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Strictures of the meatus have quite a different cause and Squeeze the swollen foreskin between the thumbs and prognosis from the gonococcal urethral strictures (27 natural treatment erectile dysfunction exercise buy 100mg eriacta fast delivery. The most important acquired If the swelling is severe hypothyroidism causes erectile dysfunction buy cheap eriacta 100 mg on-line, wrap layers of gauze coated in cause is infection associated with instrumentation and sugar over it and squeeze them erectile dysfunction ultrasound treatment buy eriacta 100 mg fast delivery. Apply it into the meatus from the the rounded plastic containers used for disposable needles nozzle of a small tube what do erectile dysfunction pills look like discount 100 mg eriacta with amex, which will then act as a dilator. If there is a sustained painful involuntary penile erection, either rigid, or merely turgid, this is priapism, which is a urological emergency. If this is secondary to sickle-cell disease (in which it is common), leukaemia, use of sildenafil or similar medication, or some neurogenic cause, such as paraplegia, it usually settles with sedation and without impairing subsequent erections. The danger is that if priapism from any cause persists too long, the corpora cavernosa may become ischaemic and fibrotic, so that he becomes permanently impotent. This will usually provide a cure, especially if the priapism is due to sickle-cell disease. Introduce two 19G needles through the glans penis into each corpus cavernosum (27-30A) and use one for aspiration and one for irrigation Fig. B, introduce one blade of a pair of fine scissors fistula already exists between the corpora. Kindly contributed by Neville Harrison There is no danger of a compartment syndrome and this type of priapism will resolve spontaneously. Use an adrenergic drug sooner rather than later: through one of the needles already Put one blade of a pair of fine-pointed scissors into the inserted, inject 1ml of 1:10,000 adrenaline diluted in 1l 5% meatus, and cut its ventral aspect in the midline. Glucose or 0fi9% saline every 5min up to 1hr till To stop the stenosis recurring, cut 15cm beyond the detumescence occurs. Massage the penis to distribute the meatus, and suture the mucosa to the skin with long-acting drug through both corpora. Use the first 2 sutures on either side as If this is not effective, especially if priapism has been retractors to open the wound, and expose the mucosa of present >4hrs, proceed to make a fistula. Presentation is with a swollen and often infected foreskin, or with phimosis secondary to it. The tumour spreads, until the whole foreskin is involved, after which it invades the corpus spongiosum, and later the corpora cavernosa. It also spreads to the inguinal lymph nodes, which ultimately ulcerate, so that he dies from sepsis, toxaemia, or sudden haemorrhage from the femoral vessels. The carcinoma does not obstruct the urethra completely, nor is it painful at first, so that commonly presentation is late. In priapism the turgid corpora cavernosa usually possible; and although it is not easy to do well, project up under, and into, the glans penis. B, and C, use a sharp knife to make an it is not nearly as difficult as a complete amputation. Operative Surgery: Urology, Butterworth 1981 good, even if you have to perform a block dissection of p. After a complete amputation, it is necessary position through the same skin wound, and push it through to squat to pass urine. If you fashion the perineal meatus the glans to the coronal septum (between the glans and the carefully, it will function well, and is unlikely to stenose. The method of complete amputation described here leaves Note that the ends of the erected corpora cavernosa the crura of the corpora cavernosa attached to the bone, project well into and under the glans. There is nothing to be gained by doing a block dissection of unaffected inguinal nodes prophylactically. Feel the shaft of the penis carefully to determine the exact You should withdraw tissue consisting of fibrous septum, extent of the tumour. Repeat the manoeuvre in another site close by and then do Feel the inguinal nodes. They will probably be