Quinacrine hydrochloride pellets: preliminary data on a nonsurgical method of female sterilization

What happened to quinacrine non-surgical female sterilization?

Quinacrine sterilization (QS) is a nonsurgical female method used by more than 175,000 women in over 50 countries. With FDA approval, QS is expected to be used by hundreds of millions of women. The negative international health consequences of the results of a 2-year rat study in 2010 by Cancel et al. in Regulatory Toxicology and Pharmacology (RTP) (56:156-165) are incalculable. S1C(R2) was ignored in this study, including the fundamental concept of maximum tolerated dose (MTD), which resulted in the use of massive doses (up to 35 times the MTD) which killed many of the rats and destroyed the uterus of survivors. The design of this rat study was built on the false assertion that this study mimics what happens in women. Cancel et al. (2010), concludes it "seems most likely" that genotoxicity was a major factor in the carcinogenicity observed, prompting the FDA to halt further research of QS. In RTP, McConnell et al. (2010), and Haseman et al. (2015), using the authors' data, definitively determined the carcinogenicity to be secondary to necrosis and chronic inflammation. Decisions made in the design, conduct, analysis, interpretation and reporting in this study lack scientific foundation. This paper explores these decisions.

A Quinacrine Analogue Selective Against Gastric Cancer Cells: Insight from Biochemical and Biophysical Studies

One of the earliest synthetic antimalarial drugs, quinacrine, was recently reported as interesting for the treatment of acute myeloid leukemia. Inspired by this and similar findings, we evaluated a set of quinacrine analogues against gastric (MKN-28), colon (Caco-2), and breast (MFC-7) cancer cell lines and one normal human fibroblast cell line (HFF-1). All the compounds, previously developed by us as dual-stage antimalarial leads, displayed antiproliferative activity, and one of the set stood out as selective toward the gastric cancer cell line, MKN-28. Interestingly, this compound was transported across an in vitro MKN-28 model cell line in low amounts, and approximately 80 % was trapped inside those cells. Nuclear targeting of the same compound and its interactions with calf thymus DNA were assessed through combined fluorescence microscopy, spectroscopy, and calorimetry studies, which provided evidence for the compound's ability to reach the nucleus and to interact with DNA.

Expression changes of antioxidant, apoptotic, anti-apoptotic genes and miR-15b-34a-21-98 in over tissue by using erythromycin, quinacrine and tetracycline in non-surgical sterilization

In the present study, effects on expression of antioxidant, apoptotic and anti-apoptotic genes (GSR, GRX3, SOD1, RAI-NOS, HSP7, BAX, Bcl-2, CASP3 and MDH1) of substances being used in non-surgical sterilization such as quinacrine, erythromycin and tetracycline were evaluated in over tissue. Moreover, expression of some specific mi-RNA (miR-15b, miR-21, miR34a and miR-98) that playing a role in apoptosis was determined in same tissue. Prospective comparative experimental study. Genetics and Histology laboratory. Total number of 28 Wistar albino 12-14 week old female rats with regular cycles and 200-220 grams in weight. Total RNA was isolated from tissues by using a RNA isolation kit. Gene expression levels were evaluated by Real-Time PCR method. Tubal passage and fibrosis induction in tissues was observed in the histochemical analysis. In the statistical analysis of data Kruskal-Wallis variance analysis and Mann-Whitney U test were used and p < 0.05 were accepted as significant. While the expressions of target genes found to be increased in quinacrine and erythromycin group when compared to control group, this increase was insignificant. In quinacrine group, increase in the SOD1 expression levels was only statistically significant (p < 0.05). Expression levels of miR-15b, miR-21, miR34a and miR-98 microRNAs were found to be up-regulated in all experimental groups, despite this, only the increased expression miR-34 was found as statistically significant when compared to control. Tubal blockage and fibrosis induction scores of quinacrine, erythromycin and tetracycline were significantly higher than control. Results of the present study suggest that the doses treated of quinacrine, erythromycin and tetracycline used in non-surgical sterilization effect poorly the expression of anti-oxidant, apoptotic and anti-apoptotic genes, but the expression of miR-34 playing the role in apoptosis increased after treatment of these substances.

Endometrial abnormalities on transvaginal ultrasonography and histopathology in women after quinacrine sterilization

OBJECTIVE

To describe endometrial abnormalities on transvaginal ultrasonography and histopathology in women after quinacrine sterilization.

METHODS

It was an analytical cross sectional study conducted during February 2012 to April 2013. The sample size calculated at 95% confidence level was 540. Sampling technique used was simple random sampling. The medical history, examination, transvaginal ultrasonography and biopsy of suspected lesion was performed in quinacrine sterilized women.

RESULTS

The calculation of statistics showed the mean age at quinacrine sterilization was 38.5 years, standard deviation 6.517, and standard error 0.461. The endometrium was regular and smooth with homogenous images in 86% (n= 466), irregular endometrium with heterogeneous images on transvaginal ultrasound in 9.4% (n =51) and endometrial growth with high level echoes in 4.2% women (n= 23). The histological findings included hyperplasia and well differentiated adenocarcinoma in two patients respectively.

CONCLUSION

The irregular endometrium, adhesions, and growths were found after quinacrine sterilization. The risk of endometrial growth was more after 10 years duration of quinacrine sterilization.

