Vacuum Aspiration Abortion Research Articles

Abortion-related care and the role of the midwife: a global perspective.

IntroductionThe International Confederation of Midwives (ICM) represents 132 midwifery associations in 113 countries. The ICM disseminates the Essential Competencies for Basic Midwifery Practice (EC) that describes the global scope of midwifery practice. The basic (core) and expanded (additional or optional) role of midwives in providing abortion-related care services was first described in 2010. A literature review about three items that are particularly critical to access to abortion services was conducted. Findings that emerged in the recent 2016–2017 update study about these three items are presented.MethodsA modified Delphi study was administered via the Internet in a series of three rounds. Thirty-seven statements of abortion-related knowledge and skill were presented.ResultsA total of 895 individuals participated. The total of respondents across all three rounds represented 90 of the 105 member countries at the time of the study. The role of midwives in providing comprehensive abortion care, including referral for abortion and provision of postabortion family planning, achieved the necessary 85% agreement to be designated as essential (basic) knowledge or skill for the global scope of midwifery practice. The provision of medication abortion and performance of manual vacuum aspiration abortion were designated as optional for midwives who wished to provide these services. Endorsement of these latter practices was highest in both Francophone and Anglophone regions of Africa, Asian Pacific countries, and countries at a lower state of economic development.ConclusionThe role of midwives in provision of abortion-related care services was reaffirmed in the recent Delphi study to inform the update to the EC. The role of midwives as direct providers of medical and vacuum aspiration abortions was reaffirmed for those individual midwives who wish to obtain the requisite competency to provide those services, in jurisdictions where these services are legally authorized.

Medical abortion and manual vacuum aspiration for legal abortion protect women’s health and reduce costs to the health system: findings from Colombia

The majority of abortions in Colombia continue to take place outside the formal health system under a range of conditions, with the majority of women obtaining misoprostol from a thriving black market for the drug and self-administering the medication. We conducted a cost analysis to compare the costs to the health system of three approaches to the provision of abortion care in Colombia: post-abortion care for complications of unsafe abortions, and for legal abortions in a health facility, misoprostol-only medical abortion and vacuum aspiration abortion. Hospital billing records from three institutions, two large maternity hospitals and one specialist reproductive health clinic, were analysed for procedure and complication rates, and costs by diagnosis. The majority of visits (94%) were to the two hospitals for post-abortion care; the other 6% were for legal abortions. Only one minor complication was found among the women having legal abortions, a complication rate of less than 1%. Among the women presenting for post-abortion care, 5% had complications during their treatment, mainly from infection or haemorrhage. Legal abortions were associated not only with far fewer complications for women, but also lower costs for the health system than for post-abortion care. We calculated based on our findings that for every 1,000 women receiving post-abortion care instead of a legal abortion within the health system, 16 women experienced avoidable complications, and the health system spent US $48,000 managing them. Increasing women’s access to safe abortion care would not only reduce complications for women, but would also be a cost-saving strategy for the health system.

How Clinicians Develop Confidence in Their Competence in Performing Aspiration Abortion

In this article we explore how nurse practitioners, physician assistants, and nurse midwives in California (collectively referred to as clinicians) developed confidence while learning to provide vacuum aspiration abortion. We interviewed clinicians (n = 30) who worked in reproductive health care settings and had participated in a large abortion-training study. Although the training had moral and political significance for the trainees, in this article we focus on their experience of skill development and how they gained confidence and competence in aspiration abortion, a procedure typically performed by physicians. We argue that confidence is not one dimensional. Understanding the diverse ways in which clinicians arrive at confidence might inform health care training and education generally. By examining attained competency from the clinicians' perspectives, we continue the discussion within the social science of health care and medicine about how clinicians know what they know and what expertise feels like to them.

Developing clinician competence in manual vacuum aspiration abortion

Thirty nurse practitioner, nurse-midwife and physician assistant trainees provided in depth interviews about their experience of training to develop competence in the provision of vacuum aspiration abortion. Their trainers identified achievement of competence over time as occurring earlier in the training process than trainees self-report of development of confidence. Analysis of their transcribed interviews revealed that confidence in one's competence is not one-dimensional. Clinician confidence was impacted by external factors such as feedback from trainers and experiences with complications, but there were important internal measures and strategies for confidence employed by clinicians as well. Understanding the diverse ways in which clinicians arrive at confidence may inform abortion care training and sexual and reproductive health education generally. Participants will be engaged in discussion about the development of clinical competence, and about how clinicians know what they know and what expertise feels like to them.

