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From 2015 to 2018, the Ethiopian Society of Obstetricians & Gynecologists (ESOG), the American College of Obstetricians and Gynecologists, the Ethiopian Federal Ministry of Health, and the Center for International Reproductive Health Training at the University of Michigan collaborated to define and execute the goals of ESOG to enhance education, research, publishing, and clinical care in Ethiopia. We outline the processes used to define and execute these goals, accomplishments toward achieving them, and key lessons learned.

To assess the ectopic pregnancy risk among women who conceived with assisted reproductive technology (ART) procedures.The ectopic rate for ART pregnancies was calculated from population-based data of pregnancies conceived with ART in U.S. clinics in 1999-2001. Variation in ectopic risk by patient and ART treatment factors was assessed by using bivariate analyses and multivariable logistic regression.Of 94,118 ART pregnancies, 2,009 (2.1%) were ectopic. Variation was observed by procedure type. In comparison with the ectopic rate (2.2%) among pregnancies conceived with in vitro fertilization and transcervical transfer of freshly fertilized embryos from the patient's oocytes (fresh, nondonor IVF-ET), the ectopic rate was significantly increased when zygote intrafallopian transfer (ZIFT) was used (3.6%) and significantly decreased when donor oocytes were used (1.4%) or when a gestational surrogate carried the pregnancy (0.9%). Among fresh nondonor IVF-ET procedures, the risk for ectopic pregnancy was increased among women with tubal factor infertility (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.7-2.4; referent group = ART for male factor), endometriosis (OR 1.3, 95% CI 1.0-1.6), and other nontubal female factors of infertility (OR 1.4, 95% CI 1.2-1.6) and decreased among women with a previous live birth (OR 0.6, 95% CI 0.5-0.7). Transfer of embryos with an indication of high implantation potential was associated with a decreased ectopic risk when 2 or fewer embryos were transferred (OR 0.7, 95% CI 0.5-0.9), but not when 3 or more embryos were transferred.Ectopic risk among ART pregnancies varied according to ART procedure type, reproductive health characteristics of the woman carrying the pregnancy, and estimated embryo implantation potential.II-2.

To review evidence on the combined hormonal patch, combined hormonal vaginal ring and the etonogestrel implant, with a focus on safety and effectiveness of use among women with special health conditions, we searched MEDLINE, Pre-MEDLINE and the Cochrane Library for reports published from 1980 through March 2005. Articles eligible for review included 11 on the hormonal patch, nine on the hormonal ring, and 11 on the etonogestrel implant. Limited evidence suggests patch efficacy is lower among women >90 kg. No evidence was identified for vaginal ring use among women with medical conditions. A single small study found that etonogestrel implants had no adverse effects on bone mineral density among women 18–40 years old. Limited evidence also suggests no adverse effects of the etonogestrel implant on lactation parameters or infant development among users enrolled 28 to 56 days postpartum and followed for 4 months.

This systematic review examines evidence regarding when during the menstrual cycle a woman can initiate combined oral contraceptive (COC) use and what can be done if a woman misses COCs. We searched the MEDLINE and EMBASE databases for articles published from 1966 to March 2005 related to COC initiation and to the effects of late or missed COCs. We identified 11 studies related to COC initiation and 25 studies related to the effects of missed pills. Evidence from these studies suggested that taking hormonally active pills for 7 consecutive days prevents normal ovulation and that initiating COCs through Day 5 of the menstrual cycle suppresses follicular activity. Studies on the effects of missed COCs generally showed that the risk of ovulation is greatest when the pill-free interval lasts >7 days. Limitations of this body of evidence include small sample sizes that may not reflect variation in larger populations, lack of a standard measurement of ovulation and difficulty in discerning how ovulation resulting from late or missed COCs corresponds to the risk of conception.

Our objective in this systematic review was to evaluate evidence regarding controversial issues in the clinical management of women using injectable and implantable contraceptives. We searched MEDLINE and EMBASE for reports of primary research, published from 1966 through April 2005 in peer-reviewed journals, related to the initiation of combined or progestogen-only injectables and contraceptive implants, the effects of late contraceptive injections or the duration of levonorgestrel implant effectiveness. Results of the studies we reviewed showed that initiating injectable and implantable contraceptives through day 7 of the menstrual cycle suppresses follicular activity. Time to ovulation after study participants discontinued using injectables varied widely: from 4 to 8 weeks after the last administration of combined injectables, from 15 to 49 weeks after the last injection of depot medroxyprogesterone acetate and from 5 to 19 weeks after the last injection of norethisterone enanthate. Norplant implants left in place for up to seven completed years remained effective among women who weighed

A healthy, multiparous 23-year-old woman requests advice about contraception. Her last child was conceived while she was using oral contraceptives, which she took irregularly. She wants no more children and desires a highly effective and long-acting method of contraception. She is sexually active in a monogamous relationship and had been treated for gonococcal cervicitis at the age of 16 years. She has normal menses. Findings on pelvic examination are normal. What contraceptive methods are appropriate for her?.

Objective To examine rates and risk factors for spontaneous abortion among pregnancies conceived using assisted reproductive technology (ART). Methods Subjects were 62,228 clinical pregnancies resulting from ART procedures initiated in 1996–1998 in US clinics. Spontaneous abortion was based on ART clinic report and was defined as loss of the entire pregnancy. Spontaneous abortion rates for ART pregnancies were compared with spontaneous abortion rates from the National Survey of Family Growth, a population-based survey of US women 15–44 years. Results The spontaneous abortion rate among ART pregnancies was 14.7%. This was similar to rates among pregnancies reported in the National Survey of Family Growth. Among pregnancies conceived with the patient’s oocytes and freshly fertilized embryos, the spontaneous abortion risk ranged from 10.1% among women 20–29 years to 39.3% among women older than 43. Spontaneous abortion risk among pregnancies conceived with donor eggs was 13.1% with little variation by patient age. Spontaneous abortion risk was increased for pregnancies conceived with frozen and thawed embryos and decreased among multiple-gestation pregnancies. Spontaneous abortion risk was increased among women reporting previous spontaneous abortions and ART attempts, and among women who used clomiphene or zygote intrafallopian transfer. Pregnancies conceived by young women, but gestated by a surrogate, were at increased risk for spontaneous abortion in comparison with young women who gestated their own pregnancies. Conclusion These findings suggest that ART does not pose a risk for spontaneous abortion. Factors related to oocyte or embryo quality are of primary importance in assessing spontaneous abortion risk.

