The impact of the Lagos manual vacuum aspiration (MVA) training courses on medical education.

The Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos commenced training programmes in the use of manual Vacuum Aspiration (MVA) for the treatment of septic abortion in 1989. The courses were evaluated using pre-tests and post-tests, and those of the participants from the first 5 years were analysed. 142 doctors and 72 nurses were trained from teaching hospitals, parastatal and private hospitals. The results of 154 participants (71%) were recovered and analysed. The training courses significantly increased the medical knowledge of both doctors and nurses; those from the Teaching Hospitals appearing to gain more. The amount of knowledge gained by those from the private sector, although showing a statistically significant increase was much less than the other participants. More emphasis should be placed on improving the performance of those from the private sector.

Metabolic effects of once-a-month combined injectable contraceptives. The World Health Organization Task Force on Long-Acting Systemic Agents for Fertility Regulation, Geneva, Switzerland.

The results of metabolic studies on once-a-month combined injectable contraceptives are summarized, focusing on four preparations: dihydroxyprogesterone acetophenide 150 mg/estradiol enanthate 10 mg; depot-medroxyprogesterone acetate 25 mg/estradiol cypionate 5 mg; norethisterone enanthate 50 mg/estradiol valerate 5 mg; and 17 beta-hydroxyprogesterone caproate 250 mg/estradiol valerate 5 mg. Their effects on carbohydrate metabolism, lipid metabolism, hemostasis, serum prolactin, cortisol, binding globulins and liver functions are reviewed. Areas requiring further research are identified.

A review of referred IUCD related problems in Lagos University Teaching Hospital.

A review of 168 patients referred with IUCD related problems was done. The two most common indications for referrals were difficulty at removal (73.8%) and missing/lost IUCD thread 23.8%. In 22.5% (9) of cases referred as missing/lost IUCD, the threads were visible on inspection of the cervix during speculum examination 21.4% (36) of the referred patients had routine removal by simple traction, while the retrieval hook was successfully used in 75% of the cases, only 3 patients (1.7%) required removal under general anaesthesia. A proper speculum examination combined with uterine sounding and the use of the retrieval hook at the peripheral centres will greatly reduce the need for referring IUCD related cases to a tertiary centre.

A multicenter clinical trial in Nigeria with a low-dose oral contraceptive, Marvelon.

The monophasic combination preparation, Marvelon, is a modern, technically improved oral contraceptive. It was tested for contraceptive reliability, cycle control and acceptability in 4 clinical centers in Nigeria for a period of one year. A total of 408 women was included in these studies, and 3102 cycles were monitored. The results showed a high contraceptive reliability and an excellent cycle-control. It was well tolerated. There were very few side-effects and the symptoms during medication were minor and hardly needed any treatment. At 12 months, 43.1% of the acceptors were still in the trial. Seventy-nine women (19.4%) discontinued before the end of the study for any reason. Drop-out reasons of these women were mainly non-medical. For the remainder of drop-outs no reason was given. This study suggests that this new oral contraceptive adequately satisfies the contraceptive needs of modern women.

Erect lateral pelvimetry and the outcome of labor in Lagos.

The erect lateral radiograph pelvimetry measurements was related to the outcome of labor in 173 patients. The most common indication for pelvimetry was one previous caesarean section in 90 (52%) patients. Sixty-nine (39.9%) pelvimetry measurements were performed because of suspected cephalopelvic disproportion, while 20 (11.6%) were done because of breech presentation. In patients with a cephalic presentation at delivery, the mean +/- standard deviation (SD) obstetric conjugate for the 87 women who delivered vaginally (group 1) was 11.42 +/- 1.5 cm, while that of the 45 women who had emergency caesarean section (group 2) was 10.77 +/- 1.5 cm. The mean +/- SD anteroposterior outlet diameter for groups 1 and 2 were 12.24 +/- 1.9 cm and 11.84 +/- 1.7 cm respectively. Both differences were found to be statistically significant (p < 0.001 and p < 0.05 respectively). The mean +/- SD birthweight of the babies in groups 1 and 2 were 3.34 +/- 0.79 kg and 3.42 +/- 0.86 kg respectively. There was no statistically significant difference between the two groups (p < 0.05). The critical obstetric conjugate for safe vaginal delivery was 9.88 cm while the corresponding value for the anteroposterior pelvic outlet diameter was 10.24 cm.

A multicenter clinical trial in Nigeria with Multiload-Cu250 (MLCu250) and Multiload-Cu375 (MLCu375) intrauterine devices.

A multicenter study was conducted in Nigeria, comparing the Multiload-Cu250 (MLCu250) with the Multiload-Cu375 (MLCu375). The two intrauterine devices were studied on aspects of effectiveness and acceptability. Parameters were observed and analyzed, using the life-table method of Tietze and Lewit. Continuation rates were excellent. Overall results were in line with studies done elsewhere in the world with Multiload devices, showing a slight superiority of the MLCu375 over the MLCu250.

Failed contraception in Nigerian women: outcome of pregnancy and subsequent contraceptive choice.

