Effect of replacement of antibiotics with thyme and celery seed mixture on the feed intake and digestion, ruminal fermentation, blood chemistry, and milk lactation of lactating Barki ewes.

The study investigated the effect of in-feed administration of dried thyme leaf and celery seed mixture (at 1 : 1 DM basis) compared with salinomycin ionophore on milk production and milk nutritive value of Barki ewes. Thirty ewes (37.5 ± 1.8 kg), divided into 3 treatment groups, were fed: (1) a complete control diet comprising concentrates and fodder maize (Zea mays L.) at 60 : 40 dry matter basis, (2) the control diet plus 20 g of thyme and celery mixture supplementation and (3) the control diet supplemented with 1 g of salinomycin per ewe daily for 90 days. Inclusion of thyme-celery treatment increased (P < 0.05) weight gain, average daily gain, milk yield, milk component yields, and feed efficiency, without affecting milk composition. In addition, the thyme-celery treatment enhanced (P < 0.05) nutrient intake and digestibility, total ruminal volatile fatty acids, branched chain fatty acids, and acetate proportions and decreased ammonia-N concentration. Thyme-celery treatment increased (P < 0.05) serum glucose, thyroxine, and glutamate-pyruvate transaminase concentrations. It is concluded that the thyme and celery mixture (1 : 1 DM basis) at 20 g per lactating ewe daily can replace the salinomycin ionophore. Enhanced feed utilization and lactational performance as well as milk nutritive value for human consumption were observed with the natural additive mixture supplementation.

Rising cesarean section rates, a patient's perspective: experience from a high birth rate country.

PURPOSE OF INVESTIGATION: To investigate the effect of social class, education and antenatal care on cesarian section (CS) rate and women's preference for CS. MATERIALS AND METHODS: This is a descriptive study performed on 509 women attending postnatal clinics in three primary care units in Ismailia governorate, Egypt. The study performed via a structured questionnaire including questions related to background socio-demographic data, questions related to obstetrical history for the last pregnancy and delivery, and questions related to economic standards. RESULTS: The study included 266 participants (52.3%) that delivered by CS in their last delivery. CS rate was significantly higher in highly educated women and high economic standard. Only 29 (7.7%) reported that they had preferred CS as a method of delivery. Educational level and economic standards significantly affected the proportion of women preferring CS as a method of delivery (p = 0.02 and p = 0.01, respectively). In a stepwise logistic regression model, significant factors affecting CS rate were: the method of delivery preferred (p < 0.005) and educational level (p < 0.05). CONCLUSION: Educational level and economic standards significantly affected women's preference towards CS and CS rate.

Blood metabolites and hormone-based programmed breeding treatments in anovular lactating dairy cows.

The objectives were to (1) compare blood metabolites and reproductive outcomes in lactating dairy cows not inseminated before (early) and after (late) 100 d in milk (DIM) because of prolonged anovulation or anestrus; and (2) evaluate reproductive responses of cows ≤100 DIM to GnRH+PGF(2α) treatments after a fixed-time artificial insemination (AI; Ovsynch) or after induced estrus (Select Synch). In blood samples collected before initiating hormone-based breeding programs, anovular cows ≤ 100 DIM had the greatest serum total protein and globulin concentrations and the lowest tri-iodothyronine concentrations. Anovular and ovular cows >100 DIM had the greatest serum urea concentrations. Ovaries in cows (n=40) >100 DIM were examined by transrectal ultrasonography, and those without a detectable corpus luteum (CL; anovular) were given GnRH and then PGF(2α) 7 d later (Select Synch), whereas cows with a CL (ovular) were given 2 PGF(2α) injections 12 d apart. Cows were inseminated at observed estrus after the second or only PGF(2α) injection. More ovular (79%; 15/19) than anovular cows (24%; 5/21) were detected in estrus. No differences were detected between ovular and anovular cows in DIM at first AI, conception rate to first AI, cumulative pregnancy rates, number of services per conception, or days open. Cows (n=93) ≤100 DIM were assigned randomly to 3 treatments: (1) control (n=20) AI at estrus; (2) GnRH and then PGF(2α) on 7d (Select Synch; n=42) and monitored for signs of estrus for 5d and AI accordingly; or (3) 2 GnRH injections 9 d apart with PGF(2α) given 48 h before second GnRH injection and AI at 16h after the second GnRH injection (Ovsynch; n=31). Among cows ≤100 DIM, controls had more days to first service (149±16 d) than Select Synch cows (117±7 d). Ovsynch cows had the fewest days to first service (84±10 d) compared with control (149±16 d) and Select Synch (117±7 d) cows. Conception rates in control (25%) and Select Synch (26.2%) cows did not differ from those in Ovsynch cows (29%). Ovsynch cows had greater cumulative pregnancy rates and fewer days open than control (161±20 vs. 258±29 d), but did not differ from Select Synch (233±19d). Timed AI produced comparable fertility and superior cumulative pregnancy rates, fewer days to first service, and fewer days open than AI at observed estrus in cows inseminated ≤100 DIM.

