[Induced abortion in France: results of the COCON study]. / Prise en charge de l'IVG en France: résultats de l'enquête COCON.

OBJECTIVE: The aim of this article is to describe conditions of abortions practices in France. MATERIALS AND METHODS: The study was based on the COCON survey. This survey was carried out among a representative sample of 2863 women aged 18 to 44 living in metropolitan France. Women were interviewed by telephone. The analysis was performed among a sub-sample of 320 women who had had an abortion between 1996 and 2000. Results were compared with those of the national notification of induced abortions. RESULTS: Altogether, the way in which abortions were carried out was appropriate, but differences were observed according to the type of hospital: access to care was easier in the private sector; however a pre-abortion interview was less often carried out and a post-abortion interview less often proposed in the private sector. Besides, in both sectors, women were rarely allowed to choose the abortion technique, or the type of anesthesia in the case of a surgical abortion. CONCLUSION: The COCON study is the first population based survey describing the characteristics of care regarding voluntary abortion. It shows the persistence of differences in practices between the public and the private sectors.

[Fertility after ectopic pregnancy: 10-year results in the Auvergne Registry]. / Fertilité après grossesse extra-utérine: résultats sur 10 ans du registre d'Auvergne.

OBJECTIVES: The purpose of this work was to study the fertility after ectopic pregnancy (EP) according to the type of contraception at the time of EP (none, IUD, other) and treatment (medical, conservative surgical, radical). MATERIAL AND METHODS: Ten-year Auvergne EP registry data were analyzed (1626 women, among whom 741 tried to become pregnant again). Fertility was characterized by the time to a new pregnancy and its outcome (EP recurrence, intrauterine pregnancy (IUP)). The censored data methodology was used. RESULTS: The rate of recurrence was much higher in women who had a IUD at the time of EP than in women without contraception. The opposite trend was observed for IUP (the rate of IUP was 1.7-fold higher in women who had a IUD at the time of EP). The rate of recurrence doubled in women treated medically. The rate of IUP was significantly lower in women given conservative treatment than in women given radical treatment. CONCLUSION: Contraception at the time of EP must be considered when studying subsequent fertility. The increase in rate of recurrence following medical treatment observed in the present study should be confirmed by others in search for an explanation. Our results point out the need for control trials on EP treatment, and provide data for planning such trials.

[Comparison of fertility rates after ectopic pregnancy in Auvergne and Lille regions]. / Comparaison de la fertilité après grossesse extra-utérine dans la région de Lille et en Auvergne.

OBJECTIVES: Fertility rates after ectopic pregnancy (EP) were compared between the Auvergne region (central France) and the Lille region (northern France) in order to determine whether fertility factors are similar. We also wanted to determine whether regional differences persist if known fertility factors are taken into account. MATERIAL AND METHODS: Data from the Auvergne EP register 1992-1998 (1.285 women, among whom 552 tried to become pregnant again) and from Lille register 1994-1997 (678 women, among whom 343 tried to become pregnant again) were analyzed. Fertility was characterized by the time to a new pregnancy and its outcome (EP recurrence, intrauterine pregnancy (IUP)). Censored data methodology was used. RESULTS: Despite differences in general fertility characteristics between regions, fertility factors were the same with similar relative risks for age, history of infertility, previous tubal damage, use of an intrauterine device at the time of EP and EP treatment. When these factors were taken into account, fertility rate after EP remained significantly better in Auvergne than in the Lille region. CONCLUSION: This common analysis of data from two registers confirms, from a quantitative point of view, the role of the main factors associated with fertility after EP. However, other factors such as EP management or the surgical technique may intervene.

[Cost-effectiveness analysis of laparoscopic surgery versus methotrexate: comparison of data recorded in an ectopic pregnancy registry]. / Comparaison coût-effectivité de la coelio-chirurgie versus le traitement médical au méthotrexate à partir du registre des grossesses extra-utérines d'Auvergne.