The objective of this study is to determine if interval tubal sterilization leads to a change in female sexual interest or pleasure and to identify predictors of a positive or negative effect. The study population comprised 4576 women enrolled in a prospective multicenter cohort study between 1978 and 1983. Potential demographic clinical and surgical predictors of sexual outcome were tested for significant variation from the overall pattern of unchanged increased and decreased sexual interest and pleasure. Over 80% of the 4576 study women reported no consistent change in either sexual interest (80.0%) or pleasure (81.7%) after interval tubal sterilization. Among women with consistent change positive effects were reported 10 and 15 times more often than negative effects for sexual interest and pleasure respectively. All subgroups of women except for those with post-sterilization regret were significantly (P < 0.05) more likely to experience increased rather than decreased interest or pleasure. Women with post-sterilization regret were the subgroup most likely to have a negative effect; in multivariate analyses post-sterilization regret was the only factor to be a predictor for decreased interest (odds ratio 4.0) and decreased pleasure (odds ratio 5.1). Similarly women reporting regret were significantly less likely to report increased interest or pleasure. Whether the regret or the decreased sexual interest or pleasure occurred first is unclear. Interval tubal ligation is unlikely to result in changed sexual interest or pleasure. Among these with change the majority experienced positive sexual effects. (authors)

OBJECTIVE: To compare the 5-year cumulative probability of regret and risk factors for regret among women whose husbands underwent vasectomy with women after tubal sterilization. METHODS: A total of 525 women whose husbands underwent vasectomy were compared with 3672 women who underwent tubal sterilization in a prospective, multicenter, cohort study. RESULTS: The cumulative probability of a woman expressing regret within 5 years after her husband’s vasectomy was 6.1% (95% confidence interval [CI] 3.6, 8.6), which was similar to the 5-year cumulative probability of regret among women after tubal sterilization (7.0%, 95% CI 5.8, 8.1). Women who reported substantial conflict with their husbands before vasectomy were more than 25 times more likely to request that their husband have a reversal than women who did not report such conflict (rate ratio 25.3, 95% CI 2.9, 217.2). Similarly, women who reported substantial conflict with their husbands or partners before tubal sterilization were more then three times as likely to regret their decision and more than five times as likely to request a reversal than women who did not report such conflict (rate ratio 3.1, 95% CI 1.4, 7.0, and rate ratio 5.4, 95% CI 1.6, 17.6, respectively). CONCLUSION: Most women did not express regret after their husband’s vasectomy and the probability of regret was similar to sterilized women. However, when there was substantial conflict between a woman and her husband before vasectomy or tubal sterilization, the probability of subsequent request for reversal was increased.

OBJECTIVE: To review new evidence regarding ten controversial issues in the use of contraceptive methods among women with special conditions and to present World Health Organization recommendations derived in part from this evidence. DATA SOURCES: We searched MEDLINE and PREMEDLINE databases for English-language articles, published between January 1995 and December 2001, for evidence relevant to ten key contraceptive method and condition combinations: combined oral contraceptive (OC) use among women with hypertension or headaches, combined OC use for emergency contraception and adverse events, progestogen-only contraception use among young women and among breast-feeding women, tubal sterilization among young women, hormonal contraception and intrauterine device use among women who are human immunodeficiency virus (HIV) positive, have AIDS, or are at high risk of HIV infection. Search terms included: “contraception,” “contraceptives, oral,” “progestational hormones,” “medroxyprogesterone-17 acetate,” “norethindrone,” “levonorgestrel,” “Norplant,” “contraceptives, postcoital,” “sterilization, tubal,” “intrauterine devices,” “hypertension,” “stroke,” “myocardial infarction,” “thrombosis,” “headache,” “migraine,” “adverse effects,” “bone mineral density,” “breast-feeding,” “lactation,” “age factors,” “regret,” and “HIV.” STUDY SELECTION: From 205 articles, we identified 33 studies published in peer-reviewed journals that specifically examined risks of contraceptive use among women with pre-existing conditions. TABULATION, INTEGRATION, AND RESULTS: Combined OC users with hypertension appear to be at increased risk of myocardial infarction and stroke relative to users without hypertension. Combined OC users with migraine appear to be at increased risk of stroke relative to nonusers with migraine. The evidence for the other eight method and condition combinations was either insufficient to draw conclusions or identified no excess risk. CONCLUSION: Of ten contraceptive method and condition combinations assessed, the evidence supported an increased risk of cardiovascular complications with combined OC use by women with hypertension or migraine. As new evidence becomes available, assessment of risk and recommendations for use of contraceptive methods can be revised accordingly.

Background The existence of a post–tubal-ligation syndrome of menstrual abnormalities has been debated for decades. We used data from the U.S. Collaborative Review of Sterilization to determine whether the likelihood of persistent menstrual abnormalities was greater among women who had undergone tubal sterilization than among women who had not. Methods A total of 9514 women who underwent tubal sterilization and 573 women whose partners underwent vasectomy were followed in a multicenter, prospective cohort study for up to five years by means of annual telephone interviews. All women were asked the same questions about six characteristics of their menstrual cycles in the presterilization and follow-up interviews. Multiple logistic-regression analysis was used to assess the risk of persistent menstrual changes. Results The women who had undergone sterilization were no more likely than those who had not undergone the procedure to report persistent changes in intermenstrual bleeding or the length of the menstr...

Objective: To examine the association between assisted hatching and monozygotic (MZ) twinning. Design: Case-control. Setting: Population-based sample of IVF-ET cycles initiated in U.S. clinics, 1996. Patient(s): The IVF-ET (n = 35,503) cycles and 11,247 resultant pregnancies. Intervention(s): Use of an assisted hatching procedure on embryos transferred. Main Outcome Measure(s): Cases were pregnancies for which number of fetal hearts observed on ultrasound exceeded number of embryos transferred. These pregnancies were considered to contain at least one MZ set of twins. Cases were compared with two control groups: other multiple-gestation pregnancies (≥2 fetal hearts but number of fetal hearts ≤ number of embryos transferred); and singleton pregnancies (1 fetal heart). Result(s): Women with a case pregnancy were more likely to have received embryos treated with assisted hatching procedures than were women in either control group. After adjustment for patient age, number of embryos transferred, prior cycles, infertility diagnosis, intracytoplasmic sperm injection, and whether embryos from the current cycle were cryopreserved for later use, odds ratios and 95% CIs for use of assisted hatching were 3.2 (1.2–8.0), compared with other multiple-gestation pregnancies, and 3.8 (1.8–9.8), compared with singleton pregnancies. Conclusion(s): Assisted hatching may pose a risk for MZ twinning.

Objective: To examine cigarette smoking as a risk factor for different types of epithelial ovarian cancer. Methods: We used data from the Cancer and Steroid Hormone Study, a multicenter, population-based, case control investigation. Cases were 447 women aged 20–54 years with diagnoses of epithelial ovarian cancer. Controls were 3868 women selected by random-digit dialing. Conditional logistic regression was used to obtain odds ratios (ORs) and 95% confidence intervals (CIs) as estimators of the relative risk of ovarian cancer. With age and study site as conditioning variables, OR point estimates were additionally adjusted for parity and use of oral contraceptives. Results: The OR of mucinous epithelial ovarian cancer for women who had ever smoked was 2.3 (95% CI 1.4, 3.9) and for current smokers was 2.9 (95% CI 1.7, 4.9). The OR of mucinous tumors for current smokers was significantly elevated regardless of years since first cigarette or age at which women first smoked. The OR of mucinous tumors for current smokers increased slightly as cumulative pack-years of smoking increased, although the trend was not significant. Similar patterns of elevated risk were not observed among serous, endometrioid, or other histologic types. Odds ratio point estimates for former smokers were not significantly elevated for any histologic type. Conclusion: Current cigarette smoking was a risk factor for mucinous epithelial ovarian cancer, but not other histologic types.

