Opening addresses.

PIP: The theme of the 3rd International Conference of the Society of Gynecology and Obstetrics of Nigeria (SOGON) held October 26, 1986 in Enugu was maternal morbidity and mortality in Africa. The opening addresses emphasize the high maternal mortality rate in Africa and SOGON's dedication to promoting women's health and welfare. In order to reduce maternal mortality, the scope of this problem must be made evident by gathering accurate mortality rates through maternity care monitoring and auditing. Governments, health professionals, educators, behavioral scientists, and communication specialists have a responsibility to improve maternal health services in this country. By making the population aware of this problem through education, measures can be taken to reduce the presently high maternal mortality rates. Nigerian women are physically unprepared for childbirth; therefore, balanced diets and disease prevention should be promoted. Since about 40% of deliveries are unmanaged, training for traditional birth attendants should be provided. Furthermore, family planning programs should discourage teenage pregnancies, encourage birth spacing and small families, and promote the use of family planning techniques among men. The problem of child bearing and rearing accompanied by hard work should also be investigated. For practices to change so that maternal mortality rates can be reduced, attitudes must be changed such that the current rates are viewed as unacceptable.^ieng

Etiologic classification and sociomedical characteristics of infertility in 250 couples.

Two hundred fifty infertile couples were studied during a 30-month period. Of these, 77 couples (30.8%) were polygamous. Tubal disease was the commonest etiologic factor, being the sole factor in 24% and a factor in 41.2%. Oligo-azoospermia was the sole factor in 20.8% and a factor in 34.4%. Anovulation was the sole factor in 16.8%. Female factors were the sole findings in 129 patients (51.6%), while male factors were the sole findings in 54 (21.6%). In 36 (14.4%), combined factors were present. There were 56 (22.4%) pregnancies including 27 (63%) pregnancies in 43 patients who were treated for anovulation. There were five pregnancies in 103 patients with tubal disease. Thirty-five (62.5%) pregnancies ended in live births, while eight (14.3%) were abortions or ectopic gestations.

A simplified method for the management of ovulating but infertile women.

PIP: A simplified regime was used for the management of 21 ovulating infertile women, age range 22 to 40, who were seen at Lagos University Teaching Hospital. 12 had secondary infertility, 9 primary infertility. The treatment schedule was: 3 months observation; 3 months clomiphene citrate 50mg for 5 days per cycle; laparoscopy and hydrotubation were performed in those who were not pregnant after 6 months; patients with no abnormalities on laparoscopy were placed on Bromocryptine for 3 months, 2.5mg twice daily, followed by 3 more months of observation. 11 women became pregnant (53%). The number of pregnancies (6) during observation did not differ (p.5) from the number (4) during treatment cycles. Luteal phase plasma progesterone levels during observation did not differ from those during Clomiphene therapy, or those during bromocryptine therapy. 8 of the 12 patients with secondary infertility and 3 of the 9 with primary infertility became pregnant. 2 striking features of the study are the overall pregnancy rate and the similar pregnancy rates between observation and treatment segments. Whatever beneficial effects clomiphene and bromocryptine may have, they are not sufficiently reflected in mid-luteal phase plasma progesterone levels. These features highlight the need for more detailed and prolonged studies to identify those patients who would benefit from reassurance and observation, and separate them from those that will need drug therapy to achieve pregnancy.^ieng

Prevalence of hyperprolactinaemia and galactorrhoea in secondary amenorrhoea.

Using Commercial R.I.A. Kits, plasma prolactin levels have been assayed in 41 Nigerian women with secondary amenorrhoea and in 10 normal ovulating women. The prolactin levels were 34.5 +/- 28.9 ng/ml and 14 +/- 6.8 ng/ml respectively; these prolactin levels differed significantly (p less than 0.001). Fifteen amenorrhoeic women had prolactin levels exceeding 28 ng/ml while no normal women had such prolactin levels. The highest prolactin levels, greater than 100 ng/ml were in the two patients with pituitary tumours. The relative frequency of galactorrhoea in patients with secondary amenorrhoea was 19.5%. The results of this study are comparable with those obtained in Caucasians.

A comparative study of the effectiveness of the Lippes Loop, the Copper-T-200, and the Nova-T intrauterine contraceptive devices in Lagos, Nigeria.