Clinical research of endometrial miniature casing in termination of pregnancy

Objective To study the application advantages of the endometrial miniature casing( hereinafter referred to as the tiny tube) used in the artifical abortion operation of first trimester.Methods 300 women about first trimester were terminated and conforms to the related condition,randomly divided into three groups:endometrial miniature casing was used.Method traditional vacuum aspiration and drug abortion termination of first trimester.The intraoperative pain,blood loss,vaginal bleeding time and completely abortion rate were obcerved.Results Tiny tubes group was significantly higher in the painless rate than groups of the traditional vacuum aspiration and the drug abortion (P ＜ 0.05 ),and significantly less than in the blood loss and vaginal bleeding time( P ＜ 0.05 ).Tiny tubes group and traditional vacuum aspiration group had similar completely abortion rate,both are higher than the drug abortion group.Conclusion The tiny tube used in the artifical abortion operation of first trimester could obviously reduce the intraoperative pain,decrease operative and postoperative bleeding.The operation was simple,minimally invasive,and promotion of basic-level hospitals. Key words: Endometrial miniature casing; Early first trimester, Termination of pregnancy

Patient Characteristics and Service Trends Following Abortion Legalization in Mexico City, 2007–10

Legal abortion services have been available in public and private health facilities in Mexico City since April 2007 for pregnancies of up to 12 weeks gestation. As of January 2011, more than 50,000 procedures have been performed by Ministry of Health hospitals and clinics. We researched trends in service users' characteristics, types of procedures performed, post-procedure complications, repeat abortions, and postabortion uptake of contraception in 15 designated hospitals from April 2007 to March 2010. The trend in procedures has been toward more medication and manual vacuum aspiration abortions and fewer done through dilation and curettage. Percentages of post-procedure complications and repeat abortions remain low (2.3 and 0.9 percent, respectively). Uptake of postabortion contraception has increased over time; 85 percent of women selected a method in 2009-10, compared with 73 percent in 2007-08. Our findings indicate that the Ministry of Health's program provides safe services that contribute to the prevention of repeat unintended pregnancies.

Expanding the Pool of Abortion Providers: Nurse–Midwives, Nurse Practitioners, and Physician Assistants

Nearly half of all pregnancies in the United States are unintended, and approximately half of those are terminated (Finer & Henshaw, 2006). Abortion is one of the most frequently performed procedures among women of reproductive age, yet wide geographic disparities persist in the availability of abortion care. The abortion rate is as low as 1 per 1,000 women in some states (Wyoming) and as high as 40 per 1,000 women in others (Delaware; Jones & Kooistra, 2011). Women in nonmetropolitan areas have more limited access to abortion care; 97% of nonmetropolitan counties lacked an abortion provider in 2008 (Jones & Kooistra, 2011). Ensuring adequate access to a service that one in three women will need by age 45 remains a critical public health problem, especially in rural areas. Incorporating abortion into women’s primary care services is one way to ensure access that would also promote continuity of care. This would benefit women in all parts of the country, but especially in medically underserved areas. Nurse practitioners (NPs), certified nurse-midwives (CNMs), and physician assistants (PAs) are important providers of primary health care services to women of reproductive age, and their skills could be leveraged to improve access to abortion (Taylor, Safriet, Dempsey, Kruse, & Jackson, 2009). These clinicians already routinely provide important components of abortion care, including taking medical histories, confirming and dating pregnancies, providing pregnancy and abortion options counseling, and referring patients when complications arise. NPs, CNMs, and PAs also provide services that require procedural skills similar to those of early aspiration abortion, including inserting intrauterine devices and performing endometrial biopsies. PAs were among the first abortion providers in New England after Roe v. Wade (Joffe & Yanow, 2004), and PAs, NPs, and CNMs currently provide abortions in 15 states and many countries around the world (Abortion Access Project, 2011; Berer, 2009). Multiple studies have documented the safety of abortion care provided by these clinicians (Freedman, Jillson, Coffin, & Novick, 1986; Goldman, Occhiuto, Peterson, Zapka, & Palmer, 2004; Warrineret al., 2006). A number of barriers impede CNMs, NPs, and PAs from providing this care. Each profession practices under its own regulations, and these vary from state to state. These clinicians practice with a large degree of autonomy in some states, but in others their work must be closely supervised by a collaborating physician. Many states limit the provision of abortion care to licensed physicians by law. Most of these laws were enacted after Roe v. Wade in 1973, when public health officials were concerned about untrained providers harming women. Thus, these physician-only laws were not designed to constrain other