Objective: To determine risk factors for pregnancy after tubal sterilization with bipolar electrocoagulation. Methods: A total of 2267 women who had bipolar electrocoagulation were followed for up to 8 to 14 years as part of a multicenter, prospective, cohort study conducted in medical centers in nine United States cities. We used proportional hazards analysis and cumulative life-table probabilities to assess pregnancy risk in these women. Results: The 5-year cumulative probability of pregnancy for women sterilized in 1978–1982 was 19.5 per 1000 procedures (95% confidence interval [CI], 12.2, 26.9); the comparable probability for women sterilized in 1985–1987 was significantly lower, 6.3 per 1000 procedures (95% CI, 0.0, 13.5) (one-tailed P = .01). Women enrolled in 1985–1987 who had fewer than three sites of coagulation had a probability of failure of 12.9 per 1000 procedures (95% CI, 0.0, 38.0); by contrast, women who had three or more sites coagulated had a probability of failure of 3.2 per 1000 procedures (95% CI, 0.0, 9.6) (one-tailed P = .01). Conclusion: The long-term probability of pregnancy after tubal sterilization with bipolar coagulation was very low when three or more sites of the fallopian tube were coagulated. Bipolar coagulating systems can be highly effective for sterilization when the fallopian tube is coagulated adequately.

Objective: To evaluate the cumulative probability of regret after tubal sterilization, and to identify risk factors for regret that are identifiable before sterilization. Methods: We used a prospective, multicenter cohort study to evaluate the cumulative probability of regret within 14 years after tubal sterilization. Participants included 11,232 women aged 18–44 years who had tubal sterilizations between 1978 and 1987. Actuarial life tables and Cox proportional hazards models were used to identify those groups at greatest risk of experiencing regret. Results: The cumulative probability of expressing regret during a follow-up interview within 14 years after tubal sterilization was 20.3% for women aged 30 or younger at the time of sterilization and 5.9% for women over age 30 at sterilization (adjusted relative risk [RR] 1.9; 95% confidence interval [CI] 1.6, 2.3). For the former group, the cumulative probability of regret was similar for women sterilized during the postpartum period (after cesarean, 20.3%, 95% CI 14.5, 26.0; after vaginal delivery, 23.7%, 95% CI 17.6, 29.8) and for women sterilized within 1 year after the birth of their youngest child (22.3%, 95% CI 16.4, 28.2). For women aged 30 or younger at sterilization, the cumulative probability of regret decreased as time since the birth of the youngest child increased (2–3 years, 16.2%, 95% CI 11.4, 21.0; 4–7 years, 11.3%, 95% CI 7.8, 14.8; 8 or more years, 8.3%, 95% CI 5.1, 11.4) and was lowest among women who had no previous births (6.3%, 95% CI 3.1, 9.4). Conclusion: Although most women expressed no regret after tubal sterilization, women 30 years of age and younger at the time of sterilization had an increased probability of expressing regret during follow-up interviews within 14 years after the procedure. (Obstet Gynecol 1999;93:889–95.)

Objective: To compare the risk of hysterectomy among previously sterilized women and women whose husbands had undergone vasectomy, and to evaluate whether this risk differed by age at surgical procedure or by method of tubal occlusion. Methods: Our study population comprised 7718 women enrolled in a prospective, multicenter cohort study between 1978 and 1986. After stratifying by the woman’s age at surgical procedure, we used the life-table approach and adjusted hazards ratios to examine whether the relative risk of hysterectomy during the 5 years after enrollment differed between the 7174 women who had been sterilized and the 544 women whose husbands had undergone vasectomy. Results: The 5-year cumulative probability of hysterectomy was 8% among the previously sterilized women and 2% among the women whose husbands had undergone vasectomy. Among women 34 years of age and younger at enrollment, sterilized women were 4.4 times as likely to have a hysterectomy as women whose husbands had undergone vasectomy (95% confidence interval [CI] 1.9, 10.0). Findings were similar for women 35 years of age and older (rate ratio = 4.6; 95% CI 1.4, 14.5). Each of the six most commonly used methods of tubal occlusion was associated with an increased risk of hysterectomy. Conclusion: Women undergoing tubal sterilization were more likely than women whose husbands underwent vasectomy to undergo hysterectomy within 5 years after sterilization, regardless of age at sterilization. An increased risk of hysterectomy was observed for each method of tubal occlusion.

The Center for Disease Control and Prevention (CDC) the premier agency in the United States for health promotion and disease prevention is set to release the United States Selected Practice Recommendations for Contraceptive Use (US SPR). The US SPR will directly assist family planning clinicians in helping clients to both choose and use their contraceptive methods successfully. Moreover it provides clear evidence-based recommendations in three general categories: (a) initiation of contraceptive methods; (b) follow up conditions to routinely check; and (c) management of problems during method use. Additional guidance is also provided on the topics of emergency contraception use of the standard days method male and female sterilization and contraceptive use among women over age 44. The global community has seen the encouraging growth of longer-acting contraceptive methods especially implants and intrauterine devices which are not dependent on daily- or coital-related adherence. As such these methods are much more effective under typical use conditions than other contraceptives in preventing unintended pregnancy. Managing modern contraceptive choices has become a clinical subspecialty of its own and more than ever providers need synthetic access to the evidence base upon which their practice depends. The US SPR answers this need and provides detailed guidance regarding safe and effective use of these methods. Copyright © 2013 Elsevier Inc. All rights reserved.

OBJECTIVE: Our purpose was to determine the risk of pregnancy after tubal sterilization for common methods of tubal occlusion. STUDY DESIGN: A multicenter, prospective cohort study was conducted in U.S. medical centers. A total of 10,685 women who underwent tubal sterilization was followed up for 8 to 14 years. The risk of pregnancy was assessed by cumulative life-table probabilities and proportional hazards models. RESULTS: A total of 143 sterilization failures was identified. Cumulative 10-year probabilities of pregnancy were highest after clip sterilization (36.5/1000 procedures) and lowest after unipolar coagulation (7.5/1000) and postpartum partial salpingectomy (7.5/1000). The cumulative risk of pregnancy was highest among women sterilized at a young age with bipolar coagulation (54.3/1000) and clip application (52.1/1000). CONCLUSIONS: Although tubal sterilization is highly effective, the risk of sterilization failure is higher than generally reported. The risk persists for years after the procedure and varies by method of tubal occlusion and age. (AM J OBSTET GYNECOL 1996;174:1161-70.)

Our objective was to examine trends in the use of bilateral oophorectomy in the United States from 1965 to 1990 by age, race, and indication. The National Hospital Discharge Survey data se...

