Hysteroscopic and hysterosalpingographic study after intrauterine insertion of quinacrine pellets for non-surgical sterilization: results in 180 women.

OBJECTIVES: Document the effects on the tube and uterus of one, two and three doses of 252 mg of quinacrine. METHOD: The study included 180 fertile women seeking permanent contraception at the Shatby Family Planning Clinic in Alexandria, Egypt, in 1988. All cases received three applications of seven 36 mg quinacrine hydrochloride pellets during the proliferative phase of three consecutive menstrual cycles. The patients were randomly divided into groups A, B and C. Hysterosalpingography (HSG) was performed on the 6th day of menstruation and hysteroscopy on the 10th day of the same cycle after the first application in group A, the second, in group B and the third, in group C. The study was concluded in 1999. RESULTS: HSG showed 52 cases of bilateral obstruction, four of bilateral patency, and four of unilateral patency in group A. All in groups B and C elicited bilateral tubal obstruction. Cornual obstruction was seen in 33%, 65% and 85% in group A, B and C, respectively. Intramural obstruction was found in 50%, 33% and 10% in the three groups. Isthmic tubal obstruction was detected in 8%, 2.5% and 5% in groups A, B and C, respectively. Four types of ostial appearances could be recognized hysteroscopically. Type 0 (patent tubes), Type I (distal tubal blockage), Type II (intramural obstruction) and Type III (cornual obstruction). In group A, Type 0 was evident in 10%, Type I in 8%, Type II in 50% and Type III in 33% of cases. The respective figures in group B were 0%, 2.5%, 33% and 65%, while in group C, they were 0%, 5%, 10% and 85%. Hysteroscopy showed no abnormal endometrial findings in group A, but 35% and 85% of cases in group B and C showed some changes. CONCLUSIONS: Two applications of quinacrine were 100% effective. The side effects of quinacrine pellet applications were minimal and well tolerated by all the users. The possibility of reversal of the procedure is outlined.

Development of flexible culdoscopy.

STUDY OBJECTIVE: To assess correlation between findings at standard laparoscopy and office flexible culdoscopy. DESIGN: Observational study (Canadian Task Force classification II-1). SETTING: University-affiliated hospital. PATIENTS: Eleven women undergoing diagnostic laparoscopy to evaluate infertility. INTERVENTIONS: Microlaparoscopy and flexible culdoscopy. In the first six cases laparoscopy was performed first followed by culdoscopy; in the last five cases the order was reversed. MEASUREMENTS AND MAIN RESULTS: The number of endometriotic implants or adhesions was counted for both operative techniques. The flexible 2.2-mm culdoscope provided a view of the pelvis similar to the laparoscope. Correlation between the procedures was 100%. The flexible scope achieved better visualization than the standard rigid posterior cul-de-sac culdoscope. CONCLUSION: Flexible culdoscopy is a excellent procedure for diagnostic endoscopy. It correlates well with office laparoscopy, requires less anesthesia, and is better tolerated by patients. Several operative procedures are currently being tested through this mode of access.

Laparoscopic Pelvic Adhesiolysis Using CO2 Laser

Pelvic adhesions constitute one of the main problems in infertility management. In this study the role of CO2 laser in managing this problem was assessed. One hundred sixty-seven patients with pelvic adhesions suffering from chronic pelvic pain and inability to conceive [Primary infertility 58 (34.7%), secondary infertility 109 (65.3%)] were included in this study. The patients were categorized by diagnostic laparoscopy as mild, 72 (43.1%) group I; moderate, 58 (34.7%) group II; and severe 37 (22.2%) group III. All patients were subjected to operative laparoscopy (3 puncture technique) and CO2 laser adhesiolysis using the Surgilase 50. All patients were followed for one year after the procedure. Complete relief of pain was observed in 60 (83.3%), 36 (62.1%) and 19 (51.4%) women in group I, II, and III, respectively. Pregnancy occurred in 51 (70.8%), 28 (48.3%), and 8 (21.6%) patients in group I, II, and III, respectively. CO2 laser is a precise and effective means of pelvic adhesiolysis in properly selected patients.

