancy. In the past decade, research has concentrated on the development of new devices that have both higher continuation rates and lower rates of expulsion and removal for bleeding abnormalities. An important recent concern has been the possible increased risk of pelvic inflammatory disease (PID) and subsequent tubal infertility associated with IUD use. However, it now appears that methodological problems have caused the IUD-associated risk of PID to be overestimated. The increased risk with IUDs seems to be limited to the 1st 4 months of use. No increased risk of tubal infertility has been found among IUD users in stable, monogamous sexual relationships. The use of a copper IUD after the 1st pregnancy is not associated with secondary infertility due to tubal disease. Finally, the newer copper IUDs have low rates of ectopic pregnancy.
Contraceptive Technology Update. 1980 Jun; 1(3):35-37.Add to my documents.
Nongonococcal urethritis and other selected sexually transmitted diseases of public health importance.
World Health Organization Technical Report Series. 1981; (660):1-142.The objectives of this Scientific Group meeting were: 1) to assess the public health importance of sexually transmitted diseases (STD) other than gonorrhea and syphilis; 2) to review the etiology, clinical manifestations, diagnosis, therapy, and epidemiology of STD; 3) to propose measures to be applied at different levels of existing health services for STD prevention and control; 4) to recommend lines of research, and 5) to suggest cooperative activities for the study and control of STD. Etiology, epidemiology, diagnosis, and treatment of the following are presented: infections caused by chlamydia trachomatis, genital herpes, ureaplasma urealyticum, mycoplasma hominis, hemophilus ducreyi, cytomegalovirus, trichomoniasis, donovanosis, nongonococcal urethritis, epididymitis, vulvovaginitis, cervicitis, urethritis in women, genital ulcers, pelvic inflammatory disease (PID), and sexually transmitted hepatitis B. Several studies have revealed that IUDs are used significantly more often by women with PID than by comparable control women. In these studies the ratios of IUD-using patients with this disease compared to IUD-using controls ranged from 9:1 to 5:1. In a Seattle, Washington study 22.3% of all cases of PID were calculated to have been caused directly by IUD usage. Oral contraceptives (OCs) were used by 24.3% of the patients with PID and 44.6% of the control women in 1 study. In the Seattle study the corresponding figures were 24 and 42%. These data suggest that OC use decreases the risk of ascent of a genital infection to the tubes. The reason for this might be the absence of ovulation, brief scanty bleeding from an inactive endometrium, and modified uterine muscular activity in gential tracts under the influence of OCs. Some findings relating to the relationship between infertility and STD are: 1) highest rates of infertility are observed in areas with poor health care and a high prevalence of STD; 2) there is a correlation between gonorrheal, chlamydial, and M. hominis infection with postpartum infection; 3) there is a correlation between urethral stricture and a high rate of gonococcal infection; and 4) there is a high frequency of secondary infertility in women with postabortion infection.
[Characteristics of the clinical course of acute adnexitis in patients using intrauterine contraceptive devices (IUD)] Osobennosti klinicheskogo techeniia ostrykh vospalitelnykh zabolevanii pridatkov matki na fone ispolzovaniia vnutri-matochnykh kontratseptivov.
AKUSHERSTVO I GINEKOLOGIIA. 1990 Oct; (10):41-4.In recent years, the role of IUDs and the appearance of acute inflammatory adnexitis have been the focus of attention. A 1985 study reported on 17 of 127 women patients with inflammatory diseases of the internal genitalia that developed due to IUD use who underwent uterine surgery. 110 of these 19-57 year old women were studied to ascertain the characteristics of the clinical course of adnexitis that developed due to IUD use. Every third patient (39 cases) had in their anamnesis an inflammatory disease of the internal genital organs. On examination, inflammatory erosion of cervix was discovered in 5 patients; in 7 patients, uterine myoma; and in 9 patients, disturbance of menstrual function. In every third patient (42 patients or 38.2%), on admission to the hospital, the blood leucocyte count was normal, while in the rest it was elevated. In 65 patients (59.1%), the malady started in an acute form in the first 3 days; in 45 patients (40.9%) it developed gradually and the women were admitted 10-35 days after its inception. Acute bilateral adnexitis with pelvioperitonitis occurred in 35 of 110 patients and diffused peritonitis in 12. Acute adnexitis accompanied the formation of inflammatory tubal ovarian tumors in 19 patients (6 suppurative) and tubal ovarian tumors in 36 patients (23 suppurative). Laparoscopy was performed in 25 patients. In 33 patients uterine surgery was carried out (among them uterine extirpation in 16, amputation of the uterus in 9, bilateral tubectomy in 2, and unilateral tubectomy in 1). Every second patient had pyosalpingitis with suppurative ovaritis, every third had suppurative endomyometritis, and every tenth had parametritis. In every second patient the acute adnexitis was accompanied by pelvioperitonitis or peritonitis. As an antinflammatory measure blood transfusions were carried out in 12 patients. The average stay before the operation lasted 3.68 days; after the operation they stayed in the hospital an average of 13.80 days.
