Two case reports are presented, describing the use of a 7-MHz ultrasound transducer to locate and visualize Norplant rods that could not easily be removed. The first patient was referred to the radiology department for a sonogram for unrelated reasons; her self-reported history led to the attempt to locate a retained Norplant rod. The second patient was first referred by a physician for the stated purpose of rod localization. After ultrasonic localization of the retained rods, both patients returned to their physicians' offices and underwent successful removal of the rods. Morbidity related to difficult rod retrieval can be reduced by using ultrasound for localization.

Progestogen-only implantable contraceptives are used by increasing numbers of women worldwide. This review outlines the evidence accumulated on these methods to date. Reviews of toxicological evaluations, clinical trials, endocrinological, epidemiological and social science studies, as well as operations research and economic evaluation were undertaken in preparation for an Expert Consultation convened by the World Health Organization in 2001. At the meeting, these reviews were further evaluated and the research results summarized in this consensus paper. A large body of evidence demonstrates the high contraceptive effectiveness and safety of the 5-year levonorgestrel-releasing implants Norplant and Jadelle. Information on the 3-year etonogestrel-releasing implant Implanon is more limited, but suggests that this implant has a high contraceptive effectiveness and a satisfactory safety profile. Information available on levonorgestrel-releasing implants manufactured and approved in China suggests that their clinical performance is satisfactory, but was insufficient to allow their full safety assessment. For all implants, there is insufficient information on their use by women with medical conditions. Provision of contraceptive implants requires good quality family planning services and specific provider training.

BACKGROUND

Men's Knowledge of and attitudes to family planning (FP) in suburban and rural Nigeria is still poor despite a global move to increase the involvement of men in reproductive health matters. A cross-sectional survey was conducted to determine men's knowledge of and attitude to family planning at Ganmo, a sub-urban community on the outskirts of Ilorin, Nigeria.

METHODS

The study employed an interviewer administered semi-structured questionnaire to elicit information from 360 men in the households. Only males above the age of 15 years resident in the community were selected for interview A proportionate sampling procedure was employed in selecting the required numberof men from each of the 32 compounds that make up the community.

RESULTS

Nearly all men (96.5%) were aware of family planning and a majority of them were aware of some common methods of family planning e.g. Oral Contraceptive Pills (OCPs) (72.5%), Injectables (69.2%), Condoms (86.6%) and Traditional methods (70.6%). Knowledge of other alternative female methods was low e.g. Norplant (17.5%), IUCD (26.3%), Diaphragm (39.8%), Vaginal cream (30.2%), Vaginal tablet (37.8%) and Vaginal sponge (16.8%), and Tubal Ligation (51.3%). Knowledge of male controlled FP methods like Withdrawal (49.6%), Rhythm or periodic abstinence (54.6%) and Vasectomy (28.6%) was also poor. The Respondents had low knowledge of common side effects of FP methods e.g. nausea (9.8%), vomiting (13.1%), abnormal menstruation (34.4%), pain (23.2%) and unwanted weight gain (17.0%); some 25.3%% of respondents had no knowledge of any side effects. The attitude of respondents to family planning was also relatively poor as only a moderate proportion of men supported the FP concept (52.7%) and the Nigerian Population Policy (54.8%) of "four children to a woman". Some 54.8% of respondents were in support of men discussing about FP with their spouses. The major reasons for non-approval of FP by men were the fear of side-effects (70.4%) and perception of FP as being against religion (52.1%). The predictors of poor FP attitude were not having formal education, practice of polygyny and to a lesser extent being a Muslim.

CONCLUSIONS

The study concluded that, men at Ganmo have limited knowledge of, and poor attitude to FP An intensive drive at a community based adult reproductive health education was advocated among other recommendations.

