Daniel Faúndes

The risk of inadvertent intrauterine device insertion in women carriers of endocervical Chlamydia trachomatis

The most important complication attributed to the use of intrauterine device (IUD) is pelvic inflammatory disease (PID), often associated with Neisseria or Chlamydia infection. Consequently, the IUD should not be inserted in women at risk of infection or with symptoms of endocervicitis. To evaluate the effectiveness of such a policy, a systematic investigation of Chlamydia and Neisseria was carried out among 407 contraceptive acceptors. Twenty-seven cases were positive for Chlamydia and none were positive for Neisseria. There were no statistical differences in the proportion of women with and without Chlamydia who had vulvovaginal or cervical signs or symptoms, although twice as many women had pain at pelvic exam in the Chlamydia-infected group. In 29 women in whom infection was clinically suspected, two were found to be infected with Chlamydia. IUD were not inserted in women suspected of having infection, but 19 of 327 IUD acceptors were subsequently found to have a positive Chlamydia test result. Two women returned with symptoms of PID and 17 were asymptomatic, but all were treated. PID was not suspected in any other subject. These results reinforce the need for careful selection of IUD acceptors and for thorough counseling for symptoms of PID and the need for immediate consultation.

Forearm bone density in users of Depo-Provera as a contraceptive method

OBJECTIVE To determine the influence of depot medroxyprogesterone acetate (MPA) on bone mineral density when used as a contraceptive method. DESIGN Cross-sectional study. SETTING Academic tertiary-care hospital. PATIENT(S) Fifty premenopausal women who had used depot MPA as a contraceptive method for > or =1 year and 50 women who had never used hormonal contraceptive methods. INTERVENTION(S) Bone mineral density was evaluated at the midshaft and at the distal radius of the nondominant forearm using single x-ray absorptiometry. MAIN OUTCOME MEASURE(S) Bone mineral density. RESULT(S) Bone mineral density at the midshaft of the forearm was lower in depot MPA users than in women who had never used hormonal contraceptive methods, but the difference was not statistically significant. At the distal portion, bone mineral density was significantly lower in the study group. The duration of depot MPA use was not related to bone mineral density. CONCLUSION(S) Women > or =35 years of age presented with a lower bone mineral density only at the distal portion of the forearm after the use of depot MPA for > or =1 year. However, this decrease was not related to the duration of depot MPA use. It is not possible to conclude that women who use depot MPA are at risk of osteoporosis.

Timing of onset of contraceptive effectiveness in Depo-Provera users: Part I. Changes in cervical mucus

OBJECTIVE To evaluate the changes in cervical mucus within the first hours or days after depot medroxyprogesterone acetate (MPA) injection so as to estimate the time at which cervical mucus becomes hostile enough to prevent pregnancy. DESIGN Multicenter, clinical descriptive study. SETTING Family planning clinic. PATIENT(S) Thirty women who were between days 8 and 13 of their menstrual cycle and who had requested Depo-Provera were enrolled in the study. INTERVENTION(S) Cervical mucus and blood samples were obtained; transvaginal ultrasonography was performed. MAIN OUTCOME MEASURE(S) Cervical mucus scores, sperm penetration distances, ovarian follicular size, and serum levels of progesterone and estradiol. RESULT(S) From 6 to 24 hours after injection, there was a sharp decline in the cervical mucus score for most of the subjects. All subjects exhibited poor mucus on day 3 after injection, and by day 7, all subjects had zero scores, with the exception of two outliers on each day. Sperm penetration, as measured by the vanguard sperm distance, was already poor (< 1 cm) in 7 of the 30 subjects at the time of injection and was reduced progressively up to 24 hours after injection, when only four subjects had a sperm penetration of > 1 cm. A rapid decline in the estimated number of sperm was observed at 12 hours and more so at 24 hours in the majority of subjects. CONCLUSION(S) The data presented in this report confirmed that depot MPA causes profound changes in cervical mucus after injection. Although very little change was seen at 6 hours, alterations were observed subsequently, with 90% of the subjects showing a poor cervical mucus score 24 hours after administration of the progestin. No reliable clinical marker is available to identify in which women depot MPA might exert its effect on cervical mucus within 3 days. Thus, we believe that at present, women should be informed of this uncertainty and should use a backup method of contraception for 7 days when the first injection of depot MPA is provided after the seventh day of the menstrual cycle.

The use of vaginal ultrasound to identify copper T IUDs at high risk of expulsion

A total of 235 women who had a TCu 380A IUD inserted had a vaginal ultrasound scan performed to identify if the IUDs were correctly placed in the uterine fundus. Women identified as having a misplaced IUD had it removed. The remaining women were compared to 201 women who had an IUD inserted and had no ultrasound evaluation, matched by age and parity. Women were followed-up for one year. Gross cumulative discontinuation rates and continuation rates were calculated by life table analysis. Comparison between groups was done by the Gehan test. The study group had 34 IUDs removed because they were misplaced according to the established criteria. The expulsion rate was significantly higher in the control group, also influencing the continuation rate which was lower in the same group. Of the 34 women who had their IUD removed because it was not correctly placed, only 22 requested and had another IUD inserted. The removal of IUD determined by an ultrasound to be incorrectly placed significantly decreased expulsion rates. However, many IUDs may have been removed unnecessarily, probably resulting in many women not returning to the clinic or deciding to use another contraceptive method.

