Recognizing and treating premenstrual dysphoric disorder in the obstetric, gynecologic, and primary care practices.

The author's aim is to aid primary care physicians and obstetrician-gynecologists in correctly diagnosing and treating premenstrual dysphoric disorder (PMDD). The symptoms fluctuate markedly, but their timing is key. PMDD patients experience symptoms only during the luteal phase and will have a symptom-free interval after the menstrual flow and before ovulation. The author discusses self-report instruments, which are valuable tools for diagnosis when combined with the ICD-10 criteria for premenstrual syndrome (PMS) or the DSM-IV criteria for PMDD and the ruling out of medical and psychiatric conditions, such as diabetes, hypothyroidism, major depression, and dysthymia, that cause similar symptoms. Treatment strategies ranging from nonpharmacologic approaches such as dietary modification and aerobic exercise to pharmacologic interventions such as antidepressants, anxiolytics, and agents to suppress ovulation are examined.

Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis. Pelvic Pain Study Group.

OBJECTIVE: To evaluate and compare the safety and efficacy of leuprolide versus placebo in managing chronic pelvic pain in women with clinically suspected endometriosis. METHODS: Women 18-45 years of age with moderate to severe pelvic pain of at least 6 months' duration underwent extensive, noninvasive diagnostic testing and laboratory evaluation, including pelvic ultrasound, complete blood count, determination of erythrocyte sedimentation rate, and endocervical cultures. Those with clinically suspected endometriosis were randomized to double-blind treatment for 3 months with depot leuprolide (3.75 mg/mo) or placebo. The accuracy of the clinical diagnosis of endometriosis was evaluated by posttreatment laparoscopy. RESULTS: Of 100 women randomized, 95 completed the study: 49 in the leuprolide group and 46 in the placebo group. Women in the leuprolide group had clinically and statistically significant (P < or = .001) mean improvements from baseline after 12 weeks of therapy in all pain measures. These mean improvements were significantly greater (P < or = .001) than those in the placebo group. At 12 weeks, mean decreases in physician-rated scores for dysmenorrhea, pelvic pain, and pelvic tenderness were 1.7, 1.0, and 0.8 points greater, respectively, in the leuprolide group than in the placebo group (on a four-point scale). Thirty-eight (78%) of 49 and 40 (87%) of 46 patients in the leuprolide and placebo groups, respectively, had laparoscopically confirmed endometriosis after 12 weeks of treatment. No women withdrew from the study because of adverse events. CONCLUSION: Depot leuprolide was effective and safe for treating patients with chronic pelvic pain and clinically suspected endometriosis, confirming the potential of its empiric use in these patients.

Primary care in obstetrics and gynecology resident education: a baseline survey of residents' perceptions and experiences.

OBJECTIVE: To determine the perceptions and practices of American obstetrics and gynecology residents concerning primary care immediately before the institution of Residency Review Committee Special Requirements for Obstetrics and Gynecology. METHODS: The Council on Resident Education in Obstetrics and Gynecology In-Service Examination in 1995, given to 4361 residents, who represented all programs in the country, included a questionnaire on whether obstetrics and gynecology was primary care and whether they planned to do primary care after residency. Primary care services were categorized by counseling and screening, as defined by the U.S. Preventive Health Services Task Force. Variables included gender, residency level (upper or lower), and type of residency (community or university based). Data were analyzed using the chi2 text and multiple analyses of variance. RESULTS: The response rate was 94% (4099 of 4361), representing a nationwide complement. Eighty-seven percent of the respondents believed that obstetrics and gynecology was primary care and 85% planned to practice accordingly after residency. Residents spend less than 25% of their time counseling on nongynecologic subjects and less than 25% of their time screening for nongynecologic entities, so their perception as primary care providers focused on traditional obstetric and gynecologic counseling and screening services. When assessments were made by gender, level of training, and type of residency, significant differences were found in many variables regarding counseling and screening practices. CONCLUSION: Our survey results suggest that most American obstetrics and gynecology residents consider obstetrics and gynecology primary care but that there were limitations in the educational venues for learning about nongynecologic primary care before the implementation of the Residency Review Committee Special Requirements. Improvement in nongynecologic primary care teaching is a reasonable expectation because residency programs have had 3 years to institute the mandated changes and provide it to residents.

Development of a program teaching laparoscopic sterilization using local anesthesia.