Two hundred five women attending the Family Planning Clinic of the Department of Community Health were admitted into a nonrandomised study to compare the effectiveness of the Copper-T-200, Nova-T, and Lippes Loop intrauterine devices. Members of the study group of women were found to be older than their European counter-parts and also tended to have a higher parity (81.0% of the total group having more than three children). The expulsion rates and removal rates for bleeding and pain for Copper-T-200 and Nova-T users were respectively 6.5 and 3.8 and 5.0 and 1.5. These results were significantly lower than the rates for the Lippes Loop users which were 14.7 and 6.7, respectively. The continuation rates were higher for the Copper-T-200 (88.2) and the Nova-T (91.3) than for the Lippes Loop (75.5). These findings were essentially similar to those of other worldwide studies.

A multicenter study of levonorgestrel-estradiol contraceptive vaginal rings. I-Use effectiveness. An international comparative trial.

PIP: Contraceptive vaginal rings (CVRs), with approximate daily release rates of 250-290 mcg of levonorgestrel and 150-180 mcg of estradiol and manufactured in a shell design, were studied for effectiveness and acceptability in multicentered trials involving 1103 ring users in Brazil, Chile, Dominican Republic, Sweden, U.S., Denmark/Finland, and Nigeria. A comparison group of 533 women used the oral contraceptive Nordette. Both 1st and all segment 1 year gross pregnancy rates among CVR users were less than 3/100, rates similar to Nordette users. Continuation at 1 year was 50/100 users of the ring (all segments) and 38/100 among Nordette users, more of whom were lost to follow-up. Gross 1 year rates of termination for medical reasons ranged from 25-29/100. Ring users were more likely to terminate for vaginal problems and pill users for headache, nausea, and associated reasons. These trials indicate that CVRs of this design are as effective and have continuation rates equal to and possibly superior to Nordette under the same study conditions.^ieng

A multicenter study of levonorgestrel-estradiol contraceptive vaginal rings. II-Subjective and objective measures of effects. An international comparative trial.

Comparative clinical trials of 2 sizes of contraceptive vaginal rings and of an oral contraceptive were undertaken at 8 investigational sites (9 clinics). More than 500 women enrolled on each of the 3 study regimens. Side effects of the rings and of Nordette, the oral contraceptive, were evaluated by noting spontaneous complaints, by recording medications taken and by physical examination. Inquiries about changes in the frequency of specific conditions were made at the end of the subjects participation in the first year of the study. The incidence of spontaneous complaints was similar among users of the 2 different-sized rings and of the pill.

A multicenter study of levonorgestrel-estradiol contraceptive vaginal rings. III-Menstrual patterns. An international comparative trial.

Menstrual events among users of contraceptive vaginal rings (CVRs), releasing levonorgestrel and estradiol, were studied in comparison with a combined oral contraceptive, Nordette, in multicentered trials. CVRs were made with outside diameters of 50 and 58 mm and released about 250 micrograms and 290 microgram of levonorgestrel and 150 microgram and 180 microgram of estradiol per day, respectively. The CVRs were used continuously for 3 weeks and then removed for 1 week. Both the CVRs and Nordette were perceived to reduce menstrual flow and days of menstrual bleeding. Twenty to 25% of CVR users perceived increased intermenstrual bleeding or spotting. Diaries indicate, however, that on average, CVR users experienced about 1 day per month of bleeding or spotting with the ring in place. CVRs and Nordette produced approximately the same total number of bleeding and spotting days during 6 cycles of use, 27-29, but the small (50-mm OD) ring was associated with somewhat more spotting. This ring was also associated with somewhat more prolonged bleeding and spotting runs and with more prolonged nonbleeding intervals than reported by users of the larger (58-mm OD) ring or of Nordette. Differences among regimens, however, tended to be small even when statistically significant. Evidence from menstrual diaries indicates that these CVRs, and in particular 58-mm ring, provide control over the menstrual cycle comparable to the Nordette.

A comparative study of the clinical performance of two copper-releasing IUDs, Nova-T & Copper-T-200 in Lagos, Nigeria.

A non-randomised study was performed to compare the use-effectiveness of the Copper-T-200 and Nova-T intrauterine devices. It was found that generally, results compared favourably with other world-wide studies. No accidental pregnancies were experienced and no significant difference was found between the expulsion rate of the Nova-T (5.0) and that of the Copper-T-200 (6.5) and the removal rates for bleeding and pain, which were 1.5 and 3.8, respectively. The continuation rate for the Nova-T was 91.3 compared with 88.2 for the Copper-T. The total experience was based on 815 woman-months of use.