The use of nomegestrol acetate subdermal contraceptive implant, uniplant, during lactation.

Uniplant is a single contraceptive implant intended for one year use. It contains the progestogen nomegestrol acetate. The clinical performance and the effect of its use during the first postpartum year on breastfeeding performance and growth and health of the infants were studied and compared to the findings in a parallel group who used an intrauterine contraceptive device (IUD) in a prospective, non-randomized study. This was carried out in Assiut, Egypt. Two-hundred-forty fully breastfeeding mothers asking for initiation of contraception early postpartum were assigned according to their choices into either nomegestrol subdermal contraceptive implant (Uniplant) (120 women) or intrauterine contraceptive device (CuT 380A) (120 women). The mother and infant pairs were followed up at monthly intervals during the first three months and at two-month intervals thereafter up until the first birthday of the baby. No pregnancy occurred in the two groups. Amenorrhea was significantly more prolonged in the Uniplant group than in the IUD group. There were no significant differences in net continuation rates between the two groups (88.3 versus 92.4 per 100 women, respectively). There were no significant differences between the two groups in the number of breastfeeding episodes, time of weaning, and the cumulative rates of full and partial breastfeeding. There were no significant differences between the two groups in infant weight, weight gain per day, or in infant linear growth. There were no significant differences in the incidence of important health problems affecting the infants of the two groups. However, there were seven infant deaths, six of them were in the Uniplant group. Uniplant subdermal contraceptive implants can be offered as a new contraceptive option suitable for nursing mothers.

PIP: During November 1992-November 1994 at Assiut University Hospital in Egypt, 120 of 240 fully lactating women requesting contraception during the second postpartum month chose the nomegestrol acetate contraceptive subdermal implant Uniplant, while the other 120 chose the copper-releasing IUD CuT 380A. This prospective, non-randomized study evaluated the use of Uniplant during lactation. The mothers and their infants were followed-up once a month for 3 months and then every 2 months up to the infants' first birthday. Neither group experienced a pregnancy. Women in the Uniplant group were less likely to have resumed menstruation at 12 months postpartum than those in the IUD group (38% vs. 63%; p 0.001). The 12-month net continuation rates were statistically similar (88.3% for Uniplant users and 92.4% for IUD users). Reasons for IUD discontinuation were infant death (6), lost to follow up (5), irregular bleeding (2), and depression (1). Reasons for Uniplant discontinuation were lost to follow up (4), irregular bleeding (2), moving to a distant residence (2), and infant death (1). The 2 groups were similar in terms of breast feeding episodes, time of weaning, and the cumulative rates of full and partial breast feeding. Health problems (diarrhea, fever, and cough) affected the infants of both groups at similar incidence rates. The infants in both groups had similar weight, weight gain per day, and linear growth. Six of the 7 infant deaths occurred in the Uniplant group. The difference in the infant death rate was not significantly different, however. Gastroenteritis was responsible for 5 infant deaths. Bronchopneumonia and unexplained convulsion claimed the life of 1 infant each. These findings suggest that Uniplant is an acceptable and effective contraceptive method during lactation and has no adverse effect on infant growth and health.

The perimenopause and contraception.

OBJECTIVES: To review the implications of pregnancy in women in their forties and the contraceptive options open to them. METHOD: Medline and popline reviews of the literature. RESULTS: Women in their forties are still potentially fertile, and pregnancy in this age group is attended with increased maternal mortality, spontaneous abortion, fetal anomalies and perinatal mortality. In developing countries, these risks are compounded by high parity and poor medical care. Contraception for women in this age group has special risks and benefits, both should be balanced to choose between the different options available. Recent epidemiological and clinical pharmacology studies have indicated the safety of extending the use of combined oral contraceptives (COCs) beyond the age of 35 years and up to menopause. The improved picture of COCs has largely resulted from the use of low-dose-formulations, and avoidance of their use in women with risk factors for developing cardiovascular diseases. Besides their high reliability, which is desirable at this age, COCs will prevent the occurrence of climacteric symptoms and menstrual irregularities which are frequently complained of in the premenopausal years. Moreover, the use of COCs has a substantial protective effect against ovarian and endometrial cancers. Women who have reasons for avoiding COCs can use progestogen-only contraceptives like pills, depot injectables and implants. Norplant combines high efficacy and the long-term effect. Both copper-releasing and levonorgestrel-releasing IUDs (LNG-IUD) combine the advantages of high efficacy and long term effect. The reduced fecundity above the age of forty can allow extending the use beyond the accepted term, and up to one or two years beyond the menopause without the need for replacement. The levonorgestrel IUD has the advantage of reducing the amount of menstrual bleeding. The extent of use of barrier methods will depend upon the availability of a back-up by abortion service in case of failure. The condom has the added benefit of protection against STDs. Male or female sterilization is an excellent contraceptive option, provided that this approach is culturally acceptable and available at reasonable cost and low risk. CONCLUSION: Increasing the number of contraceptive options available to premenopausal women will improve proper counseling and enhance compliance.

