Proximal tubal occlusion first or oocyte retrieval first for patients with hydrosalpinx?

PURPOSE

Our study aimed to investigate the best time to manage hydrosalpinx to improve pregnancy outcomes during in vitro fertilization-embryo transfer (IVF-ET).

METHODS

Patients with hydrosalpinx who received IVF treatment were analyzed retrospectively. And two groups were included to compare the effects of different timing treatment of hydrosalpinx on IVF pregnancy outcomes, "Proximal Tubal Occlusion First Group" (Group Ligation-COH) and "Oocyte Retrieval First Group" (Group COH-Ligation). The main outcome measures included: ovarian response indexes, laboratory indexes and clinical pregnancy outcomes. Univariate and multivariate Logistic regression analysis was performed for outcome indicators, and the odds ratios (OR) and 95% confidence interval (CI) were used.

RESULTS

A total of 1490 patients were included (n = 976 Ligation-COH and n = 514 COH-Ligation). The Gn starting dose and MII rate in group Ligation-COH were significantly higher than those in group COH-Ligation (203.33 ± 58.20 vs. 203.33 ± 58.20, 81.58% vs. 80.28%, P < 0.05). The number of oocytes obtained and the number of available D3 embryos in group COH-Ligation were higher than those in group Ligation-COH (15.10 ± 7.58 vs. 13.45 ± 6.42, 10.92 ± 5.81 vs. 9.94 ± 5.15, P < 0.05). Although the number of ET cycles per IVF cycle in group COH-Ligation was higher than that in group Ligation-COH (1.88 ± 1.00 vs. 1.48 ± 0.70, P < 0.05), the biochemical pregnancy rate, clinical pregnancy rate, multiple pregnancy rate, live birth rate and cumulative live birth rate in group Ligation-COH were significantly higher than those in group COH-Ligation (60.83% vs. 46.27% for biochemical pregnancy, 55.69% vs. 38.5% for clinical pregnancy, 26.18% vs. 17.74% for multiple pregnancy, 47.08% vs. 25.26% for live birth, 69.47% vs. 47.47% for cumulative live birth, P < 0.05), and the miscarriage rate in group Ligation-COH was lower than that in group COH-Ligation (10.47% vs. 17.20 for early abortion, 4.49% vs. 15.86% for late abortion, P < 0.05). In logistic regression analysis, after adjustment for age and multiple factors, the above results were still statistically significant differences (P < 0.001). For elderly patients, the clinical pregnancy rate, multiple birth rate and live birth rate in group Ligation-COH were also higher than those in group COH-Ligation (P < 0.001). No significant differences were detected for patients with diminished ovarian reserve.

CONCLUSIONS

For the choice of ligation operation time, we recommend that patients choose tubal ligation first and then ovulation induction and oocyte retrieval treatment.

Tubal sterilization: focus on the U.S. experience

OBJECTIVE

To review the frequency, effectiveness, and clinical sequelae of tubal sterilization with a focus on the U.S. experience.

DESIGN

A review of U.S. health care statistics and English-language literature using a MEDLINE search, bibliographies of key references, and U.S. government publications.

PATIENT(S)

Women seeking tubal sterilization.

INTERVENTION

Tubal sterilization.

MAIN OUTCOME MEASURE(S)

Effectiveness and long-term risks and benefits.

RESULT(S)

Half of the 700,000 annual bilateral tubal sterilizations (TS) are performed postpartum and half as ambulatory interval procedures. Eleven million U.S. women 15-44 years of age rely on TS for contraception. Failure rates vary by method with one third or more resulting in ectopic pregnancy. Reversal is most successful after use of methods that destroy the least tube. Evidence of menstrual or hormonal disturbance after TS is weak, although some studies find higher rates of hysterectomy among previously sterilized women. Decreased risk of subsequent ovarian cancer has been observed among sterilized women.

CONCLUSION(S)

Tubal sterilization is highly effective and safe. Failures, although uncommon, occur at higher rates than previously appreciated. Evidence for hormonal or menstrual changes due to TS is weak. Tubal sterilization is associated with decreased risk of ovarian cancer.