Background Nearly all studies have suggested that the use of oral contraceptives (OC) is not associated with the aggregate risk of breast cancer diagnosed in women aged 20-54 years. Because of age-specific differences in the breast cancer-parity relationship and because of age-specific differences in other breast cancer risk factors, the Centers for Disease Control reexamined data from the Cancer and Steroid Hormone Study (CASH) to assess whether OC use has different effects on the risk of breast cancer at different ages of diagnosis. Methods This population-based case-control study was designed to examine the relationship between the use of OC and the risk of breast, ovarian, and endometrial cancer. CASH was conducted in eight geographic areas in the United States during 1980-1982. All participants were interviewed at home with a pretested standardized questionnaire including a calendar of life events and a photograph book of all pills marketed in the United States. Results We found that the relationship between the risk of breast cancer and OC use appeared to vary by the age at diagnosis. Among women aged 20-34 years at diagnosis or interview, those who had ever used OC had a slightly increased risk of breast cancer (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.0-2.1) compared with women of the same ages who had never used OC. Among these women, there were no trends of increasing or decreasing risk with any measure of OC use. Among women aged 35-44 years, there was no association between OC use and breast cancer. Among women aged 45-54 years, those who used OC had a slightly decreased risk of breast cancer (OR, 0.9; 95% CI, 0.8-1.0). Among these women, risk estimates decreased significantly with increasing time since first and last use. Conclusions Although the slightly increased risk estimates for the youngest women were compatible with findings by other investigators, the decreased risk estimates for the oldest women have not been described in as many studies. Available data provide no reasons to change prescribing practices or the use of OC that are related to the breast cancer risk.

Selected issues in data analysis in the Collaborative Review of Sterilization (CREST) a multicenter prospective observational study of women undergoing tubal sterilization were examined. Menstrual function after sterilization was analyzed in 5068 women at baseline who were enrolled in the period 1978-83 and followed for 5 years with yearly interviews. 4716 had follow-up information 1 year after TS. The generalized estimating equations (GEE) approach to longitudinal data analysis was used. The main response variables wee the presence or absence of menstrual dysfunction indicators: severe pain heavy bleeding intermenstrual spotting and irregularity of cycle. Covariates included in the model were: year of observation method of tubal sterilization race age at time of sterilization Quetelets index education gravidity history of surgery observed pathology at time of surgery and method of contraception most often used during the month before tubal sterilization (TS). The prevalence of menstrual dysfunction before TS compared with after TS and estimation of post-TS rates of menstrual dysfunction given a womans menstrual function at baseline (before TS) were explored. The response rates for the 2nd 3rd 4th and 5th years were 89 84 17 and 72%. The models refitted with imputed values showed the same trends as the original models. At baseline and 1 year after TS 59% of women had some form of menstrual dysfunction. This figure dropped to 57% for the next 2 years and then increased to 67% by the 4th and 5th year. The adjusted rates of menstrual dysfunction at the 5th year were higher than at baseline; this was similar to the pattern among adjusted rates that was similar to the pattern of crude marginal and transitional probabilities. Marginal modelling resulted in a statistically significant increase in the odds of menstrual dysfunction at 5 years after tubal sterilization.

More than 10 million women in the United States have undergone tubal sterilization. There has been concern that this procedure may increase the risk of later menstrual dysfunction. The Collaborative Review of Sterilization (CREST) is a large, multicenter, prospective study of tubal sterilization in the United States. This report describes CREST participants who were interviewed immediately before sterilization and again in annual poststerilization interviews for up to 5 years between 1978 and 1988. The authors analyzed reported changes in six menstrual cycle characteristics for 5,070 women undergoing interval sterilizations. Longitudinal, multivariate regression was used to adjust for baseline menstrual function and other potential confounders. Five years after sterilization, 35% of the CREST participants reported high levels of menstrual pain, 49% reported heavy or very heavy menstrual flow, and 10% reported spotting between periods. In contrast to the fifth year, the first year of follow-up was similar to presterilization menstrual function; in the first year, 27% of participants reported high menstrual pain, 41% reported heavy menstrual flow, and 7% reported spotting. These findings may be affected by aging of the cohort and other study limitations, but they suggest that if tubal sterilization leads to changes in menstrual function, such changes may take some time to develop.Over 100 Million women worldwide have undergone tubal sterilization. The Collaborative Review of Sterilization (CREST) study at 12 medical centers in the US between 1978-83 examined 5070 women at 4 periodic intervals up to 5 years after the procedure. The purpose was to ascertain whether there were any changes in 6 menstrual cycle characteristics. Several different sterilization methods were examined: unipolar coagulation, bipolar coagulation, silastic band application, spring clips application, partial salpingectomy, and thermocoagulation. Other baseline characteristics which might affect changes in menstrual function over time were examined, i.e., race, body mass index, education, age, gravidity, history of pelvic pathology and pelvic surgery, method contraception immediately preceding sterilization, and incidental pelvic pathology during the sterilization. The presurgery interview included information on baseline menstrual function. The findings from multivariate analysis with unadjusted data showed changes at 5 years but not 2, including increases in menstrual pain, amount of bleeding, and intermenstrual spotting in an amount 1.3-1.8 times greater than those reporting in year 2. There were significant decreases in days/cycle and days of bleeding/cycle for the most women reporting changes. Sterilization method analysis revealed differences between methods for days/cycle, amount of bleeding, menstrual pain, irregularity, and spotting. 33% of women with the spring clip procedure reported increases in menstrual pain. The adjusted model, showed statistically significant differences in cycle length in the 5th year vs. the 1st year, as well as increases in menstrual pain, amount of bleeding, and spotting. Women with the longest cycle lengths in the adjusted analysis used the unipolar coagulation method, and the shortest cycle lengths, the spring clip. Those with the spring clip were also more likely to have menstrual pain and greater bleeding. Black women reported less irregularity and spotting and fewer days of bleeding. Older age at sterilization was related to less pain and greater regularity. The changes in bleeding pattern and menstrual pain are of greatest concern and the most frequently reported in other studies of effects of sterilization. Tissue destruction was found not to be related. Caution is urged in the interpretation of findings. Future research should focus on follow up after 5 years and comparisons with nonsterilized women.

Several hypotheses predict that tubal sterilization and hysterectomy may influence a woman's risk of developing ovarian cancer. To examine the relation between these surgeries and epithelial ovarian cancer, the authors analyzed data from the Cancer and Steroid Hormone Study, a case-control study of women aged 20-54 years. Eight population-based cancer registries in the United States identified women with newly diagnosed epithelial ovarian cancer during 1980-1982 (n = 494). A comparison sample of female residents of these eight areas (n = 4,238) was identified through random digit dialing. Women who had had tubal sterilization (relative risk (RR) = 0.69, 95% confidence interval (Cl) 0.50-0.95), a hysterectomy only (RR = 0.55, 95% Cl 0.38-0.81), or a hysterectomy with unilateral oophorectomy (RR = 0.60, 95% Cl 0.31-1.17) had lower risks of ovarian cancer than did women who had never had any sterilization surgery. However, the negative associations with tubal sterilization and hysterectomy only appeared to wane after two decades. These findings may be partly explained by the screening for occult ovarian pathology that often accompanies pelvic surgery: Women whose ovaries screen as "negative" may be temporarily at low risk of being diagnosed with ovarian cancer. However, because the decreased risks persisted for so long, it is conceivable that hormonal, mechanical, or circulatory sequelae of these sterilization procedures may act to lower ovarian cancer risk.