JOURNAL OF INFECTIOUS DISEASES. 1994 Aug; 170(2):313-7.Genital ulcers are implicated as a risk factor enhancing susceptibility to human immunodeficiency virus type 1 (HIV-1) infection. A prospective study to determine the incidence of and risk factors associated with acquisition of HIV-1 in women with genital ulcers was done. HIV-1-seronegative women with genital ulcers attending a clinic for sexually transmitted diseases in Nairobi were followed to HIV-1 seroconversion over a 6-month period. Of 81 women, 10 seroconverted to HIV-1. The crude 6-month incidence of HIV-1 infection was 12%. Risk factors associated with seroconversion included cervical ectopy (rate ratio [RR], 4.9; 95% confidence interval [CI], 1.5-15.6) and pelvic inflammatory disease (RR, 6.3; 95% CI, 1.9-20.4). Thus, cervical ectopy and pelvic inflammatory disease may increase susceptibility to HIV-1 in women with genital ulcers. (author's)
WOMEN'S GLOBAL NETWORK FOR REPRODUCTIVE RIGHTS NEWSLETTER. 1994 Jan-Mar; (45):13-4.Researchers are exploring ways of increasing the effectiveness and acceptability of the diaphragm. According to one Brazilian study, women tend to continue use of the diaphragm, with a higher rate of effectiveness, when it is used alone without spermicides. This may be due to convenience and cost. The retrospective study comparing 441 women who used diaphragms in conjunction with spermicides to 215 who used diaphragms alone demonstrated a significantly higher failure rate in the former group (9.8 per 100) than in the latter (2.8 per 100). There were also significantly more discontinuations for vaginal discharge and other medical reasons in the first group. The Coletivo Feminista Sexualidade e Saude in Sao Paulo, Brazil reports a high diaphragm acceptance rate with a high 1-year continuation rate (72%) among its clients. The clinic emphasizes adequate training of its clients in the use of the diaphragm, including follow up visits, which is important to the success of the method. Studies show that diaphragms used with spermicides also provide significant protection against sexually transmitted diseases. Women using this method are less likely (p < .05) to have cervical gonorrhea (relative risk = .32) or trichomoniasis (relative risk = .24), or to be hospitalized for pelvic inflammatory disease.
RADIOLOGY. 1994 May; 191(2):507-12.Transcervical tubal recanalization was performed in 19 patients in whom previous surgery had failed to reverse sterilization (n=7) or to reconstruct fallopian tubes obstructed from inflammatory disease (n=12). The patients were 25-41 years old, had been infertile for more than 18 months after the failed surgery and had no other clinical cause of infertility. 4 of the cases of failed reversal surgery had fistular tracts, and 1 also had a structure. The other 3 reversal patients and all 12 failed tuboplasty and tube reimplantation patients has strictures at the site of implantation or anastomosis. The standard technique for transcervical recanalization was followed. The transcervical recanalization only succeeded in 13/15 patients with stenoses. 3 of these became pregnant naturally 1-16 months after recanalization and 2 after in vitro fertilization and embryo transfer. Reocclusion occurred in 2 of 10 patients reexamined 6-36 months postoperatively. It was concluded that transcervical recanalization is a suitable alternative to repeat microsurgical reimplantation or to tuboplasty in cases such as these.
