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Dr DALEY: Ms B is a 17-year-old student and mother of a 3-year-old daughter who desires to avoid pregnancy. She lives in Boston with her mother and attends a high school program for students with children. Her health care insurance is through the Massachusetts Medicaid program. Ms B became sexually active at 12 years of age and presented to her primary care physician, Dr J, within 2 months of becoming sexually active requesting contraception. A combination oral contraceptive (norethindrone [1 mg] and ethinyl estradiol [35 μg]) was prescribed. At age 13, the patient became pregnant and had an uneventful pregnancy resulting in the birth of a healthy daughter. At the first postnatal visit, the patient reported being sexually active and was not using contraception. The same oral contraceptive was again prescribed, which the patient used for only 2 months. The patient was also treated for a cervical chlamydial infection. Depot

In Reply. —We thank Drs ter Riet and Kessels for attempting to explain the similar sample sizes we found in treatment and control groups. Unfortunately, their suggestion of widespread use of a form of restricted randomization does not shed any new light on our findings. In our original article, we stated, "The strong tendency for the comparison groups to be of equal or similar sizes may be explained by unreported use of (1) restriction, usually blocking...." That explanation includes the model postulated by ter Riet and Kessels, which is just one of many different forms of restriction. Ter Riet and Kessels observe that our "model does not reflect randomized trial conduct in practice." Indeed, that just restates our main argument. The authors of the 96 reports stated or (more usually) implied use of simple, unrestricted randomization. Thereby, they, not we, specified the form of the model used. Furthermore, our approach

Objective. —To assess the methodologic quality of approaches used to allocate participants to comparison groups in randomized controlled trials from one medical specialty. Design. —Survey of published, parallel group randomized controlled trials. Data Sources. —All 206 reports with allocation described as randomized from the 1990 and 1991 volumes of four journals of obstetrics and gynecology. Main Outcome Measures. —Direct and indirect measures of the adequacy of randomization and baseline comparisons. Results. —Only 32% of the reports described an adequate method for generating a sequence of random numbers, and only 23% contained information showing that steps had been taken to conceal assignment until the point of treatment allocation. A mere 9% described both sequence generation and allocation concealment. In reports of trials that had apparently used unrestricted randomization, the differences in sample sizes between treatment and control groups were much smaller than would be expected due to chance. In reports of trials in which hypothesis tests had been used to compare baseline characteristics, only 2% of reported test results were statistically significant, lower than the expected rate of 5%. Conclusions. —Proper randomization is required to generate unbiased comparison groups in controlled trials, yet the reports in these journals usually provided inadequate or unacceptable information on treatment allocation. Additional analyses suggest that nonrandom manipulation of comparison groups and selective reporting of baseline comparisons may have occurred. ( JAMA . 1994;272:125-128)

Ovarian cancer remains the deadliest gynecologic malignancy in the United States, killing more women each year than cervical and endometrial cancers combined. Despite aggressive operations and intensive chemotherapy, the 5-year survival rate is less than 40%. 1 Complications such as bowel obstruction, inanition, ascites, and pleural effusions can make this a wretched way to die. Hence, the finding of Hankinson et al 2 in this issue of JAMA is heartening: tubal sterilization may protect against this malignancy. See also p 2813. The Nurses' Health Study is not the first to observe this protection. 3-5 The importance of this research, however, stems from its design: a large, prospective cohort study. Cohort studies avoid some of the vexing problems of case-control studies, such as selection of an appropriate control group. Ascertainment bias is unlikely to have accounted for these results. The respondents were knowledgeable health professionals, and medical records confirmed reported illness. While

In Reply. —I reported in my Commentary 1 the "absence of any randomized controlled trials showing this operation [LAVH] is preferable to standard vaginal hysterectomy." Indeed, the only published randomized controlled trial 2 found that the new operation increased postoperative pain, lengthened the operating time by an hour, and added over $3000 to the costs of the operation compared with standard vaginal hysterectomy. I am unaware of any published randomized controlled trials comparing LAVH with standard abdominal hysterectomy. Until these are done, claims of "great benefit to the patient" from the new operation seem premature. Having performed laparoscopy for 20 years, I agree with Dr Dorsey that laparoscopy has made important contributions to gynecology. However, I urge that new uses for laparoscopy, like other technologies, be critically evaluated to determine what its appropriate role should be. 3 Decisions about surgical treatments should be based on science, not on marketing or