Ovarian endocrine function was assessed in 88 women using NORPLANT subdermal implants during different periods of use and in a control group of 15 women using non-hormonal contraception. Blood samples for estradiol (E2) and progesterone (P) assays were obtained twice a week for five consecutive weeks. Three distinct E2 patterns were observed: one was characterized by fluctuating levels within a normal range (20 to 400 pg/ml), a second pattern corresponded to continuous low E2 levels (below 75 pg/ml in the 10 samples) and the third was characterized by high broad estradiol peaks reaching over 400 pg/ml. The proportion of sampling runs characterized by normal fluctuating levels increased from 38% in the first two years of use to 80% during the fifth year of use. Low E2 profile was only observed during the first two years of use (27%) and in only 1 case at the beginning of the third year of use (5%). The percentage of cycles with high broad estradiol peaks remained between 20-40% without a clear tendency to change in either direction with duration of use. Thirty-three percent of the observed sampling runs had luteal activity (P above 3 ng/ml). The proportion of runs with luteal activity increased from 14% during the first two years of use to 40% during the third and fourth, and 60% during the fifth year of use. All control subjects had luteal activity. The mean highest progesterone level was lower in the NORPLANT runs (8.7 +/- 3.9 ng/ml) as compared to the controls (11.3 +/- 3.8 ng/ml). NORPLANT sampling runs with luteal activity had normal fluctuating E2 levels with only one exception. However, not all cycles with normal E2 levels showed luteal activity. On the other hand, all runs with low E2 levels or high broad E2 peaks were without luteal activity. In summary, women using continuous low-dose levonorgestrel contraception through NORPLANT subdermal implants, have a variable degree of ovarian activity as compared with the more complete depression of ovarian function observed among pill or injectables' users. Ovarian activity becomes closer to normal during the third through fifth year of use.

The disappearance of levonorgestrel from plasma after the removal of NORPLANT subdermal implants was studied in 12 women who had been treated from 5.5 to 78 months. The existence of one or two half-lives for the rate of disappearance was assessed. The influence of body weight, body fat and length of treatment upon levonorgestrel clearance was studied through stepwise regression analysis. It was found that the levonorgestrel decay rate after implant removal can be entirely accounted assuming one half-life of 42 +/- 16 h (mean +/- SD; range 13 to 62 h). Stepwise regression analysis showed that levonorgestrel half-life is positively correlated with body weight and not significantly correlated with the length of treatment or body fat. It is concluded that, after long-term administration of levonorgestrel via subdermal implants, the major part of the steroid is cleared from plasma within 96 h and that only trace amounts are detected in the following days.

The standard technique for Norplant implants removal was compared with a new technique called the "U" technique, which employs the use of a modified no-scalpel vas deferens holding forceps to grasp and remove the capsules. Seventy-six women requesting Norplant implants removal were randomly assigned to Group 1 (standard removal technique) or Group 2 ("U" removal technique). Variables measured included: (a) time required for complete removal, (b) number of capsules not broken or damaged during removal, and (c) number of incisions required for removal of all six capsules. In clients with visible or palpable capsules, the standard removal technique required significantly more time to remove all six capsules, on average, than the "U" technique (19 versus 7 minutes, p < 0.001); also more capsules were damaged during removal (5.6 undamaged versus 6.0, p < 0.01). In addition, with the standard technique, five clients required two incisions for removal of all six capsules while none of the clients required more than one incision with the "U" technique. Our conclusion is that the "U" technique is a quicker and easier method of removing Norplant capsules than the standard technique.

OBJECTIVE

To compare acceptability, tolerance of side effects, and continuation rates among adolescent and adult Norplant accepters.

METHODS

An 18-month observational study was conducted of 136 adolescents and 542 adults who received Norplant at the Francis Scott Key Medical Center in Baltimore, Maryland. Data were collected from the following: a self-administered history form completed at the preinsertion visit, a self-administered follow-up form completed at routine follow-up visits, problem-visit chart review, and telephone contact for patients noncompliant with follow-up appointments.

RESULTS

The adolescents ranged in age from 13-18 years (mean 16.4), and adults ranged in age from 19-46 (mean 24.7). The mean parity among teenagers was 1.4; among adults, 3.2. Thirty-nine percent of teenagers and 64% of adults had had one or more therapeutic abortions. Forty percent of adolescents and 47% of adults reported at least one contraceptive failure in the past. Both adolescent and adult Norplant accepters made few telephone calls or problem visits because of complaints or side effects. Compliance with routine annual follow-up was poor for adolescents (24 of 136, 18%) and adults (72 of 542, 13%). Follow-up of noncompliant patients revealed low rates of implant removal. Fifteen adolescents (11%) and 60 adults (11%) had Norplant removed. The most common reasons for removal included irregular bleeding, weight gain, headaches, and desire for pregnancy.

