Leena Tuomivaara

Ovarian function during the use of a single contraceptive implant: Implanon compared with Norplant.

OBJECTIVE To study the mechanism of action of Implanon, a single-rod contraceptive implant containing etonogestrel, in healthy women during 3 years. DESIGN Prospective, randomized comparison with Norplant. The study was conducted for 2 years in Sweden but was extended to 3 years in Finland. SETTING Two outpatient clinics. PATIENT(S) Thirty-two healthy women who were between 18 and 40 years of age with normal ovulatory cycles. Seven women receiving Implanon and three receiving Norplant participated in the third year. INTERVENTION(S) On or between days 1 and 5 of a spontaneous menstrual cycle, the subjects received either the etonogestrel-containing implant (Implanon) or the levonorgestrel-containing implant (Norplant). MAIN OUTCOME MEASURE(S) Ultrasonography was performed and/or progesterone concentrations were determined to confirm ovulation in a control cycle. Follicular development, endometrial thickness, and serum concentrations of 17beta-estradiol and progesterone were assessed twice per week during 4-week periods at regular intervals and after implant removal for 6 weeks to monitor return of ovulation. Times required to remove the respective implants were evaluated, as were possible complications. RESULT(S) Seven women who received Implanon and three who received Norplant completed 3 years of study. There were no pregnancies. Ovulation was observed for the first time with Norplant after 18 months. The first ovulation with Implanon was observed after 30 months. Mean endometrial thickness was <4 mm during treatment with Implanon from month 12 onward. The mean (+/-SD) time to remove Implanon was 5.9 +/- 3.4 minutes. The mean (+/-SD) time to remove Norplant was 17.9 +/- 9.9 minutes. Ovulation resumed promptly after the use of either implant. CONCLUSION(S) Results from this study provide convincing evidence of 3-year contraceptive efficacy with Implanon, mainly by ovulation inhibition.

Radical or conservative surgery for ectopic pregnancy? A follow-up study of fertility of 323 patients

The fertility of 323 patients desiring pregnancy after operation for ectopic pregnancy was analyzed after a follow-up period of 1 to 11years (mean 5.1years). The conception rate was 82%. Full-term delivery was obtained in 79% of the pregnant patients and repeat ectopic pregnancy in 13%. Nulliparous women had a significantly lower ( P P P P P

Comparison of fallopian tube sperm perfusion with intrauterine insemination in the treatment of infertility

OBJECTIVE To compare the efficacy of fallopian tube sperm perfusion utilizing a Foley catheter technique with standard IUI. DESIGN Randomized controlled study. SETTING The infertility units of the University Central Hospital and the Family Federation of Finland, Oulu, Finland. PATIENT(S) One hundred infertile women with unexplained factor, minimal to mild endometriosis, mild male factor, or ovarian dysfunction, undergoing 50 IUI and 50 fallopian tube sperm perfusion cycles stimulated by clomiphene citrate and hMG. INTERVENTION(S) Thirty-six hours after hCG administration, patients were randomized to either the IUI group (group 1, 50 patients and cycles) or the fallopian tube sperm perfusion group (group 2, 50 patients and cycles). Intrauterine insemination was performed using a standard method and fallopian tube sperm perfusion with a pediatric Foley catheter, which prevents the reflux of sperm suspension. MAIN OUTCOME MEASURE(S) Number of clinical pregnancies. RESULTS(S) The fallopian tube sperm perfusion method using a Foley catheter technique was easy to perform and convenient for the patients. The overall pregnancy rate per cycle was 8% for fallopian tube sperm perfusion and 20% for IUI, a difference that was not significant. CONCLUSION(S) The fallopian tube sperm perfusion method using a Foley catheter offers no advantage in comparison with the conventional IUI technique.

Comparison of a local injection of hyperosmolar glucose solution with salpingostomy for the conservative treatment of tubal pregnancy

OBJECTIVE To compare a local injection of hyperosmolar glucose and salpingostomy for the laparoscopic treatment of tubal pregnancy in terms of immediate success and postoperative tubal patency. DESIGN Prospective. PATIENTS, SETTING: Forty women with an unruptured tubal pregnancy were enrolled from among 117 women with ectopic pregnancies (EPs) admitted consecutively to the university clinic. The inclusion criteria were as follows: [1] concentration of beta-hCG in the serum < or = 5,000 IU/L; [2] no living fetus in the EP; and [3] unruptured tubal pregnancy at laparoscopy. INTERVENTIONS After randomization, 20 of these patients were treated with a local injection of hyperosmolar (50%) glucose solution and 20 women by salpingostomy. Tubal patency was evaluated at relaparoscopy or by hysterosalpingography 6 to 13 months after the primary treatment. RESULTS The mean decrease in beta-hCG concentration from the preoperative value to the first postoperative day was 37% and 52% in the glucose and salpingostomy groups, respectively, and the mean resolution time was 13 and 12 days, respectively. Human chorionic gonadotropin showed a persistent EP in 4 women (20%) in the glucose group and 2 (10%) in the salpingostomy group. A patent treated tube was found in 9 of 13 women in the glucose group and 9 of 10 in the salpingostomy group at re-examination. During a follow-up of 6 to 20 months 4 women in the glucose group and 4 women in the salpingostomy group had an intrauterine pregnancy. CONCLUSION A local injection of hyperosmolar glucose is a reasonable method treating tubal pregnancy in selected cases but does not seem to offer any advantage over salpingostomy concerning persistent trophoblastic disease rate.

