Joseph Ifeanyichukwu Ikechebelu

HIGH PREVALENCE OF MALE INFERTILITY IN SOUTHEASTERN NIGERIA

Three hundred and fourteen Nigerian couples were evaluated thoroughly for the cause of their infertility in our clinics located at Nnewi and Awka in Southeastern Nigeria. Two hundred and four (65.0%) of them had primary infertility and 110 (35%) had secondary infertility. The median duration of the infertility was 5 years and majority of the female patients (67.2%) were aged between 25 and 34 years. A positive male factor alone was found in 133 (42.4%) couples and female factor alone in 81 (25.8%) couples (P < 0.01). Sixty-five (20.7%) couples had a combination of male and female factors, while the cause of infertility was unexplained in 35 (11.1%) couples. Oligozoospermia (35.9%) and asthenozoospermia (32.3%) were the most common aetiological factors responsible for male infertility. Tubual occlusion (49.0%) was the most common cause of female infertility. Genital tract infection resulting from sexual promiscuity and poorly treated sexual transmitted diseases were responsible for these abnormalities. In this part of the world, the wife is commonly blamed whenever there is infertility. However, this study has revealed the greater contribution of male factors to infertility. More attention should be paid to male partners whenever a couple presents for infertility. Men should also be a major target of any intervention aim at prevention.

Breast-feeding, return of menses, sexual activity and contraceptive practices among mothers in the first six months of lactation in Onitsha, South Eastern Nigeria.

Summary The objective of this study was to determine the exclusive breast-feeding practices, return of menstruation, sexual activity and contraceptive practices among breast-feeding mothers in the first six months of lactation. The study was based in Onitsha, South Eastern Nigeria. A structured questionnaire was used to obtain data from breast-feeding mothers on their age, educational attainment, breast-feeding practices, return of menstruation, sexual activity and contraceptive practices within the first six months of lactation at intervals of 6 weeks, 10 weeks 14 weeks and 6 months post delivery. Analysis of the information obtained showed that out of the 178 mothers who participated in the study 81% of the mothers were within the ages of 20 – 34 years. While all the mothers had formal education, the majority (59%) had secondary education. Seventy-three percent initiated breast-feeding within one hour of delivery. On discharge from hospital, all of them had already established breast-feeding which continued up to six weeks and dropped to 97.8% at six months. Exclusive breast-feeding which was practised by 100% on discharge dropped to 3.9% at six months. The feeding regimen was on demand as practised by 98.9% of the mothers. Menstrual flow had returned in 33.8% of the mothers by 6 weeks of lactation, and had risen to 70.2% at six months. There was more prolonged lactational amenorrheoa in exclusively breast-feeding mothers than in those who were not. By 6 weeks post delivery 31.6% of the mothers had resumed sexual activity and this rose to 93.6% at six months. With the resumption of sexual activity only 5% of the mothers resorted to contraceptive practices other than lactational amenorrhea and this increased to 54% at six months. There was no pregnancy in any of these women during the six months period. While appreciating the role of lactational amenorrhea in child spacing and considering the early return of sexual activity among the mothers the practice of introducing contraceptive practices needs to be encouraged especially in women whose menstruation has returned.

Comparison of carbon dioxide and room air pneumoperitoneum for day-case diagnostic laparoscopy.

Abstract Laparoscopic examination is useful in the evaluation of infertile women. To perform this test, pneumoperitoneum is required to distend the abdomen, improve visibility and displace the intestines out of the pelvis. Several gases have been used to achieve this purpose including nitrous oxide (N2O), carbon dioxide (CO2), helium, xenon and air. This is a prospective study in a private fertility centre comparing CO2 and room air pneumoperitoneum for diagnostic laparoscopy. Also the safety of room air was evaluated. One hundred and forty five patients received CO2 (group 1, n = 73) or room air (group 2, n = 72) pneumoperitoneum. Ketamine anaesthesia was used for all the patients and the cost of the procedure was same for the study. CO2 pneumoperitoneum offered better visibility during laparoscopy and the patients also had a better outcome: Wound infection (CO2 – 2/73: 2.7% Vs. Air – 11/72: 15.3%); abdominal discomfort (feeling of retained gas in the abdomen) CO2 – 5/73: 6.9% Vs. Air – 61/72: 84.7%) and shoulder pain (CO2 – 0/73; 0.0% Vs. Air – 56/72: 77.8%). Group 1 patients returned to normal activity earlier (1.5 days ± 1.3 SD Vs. 4.8 days ± 2.1 SD). We conclude that CO2 pneumoperitoneum has a better outcome than Air especially for day-case diagnostic laparoscopy. However, room Air pneumoperitoneum is safe, cheap, and available and may be recommended for low resource settings.