Multicenter clinical trial on the efficacy and acceptability of a single contraceptive implant of nomegestrol acetate, Uniplant.

Uniplant, a single Silastic implant containing nomegestrol acetate, provides contraceptive efficacy for one year. Uniplant use for one year was studied in 1,803 healthy women of reproductive age, enrolled from 10 centers in 9 countries, after informed consent. Implants were placed subdermally either in the upper arm or in the gluteal region. Two-hundred-seventy-six subjects discontinued prior to completing one year of study. Cumulative discontinuation rate at 12 months was 15.72%. Medical reasons for discontinuation were principally menstrual-related. Fifteen pregnancies occurred during the one year study period, resulting in a 12-month net cumulative pregnancy rate of 0.94%. Approximately 56% of subjects using Uniplant had bleeding patterns similar to normal menstruation. Results from this study confirm that Uniplant is an efficient, well tolerated, 12-month contraceptive implant, with the advantage of easier insertion and removal of the single implant compared to other multiple implant methods.

Comparative study on intermittent versus continuous use of a contraceptive pill administered by vaginal route.

A multicenter, international, randomized, comparative trial was conducted to assess the acceptability, efficacy and safety of two different schedules of a contraceptive pill, containing 250 micrograms levonorgestrel and 50 micrograms ethinyl estradiol, administered by the vaginal route. One schedule of daily administration for 21 days with a seven-day interruption to allow withdrawal bleeding was compared to daily administration without interruption for bleeding. A total of 900 women were recruited in three countries, Brazil, Egypt and China; 7,090 women-months of vaginal pill use were recorded (3,364 using the pills intermittently and 3,726 continuously). Four undesired pregnancies occurred, one in Egypt and three in China, all four in women using the pills intermittently. There was a statistically significant difference (p = 0.486) in pregnancy rate between the two groups. There were no other significant differences in discontinuation rates despite marked differences in bleeding patterns, amenorrhea predominating in the continuous use group. Hemoglobin levels increased significantly in the two groups but hematocrit was significantly higher in the continuous use group.

PIP: 900 healthy women 16-42 years old were recruited in Brazil, China, and Egypt for a multicenter, randomized, comparative clinical trial to determine the acceptability, efficacy, and safety of two different schedules of a contraceptive pill with 250 mcg levonorgestrel and 50 mcg ethinyl estradiol administered vaginally. The two schedules were: 1) daily vaginal use of the pill for 21 days, followed by withdrawal for regular bleeding, and restarted 7 days later, and 2) use of the pill by the vaginal route nonstop for one year. There were no significant difference in cumulative discontinuation rates between the two groups (total, 15.5 for intermittent group and 14.64 for continuous group), except for unwanted pregnancy. The only unwanted pregnancies occurred to 4 women in the intermittent group (1.04%) (p = 0.0486). Women in the continuous use group were more likely than those in the intermittent group to have spotting at least once (20.6% vs. 4.4%; p 0.001). Women in the continuous group were more likely than those in the intermittent group to have amenorrhea. For example, the mean number of bleeding/spotting days during all time intervals was lower for the continuous group than for the intermittent group (p 0.001; last interval, 0.97 vs. 12.83). Hemoglobin levels increased considerably in both groups between baseline and one year of use (11.61 vs. 11.9 g/dl for intermittent group and 11.54 vs. 11.81 g/dl for continuous use; p 0.001). The mean value of hematocrit at 12 months for the continuous group was higher than that at baseline (38.8% vs. 38.2%; p = 0.011). It did not increase in the intermittent group, however. Women in both groups gained weight during the 12 months of pill use. The weight gain was significant for the continuous group only. These findings suggest that continuous use of vaginal contraceptive pills may be more advantageous than intermittent use oral contraceptives and may benefit anemic women and those who bleed heavily during menstruation.