A program teaching laparoscopic sterilization using local anesthesia was developed and implemented in a large residency program in which sterilization using general anesthesia was already being taught in a traditional fashion. Important steps for the development of such a program included the designation of an individual with overall responsibility for the program, identification of potential obstacles along with feasible solutions, and training of residents and staff in the new techniques. The major obstacles to implementation included opposition from anesthesia personnel, the need for additional training in the new techniques for both residents and faculty, nursing staff resistance, and the uncertainty of patient acceptance. Solutions included involving anesthesia personnel in program planning as well as in the ultimate performance of the procedures, practicing local techniques during cases under general anesthesia, limiting initial cases to candidates anticipated to be uncomplicated, and using nondirective counseling of patients. Similar strategies can be useful both to other residency programs and individuals wishing to offer local anesthesia as an option for laparoscopic sterilization at their hospitals.

Applications for residency programs in obstetrics and gynecology, 1996-1997.

OBJECTIVE: The purpose of this work is to report on application patterns for residency positions in obstetrics and gynecology. METHODS: The Electronic Residency Application Service (ERAS) of the Association of American Medical Colleges (AAMC) records each application for a position in a participating residency program. In the 1996-97 application cycle, all but 16 obstetrics and gynecology residency programs participated. Electronic records were analyzed to obtain a statistical picture of the residency application process. RESULTS: Applications for residency positions in obstetrics and gynecology were processed for 1607 graduates of US medical schools, including 110 graduates of osteopathic medical schools. Canadian applicants were six, and other foreign applicants numbered 524. More than two-thirds of US applicants were women, and nine of ten were citizens or permanent residents. Most applicants sent official United States Medical Licensure Examination (USMLE) transcripts to all programs to which they applied. Ninety-five percent of applicants supplied an e-mail address. CONCLUSION: The introduction of ERAS has been successful for obstetrics and gynecology and has provided new information about patterns of applications. The ease of application using the electronic system did not lead to a substantial increase in numbers of applications. Statistics regarding the number of applicants, ratio of women to men, and participation of foreign medical graduates will be of interest to manpower planners.

What to expect from a residency program: answers from a directory of residency programs in obstetrics and gynecology.

OBJECTIVE: To answer questions about obstetric-gynecologic resident salary, night call, vacation, outside employment, gender mix, and training experiences using data from a national directory of residency programs in obstetrics and gynecology. METHODS: The 259 US civilian residency programs were analyzed, using information from the 1996 directory database. We compared programs by size (four or fewer residents per year versus more than four residents per year) and geographic region for each of the questions. We used parametric and nonparametric statistical tests to determine statistical significance. RESULTS: First-year residents earn an average of $31,414 annually and receive a 5% increase each year, although salary varies significantly by region. Residents are on call an average of every 3rd night (twice a week) in the 1st year and every 4th or 5th night in the chief year. Residents in small programs take more night call than those in large programs. A separate night call rotation was more common in large programs. Vacation time varied by year of training and region. Male-to-female ratios in training differed significantly by year in training, program size, and region. The median number of training experiences was identified in each of the categories required by the Residency Review Committee in obstetrics and gynecology. Training experiences varied significantly by program size in three of the 15 categories. CONCLUSION: Program size and geographic region should be considered when comparing programs with regard to pay, work, time off, outside employment, gender mix, and training experiences. Program advisors and potential applicants are encouraged to use this information in comparing programs.

The effect of same-day pregnancy testing on the incidence of luteal phase pregnancy.

OBJECTIVE: To assess the impact of same-day pregnancy testing on the incidence of luteal phase pregnancy (pregnancy in which conception occurs before sterilization). METHODS: Retrospectively, all patients (N = 1006) undergoing laparoscopic tubal ligations at the Regional Medical Center, Memphis, from May 1990 through December 1991 were reviewed for sterilization failures. Negative urine pregnancy tests were documented on all scheduled patients at their preoperative examination. After the first 401 sterilizations, same-day pregnancy testing with enzyme-linked immunosorbent assay (ELISA) pregnancy tests was instituted. We reviewed the records of all presumed sterilization failures as well as all patients with a positive pregnancy test on the day of surgery. Last menstrual period, ultrasound records, and date of delivery were analyzed to determine time of conception. RESULTS: Seven luteal phase pregnancies were discovered among the first 401 sterilization cases (17 per 1000). No luteal phase pregnancies occurred in the next 605 sterilizations after institution of same-day pregnancy testing. Eight patients' sterilizations were canceled because of a positive pregnancy test on the morning of surgery. If these patients had not been eliminated, the incidence of luteal phase pregnancies in this second group would have been 13 per 1000 sterilization procedures. CONCLUSION: Same-day pregnancy testing with an ELISA-type pregnancy test is a rapid, inexpensive, and effective means of reducing the incidence of luteal phase pregnancy.