An evaluation of the effect of parity and age on malaria parasitaemia in pregnancy.

Summary A higher prevalence of malaria infection (peripheral or placental) has been reported in the primigravidae and secondigravidae when compared with multigravidae. This study set out to determine the effect of parity and age on the prevalence of malaria parasitaemia in pregnancy at the booking antenatal visit at the Nnamdi Azikiwe University Teaching Hospital, Nnewi. Peripheral blood smears were examined in 420 pregnant women at their booking antenatal visit and in 200 control subjects attending the outpatient clinic on the same day for malaria parasites. These subjects (pregnant women and controls) met the inclusion criteria of being HIV sero-negative, not sickle-cell positive, did not have a history of recent blood transfusion and had been resident in Nnewi for 1 year. The result showed that there was a statistically significant difference between the prevalence rate of malaria parasitaemia in the primigravidae (87.9%: 109 of 124) and grand multigravidae (63.6%: 28 of 44); and the rates were found to decrease with increasing parity. The primigravidae had a higher mean parasite density (2,155/μl) when compared with the multigravidae (1,950/μl). This study also revealed that pregnant women <20 years had the highest prevalence rate of 86.4% (19 of 22). This study demonstrates the higher prevalence of malaria parasitaemia in pregnant women of lower parity, i.e. primigravidae and secondigravidae. Therefore, targeting malaria control efforts to women in their first and second pregnancy will be an important strategy to reach most infected women and minimise resource expenditure. These women should be motivated to use insecticide treated bed nets (ITBN) and other personal malarial control measures during pregnancy.

HIV infection and sexual behaviour among infertile women in southeastern Nigeria

This prospective study was carried out to estimate the prevalence of human immunodeficiency virus (HIV) infection and the risk factors for HIV infection in women undergoing laparoscopy evaluation for infertility. Of 1906 women evaluated between January 1995 and December 2000, 130 (6·82%) tested positive for HIV infection. Husbands of 58·5% of the HIV positive women also tested positive. Analysis of their sexual behaviour within the duration of the marriage revealed that the HIV positive infertile women had more sexual partners [86·2% (112/130) average of five partners vs. 38% (675/1776) average of two partners; P <0·001] and previous sexually transmitted infections [73·1% (95/130) vs. 56·8% (1009/1776); P <0·001] than the HIV negative infertile women. Previous history of induced abortion and blood transfusion was not significantly different for HIV positive and negative women (42·3% vs. 39·3%) and (1·5% vs. 1·0%), respectively, P >0·20. In conclusion, infertile women are exposed to a higher risk of HIV infection due to their promiscuous sexual behaviour in search of pregnancy.

Clinical presentation of uterine fibroids in Nnewi, Nigeria: A 5-year review

Background: Uterine leiomyomas are the commonest benign tumors in women, with a higher preponderance amongst Africans. Several etiological factors have been suggested, with subtle variations in clinical presentation being reported in different studies. This may constitute a determinant for the management measures undertaken. Aim: To review the clinical presentation and management measures undertaken for uterine leiomyoma. Subjects and Methods: A retrospective study was conducted at Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, from January 2002 to December 2006. A review of case records of patients with a diagnosis of uterine leiomyoma was done. The data were analyzed and presented in tables using comparative percentages. Results: Uterine leiomyoma constituted 117 of the 1094 gynecological admissions during this study period (10.7%, 117/1094). The mean (SD) age of presentation was 35.7 (6.1) years. Most of the patients were nulliparous (76.7%, 79/103) and 51.5% (53/103) were married. The commonest mode of presentation was lower abdominal mass (66.9%, 67/103) and the least was recurrent abortion (1%, 1/103). Surgery was employed in all cases, with myomectomy being the commonest modality used in 90.3% (93/103) of cases. The common postoperative complications were prolonged pain (49.5%, 51/103) and postoperative pyrexia (34.9%, 36/103). Conclusion: The symptom of lower abdominal mass correlates with late presentations in our setting. This makes the application of newer therapies like laparoscopic myomectomy difficult even when they are available. Other therapies which are independent of fibroid size (like uterine artery embolization) are not readily available in our environment. This further emphasizes the importance of myomectomy as the most important treatment modality in our environment.

