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Ovulation following therapeutic abortion
Ovulation following therapeutic abortion E.
FOR RES T BOY D,
JR., M. D .
EMIL G. HOLMSTROM, M.D. Los Angeles, California Therapeutic abortion is quickly becoming one of the most frequently performed of all operations. One of its significant problems relates to postabortal advice regarding contraception. In a relatively stable large population group, the date datil of the first postabortal ovulation was determined by endometrial biopsy and correlated, when possible, with the basal body temperature graph. The results of this study on 91 patients, with evidence of unsuspected early ovulation in a significant pro portion, suggest that contraception measures should be employed within two weeks of the procedure if immediate pregnancy is unwanted.
W HEN PAT lEN T S returned for their first examination after a therapeutic abortion and were again pregnant, the adequacy of postabortal contraceptive advice became suspect. While the recurrent rate is not high, it is startling and somewhat disconcerting when present. The return of ovulation following term deliveries in nonnursing mothers has been variously reported at 30 per cent within 90 days! to 13 per cent within 43 days, with the earliest at Day 33. 2 Investigation of ovulation as early as the first bleeding (menses) postabortal or post partum has not been reported. As the increase in therapeutic abortion occupies more and more of our office, operating room, and conversation time, this continuing study was begun. The purpose was to establish the current incidence of ovulation following therapeutic abortion. The relatively stable population of approximately one million in our study enabled us to follow with relative ease the large group of patients involved. Hopefully, this study will also lead us to conclusions regarding the
effect of therapeutic abortion on the birth rate, needs in family planning practices, and evaluation of current abortion techniques. Methods and materials
From January 1 to June 30, 1971, all patients requesting therapeutic abortion were interviewed. Those who were not planning to use hormonal contraception and who were willing and able to participate were included. Each patient was instructed individually as to the basal body temperature graph procedure, including a record of the amount and duration of bleeding and the completing of a short questionnaire. The latter pertained to contraception efforts at the time of conception, plans for future contraceptive efforts, and reasons for requesting the abortion. The patient was advised to return on the first or second day of her first menstrual period following the therapeutic abortion. At this time, the desired contraceptive advice was given, and an endometrial biopsy was obtained. All slides were reviewed by the Department of Pathology and by one of us (E. G. H.) and evidence of prior ovulation with its approximate dating, or its absence, was determined on the basis of histologic findings. If the endometrial biopsy showed that ovulation had occurred, the date of ovulation
From The Department of Obstetrics and Gynecology, the Southern California Permanente Medical Group, and The Kaiser Foundation Hospital. Presented (by invitation) at the Thirty-eighth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Rancho La Costa, California, October 5-10, 1971.
469
470
Boyd and Holmstrom
.June 15, 1972 Am, j. Obstct. Gynceo!.
Table I. Basic characteristics Subjects
Caucasian
(%)
Age (yr.)
Married
(%)
Primigravida
Recidivist (%)
54 33
16-33 (25%) 15-41 (27%)
63 46
18 28
0 8.1
Nonovulating patients (11) Ovulating patients (61)
Table II. Weeks at evaluations
Subjects
)l'onovu!ating patients (11) Ovulating patients (61)
Weeks of pregnancy at first visit
Size of uterus at time of abortion (weeks)
7.4 (3-10) 7.3 (2-13)
10 (4-12 ) 8.6 (6-14 )
was calculated by subtracting 14 days from the onset of the current menses. All charts and patient material were verified and tabulated. The basal body temperature graphs were utilized as an adjunct. All requests for therapeutic abortion were reviewed by the Therapeutic Abortion Committee after psychiatric consultation was obtained. The patients were examined by at least 3 doctors including the initiating, operating, discharging, and follow-up physicians. The duration of the pregnancy, as estimated by uterine size, was primarily the decision of the operating surgeon, and no abortions were performed if the pregnancy was judged to be greater than twelve weeks in duration. All patients were treated as inpatients, by suction curettage (a few without concomitant sharp curettement), and all had general anesthesia. The entire Medical Group cooperated in evaluation, operation, or follow-up. each according to his own protocol. During the time noted, there were 1,928 deliveries at this hospital. There were 653 abortion requests, and 630 abortions were performed. Five hundred and forty-nine were first-trimester abortions. Because of desire for early hormonal prophylaxis, language barriers, patients' unreliability, and other reasons (unrelated operations, travel, patient refusal), 380 patients were not utilized for this study. Of 169 patients participating, 91 have been considered acceptable for analysis to
I
First menses after abortion (weeks)
4.3
(2-9)
5.2 (2-10)
date. Others will be added as their reports become verified. Seventeen patients (19 per cent) were deleted from the study because detailed review indicated inadequate workup, doubt as to dating accuracy, or operative delay. Two had second-trimester amnioinfusion. Results and comment
Of the 72 patients comprising the study, 11 had not ovulated at the time of endometrial biopsy. Table I shows their basic characteristics as compared with the 61 who had ovulated. Table II compares the weeks of pregnancy at the initial examination, size of the uterus at the time of abortion, and the time of onset of the first menses after abortion. The basal body temperature graphs correlated to within 72 hours in 26 of 61 ovulating patients, or 43 per cent. (Thirtyfive of the histologically proved ovulating patients' temperature graphs were not adequately recorded or evidenced no ovulation.) None of the graphs in the nonovulating patients indicated ovulation. Fig. 1 shows the postabortal ovulation day of the 61 ovulating patients and the day of biopsy in the nonovulating patients. Sixtyone of the 72 patients, or 85 per cent, ovulated prior to their first menstrual period, with all but one ovulating prior to the thirtysixth postabortal day, well before the usual 6 week check-up. The mean day was 22, with
Ovulation after therapeutic abortion
Volume 113 Number 4
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OVULATION DAY POSTABORTAL Fig. 1. Postabortal ovulation day of the 61 ovulating patients and the day of biopsy in the nonovulating patients. Patients without biphasic temperature. 0 = Patients with biphasic temperature within 72 hours. l' = Mean.