Quinacrine impairs enterovirus 71 RNA replication by preventing binding of polypyrimidine-tract binding protein with internal ribosome entry sites

Since the 1980s, epidemics of enterovirus 71 (EV71) and other enteroviruses have occurred in Asian countries and regions, causing a wide range of human diseases. No effective therapy is available for the treatment of these infections. Internal ribosome entry sites (IRESs) are indispensable for the initiation of translation in enteroviruses. Several cellular factors, as well as the ribosome, are recruited to the conserved IRES during this process. Quinacrine intercalates into the RNA architecture and inhibits RNA transcription and protein synthesis, and a recent study showed that quinacrine inhibited encephalomyocarditis virus and poliovirus IRES-mediated translation in vitro without disrupting internal cellular IRES. Here, we report that quinacrine was highly active against EV71, protecting cells from EV71 infection. Replication of viral RNA, expression of viral capsid protein, and production of virus were all strongly inhibited by quinacrine. Interaction of the polypyrimidine tract-binding protein (PTB) with the conserved IRES was prevented by quinacrine. Coxsackieviruses and echovirus were also inhibited by quinacrine in cultured cells. These results indicate that quinacrine may serve as a potential protective agent for use in the treatment of patients with chronic enterovirus infection.

Hysteroscopic sterilization in women with severe cardiac disease: experience at a tertiary center

OBJECTIVE

To determine the feasibility and effectiveness of hysteroscopic sterilization as a minimally invasive sterilization method for women with high-risk cardiac disease.

PARTICIPANTS AND METHODS

In a retrospective cohort study, 18 women with high-risk cardiac conditions that strictly contraindicated pregnancy were compared with a reference cohort of 157 women without cardiac disease. All underwent microinsert hysteroscopic sterilization at Mayo Clinic from January 2003 through February 2007. End points included successful placement, fallopian tube patency determined by hysterosalpingogram 3 months after the procedure, and pregnancy status.

RESULTS

Women in the cardiac cohort were younger than those in the reference cohort (median age, 25 vs 39 years; P<.001), had lower parity (median, 0 vs 2; P<.001), and had a higher proportion of patients categorized as American Society of Anesthesiologists' physical status 3 (severe systemic disease) and physical status 4 (systemic disease that is a constant threat to life) (83% vs 6%; P<.001). No significant differences were noted for use of general anesthesia (17% vs 27%; P=.41), successful bilateral device placement (100% vs 95%; P>.99), postoperative pain score (median, 0 for both groups; P=.87), or length of hospitalization (median, 6 vs 6 hours; P=.63). No intraoperative complications occurred. Follow-up hysterosalpingography showed high tubal occlusion rates in both cohorts (100% cardiac; 98% reference; P>.99). No pregnancies occurred during a median follow-up period of 20 months (interquartile range, 8-33 months).

CONCLUSION

For women with cardiac disease and strict contraindications for pregnancy, microinsert hysteroscopic sterilization provided minimally invasive, permanent, and reliable contraception.

Transcervical sterilization

PURPOSE OF REVIEW

To discuss the methods for achieving success with currently available transcervical sterilization procedures for permanent female contraception.

RECENT FINDINGS

The transcervical approach has long been thought to be the optimal method for permanent female sterilization, with tubal access achieved by blind, direct (hysteroscopic) or indirect (radiological) techniques, and occlusion being achieved by chemical, mechanical, or thermal techniques. Some combination of these access and occlusion methods encompasses all the current procedures and two types predominate. Quinacrine sterilization is a procedure that is widely used in the developing world, while hysteroscopic procedures such as the Essure and Adiana procedures are either currently available or emerging as visually controlled, device-dependent methods for reliable transcervical sterilization that may be performed in an outpatient or office setting with minimal anesthesia and high patient acceptability. Other devices are used but have less supportive data for their continued use.

SUMMARY

Transcervical methods of female sterilization have good tubal access and occlusion rates, high patient acceptability, and can be performed in an outpatient setting. This combination of factors may offer significant advantages to traditional laparoscopic approaches and render them more cost-effective.

Transcervical sterilization

The transcervical approach to permanent female sterilization has been studied for more than 150 years. Methods for accessing the tubes via this approach include blind, radiological and visual (hysteroscopic) techniques. Modalities for occluding the fallopian tubes include thermal, chemical and mechanical means. Some combination of the approach and the occlusive method define all known procedures. Initial attempts at transcervical sterilization were not widely adopted due to an inability to occlude the tube reliably, resulting in pregnancy and/or high morbidity from the procedure. Quinacrine sterilization is a procedure that is widely used in the developing world, but this has not been taken up by the developed world. There are limitations in diagnosing tubal occlusion with this technique. New methods for transcervical sterilization include the Essure and the Adiana procedures. These methods involve hysteroscopic placement of devices that rely on both mechanical occlusion and stimulation of tissue ingrowth to effect tubal occlusion. These new devices can be delivered to more than 90% of tubes, have very high success rates of pregnancy prevention (>99% in studies to date) and are acceptable to patients. Most importantly, they can be fitted under local anaesthesia in an ambulatory setting. The cost advantages of transcervical sterilization have not yet been investigated. It is possible that such a modality for permanent female sterilization may be demonstrated to be highly cost-effective.