To assess the risk for pelvic inflammatory disease (PID), a practitioner must evaluate the likelihood that a woman has PID or will be exposed to a sexually transmitted disease causing PID. Successful risk assessment depends on accurate information about variables influencing risk of PID. To determine the current state of knowledge about PID risk variables, we examined data in published reports. Data on each risk variable were scrutinized to discern which link(s) in the PID risk chain it affects (acquisition of a sexually transmitted disease, development of PID, or development of PID sequelae) and whether it is a risk marker or a risk factor. Most PID risk variables, particularly sexual behaviors, are associated with acquisition of a sexually transmitted disease, rather than development of PID itself. With the exception of age, demographic and social indicators of risk appear to be risk markers, while contraceptive practices appear more often to be risk factors than risk markers. Additional data are needed for most PID risk variables confidently to categorize them as risk factors. Enough information is available, however, to begin assessing risk for PID, so that appropriate counseling can ensue and timely diagnosis can be made. ( JAMA . 1991;266:2581-2586)

To the Editor.— Worldwide, approximately 5000 children have been born as the result of in vitro fertilization (IVF). In the United States alone, there are about 1 million cases of pelvic inflammatory disease each year. If we assume that 130 000 to 500 000 of these cases lead to tubal occlusion, 1 then in the United States alone in one month or less, pelvic inflammatory disease creates more new cases of infertility than have been successfully treated by all IVF programs in the world since Louise Brown was born in 1978. Recently, it has been demonstrated that use of condoms and spermicides reduces the risk of acquiring chlamydial infections and other sexually transmitted diseases and reduces the risk of infertility. 2,3 In a relatively short span of time, the active promotion of the use of condoms and spermicides to those at risk of tubal disease could prevent more cases of infertility than IVF

Little is known about maternal deaths after spontaneous abortion. We studied 122 such deaths reported to the Centers for Disease Control from 1972 through 1980; 21 were intrauterine (contraceptive) device related. The number of non-IUD-related deaths decreased from 15 in 1972 to six in 1980; the mortality ratio (deaths per million live births) decreased from 4.6 in 1972 to 1.7 in 1980. Non-IUD-related deaths were results of infection (48%), hemorrhage (21%), embolism (11%), and other causes (20%). Risk factors for these deaths were age over 29 years, being of minority race, and unmarried status. Most deaths (58%) occurred between 12 and 19 weeks' gestation. The risk of death was much higher for abortion in the second trimester than in the first. Deaths following spontaneous abortion, although rare, do occur; older, black, and unmarried women are at higher risk. (JAMA1985;253:3119-3123)

In Reply.— Dr Iffy's continued concerns about the effects of induced abortion, particularly DE he also selectively references those American studies that he believes support his contentions. In the interest of space, we refer the reader to a recent review article 4 that synthesized all the available data on the effects of induced abortion on reproductive function. It comes to a conclusion different from Dr Iffy's. His assessment of the influence of follow-up information on the rate of abortion complications is erroneous. Women who suffer complications after legally induced abortion are more (not less) likely than women without any complications to notify the facility performing

EACH DAY, tens of millions of Americans swallow a pill, slide in a diaphragm, or slip on a condom to prevent unwanted pregnancies. These strategies are working, although not as well as they could. While rates of unwanted pregnancies have declined dramatically in recent years,1nonuse or inconsistent use of contraception, especially among sexually active teenagers,2persists. In general, fear of complications, not the complications themselves, is the most powerful deterrent to contraception.3Much of this fear is unwarranted, fueled in part by inaccurate or incomplete media coverage.4Although no new contraceptive chemical has been introduced in the United States since 1968,5the safety and acceptability of existing contraceptive methods have improved greatly. In this review, I will provide a brief clinical update on reversible contraception, including current use of contraception, the efficacy of various methods, the safety of these methods, and a brief overview

The growing number of couples seeking to adopt may have outstripped the number of babies in the United States available for adoption. Although increased availability and use of abortion have resulted in fewer single women continuing their pregnancies, the increased tendency of unmarried mothers to raise rather than relinquish their children has, in particular, limited the number of babies available for adoption. Despite the unpopularity of adoption among women with unintended pregnancies, addressing this option remains an important part of pregnancy counseling. Appropriate obstetric care of women placing their babies for adoption includes acknowledgment of the loss these women experience. Knowledge of adoption resources and willingness to discuss adoption can help physicians provide better care of unintentionally pregnant as well as infertile patients. ( JAMA 1987;258:3537-3541)

In Reply.— We appreciate the opportunity to respond the questions posed in Dr Myers' letter. Mention of "postcoital disinfection" among males was intentionally omitted from our review of local measures because we could find no controlled studies of efficacy. Supervised application of local germicides for personal use were widespread during wartime. The efficacy of these measures was inferred from subsequent dramatic declines in rates of sexually transmitted diseases. 1 However, the mandatory punishment for acquisition of these diseases (court martial) probably resulted in dramatic declines in reporting. In the early 1900s, any "enthusiastic endorsement" by the medical profession for local preventive methods probably resulted from the alarming lack of antibiotic cures for gonorrhea and syphilis rather than from the inherent efficacy of the methods. Although in vitro germicidal qualities of spermicides were described decades ago, in vivo efficacy has been studied only recently. The first report of clinical efficacy was