Hysteroscopic and hysterosalpingographic study after intrauterine insertion of quinacrine pellets for non-surgical sterilization.

60 fertile females seeking permanent contraception were included in this study. All cases received 3 applications of 7 36 mg quinacrine hydrochloride pellets during the proliferative phase of 3 consecutive menstrual cycles. The patients were randomly divided into 3 groups. Hysterosalpingography was performed on the 8th day of menstruation and hysteroscopy on the 10th day of the same cycle after 1st application in group A, after the 2nd application in group B, and after the 3rd application in group C. Hysterosalpingography showed 17 cases of bilateral obstruction, 1 case of bilateral patency, and 2 cases of unilateral patency in group A, while in groups B and C, all elicited bilateral tubal occlusion. Cornual obstruction was seen in 33%, 65%, and 85% in groups A, B, and C, respectively. Intramural obstruction was seen in 50%, 33%, and 10% in 3 groups. Hysteroscopy showed no abnormal findings in group A, while 35% and 85% of cases in groups B and C showed some changes. 4 types of ostial appearances could be recognized hysteroscopically: Type 0 (patent tubes), type I (distal tubal blockage), type II (intramural obstruction), and type III ( cornual obstruction). In group A, type 0 was seen in 10%, type I 80%, type II 50%, and type III 33%. The respective figures in group B were 0%, 2.5%, 33%, and 65%, while in group C, 0%, 5%, 10%, and 85%. 2 applications of quinacrine are 100% effective, the hysteroscopic endometrial changes detected were transient. The possibility of reversal of the procedure is outlined.

Hysteroscopic findings in complicated and non-complicated IUD users.

The hysteroscopic findings in 100 IUD users have been evaluated. 50 women had no IUD-related problems and requested removal of the device, while the other 50 complained of either bleeding and/or pain or lost strings. Of the 29 cases with IUD-related bleeding and/or pain, hysteroscopy revealed malposition (n=6), partial expulsion (n=3), partial perforation (n=2), embedding (n=1), or disproportion (n=6). Disproportion presented as crumpling of the device in the uterine cavity or protrusion of the tip of the transverse arm inside the tubal ostia. Endometrial lesions were also more commonly seen in the study group than the control group, i.e., endometrial hyperplasia (n=8), endometrial polyps (n=8), intrauterine adhesions (n=5), and submucous fibroids (n=2). Of the 21 IUD patients with missing strings, there were previous failed trial of blind removal in 11 cases. Most lost IUDs were found inside the uterine cavity (81%) with curling and ascending strings. Partial perforation, abdominal translocation, and unnoticed complete expulsion were detected in 19% of the patients. Direct visualization of the endometrial cavity is invaluable in treating IUD users who complain of pain and/or bleeding and in locating and retrieving missing IUDs.

Changes in genital vasculature after tubal Falope-ring sterilization.

PIP: 10 women for whom total abdominal hysterectomy and bilateral salpingo-oophorectomy was planned had unilateral Falope ring sterilization 1 month previously by laparoscopy to provide specimens for study of the vasculature of the ovary and fallopian tubes. The indication for hysterectomy was unremitting uterine bleeding uncontrolled by curettage. The subjects ranged in age from 30 to 46 (mean 40.3 years) and in parity from 4 to 11 (mean 6.1). The specimens were injected with 50% lead oxide in 10% formol in the uterine and ovarian arteries, and with barium in the uterine and ovarian veins. X-ray films were taken the same day. all specimens showed venous dilation. In all cases the ovarian branch of the uterine artery and its anastomoses with the ovarian artery were intact. The degree of compromise of the arterial circulation depended on the position of the Falope ring, less damage when the ring was on the medial or middle tube, and more damage when it was more distal. Circulation to the ligated tube distal to the ring was diminished. The implications of these results on the possibility of menstrual irregularities after tubal sterilization and on potential for reanastomosis were discussed.^ieng

Changes in the circulating levels of hemoglobin, hematocrit, serum iron and total iron binding capacity after four methods of surgical tubal sterilization.

