"The gynaecologist as a clinician and researcher: A career of hope" - Prof. Ejiro Edward Emuveyan

BEING text of the inaugural lecture delivered by Prof. Ejiro Edward Emuveyan of the University of Lagos College of Medicine, Idi-Araba, Lagos, at the University’s Main Auditorium, Akoka, Yaba, Lagos, recently.

Preamble

What it takes to be a general medical practitioner
A general medical practitioner is a medical school graduate who has successfully undergone training that lasted at least 12 semesters. He or she is exposed to and must pass his examination in Anatomy, Physiology, Biochemistry, Pharmacology and Pathology in Basic Medical Sciences and Community Health, Internal Medicine, Surgery, Obstetrics and Gynaecology and Pediatrics in the Clinical Sciences.
When he graduates, he obtains a degree of Bachelor of Medicine and Bachelor of Surgery. After a year of internship he is given a license of full registration as a general medical practitioner by the Medical and Dental Council of Nigeria. The first year of practice he spends in the National Youth Service. Thereafter he can work as a general medical practitioner in a private, public or specialist hospital.

THE MAKING OF A GYNAECOLOGIST

From General Practitioner to a Gynaecologist
A general medical practitioner could proceed to specialize in any of the medical specialties namely, Internal Medicine, Surgery, Obstetrics and Gynaecology, Pediatrics, Public Health, Pathology, Psychiatry and a few others. For Obstetrics & Gynaecology this is a four-year residency training in most countries. There are further subspecialties in obstetrics & gynaecology.

Origin of Sub-Specialties in OB/GYN
The evolution of formal subspecialty training in Obstetrics & Gynaecology(Ob/GYN) can be traced to North America (mainly USA). The American Board of Obstetrics & Gynaecology were the first credentialing body to set up sub-specialty board to establish educational objectives for the training of sub-specialists in different areas of obstetrics & gynaecology in the 1960s.
The main stimulus for such training came from: The health consumers in the United States who were demanding a higher level of specialized care
The pressure on practices by activities of attorneys who specialize in malpractice suits.
It is important to bear in mind that: Exposure to Ob/Gyn in US Medical Schools is usually for a very short period and that most medical graduates have very limited skills and knowledge in the field.
Virtually all practitioners of medicine in USA must have undergone one form of residency training or another before being licensed to practice fully in most states.
Thus there are a lot of people trained in the general rudiments of Ob/Gyn and certified as specialist without actually mastering some of the more intricate aspects of its practice.
Those who had managed to acquire additional skills in certain specialized areas of Ob/Gyn practice wanted recognition and certification for what they have achieved because of:
  • The need to have more of such patients referred to them by general Ob/Gyn practitioners to further sharpen their skills.
  • Higher remuneration for the highly specialized services they offer.
Major Sub-Specialties
The three sub-specialties for which examination boards were first set up in the USA were:
  • Maternal & Fetal Medicine, Reproductive Endocrinology and Fertility Management.
  • Gynaecological Oncology
As other countries, notably the UK, started to follow this path, other sub-specialties began to emerge such as those focusing on:
  • Gynaecological Urology
  • Community Gynaecology (incorporating Family Planning and Sexually Transmitted Infection Management)
  • Reproductive Genetics.
Even among these sub-specialists ‘super specialists’ have begun to emerge such as those focusing on:
  • Fetal Therapy (incorporating Fetal Surgery) from Maternal & Fetal Medicine, Assisted Reproduction (IVF and its spin offs) from Reproductive Endocrinology & Fertility Management
  • Preventive Oncology – From Gynaecology Oncology.
2.4 Current Situation in Nigeria
In the West African sub-region today, there is no formal sub-specialist training in Obstetrics & Gynaecology
In many of the training institutions, no trained sub-specialists exist for any of the sub-specialties identified.
Most of the practitioners in these institutions even in academic department such as Colleges of Medicine and University Teaching Hospitals are all purpose Ob/Gyn doctors without any areas of special expertise.
In 1980 our department of Obstetrics & Gynaecology at the College of Medicine, University of Lagos / Lagos University Teaching Hospital - was restructured into four sub-specialties called units namely.
  • Oncology and Pathological studies (OPS);
  • Experimental and Maternal Medicine (EMM);
  • Ultrasound and Fetal Medicine (UFM);
  • Reproductive Endocrinology and Fertility Regulation (REF).
This early structuring of our department has paid off as most Ob/Gyn residents trained in LUTH since the 1980s have been able to have their bearing and focus in sub-specialty work from their residency training days.