CONCLUSIONS

Implant acceptability, continuation, and tolerance of side effects were high and comparable among adolescent and adult accepters. Initial implant users were primarily adolescents or adults who had experienced problems with other forms of reversible contraception. Adherence to scheduled follow-up appointments was poor, regardless of age.

Forty-seven normal non-smoking parous women were enrolled in a longitudinal study of the effect of use of the subdermal levonorgestrel implants, NORPLANT, on serum lipids. Blood samples were collected after an overnight fast before insertion and after three, six, nine and twelve months of use. The high-density lipoprotein cholesterol showed no change until the twelfth month when it was increased (P less than .05). Total cholesterol, low-density lipoprotein cholesterol and triglyceride levels decreased significantly during NORPLANT use.

OBJECTIVE

To determine the effect of a single dose of mifepristone (200 mg) on endometrial estrogen and progesterone receptors in Norplant users.

METHODS

A prospective single-blind placebo-controlled pilot study. SETTING; Women were recruited from a large family planning clinic and were studied either at the clinic or in a clinical research unit attached to a teaching hospital gynecology department.

METHODS

Eight women using Norplant and experiencing vaginal bleeding more often than once every 24 days. All completed the study.

METHODS

Endometrial biopsies were taken after treatment with both placebo and 200 mg of mifepristone, both given at the start of a bleeding episode.

METHODS

Expression of endometrial progesterone (PR) and estrogen (ER) receptors, ovulation, and vaginal bleeding.

RESULTS

Mifepristone administration was associated with down-regulation of PR receptor subtype B and up-regulation of ER. Women treated with mifepristone showed a tendency to increased ovulation rates and reduced vaginal bleeding.

CONCLUSIONS

The effect of mifepristone on endometrial steroid receptors was consistent with functional inhibition of progesterone. The findings warrant further investigation of this regimen as a strategy to reduce frequent bleeding.

With the objective of evaluating the ovulatory function among long-term Norplant implants users with regular menstrual cycles, we undertook this prospective study including 11 Norplant implants users and 11 control women who were not using hormonal methods of fertility control. Exposed and unexposed women had had at least three regular menstrual cycles preceding enrollment. All women were followed during one menstrual cycle by serial vaginal ultrasound and estradiol (E2), progesterone (P), LH, and FSH measurements. Three Norplant implants users ovulated, three had luteinization of an unruptured follicle (LUF), three had persistent follicle growth up to a mean of 33 mm without rupture, and two had no follicular development beyond 16 mm. Ten of the controls had normal ovulation and one had LUF. Mean peak LH and FSH among Norplant implants users who ovulated were three- to four-fold lower than among controls. Although users of Norplant implants with regular cycles frequently have luteal activity, the results of this study suggest that elevation of P during the second half of the cycle does not necessarily indicate ovulation has occurred and may frequently be associated with the presence of luteinized unruptured follicle. When ovulation occurs, there are usually abnormal hormone levels (low LH/FSH peak, low progesterone) which may also contribute to the contraceptive effect of Norplant implants.

Changes in carbohydrate metabolism, measured by oral glucose tolerance test, were studied in Norplant users before and after removal. The mean area under the glucose curve rose from 24.7 min mmol/L before Norplant insertion to 35.1 min mmol/L before removal and decreased to 26.1 min mmol/L four weeks after Norplant removal. The areas before insertion and after removal were not statistically different (95% confidence interval -3.3 to 0.56, P = 0.16). The mean areas under the insulin curves before insertion (53.14 min uU/L) and after removal (59.46 min uU/L), however, were significantly different (95% confidence interval -7.64 to -5.0, P less than 0.0001). We conclude that changes in carbohydrate metabolism induced by Norplant are reversible once the implants are removed. While the changes in glucose induced by Norplant returned to pre-insertion levels within 4 weeks after removal, insulin changes were slower to return to pre-insertion values.

During a 30-month period, changes in carbohydrate metabolism (measured by oral glucose tolerance test) were studied in 20 Norplant acceptors. Changes were first observed one month after Norplant insertion and peaked between 12-18 months. The area under the glucose curve rose by 12.3% and 40.5% one and 12 months post insertion, respectively. At 18, 24 and 30 months the rise was, respectively, 41.9%, 40% and 38.6%. Although the changes under the insulin curves were similar, the increase at one month was doubled (25.7%). Only fasting insulin values showed very slight and insignificant changes during the 30-month period. All the changes were, however, within the normal limits for healthy women. We conclude that although Norplant induces changes in carbohydrate metabolism, these changes remain within normal limits, peak at 12 months and either remain the same or decrease with time.

