A survey of the knowledge, attitude and practice of family planning was conducted in Dharan, Nepal. The town offers a full range of family planning services free of charge. There was a strong desire to limit family size; 52.5% of couples were currently using some modern method of family planning. Of the current users, 62.3% had been sterilized, including 92.3% of those in the lowest socioeconomic group. Health risks and incompleteness of the family were the most common reasons for non-use of contraception, the latter reason reflecting ignorance of the temporary nature of some methods. There was a strong preference for male children and couples rarely used contraception until at least one so had been born. Even in this prosperous town where couples were highly motivated towards family planning and all methods were readily available, there was heavy reliance on sterilization. This is typical of Nepal and has largely been responsible for the failure of the family planning programme--as most couples choosing sterilization are in the older age group and have completed a relatively large family. If Nepal is to succeed in meeting its target of reducing the total fertility rate (i.e., births per woman) from the current 5.8 to 4 by the year 2000 it will need not only to expand services but actively to promote temporary methods of contraception, particularly the more reliable longer acting reversible methods such as Depo-Provera, Norplant and intrauterine contraceptive devices.

OBJECTIVE

This study investigated clinical and contraceptive characteristics of a group of southern Thai women who had two consecutive Norplant implantations at Songklanagarind Hospital.

METHODS

Seventy reinsertions were performed from 251 original Norplant implantations during the years 1986-1996. Four women had an exposed capsule within 3 months after reinsertion, and two of them subsequently had to have the capsule removed due to infection.

RESULTS

Following implantation, the recipients had gradually increased body mass index and systolic blood pressure, which returned to baseline 6 months after discontinuance after 10 years of implantation. Long-term continuation rates were 76.7% and 74.0% at the end of the first and second 5-year periods, respectively.

CONCLUSIONS

The failure rate was 1.8% during the second period compared to 1.1% during the first period.

OBJECTIVE

To evaluate the long-term effects of the new reformulated 2-rod Norplant implant on haemostasis in a prospective group of subjects who have completed 5 years of use.

METHODS

Data from 11 women who have completed 5 years' use of the new reformulated 2-rod subdermal implant from the original 16 women who were recruited and randomized to receive this new improved implant in a comparative study were analysed. Clinical assessment and serial blood sampling were done prior to insertion of implant and after 1, 3, 12, 18, 24, 36, 48 and 60 months of implant use. Each subject served as its own control and Analysis of Variance with Student-Newman-Kuels test was used for statistical analysis. The following parameters were determined: plasminogen activators (t-PA, u-PA), plasminogen activator inhibitor-1 (PAI-1), D-dimer, beta-thromboglobulin (beta-TG), thrombin-antithrombin (TAT)-complex, fibrinogen, Factor VII, platelets, haematocrit and haemoglobin levels.

RESULTS

No significant change was observed for t-PA levels in prolonged implant use. u-PA antigen showed a significant decrease whilst D-dimer were significantly elevated at only 24 months of implant use compared to pre-implant level. PAI-1 levels were not significantly changed but fibrinogen and FVII levels increased at 36 months and 42 months of use with enhanced platelet activation shown by beta-TG levels at 24 months. Platelet numbers were not affected by prolonged implant use. Haemoglobin concentration and haematocrit level showed significant fluctuations and then return to pre-implant level by 54 and 60 months.

CONCLUSIONS

Enhanced fibrinolysis with platelet activation at 24 months of implant use were seen during the 60 months of 2-rod reformulated Norplant implant use. Hypercoagulable state was not observed although fibrinogen and FVII levels remain above the pre-implant levels as coagulation activation was not enhanced. The increased haemoglobin and haematocrit levels seen indicate enhanced bone marrow activity. There was no association between the use of reformulated 2-rod Norplant implant over 60 months of use and prothrombotic state.

A 2-year prospective, randomized study of 60 implant users was performed to evaluate fasting serial serum apolipoprotein A-I, A-II, and B levels before insertion and every 3 months in users of two contraceptive implants releasing levonorgestrel (Norplant) and 3-ketodesogestrel/etonogestrel (Implanon) in Birmingham, United Kingdom. All changes in serum apolipoprotein concentrations, irrespective of an increase or decrease, were smaller than one standard deviation of the mean concentration at baseline and did not exceed the normal range for the laboratory, thus implying no evidence of an increased risk of coronary heart disease.

A longitudinal study of coagulation parameters was carried out on 100 Singaporean acceptors using Norplant for contraceptive purposes. At the end of 2 years of use, results from this ongoing study indicate that these acceptors continue to have an increased predisposition to thrombosis as evidenced by significant increases in platelet count and aggregability. The shortened but stable prothrombin time and activated partial thromboplastin time and increase in certain coagulation factors indicate that Norplant acceptors still have a possible potential for hypercoagulation at the end of two years of use.