Laparoscopic tubal anastomosis and reversal of sterilization

Fallopian tube interruption is a common form of contraception worldwide. For a variety of reasons (e.g. change in marital status, wish for additional children, psychological factors), many of these women seek restoration of fertility. Laparoscopic tubal anastomosis is one of the newest of these procedures by which this can be achieved. Sixteen women underwent laparoscopic microsurgical anastomosis. We used a three-stitches technique with tubal cannulation adapted from methods described in the literature. Five pregnancies occurred, giving an overall pregnancy rate of 31.2%. Surgical outcome depends on the patient's age, the method of tube interruption and the length of Fallopian tube segments being anastomosed. In this study, the feasibility of laparoscopic tubal sterilization reversal is confirmed, as well as the benefits offered by laparoscopic procedures in terms of quality of life. Further improvement of surgical outcome will be achieved not only through better laparoscopic techniques but also through careful screening for surgical indications.

Peripherally administered sufentanil inhibits pain perception after postpartum tubal ligation

The clinical effectiveness of locally administered opioids is still under discussion; in particular, the potency of morphine in settings other than intra-articular arthroscopy has been questioned. We developed another pain model, postpartum resection of the fallopian tubes for sterilisation, in which each patient serves as her own control when one side is infiltrated with the active drug (in this study sufentanil 5 mg) and the contralateral side with normal saline. In the control group both sides are infiltrated with plain saline. After 30 min from the end of anaesthesia onwards, 26 out of 30 patients observed significant pain relief on the side of the sufentanil infiltration, which in 11 patients lasted until the end of the observation period 24 h postoperatively; no difference was observed in the control group. In our pain model with a high assay sensitivity, the infiltration of one side with the lipophilic test drug, sufentanil, caused local analgesia in primarily non-inflamed tissue. The use of each patient as her own control excluded inter-subject bias.

[Complications of tubal sterilization by minilaparotomy under local anesthesia]

Between January 1, 1991 and June 30, 1996, physicians performed 800 cases of tubal ligation via minilaparotomy under local anaesthesia in the Obstetrics and Gynecology clinic of the Dakar University Teaching Hospital (Senegal). There were complications in 7 (0.87%) cases (bladder and bowel injuries: 6 cases, and post operative infection: 1 case). The most frequent risk factors were: surgeon skill (lack of experience of surgeon in minilaparotomy), type of patients (obesity, previous abdominal surgery). It was concluded, proper training and experience of the surgical team is needed to minimize sterilization related complications.

Tubo-ovarian abscess after tubal ligation

Tubo-ovarian abscess usually results from ascending infection of the lower genital tract. In a few cases it can occur as a result of direct contamination at the time of tubal sterilization. We describe a case that presented seven years after post partum tubal sterilization, showing both acute and chronic components.

Effective analgesia after bilateral tubal ligation

Postpartum bilateral tubal ligation is a brief surgical procedure with minimal tissue injury, yet postoperative recovery times and analgesia requirements are often disproportionately large. To evaluate the analgesic efficacy of local anesthetic infiltration, 20 parturients scheduled for elective minilaparotomy and bilateral tubal ligation with either spinal or epidural anesthesia participated in this prospective, randomized, controlled, double-blind trial. All patients received IV metoclopramide 10 mg and ketorolac 60 mg intraoperatively, as well as preincisional infiltration of the infraumbilical skin incision with 0.5% bupivacaine. Infiltration of bilateral uterine tubes and mesosalpinx was performed with either 0.5% bupivacaine (n = 10) or isotonic sodium chloride solution (saline) (n = 10). IV meperidine (25 mg every 3 min as needed) was given to treat pain in the postanesthesia care unit (PACU). The total amount of meperidine administered in the PACU was significantly larger in the saline group than in the bupivacaine group. Pain scores at 30, 45, 60, 75, and 90 min postoperatively and on the seventh postoperative day were significantly lower in the bupivacaine group than in the saline group. During tubal ligation, infiltration of uterine tubes and mesosalpinx with 0.5% bupivacaine significantly enhanced analgesia both in the immediate postoperative setting and on the seventh postoperative day compared with infiltration with sodium chloride.

IMPLICATIONS

During bilateral tubal ligation with either spinal or epidural anesthesia, preemptive analgesia using IV ketorolac, IV metoclopramide, and infiltration of the incised skin and uterine tubes with 0.5% bupivacaine allowed 9 of 10 patients to recover with no pain, nausea, vomiting, or cramping and to maintain good analgesia for 7 days postoperatively.