Single-dose methotrexate for treatment of ectopic pregnancy.

Methotrexate treatment of unruptured ectopic pregnancy is safe and effective and preserves reproductive potential. Previous protocols have required multiple methotrexate doses with or without citrovorum rescue. The purpose of this study was to determine whether patients with an unruptured ectopic pregnancy 3.5 cm or less in greatest dimension could be treated with single-dose intramuscular methotrexate (50 mg/m2) without citrovorum rescue. Thirty-one patients were eligible for this outpatient treatment protocol. One patient withdrew from follow-up, leaving 30 patients (96.8%) in the study group. Patients had a mean age of 28.5 years (range 18-37) and a mean gravidity of 3.0 (range 1-8); nine of 30 (30%) had previously undergone a salpingectomy for ectopic pregnancy. Pre-treatment hCG titers ranged from 130-16,700 mIU/mL (mean 4558). Pre-treatment transvaginal sonography visualized the ectopic in 28 of 30 patients (93.3%) and revealed cardiac activity in six patients. Patients were monitored with hCG titers three times per week for the first week, and then weekly until the hCG was less than 15 mIU/mL. A complete blood count and liver enzymes were obtained before treatment and on day 7. All patients had a continued rise in hCG titer for at least 3 days after methotrexate injection, although all levels began to decline by day 7. No patient required a second dose of methotrexate and no patient experienced any side effects. Twenty-nine of 30 patients (96.7%) were successfully treated. Six of 30 (20%) experienced an increase in lower abdominal pain between days 5-10, and two were hospitalized overnight for observation.(ABSTRACT TRUNCATED AT 250 WORDS)

Ovarian abscess arising within an endometrioma.

Ovarian abscess is a rare gynecologic entity; only 120 cases have been reported in the world literature. In contrast to the more commonly encountered tubo-ovarian abscess, tubal involvement is absent in the ovarian abscess. This report describes a case of an ovarian abscess arising de novo within an endometrioma. The woman presented with a 20-cm pelvic-abdominal mass with paracaval adenopathy and bilateral ureteral obstruction. Treatment with broad-spectrum antibiotics was unsuccessful. The surgical specimen revealed endometrial glands, stroma, hemosiderin-laden macrophages, and evidence of abscess formation.

Management of separation pain after single-dose methotrexate therapy for ectopic pregnancy.

OBJECTIVE: To evaluate the conservative management of pain after systemic methotrexate therapy for ectopic pregnancy; identify prognostic factors for success; and compare hCG resolution time for patients with and without pain. METHODS: A retrospective review of patients with ectopic pregnancy requiring evaluation for pain after receiving single-dose methotrexate therapy is performed. Results of hematocrits, ultrasound findings, hCG levels, time for hCG levels to reach less than 15 mIU/mL, and outcome were noted. RESULTS: Fifty-three patients with 64 episodes of pain were identified. Seven hospitalized patients required surgery during admission. Two previously hospitalized and one outpatient also ultimately underwent surgery. For hospitalized patients, there were no statistical differences between patients who did or did not undergo surgery during admission for any variable studied, including the presence of free peritoneal blood or rebound tenderness. However, comparison of hospitalized and nonhospitalized patients showed those with rebound tenderness were more likely to be admitted. Hospitalized patients not requiring surgery had shorter resolution time than nonhospitalized patients. For hospitalized and nonhospitalized patients, the median time from treatment to presentation for pain was 8 days. CONCLUSION: The occurrence of pain following methotrexate therapy for ectopic pregnancy should not be the sole indication for surgical intervention. The majority of stable patients with pain after methotrexate therapy, even with rebound or free peritoneal fluid, can be treated successfully without surgery, either in hospital with close observation for severe pain or as outpatients for patients with less severe pain.

Endometrial sampling prior to hysterectomy.

