活性金属单环165的临床研究

不锈钢环型节育器(金单环)在中国广为应用。为提高金单环的避孕效果,进行了金单环支撑力与脱落关系的研究,对200,165,135g不同支撑力进行比较性研究筛选出较为合理的支撑力为165g,其外形和金单环相似,分大、中、小三种型号,大号外径22mm,中号21mm,小号为20mm。外层为不锈钢丝螺旋簧,在螺旋环内相间置入纯铜丝(200mm2)和消炎痛硅橡胶各二段(消炎痛总含量5mg左右,现已改为10mg)。于1988年10月～1989年6月全国南北方7省市11所医院共放置1000例,经3年定期随访,12,24,36个月继续存放率各为92.5,88.99及85.94/100妇女年,36月累积带器妊娠率仅1.61/100妇女,脱落率比原金单环明显降低近40％,因症取出率为3.12。于放置前后进行月经血量测量24例,放置后3、6月各增加24.4％和27.4％。行子宫内膜“含铜含药组”和“有铜无药”组对照检查各11例,含药组炎症细胞略少。作宫颈粘液中铜离子含量测定,以6月内含量较高,6月后趋向平稳。消炎痛释放测定,1月内释放较快,一年后残留20％左右。经1249例临床观察,活性金单环165是一种不需特殊培训易于推广的、安全、经济并能长期放置的IUD。     

放置含铜IUD后异常出血者子宫内膜组织铜离子浓度和血管内皮生长因子表达关系的研究

目的:分析含铜宫内节育器(IUD)TCu380AIUD中铜溶蚀、子宫内膜组织中铜离子和血管内皮生长因子(VEGF)浓度与子宫异常出血的关系。方法:收集32例因子宫异常出血和36例月经规律但因非医疗原因取器者,选择18例未放置IUD且月经规律的妇女作对照,进行TCu380AIUD体外铜离子释放量的测定,检测各组妇女子宫内膜组织铜离子和VEGF的含量。结果:子宫异常出血妇女的CuIUD日铜溶蚀量高于月经规律妇女(P<0.05),子宫异常出血妇女的内膜组织铜离子含量和VEGF表达明显高于月经规律妇女的内膜组织(P<0.05),子宫内膜VEGF表达与子宫内膜组织铜离子含量呈正相关。结论:CuIUD的高溶蚀量可能导致子宫内膜组织铜离子含量的增加,造成子宫内膜VEGF分泌增多,进而发生子宫异常出血。     

活性γ型宫内节育器的研究

活性γ型宫内节育器(IUD)结构分三层,以不锈钢丝为主要材料,呈γ形,带有铜丝及消炎痛。自1986年起经临床预试验49例扩大预试验249例及全国多中心试验1000例,定期随访结果表明,放置3年时的带器妊娠率为0.9/100妇女,脱落率1.61,因症取出率2.02,续放率93.73;对照组TCu220C相应为1.61、1.40、4.71和90.27/100妇女。放置前后月经血量测量,说明平均减少17％～25％;子宫内膜活检变化无特殊性,较带铜IUD有较少炎细胞浸润和间质较明显水肿;宫颈粘液铜离子含量测定,预期可释放10年以上;消炎痛体内、外释放量测定表明:适应临床IUD引起月经多的好发期在1年内。研究结果表明γ-IUD具有妊娠和脱落率低,出血副作用甚少,预期可长期放置的优点,是钢、铜、药相结合的新型IUD,值得推广。     

克罗米芬联合补佳乐促排卵的临床观察

目的探讨在克罗米芬促排卵中加小剂量雌激素对子宫内膜厚度、宫颈粘液评分的影响。方法72倒排卵障碍性不孕症患者随机分为单用克罗米芬（CC）和CC联合补佳乐组。对照组为月经规律的已婚已育妇女。所有研究对象均B超监测卵泡,增殖晚期子宫内膜厚度、类型,并取宫颈粘液检查评分。结果比较三组子宫内膜厚度有统计学差异（P〈005）。两两比较后CC联合补佳乐组及对照组的子宫内膜厚度无统计学差异,两组子宫内膜厚度均显著高于CC组。HCG日宫颈粘液InSler评分结果比较CC联合补佳乐组高于CC组,但差异无统计学差异;两组均低于对照组宫颈粘液InSler评分,差异有统计学意义。结论克罗米芬促排卵时联合小剂量雌激素可改善子宫内膜厚度及宫颈粘液情况。     