OBJECTIVES: To compare the cost efficacy ratios of medical therapy (methotrexate - MTX) and laparoscopic surgery for ectopic pregnancy, based on an observational study of effectiveness. MATERIAL AND METHODS: Data were collected by a population register of the Auvergne area. We computed the costs before, during and after hospitalization of women who could be treated either by MTX or laparoscopic surgery. We detailed costs related to the various existing facilities. We considered the entire treatment. RESULTS: One hundred nine cases of ectopic pregnancy were treated by laparoscopic surgery and 46 by MTX. Second-line therapy was required in 3% of women who underwent laparoscopic surgery, and 35% of those given MTX. MTX was found to be less costly (1,342 euros) than laparoscopic surgery (2,113 euros). The efficacy threshold for MTX was 11% (giving a failure rate of 89%). CONCLUSION: MTX is much more cost effective than laparoscopic surgery but the frequent need for second-line treatment must also be assessed.

[Emergency contraception in France: the user profile]. / Caractéristiques des utilisatrices de pilule du lendemain, en France.

OBJECTIVES: Emergency contraception pill (ECP) has recently become available in France without prescription since 1999. The aim of this study was to explore knowledge, attitudes toward, and use of ECP. PATIENTS AND METHODS: A national sample of 1639 women were interviewed by telephone randomly selected from the telephone directory. After sending a letter to each household to minimize the number of refusals, finally 397 eligible women aged 18-44 years accepted to answer. RESULTS: Seventy-one percent of women know ECP and 9% had ever used ECP. ECP users were younger, more often single, but no important difference was found with education level, religion and knowledge of ECP between users and non-users. Only 25% of the women knew the exact correct time for using it (within 72 h following an unprotected sex). ECP users had more sexual partners in their life (12 vs. 4, P < 0.05) and 27% vs. 8%, had a previous history of sexual transmitted disease (P < 0.01). ECP users had a different contraceptive profile than non-users; they used less effective methods but the frequency of contraception use was found to be higher. Finally, over 1 year, the percentage of potential ECP users can be estimated at 13% considering women who had reported problems with condom use, forgot their pill once or more. DISCUSSION AND CONCLUSION: ECP users are different from non-users, but all women are concerned and should receive increased education on ECP use. Making ECP more easily available in population may reduce the rate of unintended pregnancy.

Emergency contraception: from accessibility to counseling.

Since emergency contraception (EC) users have a higher risk sexual profile, they may miss an opportunity for medical counseling if getting EC directly from a pharmacy. However, direct access to emergency contraception through pharmacies has been shown to increase EC use. Informational materials destined for EC users could alert women to the importance to check for sexually-transmitted infections considering health issues related to STDs.

Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases.

BACKGROUND: Several risk factors for ectopic pregnancy (EP) have been identified, but the site of implantation of EP has been little studied. METHODS: A total of 1800 surgically treated EP was registered between January 1992 and December 2001 in the Auvergne EP register and the women concerned were followed up. In this large population-based sample, we studied the distribution of EP sites, immediate complications, determining factors, and subsequent fertility. RESULTS: EP sites were interstitial (2.4%), isthmic (12.0%), ampullary (70.0%), fimbrial (11.1%), ovarian (3.2%) or abdominal (1.3%). No cervical pregnancies were observed. Complications and treatment depended on the site of EP. In multivariate analysis, the only risk factor associated with EP site was current use of an intrauterine device (IUD), which was more frequent in distal EP. The 2 year cumulative rate of subsequent spontaneous intrauterine pregnancy (IUP) increased progressively from interstitial to ovarian EP. Fair concordance (weighted kappa = 0.31) was observed between the sites of two successive EP if they were homolateral. CONCLUSION: In addition to providing an accurate description of the sites of implantation of EP, this study shows that current IUD use 'protects' against interstitial pregnancies, which are the most difficult to manage. It shows that subsequent fertility tends to be higher in women with distal EP.

Smoking cessation or reduction in women attempting to conceive after ectopic pregnancy.

The relationship between smoking cessation or reduction and attempt to conceive was studied in 646 women treated for ectopic pregnancy (EP) (Auvergne register of EP, France). Women were prospectively followed. Tobacco consumption was recorded as the mean number of cigarettes smoked per day at the time of interview. Smoking reduction was defined as stopping smoking or decreasing tobacco consumption by at least 3 cigarettes per day. Statistical analysis was performed using conditional logistic regression. The results confirmed that women reduced tobacco consumption when they became pregnant. However, no association was found between smoking reduction and attempting to conceive again. These results suggest that both women and physicians need to be informed about the possible tobacco consumption effects of smoking on fertility.

Recent declining trend in ectopic pregnancy in France: evidence of two clinicoepidemiologic entities.