Placement of the Essure Permanent Birth Control Device with Fluoroscopic Guidance: A Novel Method for Tubal Sterilization

An effective transcervical method for fluoroscopically guided fallopian tube occlusion has long been sought for female sterilization. The Essure permanent birth control device was approved by the Food and Drug Administration in November 2002 and is currently indicated for hysteroscopic placement. In a series of eight patients, bilateral Essure microcoils were placed with fluoroscopic guidance in seven patients for a success rate of 87.5%. One patient described peri- and postprocedure pelvic pain, otherwise no complications were identified. All patients returned to normal activities within 24 hours. Fluoroscopically guided transcervical tubal sterilization with the Essure microcoil device (Conceptus, San Carlos, CA) is a viable outpatient procedure.

Quinacrine nonsurgical female sterilization in Baroda, India: 23 years of follow-up of 84 women

OBJECTIVES

Evaluate the long-term effectiveness and safety of transcervical insertion of quinacrine hydrochloride pellets for nonsurgical female sterilization (QS).

METHODS

During the period June 1979 through January 1980, 84 women were admitted to a study at the Baroda Medical College and Hospital, Baroda, India. Our protocol called for three transcervical insertions of 252 mg of quinacrine hydrochloride to be deposited in the uterus of each patient. Follow-up was scheduled at 6, 12 and 48 months after the last administration.

RESULTS

These women were 25 to 39 years of age at the time of the QS procedure and now, 23 years later, have completed their reproductive years. There were 4 pregnancies subsequent to the completion of QS, all prior to their 4-year follow-up. Thus, the life-time failure rate for these women was 3.7%. Complaints were minor, especially when compared to surgical sterilization. There were no long-term effects suspected of being attributable to QS.

CONCLUSIONS

QS appears to be a reasonably effective method that is much safer than surgical sterilization.

Hysteroscopic and hysterosalpingographic study after intrauterine insertion of quinacrine pellets for non-surgical sterilization: results in 180 women

OBJECTIVES

Document the effects on the tube and uterus of one, two and three doses of 252 mg of quinacrine.

METHOD

The study included 180 fertile women seeking permanent contraception at the Shatby Family Planning Clinic in Alexandria, Egypt, in 1988. All cases received three applications of seven 36 mg quinacrine hydrochloride pellets during the proliferative phase of three consecutive menstrual cycles. The patients were randomly divided into groups A, B and C. Hysterosalpingography (HSG) was performed on the 6th day of menstruation and hysteroscopy on the 10th day of the same cycle after the first application in group A, the second, in group B and the third, in group C. The study was concluded in 1999.

RESULTS

HSG showed 52 cases of bilateral obstruction, four of bilateral patency, and four of unilateral patency in group A. All in groups B and C elicited bilateral tubal obstruction. Cornual obstruction was seen in 33%, 65% and 85% in group A, B and C, respectively. Intramural obstruction was found in 50%, 33% and 10% in the three groups. Isthmic tubal obstruction was detected in 8%, 2.5% and 5% in groups A, B and C, respectively. Four types of ostial appearances could be recognized hysteroscopically. Type 0 (patent tubes), Type I (distal tubal blockage), Type II (intramural obstruction) and Type III (cornual obstruction). In group A, Type 0 was evident in 10%, Type I in 8%, Type II in 50% and Type III in 33% of cases. The respective figures in group B were 0%, 2.5%, 33% and 65%, while in group C, they were 0%, 5%, 10% and 85%. Hysteroscopy showed no abnormal endometrial findings in group A, but 35% and 85% of cases in group B and C showed some changes.

CONCLUSIONS

Two applications of quinacrine were 100% effective. The side effects of quinacrine pellet applications were minimal and well tolerated by all the users. The possibility of reversal of the procedure is outlined.

Quinacrine sterilization (QS) among high-risk women: a study of 134 cases

OBJECTIVE

To determine if quinacrine sterilization (QS) is safe and effective in women at high risk for surgery.

METHODS

A trial was initiated at the Government Medical College in Patiala, India, in December 1993. Patient intake was terminated in July 1999 and the cut-off date for this analysis was March 31, 2003. Using a modified IUD inserter, seven 252 mg quinacrine pellets with 50 mg of diclofenac were transcervically inserted into the uterus. DMPA 150 mg was administered IM at the time of the first insertion as a back-up contraceptive. This same combination was inserted a month later. A total of 134 women underwent QS. Of these, 92 were considered to be at high risk for surgery, 27 were afraid of surgery or voluntarily opted for QS, and 15 had had failed surgical sterilization or surgery was found not to be technically feasible. Follow-up was scheduled for 1, 3, 6 and 12 months, and then annually after the second insertion or whenever side effects or complications were experienced.

RESULTS

Mean follow-up was 7.2 years. No pregnancies or serious complications were experienced.

CONCLUSION

QS is a safe and effective option for women at high risk of surgical complications.

A 22-year experience with quinacrine sterilization in a rural private clinic in Midnapore, India: a report on 5 protocols and 1838 cases

OBJECTIVES

Evaluate the safety and effectiveness of quinacrine for non-surgical female sterilization in five different protocols.