THE BROAD PICTURE OF THE DISCIPLINE

The discipline has changed dramatically in recent years. We are witnessing a literal explosion in our knowledge of human reproduction and a corresponding improvement in our technical ability to diagnose and treat complicated diseases. We now can fertilize human eggs in the laboratory and reimplant the embryo in the womb and we can test the early embryo for selected genetic disorders. Through ultrasound, amniocentesis, chorionic villus sampling and fetal blood sampling we can identify karyotype abnormalities, congenital anomalies and congenital infections and in selected instances offer life-saving medical and surgical treatment.
Through electronic fetal monitoring, doppler velocimetry and biophysical assessment, we can evaluate fetal well- being and determine the optimal timing of delivery.

In gynaecology we now have available new and potent antibiotics for the treatment of genital tract infections. We have developed several new and exciting therapies for prevention of osteoporosis. Medical management has largely replaced surgical treatment for abnormal uterine bleeding and ectopic pregnancy. In situation where open abdominal surgery used to be the norm, sophisticated laparoscopic approaches are now possible. Treatment for gynaecologic malignancies continue to improve and many patients now can have hope for complete cure.

THE CHALLENGES

Maternal Mortality Statistics
Figures released in October 2007 jointly by UNFPA, WHO, UNICEF and the World Bank2 revealed that women continue to die of pregnancy related causes at a rate of about one every minute. However there has been a decline in maternal deaths globally at a rate of less than 1%. The number of women dying in pregnancy or childbirth has shown modest decrease between 1990 and 2005; from 576,000 per year in 1990 to 536,000 per year in 2005.
The United Nations has made a global reduction of maternal mortality one of its main priorities and at the UN Millennium Summit in 2000,3 the promotion of gender equality and empowerment of women and the aim ‘to reduce by three quarters, between 1990 and 2015, the maternal mortality ratio’, were formulated as the third and fifth of eight Millennium Development Goals (Table 1).

Table 1 - The Millennium Development Goals

1. Eradicate extreme poverty and hunger
Reduce by half the proportion of people living on less than a dollar a day
Reduce by half the proportion of people who suffer from hunger.

2. Achieve universal primary education
Ensure that all boys and girls complete a full course of primary schooling

3. Promote gender equality and empower women
Eliminate gender disparity in primary and secondary education preferably by 2005, and at all levels by 2015.

4. Reduce child mortality
Reduce by two thirds the mortality rat among children under 5.

5. Improve maternal health
Reduce by three-quarters the maternal mortality ratio

6. Combat HIV/AIDS, malaria and other diseases
Halt and begin to reverse the spread of HIV/AIDS.
Halt and begin to reverse the incidence of malaria and other major diseases

7. Ensure environmental sustainability
Integrate the principles of sustainable development into country policies and programmes; reverse loss of environmental resources.
Reduce by half the proportion of people without sustainable access to safe drinking water and basic sanitation.
Achieve significant improvement in lives of at least 100 million slum dwellers, by 2020.