PIP: In a nonrandomized trial, Copper T 200 and Nova T IUDs were inserted in 67 and 65 women respectively during a menstrual period or within 1 or 2 days postmenstrually. Life table method by Tietze and Lewitt was used in data analysis. 70% of the patients were over 30 years in both groups. Lowest number of insertions was in the 20-24 age group for both devices. No accidental pregnancies were observed for 12 months of use for either group. Expulsion rate for Nova T was 5.0 and for Copper 200 was 6.5; the difference was not considered significant. The lower expulsion rate associated with higher age range and parity of the Lagos women confirm observation by others that increasing age and parity were associated with declining expulsion rate. Removal rates for bleeding and pain were 1.5 for Nova T and 3.8 for Copper 200. These rates are comparable with those in Europe. Continuation rates were 91.3 for Nova T and 88.2 for Copper 200. It was concluded that use of copper IUDs may help promote a more favorable attitude to use of IUDs in developing countries.

Reproductive performance after the repair of obstetric vesico-vaginal fistulae.

Between 1966 and 1976, 148 out of 162 patients with obstetrically acquired vesico-vaginal fistulae were successfully repaired in Lagos University Teaching Hospital. The reproductive performance of these patients after repair has been reviewed with special regard to menstruation, satisfactory coitus and childbearing. Before the repair of the fistulae 66 patients (40.6%) had secondary amenorrhoea ranging from 4 months to 15 years. There were 3 cases each of oligomenorrhoea and cryptomenorrhoea. After repair menstruation returned within 6 months in 58 patients. Secondary amenorrhoea is thought to be due to a combination of severe malnutrition, anaemia, endometritis, psychological upsets and occasionally endocrine malfunction due to focal anterior pituitary necrosis. Repair of the fistulae worsened gynatresia in 17 cases. Twelve patients had dyspareunia and 3 others had apareunia. Thirty-one patients achieved 38 pregnancies after repair. Thirty-two infants were delivered by lower segment Caesarean section. There were 5 vaginal deliveries and one abortion. The average birth weight was 2.96 kg. The corrected perinatal mortality was nil. Five cases had a recurrence of the fistulae after delivery and 2 others had stress incontinence. Electric lower segment Caesarean section is the ideal method of delivery.

Intravaginal contraception with the synthetic progestin, R2323.

PIP: A Silastic intravaginal ring (IVR) containing R2323 (17 alpha-ethinyl-17 beta-hydroxy-18-methyl-4,9,11-estrien-3-one) in its center core was tested in vitro and in 4 women for 1 cycle each. Initially 330 mg of drug was released/day from the IVR in vitro, and after 150 days the value had declined to about 230 mg. Ovulation was inhibited in the 4 subjects due to the constant release of R2323 as evidenced by the steroid blood levels of 1-3 ng/ml. When the IVR was removed, R2323 blood levels quickly fell to zero. All the women had normal withdrawal bleeding, and 2 subjects followed during a recovery cycle had ovulatory levels of progesterone.^ieng

Important factors in the use-effectiveness of the copper-T-200 IUD.

PIP: The influence of the time insertion of an intrauterine device (IUD), changes in the characteristics of the menstrual flow after insertion, coital frequency, and the administration of prophylactic antibiotics at the time of insertion on evaluative parameters of the use-effectiveness of the TCu-200 IUD was evaluated in 2689 patients. The continuation rate was highest when the device was inserted either during or immediately after menses. The time of insertion had no effect on the rate of accidental pregnancy (p less than .05). Pregnancy did not occur in 95 subjects whose menstrual cycle became more regular, compared to a pregnancy rate of 1.6 for the entire group. The removal rate for bleeding and pain was higher in women who complained of changes in their menstrual cycle. Removals for infection were not markedly changed by treatment with antibiotics, though pregnancy rates were somewhat higher. Coital frequency had no significant effect on any of the parameters.^ieng

Treatment of trichomonal vaginitis with single dose tinidazole (Fasigyn).

A new trichomonacidal agent, Tinidazole, (Fasigyn) has been used in a single oral dose of 2 g in 24 patients with very good results. An over-all cure rate of 100% (6 patients) was achieved in in-patients and of 94% 23 out of 24 patients in out-patients. The failures may be attributed to recurrence due to concomitant bacterial infection or to re-infection by a male partner. This regime is therefore strongly recommended as the treatment of choice for Trichomonal vaginalis infection.