enlarged by the same thing with the other corpus cavernosum. Fine needle the penis should now become flaccid rapidly, and remain cytology is very useful here. Control brisk bleeding from the puncture site by pressure or with a figure of 8 absorbable suture. There is no need for a pressure dressing, nor for an Ulceration alone does not always mean carcinoma is indwelling catheter. So always take a biopsy, and wait for histological proof before you amputate the penis. Do not amputate If you do not have a trucut needle, make cuts until you have received the report. Surgery is not urgent, (27-30B,C) on each side with a #11 blade, rotate the blade because the tumour is very slow-growing. Split the distal end of the urethra Suggesting chancroid: an irregular undermined painful longitudinally. Evert each half, and suture it carefully so that it everts onto Enlarged groin nodes. Epithelium will grow over the raw surface Suggesting primary syphilis: a round or oval painless of the corpus spongiosum. Suggesting venereal warts: small multiple lumps 1-3mm in diameter, covered by epithelium. Suggesting donovanosis (granuloma inguinale): a slow-growing lesion, which may destroy the foreskin, and parts of the shaft of the penis. If the growth is limited to the foreskin and is freely mobile over the glans, make a circumcision and follow up closely. If it has involved the foreskin and the glans, or the shaft of the penis, take a biopsy, and as soon as the diagnosis is confirmed, perform a partial amputation 2cm proximal to the lesion. If there is a recurrence, it will probably be in the inguinal nodes, not in the stump of the penis. If they are palpable and clinically cancerous, biopsy the primary and get fine needle cytology on the nodes, if possible. If there is cancer in the nodes, amputate the penis, with a simultaneous bilateral block dissection of the groin (17. Aim to fashion the urethral orifice carefully, so that a stricture does not develop. Cut a shorter Carcinoma of the penis, which you cannot excise with a 2cm dorsal flap. The ulcer is almost always infected, so treat with Pass transfixion sutures of # 1 absorbable through each of cloxacillin 500mg qid for 1wk pre-operatively. Extend the Cut a small circular slit in the ventral flap, and pull the arm in the midline posteriorly for about 5cm, between the urethral stump through it. Leave the end of the urethra two sides of the scrotum (27-32A) (extend it further protruding. Find, clamp, tie, and divide the large dorsal vein 2-3cm anterior to the anal verge. Do not try to evert the stump, or the where the scrotum hangs from the perineum, about 4-5cm urethra may form a stricture. Insert corrugated rubber drains (4-14B) through 2cm incisions laterally in the scrotum, and suture these to the Dissect the corpus spongiosum on its ventral and lateral skin. This allows good skin cover, Now free the corpora cavernosa until they diverge as the and is less likely to get in the way when urinating through crura, at the inferior border of the symphysis pubis the perineal urethrostomy. When chronic this produces the appearance of elephantiasis which may involve: (1). The penis will either be buried in it, or separate, but covered with much thickened skin. In elephantiasis the texture of the skin of the scrotum is altered; it pits on pressure, it cannot be moved over the deeper tissues, veins are not visible, and the mass cannot be reduced. B, make a racquet-shaped incision round the base of the penis, and carry it vertically downwards in the midline of the scrotum. If there is elephantiasis of the foreskin (27-34), do not make a standard circumcision, or you will remove its inner normal layer. Instead, dissect off the thickened outer layer, and fold the inner one back over the shaft of the penis. If the elephantiasis is mild and early, a limited operation may be all that is necessary. For example, you may only need to remove a dorsal strip of thickening on the penis, and close the resulting defect. If the scrotum is enormous (27-33A), either operate with the patient sitting and the legs over the edge of the table, or arrange a hook, and a block and pulleys, in the theatre ceiling before the operation starts (27-33B), so that you can raise the scrotum.