Many gynecologists use routine endometrial sampling prior to hysterectomy to detect an unsuspected endometrial carcinoma. Gynecologists who formerly performed uterine curettage under anesthesia before hysterectomy now often use an outpatient endometrial sampling technique. Although safe, this procedure is complicated by discomfort, cost, and the risk of infection or uterine perforation. The purpose of this study was to determine the utility of pre-hysterectomy endometrial sampling. Between 1981-1985, 619 patients undergoing hysterectomy had preoperative endometrial sampling using Vabra aspiration, the Novak curette, or D&C. The endometrial sampling histology was compared with that in the hysterectomy specimen. There were 30 instances in which the endometrial sampling failed to identify either endometrial hyperplasia or carcinoma. In the two cases of endometrial carcinoma, D&C was the sampling method used. The findings of this study indicate that these three techniques of endometrial sampling are equal in their diagnostic capabilities. The results confirm the need for biopsy in patients with postmenopausal bleeding or with abnormal uterine bleeding at age 35 years or older. Our findings do not support routine endometrial sampling prior to hysterectomy.

Hysterectomy for chronic pelvic pain of presumed uterine etiology.

This study evaluates the long-term outcome of 99 women who underwent hysterectomy for pelvic pain of at least 6 months' duration. All had symptoms and physical examination findings suggestive of disease confined to the uterus. Patients were excluded if there was previously documented extrauterine pelvic disease, extrauterine pelvic disease at the time of surgery, or uterine weight exceeding 200 g. Histopathologic analysis revealed leiomyomata in 12 (12.1%), adenomyosis in 20 (20.2%), and both leiomyomata and adenomyosis in two (2.02%). The average uterine weight was 91.1 g (range 24-198). Patients were followed after hysterectomy for an average of 21.6 months (range 15-64), with 77 of 99 (77.8%) showing significant improvement and 22 (22.2%) having persistent pelvic pain. Despite preoperative history and physical findings suggesting and histologic findings confirming uterine disease, nearly a quarter of the patients had persistent pelvic pain after hysterectomy for chronic pelvic pain. These findings should have a significant impact on the therapeutic choices recommended by gynecologists and may alter the informed consent that patients give in such cases.

Vaginal cuff closure at abdominal hysterectomy: comparing sutures with absorbable staples.

To compare two methods of vaginal cuff closure during abdominal hysterectomy, 60 patients were randomized to one of two cuff-closure methods. The vaginal cuff was closed with three interrupted 0-Dexon sutures in 30 and with absorbable staples in 30. Both groups were similar with respect to age, gravidity, parity, preoperative indication, hemoglobin, and hematocrit. The operative technique and quantity of irrigation used was standardized. Operative blood loss was calculated by the weight method and an unactivated, medium flat Jackson-Pratt drain was left in place for collecting postoperative cuff cultures at 24 and 48 hours. The mean operative times in the suture group (97.4 minutes) and staple group (93.4 minutes) were not significantly different (P greater than .05). Cuff-closure time was more rapid (P = .0001) in the staple group (5.8 minutes) than in the suture group (9.3 minutes). Intraoperative cultures were positive in eight of 30 suture patients (26.7%) and eight of 30 staple patients (26.7%). Postoperative cultures at either 24 or 48 hours were positive in four women (13.3%) in the suture group and six (20%) in the staple group. Febrile morbidity occurred in six (20%) in each group. Three staple and two suture subjects developed a vaginal cuff abscess or hematoma, one of whom was readmitted to the hospital for intravenous antibiotics and draining of the vaginal cuff abscess. The presence of a positive vaginal cuff culture did not predict clinical outcome. Based on these observations and the increased cost of the stapling device, we conclude that there is no significant clinical advantage of surgical staples over traditional sutures for vaginal cuff closure at abdominal hysterectomy.

Discrepancy of cervical cytology and colposcopic biopsy: is cervical conization necessary?

The purpose of this study was to determine whether diagnostic cervical conization is necessary in the patient with a discrepancy between the Papanicolaou smear and the colposcopically directed biopsy(s). Patients eligible for the study had at least a two-degree discrepancy, eg, CIN III cytology and CIN I or less on colposcopic biopsies, or CIN II cytology with biopsies showing no dysplasia. Of the 786 records reviewed, 87 (11.1%) had such a discrepancy. Twelve of 87 patients (13.8%) were pregnant and ten of 87 (11.5%) failed to return after their initial colposcopic evaluation, leaving 65 patients in the study group. Of these, 20 of 65 (30.8%) were treated medically, nine (13.8%) had cryotherapy, and 36 (55.4%) underwent diagnostic cervical conization. Of patients undergoing cervical conization, three had microinvasive carcinoma of the cervix. Following medical therapy, only two of 20 patients (10%) had negative cytology, two (10%) had CIN I, five (25%) received additional therapy, and 11 (55%) were lost to follow-up. Seven patients did not return for follow-up Papanicolaou smear after medical treatment, and four did not return after their initial posttreatment Papanicolaou smear revealed persistent dysplasia. Of the nine patients treated with cryotherapy, six (66.7%) had a negative Papanicolaou smear at the time of their initial follow-up. The results of this study emphasize the importance of proceeding with diagnostic or therapeutic conization if a two-stage or greater discrepancy exists between the colposcopically directed biopsies and the cervical cytology. The risk of not diagnosing a microinvasive or invasive cervical carcinoma far outweighs the risk of conization.