FAMILY PLANNING NEWS. 1994; 10(1):2.Although the IUD remains a subject of debate, Dr. Emily Bernardo from the Philippines suggests that it is of undoubted value in carefully chosen users. Her country is currently reporting a 36% unmet need for birth control and Dr. Bernardo stressed the need for more public and professional confidence in the IUD. In the region as a whole, some 13% of Asian women using contraceptives now choose the IUD. More might do so but for the fear of ectopic pregnancy and pelvic inflammatory disease (PID). Recent major analyses by Family Health International and the WHO show that any increased risk of PID is greatest soon after insertion of the device and thereafter in women exposed to sexually transmitted diseases. The current rate of PID among IUD users in the Philippines compares favorably with that reported by Family Health International--1.4 vs. 1.6 cases, respectively, per 1000 woman-years of use. WHO data indicate that women using the most widely prescribed IUDs have ectopic pregnancy rates of up to 1.5 per 1000 woman-years of use. Rates tend to vary in proportion to the surface area of copper on the device: the greater the area, the lower the ectopic rate. Dr. Bernardo said that such data only supports her contention that the IUD is both safe and effective. (full text)
[Relationship between the incidence of ectopic pregnancy and the use of intrauterine devices (IUDs)]
CHUNG-HUA FU CHAN KO TSA CHIH [CHINESE JOURNAL OF OBSTETRICS AND GYNECOLOGY]. 1993 Feb; 28(2):94-6, 123.The relationship between the incidence of ectopic pregnancy (EP) and the use of IUD was examined by the method of analytical epidemiological study. 10,843 women of childbearing age from the western district of Beijing were investigated and the following conclusions were reached: 1) The incidence of EP in IUD users was 0.91 per 1000 women per year; and the EP incidence in women not using any contraceptives was 2.23 per 1000 women per year; 2) the incidence of EP in women who had been using an IUD for 2 years was significantly higher than that in women who had been using an IUD for more than 2 years (5.64 per 1000 women per year and 0.47 per 1000 women per year, respectively); 3) the probability of suffering from EP for accidental pregnancy in IUD users was 4.84%, which was much higher than that of women who were not using a contraceptives (0.20%); 4) the risk of EP in IUD users with pelvic inflammatory disease (PID) was 6.64 times as compared to those without PID; 5) EP was not related to any previous Cesarean section or induced abortion. (author's modified) (summaries in ENG, CHI)
East African Medical Journal. 1993 Sep; 70(9):592-4.Staff of the infertility clinic at King Khalid University Hospital in Riyadh, Saudi Arabia, cared for a Yemeni woman who had a poor obstetric history. She had had pelvic inflammatory disease. Her 1st pregnancy concluded in a full term vaginal delivery, but gastro-enteritis caused the infant's death at 4 months. She delivered her 2nd child at 32 weeks gestation and the infant died 3 days later. Her 3rd and 4th pregnancies occurred in the right tube. A laparotomy, conservative evacuation of the conceptus from the right tube, and peritoneal lavage were used to treat the ectopic pregnancies. She experienced spontaneous abortion of the 5th pregnancy at 10 weeks. The woman presented at the hospital's gynecology clinic at 40 days amenorrhea with low abdominal pain and a small amount of vaginal bleeding. She had not passed any clots or tissue. The general examination was normal. The pregnancy test was positive. Since she had past ectopic pregnancies, the physicians conducted an ultrasound, which revealed no intrauterine pregnancy and a heterogenous 4.5 cm x 5.5 cm mass near the left tube. Laparoscopy confirmed a normal size uterus, a mass on the left tube, and bleeding into the peritoneum. Laparotomy was performed to remove the unruptured left ampullary ectopic pregnancy in such a way as to preserve the patency of the tube and therefore fertility. The surgeons also conducted peritoneal lavage with dextran saline to remove the blood in the peritoneum. The surgeons lysed the adhesions they found between the omentum, abdominal wall, and the uterus. Both ovaries were in good condition. The right tube was in good condition. She did fine postoperatively and was released 7 days after operation. The physicians could not determine the patency of the left tube, because she was lost to follow up. This case shows that conservative management of the tubes to retain tubal patency was successful, since she was able to conceive, but recurrent ectopic pregnancies may damage the tubes.