BACKGROUND

The complications of Norplant removal relate primarily to the length of time and amount of dissection required for removal of the capsules. Complications include swelling and pain at the removal site and, at times, capsule fracture. The inability to locate one or more of the capsules is a rare complication. Recommended methods for locating the capsules include plain film radiography and ultrasound imaging. However, in circumstances where neither of these techniques succeeds, no specific recommendations exist to enhance visibility of the capsules.

METHODS

We used compression film screen mammographic techniques of the soft tissue at the site of insertion to locate a "lost" Norplant capsule after both plain films and ultrasound images failed to reveal the location of the capsule.

CONCLUSIONS

Film screen mammographic techniques may help locate "lost" Norplant capsules that are not visualized with either plain film radiography or ultrasound imaging of the insertion site.

Plasma levels of levonorgestrel, sex hormone binding globulin (SHBG) and estradiol were studied during four years in 283 healthy women using either NORPLANT implants or two covered rods (NORPLANT-2). The women were randomized to use either type of implant. Both implant systems have previously been shown to have similar release rates of levonorgestrel. In both groups plasma levels of levonorgestrel decreased throughout the study, and there were no statistically significant differences between the two groups in mean plasma levels of levonorgestrel. During the study 8 women became pregnant. All pregnancies but one occurred after 35 months of implant use and only in women using the covered rods. No significant differences were seen between the women who became pregnant and the rest of the group using two covered rods with respect to plasma levels of levonorgestrel. SHBG capacity tended to be somewhat higher in women using the two covered rods. As levonorgestrel is to a great extent bound to SHBG, and in that form not biologically active, a "free levonorgestrel index" was calculated as a ratio between levonorgestrel and SHBG. This index was significantly lower in users of two covered rods than in users of NORPLANT implants at 1, 12 and 48 months of use. Women who became pregnant had significantly lower "free levonorgestrel index" than had the rest of the group. It is postulated that the difference in "free levonorgestrel index" between users of the two implant systems reflect differences in release rate, the covered rods having a lower release rate of levonorgestrel than NORPLANT throughout the observation period. It is concluded that "free levonorgestrel index" is a better parameter than levonorgestrel plasma levels to describe implant function, and to discriminate women who are at risk of pregnancy.

A prospective, randomized clinical trial observed the effects of Norplant long-term contraceptive implants and domestic implants similar to Norplant on bone mineral density and bone metabolism in female acceptors for 1 year. Bone mineral density (BMD) and bone mineral content (BMC) of lumbar 2-4 and proximal femur of 61 normal women of child-bearing age were measured by dual energy x-ray absorptiometry (DEXA) before and 12 months after implants insertion in both groups. BMD and BMC of lumbar 2-4 in both groups 12 months after implant insertion significantly increased (p < 0.01); with an average increase of 2.40% and 3.34%, respectively in the Norplant implant group, and 2.75% and 4.47%, respectively in the domestic implant group. Urine hydroxyproline and creatinine ratio (Hop/Cr) in the domestic implant group significantly decreased (p < 0.01). There was no significant differences in the effects on BMD and BMC of lumbar spine and femur and on bone metabolism between the two groups of contraceptive implants (p>> 0.05). Levonorgestrel releasing contraceptive subdermal implants were not deleterious to the skeleton in women of child-bearing age. There was no significant effect on achieving maximum bone mass in young women.

The purpose of the study was to evaluate the efficacy, acceptability, side effects and continuation rates of the implant system in Thai women. A five-year clinical study of 308 women receiving Norplant-6 implants in Bangkok was conducted. Acceptors' mean age was 29 years, and mean number of children was about two. More than half of the users (63%) finished primary school. The cumulative continuation rates for Norplant implants at first, second, third, fourth and fifth years were, respectively, 98%, 91%, 83%, 78% and 71%. Eight out of a total of eleven pregnancies occurred in the fourth and fifth year of use. The cumulative pregnancy rate was 1.1% for the third year, 2.0% for the fourth year and 4.2% for the fifth year. Desire for future pregnancy was the leading cause for termination of Norplant implants use. The five-year cumulative termination rate for planned pregnancy was 9.2%. Disruption of menstrual rhythm, particularly increased bleeding, was the other main reason for termination; however, the prevalence of menstrual irregularities appeared to diminish with time. The cumulative termination rate for menstrual irregularities in the fifth year of the study was 4.4%. The complaints of "other medical reasons" for removal of Norplant implants were acne, severe headache, and chloasma. The five-year cumulative termination rate for other personal reasons was 7.9%. These personal reasons were husband having vasectomy, husband objection and divorce. It can be seen from this five-year study that Norplant implants are well accepted by Thai women. However, the efficacy in preventing pregnancy was not acceptable during the fourth and fifth year of use in this study, which was different from results of other international studies.