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An expectation that all staff critical factor in deciding which treatment modalities to erectile dysfunction age 25 trusted 100mg eriacta use erectile dysfunction san antonio purchase eriacta 100mg with visa, or members will effectively contribute to erectile dysfunction medication options purchase eriacta no prescription oncology case management whether to erectile dysfunction song order eriacta canada treat the disease at all or to instead rely on palliative is not realistic unless they have been trained to do so. Chemotherapy, immunotherapy, adjunctive therapies, should assess their training programs to ensure that the unique radiotherapy, and surgery can be used individually or in tandem requirements of oncology treatment are specifically addressed. Chemotherapy is now commonly used in veterinary healthcare team to implement clinical protocols are provided in oncology. However, the inherent toxicity of chemotherapy agents recently published feline healthcare guidelines. Managing the patients quality of life includes maintaining a reasonable level of example, compassion fatigue is a phenomenon characterized by a pain-free, functional activity during treatment and minimizing gradual decline in interest and empathy toward individuals treatment side effects. A team approach to oncology case management is an fact that cancer is often a disease of older pets, the time of life when excellent way to combat compassion fatigue affecting an individual the petowner relationship is usually strongest. A comparative analysis of low Vet Clin North Am Small Anim Pract 2014 44(5):893908. Antitumor effects of deracoxib on tissues highly sensitive to the toxic effects of maximum tolerated dose treatment in 26 dogs with transitional cell carcinoma of the urinary regimens. Vet Clin North Am Antineoplastic and Other Hazardous Drugs in Healthcare Settings. College of Veterinary Medicine, Veterinary Clinical effects of toceranib combined with low-dose cyclophosphamide in dogs Pharmacology Laboratory, Washington State University. College Of Veterinary Medicine, Veterinary Clinical of delayed vomiting associated with administraiton of doxorubicin to Pharmacology Laboratory, Washington State University. Pets, vets, and frets: what relationship-centered care research Pract 2014;44(5):90923. Effectiveness and Safety of Autologous Fat Transfer in Various Treatment Protocols. There can be important differences between the submitted version and the official published version of record. Link to publication General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. If the publication is distributed under the terms of Article 25fa of the Dutch Copyright Act, indicated by the Taverne license above, please follow below link for the End User Agreement: Letschert in accordance with the decision of the Board of Deans, to be defended in public th on Thursday the 12 of April 2018, at 16. Plastic and Reconstructive Surgery 2016 Jan;137(1):31e-43e Chapter 5 Autologous Fat Grafting: A Promising Technique with Various Indications. Plastic and Reconstructive Surgery Global Open, 2017; 5:e1606, Published online 22 December 2017. Chapter 10 General Discussion 227 Chapter 11 253 Valorization addendum 255 Summary 261 Nederlandse samenvatting 265 Acknowledgements (dankwoord) 269 List of publications 273 About the author 275 8 Chapter 1 General Introduction 9 General Introduction Prelude the nomenclature surrounding the technique of the reinjection of autologous fat has evolved parallel to its many other aspects during the formation of this dissertation. Breast cancer and reconstructive options 1,2 Breast cancer is still the most common cancer in women in Europe and 3 worldwide with over nearly 1. Ongoing developments in early screening as well as better and more 5 targeted therapies have dramatically improved the survival rate with 5 and 10 6 year survival rates following diagnosis being 87% and 82% respectively. One of the important distinctions that has to be made early in the diagnosis, for the treatment/survival as well as the reconstructive options, is the extension and the type of tumor. The two most common types of breast cancer are the ductal (originating from the epithelial cells of the milk ducts) and lobular (originating from mammary glandular tissue) carcinomas which can be contained to a local cluster of precancerous cells (carcinoma in situ or cis) or invasive in relation to adjacent tissues. Of the invasive or infiltrating type, ductal carcinoma comprises 7 70% to 80% compared to approximately 8% lobular carcinoma. The most important goal in treating a patient with newly diagnosed breast can cer is survival. Over the last decades smaller, less mutilating forms of breast cancer surgery have been developed that achieve the same survival rates as the rigor ous radical mastectomies of the previous century. These techniques do not only restore the direct postopera tive breast volume and contour but also decrease the possibility of long-term, post-radiation complications such as contour distortion and loss of volume due 15,16 to parenchymal fibrosis and (scar) retraction. While all these techniques can achieve excellent cosmetic results, they are not flawless or without (sometimes disastrous) complications. This was followed by the 1950s and 1960s when augmentation was car ried out with solid alloplastic materials like, amongst others, polyurethane. Be cause of the significant complications, this technique was abandoned and re placed by the direct intra-parenchymal injection of semi-solid materials like beeswax, paraffin and even silicone itself before again being abandoned be 19-21 cause of complications. Both implants share a silicone sheath, which, as part of the fifth generation, currently is being offered in a wide 23 variety of sizes and