=
the earliest verified ovulation occurring on the tenth postabortal day. In some of the nonovulating patients, the biopsies were probably taken too soon for ovulation determination. However, they were taken at the time of vaginal bleeding misinterpreted as a menstrual flow. Also, some patients had ovulated prior to this time. This study is pertinent to two groups of patients: those patients who were aborted for nonrecurring reasons, such as rubella inREFERENCES
1. Sammartino, R., Gori, R. M., and Bayona, E.: Obstet. Gynecol. Latino-Am. 1: 11, 1953.
Discussion
J.
Los Angeles, California. The authors have employed endometrial DR. WILLIAM
DIGNAM,
fection, inappropriate medications, trauma, and irradiation; and those who did not desire children at the time. For the first time, we have objective evidence that they should be supplied with contraception within 10 days after therapeutic abortion. This brief study indicates that contraceptive advice should take into consideration the possibility that conception can occur in the second week after therapeutic abortion.
2. Kava, H. W., Klinger, H . P., Molnar, J. J., and Romney, S. L.: AM. J. Os STET. GYNECOL. 102: 122, 1968. biopsy in an attempt to identify the time of the first ovulation following induced abortion. The validity of accepting secretory endometrium as
472 472
Boyd and Boyd and Holmstrom Holmstrom
prior ovulation ovulation has has been been properly properly cntlcntlproof of proof of prior cized. However, cized. However, such such biopsies biopsies have have usually usually been been or for for demontratdemontratemployed for employed for infertility infertility patients patients or ing the ing the efficacy efficacy of of drugs drugs administered administered to to produce produce ovulation. Cnder ovulation. Cnder those those circumstances, circumstances, our our papatients' best tients' best interests interests are are served served by by very very cautious cautious acceptance of acceptance of this this evidence, evidence, and and more more specific specific of ovulation ovulation is is demanded demanded frequently. frequently. evidence of evidence Immediately Jmmediately following following aa pregnancy, pregnancy, however, however, our our patient's interests patient's interests are are best best served served by by an an equally equally cautious viewpoint cautious viewpoint and and insistence insistence upon upon proof proof that that secretory endometrium secretory endometrium is is not not clear clear evidence evidence of of recent ovulation. recent ovulation. Secretory endometrium is is the the result result of of the the Secretory endometrium action of action of estrogen estrogen and and progesterone progesterone upon upon that that endometrium. Csually endometrium. Csually these these hormones hormones emanate emanate from aa corpus from corpus luteum. luteum. There There is is evidence evidence that that the the lutem continues continues to to function function throughout throughout corpus lutem corpus is theoretically theoretically possible possible for for secresecrepregnancy so pregnancy so it it is endometrium to to be be produced produced by by hormones hormones tory endometrium tory that body, body, even even in in the the postpartum postpartum period. period. from that from However, Le However, Le Maire Maire and and associates associates 11 have have recently recently that the the corpus corpus luteum luteum ceases ceases demonstrated that demonstrated after pregnancy. pregnancy. At At least least this this is is functioning soon functioning soon after true for true for term term pregnancy. pregnancy. There is There is aa paucity paucity of of reports reports of of measurements measurements of hormones of hormones in in urine urine or or blood blood at at frequent frequent of patients patients in in the the intervals in intervals in significant significant numbers numbers of postpartum or postpartum or postabortal postabortal period period so so that that it it is is difficult to difficult to draw draw firm firm conclusions conclusions concerning concerning the the of ovulation ovulation from from these these data. data. Our Our resumption of resumption own work own work 22 and and that that of of others others show show that that folliclefollicle(FSH) is is present present only only in in stimulating hormone stimulating hormone (FSH) very small very small amounts amounts in in maternal maternal serum serum throughthroughhuman pregnancy. pregnancy. Few Few data data are are available available out human out concerning serial concerning serial measurements measurements of of the the gonadogonadoor urine urine in in the the postpartum postpartum tropins in tropins in blood blood or period, and, period, and, in in most most of of these these reports, reports, patients patients time were not were not studied studied for for aa sufficient sufficient period period of of time following delivery, following delivery, so so that that one one cannot cannot determine determine the time the time when when FSH FSH rose rose to to the the levels levels necessary necessary to produce to produce ovulation. ovulation. not see see secretory secretory or or Certainly, one Certainly, one does does not decidual endometrium decidual endometrium persisting persisting very very long long after after term delivery. term delivery. The The subject subject of of endometrial endometrial regenregenin aa eration following eration following delivery delivery was was reviewed reviewed in J. Whitridge Whitridge Williams Williams 33 classic contribution classic contribution by by J. in 1931. in 1931. He He concluded concluded that that the the endometrium endometrium is is during the the third third usually completely usually completely regenerated regenerated during week following week following labor labor and and that that the the persistence persistence of of chorionic giant chorionic giant cells cells in in the the decidua decidua basalis basalis and and underlying muscularis underlying muscularis was was rare rare beyond beyond the the eighth eighth or tenth or tenth day day post post partum. partum. One cannot One cannot help help but but be be impressed impressed with with the the
Am. Am.