OBJECTIVE

To identify factors associated with the use of various birth control methods among sexually active adolescent girls.

METHODS

A survey distributed as part of a larger study measuring compliance with hepatitis B vaccination.

METHODS

A hospital-based and a school-based clinic.

METHODS

Demographic and health behavior data including sexual activity, contraceptive method, substance use, condom use, and history of sexually transmitted diseases (STDs) were collected. Birth control method was confirmed by medical record review. Associations with the outcome variable of birth control method were analyzed using chi square, Kruskal-Wallis analyses of variance, and t-tests, followed by logistic regression analysis.

RESULTS

Among sexually experienced girls, 39% (n = 123) reported using oral contraceptive pills (OCPs), 5.4% (n = 17) used Depo-Provera (medroxyprogesterone acetate) or Norplant (levonorgestrel), and 55.6% (n = 175) used no hormonal method. Logistic regression analysis revealed that the factors most significantly associated with the use of hormonal methods were older age (odds ratio [OR] = 1.19; 95% confidence interval [CI], 1.07-1.33), not using a condom at last intercourse (OR = 0.55; CI, 0.34-0.90), and having had a well visit within 1 year (OR = 2.11; CI, 1.12-3.70). OCP users were less likely than Depo-Provera or Norplant users to have used alcohol (p = 0.041), cigarettes (p = 0.002), or marijuana (p = 0.018) in the past 30 days. OCP users were less likely than nonusers of hormonal methods to have smoked cigarettes (p = 0.034) or marijuana (p = 0.052). The school-based clinic had a greater proportion of subjects using long-acting progestins (p < 0.001).

CONCLUSIONS

The decreased rate of condom use among those who used hormonal birth control methods and the different rates of health risk behaviors among users of various methods require targeted counseling efforts to decrease pregnancy and STD rates among young women.

The acidity of lidocaine used as a local anesthetic during the insertion of Norplant System capsules can cause patient discomfort. Buffering lidocaine with sodium bicarbonate significantly reduced pain scores reported by 46 women who participated in this randomized, double-blind study. Derived from a pain scale of 1 to 10, the mean difference in reported pain scores with and without buffering was 1.17 (P = 0.0098) with women using themselves as controls, for an average reduction in pain of 29%. Because this added step minimized patient discomfort, it might make the Norplant System a more attractive option for women apprehensive about insertion pain.

The growth and development of breastfed infants whose mothers used the contraceptive implants Norplant containing levonorgestrel and the injectable containing norethisterone enanthate were studied. Each group comprised of 120 women who initiated the use during the 5th to 7th week postpartum and were compared with a similar number of IUD using mothers. The breastfeeding performance did not differ between groups. The infants of the three groups performed similarly as regards their physical growth and health as well as the time of acquisition of the various milestones of psychomental development. A vaginal ring releasing 10 mg of the "natural" progesterone per 24 h was tested in breastfeeding mothers. The continuous use of the ring produced a serum level of progesterone around 4 ng/ml. This was effective in augmenting lactational infertility even through the later phases of breastfeeding when such an effect starts to wane off. The use of the ring proved to be acceptable and had no ill-effect on breastfeeding or infant growth or health. Using the natural progesterone as a contraceptive adds a new measure of safety, since the amount of the steroid secreted in the mother's milk will not be effectively absorbed from the infant's gut. These studies suggest the possibility of using two new methods for breastfeeding mothers; Norplant and the progesterone vaginal contraceptive ring. These can be initiated early postpartum, whenever this is considered needed.