shapes. Mul 25-31 tiple clinical studies as well as a meta-analysis combining data from over 87 32 000 women has shown no correlation between breast implants and auto immune or connective tissue disease. With these new developments and the steady growth of wom 35 en seeking breast augmentation (290. Scars Besides the mutilating effects of breast cancer surgery, the sequelae of scars in general, regardless of the location or etiology can be equally emotional for pa 36 tients. Even though for physicians a scar, especially a matured scar signifies the endpoint of tissue healing, for patients its meaning can have pronounced implications for multiple aspects of daily live and, in addition, can be anchored on a psychological, social or even cultural level. The prevention and treatment of scars is a well-covered subject in present day education in plastic surgery. It covers patient selection (Asian population), surgical techniques and scar revi sion, as well as treatment protocols containing pressure masks, silicone dress ings, steroid injections, radio-/ cryotherapy, laser treatment and even antitumor 37-40 or immunomodulatory drugs. Soft-tissue fillers and facelifting are amongst the oldest known techniques used to alter the facial 42 appearance, with Robert Gersuny injecting vaseline in 1899 and Hollander 43 performing the self-proclaimed first facelift in 1901. Fast forwarding to 1992 when the first cosmetic use of the Clostridi um Botulinum A exotoxin better known as Botox was described by Car 45 ruthers et al. Currently, there seems to be a shift towards the use of dermal fillers at the ex pense of surgical procedures like the facelift, which saw a 17% decrease since the beginning of the new millennium. On one hand this shift might be rep resenting the increasing demand of patients to achieve maximal results with minimal invasive preferably outpatient clinic procedures. On the other hand it might also represent the way our concepts of how the face changes with time, is evolving. The loss of elasticity that causes sagging of the skin was traditionally treated with resuspension and removal of excess (dermal) tissue. However, we know now that lack of support or volume beneath it might be the cause of sag ging of the skin and can be to some extent treated with injectables before 47 any surgical procedures. It was Eugene Hollander who, in 1909, suggested the idea of injecting fat through a cannula and both 14 General Introduction 50 51 Erich Lexer and Charles Miller further elaborated on the idea by describing its use for different conditions. It wasnt until the work of Lyndon Peer, in the 1950s, that a better un derstanding began to develop about the reabsorption, which was considered around 45% at 1 year as a result of cell rupture/ -death influenced by adjustable factors like graft size and -handling. In clinical practice the choice of harvest-location is generally based on the de sires of the patient and the accessibility of the fat. Several studies have indicated 61 superiority of one harvest location over the other with Jurgens et al. With this, it seems like the golden standard for the harvesting location is yet to be found, as was reported 63 in the recent review by Strong et al. The infiltration solution has been standardized in various protocols which led to specially named solutions like the Coleman and Klein solutions but generally comprise of saline plus a local anesthetic for postoperative pain relief, combined with epinephrine for vasoconstriction. Preparation of the lipoaspirate one of the most debated subjects in the clini cal setting, besides centrifugation, generally consists of decantation or filtering through a simple membrane (mesh) eventually combined with washing. All these forms of preparation have been reported as superior over each other, in various studies. For example, decantation, which describes the process of set tling the precipitate and subsequently distracting the required (middle) layer, showed the highest number of adipocytes and mesenchymal stem cells com 71 pared to washing and centrifugation in one study. However, centrifugation has proved itself superior over the other methods on important aspects like cell concentration/ -viability and subsequently graft absorption rate in a number 72-75 of different studies with ideal settings generally not exceeding either 3000 rpm or 2 minutes. While no consensus on the golden standard in preparation has been reached there seems to be a clinical preference for centrifugation, possibly also because of the adherence of most surgeons to the original Cole man Method. When venous blood is used for supplementation it is commonly for extraction 82 of either the Platelet-Rich-Plasma (PrP) or the Platelet-Rich-Fibrin (PrF) which 83,84 is described to improve either the angiogenesis or the vascularization of the 85-87 graft respectively. Finally the injection technique and -planes are a subject of great scientific inter est with substantial variations related to not only indication but also comorbidi ties and previous surgery. While there seems consensus on the technique which should be in a retrograde, fanning matter, leaving small aliquots of fat 88,89 the injection planes, especially following, breast surgery can be of signifi cant importance. In plastic and reconstructive surgery this interest is generally focused on its application in the treatment of 91 Dupuytren disease and its abilities to correct contour deformities because of its volume-restoring capabilities. The part of the human body where the plastic surgeon is most often confronted with problems regarding contour deformities and a general lack of volume are the breasts, mostly of course in the female population. Scars are universal in the sense that no human being can go throughout life without suffering a few of his-/ or her own.