A randomized trial of tramadol versus ibuprofen as an adjunct to pain control during vacuum aspiration abortion

Background The study was conducted to determine whether tramadol is more effective than ibuprofen for reducing pain during uterine aspiration for abortion. Study Design Women presenting to a community-based abortion clinic were invited to participate in this double-blind, randomized trial. Following informed consent, subjects were randomly assigned to receive either 50 mg tramadol or 800 mg ibuprofen orally in addition to the standard clinic analgesic protocol. The primary outcome was pain as verbally rated on a scale from 0 to 10. Measurements were obtained immediately after and 30 min postprocedure. Results One hundred fifty-eight women were enrolled, 80 women were randomized to ibuprofen and 78 women, to tramadol. Immediately after the procedure, the mean pain scores in both treatment groups were 4.9 (95% CI=4.3–5.5). Thirty min postoperatively the mean pain score in the ibuprofen group was 2.8 compared to 3.6 in the tramadol group (p=.04). Conclusion There was no difference in immediate postprocedure pain between women receiving tramadol or ibuprofen. Ibuprofen is somewhat more effective than tramadol at reducing pain 30 min following surgical abortion.

Rates of Complication in First-Trimester Manual Vacuum Aspiration Abortion Done by Doctors and Mid-Level Providers in South Africa and Vietnam: A Randomized Controlled Equivalence Trial

The following abstracts of articles from leading journals have been selected on the basis of their importance to the practice of obstetrics and gynecology.

Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and mid-level providers in South Africa and Vietnam: a randomised controlled equivalence trial

We assessed whether the safety of first-trimester manual vacuum aspiration abortion done by health-care providers who are not doctors (mid-level providers) is equivalent to that of procedures done by doctors in South Africa and Vietnam, where mid-level providers are government trained and accredited to do first-trimester abortions. We did a randomised, two-sided controlled equivalence trial to compare rates of complication in abortions done by the two groups of providers. An a-priori margin of equivalence of 4.5% with 80% power and 95% CI (alpha=0.05) was used. 1160 women participated in South Africa and 1734 in Vietnam. Women presenting for an induced abortion at up to 12 weeks' gestation were randomly assigned to a doctor or a mid-level provider for manual vacuum aspiration and followed-up 10-14 days later. The primary outcome was complication of abortion. Complications were recorded during the abortion procedure, before discharge from the clinic, and at follow-up. Per-protocol and intention-to-treat analyses were done. This trial is registered at with the identifier . In both countries, rates of complication satisfied the predetermined statistical criteria for equivalence: rates per 100 patients in South Africa were 1.4 (eight of 576) for mid-level providers and 0 for doctors (difference 1.4, 95% CI 0.4 to 2.7); in Vietnam, rates were 1.2 (ten of 824) for mid-level providers and 1.2 (ten of 812) for doctors (difference 0.0, 95% CI -1.2 to 1.1). There was one immediate complication related to analgesics. Delayed complications were caused by retained products and infection. With appropriate government training, mid-level health-care providers can provide first trimester manual vacuum aspiration abortions as safely as doctors can.

Gemeprost versus misoprostol for cervical priming before first-trimester abortion: a randomized controlled trial

Objective To compare the efficacy of 400 μg of misoprostol with that of 1 mg of gemeprost as cervical priming agents when administered vaginally 3 to 4 hours before first-trimester vacuum aspiration abortion. Methods In a prospective controlled trial 90 nulliparous women who requested termination of pregnancy before 12 weeks’ gestation were randomized to receive vaginally either misoprostol or gemeprost for cervical priming. The force to dilate the cervix was measured by the use of a cervical tonometer connected to Hegar dilators from 3 to 10 mm. The main outcome measures were baseline cervical dilation; the peak force to dilate the cervix at 8, 9, and 10 mm; and the cumulative force to dilate the cervix to 10 mm. Results Baseline cervical dilation did not differ significantly between the women who received misoprostol and those who were treated with gemeprost. Neither the peak force required to dilate the cervix at 8, 9, and 10 mm nor the cumulative force to dilate the cervix to 10 mm showed any significant difference between the two groups. Conclusion Vaginally administered misoprostol (400 μg) is as effective as gemeprost (1 mg) for cervical priming 3 to 4 hours before surgical termination of first-trimester pregnancies.