OBJECTIVE: To assess the recent incidence of ectopic pregnancy (EP) in France (1992-1997) and to relate this incidence to trends in risk factors and use of contraception. DESIGN: Population register-based study. SETTING: Auvergne EP register (central France). PATIENT(S): Women aged 15-44 years with EP in the Auvergne region. MAIN OUTCOME MEASURE(S): Rates of EP, frequencies of exposure to risk factors, and sales of contraceptive methods in 1992-1997. RESULT(S): The overall EP rate decreased 13.7%, from 96.4 per 100,000 women aged 15-44 in 1992 to 83.2 per 100,000 in 1997. The rate of EP associated with reproductive failure remained stable, but the rate of EP associated with contraceptive failure (mostly intrauterine device failure) decreased 26.6%. The trends in the prevalence of the main risk factors for EP and sales of contraceptive methods are concordant with the changes in EP rates: Risk factor prevalence did not change over time, but intrauterine device sales in the area declined in parallel. CONCLUSION(S): The rates of EP as the result of contraceptive failure and as a result of reproductive failure evolve differently in the population and should not be confused in epidemiologic studies. This finding, along with published evidence that the two types of EP have different risk factors, location, prognosis, and perception by women, indicates that they are two distinct clinical entities possibly requiring different management.

Risk factors for extrauterine pregnancy in women using an intrauterine device.

OBJECTIVE: To identify the risk factors for ectopic pregnancy (EP) in women using an intrauterine device (IUD). DESIGN: Case-control study. SETTING: Auvergne region (France). PATIENT(S): Women using an IUD and suffering EP (243 cases) or having an intrauterine pregnancy (140 controls). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Sociodemographic characteristics, smoking, medical history, and medicines taken before the pregnancy. Type of IUD, duration of use, position and visibility of the thread at diagnosis, and presence of abnormal clinical signs. RESULT(S): Seven factors were associated with an increase in the risk of EP: histories of spontaneous abortion, IUD use, and tubal damage; progesterone IUD at the time of conception; insertion of an IUD during the month following a previous pregnancy; duration of use of the IUD in place at the time of conception; and pelvic pain resulting in medical consultation after the insertion of the IUD. Conversely, five factors were associated with a decrease in the risk of EP: history of treated low genital tract infection; history of contraception using the progestagen pill; use of paracetamol or aspirin before the pregnancy; and displacement of the IUD. CONCLUSION(S): This study suggests that the IUD itself may have an etiological role in EP.

A population-based analytical approach to assessing patterns, determinants, and outcomes of health care with application to ectopic pregnancy.

OBJECTIVE: Health care has variable features, specific determinants, and consequences on people's health that should be investigated in a population perspective. We present a population-based analytical approach to assessing patterns, determinants, and outcomes of health care. METHODS: The approach uses standard epidemiological methods for sample selection and analysis, as well as statistical methods concerning model fitting and validation strategy. It also uses psychometric methods allowing pattern identification: factor analysis, cluster analysis, and polytomous logistic regression to investigate the factors associated with identified patterns of care. The approach is illustrated with an application to ectopic pregnancy (EP). RESULTS: EP diagnostic and therapeutic procedures appeared to be closely related, suggesting 3 differentiated patterns of care. Predictors of these patterns were not only the clinical features and the woman's prior gynecological history but also center characteristics and location. These patterns were found to influence immediate and middle-term outcomes and risk of recurrence of EP. CONCLUSIONS: We illustrate the feasibility and profitability of a population-based analytical approach to identify patterns, determinants, and consequences of care. This approach could be used to analyze other pathological conditions and health care systems.

Fertility following radical, conservative-surgical or medical treatment for tubal pregnancy: a population-based study.