Digital and palmar dermatoglyphics of two Egyptian northern Sinai tribes.

Digital and palmar dermatoglyphics were analyzed in two northern Sinai tribes. The sample consists of 200 normal individuals (males and females), 100 from each tribe. The results were compared to urban Egyptians and some selected African tribes. A high degree of similarity was observed in most of dermatoglyphic traits between each tribe and the urban Egyptian sample. Certain quantitative dermatoglyphic traits of the two tribes showed a strong resemblance to those of African populations. These results may point to a common gene pool of the two tribes and the urban Egyptians. Moreover, the present study suggests some genetic admixture of the northern Sinai tribes with the neighboring African populations. The study emphasizes that the dermatoglyphic features are important biological elements that may prove or disprove the phenotypical and genotypical relationships between various populations in the different environments and geographical locations.

Comparative study on the efficacy, acceptability, and side effects of a contraceptive pill administered by the oral and the vaginal route: an international multicenter clinical trial.

The objective of this multicenter randomized clinical trial was to compare the efficacy, acceptability, and occurrence of side effects associated with the oral versus vaginal route of administration of contraceptive pills. Eight hundred nineteen healthy, parous women of reproductive age were recruited at family planning clinics and research centers, members of the South to South Cooperation in Reproductive Health, in seven countries of the developing world. These women were randomly assigned to use either oral or vaginal administration of the same contraceptive pill, which contained 250 micrograms levonorgestrel and 50 micrograms ethinyl estradiol. No statistically significant differences were found in discontinuation rates between the two groups after 1 year. Involuntary pregnancy rates after 1 year were not statistically significantly different between the two groups. The vaginal route of administration appears to be as acceptable and efficacious as the oral route.

PIP: The objective of this multicenter randomized clinical trail was to compare the efficacy, acceptability, and occurrence of side effects associated with the oral versus vaginal route of administration of contraceptive pills. This study started in June, 1987, and data collection extended up to April, 1992, at family planning clinics and research centers, members of the South to South Cooperation in Reproductive Health, in seven countries of the developing world. The 819 subjects were from 17 to 39 years of age, had already had at least one pregnancy, had had regular menstrual cycles for 3 months before, were exposed to the risk of pregnancy, and were not using any other method of contraception. 424 were randomly assigned to use the pills orally (which contained 250 mcg levonorgestrel and 50 mcg ethinyl estradiol), whereas 395 inserted the pills vaginally. 625 subjects completed at least 6 months of use, 326 used the pills orally and 299 used the pills vaginally. 385 subjects completed 1 year of pills use, 201 in the oral group and 184 in the vaginal group. The 1-year discontinuation rate per 100 subjects per year for the oral group was 34.71 +or- 2.42, while it was 36.35 +or- 2.53 for the vaginal group. This difference was not statistically significant. The only single reason of statistically significant difference for discontinuation was "desire for pregnancy" (p = 0.444). Paired value analysis of subjects completing 12 months of study showed that women in the oral group had a statistically significant increase in weight, from a mean of 55.8 kg at admission to a mean of 56.9 kg at 6 months (p 0.05) and 57.3 kg at 1 year (p = 0.05). The mean weight of the vaginal group increased from 56.52 kg to 57.22 kg (p = 0.036) at 12 months. Significantly more complaints of vaginal discharge were recorded in women using the pills by the vaginal route (p = 0.001). However, only one subject discontinued the pills because of vaginal discharge.

Sonographic assessment of ovarian and endometrial changes during long-term Norplant use and their correlation with hormonal levels.

OBJECTIVE: To study the probability of ovulation and subclinical abortion during long-term use of Norplant and to assess the concomitant endometrial development. DESIGN: This was a prospective nonrandomized comparative study. The ovaries and endometrium were assessed daily by ultrasonography during 59 menstrual cycles in 50 women who were using Norplant for > 1 year. Serum concentrations of E2, P, FSH, LH, pregnancy specific beta 1 glycoprotein (Sp1), and hCG were also daily measured. The findings were compared with those in 35 ovulatory cycles in normal fertile women not using contraception. SETTING: Clients of the Family Planning Clinic of Assiut University Hospital (Norplant users) and the hospital women staff (controls). RESULTS: Sonographic and hormonal evidence of ovulation were observed in one third of Norplant users; two of them resulted in conception. However, the majority of these ovulatory cycles showed low midcycle peaks of E2, FSH, and LH and evidence of luteal phase defect (LPD). Excessive follicular enlargement was observed in 46% of the cycles. Norplant users had significantly thinner endometrium that did not exhibit the normal phasic changes in sonographic texture. Apart from conceptive cycles, no rise in Sp1 or hCG was observed. CONCLUSIONS: Norplant acts mainly by inhibiting ovulation, but when this occurs, it is associated with LPD and subnormal endometrial development. Subclinical abortion does not contribute to the contraceptive effect.