The Collaborative Review of Sterilization is a prospective, multicenter study that interviewed 7,590 women before they underwent tubal sterilization and then conducted yearly follow-up interviews that included questions on sterilization regret. These women contributed 26,641 observations (for up to 5 years after the procedure, 1978 to 1988) to an analysis of the presterilization characteristics most consistently associated with poststerilization regret. Young age at the time of sterilization was the strongest predictor of regret, regardless of parity or marital status; among women 20 to 24 years of age at sterilization, an average of 4.3% reported regret over the follow-up period. The rate of regret was significantly lower for women 30 to 34 years of age (2.4%).

Pelvic inflammatory disease (PID) is a polymicrobial infection of the female upper genital tract typically due to sexual transmission of Neisseria gonorrhoeae and/or Chlamydia trachomatis. Other microbes can be involved as well that are from the vagino-cervical endogenous flora. Approximately one million PID cases are diagnosed each year in the United States with about one-third occurring in adolescents. Complications include chronic pelvic pain and infertility. The known risk factors (i.e., age, coital patterns, immunopathology, others) as well as current issues of diagnosis and management are considered. Improved outcomes can be seen if clinicians have a low index of suspicion for PID, provide regular chlamydia screening in sexually active adolescent females, carefully follow up-to-date management protocols from the US Centers for Disease Control and Prevention, and emphasize comprehensive sexuality education that include regular use of condoms with coital behavior. Other principles of prevention are also reviewed.

The contraceptive effect of oral contraceptive use provides an important health benefit, particularly in developing countries, where the risks of pregnancy and childbearing are increased. Several important noncontraceptive health benefits of oral contraceptive use include the prevention of endometrial and ovarian cancers. Data are generally reassuring concerning the risks of oral contraceptive use, which include cardiovascular disease and breast and cervical cancer.

To examine the relationship between cigarette smoking and pelvic inflammatory disease we analyzed data from a hospital-based, case-control study of pelvic inflammatory disease. Case subjects were 197 women hospitalized with their first episode of pelvic inflammatory disease; control subjects were 667 women hospitalized with nongynecologic conditions. Logistic regression was used to control for potentially confounding factors, including number of recent sexual partners, frequency of intercourse, and previous episodes of gonorrhea. Compared with women who had never smoked, current cigarette smokers had a significantly elevated relative risk of pelvic inflammatory disease of 1.7 (95% confidence interval, 1.1 to 2.5). Similarly, former cigarette smokers had a significantly elevated relative risk of pelvic inflammatory disease of 2.3 (95% confidence interval, 1.3 to 4.2). However, a dose-response relationship was not observed. These results suggest that cigarette smoking is associated with pelvic inflammatory disease. Whether or not this association is causal requires clarification. The high prevalence of cigarette smoking and the serious consequences of pelvic inflammatory disease make such clarification an important consideration for future research.

The authors examined the relation between cigarette smoking and breast cancer in the Centers for Disease Control Cancer and Steroid Hormone Study, a multicenter, population-based case-control study. The study compared 4,720 women aged 20-54 years with newly diagnosed breast cancer identified through population-based tumor registries with 4,682 women randomly selected from the same geographic areas. Women who reported ever smoking cigarettes had a risk of breast cancer of 1.2 (95 percent confidence interval 1.1-1.3) compared with never smokers. There was no consistent dose-response pattern with any measure of smoking (pack-years of smoking, average number of cigarettes per day, or total years smoked) and little difference in risk between current and former smokers. There was some variation in risk by age, with slightly higher risk estimates for younger women than for older women. Although current smokers had an earlier natural menopause than did never smokers, the authors found no evidence of a protective effect of cigarette smoking on breast cancer risk. These findings suggest that the risk of breast cancer in women who smoke is the same as, or perhaps slightly higher than, women who have never smoked.

The objective was to examine the relationship between the use of oral contraceptives and the risk of death from breast cancer. We used interview data from the Cancer and Steroid Hormone Study linked to cancer registry data from the Surveillance Epidemiology and End Results Program to examine the 15-year survival and prior use of oral contraceptives among 4292 women aged 20 to 54 years when diagnosed with breast cancer from December 1 1980 to December 31 1982. Cox proportional hazard models were used to estimate the relative rate of death from breast cancer by oral contraceptive use. Duration of oral contraceptive use time since first use age at first use and use of specific pill formulations were not associated with survival. For time since last use the risk of death from breast cancer decreased significantly with increasing time since last use of oral contraceptives but a consistent gradient effect was not observed. Adjusted hazard ratios ranged from 0.86 to 1.41 and were 1.00 or less for all recency categories except during 13 to 24 months before diagnosis; none was statistically significant. Women who were currently using oral contraceptives had an adjusted hazard ratio of 0.90 (0.68 1.19). Overall oral contraceptive use had neither a harmful nor a beneficial effect on breast cancer mortality. The differences between pill users and nonusers were slight and the risk estimates were usually reduced with confidence limits that nearly always included 1.0. (authors)

A 1993 editorial in "Fertility and Sterility" accompanying publication of two cohort studies by Giovannucci et al. indicating a positive association between vasectomy and prostate cancer noted the observed association could have resulted from chance bias or a causal association. There is strong potential for bias in the selection of study participants and in the additional medical attention received by sterilized men. Men who undergo vasectomy may have different life-style characteristics than those who do not. Meta-analyses of prostate cancer risk have calculated higher odds ratios in studies judged to have inadequate selection of controls and possible detection bias than in more methodologically rigorous studies. Overall a review of the research evidence reveals inconsistent study findings weak strength of any observed association and little biologic plausibility for a vasectomy-prostate cancer link.

Background One of the mechanisms by which intrauterine devices (IUDs) prevent pregnancy is the creation of a sterile inflammatory response in the endometrium. Additionally, hormone-releasing IUDs or intrauterine systems (IUSs) release progestins or progesterone into the uterus. Both of these mechanisms may affect users' risk for neoplasia. Study Design We searched the PubMed database for studies on IUD use and risk for neoplasia conducted between 1960 and September 2006 and published in all languages. We excluded case reports and case series. For the association between ever using an IUD and risk for endometrial cancer, we conducted a meta-analysis using a Bayesian random-effects model to account for between-study heterogeneity. Results We found no evidence of increased risk for neoplasia with IUD use. Nine case–control studies and one cohort study found reduced risks for endometrial cancer with having ever used an IUD (pooled adjusted odds ratio=0.6, 95% confidence interval=0.4–0.7). No trend in associations was observed with characteristics of IUD use, type of IUD and histologic type of cancer. Four case–control studies found no association between IUD use and risk for cervical cancer. One study found no increased incidence of breast cancer among levonorgestrel-releasing IUS users as compared with the general population in Finland. Finally, three studies found no association between IUD use and occurrence of hydatidiform moles or malignant sequelae. Conclusions Use of an IUD does not appear to increase the risk for neoplasia. While nearly all studies found that IUD use was associated with a decreased risk for endometrial cancer, it remains unclear whether this association is causal.