One-hundred women requesting voluntary surgical sterilization were included and enrolled into four groups (each n = 25). Four sterilization modalities were used namely: Falope ring, electrocoagulation, clip and Pomeroy ligation. The circulating levels of hemoglobin, hematocrit, serum iron and total iron binding capacity were studied before sterilization and at 3, 6 and 12 months thereafter. No significant changes were observed at 3 and 6 months post-sterilization. At 12 months a significant increase in the hemoglobin and serum iron was observed with a significant decrease in total iron binding capacity. Falope ring, clip and Pomeroy ligation were of a higher rank in this context versus electrocoagulation.

Prostaglandins and cellular reaction in uterine flushings. I. Effect of IUD insertion.

Uterine prostaglandin (PG) levels and cellular reaction in response to IUDs were elevated in sixty women. Short-term users (n = 30) were studied in a control cycle and 3 months after IUD insertion, and long-term users (n = 30) were studied at least 2 years after device insertion. A uterine wash was performed in the proliferative and luteal phase of each investigated menstrual cycle; the cellular components were counted and levels of PGE2, PGF2 alpha and their 13,14-dihydro-15-keto metabolites measured. A significant rise in PG levels was observed in the uterine wash shortly after IUD insertion, particularly in the luteal phase. However, there was a significant reduction in PG levels among long-term users, though the cellular reaction showed a continued increment. The absence of correlation between the biochemical and biological responses indicated that neither of them was totally dependent on the other. The decreased PG levels among long-term users does not support the concept of a key role for these substances in the mechanism of action of IUDs. The temporary post-insertion rise in PG levels coincides with the phase of increased bleeding and pain.

Prostaglandins and cellular reaction in uterine flushings. II. Effect of PG synthesis inhibition in IUD users.

The effect of oral administration of indomethacin (100 mg/day), a potent inhibitor of prostaglandin (PG) biosynthesis, on the PG levels and cellular profile in the uterine flushings in response to the use of an IUD (Lippes Loop size C) was studied in sixty women. Indomethacin reduced the cell counts in both follicular and luteal phases of menstrual cycles before and after IUD insertion. The anti-inflammatory drug decreased PGE2 and PGF2 alpha levels in both phases of the cycle before IUD insertion. After insertion, it inhibited only the formation of PGF2 alpha and its 13,14-dihydro-15-keto metabolite in the luteal phase but not in the follicular phase. In long-term users, however, the drugs reduced the levels of all PGs studied in the luteal phase and only PGF2 alpha and its metabolite in the follicular phase. The implications of these findings in the mechanisms of contraceptive action of IUDs and their side effects are discussed.

Blood hormone levels in egyptian women on norethisterone oenanthate.

Ten Egyptian women who were using the injectable contraceptive norethisterone oenanthate (NET-OEN) for at least 6 months were monitored weekly for a period of 12 weeks by measuring 3 pituitary hormones (FSH, LH and prolactin) and 2 ovarian hormones (oestradiol 17-B and progesterone). It was concluded that NET-OEN is a strong ovulation inhibitor, at least after its use for 6 months. Prolactin levels were depressed and this is in contradiction with the findings in rats.

PIP: 10 Egyptian women who were using the injectable contraceptive norethisterone enanthate (NET-EN) for at least 6 months were monitored weekly for a period of 12 weeks by measuring 3 pituitary hormones (FSH, LH, prolactin) and 2 ovarian hormones (estradiol 17-B and progesterone). It was concluded that NET-EN is a strong ovulation inhibitor, at least after its use for 6 months. Prolactin levels were depressed and this is in contrast to the findings in rats.

Effect of Lippes loop on sperm recovery from human fallopian tubes.

Recovery of human sperm from the fallopian tubes after natural insemination have been studied in sixty women; out of these, thirty cases were fitted with the Lippes loop, type C, for at least six months. The mean sperm count/high power field (HPF X 400) and percentage of motile sperm in the cervical mucus in both control and Lippes loop groups showed no significant differences. No sperm were recovered from the fallopian tubes of the Lippes loop group, while fourteen control cases had a positive recovery of sperm from the tubal washings. The mean number of white blood corpuscles in the tubal washings of Lippes loop-fitted cases was found to be significantly higher than in control cases. The phagocytic capacity of these cells may explain the low incidence of sperm recovered from the fallopian tubes in such cases.