PIP: 59 cycles in 50 women with Norplant inserted 18-48 months previously were observed daily with ultrasonic scanning and analysis of serum estradiol, progesterone, FSH, LH, pregnancy-specific beta1 one-glycoprotein (Spl) and hCG, compared to 38 menstrual cycles in matched controls not using contraception. Subjects were all parous, married clients at the Family Planning Clinic of Assiut University Hospital, Assiut, Egypt, or hospital staff controls. 35 of the 38 control cycles were ovulatory, and 3 conceptions were noted by ultrasonic and hormonal criteria. In Norplant users there were waves of folliculogenesis, some even occurring during vaginal bleeding. Estradiol levels were highest when the largest follicles were seen in anovulatory cycles, and lowest in quiescent cycles with no follicle development. This correlation was highly significant (p0.01).

Experience with NORPLANT in Egypt.

Experience with the contraceptive NORPLANT in Egypt dates back to early 1980 when the first multicentre trial was initiated. To date, more than 3000 women have received this contraceptive at the Assiut University Family Clinic alone. Analysis of the overall experience in this clinic has indicated a 5-year cumulative continuation rate of 51 and a pregnancy rate of 1.8 per 100 women. Clinical pharmacology studies pertaining to the safety of NORPLANT in our community have indicated no deleterious effect on the lipid profile, liver functions and blood coagulation system. Two studies conducted in Egypt have indicated that the initiation of NORPLANT use shortly after delivery does not have any unfavourable effect on lactational performance, or on physical or psychomotor development of the breast-fed infants. This is particularly important in Arab and Moslem cultures where prolonged breast-feeding is emphasized. A study utilizing focus-group discussion to assess users' attitudes to NORPLANT has indicated the need to improve the informational/educational package given in the service by emphasizing certain cultural considerations. On the whole, this first implant method has proven to be safe and acceptable in Egypt, where there is a special need for long-term methods for contraception, particularly as sterilization is not socially acceptable.

PIP: Egyptian women first experienced the contraceptive implant, Norplant, in early 1980, but Egypt still has not registered Norplant for public use. The 1980 preintroductory trial Norplant took place in 4 centers. 84% of the women accepting Norplant continued to accept it for more than 12 months. The net cumulative continuation rates at the center in Assiut in southern Egypt were 86.6% at 1 year, 69.2% at 3 years, and 50.9% at 5 years. The 5-year pregnancy rate was 1.4%. The Assiut clinic still provides Norplant (as of early 1993, 3130 Norplant acceptors and more than 10,000 woman-years of Norplant use). Most Norplant acceptors at Assiut (85%) have at least 4 children. Researchers at Assiut University found no changes in serum lipids and a slight, but significant, increase in serum high-density lipoprotein cholesterol after 12 months of using Norplant. They also did not find Norplant to have a significant effect on several liver function tests. This finding is especially important in Egypt where schistosomiasis and acute viral hepatitis are endemic. After 6 months of Norplant use, the Assiut researchers reported a significant increase in factor VII activity and a significant decrease in antithrombin III. Yet these changes were considerably smaller than those in oral contraceptive (OC) users. Besides, OC users experienced changes in other factors which increase blood coagulability. Also in Assiut, 50 lactating mothers used Norplant beginning at the 2nd month postpartum. Norplant did not affect lactational performance or infant health. Further, it did not prevent breastfed infants from reaching the various milestones of psychomental development. Assiut university conducted focus groups to learn about Norplant acceptability. The focus groups emphasized the need for service to improve the information and education they provide clients. A physician at Assiut University calls for facilities to remove Norplant on demand to increase acceptability.

Acute viral hepatitis in pregnancy.

OBJECTIVE: To describe the clinical outcome of pregnancy and vertical transmission of acute viral hepatitis in pregnancy. METHODS: Forty-eight pregnant patients with acute viral hepatitis were evaluated clinically and by abdominal ultrasonography. Serological studies for hepatitis markers were performed using radioimmunoassay. The results were evaluated using Student's t-test and tests of proportion. RESULT: Thirty-five (72.9%) delivered live birth babies at term, while 13 (27.1%) had fetal complications and/or losses. The percentage of fetal complications and/or losses was higher in patients who had non-A, non-B hepatitis (30.8%) than those who had type B hepatitis (25%). The most common fetal complication was premature delivery (14.9%) followed by stillbirth and abortion (8.3%) for each. The overall percentage of vertical transmission of hepatitis B virus was 2 out of 27 (7.4%). CONCLUSION: Acute viral hepatitis carries a high risk for both mother and fetus. Routine vaccination of all susceptible women and babies against hepatitis B is recommended in endemic areas.