J. J.
June 15, June 15, 19i2 19i2 Obs!c!. Gyneeo!. Obs!c!. Gyneeo!.
forthright nature forthright nature of of Dr. Dr. Williams' Williams' writing. writing. In In his his "D'Erchia review of review of previous previous literature, literature, he he states, states, "D'Erchia strongly opposed strongly opposed that that view" view" (that (that there there were were practically no practically no glands glands in in the the decidua decidua basalis) basalis) "but "but in other in other respects respects his his article article is is of of interest interest only only in in the fact the fact that that the the subsequent subsequent investigation investigation has has that practically practically every every statement statement he he made made proved that proved was incorrect." was incorrect." In In discussing discussing why why sterilization sterilization was deferred was deferred instead instead of of being being effected effected in in conconjunction with junction with aa cesarean cesarean section section at at the the time time of of labor, he labor, he states, states, "And "And my my answer answer is is that that in in aa teaching clinic, teaching clinic, II have have thought thought it it necessary necessary so so far as far as possible possible to to limit limit the the performance performance of of cesarean section cesarean section to to patients patients presenting presenting aa clear-cut clear-cut Obstetric indication, indication, as as to to do do otherwise otherwise would would Obstetric which II believe believe consticonstifoster unclear unclear thinking, thinking, which foster major defects defects of of American American tutes one tutes one of of the the major Obstetrics." Obstetrics." Sharman 44 has Sharman has provided provided an an excellent excellent review review of of appearance of of the the the publications the publications reporting reporting the the appearance endometrium in endometrium in the the postpartum postpartum period. period. His His own work own work consists consists of of an an extensive extensive study study of of the the endometrium following endometrium following term term delivery. delivery. He He examined uteri examined uteri removed removed from from 10 10 women women from from day post post partum. partum. He He the first the first to to the the fifty-fourth fifty-fourth day also examined also examined 626 626 endometrial endometrial biopsy biopsy specimens specimens day to to the the ninth ninth from 285 from 285 women women from from the the fifth fifth day month post month post partum. partum. Of Of these, these, 165 165 were were not not lactating at lactating at the the time time of of the the first first biopsy. biopsy. From From this group, this group, 461 461 biopsies biopsies were were obtained. obtained. Of Of these, these, endometrium in in the the proliferative proliferative 326 showed 326 showed endometrium and 135 135 showed showed endometrium endometrium in in the the phase and phase secretory phase. secretory phase. The The earliest earliest presumptive presumptive evieviof ovulation ovulation was was found found on on the the forty-fourth forty-fourth dence of dence postpartum day. postpartum day. Kava and Kava and colleagues colleagues 55 in in 1968 1968 reported reported on on 92 92 endometrial biopsies endometrial biopsies obtained obtained in in nonlactating nonlactating women from women from 33 33 to to 93 93 days days post post partum. partum. Sixteen Sixteen of of these these biopsies biopsies showed showed secretory secretory endometrium. endometrium. The earliest The earliest of of these these was was on on Day Day 33, 33, and and 12 12 of of of ovulation ovulation before before the patients the patients showed showed evidence evidence of the forty-third the forty-third postpartum postpartum day. day. many of of the the reported reported studies, studies, Unfortunately, in Unfortunately, in many at arbitrary arbitrary intervals intervals the biopsies the biopsies were were taken taken at rather than than at at the the time time of of the the following delivery following delivery rather first episode first episode of of bleeding bleeding so so that that it it is is difficult difficult to to determine the determine the true true incidence incidence of of ovulation ovulation precedprecedthat first first episode episode of of bleeding. bleeding. However, However, from from ing that ing the data the data that that are are available, available, aa number number of of authors authors drawn the the conclusion conclusion that that the the first first have drawn have term delivery delivery is is menstrual period menstrual period following following term usually not usually not preceded preceded by by ovulation. ovulation. There are There are fewer fewer data data available available from from patients patients In 1942, 1942, Rutherford Rutherford and and following ahortion. following ahortion. In
Volume 113 Volume 113 Number .. Number ..