克罗米芬联合补佳乐促排卵的临床观察

目的探讨在克罗米芬促排卵中加小剂量雌激素对子宫内膜厚度、宫颈粘液评分的影响。方法 72例排卵障碍性不孕症患者随机分为单用克罗米芬(CC)和CC联合补佳乐组。对照组为月经规律的已婚已育妇女。所有研究对象均B超监测卵泡,增殖晚期子宫内膜厚度、类型,并取宫颈粘液检查评分。结果比较三组子宫内膜厚度有统计学差异(P<0.05)。两两比较后CC联合补佳乐组及对照组的子宫内膜厚度无统计学差异,两组子宫内膜厚度均显著高于CC组。HCG日宫颈粘液InSler评分结果比较CC联合补佳乐组高于CC组,但差异无统计学差异;两组均低于对照组宫颈粘液InSler评分,差异有统计学意义。结论克罗米芬促排卵时联合小剂量雌激素可改善子宫内膜厚度及宫颈粘液情况。     

左炔诺孕酮宫内缓释系统(曼月乐)治疗子宫腺肌病的临床疗效

目的研究左炔诺孕酮宫内缓释系统(曼月乐)治疗子宫腺肌病的临床疗效。方法选择2010年1月至2013年1月期间我院收治的120例子宫腺肌病患者为研究对象,随机分为给予左炔诺孕酮宫内缓释系统治疗的观察组60例和给予米非司酮治疗的对照组60例。观察两组的月经情况、子宫情况及CA125含量。结果治疗后,观察组的出血量(29.5±4.2)mL、NRS评分1.7±0.3、子宫内膜厚度(4.9±0.8)mm、子宫体积(217.3±29.8)cm3及CA125含量(19.3±2.5)μg/L,均明显低于对照组(P<0.05)。结论左炔诺孕酮宫内缓释系统治疗有助于改善月经情况、减小子宫体积和子宫内膜厚度、降低CA125含量,在子宫腺肌病的治疗中具有积极价值。     

雌激素和孕激素对人类宫颈内细胞产生粘液之作用:组织化学研究

宫颈管在生殖过程对促进或阻碍精子的贮藏和输送起重要作用。目前关于宫颈内隐窝里上皮细胞产生粘液知之甚少。作者用半定量组织化学方法,企图评价激素刺激对宫颈内细胞产生粘液的作用。子宫颈标本取自27名无恶性疾患行全子宫切除术的妇女。术前,有16名妇女曾服炔雌醇(E)5～7天,每日75μg;另外11名服同样时期的甲孕酮(G),每日5μg。标本固定后,24小时内,     

左炔诺孕酮官内缓释系统（曼月乐）治疗子宫腺肌病的临床疗效

目的研究左炔诺孕酮宫内缓释系统（曼月乐）治疗子宫腺肌病的临床疗效。方法选择2010年1月至2013年1月期间我院收治的120例子宫腺肌病患者为研究对象,随机分为给予左炔诺孕酮宫内缓释系统治疗的观察组60例和给予米非司酮治疗的对照组60例。观察两组的月经情况、子宫情况及CA125含量。结果治疗后,观察组的出血量（29．5±4．2）mL、NRS评分1．7±0．3、子宫内膜厚度（4．9±0．8）mm、子宫体积（217．3±29．8）C-及CA125含量（19．3±2．5）μg／L,均明显低于对照组（P〈0．05）。结论左炔诺孕酮宫内缓释系统治疗有助于改善月经情况、减小子宫体积和子宫内膜厚度、降低CA125含量,在子宫腺肌病的治疗中具有积极价值。     

白带的生理和病理

白带是妇女阴道分泌出来的一种如鸡蛋清样的粘液。可分生理性与病理性二种:生理性的白带来自小阴唇、前庭大腺、宫颈腺体、阴道粘膜的渗出物和少量子宫内膜分泌物,是一种无色稠厚,带有粘液性的液体,其量不多;但在月经前后,由于盆腔充血和雌激素的影响,阴道渗出液和宫颈分泌物增加,白带增多。在性生活过程中,由于局部的刺激和性兴奋状态,前庭大腺可分泌较多的粘液,以起润滑作用,     