The bleeding problems experienced by users of subdermal levonorgestrel implants (Norplant) remain unexplained. The aim of the present study was to investigate the oestrogen (ER) and progesterone receptor (PR) distribution in levonorgestrel-treated endometrial biopsies from 31 subjects recruited in Jakarta, Indonesia, and to compare the sex steroid receptor immunostaining with that of endometrium from 58 normally cycling women from Melbourne, Australia. Sex steroid receptor immunoreactivity was additionally compared with days of exposure to subdermal levonorgestrel, serum oestradiol and progesterone levels and days of bleeding during a 90-day reference period. An immunohistochemical technique with an alkaline phosphatase anti-alkaline phosphatase (APAAP) detection system for use in formalin-fixed paraffin wax embedded endometrial tissue was employed. Significantly greater mean immunostaining scores of stromal PR were observed in Norplant compared with control endometrium at all stages across the cycle. No significant correlations were demonstrated between sex steroid receptor immunostaining and days of exposure to subdermal levonorgestrel, serum oestradiol or progesterone concentrations or days of bleeding during a 90-day reference period. Whether the elevated stromal PR immunostaining in Norplant-treated endometrium is a consequence of increased synthesis or reduced turnover of receptor remains unclear. As yet it is undetermined whether increased PR immunoreactivity corresponds to an increase in number of functional PR.

Progestin implants for contraception are highly effective, safe, and the most convenient choice for many women. Progestin implants currently on the market, preparing for launch, or under investigation are reviewed here. Their basic galenic and pharmacokinetic features, as well as their contraceptive effectiveness, are described. The first progestin-only contraceptive implant placed on the market was Norplant, a multiunit system. Since then, several single- and double-rod implants have been developed, each using one of four different progestins: levonorgestrel, etonogestrel, Nestorone and nomegestrol acetate. Jadelle is similar to Norplant but consists of only two, rather than six, Silastic rods to simplify insertion and removal; nevertheless, levonorgesterel serum levels are identical, and performance is the same for both systems. The single implant systems reviewed here are: Implanon with a 3-year duration; Nestorone implants for breast feeding and non-breast feeding women lasting up to 2 years; and Uniplant, which is effective for 1 year. The advantages and disadvantages of progestin implants, the importance of counseling for increasing user satisfaction, and the future outlook for this contraceptive method are also discussed.

This study was undertaken to investigate the effect of use of levonorgestrel contraceptive implants, NORPLANT, by breastfeeding mothers on lactational performance and infant growth. NORPLANT implants were inserted between days 30 and 42 postpartum in 50 lactating women. Two control groups of breastfeeding mothers, 50 each, were studied in parallel: the first used an intrauterine device (Cu T380-Ag) and the second used either barrier or no contraception. There was no difference in lactational performance among the three groups. The increments in infant weight and height in the three groups were within the normal range for Egyptian infants. However, the rates of weight and height gain in the early postpartum months were slightly, but significantly, lower in the NORPLANT group than in the two control groups. However, by the sixth postpartum month, there were no significant group differences in these growth parameters. The possible confusing effect of supplementary feeding is discussed.

The transfer of levonorgestrel to infants was studied in 42 lactating women in whom the contraceptive subdermal implants, Norplant, were inserted 30 to 40 days postpartum. The women breastfed their infants for one year. Simultaneous mother and infant blood samples were taken once during the year. The levonorgestrel serum concentrations were measured by radioimmunoassay. During the first postinsertion month, the levonorgestrel concentration in the infants serum amounted, on the average, to 5% of the maternal concentration. Thereafter, the ratio ranged from 8 to 13%. The implications of this finding are discussed.

OBJECTIVE

The objective of the study is to evaluate the effects of levonorgestrel transferred through breast milk on thyroid stimulating hormone (TSH) and luteinizing hormone (LH) levels in full breast-fed infants.

METHODS

Forty healthy postpartum women and their male newborns were recruited for the study. Women were randomly allocated to two study groups: Group 1, IUD users and group 2, Norplant users. Blood and milk samples were collected on the day of IUD or Norplant insertion and 3 and 6 months later for TSH and levonorgestrel measurements.

RESULTS

The results disclosed a significant decrease in TSH levels, and a negative relationship between LNG levels and TSH concentration in breast feeding infants at 3 months after implant insertion. The lowest TSH levels were observed at 6 months in the women from group 2.

CONCLUSIONS

The overall data indicate that the LNG levels transferred to fully breast-fed infants through breast milk from Norplant users significantly modified their TSH levels.