East African Medical Journal. 1993 Sep; 70(9):551-5.Between September 1988 and January 1989 in Kenya, health care providers recruited 150 infertile women, 15-39 years old, who had gone to a gynecological outpatient clinic at Kenyatta National Hospital in Nairobi to undergo hysterosalpingography to determine the condition of the uterus and fallopian tubes. The aim of the study was to determine whether there was an association between hysterosalpingography and pelvic inflammatory disease (PID) and the determinants for PID. Most women were between 20-29 years old, married, and had a primary education (67.3%, 90.7%, and 55.3%, respectively). One week after hysterosalpingography, 44% developed acute PID, defined as having at least 2 of the following signs or symptoms: lower abdominal pain, rebound tenderness, cervical/adnexal tenderness, foul smelling vaginal discharge, adnexal mass(es), and fever of at least 38 degrees Celsius. The most frequent signs and symptoms were lower abdominal pain and tenderness. Married women were more likely to have PID than unmarried women (47.1% vs. 14.3%). The small numbers of unmarried women made it difficult to determine the significance of the difference, however. Sexual intercourse within the 1st week after hysterosalpingography was not associated with PID (45.2% for PID cases vs. 42.1% for non-PID cases). The researchers believed that hysterosalpingography pushed existing pathogens in the vagina into the uterus, or the women already had asymptomatic PID. They recommended further studies to determine whether physicians should administer prophylactic antibiotic therapy to all women undergoing hysterosalpingography.
HIV infection among patients with acute pelvic inflammatory disease at the Kenyatta National Hospital, Nairobi, Kenya.
East African Medical Journal. 1993 Aug; 70(8):506-11.AIDS continues to exert considerable strain on the economy, as well as social aspects of our lives. Previous studies have identified the categories of people most at risk of contracting and developing HIV infection and AIDS. In this study, 20.9% of women with acute pelvic infection at the Kenyatta National Hospital, were found to be seropositive for HIV, much higher than the general population in Kenya. Though there was no direct correlation between one's age and serological status, most of the women with pelvic inflammatory disease (PID) were young, quite sexually active, and involved with several partners. 49.0% of the entire group and 53.7% of the women who were seropositive were married. This underlies the fact that marital status does not appear to offer any protection against HIV infection. The fact that the majority of these women had started coitus quite early, that they were not using any protective measure against STDs or HIV infection, and they were involved with several partners, indicate that we are very far from winning the fight against HIV infection and AIDS. There is need to revise the currently operative programs with a view to making them more effective in preventing transmission and spread of HIV infection. (author's)
BRITISH JOURNAL OF GENERAL PRACTICE. 1993 Apr; 43(369):175.A physician in Bedfordshire, England, believes that inert IUDs should not be reintroduced into the market place. He acknowledges that larger IUDs, but women who use them have a high incidence of pain and bleeding problems. The new copper-releasing IUDs have a better efficacy rate than inert IUDs. The lowest failure rate of any IUD is the levonorgestrel-releasing IUD and its efficacy is almost as good as that of the combined oral contraceptive. Medicated IUDs sometimes require periodic reinsertions, but this is insignificant when compared with the reduced pain and bleeding associated with their use, especially among low parity women. An Israeli study shows that 63% of inert IUD users suffered pain, bleeding, or discharge and more than 50% of them wanted the IUD removed. The availability of better IUDs makes this high rate unacceptable. Copper releasing IUDs remain effective and safe for as long as 8 years. Some physicians suggest that women of at least 40 years of age can use them indefinitely. Published reports show that the incidence of pelvic inflammatory disease (PID) is essentially the same for both inert IUDs and copper IUDs, e.g., 2 studies examining infertility reveal that the risks of tubal blockage are lower with copper IUDs than with inert IUDs. Besides the insertion process and background risk of sexually transmitted diseases are linked to PID and not the inherent property of the IUD. One 3-year study finds that a levonorgestrel releasing IUDs have a protective effect against PID. In the practice of the Bedfordshire physician, just 8 of 98 current IUD users use the inert IUD. He allows them to continue using their IUDs as long as they are satisfied and their hemoglobin levels remain stable. He proposes that clinicians should discard any remaining stock of inert IUDs and use only medicated IUDs.
JOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTH. 1992 Oct; 46(5):528-31.This case-control study investigated the association between reproductive, contraceptive, and menstrual factors and the risk of benign ovarian tumors. The study was carried out in 6 London hospitals and an interviewer-administered questionnaire was used. 62 women with a benign epithelial ovarian neoplasm, 37 women with a functional ovarian cyst, and 20 women with a dermoid cyst presenting between 1983 and 1985, together with 132 controls, took part of this study. On average, women with a benign epithelial ovarian neoplasm were older than those with a functional ovarian cyst, who in turn were older than those with a dermoid cyst. Nulliparity and infertility were associated with an increased risk, and multiparity with a reduced risk, of benign epithelial ovarian neoplasms. Infertility and pelvic inflammatory diseases were associated with increased risks of functional and dermoid cysts. Recent use of oral contraceptives was associated with a reduced risk of all 3 tumor types. These findings suggest that the etiology of ovarian cysts and benign epithelial ovarian neoplasms may differ. The etiology of benign and malignant epithelial ovarian neoplasms may be similar, however, since there are some risk factors which shared. (author's modified)
CEYLON MEDICAL JOURNAL. 1993 Mar; 38(1):12-4.WHO estimates 250 million new cases worldwide of sexually transmitted diseases (STDs) each year. STDs of growing concern are chlamydial infections responsible for pelvic inflammatory disease (PID) in women and pneumonia and ophthalmia in newborns, and incurable viral infections, including Herpes simplex virus, human papilloma virus (HPV), hepatitis B virus, and HIV infection. HPV types 16 and 18 are associated with cervical intraepithelial neoplasia, one of the most serious complication of STDs. PID is another serious STD complication because it tends to recur and causes chronic abdominal pain, eventually resulting in hysterectomy, infertility, ectopic pregnancy, or chronic backache. STDs adversely affect pregnancy, often leading to ectopic pregnancy, stillbirth, prematurity, congenital and perinatal infections, and puerperal maternal infections. Genital ulcer diseases, e.g., chancroid, facilitate HIV transmission. HIV infection boosts the virulence of STD pathogens, e.g., Herpes simplex virus. Many people with STDs are asymptomatic and the clinical profile of STDs is always in flux, thus resulting in less than optimal case detection. Obstacles of STD treatment include antibiotic resistance of betalactamase-producing Neisseria gonorrhoea strains and the immunocompromising effect of HIV infections. Tourists are responsible for introducing HIV infection into many countries. Some countries (e.g., Saudi Arabia) require a negative HIV test before foreigners can work in those countries. Health resources are not keeping up with the spread of STDs and HIV. Governments should embark on health education campaigns to stem the spread of HIV. They should also integrate AIDS prevention with the control of other STDs.
CONTRACEPTION. 1993 Aug; 48(2):81-108.Many studies published on IUDs during the last 2 years have consistently reported findings in favor of IUD use. Notable among these findings are: IUDs are not abortifacients; newly developed IUDs are highly effective and the efficacy is long lasting; IUDs can be safely used by most lactating women, with lower removal rates attributable to bleeding and/or pain; and immediate postplacental IUD insertion reduces the risk of expulsion usually associated with postpartum insertion. Most importantly, in apparent contrast to results often reported in the late 1960s through the early 1980s, recent findings show that IUDs per se, especially the medicated ones, are not associated with an increased risk of pelvic inflammatory disease (PID), nor are they associated with an increased risk of ectopic pregnancy or subsequent infertility. there are still issues concerning IUD use that are controversial in spite of numerous studies. Should some of the contraindications currently listed for IUD use be modified according to the newer findings? Is the risk of uterine perforation increased when the IUD is inserted in lactating women? Do IUD tails increase the risk of PID? Does oral use of antibiotics at IUD insertion helps prevent postinsertion PID? There are also issued that have not been sufficiently addressed, and more information from empirical studies needed. These include: the effect of the insertor's skill on IUD performance: IUD use in nulliparous as well as in older women; the relationship between IUD use and chlamydia infection; and longterm IUD use and safety, including actinomycosis, etc. Answers are also needed by administrators facing difficult programmatic decisions. For instance, should programs involving massive IUD removal be implemented as many IUD-wearing women are approaching or passing menopause? Similarly, are large programs to remove less effective devices and replace them with newer and more effective IUDs advisable? This article reviews the state-of-the-art findings from recent IUD studies on the above issues. (author's)
CURRENT OPINION IN OBSTETRICS AND GYNECOLOGY. 1992 Dec; 4(6):891-6.US women over 35 years old continue to need reversible contraception. Most women in this age group who need reversible contraception use the condom, diaphragm, spermicides, IUDs, or oral contraceptives (OCs). The most effective reversible contraceptives are OCs, the IUD, and the systemic contraceptive, Norplant. Healthy women older than 35 who do not smoke and have no coronary artery disease risk factors can safely use low-dose OCs. OCs do not increase the incidence of breast cancer. They appear to protect from epithelial ovarian neoplasm and functional ovarian cysts. Further, they reduce the amount and duration of vaginal bleeding. IUD use has fallen in the US due to the negative publicity of increased risk of pelvic inflammatory disease (PID). Studies have shown, however, that older women who are in a stable monogamous relationship can use an IUD without increasing their risk of PID. The only 2 IUDs available in the US are Progestasert, which releases progesterone, and Paragard T380A, which releases copper. Progestasert reduces the amount of bleeding often associated with IUD use. The risk of ectopic pregnancy is slightly increased in IUD users. Older women can choose the subdermal implant, Norplant, which is effective for 5 years. Its major disadvantage is irregular vaginal spotting or bleeding, but administration of oral estrogen controls this effect. Norplant suppresses ovulation and alters cervical mucus.