METHODS

The 5 trials were conducted sequentially. The first and largest, with 985 cases, tested the use of a curved inserter to place a 50 mg dose of quinacrine near each tubal ostia. The next 3 trials were carried out to determine the effect of adjunct procedures on the efficacy of the standard recommended protocol. The three adjuncts were 75 mg of intrauterine diclofenac, 10 mg medroxyprogesterone IM and either 10 mg of atropine IM or 20 mg of hyoscine butylbromide IM The final trial focused on the currently recommended protocol.

RESULTS

The 100 mg dose placed at the tubal ostia with the curved inserter resulted in a failure rate of 9.0% at 20 years. Diclofenac or medroxyprogesterone did not improve efficacy over quinacrine alone. Atropine or hyoscine butylbromide substantially diminished the effectiveness of the quinacrine. The failure rate with the standard protocol in our series of 122 cases was 0.8% at 3.5 years. Side effects were minor. There were no deaths nor serious complications with any of these protocols.

DISCUSSION

All 5 protocols appeared to be safe and the standard one was the most effective.

Use of erythromycin for nonsurgical female sterilization in West Bengal, India: a study of 790 cases

OBJECTIVE

Determine if erythromycin is an effective agent for achieving occlusion of the Fallopian tube for nonsurgical female sterilization.

METHODS

Two studies of 100 healthy volunteers requesting sterilization were planned, one in Julpia Andhermanik and the other in Kolkata (Calcutta). A readily available marketed tablet preparation containing 500 mg of the estolate salt of erythromycin was used for the trial. In one study (Bishnupur), the tablet was crushed before placing in a copper-T IUD inserter for placement at the fundus. In the other study (Kolkata), crushed tablets were processed into 50 mg pellets of the same diameter as standard quinacrine pellets and 10 pellets were inserted at the fundus using aseptic precautions. Procedures in each study were repeated at 30 days. Oral contraceptives were prescribed for three cycles following first insertion. No incentive was offered for participation in the trial. Follow-up treatment, including first-trimester abortion for pregnancy due to failure of the sterilization procedure, was assured without charge. Due to extraordinary patient demand, one study (Bishnupur) was expanded to 690 cases for reasons of compassion.

RESULTS

At 12 months of use, the failure rate of the sterilization procedure for the crushed 500 mg tablets was 35.8% (SE = 1.8) with 417 women at risk. At 12 months of use, the failure rate for the erythromycin pellets was 28.6% (SE = 5.0) with 43 women at risk. There were no serious complications reported in either trial. All pregnancies resulting from failure of the sterilization procedure were terminated by menstrual regulation within 10 weeks gestation.

CONCLUSIONS

The failure rate in this study is unacceptably high for erythromycin to be used as a sterilization method.

Quinacrine sterilization (QS) in Iran and the use of HSG as a measure of success

OBJECTIVES

To establish the safety, effectiveness and acceptability of quinacrine sterilization (QS) in Iran. To determine whether the hysterosalpingogram (HSG) performed under low pressure can be used to demonstrate success of the QS procedure rather than waiting for a pregnancy to occur in order to demonstrate failure.

METHODS

This study was initiated in September 1990 in a private family planning clinic in Tehran, Iran. Patient intake for this analysis was completed 31 December 1998 and the cut-off date for follow-up data to be included in this analysis was 30 July 2002. During this period, 268 women received QS. From inception until April 1994, 160 women entered the study. The first 62 women received 3 insertions and the remainder received 2. Short-term side effects were closely followed in these 160 women. From 18 February 1994 until the patient intake cut-off date, 131 women entered the study and 46 of them received an HSG.

RESULTS

With 4 to 12 years of follow-up there have been 7 pregnancies for a gross pregnancy rate of 2.6%. However, the use of the HSG tripled the risk of pregnancy for women who underwent the procedure. Furthermore, HSG, even when performed under minimal pressure, indicated failure of the QS procedure about 6% of the time when in fact both tubes would have closed had there been no intervention. Side effects were minor when compared to the complications of surgical sterilization.

CONCLUSIONS

QS was found to be safe, effective and preferred over surgical sterilization by Iranian women. HSG understated the number of patients with bilateral tubal closure, or with tubes that would have closed given a little more time.

Marie Stopes Society, Pakistan: 1000 cases of quinacrine sterilization (QS)

OBJECTIVES

To evaluate the safety, efficacy and acceptability of QS in Karachi, Pakistan.

METHODS

1000 women who had chosen sterilization during the 4-year period 1994 to 1997 inclusive were offered QS at both stationary clinics and in a mobile van at 23 sites in the outskirts of Karachi. The protocol involved transcervical insertion to the uterine fundus of 252 mg quinacrine in 7 pellets and 55 mg of ibuprofen in 3 pellets through an IUD inserter, during the proliferative phase of the menstrual cycle. Two doses were administered one month apart. A temporary method of contraception was provided for 3 cycles, usually DMPA. Follow-up was scheduled: monthly for 3 months, quarterly for 1 year and then every 6 months for 4 years.

RESULTS

The crude pregnancy rate after 4 years was 2.0%. Minor complications and complaints were reported by 59% of the patients. There was one ectopic pregnancy and no major complications.

CONCLUSIONS

QS was found to be safe and effective and has become the most popular method of sterilization in our area of Pakistan.

Quinacrine sterilization of 1997 women in Daharpur, Midnapore, West Bengal, India: a comparison of 3 protocols

OBJECTIVES

Determine the efficacy of two different dosage regimens of quinacrine placed at each cornual angle, employing a curved inserter, and for fundal placement of doses from 252 mg to 360 mg of quinacrine, depending on the age of the woman.