T-shaped IUDs accommodate in their position during the first 3 months after insertion

The objective of this study was to observe the position dynamics of the T-shaped intrauterine device (IUD) in the uterine cavity, from insertion to 90 days of use. IUD position was evaluated in 214 women by vaginal ultrasound, measuring the IUD-endometrium, IUD-myometrium, and IUD-fundus distances. The 90th percentile of the IUD-endometrium distance was 5, 6, and 8 mm at time of insertion, 30 and 90 days of use; 7, 9, and 10 mm for IUD-myometrium distance; and 23, 24, and 27 mm for IUD-fundus distance, respectively. Seventeen IUDs were classified as misplaced at insertion by using the 90th percentile of the IUD-myometrium distance as standard. Of these, only 6 remained misplaced after 90 days of use. On the other hand, 21 IUDs were beyond the 90th percentile at the 90-day observation, only 6 of which were considered misplaced at insertion. We conclude that the T-shaped IUD accommodates its position in the uterine cavity during the first 3 months following insertion, and that ultrasound evaluation of its position is not a good predictor of future evaluation.

Timing of onset of contraceptive effectiveness in Depo-Provera users. II. Effects on ovarian function.

OBJECTIVE To determine the timing of onset of contraceptive effectiveness after the first injection of 150 mg of depot medroxyprogesterone acetate (DMPA) administered between days 8 and 13 of the menstrual cycle. DESIGN Descriptive, prospective study. SETTING A tertiary university referral center. PATIENT(S) Thirty healthy women between 18 and 40 years of age. INTERVENTION Volunteers were injected with DMPA between days 8 and 13 (5 women on each day) of the menstrual cycle. MAIN OUTCOME MEASURE(S) Ovarian function determined by serum levels of E2 and progesterone and follicular development evaluated by vaginal ultrasound. RESULT(S) In nine (30%) of 30 women studied, DMPA did not prevent ovulation. All ovulations occurred in women receiving DMPA between days 10 and 13 of the cycle. No woman who received injections on day 8 or 9 ovulated. Ovulation suppression was more effective in women with low ovarian activity. All ovulation occurred within 3 days after the injection. CONCLUSION A back-up contraceptive method, used after the 7th day of the menstrual cycle, is recommended for up to 7 days after the first injection of DMPA.

Current practice in the management of symptoms of endometriosis: a survey of Brazilian gynecologists.

OBJECTIVE The purpose is to assess current medical practice in the diagnosis of endometriosis by Brazilian gynecologists. METHODS A Cross-sectional study using questionnaires was sent to all gynecologists of the São Paulo State Ob/Gyn Association. RESULTS A total of 1,660 (31.8%) replies was received. Multiple logistic regression showed that physicians who stated that endometriosis can affect women of all ages was the variable significantly associated with suspicion of endometriosis. Diagnosis was delayed less than 12 months after the first consultation when patients complained of: infertility (OR=1.81, 95% CI 1.01-3.22), dysmenorrhea (OR=2.16, 95% CI 1.18-3.93) or chronic pelvic pain (CPP) (OR=2.17, 95% CI 1.17-4.00). Time until diagnosis was shorter when the complaint was dysmenorrhea (OR=1.33, 95% CI 1.05-1.69) or CPP (OR=1.51, 95% CI 1.19-1.91) and when physicians had participated in congresses and lectures on gynecological endoscopy and endometriosis. CONCLUSION Gynaecologists who are better informed suspect and diagnose endometriosis at an early stage.

T-shaped IUD move vertically with endometrial growth and involution during the menstrual cycle

Ultrasound has been used to detect and evaluate intrauterine device (IUD) position for some years. Different definitions of the IUD in the uterine cavity have been discussed trying to relate them to bleeding and pain complaints. Most of these definitions do not take into account the uterine wall or endometrial thickness. This is a secondary analysis of a previous cross-sectional study, in which 481 IUD users had their T-shaped IUD evaluated by transvaginal sonography. The correlation between the endometrium thickness and the IUD-myometral distance was studied, defined by the linear measurement between the upper end of the IUD and the myometrium/endometrium interface. These two measurements were highly correlated over the entire sample range (r = 0.29) and an even stronger correlation existed (r = 0.66) when only cases below the 90 percentile of the IUD-endometrial distance distribution were considered. These results suggest that the IUD position in the uterine cavity is influenced by the growth and thinning of the endometrium, and that this information should be considered when evaluating the IUD position by sonography.

Morphological differences in human zygotes and embryos cultured in different media.

PURPOSE To compare the effects of four culture media on the quality of human zygotes and embryos. METHODS Prospective study analyzing 2289 human embryos cultivated simultaneously in two different culture media: HTF, the default medium, with either Universal IVF, Global or IVF-30 as the secondary media. The sibling oocytes by each patient were randomly divided between the two culture media following intracytoplasmic sperm injection (ICSI). On day 1 the pronuclear stage of zygotes were evaluated and on day 2 embryos were evaluated according to the number of cells, percentage of fragmentation and number of nuclei. Z-test and odds ratios were used in the statistical analysis. RESULTS There was a higher percentage (55.2%) of class A1 + A2 zygotes with IVF-30 compared with HTF, Global or Universal IVF media (49.1%, 44.7% and 44.2%, respectively). The percentage of Top embryos was significantly higher with Global (40.2%) compared with HTF (21.3%), IVF-30 (25.0%) or Universal IVF media (11.2%). CONCLUSIONS Global medium produced more Top embryos evaluated on day 2 of development.