Sexually Transmitted Diseases. 1993 May-Jun; 20(3):168-73.Researchers applied estimates of Chlamydia trachomatis transmission and disease parameters to a compartmental mathematical model of heterosexual, sexually transmitted disease (STD) transmission to determine the potential effect of chlamydia infection via its link to tubal infertility on population growth in sub-Saharan Africa. Epidemiologic parameters included transmission efficiency, salpingitis rate per cervical infection, tubal fertility rate per salpingitis episode, and average duration of infectivity. Sexual behavior parameters were sexual partner change and networks of sexual mixing. Demographic parameters consisted of a constant mortality rate (.02/year), a mean life expectancy (50 years), age of menarche (15 years), age of menopause (45 years), and maximum potential fertility rate. The mathematical model estimated that as the probability of infertility due to chlamydia infection increases, population growth falls almost linearly at various values of basic reproductive rates. In fact, 10% decline in population growth accompanies a 10% chlamydia prevalence. When the researchers applied estimates of gonorrhea transmission to the model, they learned that a 10% prevalence of gonorrhea results in a 30% reduction in population growth, indicating that gonorrhea has more of an effect on population growth than does chlamydia infection. Gonorrhea has higher transmissibility and shorter duration of infectivity than chlamydia infection, resulting in a higher incidence rate at any given prevalence of infection. Improved diagnosis and treatment of STDs as a result of AIDS prevention programs should result in considerable changes in the epidemiology of gonorrhea and chlamydia infection. These changes will likely speed up population growth unless STD control programs are integrated with effective family planning programs.
A survey of infertility, surgical sterility and associated reproductive disability in Perth, Western Australia.
AUSTRALIAN JOURNAL OF PUBLIC HEALTH. 1992 Dec; 16(4):376-81.In September-December 1988 in Australia, at least 1495 couples in metropolitan Perth completed a questionnaire as a part of a study to measure the extent of infertility (inability to conceive after 12 months on unprotected intercourse) and sterility (surgical procedure responsible for end of reproductive function) and to examine their characteristics and associations. 22.6% of all couples had no children. 53 couples (3.5%) suffered from current infertility. It was highest among 30-34 year old women (4.2%). 285 women (19.1%) had experienced infertility at some time in their lives. Lifetime cumulative incidence of ever having been infertile was 22.8%. Lifetime infertility was significantly associated with multiple sexual partners (p = .04), pelvic inflammatory disease (p = .0001), and appendicitis with rupture (p < .0001). Tubal pathology and male problems were the leading causes of infertility. 555 couples (37.1%) experienced surgical sterility. Just 2% of these 555 couples had an associated reproductive disability (inability to achieve desired level of reproductive function). Sterility prevalence was greatest among 40-44 year old women (72.2%). Contraceptive sterilization was the major reason for surgical sterility. 47 couples (3.1%) had reproductive disability. They comprised 36 infertile couples and 11 surgically sterile couples. 10 of the surgically sterile couples regretted their decision to undergo sterilization. 48.9% of all reproductive disabled couples had at least 1 child. 23 of the 47 couples sought medical treatment for reproductive disability. Reproductive disability peaked at 30-34 years old (female partner's age). Medical intervention allowed .9% of all women (14 women) in the survey to conceive. These results indicated a need to develop a strategy to prevent reproductive disability, especially infertility.