To the Editor.— Pronouncements of the Centers for Disease Control (CDC) concerning prevention of the acquired immunodeficiency syndrome (AIDS) carry great weight, yet the CDC's selective silence on this issue may be even more noteworthy. Since the beginning of the AIDS epidemic, the CDC has been silent about induced abortion as an option for women infected with the human immunodeficiency virus (HIV). The CDC acknowledges that perinatal transmission is one of only three known modes of transmission and it advises that HIV-infected women not conceive. 1 But what of the growing numbers 1,2 who do become pregnant? The CDC's avoidance of this issue has been persistent. The 1985 CDC committee assembled to develop guidelines to prevent perinatal transmission of AIDS concurred that the option of abortion should be discussed with HIV-infected pregnant women. This language was deleted from the final institutional report. 2 More recent reports on prevention of AIDS

In Reply.— The Lanskas and Dr Rimm suggest that because cesarean delivery is more hazardous for women than vaginal delivery, 1 "maternal mortality caused by abortion should be compared with both vaginal delivery and cesarean delivery separately." Precise national data required to calculate these rates are unavailable; nevertheless, existing data 2 do not support the hypothesis that 90% of all maternal deaths are related to cesarean delivery. Moreover, the suggested comparison would not be clinically useful. Approximately 16% 3 of women in the United States who give birth do so by cesarean delivery; a pregnant woman choosing between abortion and childbirth usually cannot predict which type of delivery she will have. A woman who chooses to carry her pregnancy to delivery is subject to the risks inherent in the process, regardless of their source. Hence, the appropriate comparison is between the mortality rate associated with all methods of abortion and

In Reply.— Dr Dolan's letter questions our conclusions regarding the relative safety of legal abortion in the United States by citing references from England and Eastern Europe that describe high rates of early and late complications. Extrapolating rates from foreign studies to this country can be misleading. The majority of published reports from the United States on the early medical complications from legal abortion 1-4 have described much lower rates of total and major complications than have the reports of Dr Stallworthy and his associates in England. 5 Moreover, the issue of late sequelae after legally induced abortion is unresolved. To date, no studies on long-term complications have been reported from the United States. However, in contrast to those studies cited by Dr Dolan, other well-controlled studies in the Far East and Eastern Europe have found no adverse effects on reproductive function for women who had previous induced abortions. 6-8

In Reply. —Dr Gunn's Letter diverts attention from the CDC's suppression of abortion information by raising two specious issues. First, he argues that no "committee" was assembled in 1985 to develop guidelines. While he is correct that the group of consultants assembled in Atlanta in October 1985 did not constitute a "committee" (a semantic nuance that is lost on those who are unfamiliar with the bureaucracy), a CDC committee was already at work by the time Dr Gunn became involved (memorandum, Richard M. Selick, MD, to James A. Curran, MD, Oct 3, 1985). Then a commissioned officer at the CDC, I was involved with both the committee and the consultants. Second, Dr Gunn alleges that there was vigorous objection to the mention of elective abortion. Louise B. Tyrer, MD, a representative from the Planned Parenthood Federation of America, recommended that HIV-infected pregnant women be counseled about the option of abortion.

Although uterine perforation is a potentially life-threatening complication of curettage abortion, little is known about the risk factors associated with uterine perforation or how to prevent it. Using linear logistic regression, we analyzed 67,175 curettage abortions performed at 13 institutions in the United States from 1975 through 1978. The overall incidence of confirmed perforation was 0.9 per 1,000 abortions. Performance of the abortion by a resident rather than by an attending physician was a powerful risk factor for perforation (relative risk, 5.5; 95% confidence interval, 3.3 to 9.2). Use of Laminaria for dilation had a protective effect, although this effect was not statistically significant (relative risk, 0.17; 95% confidence interval, 0.02 to 1.2). Among factors beyond the control of the physician, advancement of gestational age and previous delivery were significant risk factors. Use of Laminaria and performance of the abortion by an attending physician considerably lowered the risk of uterine perforation.

Two recent reports have suggested that wormlike structures characteristic of helminths are associated with preeclampsia. We identified these vermiform structures in toluidine blue O-stained venous blood smears from four women with preeclampsia, cord blood taken at delivery of three of their neonates, and venous blood from five control subjects without preeclampsia and from five healthy beagle dogs. The structures, which had diameters between 30 and 670 μm, could not be concentrated by passing the blood through a 12-μm filter, yet they could be demonstrated in stained smears prepared from blood that had been filtered. We conclude that these structures are not helminths; they are most likely artifacts of staining. (JAMA1983;250:2970-2972)

In Reply. —"A Physician's Guide to Adoption" was not intended to be exhaustive. As indicated by the article's introduction, we focused on those components of adoption that are most relevant to physicians who care for women with unintended pregnancies and for infertile couples. References cited in our article, particularly the Adoption Fact-book , 1 cover many facets of adoption that we did not address. If our article stimulates others to expand the medical literature on adoption, we would be delighted.