8. Develop a global partnership for development
Develop further an open, rule-based, predictable, non-discriminatory trading and financial system.
Address the special needs of the least developed countries, landlocked countries and small island developement states. Deal comprehensively with developing countries debt.
In cooperation with developing countries, develop and implement strategies for decent and productive work for youth. In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries.
In cooperation with the private sector, make available the benefits of new technologies, especially information and communication technologies

The lifetime risk of a 15 years old dying as a result of complication related to pregnancy and childbirth is highest in Niger (1 in7) and lowest in Ireland (1 in 48,000).
In a recent systematic analysis of progress towards MDG 5, considering maternal mortality for 181 countries, 1980 – 2008 (article posted on the web on 13th April, 2010), the following figures were obtained.
- Number of women dying from pregnancy related causes has decreased by 35% in the past 30 years. However, the rate has increased in the USA and Canada.
- Globally maternal mortality ratio was 422 per 100,000 live births 1980 and 251 per 100,000 live births in 2008.
- I in 5 maternal deaths are linked to HIV.
- Maternal mortality ratio in USA increased by 42% (i.e from 12 per 100,000 live births in 1990 to 17 per 100,000 live births in 2008).
- Maternal mortality ratio in UK was 8 per 100,000 live births in 2008.
- In Canada, maternal mortality ratio increased from 6 per 100,000 live births in 1990 to 7 per 100,000 live births in 2008.
- Only 23 countries e.g. Egypt, Poland and Romania were shown to be on track of achieving MDG 5 and lowering maternal mortality ratio by 75% between 1990 and 2015.
Evidence has shown that maternal mortality expressed as maternal mortality rate (MMR) i.e deaths/1000 births or deaths /100,000 maternities has dropped drastically in developed countries in the last 50 years. Table 3 shows MMR developed by the World Health Organisation.
The great disparity between developed and developing countries is clearly shown.

4.2 MATERNAL MORTALITY SITUATION IN NIGERIA
Nigeria’s maternal mortality statistics has been indicated as one of the highest in the World. While the maternal mortality ratio of 704 maternal deaths per 100,000 live births was obtained from a national survey in 1999, a recent document of the Federal Ministry of Health indicated a figure of 948 maternal death per 100,000 live births (range of 339/100,000 to 1,716/100,000).
Wide geographical disparity obtains with respect to maternal mortality incidence in Nigeria, with the rate in the North-east zone almost ten times that of the South-west zone in 1999.6 The leading medical causes of maternal mortality in Nigeria are hemorrhage (23%), sepsis (17%), unsafe abortion (11%), anaemia (11%), malaria (11%), eclampsia (11%), obstructed labour (11%), and effective medical approaches to managing each of these conditions currently exist. There is a dire and urgent need to effectively address the high maternal mortality situation in Nigeria in the interest of human development, social justice and poverty alleviation
The frame work in the figure identify that a variety of social economic and health system factors interplay to contribute to health outcomes in pregnancy.
These factors operate at various levels – the household, community, the health sector other social sector and the larger political environment.
The overall national maternal mortality statistics is insufficient to understand the challenges of the problem in Nigeria because of considerable geographical disparity.
My interests and deeps concerns are shown by the nature of work I have been involved in. My aim is to use clinical research to identify problems and set interventions that will help to solve them or at least reduce the burden on our women. There may be areas of clinical and research interests which I have refused to develop fully because of my convictions and family background which make me prefer to be involved only in issues that will improve the lot of many more people than just a few rich and wealthy individuals.

5. SEARCH FOR SOLUTIONS BY CLINICAL RESEARCH

5.1 Trends in Maternal Mortality Ratio
Agboghoroma and Emuveyan in 19978 examine the level and trend in maternal mortality at Lagos State University from January 1986 through December 1995. The findings were:
Maternal mortality in Lagos over 10 years, 17,691 deliveries, 342 maternal deaths, maternal mortality of 1930/100,000 births
Rising trend from 1670/100,000 births in 1986 to 3020/100,000 births in 1995.
To achieve objective of safe motherhood initiative programme efforts should be directed at providing accessible and affordable comprehensive maternal healthcare.