Methotrexate treatment of unruptured ectopic pregnancy: a report of 100 cases.

In an ongoing clinical trial, 100 patients with an unruptured ectopic pregnancy of 3.5 cm or less in greatest dimension were treated with an outpatient protocol of methotrexate and citrovorum factor chemotherapy. Methotrexate and citrovorum were given on alternating days until the hCG titer had decreased by 15% on 2 consecutive days. The patients ranged in age from 16-40 years, gravidity from 1-8, and parity from 0-5. Twenty-three patients had a previous ectopic pregnancy. Of the 100 patients, 96 (96%) received methotrexate/citrovorum as primary therapy and four (4%) were treated for persistent hCG titers after a conservative surgical procedure. The tubal pregnancies of patient nos. 1-50 were confirmed by laparoscopy, whereas patient nos. 51-100 were diagnosed according to a nonlaparoscopic algorithm. Four patients of 100 failed medical therapy and required surgery. Of these, one had an ectopic pregnancy with cardiac activity, one ruptured after intercourse, and the remaining two cases had no specific identifiable risk factors. Of the ectopic pregnancies with cardiac activity, 80% were successfully treated. Five patients (5%) had methotrexate-related side effects, all after the fourth dose, but none required treatment for these side effects. Hysterosalpingograms done on 58 patients subsequently demonstrated tubal patency in 84.5% on the involved side. To date, 37 pregnancies have occurred in this group, of which 31 (89.2%) were intrauterine and four (10.8%) were recurrent ectopic pregnancies. We conclude that methotrexate/citrovorum is safe, effective, and helps to preserve reproductive performance when used as primary therapy for unruptured ectopic pregnancy and for treatment of persistent disease following a conservative surgical procedure.

Pipelle endometrial sampling in patients with known endometrial carcinoma.

The purpose of this prospective clinical trial was to determine the reliability of the Pipelle endometrial biopsy instrument in recovering adequate tissue for confirmation of the diagnosis of endometrial cancer in patients with known endometrial carcinoma, and to compare endometrial histology of the sampling specimen with that of the subsequent hysterectomy specimen. Forty patients were enrolled in this study. All biopsies were performed in the office without anesthesia. The patients had a median age of 62 years (range 40-83). Discomfort was reported by the patient as mild, moderate, or severe; only two patients (5.0%) reported severe pain. There were no complications experienced with endometrial sampling. Thirty-nine of 40 specimens (97.5%) confirmed endometrial carcinoma; therefore, this study yielded a 97.5% sensitivity for the Pipelle endometrial sampling device. Comparing Pipelle and hysterectomy histology for individual patients, the histologic grade was the same in 29 (74.4%), while the Pipelle demonstrated a more advanced degree of differentiation in five (12.8%) and a lesser degree in five (12.8%). There was no residual tumor identified in one hysterectomy specimen (2.5%). Among the 12 patients who had a D&C for diagnostic purposes before referral, the Pipelle biopsy correlated with the D&C histology in ten of 12 (83.3%) and revealed a more advanced grade of tumor in one (8.3%) and a more differentiated grade in one (8.3%). In one patient, the D&C histology was adenocarcinoma grade 1, with the Pipelle demonstrating atypical hyperplasia and the hysterectomy specimen interpreted as endometrial adenocarcinoma in situ. This study demonstrates the Pipelle to be an accurate device for endometrial sampling in patients with endometrial carcinoma.

Serial endovaginal sonography of ectopic pregnancies treated with methotrexate.