The use of simple ketamine anaesthesia for day-case diagnostic laparoscopy.

General anaesthesia using ketamine has been shown to be safe. It is generally used in our private hospitals where there is lack of qualified personnel and sophisticated anaesthetic machines. A retrospective review of 295 cases of laparoscopy was performed over 28 months at the fertility Unit of Life Specialist Hospital Nnewi, Anambra State, Nigeria. Ketamine general anaesthesia was used for all the patients after premedication with 0.6 mg of atropine. Seventy-six and 102 patients who had additional premedication of 10 mg diazepam and 50 mg promethazine, respectively, were compared. The duration of this procedure ranged between 7 and 18 minutes, with a mean of 12 minutes. The dose of ketamine used was 100 mg mean (range 50 – 180 mg); 12.6% of the patients had some form of reaction. Diazepam reduced talkativeness during recovery but increased the recovery time significantly, from an average of 45 minutes to 3 hours. Promethazine significantly reduced vomiting and restlessness and did not significantly prolong the recovery time (from an average of 45 minutes to 70 minutes). Two patients who had only atropine as premedication had an idiosyncratic reaction of breathlessness and tonic-clonic-like movements. They responded to intravenous diazepam. Ketamine produces a safe, effective and simple general anaesthesia and is recommended for use in day-case laparoscopy, where standard anaesthetic machines and trained personnel are lacking. Use of promethazine premeditation is advocated for improved outcome.

Accuracy and cost-analysis of placental alpha-microglobulin-1 test in the diagnosis of premature rupture of fetal membranes in resource-limited community settings

To determine accuracy and costs of placental α‐microglobulin‐1 (PAMG‐1) test compared to standard clinical assessment (SCA) for diagnosing rupture of membranes (ROM).

Post‐cesarean vesicouterine fistula (Youssef syndrome): Report of two cases

Vesicouterine fistula (VUF) is a rare complication of cesarean section. We present two cases of VUF that were successfully managed by transperitoneal surgical repair. The first case presented with the Youssef classical triad: cyclical hematuria (menouria), amenorrhea and urinary continence, while the second case presented with total urinary incontinence with normal menstruation. In both cases, diagnosis was confirmed by hysterogram and both were managed by transperitoneal surgical repair. The clinical features, etiologic factors, diagnostic procedures and treatment modalities are discussed in relation to the case and others as reported in the literature.

Clinicopathological analysis of cervical cancer seen in a tertiary health facility in Nnewi, south-east Nigeria

Cervical cancer remains the commonest gynaecological cancer among women in the developing countries. The records of all the histologically confirmed cervical cancer patients managed in Nnamdi Azikiwe University Teaching Hospital, Nnewi, over a 5 year period were analysed for the clinical presentation and histological pattern of the malignancy. A total of 75 cases of cervical cancer were managed over the period giving an incidence of 65.2% of all gynaecological cancers and 13.4% of all gynaecological admissions. The majority of the patients were grandmultiparous women (81.3%) with a mean parity of 6.8. The modal age range was 60–69 years (38.7%) and the majority (94.7%) of the patients belonged to the low socioeconomic class. Squamous cell carcinoma of varying differentiation (89.3%) was the commonest histological type seen and adenocarcinoma accounted for only 8.0%. The common clinical features were post-menopausal bleeding (84.0%), vaginal discharge (72.0%), contact bleeding (63.9%) and abdominal pain (56.2%). Most (89.3%) of the patients presented late, in advanced stages of the disease, and almost all (97.3%) were referred for radiotherapy. The incidence of cervical cancer is high in our environment. Community sensitisation and provision of free cervical screening is recommended for early detection and treatment.