Mezer6 reported Mezer6 reported on on the the regeneration regeneration of of the the uterine uterine mucosa mucosa following following spontaneous spontaneous abortion abortion as as well well as as term term delivery. delivery. Fourteen Fourteen patients patients were were after term term delivery, delivery, and and 9 9 patients patients were were studied studied after studied following studied following spontaneous spontaneous abortion. abortion. The latter The latter group group had had biopsies biopsies at at 3 3 and and 7 7 days days and then then weekly weekly until until following abortion following abortion and Their first first patient patient had had menstruation occurred. menstruation occurred. Their definite early definite early secretory secretory activity activity of of the the glands glands 21 21 days after days after abortion abortion and and had had aa menstruating menstruating Day 30. 30. In In summary, summary, they they endometrium on endometrium on Day that endometrial endometrial regeneration regeneration was was comcomstated that stated plete in in 7 7 days, days, ovulation ovulation occurred occurred on on Day Day 14, 14, plete and menstruation and menstruation occurred occurred on on Day Day 28. 28. On the On the other other hand, hand, their their second second patient patient had had decidual endometrium decidual endometrium for for 53 53 days. days. From all From all of of the the material material studied, studied, they they conconcluded cluded that, that, on on the the average, average, ovulation ovulation occurred occurred about 6 weeks weeks after after term term deliveries deliveries and and about about 2 2 about 6 to 3 to 3 weeks weeks after after abortion. abortion. Sharman has Sharman has also also reported reported data data on on endomeendometrial trial biopsies biopsies following following spontaneous spontaneous abortion. abortion. He He obtained 135 obtained 135 biopsies biopsies from from 42 42 patients patients following following Of these, these, 60 60 were were done done in in the the prepreabortion. abortion. Of menstrual and it it was was noted noted that that 31 31 of of menstrual period, period, and the patients the patients (72 (72 per per cent) cent) had had ovulated ovulated before before that first that first period. period. Likewise, Hallet Likewise, Hallet 77 found found that that ovulation ovulation had had occurred in occurred in 42 42 of of 54 54 patients patients (77 (77 per per cent) cent) in the the period period following following whom he whom he studied studied in spontaneous abortion. spontaneous abortion. The authors The authors reporting reporting here here today today have have presented data presented data on on aa much much larger larger group group of of papatients. The The biopsies biopsies obtained obtained were were made made at at the the tients. that is, is, at at the the onset onset of of bleedbleedmost strategic most strategic time, time, that ing. They found found secretory secretory endometrium endometrium in in 84 84 ing. They per cent per cent of of the the patients. patients. All All but but one one of of these these had ovulated ovulated prior prior to to the the thirty-sixth thirty-sixth patients had patients day following day following abortion. abortion. that in in this this instance instance we we must must accept accept II believe believe that secretory endometrium secretory endometrium as as evidence evidence of of prior prior The authors authors have have made made an an important important ovulation. The ovulation. and are are to to be be commended commended for for bringbringcontribution and contribution ing our attention attention an an important important point. point. In In ing to to our contradistinction to contradistinction to the the OpInIOn OpInIOn frequently frequently expressed for expressed for women women following following term term pregnancy, pregnancy, that the the overwhelming overwhelming they have they have demonstrated demonstrated that
Ovulation after Ovulation after therapeutic therapeutic abortion abortion
473 473
percentage of percentage of women women do do ovulate ovulate before before the the first first episode of episode of postabortal postabortal bleeding. bleeding. They They have have also also that it it occurs occurs very very early early in in properly emphasized properly emphasized that the the postabortal postabortal period. period. REFERENCES REFERENCES
1. Le 1. Le Maire, Maire, W. W. J., J., Conly, Conly, P. P. W., W., Moffett, Moffett, A., A., Spellacy, W. Spellacy, W. N., N., Cleveland, Cleveland, W. W. W., W., and and Savard, Savard, K.: AM. K.: AM. J. J. OBSTET. OBSTET. GYNECOL. GYNECOL. 110: 110: 612, 612, 1971. 1971. 2. Parlow, 2. Parlow, A. A. F., F., Daane, Daane, T. T. A., A., and and Dignam, Dignam, W. J.: W. J.: J. J. Clin. Clin. Endocrinol. Endocrinol. Metab. Metab. 31: 31: 213, 213, 1970. 1970. 3. Williams, 3. Williams, J. J. W.: W.: AM. AM. J. J. OBSTET. OBSTET. GYNECOL. GYNECOL. 22: 664, 22: 664, 1931. 1931. 4. Sharman, 4. Sharman, A.: A.: Reproductive Reproductive Physiology Physiology of of the the Period, Edinburgh, Edinburgh, 1966, 1966, E. E. & & S. S. Postpartum Period, Postpartum Livingstone, Ltd. Livingstone, Ltd. 5. Kava, 5. Kava, H. H. W., W., Klinger, Klinger, H. H. P., P., Molnar, Molnar, J. J. J., and J., and Romney, Romney, S. S. L.: L.: AM. AM. J. J. OBSTET. OBSTET. GYNECOL. 102: GYNECOL. 102: 122, 122, 1968. 1968. 6. Rutherford, 6. Rutherford, R. R. N., N., and and Mezer, Mezer, J.: J.: J. J. A. A. M. M. A. A. 119: 119: 124, 124, 1942. 1942. 7. Hallet, 7. Hallet, R. R. L.: L.: AM. AM. J. J. OBSTET. OBSTET. GYNECOL. GYNECOL. 67: 67: 52, 52, 1954. 1954.
DR. BoYD DR. BoYD (Closing). (Closing). As As far far as as the the question question with first-trimester first-trimester abortions abortions of why of why the the patients patients with don't know. know. II have have aa suspicion suspicion ovulate earlier, ovulate earlier, II don't that possibly that possibly the the hypothalamic-pituitary-ovarian hypothalamic-pituitary-ovarian is not not quite quite as as altered altered in in the the earlier earlier stages stages axis is axis of pregnancy of pregnancy as as it it is is when when there there has has been been aa 99 month time month time lapse. lapse. Also, Also, II don't don't know know what what role role the element the element of of stress stress plays plays in in this this situation. situation. Most Most of these of these patients patients were were apparently apparently not not too too bothered bothered by the by the abortion abortion procedure procedure itself, itself, and, and, thus, thus, their their ran along along fairly fairly unaltered. unaltered. There There body dynamics body dynamics ran are many are many evidences evidences of of traumatic traumatic ovulation, ovulation, if if in women women under under stress. stress. II don't don't know know you will, you will, in what significance what significance this this element element has, has, but but it it is is interesting to interesting to speculate. speculate. When we When we perform perform an an abortion abortion for for any any reason, reason, we should we should make make the the patient patient aware aware that that she she may may and become become pregnant pregnant fairly fairly soon. soon. II ovulate and ovulate would like would like to to comment comment that that Dr. Dr. Holmstrom Holmstrom and he he carefully reviewed carefully reviewed each each of of these these slides, slides, and 30 years. years. has been has been studying studying endometria endometria over over 30 II certainly certainly would would not not presume presume to to encroach encroach on on in this this area, area, and and II feel feel secure secure in in his his knowledge knowledge in his evaluation. his evaluation.