The relationship of placenta previa and history of induced abortion

Objectives: We evaluated the risk of placenta previa being associated with a history of induced abortion by different surgical procedures. Methods: Cases ( n=192) were women who had a singleton delivery complicated by placenta previa at a major obstetric care hospital in western Washington state between April 1, 1990 and December 31, 1992. Controls ( n=622) were women with singleton deliveries not complicated by placenta previa or abruption. Odds ratios, determined by logistic regression, approximate the relative risks. Results: Vacuum aspiration abortion was not associated with an increased risk of placenta previa (OR 0.9, 95% CI 0.6–1.5). However, the risk of placenta previa increased with the number of sharp curettage abortions (OR 2.9, 95% CI 1.0–8.5 for ≥3). Conclusions: Risk of placenta previa may be increased in a dose response fashion by multiple sharp curettage abortions. However, vacuum aspiration does not confer an increased risk, and may be a better alternative.

Mifepristone versus vaginally administered misoprostol for cervical priming before first-trimester termination of pregnancy: A randomized, controlled study

Objective: This study was undertaken to compare the effectiveness of mifepristone orally administered at 24 or 48 hours before first-trimester vacuum aspiration abortion with that of vaginally administered misoprostol as a cervical priming agent. Study Design: In a randomized comparative trial 90 women who requested surgical termination of pregnancy were randomly assigned to receive 200 mg mifepristone orally 24 or 48 hours before the operation or 800 μg misoprostol vaginally 2 to 4 hours before the operation. The main outcome measures were baseline cervical dilatation, cumulative force required to dilate the cervix to 9 mm, and intraoperative blood loss. Results: The baseline cervical dilatation was significantly greater among women who received mifepristone 48 hours before the operation ( P = .02). This group also required the least mechanical force to dilate the cervix ( P = .06). There were no significant differences among the 3 groups in the intraoperative blood loss, in the operating time, or in patient acceptability. Side effects such as hot flushes and headaches were significantly higher among women who received mifepristone 24 or 48 hours before the operation than among those who received misoprostol ( P = .01 and P = .002, respectively). Conclusion: Mifepristone is an effective cervical priming agent when orally administered 48 hours before vacuum aspiration for termination of first-trimester pregnancy. Because of its cost and availability in comparison with misoprostol, however, selective use may have to be considered. (Am J Obstet Gynecol 2000;183:998-1002.)

Medical abortion: Public health and private lives

Induced abortion is a common event in the lives of women and their families. Statistics show that in the US nearly half of all women personally benefit from abortion; hence abortion is important from both a medical and a social standpoint. During the 1900s, anti-abortion laws were promulgated, subsequently resulting in the rise of maternal mortality due to complications from unsafe abortions. In the mid-1960s, state laws began to change to allow women access to safe abortions provided by licensed physicians. Since then, deaths from illegal abortions have decreased substantially. It is noted that legal abortion is one of the safest operations in contemporary medical practice, and its safety has improved through the years. Surgical skills have been enhanced and the technologies of suction curettage abortion and dilatation and evacuation introduced. In addition, abortion techniques using prostaglandin, mifepristone, methotrexate, and misoprostol have advanced.

Acceptability of suction curettage and mifepristone abortion in the United States: A prospective comparison study

Objective: We sought to compare the acceptability of suction curettage abortion with that of medical abortion with mifepristone and misoprostol in American women. Study Design: We performed a prospective, serially enrolled, cohort analysis. The study population consisted of 152 subjects receiving mifepristone and misoprostol and 174 subjects undergoing suction curettage abortion aged ≥18 years with intrauterine pregnancies of up to 63 days' estimated gestation. Questionnaires regarding expectations and experiences were administered before the abortion and at the 2-week follow-up visit. Results: Subjects undergoing medical abortions reported significantly greater satisfaction than those undergoing surgical abortions (mean rank, 121 vs 149; P <.01) but were no more likely to recommend the method they had just experienced to a friend (97% vs 93.3%). If a future abortion was required, however, 41.7% of subjects undergoing surgical abortions indicated they would opt for a medical abortion, whereas only 8.6% of subjects receiving medical abortions would choose a surgical abortion (P <.001). Failure of the abortion decreased satisfaction in the medical group and increased the likelihood of choosing a surgical abortion for a subsequent procedure (P <.001). Surgical subjects who experienced more anxiety than expected during the abortion were more likely to choose a medical procedure for a subsequent abortion (P <.01). Conclusion: Women receiving mifepristone and misoprostol were more satisfied with their method and more likely to choose the same method again than were subjects undergoing surgical abortion. Failure of a medical abortion and increased anxiety during surgical abortion were associated with preference for the alternative technique in a future procedure. (Am J Obstet Gynecol 2000;182:1292-9.)