PIP: 60 multiparas requesting permanent sterilization were selected for this study of the recovery of spermatozoa from fallopian tubes after natural insemination. Ages ranged from 23-45 years. All subjects received hormonal contraceptives for at least 6 menstrual cycles before the operation. Of these 60 subjects, 30 were fitted with Lippes Loop C-type IUDs; the other 30 women constituted the controls. Cervical mucus samples were taken after intercourse to determine sperm density and motility. In both groups, the mean sperm count per high powered field and the percentage of motile sperm in the control vs. Lippes loop group showed no significant differences (P .05). In terms of tubal sperm recovery, in all Lippes loop-fitted women, no sperm were recovered from the fallopian tubes. Sperm were recovered from tubal washing of 14 of 30 controls. The number of recovered sperm per tube ranged from 1-35 with a mean of 10.1 sperm per tube. In the control groups, the mean number of leukocytes per high power field was 7.6 and 10.5 in the tubal washings with negative and positive sperm, respectively. In Lippes loop cases, the mean number of leukocytes was 38.9, significantly higher than both groups (i.e., negative and positive sperm) of control cases (P .05). Hence it is concluded that that the phagocytic capacity of these cells may explain the low incidence of sperm recovered from fallopian tubes of IUD users.

Biochemical and cytochemical changes of alpha-esterases activity in long-term oral contraceptive users.

PIP: The alpha-esterases activity was measured in the serum and vaginal fluid of 39 women who used (OCs) oral contraceptives for long periods of time (12-15 years). The results were compared with the activity of 30 control fertile females who did not take any OCs. The alpha-esterases activity was measured by cytochemical and modified simple reproducible biochemical methods. The biochemical study revealed that serum alpha-esterases activity is not affected either by long-term use of OCs or by different types of cervical infections. On the other hand, the cytochemical and biochemical results show that there is a significant increase in the activity of vaginal alpha-esterases in pill users accompanied with cervicitis. The increase in vaginal alpha-esterases activity may shed light on the possible relationship between the activity of alpha-esterases and malignancy.^ieng

Effect on prolonged use of oral contraceptive pills on the activity of serum and vaginal ribonuclease.

PIP: 39 longterm oral contraceptive (OC) users (12-15 years) and 30 women who have never used OCs were studied to determine the activity of free alkaline ribonuclease (RNase) in vaginal fluid and in serum. All women were of reproductive age. Of the 30 controls, 14 had cervical erosions, and the remainder were clinically healthy. Of the 39 cases, 12 were clinically free of cervicitis or cervical erosion, 21 had some sort of cervicitis, and 6 had trichomonal vaginitis. The group of women using OCs who had cervical infections showed a significant increase in the RNase activities compared with the clinically free pill users (P .025 and .005, respectively). The activity of serum and vaginal free alkaline RNase activity was higher and statistically significant in the controls with cervical erosion compared with clinically free controls (P .001). In addition, OC users with cervicitis showed a significant increase in vaginal RNase activity compared with clinically free pill users (P .001), whereas the difference in mean serum RNase was not significant between these 2 groups. Specifically, OC users with trichomonal vaginitis had significantly higher serum and vaginal RNase activity values than nonpill users who were clinically free or who had trichomonas. The OC users with trichomonas showed only a significant increase in serum free RNase compared with OC users with cervicitis (P .001).^ieng

Management of missed abortion and fetal death in utero.

Termination of pregnancy in missed abortion and intra-uterine fetal death was accomplished using vaginal suppositories of 20 mg PGE2 in 31 cases and the results were compared with oxytocin induction (with or without estrogen pre-treatment) in 17 cases at the doses routinely used in our hospital. The PG suppositories proved much more superior (96.7%) than oxytocin (47.7%), but induced a higher rate of side effects. The latter were not serious and were generally tolerated by the patients. There was a positive correlation between duration of fetal retention in utero and the induction expulsion time. The over all patient acceptance of the method was quite favourable and the approach appears to be a definite advance towards management of these cases.