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Suggested Pair Suggested Pair 88Lfi Nevius 88Rfi Nevius 89 Cook 90 Cook 210Hfi | F88L | F88R | F89 | F90 | F210H 1st & 2nd Upper 1st & 2nd Upper Upper Molars; Upper Molars; 3rd Upper Molars Molars impotence 21 year old generic eriacta 100mg with amex. Precision design created specifically for a childs small mouth and tooth surfaces next generation erectile dysfunction drugs buy eriacta 100 mg online, helps you provide optimal pediatric dental care erectile dysfunction treatment photos 100 mg eriacta with amex. Hand-crafted from surgical-grade stainless steel herbal erectile dysfunction pills uk discount eriacta 100mg line, Hu-Friedys Pediatric Forceps ensure superior performance and longevity. Created for small, shallow crowns and conical shaped teeth, the Kinder design requires less force, reducing the risk of tissue damage and broken crowns. Therefore, beaks are either conical, bifurcated, or trifurcated in order to adapt to the tooth or furcations. Designed to optimize clinical efficiencies as a multipurpose instrument, the Hu-Friedy hemostats are used for clamping off blood vessels, removing small root tips and grasping loose objects. From spear-shaped blades for excising interproximal tissue, to oval designs for initial gingivectomy incisions, Hu-Friedy offers a wide range of periodontal knives for various surgical and periodontal procedures. With a precision designed hinge, the smooth surface reduces the risk of catching and or cutting the suture material during the knot tying process, enhancing clinical efficiencies. For optimal grip and control, Hu-Friedy offers a variety of design options, including standard, finger and palm controlled closure. Engineered to split or spread bone, Hu-Friedy osteotomes are available in both interchangeable or large handle designs. The tip design allows for the insertion of upper jaw region or in diffcult-to-access maxillary areas. The rounded tip minimizes the risk of perforation when lifting the Schneiderian membrane. Minimizes the risk of perforation of the mucous membrane sinus elevation procedures. Available in a variety of designs, Hu-Friedy periosteals ensure optimal access and clinical efficiencies during surgical and periodontal procedures. Handcrafted from Immunity Steel alloy and manufactured with permanently fixed blades to the handle, the periotomes are engineered to optimize edge retention and durability. Due to increased leverage, double action hinged rongeurs require less hand compression, reducing time and making it easier to contour bone. They are also available in a heavy pattern for more substantial root tip removal procedures. Paired with our surgical scalpel blades which are crafted from the finest materials for strength and durability, Hu-Friedy offers both microsurgical and standard styles to match clinician and procedural preferences. Improved blade, yet fully blade-holding mechanism adjusts to direction for use with bowed blade and angle of cutting concept pioneered by edge. Designed to exacting specifications for balanced, smooth control, Hu-Friedy offers an extensive selection including microsurgical, suture, crown and gold, bandage and general surgery scissors. Mayo, by comparison, is even longer and Wagner Kelly Mayo thicker but with a blunt end. This needle has suffcient length to easily pass under the papillae and through embrasure spaces. The needles small diameter, smaller than needles on other 6-0 suture products, penetrates tissue more easily and with less damage to the delicate tissue. The monoflament suture is hydrophobic, repels contamination and leaves no marks or creases on tissue margins. The sharp, stainless steel needle allows for smoother suturing, optimizing the overall healing process and patient comfort. I use Hu-Friedy sutures because they are unlike any suture in the industry when it comes to high quality and extreme precision. I also believe in only supporting manufacturers that support organized dentistry, and Hu-Friedy is dentistrys best supporter. Packaging and labeling are also user friendly since the operating theater requires simplicity and accuracy. Available in three styles, Plain, 1x2 and Multiple Teeth, the portfolio offers a variety of designs to accommodate clinician preferences. Also an invaluable aid for blending two or more surgical procedures within a surgical site. Cleaning: Processed & Prepped Instruments are kept together throughout cleaning, rinsing and drying, reducing the 1 2 potential