METHODS

1. The first trial involved 3 double insertions, a month apart, of 50 mg of quinacrine at each cornual angle. This trial was initiated on 14 August 1979 and completed on 26 June 1984 with 418 subjects admitted. 2. The second was a single double insertion of 100 mg at each cornual angle. This trial, initiated on 30 November 1984, was completed on 11 June 1985 with 100 subjects admitted. 3. The third trial began 2 January 1995, was completed 26 January 1998 and included 1479 subjects. There were 2 insertions, a month apart, with fundal placement of all pellets. The dose depended on the woman's age and ranged from 252 mg in the oldest to 360 mg in the youngest. The cut-off date for this trial was 23 January 2003.

RESULTS

Only relatively minor side effects or complications were seen. None required hospitalization. Failure rates with multiple low dose or single dose cornual placement of pellets were unacceptably high. When higher doses of fundal placement of quinacrine were used at two visits, one month apart, no failures occurred.

CONCLUSIONS

The third protocol shows great promise.

Quinacrine sterilization (QS): the ethical issues

QS has generated debates that are ultimately grounded in various principles, norms, and values. Through a careful analysis of opposing arguments, this paper focuses on two ethical principles claimed by both sides, namely: respect for life and beneficence. Though issues surrounding QS are complex, from the common ground of these two principles, this paper proposes a course of action that addresses many of the concerns from both points of view.

Quinacrine sterilization (QS) in Costa Rica: 694 cases

OBJECTIVES

To evaluate the safety, efficacy and acceptability of quinacrine sterilization (QS) in Costa Rica.

METHODS

From 1989 though August 1993, 694 women volunteered for QS in my private practice. All were referred by a family planning clinic or a local hospital obstetric service. The protocol used involved the transcervical insertion of 216 mg of quinacrine hydrochloride in the form of 6 pellets. A second dose was given 4 weeks later. All insertions were done in the first 14 days of the menstrual cycle. The procedure was similar to the CuT IUD placement. Temporary contraception was recommended for 3 months after the last insertion. The cut-off date for this analysis was April 1994.

RESULTS

With 7 months to 5 years of follow-up, the gross pregnancy rate was 2.5%. Side effects were relatively minor, none requiring hospitalization.

CONCLUSION

QS was found to be safe, effective and acceptable.

Quinacrine sterilization in Libya: 200 cases

OBJECTIVE

Document the safety, effectiveness and acceptability of quinacrine sterilization (QS) as an alternative to surgical sterilization in Libyan women.

METHODS

This study was initiated 1 October 1998 at the Misurata Central Hospital and Lamis Clinic. Patient intake was completed 30 September 2002. The cut-off date for this analysis was 31 December 2002. A total of 200 women were given 2 doses, each consisting of 252 mg of quinacrine hydrochloride in the form of 7 pellets inserted one month apart. They were placed at the uterine fundus during the proliferative phase of the menstrual cycle using a modified IUD inserter. Women were asked to report any unusual observations or side effects and instructed to use a barrier method or safe period for one month from the time of the first insertion. Follow-up was scheduled at 3, 6 and 12 months after the date of the second insertion and every 6 months thereafter.

RESULTS

Sixty-six women have been monitored for up to 3 years and follow-up of all patients continues. There has been no loss to follow-up. No side effects of any consequence have been reported. Thus far, no pregnancies have been reported for this protocol.

CONCLUSIONS

Findings in this study are consistent with those seen in other countries. QS has been shown to be safe, effective and acceptable among Libyan women.

Quinacrine sterilization (QS) experience in the Philippines: a preliminary report

OBJECTIVE

The first clinical trial of Quinacrine Sterilization (QS) in the Philippines was undertaken in Ceby City on January 10, 2000, to evaluate the accetability, safety, effectiveness and side effects of this technology. We intend to recruit 500 patients to utilize this technique for limiting family size. For the purposes of this report, our cut-off date is April 11, 2003.

METHODS

Over more than two years, QS was performed on 36 volunteer patients. After careful explanation of the procedure and given the opportunity to ask questions, they had signed an informed consent. The trial involved transcervical insertion of 252 mg quinacrine in the form of pellets, and placed at the tip of the uterine fundus on two occasions, a month apart. Condoms were routinely provided to all patients except those on oral contraceptive pills and DMPA after the first insertion to be used for six weeks after the second one. As the numbers are small, no statistical evaluation was called for.

RESULTS

The accumulated experience was 515 woman-months. There were no pregnancies, neither ectopic nor intrauterine. Adverse events (AE) were mild. Some patients complained of a yellow discharge and itching. Fifty percent experienced midl abdominal discomfort which was easily managed with mefenamic acid.

CONCLUSIONS

Although this is a small study, we believe that QS is both safe and effective and we are strongly encouraged to continue to offer this nonsurgical sterilization method to our patients.

Randomized trial of one versus two transcervical insertions of quinacrine pellets for sterilization

OBJECTIVE

To determine the relative effectiveness of single vs. two transcervical monthly insertions of 252 mg of quinacrine for female sterilization.

DESIGN

Controlled clinical study.

SETTING

Family planning clinics of 6 academic centers.