Planned condom use among women undergoing tubal sterilization

BACKGROUND AND OBJECTIVES

Women who are undergoing tubal sterilization are at risk for various sexually transmitted diseases (STDs) if they do not use a barrier method of contraception. There is a paucity of data concerning dual use of condoms among sterilized women.

GOAL

Planned use of condoms for protection against STDs was examined among 2,782 women undergoing surgical sterilization from 1991 to 1996.

STUDY DESIGN

Cross-sectional survey.

RESULTS

Planned condom use increased significantly over the 6-year study period. Of women who were using condoms before sterilization (n = 646), nearly half indicated no plans to do so after becoming sterilized. Thus, 11% of the total sample experienced an increased risk for exposure to human immunodeficiency virus or other STDs. Condom abandonment was significantly higher among Hispanic and married women. Multiple regression analysis was used to examine the association between condom use and various characteristics. Factors associated with future condom use were younger age, black ethnicity, being unmarried, previous STD, not having a steady partner, higher number of previous sexual partners, having used condoms for disease prevention in the past, and lack of partner involvement in the decision to undergo sterilization.

CONCLUSIONS

Use of condoms among sterilized women appears to be on the rise, women at higher risk for disease are more likely than others to be using condoms, and only a small group of women experience an increased risk for exposure to disease as a result of selecting this permanent method of contraception.

Contraceptive practices of women living in rural areas of Bihar

A prospective survey of 972 married (sexually active) women living in rural areas of Lalganj block of Vaishali district in Bihar state of India was carried out. The study was aimed at obtaining first hand information from the rural women regarding their contraceptive practices and to use the information thus gained to identify those spheres of concern where greater attention needs to be paid to make the family planning system more efficient. The population investigated consisted of women attending the combined obstetric and gynaecology clinic located at Lalganj. Tubal sterilisation was the commonest method of contraception among women surveyed ( 20.6 per cent of women). The incidence of sterilisation increased significantly as the age increased-11.6 per cent of women aged 21 to 30 had tubal sterilisation, whereas the incidence was 51 per cent in women aged 31 to 40 years. Reversible forms of contraception (IUD, oral pills and condoms) were used by only 6.8 per cent of women included in the study. Married girls aged 15 to 20 were not using any contraceptive. It was also noted that none of the women surveyed had used any contraceptive prior to her first pregnancy. Fortyper cent of women in the age group 21 to 30 years and a similar percentage (41.1 per cent) in the age group 31 to 40 years had two or more live children but did not use any contraceptive. The results reveal that tubal sterilisation is the most popular method of contraception among women living in rural areas of the state. Birth spacing, or delaying the birth of the first child by the use of reversible forms of contraception, is not the common practice among these women.

Human endometrial perfusion after tubal occlusion

We examined variations in human endometrial microvascular perfusion across one menstrual cycle in women who had undergone tubal ligation and did not report unusual menstruation. Endometrial red blood cell flux was monitored by laser Doppler fluxmetry via a fibreoptic probe atraumatically inserted transvaginally into the uterus of each of 13 conscious volunteers. The observations obtained have been compared with those previously reported from a matched control group of women [B.J. Gannon et al., Hum. Reprod., 12, 132-139 (1997)]. Women who had undergone tubal occlusion for sterilization exhibited greater endometrial perfusion during menstruation (cycle days 0-5), at the time of ovulation (cycle days 13-16) and in the late secretory phase (cycle days 23-28) than occurred in controls. In addition, vasomotion in the study group was lower than that in controls in the early and late secretory phase (cycle days 17-22 and 23-28). Tubal occlusion appeared to alter endometrial perfusion. It is possible that the reported menstrual changes in women following tubal ligation are a consequence of altered endometrial perfusion; a possible causative relationship is discussed.

Is there any evidence for a post-tubal sterilization syndrome?

OBJECTIVE

To review the literature on menstrual and hormonal changes in women who under go tubal sterilization.

DESIGN

A systematic review through MEDLINE and a literature search identified more than 200 articles in the English literature from which the most relevant were selected for this review.

RESULT(S)

Many authors have investigated the sequelae of female sterilization. Increased premenstrual distress, heavier and more prolonged menstrual bleeding, and increased dysmenorrhea have been reported. However, failure to control for age, parity, obesity, previous contraceptive use, interval since sterilization, or type of sterilization may have affected study results. Most studies that have controlled for these important variables have not reported significant changes, except in women who undergo sterilization between 20 and 29 years of age.