Outcomes of suction curettage and mifepristone abortion in the United States: A prospective comparison study

A prospective, nonconcurrent cohort analysis of 178 mifepristone/misoprostol and 199 suction curettage abortion subjects, ages ≥ 18 years, with intrauterine pregnancies ≤ 63 days estimated gestational age, was conducted to compare the outcomes of suction curettage abortion to those of medical abortion. The medical abortion subjects received 600 mg of mifeprisone orally, followed by 400 μg of oral misoprostol 2 days later. Surgical abortion subjects underwent electronic vacuum aspiration. All subjects were followed for 2 weeks or until the absence of clinical bleeding. Outcome measures included a successful abortion (complete abortion without a surgical intervention), duration of bleeding, and morbidity. Overall, 18.3% medical and 4.7% surgical patients failed their primary procedure and received an unanticipated suction curettage (RR 3.93;95% CI 1.87, 8.29). Four mifepristone subjects required curettage for acute bleeding, nine to manage ongoing pregnancy, and five for incomplete abortion. Fourteen mifepristone and eight surgical subjects required curettage for persistent bleeding. The median time delay for therapeutic curettage was significantly longer in the medical abortion group (35 versus 8 days; Mann-Whitney U = 17.0, p = 0.008). Medical subjects experienced significantly longer bleeding (mean difference = 9.6 days, 95% CI 6.8, 12.4). No significant change in hemoglobin occurred in either group. Mifepristone patients reported significantly greater pain (77.1% vs 10.5%; RR 7.4, 95% CI 4.7, 11.5), and nausea or vomiting (68.6% vs 0.6%; RR 117.9, 95% CI 16.7, 834.7). Women receiving mifepristone/misoprostol are more likely to require an unplanned surgical intervention than women who undergo suction curettage. They experience more discomfort with their procedure and in the follow-up interval, bleed for a longer period, and remain at risk for surgical completion curettage for several weeks

Randomized trial to determine optimal dose of vaginal misoprostol for preabortion cervical priming

Objective: To determine the optimal dosage of vaginal misoprostol for cervical priming before vacuum aspiration abortion. Methods: One hundred twenty women were assigned randomly to receive 200, 400, 600, or 800 μg of misoprostol given vaginally. Vacuum aspiration was performed 3–4 hours after the insertion of misoprostol tablets. The degree of cervical dilation before operation was measured with a Hegar dilator. Preoperative and intraoperative blood loss and associated side effects also were assessed. Results: Twenty-nine (96.7%) women in the 400-μg group and all in the 600-μg and 800-μg groups achieved cervical dilation of at least 8 mm. The success rate for the 200-μg group was only 23.3%, significantly less efficacious than the 400-μg dose (odds ratio 95.3; 95% confidence interval 10.9, 830.9; P < .001). There was no significant difference among the 400-, 600-, and 800-μg groups ( P = .364) with respect to achieving cervical dilation at least 8 mm. However, 800 μg was associated with significantly more side effects than 600 μg (preoperative and intraoperative blood loss, P < .001; abdominal pain, P = .005; products of conception at os, P < .001; fever higher than 38.0C, P = .002). When 400 μg and 600 μg were compared, we found that the higher dose also was associated with significantly more side effects. The 600-μg group was used twice in the comparison, but all P values remained significant even after the Bonferroni adjustment for multiple comparisons. Conclusion: Vaginal application of 400 μg of misoprostol is the optimal dose for vacuum aspiration preabortion cervical dilation in first-trimester nulliparas.