5.2 Emuveyan and Agboghoroma in 19979 carried out a ten year review (1986 – 1995) of abortion related maternal mortality in Lagos University Teaching Hospital. The interesting findings were:
  • 77 abortion deaths out of a total of 342 maternal deaths
  • Age of patients ranged from 12 to 39 years with a mean of 23.4 years
  • 47 (61%) of victims were single school girls
  • Most abortionist (80%) were not medically qualified
  • Proportion of maternal deaths due to abortion was 22.5%
Conclusion was that prevention of unwanted pregnancies could be achieved by ensuring the availability of family planning services to all and that comprehensive post abortion medical care for victims of induced abortion are necessary means to curtail abortion deaths in our society.

5.3 Odum, Emuveyan and Akinkugbe in 199010 studied mortality in eclampsia in the Lagos University Teaching Hospital. We compared the recent 10 year period 1977- 1986 with the previous 10 year period (1967 – 1976). The summary of the findings were Ten year period 572 eclamptics, 384 (66.4% pre-delivery and 188 (post-partum).
Majority 448 (98.3% unbooked and overall maternal death from eclampsia 62 (108 per 1000).
Caesarean section rate in all eclamptic patients – 22.2%
Increase C/S rate in recent years and unbooked patients in the dominant group.

5.4 Causes of Infertility in Lagos
IN Nigeria infertility is the commonest complaint in the gynaecological outpatient clinic and incidence between 20 – 30% have been reported.11 Infertility has profound effect on the socio-economic and psychosexual well being of the couple.
In a study of the etiologic classification and socio-medical characteristics of infertility in 250 couples at the Lagos University Teaching Hospital over a 30 month period by Giwa-Osagie et al.12 in 1984 the following were our findings:
  • Tubal disease- 24.0%
  • Oligoazosperrnia - 20.8%
  • Annovulation - 16.8%
  • Pregnancies - 62.8%
  • Miscarriage/ectopic - 14.3%
  • Polygamous marriages likely to delay conception
5.5 Related findings in another study in the Lagos University Teaching Hospital by Ogedengbe et al.13 in 1987 came up with pertinent conclusions with implications of pattern of tubal disease for microsurgery or In-Vitro fertilization in Lagos. The summary of the study was:
Assessment by laparoscopy in 78 out of 100 consecutive Nigeria patients; 42 bilateral tubal occlusion, 18 unilateral, 18 gross pelvic adhesions; 27 (35%) with tubal disease IVF only suitable treatment.

5.6 In 1981 Emuveyan et al.14 looked at the clinical features and endocrine profiles of polycystic ovary disease in Lagos. Diagnosis in these patients were made from findings at history taking, clinical examination, hormone profile and laparoscopy .This study established that: Complaints were those of oligomenorrhea and amenorrhea elevated LH treatment with clomiphene citrate was successful in 2/3 of patients.

5.7. In 1995 Emuveyan and Dixon15 studied over 10,000 Family Planning clients in four family planning clinics of Lagos University Teaching Hospital, Idi-Araba, The Lagos Island Maternity Hospital, Lagos, The Planned Parenthood Federations of Nigeria Headquarters and The General Hospital Ikeja. This study was summarized as follows:
Prospective sociodemographic characteristics, contraceptive behaviour, choice and outcomes: 10,142 – four family planning clinics in Lagos; 62% aged 25-34 and 64% previously used
2/3rd accepted IUCD, 15% injectables and 8% COC.
Continuation rates highest in women accepting injectables (86% at 12 months) and lowest 73% among pill users.
Menstrual symptoms were reasons for discontinuation.