FOR RES T BOY D,
JR., M. D .
EMIL G. HOLMSTROM, M.D. Los Angeles, California Therapeutic abortion is quickly becoming one of the most frequently performed of all operations. One of its significant problems relates to postabortal advice regarding contraception. In a relatively stable large population group, the date datil of the first postabortal ovulation was determined by endometrial biopsy and correlated, when possible, with the basal body temperature graph. The results of this study on 91 patients, with evidence of unsuspected early ovulation in a significant pro portion, suggest that contraception measures should be employed within two weeks of the procedure if immediate pregnancy is unwanted.
W HEN PAT lEN T S returned for their first examination after a therapeutic abortion and were again pregnant, the adequacy of postabortal contraceptive advice became suspect. While the recurrent rate is not high, it is startling and somewhat disconcerting when present. The return of ovulation following term deliveries in nonnursing mothers has been variously reported at 30 per cent within 90 days! to 13 per cent within 43 days, with the earliest at Day 33. 2 Investigation of ovulation as early as the first bleeding (menses) postabortal or post partum has not been reported. As the increase in therapeutic abortion occupies more and more of our office, operating room, and conversation time, this continuing study was begun. The purpose was to establish the current incidence of ovulation following therapeutic abortion. The relatively stable population of approximately one million in our study enabled us to follow with relative ease the large group of patients involved. Hopefully, this study will also lead us to conclusions regarding the
effect of therapeutic abortion on the birth rate, needs in family planning practices, and evaluation of current abortion techniques. Methods and materials
From January 1 to June 30, 1971, all patients requesting therapeutic abortion were interviewed. Those who were not planning to use hormonal contraception and who were willing and able to participate were included. Each patient was instructed individually as to the basal body temperature graph procedure, including a record of the amount and duration of bleeding and the completing of a short questionnaire. The latter pertained to contraception efforts at the time of conception, plans for future contraceptive efforts, and reasons for requesting the abortion. The patient was advised to return on the first or second day of her first menstrual period following the therapeutic abortion. At this time, the desired contraceptive advice was given, and an endometrial biopsy was obtained. All slides were reviewed by the Department of Pathology and by one of us (E. G. H.) and evidence of prior ovulation with its approximate dating, or its absence, was determined on the basis of histologic findings. If the endometrial biopsy showed that ovulation had occurred, the date of ovulation
From The Department of Obstetrics and Gynecology, the Southern California Permanente Medical Group, and The Kaiser Foundation Hospital. Presented (by invitation) at the Thirty-eighth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Rancho La Costa, California, October 5-10, 1971.
469
470
Boyd and Holmstrom
.June 15, 1972 Am, j. Obstct. Gynceo!.
Table I. Basic characteristics Subjects
Caucasian
(%)
Age (yr.)
Married
(%)
Primigravida
Recidivist (%)
54 33
16-33 (25%) 15-41 (27%)
63 46
18 28
0 8.1
Nonovulating patients (11) Ovulating patients (61)
Table II. Weeks at evaluations
Subjects
)l'onovu!ating patients (11) Ovulating patients (61)
Weeks of pregnancy at first visit
Size of uterus at time of abortion (weeks)
7.4 (3-10) 7.3 (2-13)
10 (4-12 ) 8.6 (6-14 )
was calculated by subtracting 14 days from the onset of the current menses. All charts and patient material were verified and tabulated. The basal body temperature graphs were utilized as an adjunct. All requests for therapeutic abortion were reviewed by the Therapeutic Abortion Committee after psychiatric consultation was obtained. The patients were examined by at least 3 doctors including the initiating, operating, discharging, and follow-up physicians. The duration of the pregnancy, as estimated by uterine size, was primarily the decision of the operating surgeon, and no abortions were performed if the pregnancy was judged to be greater than twelve weeks in duration. All patients were treated as inpatients, by suction curettage (a few without concomitant sharp curettement), and all had general anesthesia. The entire Medical Group cooperated in evaluation, operation, or follow-up. each according to his own protocol. During the time noted, there were 1,928 deliveries at this hospital. There were 653 abortion requests, and 630 abortions were performed. Five hundred and forty-nine were first-trimester abortions. Because of desire for early hormonal prophylaxis, language barriers, patients' unreliability, and other reasons (unrelated operations, travel, patient refusal), 380 patients were not utilized for this study. Of 169 patients participating, 91 have been considered acceptable for analysis to
I
First menses after abortion (weeks)
4.3
(2-9)
5.2 (2-10)
date. Others will be added as their reports become verified. Seventeen patients (19 per cent) were deleted from the study because detailed review indicated inadequate workup, doubt as to dating accuracy, or operative delay. Two had second-trimester amnioinfusion. Results and comment
Of the 72 patients comprising the study, 11 had not ovulated at the time of endometrial biopsy. Table I shows their basic characteristics as compared with the 61 who had ovulated. Table II compares the weeks of pregnancy at the initial examination, size of the uterus at the time of abortion, and the time of onset of the first menses after abortion. The basal body temperature graphs correlated to within 72 hours in 26 of 61 ovulating patients, or 43 per cent. (Thirtyfive of the histologically proved ovulating patients' temperature graphs were not adequately recorded or evidenced no ovulation.) None of the graphs in the nonovulating patients indicated ovulation. Fig. 1 shows the postabortal ovulation day of the 61 ovulating patients and the day of biopsy in the nonovulating patients. Sixtyone of the 72 patients, or 85 per cent, ovulated prior to their first menstrual period, with all but one ovulating prior to the thirtysixth postabortal day, well before the usual 6 week check-up. The mean day was 22, with
Ovulation after therapeutic abortion
Volume 113 Number 4
471
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OVULATION DAY POSTABORTAL Fig. 1. Postabortal ovulation day of the 61 ovulating patients and the day of biopsy in the nonovulating patients. Patients without biphasic temperature. 0 = Patients with biphasic temperature within 72 hours. l' = Mean.