宫内节育器20年——回顾全球经验

全世界约有6千万妇女使用各种类型IUD避孕,中国有4千万妇女使用,占世界约70%。中国常用的是惰性不锈钢圆环,但在其他发展中国家最常用的是Lippes曲。现代IUD已研究和使用了20年,但其避孕的详尽机制尚未明瞭。所有IUD都刺激子宫引致炎症反应和子宫内膜及宫腔液发生细胞和生化变化,而这些变化是避孕作用所必需的。异物(IUD)也刺激局部产生前列腺素类化合物,影响受精卵着床。含药IUD产生另一种局部避孕作用:铜影响子宫中的酶、子宫内膜细胞中DNA量、子宫粘膜的糖元代谢和雌激素的吸收,但这些变化与避孕的关系尚未明瞭。铜可能增强子宫炎症反应和子宫肌层收缩而影响着床,也可能改变宫颈粘液的生化成分影响精子活动力、获能和存活;释放激素IUD增加宫颈粘液的粘稠度阻止精子进入宫颈,     

The influence of copper surface area on menstrual blood loss and iron status in women fitted with an IUD

The influence of copper surface area on menstrual blood loss (MBL) was evaluated in 34 healthy women (mean age 36.4 +/- 1.4 yr, range 27-46 yr), who were fitted with a Multiload intrauterine device (IUD) with either 250 mm2 (MLCu-250) or 375 mm2 (MLCu-375) copper wire. MBL prior to IUD insertion was 54.4 +/- 10.3 ml for women subsequently fitted with a MLCu-250 and 56.9 +/- 6.9 ml for women fitted with a MLCu-375. An increase (p less than 0.01) in MBL was recorded 3 months after IUD insertion for both the women fitted with a MLCu-250 (86.4 +/- 10.3 ml) and a MLCu-375 (81.1 +/- 8.3 ml). This increase in MBL remained unchanged throughout the study period of one year. At no point were there any significant differences in MBL or increase in MBL between women fitted with a MLCu-250 or MLCu-375. There were no significant differences in serum ferritin, blood hemoglobin, hematocrit or erythrocyte indices before IUD insertion in the women grouped according to type of IUD, nor were any significant changes recorded in any of these parameters after IUD insertion. Thus, our findings that the increase in copper surface area from 250 mm2 to 375 mm2 had no effect on MBL were also substantiated by the hematological findings.     

宫内节育器的应用进展

宫内节育器的临床应用开始于20世纪30年代,70年代以前,以惰性宫内节育器为主,70年代后,含铜和含孕激素的宫内节育器上市,80年代我国研发了含铜含药(活性)宫内节育器。宫内节育器是中国目前使用最普遍的避孕方法,其使用受到政府主管部门的重视和支持。最近的两项研究显示,由政府采购的宫内节育器,多具有较好的性能,特别是元宫药铜220和活性γ型宫内节育器的失败率更低。失败率较高的单圈式含铜和含铜含药宫内节育器的使用率仍在20%的现象应引起重视。含孕激素宫内节育器具有健康益处,有广阔的使用前景。宫内节育器脱落下移的问题有赖于新材料的开发和应用。     

Reactive oxygen intermediates and reactive nitrogen intermediates in copper intrauterine device users.

The mechanism of action of copper in copper intrauterine devices (Cu IUD) as an antimicrobial agent is not well understood. Copper and iron are supposed to be responsible for release of reactive oxygen intermediates (ROI) and reactive nitrogen intermediates (RNI), which are very active in the presence of infection. The copper in a copper IUD could be responsible for limiting pelvic inflammatory disease. The present study was composed of 20 IUD seekers in whom ROI and RNI were studied before insertion of Cu IUD and then at 1, 4, and 12 weeks afterward. ROI showed a rise after insertion, whereas RNI showed a steady decline. Hence, it is presumed that the rise in ROI could be responsible for both the bactericidal effect of Cu IUD and also for the fall in RNI.     