OBJECTIVE: To investigate the factors influencing the choice of treatment for ectopic pregnancy and to compare the subsequent fertility rates of radical, conservative-surgical or medical treatments. DESIGN: Population-based study of 835 ectopic pregnancies registered between 1992 and 1996. SETTING: Auvergne Ectopic Pregnancy Register (France). SAMPLE: Four hundred and seventy-six women with tubal ectopic pregnancy who were not using contraception at the time of conception. Subsequent fertility was studied for the 291 women who attempted to conceive again. METHODS: Comparison of reproductive outcomes according to ectopic pregnancy treatment. Cumulative fertility curves were calculated by the Kaplan-Meier estimator and compared by log rank test for univariate analysis and by Cox regression to take into account confounding variables. MAIN OUTCOME MEASURE: Recurrence and fertility rates after ectopic pregnancy. RESULTS: The first treatment given was 'radical' for 178 women (37%), 'conservative-surgical' for 262 (55%), and 'medical' for 35 (8%). The treatment failed in 1% for radical treatment, 5% for conservative-surgical treatment, and 36% for medical treatment. The two-year cumulative rate of recurrence was 27% with no significant difference between treatments. For women with previous infertility factors (in particular diseased contralateral tube), the treatments differed significantly, with the rate of intrauterine pregnancy lower for radical treatment and higher for medical treatment than for conservative-surgical treatment. For women with no infertility factor, there was no significant difference between treatments. CONCLUSIONS: These results should be confirmed in a controlled trial. The results of this study provide the elements necessary to plan such a trial.

Fertility outcome after ectopic pregnancy and use of an intrauterine device at the time of the index ectopic pregnancy.

Fertility after ectopic pregnancy (EP) was investigated in a non-selected population taking into account intrauterine device (IUD) use at the time of the EP. Between January 1992 and June 1996, 647 women listed in the EP register of Auvergne (France) were followed up. The analysis included only the 328 women who were seeking to become pregnant: 23 women using IUD at the time of the index EP (IUD users) and 305 IUD non-users. Among IUD users, there was no recurrence of EP, and the 1 year cumulative rate was 87% [95% confidence interval (CI): 73-100%] for intrauterine pregnancies and 86% (95% CI: 72-100%) for deliveries. Among IUD non-users, the 2 year cumulative rate for recurrence of EP was 28% (95% CI: 17-39%), and the 1 year cumulative rates were 60% (95% CI: 53-66%) for intrauterine pregnancies and 44% (95% CI: 38-56%) for deliveries. The adjusted intrauterine pregnancy rate of IUD users was not significantly different from that of IUD non-users. However, IUD non-users had more miscarriages, so their delivery rate was lower.

Ruptured tubal ectopic pregnancy: risk factors and reproductive outcome: results of a population-based study in France.

OBJECTIVE: The aim of this study was to investigate the determinants of tubal rupture and to describe its treatment and effect on subsequent fertility. STUDY DESIGN: The data were taken from a population-based register from Auvergne (France). All women aged between 15 and 45 years residing permanently in this area and treated for ectopic pregnancy by surgical or medical procedures have been registered since 1992. They are then followed up prospectively until the age of 45 years. This study is an analysis of 849 tubal ectopic pregnancies registered between January 1992 and December 1996. Women with tubal rupture were compared with those in whom no tubal rupture occurred. The risk factors for tubal rupture were identified by calculating crude and adjusted odds ratios. The effects of tubal rupture on subsequent fertility were assessed by calculating cumulative intrauterine pregnancy rates and were analyzed by log-rank tests and Cox regression. RESULTS: The rate of rupture for this population was 18%. Four factors were identified that increased the risk of rupture (results of the multivariate analysis): never having used contraception (odds ratio 1.7 [1.0 to 3. 3]), a history of tubal damage together with infertility (odds ratio 1.6 [0.9 to 2.7]), induction of ovulation (odds ratio 2.5 [1.1 to 5. 6]), and a high level of beta-human chorionic gonadotropin (at least 10,000 IU/L) when ectopic pregnancy was suspected (odds ratio 2.9 [1. 5 to 5.6]). The overall cumulative frequency of intrauterine pregnancy was not significantly lower after tubal rupture (adjusted risk ratio 0.85 [0.53 to 1.38]). CONCLUSION: Although tubal rupture seriously affects the immediate health of the women concerned, it seems to have no independent effect on subsequent fertility. Better knowledge of the risk factors should make it possible to identify those women who will not benefit from nonsurgical treatment.

[Predicting the risk of extra-uterine pregnancy. Construction and validation of a French risk scale]. / Prédire le risque de grossesse extra-utérine. Construction et validation d'une échelle de risque française.