CONCLUSION(S)

Tubal sterilization is not associated with an increased risk of menstrual dysfunction, dysmenorrhea, or increased premenstrual distress in women who undergo the procedure after age 30 years. There may be some increased risk for younger women, although they do not appear to undergo significant hormonal changes.

An unusual case of wrongful pregnancy: liability of doctor resulting from misrepresentation

A married woman and her husband recovered damages from a gynaecologist after the woman gave birth to a third and normal child. The couple's second child had been delivered by way of Caesarean section. Six days after its delivery the doctor made the statement (erroneously) that he had performed a tubular ligation on the woman, following a discussion on the advisability of sterilisation. In fact no such procedure had been performed. The woman became pregnant again. The doctor was held liable on the basis of a negligent misrepresentation.

A case of failure of tubal sterilization using Pomeroy's technique

With reference to a case of pregnancy of a patient formerly subjected to tubal sterilization using Pomeroy's technique, the authors define the possibility for tubal stumps to recanalise. Despite the low percentage of failure in tubal sterilization using Pomeroy's technique, the authors conclude that it is advisable to make the earliest possible diagnosis of both intrauterine and extrauterine pregnancy on the basis of suspected symptoms in order to, especially for tubal pregnancies, avoid any tubal sterilization.

Pelvic inflammatory disease in patients with bilateral tubal ligation

Classic teaching has stated that women who have undergone bilateral tubal ligation (BTL) are not susceptible to pelvic inflammatory disease (PID). The purpose of this study was to confirm the existence of PID in patients with BTL and to compare clinical parameters of these patients with PID patients who have not had BTL. A retrospective chart review of emergency department (ED) patients diagnosed with PID over a 1-year period at a large urban university hospital found 209 patients who fulfilled the criteria for a definition of PID. Of the 209 patients with PID, 24 (11.7%) had undergone BTL. Patients with and without BTL were compared with respect to age, white blood cell count (WBC), temperature, admission rate, length of hospitalization, prior history of PID, culture results, presence of bilateral abdominal pain, presence of rebound tenderness, and complications of tubo-ovarian abscess (TOA) and hydrosalpinx. Patients with BTL had lower WBCs (11,100/microL v14,700/microL) and were 2.5 times less likely to be hospitalized compared to those patients without BTL. These results show that PID in the setting of a prior BTL not only exists but occurs with surprising frequency and deserves further study. Patients with BTL and PID may have a clinically milder form of PID than those patients without BTL.

Effects of age and non-hormonal contraception on menstrual cycle characteristics

The objective of this study was to investigate the effects of age and non-hormonal contraceptive method on menstrual cycle parameters. The menstrual cycle data were collected prospectively, and the study was cross-sectional with regard to age. The subjects were 142 women, including 14 asymptomatic volunteers and 128 women who presented to a premenstrual tension (PMT) clinic. The age range was 20-45 years. Contraceptive methods used were intrauterine device (IUD) (n = 12), tubal ligation (n = 61) and non-intensive methods (n = 69). Daily menstrual cycle diaries were used to calculate cycle length and number of days of menstruation. Daily 24-h urine collections were used to calculate the day of the preovulatory estrogen peak. Pearson correlations found significant relationships between age and preovulatory estrogen peak day (p < 0.001) and length of cycle (p < 0.002), but not between age and length of menstruation or luteal phase. Analysis of variance was highly significant for age and contraceptive method, for both cycle length and preovulatory estrogen peak day. Non-intrusive contraception users aged 30 years and younger had significantly longer follicular phases than did women with tubal ligation (p < 0.05). It was concluded that cycle length decreases with age due to shortening of the follicular phase. Further research on whether tubal ligation affects ovulation and follicular phase length in young women is needed.