Contraception with progestogens and progesterone during lactation.

The growth and development of breastfed infants whose mothers used the contraceptive implants Norplant containing levonorgestrel and the injectable containing norethisterone enanthate were studied. Each group comprised of 120 women who initiated the use during the 5th to 7th week postpartum and were compared with a similar number of IUD using mothers. The breastfeeding performance did not differ between groups. The infants of the three groups performed similarly as regards their physical growth and health as well as the time of acquisition of the various milestones of psychomental development. A vaginal ring releasing 10 mg of the "natural" progesterone per 24 h was tested in breastfeeding mothers. The continuous use of the ring produced a serum level of progesterone around 4 ng/ml. This was effective in augmenting lactational infertility even through the later phases of breastfeeding when such an effect starts to wane off. The use of the ring proved to be acceptable and had no ill-effect on breastfeeding or infant growth or health. Using the natural progesterone as a contraceptive adds a new measure of safety, since the amount of the steroid secreted in the mother's milk will not be effectively absorbed from the infant's gut. These studies suggest the possibility of using two new methods for breastfeeding mothers; Norplant and the progesterone vaginal contraceptive ring. These can be initiated early postpartum, whenever this is considered needed.

PIP: Weight gain and psychomotor development of breastfed infants of Egyptian mothers using Norplant, Cu T-380A IUDs, norethisterone enanthate injectables (NET-EN), Depo Provera and a levonorgestrel minipill were compared in 2 trials. First, groups of 120 women using Norplant and NET-EN were compared to a control group using IUDs, beginning 5-7 weeks postpartum. There were no differences in infant weight gain, mid-arm circumference, triceps-skin-fold thickness, or timing of motor milestones. The mean growth curve of all 3 groups were close to that of the 50th percentile for Egyptian infants. While timing of initiation of supplements was similar in the 3 groups, complete weaning occurred first in the IUD group, second in the Norplant group, and last in the NET-EN users. A second trail compared progesterone implants injected with a trocar that resulted in a blood level of 3 ng/ml for 5 months, with Population Council vaginal rings releasing 10 progesterone/24 hours, and CuT-380A IUDs. Serum progesterone in the ring users averaged 5.2 ng/ml for the 1st 2 weeks, then leveled off at about 4 ng/ml for about 2 months, falling to about 3 ng/ml for the last 3 weeks of use. Each women used 4 rings per year. Evidence of ovulation by ultrasonic vaginal probe and assay of estradiol and progesterone was apparent in 25% of vaginal ring users, compared to 55.9% of controls in the 2nd 6 months postpartum. There was 1 pregnancy in a ring users. The continuation rates were 66.6% for rings and 85.5% for IUDs. The reasons for discontinuation in vaginal ring continuation were logistical problems and unfamiliarity.

The recovery of fertility during breast-feeding in Assiut, Egypt.

A longitudinal study of twenty-six breast-feeding and twelve non-breast-feeding postpartum women was conducted in Assiut, Egypt in order to determine the time that ovulation resumed after childbirth, and the effect of breast-feeding frequency on the period of lactational anovulation. Breast-feeding women experienced the onset of follicular development, vaginal bleeding, ovulation and pregnancy significantly later than women who did not breast-feed. Ovulatory and non-ovulatory breast-feeders reported similar frequencies of breast-feeding episodes. The introduction of dietary supplements commonly preceded ovulation. An algorithm using three simple variables observable to the breast-feeding mother was found to predict up to 100% of the first ovulations. All breast-feeding women who did not give supplements and did not have a vaginal bleeding episode by 6 months postpartum were anovular by strict criteria for ovulation. Ovulation did not precede bleeding or supplementation in the women who experienced these events before 6 months, yielding a highly effective formula for preventing unplanned pregnancy by the informed use of breast-feeding.