The outcome of pregnancy in 56 patients who had contraceptive failure out of the 5,431 new acceptors at the Family Planning Clinic of the Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, between 1 January 1981 and 31 December 1989, were analysed. There were 40 IUD, 6 OC, and 4 injectable failures. Three patients had had voluntary surgical contraception (VSC) and 3 used barrier methods. The mean +/- SD age and parity were 32.2 +/- 4.4 years and 4.4 +/- 1.9, respectively. There were 17 (30.1%) live births, 34 (56.6%) terminations of pregnancy and 3 (5.2%) spontaneous abortions. Two (3.0%) patients were lost to follow-up. There was neither any statistically significant difference in the outcome of pregnancy between patients with 5 or more children and less than 5 children (p greater than 0.05), nor between patients less than 31 years of age and those older. Fifty per cent of the patients who had used the IUD continued with the method. Seven patients subsequently requested VSC. None of the patients using the injectable contraceptive or barrier methods continued with the method (p greater than 0.05).

PIP: Pregnancy outcome in 56 patients who experienced contraceptive failure out of a pool of 5431 acceptors at the Family Planning Clinic of the Department of Obstetrics and Gynecology, College of Medicine, University of Lagos, Nigeria was analyzed during the period January 1981-December 1989. There were 40 IUD, 6 oral contraceptive, and 4 injectable failures. 3 patients had undergone voluntary surgical contraception (VSC) and 3 used barrier methods. The mean +or- SD age and parity were 32.2 +or- 4.4 years and 4.4 +or- 1.9, respectively. There were 17 (30.1%) live births, 34 (56.5%) pregnancy terminations, and 3 (5.2%) spontaneous abortions. 2 (3.0%) patients were lost to follow up. There was neither any statistically significant difference in the outcome of pregnancy between those patients with 5 or more children and less than 5 children (p.05), nor between patients less than 31 years old and those who were older. 50% of those who had used the IUD continued with that method; 7 patients subsequently requested VSC. None of the patients using injectables or barrier methods continued with that method (p.05).

Maternal weight and weight gain during pregnancy--can the arm circumference be used as surrogate?

A survey among pregnant Nigerian women attending an antenatal clinic showed a strong correlation between the arm circumference and weight. The sensitivity and positive predictive value of mid-arm circumference less than 23 cm for first trimester weight of less than 45 kg was 85.7% and 54.5% respectively. In the second trimester, these values for mid-arm circumference of less than 24 cm and weight less than 50 kg were 55.6% and 32.3% respectively. The specificity was high, ranging up to 99.4%. The value of the screening was found to be higher amongst primigravidas. Mid-arm circumference was however found to be insensitive for monitoring of weight gain during pregnancy. Strips based on this principle may be useful as a screening tool especially for low cadre health workers to identify pregnant women considered nutritionally at risk.

Effect of repeated semen ejaculation on sperm quality.

The semen quality of 21 Medical students who produced sperm by masturbation has been assessed. The mean density of 21 samples examined on the first day was 64,4 millions per millilitre, while that on the third and fifth day of the study period were 52.2 and 50.7 millilitre respectively. This showed a statistically significant difference between the first and the third samples. Another statistically significant difference (P less than 0.5) was demonstrated in the semen volume of the first and third, and the third and fifth samples respectively. Significant differences were, however, not observed in the motility and morphology changes in the group samples. We therefore conclude that even though repeated semen ejaculations on alternate days do affect the density and volume of the semen, the most important overall effect is not such as to impair the potential fertility of the man who has normal initial sperm characteristics.

The attitude of fertile Nigerian women to sterilization.

PIP: 250 women selected at random from outpatients of the Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, Nigeria, were interviewed about their attitudes toward female sterilization by nurses with a standard questionnaire. Factors affecting attitudes toward sterilization were multiple and results are reported as percentages. The study population excluded women with infertility, a common problem, and further differed from the general population because the women were older and more highly educated. The number of living children was 3 or more in 59%; the ideal family size was at least 5 in 48%. 48% had used some type of contraception. 87.6% had heard of female sterilization, most often from medical personnel. Factors reported as affecting attitudes included: number of living children (59.6%); age of patient (52%); experience with complications of pregnancy and labor (45.2%); other medical disorders (36%); effect on reincarnation (17.6%); sex of living children (17.2%); fear of impotence (7.2%); and religion or culture (3.2%). The average age for female sterilization is 40 in Nigeria. A more extensive study of resistance to sterilization is indicated.^ieng

Unstimulated thyroid function indices of Nigerians with secondary amenorrhea.

The unstimulated plasma thyroid indices of triiodothyronine uptake (T(3)U), thyroxine (T(4)), free thyroxine index (FTI), thyroid-stimulating hormone (TSH), and prolactin levels were measured in 56 patients who were complaining of secondary amenorrhea, and in 40 control patients. No significant differences were noted in the plasma indices between the two groups. Mean ± standard error plasma prolactin levels in patients with secondary amenorrhea and in the control patients were 21.8 ± 2 ng/mL and 10.5 ng/mL, respectively. Twenty-two (39 percent) patients who were complaining of amenorrhea had hyperprolactinemia and galactorrhea. The thyroid indices of these patients did not differ significantly from the control group.