[Closure of the skin with cyanoacrylate in surgical wounds after tubal sterilization]

Close of skin with cyanocrilate in surgical wounds after tubary sterilization. The objective was to determine the use of cyanocrillate in surgical wounds coalescence, to decrease the time employed when closing the skin, as well as to aid the healing process. This is an observation, prospective, length, comparison, study. Since March, 1995, the Gyneceum-Obstetrics "Luis Castelazo Ayala" Hospital has carried out this research, forming two groups as follows. Group A: Tubary sterilization (OBT) was practiced to 36 patients applying a superficial coat of cyanocrilate. Group B included 31 patients whose skin was sutured with catgut 00. In Group A. the average time for skin closure is 14.5 seconds, in wounds with a length of 2 to 6 cm. In Group B the average time is 3.9 minutes, in wounds with a length of 1 to 4 cm. 4 cases of group A reported pain for the first 12 hours (11.1%), pruritus in wound in 3 cases (8.3%), partial dehiscence of wound, 1 case (2.7%). While in Group B the result are: Pain in 10 cases (32.2%), pruritus in 3 cases (9.6%), partial dehiscence of wound in 3 cases (9.6%), 1 case with poor edges coaptation (3.2%), and reaction to suture in 2 cases (6.4%). Not even an infection condition occurred. Cyanocrilate used in selected cases is an inexpensive, fast, easy to use efficient method, with little morbidity and likely to improve the aesthetic of surgical scar.

Voluntary female sterilisation via minilaparotomy: report from Burkina Faso

We present the first study of voluntary female sterilisation in Burkina Faso. The average woman undergoing tubal ligation was a 37 year old, married, house wife para 8 with five living children. The main reasons for TL were: achieved desired family size (45.9%) and medical reason (29.5%). The TL was usually performed (77.8%) in the postpartum, using the Pomeroy technique. With a follow up of three to fifteen months, no pregnancy has been reported and no request for reversal expressed. The authors make some suggestions to increase the prevalence of TL in Burkina Faso.

Tubal ligation and the risk of ovarian carcinoma

To assess the relationship of tubal ligation and risk of ovarian carcinoma, we conducted a case-control, retrospective analysis of 300 ovarian carcinoma cases and 606 nonmalignant disease controls, seen between 1982 and 1988 at Roswell Park Cancer Institute, Buffalo, New York. Women who had a tubal ligation had reduced risk for the development of ovarian cancer. This relative risk was 0.52, with a 95% confidence interval 0.31 to 0.85 (p = 0.0076). Controls were matched by age. Multivariate analysis adjusted for socioeconomic level, marital status, parity, age at first pregnancy, menarche age, menopause age, irregular menses, breast-feeding duration, body habitus, and oral contraceptive use. Suggested explanations for this observation are offered.

Chlamydia trachomatis and febrile complications of postpartum tubal ligation

OBJECTIVE

Our goal was to determine whether chlamydia-infected women have a higher rate of febrile complications after postpartum tubal ligation.

STUDY DESIGN

Cross-sectional analysis of 1447 women tested for chlamydial infection within 2 weeks of delivery and who underwent postpartum tubal ligation was performed. Subjects were identified with the Regenstrief Institute for Health Care database. Infected subjects were compared with uninfected subjects for incidence of fever not explained by nongynecologic sources.

RESULTS

Women infected with Chlamydia trachomatis at delivery were more likely to experience febrile postoperative complications after tubal ligation (p < 0.0001, relative risk 9.5, 95% confidence interval 4.5 to 20.1).

CONCLUSION

Women undergoing postpartum tuba ligation may benefit from prompt diagnosis and preoperative treatment of chlamydial infection.

Experimental nonsurgical transcervical sterilization with a custom-designed platinum microcoil

PURPOSE

Investigation of a technique for nonsurgical female sterilization.

MATERIALS AND METHODS

A custom designed platinum microcoil with Dacron fibers was placed unilaterally into a fallopian tube and uterine horn of 10 rabbits after transcervical selective tubal catheterization with use of fluoroscopic guidance. The contralateral uterus and fallopian tube served as controls. After the rabbits were bred, pregnancy was determined by palpation and confirmed at autopsy. Postmortem histopathologic evaluation of uteri and fallopian tubes was performed.

RESULTS

Nine of the 10 rabbits became pregnant. None of the animals had embryos on the microcoil side. Nine rabbits had a total of 45 embryos on the control side. One animal failed to become pregnant on either side. The microcoil remained in good position in all 10 rabbits. There was a microcoil-associated, mild inflammatory tissue response in the uteri and fallopian tubes.

CONCLUSION

A platinum occlusion microcoil placed in a utero-tubal location has potential as a means for nonsurgical female sterilization.