=
the earliest verified ovulation occurring on the tenth postabortal day. In some of the nonovulating patients, the biopsies were probably taken too soon for ovulation determination. However, they were taken at the time of vaginal bleeding misinterpreted as a menstrual flow. Also, some patients had ovulated prior to this time. This study is pertinent to two groups of patients: those patients who were aborted for nonrecurring reasons, such as rubella inREFERENCES
1. Sammartino, R., Gori, R. M., and Bayona, E.: Obstet. Gynecol. Latino-Am. 1: 11, 1953.
Discussion
J.
Los Angeles, California. The authors have employed endometrial DR. WILLIAM
DIGNAM,
fection, inappropriate medications, trauma, and irradiation; and those who did not desire children at the time. For the first time, we have objective evidence that they should be supplied with contraception within 10 days after therapeutic abortion. This brief study indicates that contraceptive advice should take into consideration the possibility that conception can occur in the second week after therapeutic abortion.
2. Kava, H. W., Klinger, H . P., Molnar, J. J., and Romney, S. L.: AM. J. Os STET. GYNECOL. 102: 122, 1968. biopsy in an attempt to identify the time of the first ovulation following induced abortion. The validity of accepting secretory endometrium as
472 472
Boyd and Boyd and Holmstrom Holmstrom
prior ovulation ovulation has has been been properly properly cntlcntlproof of proof of prior cized. However, cized. However, such such biopsies biopsies have have usually usually been been or for for demontratdemontratemployed for employed for infertility infertility patients patients or ing the ing the efficacy efficacy of of drugs drugs administered administered to to produce produce ovulation. Cnder ovulation. Cnder those those circumstances, circumstances, our our papatients' best tients' best interests interests are are served served by by very very cautious cautious acceptance of acceptance of this this evidence, evidence, and and more more specific specific of ovulation ovulation is is demanded demanded frequently. frequently. evidence of evidence Immediately Jmmediately following following aa pregnancy, pregnancy, however, however, our our patient's interests patient's interests are are best best served served by by an an equally equally cautious viewpoint cautious viewpoint and and insistence insistence upon upon proof proof that that secretory endometrium secretory endometrium is is not not clear clear evidence evidence of of recent ovulation. recent ovulation. Secretory endometrium is is the the result result of of the the Secretory endometrium action of action of estrogen estrogen and and progesterone progesterone upon upon that that endometrium. Csually endometrium. Csually these these hormones hormones emanate emanate from aa corpus from corpus luteum. luteum. There There is is evidence evidence that that the the lutem continues continues to to function function throughout throughout corpus lutem corpus is theoretically theoretically possible possible for for secresecrepregnancy so pregnancy so it it is endometrium to to be be produced produced by by hormones hormones tory endometrium tory that body, body, even even in in the the postpartum postpartum period. period. from that from However, Le However, Le Maire Maire and and associates associates 11 have have recently recently that the the corpus corpus luteum luteum ceases ceases demonstrated that demonstrated after pregnancy. pregnancy. At At least least this this is is functioning soon functioning soon after true for true for term term pregnancy. pregnancy. There is There is aa paucity paucity of of reports reports of of measurements measurements of hormones of hormones in in urine urine or or blood blood at at frequent frequent of patients patients in in the the intervals in intervals in significant significant numbers numbers of postpartum or postpartum or postabortal postabortal period period so so that that it it is is difficult to difficult to draw draw firm firm conclusions conclusions concerning concerning the the of ovulation ovulation from from these these data. data. Our Our resumption of resumption own work own work 22 and and that that of of others others show show that that folliclefollicle(FSH) is is present present only only in in stimulating hormone stimulating hormone (FSH) very small very small amounts amounts in in maternal maternal serum serum throughthroughhuman pregnancy. pregnancy. Few Few data data are are available available out human out concerning serial concerning serial measurements measurements of of the the gonadogonadoor urine urine in in the the postpartum postpartum tropins in tropins in blood blood or period, and, period, and, in in most most of of these these reports, reports, patients patients time were not were not studied studied for for aa sufficient sufficient period period of of time following delivery, following delivery, so so that that one one cannot cannot determine determine the time the time when when FSH FSH rose rose to to the the levels levels necessary necessary to produce to produce ovulation. ovulation. not see see secretory secretory or or Certainly, one Certainly, one does does not decidual endometrium decidual endometrium persisting persisting very very long long after after term delivery. term delivery. The The subject subject of of endometrial endometrial regenregenin aa eration following eration following delivery delivery was was reviewed reviewed in J. Whitridge Whitridge Williams Williams 33 classic contribution classic contribution by by J. in 1931. in 1931. He He concluded concluded that that the the endometrium endometrium is is during the the third third usually completely usually completely regenerated regenerated during week following week following labor labor and and that that the the persistence persistence of of chorionic giant chorionic giant cells cells in in the the decidua decidua basalis basalis and and underlying muscularis underlying muscularis was was rare rare beyond beyond the the eighth eighth or tenth or tenth day day post post partum. partum. One cannot One cannot help help but but be be impressed impressed with with the the
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June 15, June 15, 19i2 19i2 Obs!c!. Gyneeo!. Obs!c!. Gyneeo!.