PATIENT(S)

Sexually active reproductive-age women requesting sterilization.

INTERVENTION(S)

At each of six centers 70 and 30 women were randomly assigned to receive either one or two, respectively, monthly transcervical insertions to the fundus of 252 mg of quinacrine and 75 mg of diclofenac as pellets and they were followed for 1 year.

MAIN OUTCOME MEASURE(S)

Complications, side effects, and pregnancy failures.

RESULT(S)

There were no serious complications and side effects were transient and easily treated. There were 31 (7.4%) pregnancy failures in the single insertions group and 2 (1.1%) in the two insertions group, but with marked center variation.

CONCLUSION(S)

Quinacrine sterilization using two monthly insertions of 252 mg of quinacrine appears safe and reasonably effective.

Quinacrine non-surgical female sterilization in Bangladesh

This study was undertaken to evaluate the efficacy, safety, and acceptability of transcervical applications of quinacrine along with other adjuvants, such as ampicillin and ibuprofen, for sterilization. The cohort consisted of 750 normal women who requested sterilization and volunteered for this method at the family planning clinic of a tertiary hospital and community clinics in Chittagong, Bangladesh. Several different protocols were followed from October 1989 to April 1999. Each woman received one or two insertions of 180 mg or 252 mg quinacrine with or without adjuvants including 55.5 mg ibuprofen or 125 mg ampicillin. Supplementary contraception was given in the form of combined oral contraceptive pills, barrier methods, or injection of depot medroxyprogesterone acetate for 3 months. Details of each protocol are described in the text. The gross pregnancy failure rate for insertion of 180 mg in 590 women was 3.9% compared to 1.9% for the 160 who received 252 mg. There were no serious complications, and side effects were transient. We conclude that quinacrine non-surgical sterilization is a safe, acceptably effective method when two insertions of 252 mg quinacrine with medroxyprogesterone injection as a supplement is used.

Use of ethylene vinyl alcohol copolymer for tubal sterilization by selective catheterization in rabbits

PURPOSE

To assess the efficacy of ethylene vinyl alcohol copolymer (Uryx) in nonsurgically occluding the fallopian tube and achieving tubal sterilization in the rabbit model.

MATERIALS AND METHODS

Ten mature virgin female New England rabbits underwent transvaginal selective bilateral fallopian tube cannulation with use of a coaxial catheter system under general anesthesia. Selective salpingography was performed bilaterally to assess patency of the fallopian tubes. Ethylene vinyl alcohol copolymer was injected unilaterally through a microcatheter to completely fill the middle portion of the tube. Three to seven days after injection, each animal was bred. Conception was determined by ultrasonography (US) 7-19 days after effective breeding. If pregnant, the rabbit was killed. Otherwise, it was permitted to rebreed until pregnancy was achieved. Histologic specimens of the fallopian tubes were prepared and analyzed.

RESULTS

Patency of the fallopian tubes was demonstrated bilaterally in all animals by the free spillage of contrast material into the peritoneum. The delivery of ethylene vinyl alcohol copolymer into the fallopian tubes was successful in all animals but one, in which most of the plug almost immediately extruded into the uterus. Pregnancy was detected by US in the untreated fallopian tube in the nine rabbits that were receptive to breeding. No pregnancies were detected in the injected side. Histologic analysis demonstrated variable degrees of occlusion, fibrosis, and inflammation, with the majority of specimens demonstrating mild to moderate inflammation and moderate to marked fibrosis.

CONCLUSION

Ethylene vinyl alcohol copolymer can reliably be placed nonsurgically via the transvaginal approach into the fallopian tubes with use of a coaxial catheter system. Ethylene vinyl alcohol copolymer appears to result in less fibrosis than previously investigated agents and demonstrates a 100% early sterilization rate in the rabbit model.

Long-term follow-up after quinacrine sterilization in Vietnam. Part I: interim efficacy analysis

OBJECTIVE

To determine the long-term efficacy of nonsurgical sterilization with quinacrine.

DESIGN

Observational cohort study.

SETTING

Rural provinces in northern Vietnam.

PATIENT(S)

Two thousand seven hundred and nine women who had quinacrine insertions between 1989 and 1993.

INTERVENTION(S)

Interviews in 1994, 1995, and 1996 and review of available medical records. Pregnancy rates were corrected for problems in detecting and confirming pregnancies.

MAIN OUTCOME MEASURE(S)

Pregnancy rates.

RESULT(S)

Over 90% of women were interviewed at least once. Uncorrected cumulative pregnancy rates were 12.9% at 5 y after two insertions and 27.3% after one insertion. Effectiveness varied by age group: the partially corrected pregnancy rates after two insertions were 6.8% in women 35 or older at the time of insertion and 13.0% in women under 35. A subgroup of women who received oral papaverine at the time of quinacrine insertion had lower pregnancy rates, with a cumulative uncorrected rate of 5.3% at 4 years among women of all ages.

CONCLUSION(S)

Efficacy of quinacrine appears reasonable for two insertions of quinacrine in women 35 and older. It may be possible to improve efficacy by the use of papaverine or the Hieu insertion technique.

Long-term follow-up after quinacrine sterilization in Vietnam. Part II: interim safety analysis

OBJECTIVE

To determine the long-term safety of nonsurgical sterilization with quinacrine.