Psychological long-term effects of sterilization on anxiety and depression

Two-thousand cases (500 women and 500 men with sterilization; 500 women and 500 men without sterilization) in two counties and two cities in Sichuan, China, were investigated between 15 September 1992 and 30 April 1993. Information was obtained about their age, parity, marriage, contraceptives, social behavior, and present psychological characteristics. CES-D, SAS, and E.P.Q. scales were used to assess the depressive symptomatology, anxiety, and personality of the subjects. The results revealed that sterilization psychologically affected the depressive symptoms and anxiety under the neutral personality. In addition, depressive symptoms and anxiety were related to the subjects' age, educational level, income, operative doctors' attitudes to sterilization acceptors, and subjects' understanding of the sterilization.

Reduced risk of ovarian cancer in women with a tubal ligation or hysterectomy. The World Health Organization Collaborative Study of Neoplasia and Steroid Contraceptives

Possible relationships between tubal ligation and hysterectomy and epithelial ovarian cancer were assessed in data that were collected for a multinational hospital-based case-control study conducted between 1979 and 1988. Histologically confirmed incident cases (n = 393) were compared with controls (n = 2563) matched on age, hospital, and year of interview. A nonsignificant reduction in risk was observed for tubal ligation [odds ratio (OR), 0.72; 95% confidence interval (CI), 0.48-1.08] and hysterectomy (OR, 0.58; 95% CI, 0.26-1.27). There was no trend in risk with time since tubal ligation. The possible protective effect of tubal ligation was greatest in women of parity less than four. The apparent protective effect of tubal ligation was seen only for clear cell (OR, 0.32; 95% CI, 0.006-2.50) and endometrioid (OR, 0.20; 95% CI, 0.046-1.46) tumors, suggesting a hormonal mechanism for the observed associations.

Tubal sterilization by means of selective catheterization: comparison of a hydrogel and a collagen glue

PURPOSE

To test, in an animal model, two potentially suitable materials for nonsurgical selective tubal sterilization.

MATERIALS AND METHODS

A hydrogel that forms an in situ plug by phase inversion of a polymer solution was placed in four rabbit fallopian tubes, and a proprietary collagen glue was placed into three rabbit fallopian tubes by means of transvaginal fluoroscopic fallopian tube catheterization. As controls, 11 tubes were catheterized without sterilization material injection. The rabbits were bred, and the presence of embryos was confirmed with palpation and at autopsy. Histologic analysis was performed.

RESULTS

The short-term contraception rate was 100% in the hydrogel group, 33% in the collagen glue group, and 0% in the control group (P < .001 hydrogel group, P not significant in collagen group). Inflammation was minimal in the three groups (P not significant).

CONCLUSION

The collagen glue had an insufficient contraceptive effect and should be abandoned. The hydrogel used proved effective and biocompatible, and long-term studies of this compound are warranted.

Tubal ligation candidates who did not get their operation

OBJECTIVE

To identify bottlenecks in the delivery of comprehensive family planning to women in contact with the Health Services and to find ways to reduce unmet demand for contraception.

DESIGN

Exploratory descriptive study.

SETTING

Large Bulawayo Government Hospital and the high density areas in the same city.

SUBJECTS

Case notes of 284 women who indicated together with their partners that they had completed families and who had their tubal ligation forms duly signed but who never had their operation. Follow up of a sample of patients.

INTERVENTIONS

Non intervention study.

MAIN OUTCOME MEASURES

Are reproductive rights taken seriously? Is there service related unmet demand for family planning.

RESULTS

Even those who had all their paperwork in order for a durante or post partum sterilization did not have any guarantee that this service would be given. The main reason was found to be lack of well motivated health staff.

CONCLUSION

Much can be improved in contraceptive service delivery. Reproductive rights are not respected.

Self-assessment of confidence of internee doctors in performing common surgical operations

A total of 140 internee doctors who had just completed or were about to complete their internship training from four leading Medical College Hospitals of Bangladesh were asked to fill up a pre-tested structured questionnaire. Of them 115 were male and 25 were female. All the participants had 6 months compulsory training in Medicine, 123 had 6 months training in Surgery and 17 had 6 months training in Obstetrics-Gynecology. Over 50% doctors expressed lack of confidence in performing ligation, vasectomy, splinting simple fractures, venesection, episiotomy, hydrocele operation, circumcision, proctoscopy and inguinal herniorrhaphy and expressed the need for further training in those procedures. Only 10% and 1.43% internees stated that they were confident about performing ligation and vasectomy independently. Internees from Chittagong Medical College Hospitals expressed their inability to perform ligation and/or vasectomy independently. So it was recommended that surgical training should be made mandatory for all internee Doctors with extension of the Internship period by at least 6 months. Emphasis should be laid on training in vasectomy and ligation. A pre-registration evaluation test may be introduced at the end of their training period.