PIP: A longitudinal study of 26 breastfeeding and 12 non-breastfeeding postpartum women was conducted in Assiut, Egypt in order to determine the time that ovulation resumed after childbirth, and the effect of breastfeeding frequency on the period of lactational anovulation. The breastfeeding group consisted of women ages 18-40 who had successfully breastfed at least 1 child. Breastfeeding women experienced the onset of follicular development, vaginal bleeding, ovulation and pregnancy significantly later than women who did not breastfeed. Ovulatory and non-ovulatory breastfeeders report similar frequencies of breastfeeding episodes (9-10 times in 24 hours). The introduction of dietary supplements commonly preceded ovulation. An algorithm using 3 simple variables observable to the breastfeeding mother was found to predict up to 100% of the 1st ovulations. All breastfeeding women who did not give supplements and did not have a vaginal bleeding episode by 6 months postpartum were anovular by strict criteria for ovulation. Ovulation did not precede bleeding or supplementation in the women who experienced these events before 6 months, yielding a highly effective formula for preventing unplanned pregnancy by the informed use of breastfeeding.

Acceptability of injectable contraceptives in Assiut, Egypt.

The present work was a randomized comparative study of two injectable progestogen-only contraceptives. The first group (200 subjects) received 150 mg of depotmedroxyprogesterone acetate (Depoprovera) every 84 +/- 7 days and the second (200 subjects) received 200 mg of norethisterone enanthate (Noristerat) every 56 +/- 7 days. Acceptors of injectable contraceptives in Assiut, Egypt, were mainly women looking for fertility termination. Menstrual disruption was the main side effect among both treatment groups. Amenorrhoea was the commonest menstrual complaint and was the main reason for discontinuation in both groups. Only one pregnancy occurred during NET-EN use; two more pregnancies occurred, one in each of the two groups but there were indications that conception preceded the first injection. Menstrual irregularities were generally more frequent with DMPA users. However, DMPA had better one-year continuation rates than NET-EN (68.8 +/- 3.5 and 57.1 +/- 3.6 per 100 women, respectively).

Five-year experience with Norplant implants in Assiut, Egypt.

This report describes the five-year experience of the first 250 acceptors of NORPLANT implants in Assiut, Egypt. The five-year net continuation rate was 58.6 per 100 women. The five-year net cumulative pregnancy rate was 1.6 per 100 women. About three-fourths of those who continued use of this contraceptive through the fifth year reported having regular cycles. There was definite improvement in the bleeding pattern with time. The five-year net termination rate because of bleeding problems was 17.7 per 100 women. After 5 years of NORPLANT use there was a slight, statistically insignificant increase in weight, systolic and diastolic blood pressures. Of those who used contraceptives after the end of the five-year term of NORPLANT, about one-third opted to have reinsertion of the implants for a second term. About 96% of those who used NORPLANT through the fifth year reported that their experience with the contraceptive had been satisfactory.

PIP: This report describes the 5-year experience of the 1st 250 acceptors of Norplant implants in Assiut, Egypt. The 5 year net continuation rate was 58.6/100 women. The 5-year net cumulative pregnancy rate was 1.6/100 women. About 3/4 of those who continued use of this contraceptive through the 5th year reported having regular cycles. There was definite improvement in the bleeding pattern with time. The 5-year net termination rate because of bleeding problems was 17.7/100 women. After 5 years of Norplant use there was a slight, statistically insignificant increase in weight, systolic and diastolic blood pressures. Of those who used contraceptives after the end of the 5 year term of Norplant, about 1/3 opted to have reinsertion of the implants for a 2nd term. About 96% of those who used Norplant through the 5th year reported that their experience with the contraceptive had been satisfactory.

The recovery of ovarian function during breast-feeding.

The pattern of breast-feeding was daily recorded and the serum concentrations of prolactin (PRL), FSH, LH, estradiol (E2) and progesterone (prog) were measured at weekly intervals in 26 breast-feeding mothers from the time of delivery and up to the resumption of regular ovulation or to the end of the first postpartum year. Twelve postpartum non-breast-feeding women were similarly studied as controls. An algorithm was used to characterize ovulatory events into three types: the first, with evidence highly suggestive of normal ovulation (EHSO), the second, with evidence of probable ovulation (EPO) and the third with evidence indicating questionable ovulation or deficient corpus luteum function (QO/DCT). Pregnancy preceded the first menstruation in one woman in each of the breast-feeding and control groups. Of the 19 breast-feeding women who started to menstruate during the first postpartum year, five had EHSO, one had EPO, 5 had EQO/DCL and 7 had anovulatory (AO) menstruation. The corresponding figures in the 11 controls were 6, 2, 3 and 0. Pregnancy occurred before a second menstruation in one woman in both the study group and the controls. In 18 breast-feeding women observed, the second menstruation was preceded by EHSO in 7, by EPO in 3, by EQO/DCL in one and AO in 7. In 10 controls the corresponding figures were 7, 3, 0 and 0. Out of a total of 79 menstruations observed during breast-feeding the incidence of AO was 30% and of QO/DCL was 15%. In actively breast-feeding mothers, hyperprolactinemia persisted for more than 1 yr. However, menstruation and ovulation occasionally occurred before the drop of PRL to concentrations seen during the normal menstrual cycle. In the majority of women, low E2 levels were present during lactational amenorrhea, but with occasional spikes in some. A few women maintained somewhat high values of E2 for several weeks before the resumption of menstruation. The implications of these hormonal findings to the attempts to improve on the contraceptive effect of breast-feeding are discussed.