Comparison of uterine artery blood flow with levonorgestrel intrauterine system and copper intrauterine device

Background

As a contraceptive method, we investigated whether the levonorgestrel-releasing intrauterine system (LNG-IUS) has any effect on uterine artery blood flow when compared with copper intrauterine device (IUD).

Study Design

Sixty women with copper IUD and 60 women with LNG-IUS were included in the study. The age, gravidity, parity, body mass index (BMI) and menstrual flow pattern using a pictorial chart were recorded. All women were assessed by ultrasonography at the preinsertion period and 1 year after insertion. The pulsatility and resistance indices (PI and RI, respectively) of the uterine artery and endometrial thickness were evaluated in the preinsertion and postinsertion periods.

Results

In copper IUD users, preinsertion and postinsertion ultrasonographic assessments were not significantly different. However, postinsertion RI was significantly higher compared with preinsertion RI in LNG-IUS users (p=.001). The PI was also increased 1 year after insertion, but it did not reach statistically significant levels (p=.08). Endometrial thickness was also significantly decreased in the postinsertion period in women with LNG-IUS (p=.04).

Conclusion

The significant increase in uterine artery RI in LNG-IUS users 1 year after insertion might be due to its local progestational effects. It might also indicate the mechanism of the LNG-IUS in reducing menstrual blood flow.     

Effect of copper intrauterine device on the cyclooxygenase and inducible nitric oxide synthase expression in the luteal phase endometrium

Background

To evaluate the effect of copper intrauterine device (IUD) on the expression of cyclooxygenase (COX) and inducible nitric oxide synthase (iNOS) in the luteal phase endometrium.

Study Design

A prospective clinical study was conducted on 30 women who were willing to use a copper IUD contraception. Endometrial biopsies and blood samples were taken before and 3 months after the insertion of the IUD on Day 3 and Days 20–24 of the cycle. Main outcome measures were to evaluate the effect of copper IUD on uterine artery blood flow using pulsed color Doppler ultrasonography and the relationship of bleeding abnormalities and menstrual pain level with the uterine blood flow, COX-2 and iNOS expression.

Results

Only the left uterine artery pulsatility and resistance indices decreased statistically significantly (p=.005 and p=.039, respectively). Other Doppler parameters showed no change. Cyclooxygenase-2 expression of both endometrial luminal epithelium (p=.03) and gland epithelium (p=.03) increased significantly. Inducible NOS expression of the endometrial surface epithelium decreased significantly after IUD insertion (p=.01).

Conclusions

Although COX-2 expression increased 3 months after copper IUD insertion, iNOS expression of the luminal epithelium decreased. Local hypoxia caused by copper and vasoconstrictor prostanoids may play a role in IUD-related menstrual abnormalities.     

Intrauterine contraceptive insertion postabortion: a systematic review

Background

This review was conducted to evaluate the evidence regarding the safety and effectiveness of intrauterine device (IUD) insertion immediately following spontaneous or induced abortion.

Study Design

We searched MEDLINE databases for all articles (in all languages) published in peer-reviewed journals from January 1966 through March 2010 for evidence comparing immediate postabortion IUD insertion with either no IUD insertion, insertion at a different time, insertion following first-trimester compared with second-trimester abortion or copper IUD insertion compared with hormone-releasing IUD insertion postabortion. We used standard abstraction forms to summarize and assess the quality of the evidence.

Results

The search strategy identified a total of 990 articles, of which 19 met our inclusion criteria for this review. Studies comparing immediate postabortion IUD insertion with no IUD insertion found that both groups experienced similar rates of pain and infection and a similar number of bleeding days, but one study reported that women with copper IUD insertion experienced a greater amount of bleeding than women without IUD insertion after abortion. Results from studies comparing immediate postabortion IUD insertion and insertion at a time not associated with pregnancy did not report differences between the two groups in the duration of bleeding, pain, expulsions or pelvic inflammatory disease (PID). One study however reported a greater amount of bleeding and another reported more removals for medical reasons among women with postabortion IUD insertion. Evidence from studies that examined immediate vs. delayed postabortion insertion reported minimal differences in bleeding, pain, expulsion and PID between groups. Studies comparing immediate IUD insertion after first- vs. second-trimester abortion reported no difference in removals for pain and bleeding, and an increased risk of expulsion among those women who had insertions after second-trimester abortion. In addition, women with insertions immediately after abortions occurring later in the first trimester had higher expulsion rates than those with insertions after early first-trimester abortions. Studies examining women using a copper IUD compared with a hormone-releasing IUD reported inconsistent results, with one paper reporting more bleeding days in the copper IUD group and another finding higher rates of removal for bleeding in the progesterone-releasing IUD group.