[Relationships between contraception and gynecologic infections] Relazioni tra contraccezione e flogosi genitali nella donna.
PATOLOGIA E CLINICA OSTETRICA E GINECOLOGICA. 1987 Jul-Aug; 15(4):250-4.Infections of the upper genital tract are commonly referred to as pelvic inflammatory disease (PID) and are often accompanied by fever, leucocytosis, and adnexal tumefaction. Risk factors are sexual activity at an early age, types of microbes, number of partners, and frequent sexual intercourse. Some studies found more incidence of mycotic vaginitis in women using oral contraceptives (OC) with a high estrogen content. It was also suggested that OC use reduced gonococcal pelvic infections by 50% by means of reducing menstrual flow and by modifying cervical mucus, making it impenetrable to bacteria. Nevertheless, OCs protect only in severe cases of PID. OC users appear to have a higher rate of chlamydial infections of the lower genital tract. IUD users have a 1.6 to 9.3 times higher risk of getting pelvic infections depending on age, number of partners, and frequency of intercourse. The risk is highest in the first 30 days after receiving the IUD, and long use (>2 years) augments the risk of severe PID. There is increased risk of gonococcal infection in IUD users. Significantly increased numbers of anaerobic bacteria are present in cervical cultures of IUD users. Longterm IUD use is linked to a higher prevalence of actinomycetes. Among barrier methods, the use of the condom reduces the risk of infection with gonorrhea or chlamydia eightfold. The diaphragm provides effective protection against gonococcal and chlamydial infections, although its incorrect size and prolonged contact with spermicide can produce microlesions. Sterilization is associated with the reduction of genital infections; however, these are low-risk women aged >30 who are married. The spread of sexually transmitted diseases is an important factor to consider when choosing a contraceptive.
CESKOSLOVENSKA GYNEKOLOGIE. 1992 Feb; 57(1):33-7.All the women who underwent a mini-abortion in 1989 at the 2nd clinic of obstetrics and gynecology of Prague were followed-up in order to ascertain the relationship of complications after a mini-abortion to parity; the amount of time that elapsed before the manifestation of difficulty; the clinical symptoms of readmission after abortion; the week of gestation when ultrasound was performed for the diagnosis of the causes of difficulty; and the role of treatment. 1769 mini-abortions were carried out in 1989. 90 (5.08%) women were hospitalized for complications. The youngest patient was 16 years old, the oldest 42 years old. 6.66% of the affected women were under 18 years old, 10% were in the 18-20 age group, 20% were under 25 years old, and 12.22% were under 30 years old. 24.44% were 35 years old, and 17.77% were over 35 years of age. 25 (25.55%) women were primigravida, and 68.88% were multiparous with at least 1 birth. 5.55% of women had an abortion or mini-abortion in their anamnesis. The complication in 10 clinic readmission cases occurred 2 days after induced abortion in 11.11%, 4 days later in 38.88%, 6 days later in 22.22%, 8 days later in 10%, and 10 days later in 3.33%. 18.14% of women were hospitalized longer than 10 days. The most frequent cause of admitting patients was suspicion of inflammation in 50%, residue in 22.22% and endometritis in 13.5%. 7.77% of the women were admitted for bleeding, 5.55% for endometritis and adnexitis, and 1.11% for parametritis and adnexitis. Ultrasound investigation was performed for every women admitted for complications. In 58.9% there were no findings, the fetal remains had been eliminated from the uterine cavity. The association of morbidity with the length of pregnancy was demonstrated by the fact that in 6.66% the abortion was performed in the 5th week of gestation, in 23.33% in the 6th week, in 47.77% in the 7th week, and in 22.22% in the 8th week. 73 patients (81%) were treated with antibiotics. Only in 19% was the treatment limited to uterotonic hormones.