5.8 Uniplant
Subdermal contraception implants have been one of the most important addition to contraceptive technology in the past three decades. This new long-acting method involves the slow diffusion at a stable rate of a steroid progestin from polmer capsules or rods placed under the skin. The duration of contraceptive efficacy can vary from 1 to 5 years depending on the type of polymer, the number of capsules, and the specific progestin. The levonorgestrel implant Norplant system was the first of this family of long-acting methods and was for a long time the only one that had regulatory approval for distribution.
The second generation of implant included Uniplant, a single silastic implant of nomegestrol acetate which had been shown to provide contraceptive efficacy during 12 months of use.
The following was the summary of the Uniplant study by Coutinho et al.16
Original research on multicentre clinical trial on efficacy and acceptability of Nomegestrol Acetate
Uniplant in 1,803 healthy women of reproductive age from nine countries after informed consent; 276 subjects (15.72%) cumulative discontinuation rate, cumulative pregnancy rate of 0.94%, 56% had bleeding pattern similar to normal menstruation.
Uniplant is efficient, well tolerated and has advantage of easier insertion and removal compared to other multiple implant methods Uniplant considered easy to use, safe/low risk of pregnancy and causes fewer side
effects than other methods.

5.9 Gossypol
Gossypol is Chinese oral male contraceptive used in doses which led some Chinese males to develop gossypol induced hypocalaemia which caused muscle fatigue 17.
Consequently the South to South Cooperation in Reproductive Health (STS) attempted to study serum potassium concentration in normal men in different geographical locations.’’18
The details and findings from this study were: Hypokalaemia associated with gossypol a male antifertility drug.
K+ concentration in normal men in different geographic locations Austria (30) China (38), Brazil (100), Dominican Republic (38), USA (103), Nigeria (62).
Established regional differences with men in China having lower serum K+.
The follow up to this study was another study on trial of different safer dose regimens of gossypol as a male contraceptive.19 The findings were: 151 men divided into two groups.
Both groups received 15mg gossypol/day for12 or 16 weeks to reach spermatogenesis suppression and
then randomized to either 7.5 or 10mg/day for 40 weeks. K+ level FSH and testicular volume measured.
12 of 19 subjects on 7.5mg/day doses recovered sperm counts > 20x 106ml within 12 months of discontinuation; 10 of 24 on 10mg recovered sperm count, 8 of 43 remained azospermic 1 year after.
Gossypol is a medical alternative to surgical vasectomy

5.10 Mother to Child Transmission of HIV Infection

Background of PMTCT
Nigeria with a population of 140 million people is the most populous country on the African continent and home to 1 in 5 Africans. Women of reproductive age (15-49 years) are 31 million and about 5.4 million births occur annually.
Nigeria has the third highest burden of HIV/AIDS in the world. An estimated 2.99 million people are living with the virus out of which 1.7m (57%) are women. By the end of 2006, it was estimated that 305,080 new infections occurred in adults and 74,520 in children, largely acquired through MTCT. The 2005 ANC sentinel survey showed that the National average of HIV prevalence among pregnant women is 4.4% with a range of between 1.6 to 14.7%. The HIV prevalence rate was higher in the urban (4.6%) than rural areas (3.9%). Among young persons the highest prevalence rate (4.9%) is in the age group 20 to 29 years followed by 4.7% in the age group 20-24 years. 15 out of the 37 states in the country have prevalence rates above the national average. Maternal mortality rate is 800 per 100,000 live births (FMOH) and AIDS-attributable under-5 mortality is estimated at 5%. About 270,000 children are currently living with the virus.
Currently, only 26% of all pregnant women presently have access to HCT during ANC which is the most important entry point for PMTCT in the country.23 This has constrained achievement of the national target of 80% access by end of year 2010. Specifically, out of about 260,000 HIV positive pregnant women delivering annually only 14,186 (5.4%) have access to ARV prophylaxis.
Among married women who are most likely to be exposed to risk of pregnancy, only 8% use modern methods of contraception, while the total unmet need for family planning stands at 17%.
The traditional method of feeding infants is breast feeding. Exclusive breastfeeding rate is 17.2% while only 10% of infants are given Breast Milk Substitute (EBMS) exclusively. The coverage for BCG, DPT 1, and DPT 3 are 53%, 77% and 69% respectively.
To reduce the transmission of HIV infection from positive mothers to their infants, the National PMTCT programme was launched in 2002. This programme is established on the principles of four-element strategy which include: prevention of HIV infection in all women of reproductive age, prevention of unintended pregnancies among HIV-positive women; preventing transmission of HIV from HIV-positive women to their infants; follow-up for and linkages to long-term prevention, care, and support services for mothers, their children and families.
Furthermore, the national PMTCT scale up plan advocated scaling up horizontally and vertically simultaneously with the over-riding drive to reach the maximum number of clients in an equitable manner through the network approach. Under this approach, selection and sequencing of the scale up and upgrading process is guided by criteria which include:
The relative magnitude of the HIV/AIDS epidemic; the state of preparedness of the health facility in terms of structures and human resources; geographical balancing; presence of viable civil society organizations involved in PMTCT works; availability of support from development partners.