A longitudinal study of coagulation parameters was carried out on 100 Singaporean acceptors using the levonorgestrel subdermal implants NORPLANT for contraceptive purposes. At the end of 1 year of use, results from this on-going study indicate that these subjects may have an increased predisposition to thrombosis as evidenced by significant increase in platelet count and aggregability. The results also show that NORPLANT acceptors may have an enhanced potential for hypercoagulation - with a significant shortening of their Prothrombin Time and Activated Partial Thromboplastin Time and increases in Factors V and X. As previously documented, mean values for haemoglobin and haematocrit were significantly elevated by the end of 1 year. A number of other parameters achieved statistically significant differences by the end of 1 year but these were probably due to the large sample size involved and were therefore not likely to be of much clinical importance.

612 women had the benefit of contraceptive implants in the Maternity Hospital of La Rabta in Tunis over a period of 5 years (1988-1992). This study aimed at analysing the tolerance of this method by studying a group of 508 normal women and 104 women at risk (58 women were heart-diseased, 22 nursing, 13 diabetic, 11 hypertensive). The typical woman in this group is thirty years old, having 3 children, and weighing 61 kg. The implants were most of the cases withdrawn because of problems related to the menstrual cycle that were observed in 37% of the cases, equally distributed among both groups of the series. Contraceptive implants failed in 1.79% of the cases.

The return of fertility is rapid after first trimester abortion. The first ovulation may take place as soon as 2 weeks after abortion, and half of the women have ovulated by 3 weeks. Hence, commencement of effective contraception is necessary even before the first postabortal menstrual period. Women are highly motivated as regards contraception at this time. Several studies, both in developed and developing countries, have shown that the insertion of a modern copper intrauterine device (IUD) at the end of the abortion procedure is a safe and well-accepted way to start the method. Hormonal methods, such as NORPLANT, levonorgestrel-releasing IUD, injectables and oral combination pills do not affect the recovery of the pituitary-ovarian system, even though introduced immediately after abortion. The combination of preceding pregnancy, abortion procedure and immediate start of low dose oral contraceptives containing 30 micrograms of ethinyloestradiol results in a slight tendency towards hypercoagulability. This may be clinically insignificant, but it can be avoided by postponing oral contraceptives until 1 week after abortion, without losing the contraceptive efficacy of the method.

We carried out a retrospective analysis of the continuation rates of 142 Norplant acceptors. Follow-up data was available on 110. We assessed the relative impact of side effects on discontinuation. No serious complications (immediate or late) were observed during the 3-year study period and no pregnancies occurred. The 3-year continuation rate was 88%. The commonest reported side effect was cycle disruption (64% of users). However this only accounted for 31% of discontinuations. This we attribute to thorough counselling about menstrual disruption. On the other hand androgenic side effects accounted for 12% of discontinuations but were experienced by 10% of users-perhaps because some users did not expect them. We conclude that Norplant is highly acceptable when offered with specialist counselling and support. Non-bleeding side effects accounted for relatively higher discontinuations and may need to be emphasised in counselling. A dedicated service enhanced acceptability.

Changes in menstrual bleeding patterns are the most frequent reason for discontinuing NORPLANT during the first year of use. Although NORPLANT is used by more women in Asia than in any other region, the changes that occur among these women are not well documented. In pre-introductory clinical trials of NORPLANT in the Philippines and Sri Lanka, 175 women were enrolled with greater than 95% continuing the method after one year. Daily menstrual bleeding calendars were kept by 94% of subjects for nine months and by 66% for one year. In contrast to findings in previous studies which showed that approximately 60% of NORPLANT users had bleeding disruptions in the first year of use, almost all of these women experienced bleeding disruptions. In a one-year study of menstrual pattern changes, increased bleeding was found to occur with the same frequency as reduced bleeding. However, the changes experienced by the Asian women tended to be decreases, rather than increases, in menstrual bleeding.

Cytokeratins 8, 18 and 19 are members of the cytoskeletal intermediate filament family found in all simple epithelia. Intermediate filaments are dynamic intracytoplasmic structures that can be influenced by a number of external factors. Norethisterone enanthate (NET-EN) is a long-acting progestogen contraceptive that has been found to arrest endometrial growth in the rat. Both Norplant and NET-EN cause bleeding problems among users which are responsible for>> 50% of withdrawals with these methods. The aim of this study was to explore changes in the expression and distribution of cytokeratins 8, 18 and 19 in NET-EN- and Norplant-exposed endometrial epithelium which could be related to bleeding disturbances. Seven NET-EN and 37 Norplant endometrial biopsies were paraffin-embedded and stained immunohistochemically to evaluate cytokeratin expression and distribution. The results showed that women who had received NET-EN for 3-4 months had a cytokeratin distribution similar to that seen in the normal menstrual cycle. This is in contrast to endometrium from Norplant users in which cytokeratin expression was reduced and the epithelial cells were more rounded. No relationship between cytokeratin expression and breakthrough bleeding pattern was found. NET-EN and Norplant may act differently on endometrial epithelial cytokeratin.