Long gonadotrophin releasing hormone agonist/human menopausal gonadotrophin protocol for ovarian stimulation in intrauterine insemination treatment

OBJECTIVE This prospective study was undertaken to examine the usefulness of a long gonadotrophin releasing hormone agonist (GnRH-a)/human menopausal gonadotrophin (hMG) protocol in intrauterine insemination (IUI) treatment. The results were compared to those of clomiphene citrate (CC)/hMG/IUI. STUDY DESIGN Seventy-five patients were recruited to a GnRH-a/hMG group (group 1) while 88 patients underwent CC/hMG stimulation and served as controls (group 2). The study subjects were stimulated with a long GnRH-a/hMG regimen. IUI was performed 36 h after the administration of human chorionic gonadotrophin. RESULTS The number of preovulatory follicles, the thickness of endometrium and sperm parameters were similar in both groups. The hMG requirements were significantly higher in group 1 than in group 2 (21.2 +/- 5.1 vs. 8.1 +/- 3.1 ampoules). The pregnancy rate was 20% in group 1 and 12.5% in group 2, the difference being not significant. CONCLUSION The pregnancy rates were not significantly different between the GnRH-a/hMG/ IUI and CC/hMG/IUI groups. In addition, GnRH-a/hMG stimulation is notably more expensive than CC/hMG, and for these reasons, GnRH-a/hMG stimulation is not cost-effective in routine IUI therapy.

Ectopic pregnancy and infertility following treatment of infertile couples: a follow-up of 929 cases.

A follow-up analysis was made of 929 infertile couples, with special attention paid to ectopic pregnancy. The conception rate was 46%, and 9% of the pregnancies were ectopic. Previous ectopic pregnancy, an industrial occupation and smoking reduced the fecundity and increased the risk of ectopic pregnancy. Tubal damage as a verified reason for infertility and its treatment also increased the risk of ectopic pregnancy. Stepwise logistic regression analysis showed the strongest association with ectopic pregnancy to exist in the case of women with a previous ectopic pregnancy (9.9-fold risk) rather than women with primary infertility. Treatment of tubal damage by salpingostomy entailed a 6.0-fold risk and treatment by other methods a 2.8-fold risk. Women working in industry had a 3.5-fold risk of ectopic pregnancy compared with those in other professions.

An Analysis Of Etiological Risk Factors And Subsequent Fertility

The incidence of ectopic pregnancies has increased significantly in the region around Oulu Finland from 10.9-20.9 between 1973-1982. Increased use of IUDs and a comparable increase in the percentage of 2-paras correlated with the increase in ectopic pregnancies in Oulu. A Finnish researcher examined retrospective and prospective age and parity matched case control studies among 552 women with ectopic pregnancy and a follow up study of infertile women to determine the risk factors for ectopic pregnancy. Previous pelvic surgery particularly tubal surgery and treatment of an earlier ectopic pregnancy; entry of the uterine cavity with medical instruments; gynecological infections; infertility; and an IUD were significant risk factors for ectopic pregnancy. For those women who had suffered an ectopic pregnancy and were infertile the risk factors included ectopic pregnancy; tubal surgery especially surgical restoration of a Fallopian tube and working in industry. The study could not determine reasons nulliparous women experienced and ectopic pregnancy. Infertile women who had pelvic infections tubal surgery and/or an earlier ectopic pregnancy had a high risk of ectopic pregnancy. 70% of the ectopic pregnancy patients underwent a salpingectomy. Of the 323 women who wished to conceive again the conception rate was 82% delivery rate 64% and recurrent ectopic pregnancy rate 11%. The operation method was not as an important predictor of subsequent fertility as were condition of the tube and parity. Research is needed to identify risk factors for ectopic pregnancy for nulliparous women. Physicians should consider any woman who is infertile and had a previous ectopic pregnancy tubal surgery and works in industry to be at high risk for ectopic pregnancy and use modern diagnostic tools to distinguish between ectopic and intrauterine pregnancy during the 5th week of amenorrhea. As for fertile and parous women with an IUD in situ they should consider an ectopic pregnancy if pain and bleeding develops.

Radical or Conservative Surgery for Ectopic Pregnancy? A Follow-up Study of Fertility of 323 Patients

The fertility of 323 patients desiring pregnancy after operation for ectopic pregnancy was analyzed after a follow-up period of 1 to 11 years (mean 5.1 years). The conception rate was 82%. Full-term delivery was obtained in 79% of the pregnant patients and repeat ectopic pregnancy in 13%. Nulliparous women had a significantly lower (P less than 0.01) conception rate (74%) than parous women (86%). The operation method had no influence on subsequent fertility in women with an intact contralateral tube. The women with intact contralateral tubes had a significantly higher pregnancy (P less than 0.001) and full-term birth (P less than 0.01) rates (87% and 83%, respectively) but significantly lower (P less than 0.001) repeat ectopic pregnancy rate (9%) than the women with affected contralateral tube (51%, 56%, and 52%, respectively). Compared with the parous women (9%), the risk of repeat ectopic pregnancy was significantly (P less than 0.01) higher for nulliparous women (22%). Of the nulliparous women with repeat ectopic pregnancy only 16% had a full-term pregnancy.