for breakage or loss Allows for less handling of instruments, 4 3 reducing the chance for sharps injuries 3. Once a chairside procedure is finished, contaminated instruments never need to be touched again. Fits in most 10" chambers or larger sterilizers, most instrument washers and larger ultrasonics. Built-in external and internal quality control indicators relay accurate time and temperature verifcation, allowing you peace of mind. The full line of pouches include those custom ft especially for our cassettes and a smaller size for all other sterilization needs. Our unique compilation of textiles is designed to be strong and soft for easy wrapping and durability. Autoclave Wrap Autoclave Wrap offers the best combination of softness and added strength. Contains Steelgard agents to protect instruments from harmful minerals naturally found in water that contribute to buildup, spotting and corrosion. Hu-Friedy is honored to be in close association with Key Opinion Leaders, and it is a pleasure to present them to you as individuals full of life, character and vision. Hu-Friedy strives to supply our Key Opinion Leaders of all specialties with the most current offerings and information on our products and services. Being affiliated with outstanding dental professionals only helps to strengthen Hu-Friedy in our mission: To improve lives through dentistry smile after smile. The contents of this catalog including, but not limited to, all text, photographs and graphics, are the sole and exclusive property of Hu-Friedy Mfg. Please note: Some of the devices listed may not be licensed for sale in accordance with Canadian law. Vascular 146 Surgery for Extreme Sweating (Hyperhydrosis all areas; Surgical Resection Endoscopic B18. The term Criteria Based Clinical Treatments, refers to procedures and treatments that are of value, but only in the right clinical circumstances. As the incidence of some cranio-facial congenital anomalies is small and the treatment complex, specialised teams, working in designated centres and subject to national audit, should carry out such procedures; c) Tissue degenerative conditions requiring reconstruction and/or restoring function. If a General Practitioner/Optometrist/Dentist considers a patient might reasonably fulfil the eligibility criteria for a not routinely commissioned, as detailed in this document. If the referral letter does not clearly outline how the patient meets the criteria, then the letter should be returned to the referrer for more information. To consider social and other non-clinical factors automatically introduces inequality, implying that some patients have a higher intrinsic social worth than others with the same condition. Therefore, non-clinical factors will not be considered except where this policy explicitly provides otherwise. However, photographic evidence will not be accepted for consideration unless it is impossible to make the case in any other way. Therefore, please consider taking the following precautions when using the Royal Mail to forward any information about patients including photographic evidence: 10. Chronic Persistent Co-morbidities Other risk factors alongside the primary problem. Exceptional clinical A patient who has clinical circumstances which, taken as a circumstances whole, are outside the range of clinical circumstances presented by a patient within the normal population of patients, with the same medical condition and at the same stage of progression as the patient. Functional health Difficulty in performing, or requiring assistance from another to problem/difficulty/impairment perform, one or more activities of daily living. Secondary care Services provided by medical specialists, who generally do not have the first contact with a patient. Stakeholders Individuals, groups or organisations who are or will be affected by this consultation. It should only be offered in situations Intervention where the lesion is causing symptoms according to the criteria outlined below. Removal of benign skin lesions means treating asymptomatic lumps, bumps or tags on the skin that are not suspicious of cancer. Any lesion where there is diagnostic uncertainty, pre-malignant lesions (actinic keratoses, Bowen disease) or lesions with pre-malignant potential should be referred or, where appropriate, treated in primary care. Referral to appropriate speciality service (eg dermatology or plastic surgery): fi the decision as to whether a patient meets the criteria is primarily with the referring clinician.