Tubal sterilization and the risk of endometrial cancer

Several animal and human studies suggest that tubal occlusion may curtail ovarian function, altering the production and balance of endogenous estrogens and progesterone, 2 hormones closely related to endometrial carcinogenesis. Despite this, and the increasing world-wide popularity of this method of contraception, little is known about its relationship with the risk of developing endometrial cancer. To assess whether tubal sterilization influences a woman's risk of developing epithelial endometrial carcinoma, data from a large multicenter population-based case-control study of endometrial cancer were analyzed. Cases were 437 women aged 20 to 54 years with histologically confirmed epithelial endometrial cancer ascertained through 6 population-based cancer registries in the United States. Controls were 3200 women selected at random from the populations of the areas from which the cases were detected. As compared with women who had never had tubal sterilization, women who had had this surgery had a crude odds ratio of 0.58 [95% confidence interval (CI), 0.43-0.78]. However, after adjusting for the combined confounding effects of age and parity, the magnitude of the protective association decreased to 0.87 (95% CI, 0.63-1.20). The magnitude of the protective effect did not significantly change with years since surgery or age at surgery. Although a modest, non-significant protective effect is suggested, these findings indicate that tubal sterilization does not substantially alter the risk of developing epithelial endometrial cancer in women 20 to 54 years of age. If there is an increase in risk, these data indicate that it is unlikely to be any greater than 20%.

A case-control investigation on cancer of the ovary in Bangalore, India

Cancer of the ovary is the sixth leading cancer among females in Bangalore, and is a leading site of cancer in other population-based cancer registries in India. A case-control investigation was conducted utilizing the data from the population-based cancer registry in Bangalore. In addition to the core patient information, certain other details pertaining to consumption of tobacco, reproductive and obstetric factors and those related to the practice of family planning, including the method adopted, were available with the registry, for the period 1982-1985. Identical information was also available for patients residing in the registry area who did not have cancer. Ninety-seven cases of ovarian cancer in ever-married women were age-matched with 194 controls from the same area who showed no evidence of cancer. The risk of ovarian cancer was not influenced by tobacco habits, alcohol consumption, diet or the various reproductive factors. However, tubectomy as a method of family planning appeared to reduce the risk of development of ovarian cancer. This reduction in risk was not influenced by parity or age of the woman at the time of birth of the first child.

A ten-year review of uterine rupture in modern obstetric practice

The aim of this paper is to determine the antecedent factors, clinical presentation, complications and management of uterine rupture in the context of modern obstetric practice in Singapore. We conducted a retrospective study of 26 proven cases of uterine rupture in Kandang Kerbau Hospital, Singapore between January 1983 to December 1992. These cases were analysed with regards to their past history, clinical presentation, complications, management and outcome. The incidence of uterine rupture was 1 in 6331 deliveries. The ratio of cases with scarred uteri against those with unscarred uteri was 3:1. The commonest antecedent factor was previous lower segment caesarean section for the scarred group and cephalo-pelvic disproportion in the unscarred group. Overall, 46.2% of the patients had augmentation with oxytocin. The major clinical presentations were abnormal cardiotocogram (25%) and blood-stained amniotic fluid (20%) in the scarred group, and postpartum haemorrhage (50%) and shock (33%) in the unscarred group. Repair of the uterus with or without tubal ligation was performed in 95% of the patients with scarred uteri, whereas 67% of the patients with unscarred uteri underwent total abdominal hysterectomy with or without salpingo-oophorectomy. There was 1 (3.8%) maternal death. Maternal morbidity included bladder injuries, broad ligament haematoma, disseminated intravascular coagulation and gastrointestinal bleeding. The overall incidence of fetal loss was 7.4%. When compared to a previous study on uterine rupture in the same hospital, there was an improvement in obstetric performance.