Levonorgestrel concentrations in maternal and infant serum during use of subdermal levonorgestrel contraceptive implants, Norplant, by nursing mothers.

The transfer of levonorgestrel to infants was studied in 42 lactating women in whom the contraceptive subdermal implants, Norplant, were inserted 30 to 40 days postpartum. The women breastfed their infants for one year. Simultaneous mother and infant blood samples were taken once during the year. The levonorgestrel serum concentrations were measured by radioimmunoassay. During the first postinsertion month, the levonorgestrel concentration in the infants serum amounted, on the average, to 5% of the maternal concentration. Thereafter, the ratio ranged from 8 to 13%. The implications of this finding are discussed.

Influence of levonorgestrel contraceptive implants, NORPLANT, initiated early postpartum upon lactation and infant growth.

This study was undertaken to investigate the effect of use of levonorgestrel contraceptive implants, NORPLANT, by breastfeeding mothers on lactational performance and infant growth. NORPLANT implants were inserted between days 30 and 42 postpartum in 50 lactating women. Two control groups of breastfeeding mothers, 50 each, were studied in parallel: the first used an intrauterine device (Cu T380-Ag) and the second used either barrier or no contraception. There was no difference in lactational performance among the three groups. The increments in infant weight and height in the three groups were within the normal range for Egyptian infants. However, the rates of weight and height gain in the early postpartum months were slightly, but significantly, lower in the NORPLANT group than in the two control groups. However, by the sixth postpartum month, there were no significant group differences in these growth parameters. The possible confusing effect of supplementary feeding is discussed.

PIP: This study investigates the effect of using the levonorgestrel contraceptive implant, NORPLANT, by breastfeeding mothers on lactation and infant growth. NORPLANT implants were inserted between days 30 and 42 postpartum in 50 lactating women. 2 control groups of breastfeeding mothers, 50 each, were studied in parallel: the 1st used an intrauterine device (Cu T380-Ag) and the 2nd used either barriers or no contraception. There was no difference in lactational performance among the 3 groups. The increments in infant weight and height in the 3 groups were within the normal range for Egyptian infants. However, the rates of weight and height gain in the early postpartum months were slightly, but significantly, lower in the NORPLANT group than in the 2 control groups. However, by the 6th postpartum month, there were no significant group differences in these growth parameters. The possible confusing effect of supplementary feeding is discussed.

Effect of early postpartum use of the contraceptive implants, NORPLANT, on the serum levels of immunoglobulins of the mothers and their breastfed infants.

Ten breastfeeding women had the contraceptive implants NORPLANT inserted between days 30 and 39 postpartum. The immunoglobulins IgG, IgM and IgA were measured in the serum of the mothers and the infants before insertion and five months later. A control group of breastfeeding mothers who did not use any contraception or used local barrier methods were similarly studied. Although there were changes in the immunoglobulin levels with time in both mothers and infants, there were no group differences; this indicates that the use of NORPLANT does not influence these factors of humoral immunity.

PIP: This study measured major immunoglobulin levels in the serum of 10 breastfeeding mothers and their infants before insertion of the Norplant contraceptive implant (at 30-39 days postpartum) and again 5 months after insertion. 10 women who were also breastfeeding but either used no contraception or used barrier methods (diaphragm or condom) served as controls. Comparison of preinsertion and postinsertion mean serum concentrations revealed a significant rise in IgG and a significant decline in IgM in both groups of mothers. IgA concentrations declined after 6 months postpartum in both the study and control groups, but the difference was statistically significant only for women in the Norplant group. There were no significant differences between the 2 groups in changes occurring after 5 months. Similarly, there were no group differences, either at study admission or after 5 months, in the immunoglobulins of infants of Norplant-using women and controls. Overall, the changes in maternal and infant immunoglobulin levels noted in this study are similar to those expected during parturition and infancy. These results provide no evidence that use of hormonal contraception in the immediate postpartum period can make both mothers and infants more susceptible to infection. It is noted, however, that immunoglobulin levels are only 1 aspect of the immune system.