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Young women are much more likely to doctor's advice on erectile dysfunction buy 100 mg eriacta with visa experience unplanned pregnancy because they are more fertile than older women and because they are more likely to erectile dysfunction wiki eriacta 100 mg visa have intercourse without contraception erectile dysfunction caused by spinal stenosis 100 mg eriacta overnight delivery. The effect of age on pregnancy rates with different contraceptive methods is shown in Figure 10 erectile dysfunction doctors in st louis mo buy cheap eriacta online. Efficacy Factors affecting whether pregnancy will occur include the fecundity of both partners, the timing of intercourse in relation to the time of ovulation, the method of contraception used, the intrinsic effectiveness of the contraceptive method, and the correct use of the method. It is impossible to assess the effectiveness of a contraceptive method in isolation from the other factors. The best way to assess effectiveness is long-term evaluation of a group of sexually active women using a particular method for a specified period to observe how frequently pregnancy occurs. A pregnancy rate per 100 women per year can be calculated using the Pearl formula (dividing the number of pregnancies by the total number of months contributed by all couples, and then multiplying the quotient by 1,200). With most methods, pregnancy rates decrease with time as the more fertile or less careful couples become pregnant and drop out of the calculations. This method calculates the probability of pregnancy in successive months, which are then added over a given interval. Problems relate to which pregnancies are counted: those occurring among all couples or those in women the investigators deem to have used the method correctly. Because of this complexity, rates of pregnancy with different methods are best calculated by reporting two different rates derived from multiple studies. Safety Some contraceptive methods have associated health risks; areas of concern are listed in Table 10. All of the methods are safer than the alternative (pregnancy with birth), with the possible exception of estrogen-containing hormonal contraceptives (pills, patches and ring) used by women older than 35 years of age who smoke (6). Most methods provide noncontraceptive health benefits in addition to contraception. Oral contraceptives reduce the risk of ovarian and endometrial cancers and ectopic pregnancy. These recommendations are based on the best evidence available supplemented by expert opinion. All present methods of contraception are assigned to one of four categories of suitability of use by women with more than 60 characteristics or conditions. The categories are: A condition for which there is no restriction for the use of the contraceptive method; A condition for which the advantages of using the method generally outweigh the theoretical or proven risks; A condition for which the theoretical or proven risks usually outweigh the advantages of using method; A condition that represents an unacceptable health risk if the contraceptive method is used. A complex cost analysis based on the cost of the method plus the cost of pregnancy if the method fails concludes that sterilization and the long-acting methods are the least expensive over the long term (8) (Table 10. Long-Acting Reversible Contraceptives Several contraceptive methods are as effective as sterilization, but are completely reversible. These forgettable methods have pregnancy rates in typical use of less than 2 per 100 woman-years, are effective for at least 3 months without attention from the user, and are among the safest methods. Nonhormonal Methods Coitus Interruptus Coitus interruptus is withdrawal of the penis from the vagina before ejaculation. This method, along with induced abortion and late marriage, is believed to account for most of the decline in fertility of preindustrial Europe (11). Coitus interruptus remains a very important means of fertility control in many countries. Eighty-five million couples are estimated to use the method worldwide, yet it has received little recent formal study. The penis must be completely withdrawn both from the vagina and from the external genitalia. Pregnancy has occurred from ejaculation on the female external genitalia without penetration. Efficacy is estimated to range from 4 pregnancies per 100 women in the first year with perfect use to 27 per 100 with typical use (Table 10. Jones and colleagues offer a modern review of this practice and conclude that it likely is as effective as the condom (13). Breastfeeding Breastfeeding can be used as a form of contraception and can be effective depending