Interval out-patient female sterilization in Lagos.

Out-patient sterilization services were introduced by the Family Planning Clinic of the Department of Obstetrics and Gynaecology, College of Medicine, Lagos, in September, 1981. This paper reviews the results of the first five years of its availability. There were 96 out-patient interval sterilizations, 47 were by the laparoscopic and 49 by the minilaparotomy procedures, representing 0.7% of maternities. Both local and general anaesthesia was used for the procedures. The patients' ages ranged from 28-52 years, all but three being above 31 years. Their parity ranged from 2-15 with between 2-10 living children. Only five patients had less than four children. 37.5% had used no contraception before. Termination of pregnancy was performed at the same time as tubal ligation in 12.5%, and 75% of these were secondary to contraceptive failure. Three patients had emergency laparotomy although in only one was it related to the sterilization procedure. Three patients were observed for 24 hours with no complications. Two patients were re-admitted after one week with pelvic peritonitis. The major complication rate was 3.1%. The failure rate was one per cent. There have been no requests for reversal. The results are compared with those of patients having puerperal sterilization during the same period, who totalled 2% of the maternities.

PIP: Outpatient sterilization services were introduced by the Family Planning Clinic of the Department of Obstetrics and Gynecology, College of Medicine, Lagos, in September, 1981. This paper reviews the results of the 1st 5 years of its availability. There were 96 outpatient interval sterilizations, 47 were by the laparoscopic and 49 by the minilaparotomy procedures, representing 0.7% of maternities. Both local and general anesthesia was used for the procedures. The patients' ages ranged from 28-52 years, all but 3 being above 31 years. Their parity ranged from 2-15 with between 2-10 living children. Only 5 patients had less than 4 children. 37.5% had used no contraception before. Termination of pregnancy was performed at the same time as tubal ligation in 12.5%, and 75% of these were 2ndary to contraceptive failure. 3 patients had emergency laparotomy although in only 1 was it related to the sterilization procedure. 3 patients were observed for 24 hours with no complications. 2 patients were re-admitted after 1 week with pelvic peritonitis. The major complication rate was 3.1%. The failure rate was 1%. There have been no requests for reversal. The results are compared with those of patients having puerperal sterilization during the same period, who totalled 2% of the maternities.

Implications of pattern of tubal disease for microsurgery or in vitro fertilization in Lagos.

Tubal disease was found in 78 of 100 consecutive Nigerian patients who had laparoscopy for infertility, while 22 patients had patent tubes. Forty-two patients had bilateral tubal occlusion; 18 had unilateral occlusion, while 18 had gross pelvic adhesions. Forty-one patients had cornual block, and 10 had hydrosalpinges. Multiparas were more prone to unilateral tubal occlusion or gross pelvic adhesions compared with nulliparas. In 27 (35 percent) patients with tubal disease in vitro fertilization (IVF) would be the only suitable treatment, while in another 10 (12 percent) patients with hydrosalpinges, IVF probably offers a better prognosis than microsurgery.

Contraceptive choice in an urban clinic in Nigeria.

PIP: Contraceptive choice in the 1st 1075 acceptors at an urban clinic in Lagos, Nigeria is studied using clinical notes of all patients who attended the clinic between September 1, 1980 and August 31, 1983. Details of previous and current contraception, age, parity and level of education are analyzed. The IUD was the most popular choice followed by the injectable contraceptive and the pill. Interval tubal ligation was chosen by some patients. Acceptors of injectables were older women of high parity and lower educational standard while pill acceptors were of lower parity and higher educational level. The IUD was acceptable to all ages and parities except those with only 1 child or none. Loss to follow-up and the wish to plan another pregnancy were the commonest reasons for discontinuing contraception. Medical reasons for discontinuing the IUD were pain, menstrual disorder, accidental pregnancy and expulsion/perforation; for discontinuing injectables the reasons were menstrual disorder, accidental pregnancy and raised blood pressure. Of acceptors of the 3 main methods, former pill and IUD users were more likely to choose the same method again. A strategy should be devised to encourage patients of lower parities and age to use contraceptives, while sterilization in patients of parity 3 and above should be even more actively advocated. Greater effort should be made to support patients through the 1st 6 months after starting any method as this is the time when a large number of discontinuations occur.^ieng

Adrenal rest tumour of the ovary associated with isosexual precocious pseudopuberty and cushingoid features.

A 2-year-old girl who presented with blindness, aphasia and inability to move the right arm and leg following a convulsive episode was found to have hypertension, precocious pseudopuberty, features of Cushing syndrome and an ovarian tumour. The hormonal profile suggested an adrenal cortical tumour, which turned out to be located in the ovary and the cause of the ovarian enlargement. Following removal of the mass, all the abnormal features regressed and the blood pressure returned to normal.

Donor insemination in Lagos.

The results of AID in a population with a high incidence of female factors is reported. Thirty-one patients started AID on 35 occasions resulting in 25 pregnancies and a cumulative conception rate of 71% at 8 months. Eleven patients with female factors present became pregnant. Some problems of AID practice in Lagos are highlighted.

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