Concerns exist as to whether the insertion of copper and levonorgestrel-releasing intrauterine devices (IUDs) increases the risk of pelvic inflammatory disease (PID) among women with sexually transmitted infection (STI). We searched the MEDLINE database for all articles published between January 1966 and March 2005 that included evidence relevant to IUDs and STIs and PID. None of the studies that examined women with STIs compared the risk of PID between those with insertion or use of an IUD and those who had not received an IUD. We reviewed indirect evidence from six prospective studies that examined women with insertion of a copper IUD and compared risk of PID between those with STIs at the time of insertion with those with no STIs. These studies suggested that women with chlamydial infection or gonorrhea at the time of IUD insertion were at an increased risk of PID relative to women without infection. The absolute risk of PID was low for both groups (0-5% for those with STIs and 0-2% for those without).

Previous research has suggested that hormonal contraceptive users, compared with nonusers, may be at increased risk for acquiring sexually transmitted infections (STIs). We searched the MEDLINE and EMBASE databases for all articles from January 1966 through February 2005 for evidence relevant to all hormonal contraceptives and STIs (including cervical chlamydial and gonococcal infection, human papillomavirus, trichomoniasis, herpes and syphilis). We used standard abstract forms and grading systems to summarize and assess the quality of 83 identified studies. Studies of combined oral contraceptive and depot medroxyprogesterone use generally reported positive associations with cervical chlamydial infection, although not all associations were statistically significant. For other STIs, the findings suggested no association between hormonal contraceptive use and STI acquisition, or the results were too limited to draw any conclusions. Evidence was generally limited in both amount and quality, including inadequate adjustment for confounding, lack of appropriate control groups and small sample sizes. The observed positive associations may be due to a true association or to bias, such as differential exposure to STIs by contraceptive use or increased likelihood of STI detection among hormonal contraceptive users.

Because use of combined oral contraceptives (COCs) confers some risk of venous thromboembolism (VTE), there is concern that this effect may be greater among women with thrombogenic mutations. We searched the MEDLINE and EMBASE databases for all articles published from January 1966 through September 2004 for evidence relevant to hormonal contraception and thrombogenic mutations. Of 301 articles identified by the search strategy, 16 evaluated COCs, and no studies were found for other hormonal methods. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. A total of 10 studies together provided "good" evidence of a greater risk of VTE (risk ratios of 1.3-25.1) and cerebral vein or cerebral sinus thrombosis among COC users with factor V Leiden mutation when compared with nonusers who have the mutation. The evidence for prothrombin and other thrombogenic mutations was not as strong as for factor V Leiden mutation. It is unclear whether the type of COC or duration of use modifies the risk of VTE among women with thrombogenic mutations.

Objective To determine whether insurance coverage for ART is associated with transfer of fewer embryos and decreased risk of multiple births. Design Retrospective cohort study of a population-based sample of IVF procedures performed in six U.S. states during 1998. Setting Three states with mandated insurance coverage (Illinois, Massachusetts, and Rhode Island) and three states without coverage (Indiana, Michigan, and New Jersey). Participant(s) Seven thousand, five hundred sixty-one IVF transfer procedures in patients ≤ 35 years of age. Main outcome measure(s) Number of embryos transferred, multiple-birth rate, triplet or higher order birth rate, and triplet or higher order gestation rate. Result(s) A smaller proportion of procedures included transfer of three or more embryos in Massachusetts (64%) and Rhode Island (74%) than in the noninsurance states (82%). The multiple-birth rate in Massachusetts (38%) was less than in the noninsurance states (43%). The insurance states all had protective odds ratios for triplet or higher order births, but only the odds ratio (0.2) for Massachusetts was significant. This decreased risk in Massachusetts resulted from several factors, including a smaller proportion of patients with three or more embryos transferred, lower implantation rates when three or more embryos were transferred, and greater rates of fetal loss among triplet or higher order gestations. Conclusion(s) Insurance appears to affect embryo transfer practices. Whether this translates into decreased multiple birth risk is less clear.

Although the provision of expensive ART services in resource-poor countries might appear to be incongruous, nevertheless, the number of ART clinics in such settings is on the rise. For example, in Latin America, the first baby conceived after IVF was born in 1984; by 1998, 84 centers were submitting data to the Latin American Registry (1). Similarly, in Egypt, where IVF was introduced in the late 1980s, at least 35 clinics currently provide a range of ART services (2). Since 1981, private clinics in India have offered ART procedures including IVF and intracytoplasmic sperm injection (ICSI), and 60 clinics have been registered by the Ministry of Health (3). China has also experienced a growth in infertility services since the early 1990s (4).

Objective: To determine the cumulative probabilities over 14 y of requesting information on sterilization reversal and of obtaining a reversal and to identify risk factors observable at sterilization for both measures of regret. Design: The U.S. Collaborative Review of Sterilization, a prospective cohort study. Setting: Fifteen medical centers in 9 cities. Patient(s): 11,232 women. Main Outcome Measure(s): Cumulative probabilities of requesting information on reversal and undergoing reversal. Result(s): The 14-y cumulative probability of requesting reversal information was 14.3% (95% confidence interval [CI], 12.4%–16.3%). Among women aged 18 to 24 y at sterilization, the cumulative probability was 40.4% (95% CI, 31.6%–49.2%). Women aged 18 to 24 y were almost 4 times as likely to request reversal information as were women ≥30 years of age (adjusted rate ratio [RR], 3.5; 95% CI, 2.8–4.4). Number of living children was not associated with requesting reversal information. The overall cumulative probability of obtaining reversal was 1.1% (95% CI, 0.5–1.6). Younger women (18 to 30 y) were more likely to obtain reversal (RR, 7.6; 95% CI, 3.2–18.3). Conclusion(s): Women who were sterilized at a young age had a high chance of later requesting information about reversal, regardless of their number of living children.

ContextTo maximize birth rates, physicians who perform in vitro fertilization (IVF) often transfer multiple embryos, but this increases the multiple-birth risk. Live-birth and multiple-birth rates may vary by patient age and embryo quality. One marker for embryo quality is cryopreservation of extra embryos (if embryos are set aside for cryopreservation, higher quality embryos may have been available for transfer).ObjectiveTo examine associations between the number of embryos transferred during IVF and live-birth and multiple-birth rates stratified by maternal age and whether extra embryos were available (ie, extra embryos cryopreserved).Design and SettingRetrospective cohort of 300 US clinics reporting IVF transfer procedures to the Centers for Disease Control and Prevention in 1996.SubjectsA total of 35,554 IVF transfer procedures.Main Outcome MeasuresLive-birth and multiple-birth rates (percentage of live births that were multiple).ResultsA total number of 9873 live births were reported (multiple births from 1 pregnancy were counted as 1 live birth). The number of embryos needed to achieve maximum live-birth rates varied by age and whether extra embryos were cryopreserved. Among women 20 to 29 years and 30 to 34 years of age, maximum live-birth rates (43% and 36%, respectively) were achieved when 2 embryos were transferred and extra embryos were cryopreserved. Among women 35 years of age and older, live-birth rates were lower overall and regardless of whether embryos were cryopreserved, live-birth rates increased if more than 2 embryos were transferred. Multiple-birth rates varied by age and the number of embryos transferred, but not by whether embryos were cryopreserved. With 2 embryos transferred, multiple-birth rates were 22.7%, 19.7%, 11.6%, and 10.8% for women aged 20 to 29, 30 to 34, 35 to 39, and 40 to 44 years, respectively. Multiple-birth rates increased as high as 45.7% for women aged 20 to 29 years and 39.8% for women aged 30 to 34 years if 3 embryos were transferred. Among women aged 35 to 39 years, the multiple-birth rate was 29.4% if 3 embryos were transferred. Among women 40 to 44 years of age, the multiple-birth rate was less than 25% even if 5 embryos were transferred.ConclusionsBased on these data, the risk of multiple births from IVF varies by maternal age and number of embryos transferred. Embryo quality was not related to multiple birth risk but was associated with increased live-birth rates when fewer embryos were transferred.