Conclusion

Intrauterine device insertion immediately after abortion is not associated with an increased risk of adverse outcomes compared with use of other contraceptive methods or with no IUD insertion after abortion and compared with IUD insertion at times other than immediately after abortion. Intrauterine device expulsion rates, while generally low, were higher with insertions that occurred after later first-trimester abortion compared with after early first-trimester abortion and higher with IUD insertion after second-trimester abortion compared with after first-trimester abortion.     

The effect of intrauterine devices (stainless steel ring, copper-T220 and levonorgestrel) on the DNA content in isolated human endometrial cells

The effect of three different intrauterine devices on the DNA content in human endometrial cells has been studied in 29 women before and after the insertion of an IUD; a stainless steel ring (9 subjects), Copper-T220 (11 subjects) and a medicated IUD releasing levonorgestrel at a rate of 2 micrograms/day (9 subjects). The material was grouped into "bleeders" (having more than 8 days of bleeding and spotting per month) and "non-bleeders" (having less than 8 days of bleeding and spotting per month). The DNA content was assessed on isolated endometrial cells smeared from thin biopsies and the amount of DNA per cell nucleus was measured by means of a Feulgen microspectrophotometric method. No significant difference was found between the "bleeders" and the "non-bleeders" as to the DNA content. Nevertheless, when the total number of subjects were pooled together, a significant increase in the DNA content was found in the post-insertion specimens in the groups of women using the SS and the T-Cu IUDs. Furthermore, a significant decrease in the DNA content was also found when the specimens obtained after the insertion of the LNG IUD were compared with those obtained after 24 months' use of the stainless steel ring and the Copper-T220 device (p less than 0.01 and p less than 0.002, respectively). It is concluded that the insertion of an inert IUD or an T-Cu IUD, induces significant alterations in the DNA content of the human endometrium adjacent to the device, whereas the use of the LNG device does not significantly modify the DNA synthesis when used for 3-10 months. No correlation was found between the DNA content per cell and the number of days of bleeding and spotting.     

Can ultrasound predict IUD expulsion after medical abortion?

Objectives

Our randomized trial compared early and delayed intrauterine device (IUD) insertion following medical abortion. In this planned substudy, we explore if endometrial thickness and initial IUD position were associated with IUD expulsion. We also describe IUD movement within the uterus during the 6 months after insertion.

Study design

We recruited women undergoing medical abortion and choosing the copper IUD for contraception (n = 156). Participants were randomly assigned to early insertion 1 week after mifepristone or delayed insertion 4–6 weeks later. We measured endometrial thickness by transvaginal sonogram 1 week after abortion and IUD distance from the fundal aspect of the endometrial cavity three times: at insertion, 6–8 weeks later and at 6 months.

Results

We analyzed endometrial thickness in 113 women, baseline IUD position in 114 women and IUD movement in 65 women. Women who expelled IUDs (n = 15) had slightly thicker endometria (p = .007) and slightly lower baseline IUD positions (p = .03) than those who retained IUDs, but no clear cutoffs emerged in the receiver operating characteristic curve analysis. Retained IUDs commonly moved up and down throughout the 6 months (from 14 mm towards the fundus to 32 mm towards the cervix). Overall, retained IUDs moved a median of 2 mm towards the cervix between insertion and exit (p < .0001).

Conclusions

After medical abortion, the risk of IUD expulsion increases with thicker endometria and lower baseline position. Since no clear cutoffs emerged in the analysis and expulsion remained uncommon even with thicker endometria, we do not recommend restricting IUD insertion based on ultrasound data.

Implication

Copper T IUDs often move within the uterus without expelling. Expulsion is uncommon, and we do not recommend restricting IUD insertion based on ultrasound data.