This paper reports the construction and validation of a composite measurement scale to predict the risk of ectopic pregnancy in France. The data from three case-control studies of ectopic pregnancy conducted in France were used. Fourteen potential factors were found to be associated to ectopic pregnancy, which were grouped by multiple correspondence analysis in four dimensions: infection, pelvic surgery, smoking and induced conception. Logistic regression was further used to model the relationship between candidate risk factors (single or grouped as suggested by multiple correspondence analysis) and ectopic pregnancy. The regression coefficients of the final model were scaled and rounded to integers so as to make the scoring system simpler to use. The resulting composite measurement scale was finally validated on two independent samples. It allows simple determination (with a nomogram) of the absolute risk of developing ectopic pregnancy, for a given level of risk factors. This indicator for the risk of ectopic pregnancy could be used by clinicians to predict occurrence and provide an indication as to which type of early pregnancy follow-up and information should be given to women planning a pregnancy. It could also be used to provide earlier diagnostic screening in case of mild symptoms.

Ectopic pregnancy and occupational exposure of hospital personnel.

OBJECTIVES: An earlier study found a relationship between occupational exposure to antineoplastic drugs and ectopic pregnancy. The present investigation aimed at confirming this finding in a larger and specifically planned study and at analyzing the relationship between ectopic pregnancy and other chemical or physical agents in the hospital work environment. METHODS: A case-referent study (140 cases and 279 referents) was carried out in 1995 in a population of women working in hospitals throughout France. The sample size was computed to have an 80% statistical power to detect a 2-fold increased risk of ectopic pregnancy (odds ratio 2). Information was collected about past and present work conditions (exposures to antineoplastic drugs, solvents, disinfectants, anesthetic gases and ionizing radiation), and known risk factors of ectopic pregnancy. Multivariate analysis was performed using logistic regression. RESULTS: No significant association between occupational exposure and ectopic pregnancy was found, either when past exposure was considered or when exposure was considered within the 3 months before conception. The relationships remained nonsignificant after adjustment for job category and for the known risk factors of ectopic pregnancy. CONCLUSIONS: It was concluded that the results of this study should be interpreted as an absence of relationship between exposure to chemical or physical agents and ectopic pregnancy.

[Tobacco and ectopic pregnancy. Arguments in favor of a causal relation]. / Tabac et grossesse extra-utérine. Arguments en faveur d'une relation causale.

BACKGROUND: The risk associated with smoking has been studied for a long time in fertility epidemiology. This paper reviews the association between smoking and ectopic pregnancy (EP) using results collected in our previous studies. It provides arguments for a causal interpretation of this association. METHODS: Data came from three case-control studies performed between 1988 and 1996 and from the register of ectopic pregnancies in Auvergne (France) from 1992 to 1995. The methods are those classically used in the analysis of case-control studies. RESULTS: The risk of EP increased significantly with smoking (p < 0.01): the adjusted OR are 1.5 for 1-9 cigarettes a day, 2.0 for 10-19 cigarettes a day, and 2.5 for more than 20 cigarettes a day. The attributable risk of smoking ranged between 17% and 32% according to the study. Similarly, the risk of EP recurrence increased significantly with smoking (p < 0.02): after adjustment, OR = 1.3 for 1-9 cigarettes a day, OR = 1.5 for 10-19 cigarettes a day, and OR = 1.7 for more than 20 cigarettes a day. Finally, smoking was associated with the site of EP. CONCLUSIONS: Thus there is a large body of arguments towards a causal relationship between smoking and EP. This provides additional arguments to persuade women to stop or to reduce smoking, especially hypofertile women.

Risk of ectopic pregnancy and previous induced abortion.

OBJECTIVES: This study investigated the role of prior history of induced abortion in subsequent ectopic pregnancies. METHODS: Data from two French case-control studies were used to examine the effect of induced abortion on ectopic pregnancy risk. Case patients (n = 570) were women admitted for ectopic pregnancy during the study period; controls (n = 1385) were women who delivered in the same center. RESULTS: The analysis among women with no previous ectopic pregnancy showed that, after control for the main ectopic pregnancy risk factors, prior induced abortion was associated with an increased risk of ectopic pregnancy (odds ratio [OR] = 1.5, 95% confidence interval [CI] = 1.0, 2.0); there was a significant trend between number of previous induced abortions and ectopic pregnancy risk (ORs = 1.4 for 1 previous induced abortion and 1.9 for 2 or more). CONCLUSIONS: This study suggests that induced abortion may be a risk factor for ectopic pregnancy for women with no previous ectopic pregnancy, particularly in the case of women who have had several induced abortions.