DESIGN

Observational cohort study.

SETTING

Rural provinces in northern Vietnam.

PATIENT(S)

Two thousand eight hundred forty women who had had quinacrine insertions and an age-matched comparison group of 1,658 women who had an intrauterine device (IUD) insertion between 1989 and 1993.

METHOD(S)

Interviews in 1994, 1995, and 1996 and review of available medical records. This is a planned interim analysis.

MAIN OUTCOME MEASURE(S)

Ectopic pregnancies and the occurrence of other adverse health events.

RESULT(S)

Over 90% of women were interviewed at least once. Despite matching on age, the groups differed on baseline parity. The ectopic pregnancy rates were similar after either one or two insertions and were similar to the rate of ectopic pregnancies after surgical sterilization in the United States. The quinacrine group reported more gynecologic health problems than the IUD group. However, after correcting for information bias, there was no dose-response effect between the one- and two-insertion quinacrine groups, suggesting the possibility of recall bias or differing baseline health status.

CONCLUSION(S)

Ectopic pregnancies do not appear to be increased compared with U.S. surgical sterilization rates. The data on other adverse events are more difficult to interpret.

Quinacrine dihydrochloride, the non-surgical female sterilant induces dicentrics, rings, and marker chromosomes in human peripheral blood lymphocytes treated in vitro: a preliminary report

During the last decade, quinacrine dihydrochloride (QDH) has been promoted for clinical trials as a much needed non-surgical female sterilant, largely in the Third World. Recently, however, these human trials have come under severe criticism due to lack of adequate evidence of biological safety of QDH, particularly of its genotoxicity in mammalian systems. In the present study, the cytogenetic analysis of QDH-treated human lymphocytes, grown as whole blood cultures in vitro, surprisingly showed a wide range of chromosomal aberrations. At a concentration of 3.0 and 6.0 microg/ml in culture, QDH was cytotoxic, as shown by the very few analyzable metaphases that could be observed. G(0) lymphocytes, treated with 0. 6 microg/ml QDH, exhibited chromosome aberrations including dicentrics, ring configurations, translocations, inversions, and marker chromosomes. Near haploid, polyploid, and endoreduplicated cells were also observed. All the rings appeared to be formed as a result of telomere fusion/association. Twenty percent of the dicentrics observed also indicated telomere fusion/association in the D and G groups of chromosomes. Overall, a frequent involvement of chromosomes 1, 2, and 3 in both unstable and stable chromosome rearrangements was also observed. Exposure of 72-h cultures to 0.45 microg/ml QDH at 69 h resulted in an accumulation of C-metaphases, suggesting that probably QDH behaves as a mitotic spindle inhibitor. The G(2) lymphocytes from two donors exposed to 0.6, 1.5 or 3.0 microg/ml of QDH showed no increase in chromatid aberrations in two donors. However, QDH at 0.6 microg/ml increased the frequency of micronucleated binucleate cells. No increase in sister chromatid exchanges was observed at this concentration. Though preliminary, these observations demonstrate the chromosome damaging ability of QDH in human lymphocytes treated in vitro. Surprisingly, like ionizing radiation, QDH acted by an S-phase-independent mechanism, unlike most of the chemical mutagens. These results warrant detailed investigations on the cytogenetic effects of QDH in vitro, as well as among women exposed to this agent during clinical trials for non-surgical sterilization. The interesting cytogenetic profile of QDH deserves to be pursued and the underlying mechanisms, in particular, the DNA topoisomerase II inhibitory effect, if any, needs to be elucidated.

Quinacrine pellet nonsurgical female sterilization in Wonosobo, Indonesia

OBJECTIVE

To evaluate the efficacy, safety, and acceptability of two monthly transcervical applications of quinacrine, 252 mg, and ibuprofen, 55.5 mg, as pellets for sterilization.

DESIGN

Prospective clinical study.

SETTING

Family planning clinic of a referral hospital.

PATIENT(S)

Two hundred normal women who requested sterilization and volunteered for this method.

INTERVENTION(S)

Each woman received quinacrine, 252 mg, and ibuprofen, 55.5 mg, transcervically as pellets in the proliferative phase of two consecutive menstrual cycles from August 1992 to October 1993.

MAIN OUTCOME MEASURE(S)

Life-table pregnancy failure rates and incidence of complications and side effects.

RESULT(S)

The pregnancy failure rate was 2.0 per 100 women at 24 months. There were no serious complications, and side effects were transient.

CONCLUSION(S)

Intrauterine insertion of quinacrine pellets is a safe and acceptably effective method of nonsurgical female sterilization.

Phase I prehysterectomy studies of the transcervical administration of quinacrine pellets

To determine the safety of transcervical administration of quinacrine pellets as a method of voluntary female sterilization, three noncomparative Phase I clinical trials of the administration of 250 mg quinacrine were carried out in 21 women who were scheduled to undergo hysterectomy 24 h or one month later. Detailed results are presented for one of the trials using 10-min pellets. Six of 10 women had minor transitory complaints during the postinsertion 24-h follow-up period. Five women reported pelvic/abdominal cramping, one experienced headache, and one experienced dizziness. Blood chemistry values were not adversely influenced by the quinacrine. The average plasma level of quinacrine peaked at 3 h, 36.1 ng/ml, slightly lower than the value observed 4 h after oral administration of 200 mg in a previous study. An average of 27% of the administered dose was recovered in tampons. Quinacrine was detected in the plasma of two women at the four/six-week visit. Selected results are presented from two other trials that were halted because of slow recruitment. The transcervical administration of 250 mg of 10-min quinacrine pellets was well tolerated. However, based on recent mutagenicity testing and meetings with regulatory officials, it appears unlikely that the use of quinacrine for nonsurgical sterilization could be approved in the United States or Europe.