OBJECTIVE: Our aim was to study the association between severity of pelvic inflammatory disease at laparoscopy and the probability of achieving a live birth, while accounting for subsequent episodes of pelvic inflammatory disease. STUDY DESIGN: Beginning in 1960 a cohort of 1288 women in Lund, Sweden, who had clinical symptoms of acute pelvic inflammatory disease and who desired pregnancy was followed for up to 24 years. All participants underwent laparoscopy and were categorized by degree of salpingitis: mild ( n = 371), moderate ( n = 580), or severe ( n = 337) pelvic inflammatory disease. Cumulative live birth rates, obtained by life-table analysis, and proportional hazards ratios were compared among women by severity of pelvic inflammatory disease, while accounting for subsequent episodes. RESULTS: The cumulative proportion of women achieving a live birth after 12 years was 90% for women with mild, 82% for women with moderate, and 57% for women with severe pelvic inflammatory disease. The occurrence of subsequent episodes in women with mild pelvic inflammatory disease did not diminish their long-term probability of live birth, whereas it significantly lowered the probability of live birth in women with severe pelvic inflammatory disease. Women with severe disease and subsequent episodes were eight times more likely to fail to achieve live birth compared with women with a single pelvic inflammatory disease episode with mild disease (relative risk 8.1; 95% confidence interval 3.0 to 22.2). CONCLUSIONS : Increasing severity of pelvic inflammatory disease correlates with a lower long-term probability of live birth. Subsequent episodes have a greater impact on women with severe pelvic inflammatory disease at the index episode compared with those with milder disease. (Am J Obstet Gynecol 1998;178:977-81.)

Objective To examine differences in clinical and pathologic characteristics between women undergoing hysterectomy who had had prior tubal sterilization and those who had not. Methods: One thousand eight hundred fifty-one women undergoing hysterectomy were enrolled as part of a multicenter, prospective cohort study. We used logistic regression to describe the association between prior tubal sterilization and patient characteristics at hysterectomy. Results Although sterilized women were not more likely than nonsterilized women to have a menstrual disorder as a presenting complaint, they were more likely to have a primary discharge diagnosis of menstrual disorder (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2–2.0). After adjustment for menstrual indices, sterilized women had an increased probability of having normal findings on pathologic examination, which differed by age (women less than 30 years: OR 3.4, 95% CI 2.0–5.8; women 30 years of age and older: OR 1.7, 95% CI 1.3–2.3). Conclusion Differences in clinical and pathologic characteristics between sterilized and nonsterilized women suggest that nonbiologic factors may influence decision making regarding hysterectomy among sterilized women.

To provide guidance to obstetricians and gynecologists for using findings from metaanalyses in clinical practice, we describe the principles and methods of metaanalysis, including its strengths and weaknesses. Then we illustrate these principles by reviewing four metaanalyses published recently in the American Journal of Obstetrics and Gynecology by using a systematic approach to evaluation based on 15 questions. In these published metaanalyses most of the questions are addressed, but we noted an absence of attention to coding aspects in all studies. The usefulness of metaanalysis largely depends on the quality of the studies that are synthesized, the conduct of the metaanalysis, and the reporting of the methods and results. Proper use of metaanalyses requires an understanding of the strengths and weaknesses of the method and attention to the manner of reporting. The principles of metaanalysis are not complex, and the potential benefits can be enormous for patient care.

To measure the influence of uterine size on the risk of operative complications among women undergoing abdominal hysterectomy for uterine leiomyomas.Four hundred forty-six women undergoing abdominal hysterectomy for pathologically confirmed leiomyomas were analyzed using data from a previously reported prospective cohort study. We compared the risk of operative complications among women with uterine weights less than 250 g, 251-500 g, and greater than 500 g. Logistic regression was used to estimate the independent effect of uterine size on the probability of operative complications.The risk of blood transfusion increased with increasing uterine weight; 13.7, 14.2, and 26.7% of women with uterine weight less than 250 g, 251-500 g, and greater than 500 g, respectively, required transfusion (P for trend.05). After adjustment for race, previous surgery, preoperative weight, concurrent endometriosis, and type of insurance coverage, women with uterine weight greater than 500 g had increased odds of having a transfusion (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.3-4.3). These women also had increased odds of having an estimated blood loss greater than 500 mL (OR 2.5, 95% CI 1.5-4.2), vaginal cuff cellulitis (OR 2.8, 95% CI 1.3-6.2), and at least one of a number of operative complications (OR 1.6, 95% CI 1.0-4.0).Women with leiomyomas whose uterine weight exceeds 500 g have an increased risk of complications from abdominal hysterectomy.

Objective To analyze reproductive-tract disorders that resulted in hospitalization of reproductive-age women in the United States. Methods Data from the National Hospital Discharge Survey for 1988,1989, and 1990 were used to study women 15–44 years old who had any gynecologic diagnoses noted in their discharge summaries. Results Based on average annual discharge rates per 10,000 women, the five most frequent diagnostic groups were pelvic inflammatory disease (PID) (average annual rate 49.3, 95% confidence interval [CI] 43.6–55.0), benign cysts of the ovary (average annual rate 32.7, 95% CI 28.8–36.6), endometriosis (average annual rate 32.4, 95% CI 28.5–36.3), menstrual disorders (average annual rate 31.4, 95% CI 27.6–35.2), and uterine leiomyomas (average annual rate 30.4, 95% CI 26.7–34.1). The highest rates for PID were among women 25–39 years old and for women of races other than white. Highest rates for uterine leiomyomas were among women 40–44 years old and for women of races other than white. Highest rates for endometriosis were among women 40–44 years old and white women. Racial differences existed among all ages in the uterine leiomyoma and endometriosis groups. Average annual rates of benign cysts and menstrual disorders increased with age, but there were no statistically significant differences according to race in these two diagnostic groups. Conclusion Our findings confirmed the importance of PID as a common cause of hospitalization among reproductive age women and identified additional gynecologic conditions as causes for hospitalization as well. We found significant age and racial differences not only among women with discharge diagnoses of PID but also among those with discharge diagnoses of uterine leiomyomas and endometriosis.