Other on-going HIV/AIDS activities e.g. ARV programmes.
As at 2007, less than 300 sites mostly, secondary, and tertiary health care facilities, mission hospitals and non governmental organization sites were providing PMTCT services in Nigeria. Most of these site receive donor support and technical assistance from UN Agencies such as WHO, UNICEF, US Government (CDC, USAID), USG implementing partners including Harvard School of Public Health/AIDS Prevention Initiative in Nigeria (APIN) Project, Institute of Human Virology/ACTION Project, FHI/GHAIN Project, Aids Relief and Columbia School of Public Health, Global Fund Against AIDS, Tuberculosis and Malaria (GFATM), Bill Gates Foundation, and the World Bank. In addition, over 4,000 different categories of health workers have been trained on all aspects of PMTCT. Provider initiated Testing and Counseling (PITC) is now evolving in ANC as dividend of RH-HIV integration.
There are a total of 23,640 health facilities in Nigeria. Of these, 85.8% are primary health care facilities, 14% secondary health and 0.2% tertiary health care facilities, while 38% of these health facilities belong to the private sector. Integration of HIV service into RH which recently commenced in the country is expected to contribute to scale-up of coverage. Availability of comprehensive PMTCT will be beneficial to both mutually reinforcing interventions. According to the 2003 National Demographic and Health Survey (NDHS), 61% of pregnant women attend ANC clinic at least once while 47% had at least 4 visits and 37% if the pregnant women deliver in the health facilities.
The goal of PMTCT in line with the 2003 National Policy on HIV and AIDS is: “to reduce the transmission of the HIV through MTCT by 50% by the year 2010 and to increase access to quality HIV testing and counseling services by 50% by the same year”.
Subsequently, a costed national health sector strategic plan inclusive of PMTCT was developed. In addition, the country has a national PMTCT scale-up plan with a target of 1632 PMTCT site nationwide by 2009. There exists national guidelines, national standard operating procedure (SOP) for PMTCT, job aids and training curriculum and manuals. A high political commitment to PLWA and PMTCT has been made by the presidential pronouncement directing that 250,000 people be placed on free ARV, free maternity services for all HIV positive pregnant women and care including ARV for infected children under 5. Nigeria has also recently development an integrated maternal, newborn and child health strategy that includes components of maternal care, PMTCT and Pediatric care and treatment.
It remains for me to illustrate PMTCT issues in figure 4 of a Hypothetical Cohort of 100 HIV positive pregnant women to demonstrates what happens in a situation where there is no PMTCT intervention. The epoch research that brought about the PMTCT revolution is shown in figure 5. while Figure 6 which follows shows the best case scenario of the US which has used the best PMTCT interventions to bring down their MTCT rates to less than 2% over the years. Since availability of anti-retroviral drugs in the programme is the key to success of PMTCT Figure 7 is provided to show where we are while figure 8 shows utilization of antiretroviral agents in ten hospitals in Nigeria.