100,000 quinacrine sterilizations

100000 quinacrine nonsurgical female sterilizations have been completed over the past decade involving transcervical insertion of quinacrine (252 mg) as pellets by one, two or three monthly insertions. No deaths have been reported and serious complications are far fewer than for surgical sterilization. Side-effects are mild and transient. Efficacy has improved from 3 pregnancy failures per 100 women at one year to approximately 1 by improved insertion technique and use of adjuvants. Long-term follow-up of early cases in Chile shows no increased risk of cancer for this method. The main advantage of quinacrine sterilization is its ability to raise contraceptive prevalence and thereby reduce maternal mortality and morbidity, especially in rural and urban slum areas of developing countries. It should be made available as an option to well informed women everywhere as an economical and safe permanent family planning method.

Quinacrine: sclerosing agent of the utero-tubal junction in women, with anticarcinogenic actions in transplanted tumors in mice

Quinacrine, an acridine derivative that was in widespread use as an anti-malarial, has been shown to have both sclerosant and anticarcinogenic actions. The sclerosant action of quinacrine has been used to produce occlusion of Fallopian tube in both experimental animals and women, and several clinical studies are reviewed. Both actions of quinacrine are potentiated by steroidal and non-steroidal antiprostaglandins as well as by ionic copper. Combinations of quinacrine with antiprostaglandin drugs, and also with copper, improved the efficacy of quinacrine when used for female sterilization and reduced side effects. A review of the experimental and epidemiological evidence suggests that quinacrine has no carcinogenic effects.

Transcervical quinacrine sterilization: clinical experience

OBJECTIVE

To review the use of quinacrine pellets for non-surgical female sterilization.

BACKGROUND

The transcervical insertion of quinacrine pellets has been under study for over 15 years. It could potentially expand access to sterilization services, because it is relatively simple to administer, with the use of a modified IUD inserter, and is inexpensive.

METHODS

Published and unpublished data are reviewed.

RESULTS

The short-term safety of transcervical quinacrine appears to be better than surgical sterilization, but it is less effective, especially among women under 35, and there are virtually no data on its reversibility. Thus, it is probably most appropriate for older women, aged 35 and over, but it could be an option for others where access to surgical sterilization is limited.

CONCLUSION

The use of quinacrine pellets for female sterilization needs to be reviewed by appropriate regulatory authorities, especially with regard to long-term safety issues, and additional clinical studies are needed to better define a standardized regimen.

A potential single insertion protocol for quinacrine pellet non-surgical female sterilization

Two preliminary single-insertion clinical trials of the quinacrine pellet method of non-surgical female sterilization were compared. Both trials used transcervical application of quinacrine, 252 mg, and diclofenac, 75 mg, as pellets. In the first trial (21 April 1992 to 17 February 1993), 58 women received oral contraceptives for three months. In the second trial (19 February 1993 to 25 May 1994), 229 women received medroxyprogesterone acetate, 150 mg IM, at the time of quinacrine insertion. At 18 months, the life-table pregnancy failure rate per 100 women of the first trial was 8.6 (SE 3.7), whereas the failure rate for the medroxyprogesterone acetate group was 0.5 (SE 0.5), p<0.05. There were no serious complications or side-effects in either group. Larger confirming trials with random allocation and long-term systematic follow-up are needed to determine whether a single injection of medroxyprogesterone improves the efficacy of quinacrine.

31,781 cases of non-surgical female sterilisation with quinacrine pellets in Vietnam

The quinacrine method of non-surgical female sterilisation involves transcervical intrauterine insertion of 252 mg quinacrine as pellets during the proliferative phase of the menstrual cycle; the drug causes inflammation and fibrosis of the proximal fallopian tube. We have carried out a field trial of 31,781 cases in twenty-four provinces of Vietnam from Jan 2, 1989, until October, 1992. There were 818 pregnancies after the procedure, of which 80 were carried to term. Some women received only one dose of quinacrine; the majority received two doses with an interval of one month. Cumulative life-table pregnancy rates per 100 women at 1 year (for studies of at least 50 cases followed for 12 months) were 2.63 (SE 0.17) among 9461 women who received two doses and 5.15 (0.48) among 2225 who received only one dose. Failure rates (pregnancies) were strongly affected by the skill of the doctor or midwife. There were no deaths and only 8 serious complications were reported (0.03%); by contrast, in a similar series of women undergoing surgical sterilisation, 30 deaths and between 540 and 1812 serious complications would be expected. All reported side-effects were minor and of short duration. There were 19 ectopic pregnancies and the incidence was 0.89 per 1000 woman-years of use. There was one birth defect (anencephaly), in a fetus conceived 2.5 months after quinacrine insertions; however, we believe it is not related to the procedure. An estimated 242 maternal deaths will be averted by these 31,781 sterilizations. This method is safe and acceptably effective for female sterilisation.