Randomized Trial to Determine Optimal Dose of Vaginal Misoprostol for Preabortion Cervical Priming

In Brief Objective To determine the optimal dosage of vaginal misoprostol for cervical priming before vacuum aspiration abortion. Methods One hundred twenty women were assigned randomly to receive 200, 400, 600, or 800 μg of misoprostol given vaginally. Vacuum aspiration was performed 3–4 hours after the insertion of misoprostol tablets. The degree of cervical dilation before operation was measured with a Hegar dilator. Preoperative and intraoperative blood loss and associated side effects also were assessed. Results Twenty-nine (96.7%) women in the 400-μg group and all in the 600-μg and 800-μg groups achieved cervical dilation of at least 8 mm. The success rate for the 200-μg group was only 23.3%, significantly less efficacious than the 400-μg dose (odds ratio 95.3; 95% confidence interval 10.9, 830.9; P < .001). There was no significant difference among the 400-, 600-, and 800-μg groups (P = .364) with respect to achieving cervical dilation at least 8 mm. However, 800 μg was associated with significantly more side effects than 600 μg (preoperative and intraoperative blood loss, P < .001; abdominal pain, P = .005; products of conception at os, P < .001; fever higher than 38.0C, P = .002). When 400 μg and 600 μg were compared, we found that the higher dose also was associated with significantly more side effects. The 600-μg group was used twice in the comparison, but all P values remained significant even after the Bonferroni adjustment for multiple comparisons. Conclusion Vaginal application of 400 μg of misoprostol is the optimal dose for vacuum aspiration preabortion cervical dilation in first-trimester nulliparas. A dose of 400 μg is optimal for misoprostol preabortion cervical priming in first-trimester nulliparas.

Potential Acceptability of Ovulation Detection Kits and RU-486 at Two College Campuses

Two innovations in fertility research may expand birth control options in the United States. Ovulation detection kits, used alone or in conjunction with barrier methods of contraception, could be used to chart the fertile period. RU-486, when used in conjunction with a prostaglandin, induces early abortion, providing an alternative to conventional vacuum aspiration abortion. To measure the hypothetical acceptability of these methods, the authors surveyed 710 women at two college campuses in California regarding potential use of ovulation detection kits and RU-486. Seventy-one percent of the women in the final sample indicated an interest in using ovulation kits. Of these women, most (72%) were interested in using an ovulation detection kit as a supplement to barrier methods, and 22% indicated they would consider the kit as a sole method of birth control. More than 68% of the women in the sample indicated they would choose an abortion if faced with an unwanted pregnancy, and 60% would hypothetically choose RU-486 in preference to a conventional pregnancy termination. The most frequently cited reason for preferring RU-486 rather than conventional methods of abortion was to avoid the risks associated with the vacuum aspiration technique.

Human fetal neocortical tissue grafted to rat brain cavities survives, leads to reciprocal nerve fiber growth, and accumulates host IgG.

The human-to-rat xenograft approach offers possibilities to study aspects of primate cortex development and function without monkeys. Human fetal cortical tissue was grafted to prepared cortical cavities of immunosuppressed host rats. Fetal tissue fragments were collected after routine low-pressure vacuum aspiration abortions performed in the first trimester of gestation. Human derived neurons and human nerve fiber outgrowth were visualized by immunohistochemistry with antibodies against human neurofilament protein 70 kD (hNFP70). Ingrowth from rat host striatum or cortex into the grafts was analyzed by immunohistochemistry with antibodies against tyrosine hydroxylase. Astrocytes were evaluated by immunohistochemistry with antibodies against glial fibrillary acidic protein. The grafts grew into different sizes (1-10 mm in diameter) and contained large numbers of hNFP70-positive nerve fibers. All grafts gave rise to outgrowth of hNFP70-positive fibers into the host with partly a cortical layering; layers III and IV received a majority of the human fibers. In several cases, the graft-derived nerve fibers entered the host brain at restricted areas, while there was no crossing over of nerve fibers at the rest of the graft-host interface. Tyrosine hydroxylase-positive fibers were usually not abundant in the grafts. Interestingly, cases of massive ingrowth occurred from host striatum into the graft in a pattern suggesting "permissive sites" at the graft-host interface in the same way as outgrowth from graft to host was found. Additionally, tyrosine hydroxylase-immunoreactive fibers from host cortex were found to grow into the transplant. Glial fibrillary acidic protein immunoreactivity was increased at the interfaces between graft and host cortex or host striatum. Immunohistochemistry using antibodies against rat IgG indicated the presence of rat IgG within the grafts, and in bordering areas of host brain, possibly indicating a defective graft-host barrier. Taken together, these results show that human cortical tissue pieces grafted to cortical cavities of immunosuppressed rats survive grafting and develop, and that reciprocal nerve fiber growth between grafts and hosts occur. Human cortical neurons can grow into the rat host brain in a pattern which is partly determined by host cortical architecture.