GENITOURINARY MEDICINE. 1993 Feb; 69(1):54-9.Actinomyces israelii (a gram-positive, branching, anaerobic or microaerophilic bacterium) infects 1.6-11.6% of IUD users worldwide. Physicians must decide whether to treat A. israelii infection with antibiotics, remove the IUD, or refer the patient to the family planning clinic. Culture techniques tend to be inadequate, so many US health professionals use a microscope to identify A. israelii and often confirm the microscopy findings with direct immunofluorescent techniques. A sophisticated culture from pelvic infection or abscesses is needed. It appears that A. israelii infection is more common in women with plastic IUDs than those with copper IUDs and in women who have had an IUD for more than 4 years. Pelvic actinomycotic disease occurs infrequently, but when it does this condition the right ovary and fallopian tube are generally involved; this condition can be life threatening. It is indistinguishable from other forms of pelvic inflammatory disease. Evidence suggests that there is a cause-and-effect relationship between IUD use and pelvic actinomycosis. It is difficult to predict which IUD users harboring A. israelii will develop subsequent serious pelvic infection. Nevertheless, Pap smears can detect A. israelii infection early so physicians can prophylactically treat it before it spreads. Prophylactic treatment in IUD users may consist of changing the IUD every 4 years of long term penicillin or doxycycline treatment. Combinations of various antibiotics used to treat actinomyces infection are penicillin, aminoglycoside, chloramphenicol, amoxycillin, metronidazole, and doxycycline. In the case of tubo-ovarian abscesses larger than 8 cm in diameter, however, surgical treatment is warranted.
NETWORK. 1993 Mar; 13(3):12-5.Even though IUDs are safe and effective when correctly inserted in women in monogamous relationships, both providers and users hold misperceptions about the safety of IUD, thereby restricting womens access to IUDs. Such practices include providers requiring numerous follow-up pelvic examinations and restrictions on who may insert IUDs. Yet research shows that follow-up pelvic examinations are not cost effective and do not necessarily improve the quality of care. Instead, providers should inform women of what symptoms and side effects warrant a follow-up examination, (e.g. irregular or excessive bleeding). Nurses, midwives, assistant midwives as well as physicians who have undergone competency-based training, including 10 to 15 correct insertions under supervision, can safely insert IUDs. Still, some countries restrict IUD insertions to just physicians, e.g., Egypt. On the other hand, midwives and assistant midwives can insert IUDs in Indonesia. The leading medical barrier is the belief that IUDs increase the risk of pelvic inflammatory disease (PID), especially in countries where IUD use is low. Providers inserted the first generation of IUDs in women at high risk of sexually transmitted diseases (STD); thus, many people attributed PID to the IUD rather than to the STDs. Studies showing an association between the Dalkon Shield and PID also fueled the fear. Research indicates that women are at an increased risk of PID, only during the first 4 to 6 weeks after IUD insertion, but thereafter no risk exists for women in monogamous relationships. Other obstacles are cost (e.g., US private physicians, US $1609-400), no promotional campaigns to improve the image of the IUD, and rumors (e.g., IUD migrates to the stomach or heart). Today most providers insert the copper-releasing IUDs, the second generation IUDs.
AFRICA HEALTH. 1993 Mar; 15(3):15-7.The real prevalence of pelvic inflammatory disease (PID) is unknown since many women are either asymptomatic or have atypical symptoms. It is often difficult to detect, manage, and prevent PID. Since PID has obstetric, gynecologic, and contraceptive-related causes, its prevalence is quite high. About 70% of PID hospital admissions in sub-Saharan Africa are a result of reproductive tract infections (RTIs) while this figure is 34% in Asia and 31% in developed countries. Only 10-20% of lower RTIs ascend into the upper genital tract and an even smaller percentage of women with PID develop chronic sequelae. Still, just 1 episode carries an increased risk of a tubal infertility, ectopic pregnancy, chronic pelvic pain, considerable pain during coitus, a new episode, and menstrual irregularities. Neisseria gonorrhoea and Chlamydia trachomatis are the most common causative organisms of PID. In Africa, the risk factors for PID are the same as they are for sexually transmitted diseases (STDs): multiple sex partners, young age at first intercourse, high frequency of coitus, and a high rate of acquiring new partners. The largest percentage of women with RTIs are monogamous women who are infected and constantly reinfected by their promiscuous husbands. The primary means to prevent PID are promotion of safer sexual behavior and condom usage. Secondary measures include accessible, acceptable, and effective STD services and education and counseling during case management. WHO suggests that STD treatment become part of the primary health care system. It has developed flow charts on syndromic diagnosis for urethral discharge in men and genital ulcer disease in women. Health workers should assume increased PID risk if the partner has had a history of urethral discharge and/or treatment for gonorrhea or nongonococcal urethritis. Partner notification is also needed for case management, but stigmatization in some countries poses a problem. WHO also recommends use of drugs which have a 95% STD cure rate.