forthright nature forthright nature of of Dr. Dr. Williams' Williams' writing. writing. In In his his "D'Erchia review of review of previous previous literature, literature, he he states, states, "D'Erchia strongly opposed strongly opposed that that view" view" (that (that there there were were practically no practically no glands glands in in the the decidua decidua basalis) basalis) "but "but in other in other respects respects his his article article is is of of interest interest only only in in the fact the fact that that the the subsequent subsequent investigation investigation has has that practically practically every every statement statement he he made made proved that proved was incorrect." was incorrect." In In discussing discussing why why sterilization sterilization was deferred was deferred instead instead of of being being effected effected in in conconjunction with junction with aa cesarean cesarean section section at at the the time time of of labor, he labor, he states, states, "And "And my my answer answer is is that that in in aa teaching clinic, teaching clinic, II have have thought thought it it necessary necessary so so far as far as possible possible to to limit limit the the performance performance of of cesarean section cesarean section to to patients patients presenting presenting aa clear-cut clear-cut Obstetric indication, indication, as as to to do do otherwise otherwise would would Obstetric which II believe believe consticonstifoster unclear unclear thinking, thinking, which foster major defects defects of of American American tutes one tutes one of of the the major Obstetrics." Obstetrics." Sharman 44 has Sharman has provided provided an an excellent excellent review review of of appearance of of the the the publications the publications reporting reporting the the appearance endometrium in endometrium in the the postpartum postpartum period. period. His His own work own work consists consists of of an an extensive extensive study study of of the the endometrium following endometrium following term term delivery. delivery. He He examined uteri examined uteri removed removed from from 10 10 women women from from day post post partum. partum. He He the first the first to to the the fifty-fourth fifty-fourth day also examined also examined 626 626 endometrial endometrial biopsy biopsy specimens specimens day to to the the ninth ninth from 285 from 285 women women from from the the fifth fifth day month post month post partum. partum. Of Of these, these, 165 165 were were not not lactating at lactating at the the time time of of the the first first biopsy. biopsy. From From this group, this group, 461 461 biopsies biopsies were were obtained. obtained. Of Of these, these, endometrium in in the the proliferative proliferative 326 showed 326 showed endometrium and 135 135 showed showed endometrium endometrium in in the the phase and phase secretory phase. secretory phase. The The earliest earliest presumptive presumptive evieviof ovulation ovulation was was found found on on the the forty-fourth forty-fourth dence of dence postpartum day. postpartum day. Kava and Kava and colleagues colleagues 55 in in 1968 1968 reported reported on on 92 92 endometrial biopsies endometrial biopsies obtained obtained in in nonlactating nonlactating women from women from 33 33 to to 93 93 days days post post partum. partum. Sixteen Sixteen of of these these biopsies biopsies showed showed secretory secretory endometrium. endometrium. The earliest The earliest of of these these was was on on Day Day 33, 33, and and 12 12 of of of ovulation ovulation before before the patients the patients showed showed evidence evidence of the forty-third the forty-third postpartum postpartum day. day. many of of the the reported reported studies, studies, Unfortunately, in Unfortunately, in many at arbitrary arbitrary intervals intervals the biopsies the biopsies were were taken taken at rather than than at at the the time time of of the the following delivery following delivery rather first episode first episode of of bleeding bleeding so so that that it it is is difficult difficult to to determine the determine the true true incidence incidence of of ovulation ovulation precedprecedthat first first episode episode of of bleeding. bleeding. However, However, from from ing that ing the data the data that that are are available, available, aa number number of of authors authors drawn the the conclusion conclusion that that the the first first have drawn have term delivery delivery is is menstrual period menstrual period following following term usually not usually not preceded preceded by by ovulation. ovulation. There are There are fewer fewer data data available available from from patients patients In 1942, 1942, Rutherford Rutherford and and following ahortion. following ahortion. In
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Mezer6 reported Mezer6 reported on on the the regeneration regeneration of of the the uterine uterine mucosa mucosa following following spontaneous spontaneous abortion abortion as as well well as as term term delivery. delivery. Fourteen Fourteen patients patients were were after term term delivery, delivery, and and 9 9 patients patients were were studied studied after studied following studied following spontaneous spontaneous abortion. abortion. The latter The latter group group had had biopsies biopsies at at 3 3 and and 7 7 days days and then then weekly weekly until until following abortion following abortion and Their first first patient patient had had menstruation occurred. menstruation occurred. Their definite early definite early secretory secretory activity activity of of the the glands glands 21 21 days after days after abortion abortion and and had had aa menstruating menstruating Day 30. 30. In In summary, summary, they they endometrium on endometrium on Day that endometrial endometrial regeneration regeneration was was comcomstated that stated plete in in 7 7 days, days, ovulation ovulation occurred occurred on on Day Day 14, 14, plete and menstruation and menstruation occurred occurred on on Day Day 28. 