on individual variables. The use of contraception during lactation should take into consideration the womens needs and the need to maintain lactation. Even with continued nursing, ovulation eventually returns but is unlikely before 6 months, especially if the woman is amenorrheic and is fully breastfeeding with no supplemental foods given to the infant (15). For maximum contraceptive reliability, feeding intervals should not exceed 4 hours during the day and 6 hours at night, and supplemental feeding should not exceed 5% to 10% of the total amount of feeding (16). To prevent pregnancy, another method of contraception should be used from 6 months after birth or sooner if menstruation resumes. Combination hormonal methods can be used after 6 weeks, once milk production is established. These recommendations are not based on any observed adverse effect of early administration, and many maternity programs begin injectable contraception with progestin at the time of hospital discharge. Fertility Awareness Periodic abstinence, described as natural contraception or fertility awareness, requires avoiding intercourse during the fertile period around the time of ovulation. A variety of methods are used: the calendar method, the mucous method (Billings or ovulation method), and the symptothermal method, which is a combination of the first two methods. With the mucous method, the woman attempts to predict the fertile period by feeling the cervical mucus with her fingers. Under estrogen influence, the mucus increases in quantity and becomes progressively more slippery and elastic until a peak day is reached. The mucus then becomes scant and dry under the influence of progesterone until onset of the next menses. Intercourse may be allowed during the dry days immediately after menses until mucus is detected. In the symptothermal method, the first day of abstinence is predicted either from the calendar, by subtracting 21 from the length of the shortest menstrual cycle in the preceding 6 months, or the first day mucus is detected, whichever comes first. The woman takes her temperature every morning and resumes intercourse 3 days after the thermal shift, the rise in body temperature that signals that the corpus luteum is producing progesterone and that ovulation occurred. The postovulatory method is a variation in which the couple has intercourse only after ovulation is detected. These devices (Persona and Clearblue Easy Fertility Monitor) can serve as aids both to becoming pregnant and to avoiding it (20). A correct use pregnancy rate of 2% and a typical use pregnancy rate of 12% were reported (21). Efficacy the ovulation method was evaluated by the World Health Organization in a five-country study. Women who successfully completed three monthly cycles of teaching were enrolled in a 13-cycle efficacy study. A review of 15 national surveys from developing countries estimated a 12-month gross failure rate of 24 pregnancies per 100 (23). Risks Conceptions resulting from intercourse remote from the time of ovulation more often lead to spontaneous abortion than conceptions from midcycle intercourse (24). Condoms In the 1700s, condoms made of animal intestine were used by the aristocracy of Europe, but condoms were not widely available until the vulcanization of rubber in the 1840s (1). Modern condoms usually are made of latex rubber, although condoms made from animal intestine are still sold and are preferred by some who feel they afford better sensation. New condoms made from nonlatex materialssuch as polyurethane or synthetic elastomers that are thin, odorless, transparent, and transmit body heatare available. Although the nonlatex condoms may break more easily than the latex varieties, substantial numbers of study participants preferred them and would recommend them to others (25). Petroleum-based products such as mineral oil must be avoided because even brief exposure to them markedly reduces the strength of condoms (27). Risks Latex allergy could lead to life-threatening anaphylaxis in either partner from latex condoms. Nonlatex condoms of polyurethane and Tactylon should be offered to couples who have a history suggestive of latex allergy. Female Condom the original female condom introduced in 1992 was a polyurethane vaginal pouch attached to a rim that partly covered the vulva. Breakage may occur less often with the female condom than the male condom; slippage appears to be more common, especially for those new to its use (39). Subsequent analysis found that with perfect use, the pregnancy rate may be only 2. This rate is comparable to perfect use of the diaphragm and cervical cap, the other female barrier methods (41).

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