Objective: To examine relationships among human immunodeficiency virus (HIV) serostatus, postpartum contraceptive choice, and the rate of repeat pregnancy within a short interval. Methods: This retrospective cohort study was performed in 83 seropositive and 218 seronegative women identified from an inner-city prenatal population undergoing routine voluntary HIV antibody screening from July 1987 through June 1989. Postpartum contraceptive choices and rate of repeat pregnancies were compared based on HIV serostatus. Results: Seropositive women were significantly more likely than seronegative women to undergo tubal sterilization (27 versus 15%; odds ratio [OR] 2.9, 95% confidence interval [CI] 1.5–5.9). This relationship persisted after controlling for age, race, marital status, and parity by logistic regression modeling (adjusted OR 2.9, 95% CI 1.4–5.9). Seropositive women were significantly less likely than seronegative women to select oral contraceptives (34 versus 68%; OR 0.2, 95% CI 0.1–0.4), a relationship that persisted after controlling for age, race, marital status, parity, and foam and condom use (adjusted OR 0.2, 95% CI 0.1–0.5). Seropositive women were significantly more likely than seronegative women to select foam and condoms as their primary method of contraception (30 versus 15%; OR 2.4, 95% CI 1.2–4.5), a relationship that did not persist after controlling for age, race, marital status, and parity (adjusted OR 0.7, 95% CI 0.4–1.3). The risk of repeat pregnancy was slightly lower in seropositive versus seronegative women (34 versus 44%; OR 0.7, 95% CI 0.4–1.3). Most repeat pregnancies among sera positive and seronegative women were unplanned (90 and 82%, respectively). Conclusion: There was a relationship between the method of postpartum contraception and HIV serostatus, but no significant difference in repeat pregnancy rates associated with choice of method.

The 1993 membership survey of the American Association of Gynecologic Laparoscopists received 938 responses, or 13% of the membership. The surgeons reported performing 22,966 sterilizations and 36,482 diagnostic procedures. The distribution of sterilization techniques has remained stable since 1985. Complication rates associated with diagnostic procedures remain consistently higher than those with sterilizations. One death was reported from sterilization, none for diagnostic procedures.

A reanalysis of published and unpublished data from epidemiological studies examines the association between height, body mass index, and the risk of developing ovarian cancer., Background Only about half the studies that have collected information on the relevance of women's height and body mass index to their risk of developing ovarian cancer have published their results, and findings are inconsistent. Here, we bring together the worldwide evidence, published and unpublished, and describe these relationships. Methods and Findings Individual data on 25,157 women with ovarian cancer and 81,311 women without ovarian cancer from 47 epidemiological studies were collected, checked, and analysed centrally. Adjusted relative risks of ovarian cancer were calculated, by height and by body mass index. Ovarian cancer risk increased significantly with height and with body mass index, except in studies using hospital controls. For other study designs, the relative risk of ovarian cancer per 5 cm increase in height was 1.07 (95% confidence interval [CI], 1.05–1.09; p, Editors' Summary Background Cancer of the ovaries, usually referred to as ovarian cancer, is the fifth leading cause of cancer death in women, and, unfortunately, symptoms (such as abdominal pain and swelling) usually occur late in the disease process; fewer than one-third of ovarian cancers are detected before they have spread outside of the ovaries. There is no definitive evidence that screening reduces mortality from ovarian cancer, and given the poor prognosis of advanced ovarian cancer, there has been much research over recent years to increase understanding of this serious condition. There are recognized risk factors that increase the chance of developing ovarian cancer, such as increasing age, having fewer children, not having used oral contraceptives, and use of menopausal hormone therapy. Age and oral contraceptive use have by far the biggest impact on ovarian cancer risk. Why Was This Study Done? To date, there is no definitive information about the relevance of women's height, weight, and body mass index to their subsequent risk of developing ovarian cancer. There have been roughly 50 epidemiological studies of ovarian cancer, but only about half of these studies have published results on the association between body size and ovarian cancer risk, and so far, these findings have been inconsistent. Therefore, the researchers—an international collaboration of researchers studying ovarian cancer—re-analyzed the available epidemiological evidence to investigate the relationship between ovarian cancer risk and adult height, weight, and body mass index, and to examine the consistency of the findings across study designs. What Did the Researchers Do and Find? After an extensive literature search, the researchers identified 47 eligible studies that collected individual data on women's reproductive history, use of hormonal therapies, height, weight, and/or body mass index, and in which the principal investigators of each study accepted the invitation from the researchers to be involved in the re-analysis. The researchers combined data from the different studies. To ensure that women in one study were only directly compared with controls (similar women without ovarian cancer) in the same study, all analyses were routinely stratified by study, center within study, age, parity, use of oral contraceptives, use of hormonal therapy for menopause, and menopausal status or hysterectomy. The 47 studies were conducted in 14 countries and comprised a total of 25,157 women with ovarian cancer (mostly from Europe and North America) and 81,311 women without ovarian cancer. The researchers found a significant increase in relative risk (1.07) of ovarian cancer per 5 cm increase in height. Furthermore, this risk did not vary depending on other studied factors—age, year of birth, education, age at menarche, parity, menopausal status, smoking, alcohol consumption, having had a hysterectomy, having first degree relatives with ovarian or breast cancer, use of oral contraceptives, or use of menopausal hormone therapy. However, the researchers found that for body mass index, the risks depended on whether women had ever taken menopausal hormone therapy: the relative risk for ovarian cancer per 5 kg/m2 increase in body mass index was 1.10 in women who had never taken menopausal hormone therapy but was only 0.95 in women who had previously taken menopausal hormone therapy. What Do These Findings Mean? These findings suggest that increasing height can be considered as a risk factor for ovarian cancer and that in women who have never taken menopausal hormone therapy, increased body mass index can be considered an additional risk factor. These findings have public health implications, especially in high-income countries, because the average height of women has increased by about 1 cm per decade and average body mass index has increased by about 1 kg/m2 per decade. The findings suggest an associated increase in ovarian cancer incidence of 3% per decade if all other factors relevant for ovarian cancer remain constant. Additional Information Please access these web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001200. The following organizations give more information on ovarian cancer which may be of use to patients: MedicineNet, the US National Cancer Institute, Ovarian Cancer National Alliance, Macmillan Cancer Support

To describe patient characteristics and diagnoses associated with hysterectomy in the United States from 1988-1990 using data from the National Hospital Discharge Survey.We analyzed data from the National Hospital Discharge Survey, an annual probability sample of discharges from nonfederal, short-stay hospitals in the United States. A population-based sample of all women aged 15 years or older in the United States civilian population who had a hysterectomy during 1988-1990 was examined to characterize factors associated with hysterectomy: patients' age and race, diagnoses, surgical approach, and oophorectomy.Approximately 1.7 million women had a hysterectomy during 1988-1990. The highest rates--100.5 hysterectomies per 10,000 women--were for women aged 30-54 years. Total rates of hysterectomy for black women were similar to those for white women (61.7 and 56.5 per 10,000 women, respectively); uterine leiomyoma ("fibroid tumor") was reported as the primary diagnosis for 61% of black women and 29% of white women. Abdominal surgery was used for 75% of all hysterectomies. Concomitant bilateral oophorectomy was done for 37% of the women under 45 years old and 68% of the women 45 years or older.Two-thirds of all hysterectomies for noncancerous conditions were performed for uterine leiomyoma or endometriosis--conditions that are most common before the age of menopause. Future assessments of the appropriateness of hysterectomy will require better understanding of these disorders. Continued monitoring of hysterectomy rates is critical to understanding the appropriate use of hysterectomy, alternative therapies for uterine disorders, and future trends in women's health care.