28. On the On the other other hand, hand, their their second second patient patient had had decidual endometrium decidual endometrium for for 53 53 days. days. From all From all of of the the material material studied, studied, they they conconcluded cluded that, that, on on the the average, average, ovulation ovulation occurred occurred about 6 weeks weeks after after term term deliveries deliveries and and about about 2 2 about 6 to 3 to 3 weeks weeks after after abortion. abortion. Sharman has Sharman has also also reported reported data data on on endomeendometrial trial biopsies biopsies following following spontaneous spontaneous abortion. abortion. He He obtained 135 obtained 135 biopsies biopsies from from 42 42 patients patients following following Of these, these, 60 60 were were done done in in the the prepreabortion. abortion. Of menstrual and it it was was noted noted that that 31 31 of of menstrual period, period, and the patients the patients (72 (72 per per cent) cent) had had ovulated ovulated before before that first that first period. period. Likewise, Hallet Likewise, Hallet 77 found found that that ovulation ovulation had had occurred in occurred in 42 42 of of 54 54 patients patients (77 (77 per per cent) cent) in the the period period following following whom he whom he studied studied in spontaneous abortion. spontaneous abortion. The authors The authors reporting reporting here here today today have have presented data presented data on on aa much much larger larger group group of of papatients. The The biopsies biopsies obtained obtained were were made made at at the the tients. that is, is, at at the the onset onset of of bleedbleedmost strategic most strategic time, time, that ing. They found found secretory secretory endometrium endometrium in in 84 84 ing. They per cent per cent of of the the patients. patients. All All but but one one of of these these had ovulated ovulated prior prior to to the the thirty-sixth thirty-sixth patients had patients day following day following abortion. abortion. that in in this this instance instance we we must must accept accept II believe believe that secretory endometrium secretory endometrium as as evidence evidence of of prior prior The authors authors have have made made an an important important ovulation. The ovulation. and are are to to be be commended commended for for bringbringcontribution and contribution ing our attention attention an an important important point. point. In In ing to to our contradistinction to contradistinction to the the OpInIOn OpInIOn frequently frequently expressed for expressed for women women following following term term pregnancy, pregnancy, that the the overwhelming overwhelming they have they have demonstrated demonstrated that
Ovulation after Ovulation after therapeutic therapeutic abortion abortion
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percentage of percentage of women women do do ovulate ovulate before before the the first first episode of episode of postabortal postabortal bleeding. bleeding. They They have have also also that it it occurs occurs very very early early in in properly emphasized properly emphasized that the the postabortal postabortal period. period. REFERENCES REFERENCES
1. Le 1. Le Maire, Maire, W. W. J., J., Conly, Conly, P. P. W., W., Moffett, Moffett, A., A., Spellacy, W. Spellacy, W. N., N., Cleveland, Cleveland, W. W. W., W., and and Savard, Savard, K.: AM. K.: AM. J. J. OBSTET. OBSTET. GYNECOL. GYNECOL. 110: 110: 612, 612, 1971. 1971. 2. Parlow, 2. Parlow, A. A. F., F., Daane, Daane, T. T. A., A., and and Dignam, Dignam, W. J.: W. J.: J. J. Clin. Clin. Endocrinol. Endocrinol. Metab. Metab. 31: 31: 213, 213, 1970. 1970. 3. Williams, 3. Williams, J. J. W.: W.: AM. AM. J. J. OBSTET. OBSTET. GYNECOL. GYNECOL. 22: 664, 22: 664, 1931. 1931. 4. Sharman, 4. Sharman, A.: A.: Reproductive Reproductive Physiology Physiology of of the the Period, Edinburgh, Edinburgh, 1966, 1966, E. E. & & S. S. Postpartum Period, Postpartum Livingstone, Ltd. Livingstone, Ltd. 5. Kava, 5. Kava, H. H. W., W., Klinger, Klinger, H. H. P., P., Molnar, Molnar, J. J. J., and J., and Romney, Romney, S. S. L.: L.: AM. AM. J. J. OBSTET. OBSTET. GYNECOL. 102: GYNECOL. 102: 122, 122, 1968. 1968. 6. Rutherford, 6. Rutherford, R. R. N., N., and and Mezer, Mezer, J.: J.: J. J. A. A. M. M. A. A. 119: 119: 124, 124, 1942. 1942. 7. Hallet, 7. Hallet, R. R. L.: L.: AM. AM. J. J. OBSTET. OBSTET. GYNECOL. GYNECOL. 67: 67: 52, 52, 1954. 1954.
DR. BoYD DR. BoYD (Closing). (Closing). As As far far as as the the question question with first-trimester first-trimester abortions abortions of why of why the the patients patients with don't know. know. II have have aa suspicion suspicion ovulate earlier, ovulate earlier, II don't that possibly that possibly the the hypothalamic-pituitary-ovarian hypothalamic-pituitary-ovarian is not not quite quite as as altered altered in in the the earlier earlier stages stages axis is axis of pregnancy of pregnancy as as it it is is when when there there has has been been aa 99 month time month time lapse. lapse. Also, Also, II don't don't know know what what role role the element the element of of stress stress plays plays in in this this situation. situation. Most Most of these of these patients patients were were apparently apparently not not too too bothered bothered by the by the abortion abortion procedure procedure itself, itself, and, and, thus, thus, their their ran along along fairly fairly unaltered. unaltered. There There body dynamics body dynamics ran are many are many evidences evidences of of traumatic traumatic ovulation, ovulation, if if in women women under under stress. stress. II don't don't know know you will, you will, in what significance what significance this this element element has, has, but but it it is is interesting to interesting to speculate. speculate. When we When we perform perform an an abortion abortion for for any any reason, reason, we should we should make make the the patient patient aware aware that that she she may may and become become pregnant pregnant fairly fairly soon. soon. II ovulate and ovulate would like would like to to comment comment that that Dr. Dr. Holmstrom Holmstrom and he he carefully reviewed carefully reviewed each each of of these these slides, slides, and 30 years. years. has been has been studying studying endometria endometria over over 30 II certainly certainly would would not not presume presume to to encroach encroach on on in this this area, area, and and II feel feel secure secure in in his his knowledge knowledge in his evaluation. his evaluation.