Methotrexate therapy is a newly established treatment modality for ectopic pregnancy. We performed this study to determine the time frame for resolution of the sonographically identifiable mass during such therapy and to determine the role of sonography in the management of these patients. Eighteen patients treated with methotrexate for laparoscopically proven ectopic pregnancy consented to long-term follow-up with endovaginal sonography. These 18 patients constitute the study group. The time required for sonographic resolution of the mass was variable, although poor patient compliance with sonographic follow-up affected the conclusions regarding resolution time. One hundred eight days was the longest period accurately known for resolution of a mass. In seven patients, the mass persisted after a negative hCG titer. Enlargement of the adnexal mass during therapy did not necessarily predict treatment failure, as only two of ten such patients required surgery for rupture. Serial sonography did not alter the management of most patients and appears not to be warranted on a routine basis. Follow-up sonography was most useful when complications were suspected. All patients considered for methotrexate therapy should first have an endovaginal sonogram, as cardiac activity remains a relative contraindication to this treatment. We have determined that the mass of an ectopic pregnancy may remain after the hCG is negative. Therefore, a persistent mass should not be interpreted as treatment failure.

Peritoneal closure at vaginal hysterectomy: a reassessment.

OBJECTIVE: To evaluate the clinical outcome of patients who underwent vaginal hysterectomy with or without peritoneal closure. METHODS: This study was a randomized trial. Using computer-generated numbers, all patients undergoing vaginal hysterectomy without oophorectomy were randomized to either no peritoneal closure (n = 57) or routine peritoneal closure (n = 49). Patients were followed-up for a minimum of 1 year for development of complications and postoperative dyspareunia. At 4-6 postoperative weeks, the distance between the ovaries and the vaginal cuff was measured by ultrasound. RESULTS: Postoperative complications were similar in both groups. The incidence of deep-thrust dyspareunia at 6 and 12 months was also similar. No statistical differences between the two groups were noted in the ovary to vaginal cuff distances either overall or when patients with dyspareunia were considered separately. CONCLUSION: The data in this study do not support the use of reperitonealization on a routine basis. However, because of a lack of statistical power, larger studies will be required to confirm this theory.

A model for resident surgical training in laparoscopic sterilization.

OBJECTIVE: To measure the effects of a specific instructional program designed to teach residents laparoscopic sterilization. METHODS: The teaching module consisted of a 40-minute videotape and monograph, which each resident studied 1-3 days before beginning a 4-5-week rotation on which he or she performed laparoscopic sterilization procedures. The change in knowledge was measured by comparing pre- and post-test assessments. Twenty-three PGY-2 gynecology residents were administered the peer-reviewed and validated pre-test, which consisted of 31 multiple-choice questions covering the following aspects of laparoscopic sterilization: 1) indications and complications, 2) general aspects of sterilization, 3) sterilization methods, and 4) technical aspects of occlusive device application. A post-test, which consisted of the identical 31 items with the question order changed, was administered after the teaching module was completed. RESULTS: The mean number of correct answers on the post-test (27.2 +/- 2.3, range 22-31) was significantly higher (P < .05) than the mean number of correct answers on the pre-test (17.9 +/- 3.4, range 13-24). There was no difference in residence scores if the module was completed early or late in the academic year or during the first or second year that the program was in effect. CONCLUSION: This study demonstrates that knowledge of a specific surgical technique can be measured and that structured learning packages can be effective. Efforts to teach residents a specific curriculum can have a significant effect on their fund of knowledge. Other specially designed programs may be applicable to procedures commonly performed by gynecologic residents.

Chromopertubation at laparoscopic tubal occlusion.

OBJECTIVE: To evaluate the role of chromopertubation following laparoscopic sterilization in terms of occlusive device displacement, infectious complications, and sterilization failures. METHODS: Five hundred consecutive women scheduled for laparoscopic sterilization were randomized to rings, electrocoagulation, or clips for tubal occlusion. Subjects were further randomized to chromopertubation or no chromopertubation. At chromopertubation, any occlusive device displacement or dye spillage was noted. Patients were followed postoperatively for sterilization failure or infectious complications. Statistical analysis used the chi 2 test. RESULTS: At chromopertubation, no device dislodgment, change in position, or dye spillage from the occlusion site was noted. Dye spillage from the end of the fallopian tube occurred in five patients, and immediate repeat tubal occlusion was performed. Six true sterilization failures occurred during the follow-up period. Despite elimination of five apparent failures in the chromopertubation group, there was no significant difference between the no-chromopertubation and chromopertubation groups with regard to failure rate. There were also no significant differences in postoperative wound infections or development of pelvic inflammatory disease. CONCLUSION: Chromopertubation at sterilization is associated with minimal complications but has limited value in eliminating sterilization failures.