The current concepts in PMTCT advocate:
1. Use of CD cell count of 350 to identify those who need antiretroviral drugs for treatment of their own disease and also to prevent their babies from been infected
2. Those who have CD4 cell count of more than 350 will need antiretroviral drugs for prophylaxis ie preventing their babies from been infected.
3. Current strong evidence suggest that in those using the drug for preventing vertical transmission of infection to their babies early initiation of antiretroviral prophylaxis can reduce MTCT rate to as low as 1%
5.11 Prenatal Diagnosis of Sickle-cell Disorder
Haemoglobin disorders are the commonest of human hereditary diseases. Over 4.5 percent of the worlds population carry a heamoglobin disorder trait and the globally birth rate of affected individuals is over 2 per 1000. Almost three- quarters of affected births are in Africa 24( where over 200,000 children are born annually with a severe sickle-cell disorder.

The great majority have sickle-cell anaemia (SS).
In Nigeria alone, 25 per cent of the population of about 115 million carry sickle-cell trait (HB,AS), and about 100,000 children are born annually with a serious sickle-cell disorder.
In 1999 Akinyanju et al25 introduced prenatal diagnosis of sickle-cell disorder in Nigeria to meet a rising demand. The following was the brief summary of the study: 25% of Nigerian population carry sickle –cell trait Hb AS, 124 USS-guided TC or TA sampling of chorionic villi from 9 weeks gestation.
Characteristics of population described 72TA & 52TC 7.2% miscarried.
DNA analysis 29 (23.4%) AA; 67 (54%) AS and 23 (18.5%) SS.
96% of women with 55 fetuses terminated the pregnancies.
Need for reliable electricity supply to provide equitable services emphasized.

Adjunctive Therapy prior to surgery in the management of uterine fibroids
Uterine fibroids are the most common benign solid neoplasia of the female genital tract, occurring in 20-25% of women over 30 years of age especially the nulliparous one. They are frequently found in gynaecological practice and may be associated with sub-fertility and symptoms such as menorrhagia, pelvic discomfort and dyspareunia. Figure 9 shows the various locations of uterine fibroids.
The incidence of these tumours is sometimes higher in black women than in white women. In women with symptomatic fibroids gonadotrophin releasing hormone (GnRH) Buserelin and Goserelin have been shown to reduce uterine fibroid to about 50% of their original size (assessed by ultrasonic measurement) and Shaw26 has suggested that LHRH analogues should be used as an adjunct to the surgical management of fibroids.
In 2005 Emuveyan, Ifenne and Ohaju-Obodo27 in a randomized controlled study of goserelin (Zoladex) as an adjunctive therapy prior to surgery in the management of uterine fibroid in Lagos and Zaria reported as follows:
To assess goserelin as adjunctive therapy in management of fibroid
40 pre-menopausal patients (26-50 years) with uterine size 12-26 weeks enrolled in a randomized control study.
One group prospectively randomized to surgery and another to goserelin treatment for 3 months followed by surgery.
Fibroids volumes reduced by a median value of 31.7% and 58.1% respectively for Zoladex patients compared to an increase of 3.3% and 0.6% in uterine and fibroid volumes in the surgery only patients
Goserelin treatment prior to surgery demonstrated benefit in patients with uterine leiomyoma.

CONCLUSION

Mr Vice-Chancellor Sir, distinguished ladies and gentlemen, I have discussed the training of medical practitioners and how these doctors undergo specialist medical training before they can be licensed as Obstetricians and Gynecologists. I have also enumerated the evolution of subspecialty training and its impact of quality of care which these super specialists provide for their patients. I have identified the challenges of maternal and issues of maternal mortality ratio with Nigeria having one of the highest MMR in the world. I took some selected contributions that I and my colleagues have made with a view to solving these issues of our day. Your conclusion may be as good as mine and can be summed up in Proverbs 13:12
“Hope deferred makes the heart sick, but a longing fulfilled is a tree of life.”

It is imperative therefore that if our verdict of hoping of improvement both in the safety of our work and that of the critical tools one needs to get sactisfactoryed results is dashed we must not despair but instead we should continue to hope for the best and prepare for the worst.

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