[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.

Controlled ovarian hyperstimulation as a risk factor for ectopic pregnancy.

As part of a case-control study of ectopic pregnancy, we evaluated the potential etiologic role of controlled ovarian hyperstimulation in a population with no previous history of ectopic pregnancy. Ovulation induction alone was associated with an increased risk of ectopic pregnancy (adjusted odds ratio = 3.98; 95% confidence interval 1.10-14.30). In contrast, ovulation induction for in vitro fertilization did not increase the risk further (adjusted odds ratio = 2.45; 95% confidence interval 0.54-11.13). These results suggest that hormonal factors may be involved in the development of ectopic pregnancy.

Sexually transmitted diseases as major causes of ectopic pregnancy: results from a large case-control study in France.

OBJECTIVE: To evaluate the current impact of sexually transmitted diseases (STDs) and their consequences on the occurrence of ectopic pregnancy (EP). DESIGN: Case-control study. SETTING: Fifteen maternity hospitals in the Rhône-Alpes region, France. SUBJECTS: Six hundred twenty-four women with EP diagnosed from October 1988 to December 1991 and 1,247 controls who delivered liveborn children during the same period. MAIN OUTCOME MEASURES: Information on risk factors included behavioral, clinical, and serological indicators of STDs and other known risk factors of EP. RESULTS: Logistic regression identified several indicators of STDs as strong and independent risk factors for EP: previously treated STD without history of salpingitis; history of probably pelvic inflammatory disease (PID) and, especially, history of confirmed PID; previous STDs of the sexual partner; and Chlamydia trachomatis seropositivity. The adjusted attributable fractions of EP for previous symptomatic STDs, symptomatic STDs of the sexual partner, and C. trachomatis seropositivity were 20%, 3.5%, and 25.2%, respectively, giving a total of 43% of EP cases attributable to infectious factors. CONCLUSIONS: Our findings and previous epidemiological and biological evidence suggest that STD is a major cause of EP. The evidence is particularly strong in the case of C. trachomatis infection. An effective way of dramatically reducing the EP rate would be to prevent STD through education programs sensitizing young women to the complications of STD and public health measures promoting the use of protective methods such as condoms.

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.

Prevention of sexually transmitted diseases: a randomised community trial.

STUDY OBJECTIVE: The aim was to evaluate the effectiveness of a programme for the prevention of sexually transmitted diseases which affect fertility. DESIGN OF THE PREVENTION PROGRAMME: The programme took place in six French geographical departments. Three of these, randomly selected, served as experimental departments while the other three were matched with the first three and served as controls. DESIGN OF THE EVALUATION: Genital discharge was used as the indicator of a sexually transmitted disease. In each department, about 40 voluntarily participating general practitioners (263 in total) gathered information on the frequency of infected patients and on their characteristics, both before and after the campaign. PATIENTS: Before and after the programme respectively, 412 and 288 women and 117 and 94 men with a genital discharge were described. MEASUREMENTS AND MAIN RESULTS: After the programme, tests for chlamydia trachomatis were prescribed more often to both women and men with a discharge in the experimental departments. The characteristics of women having consulted a general practitioner with a discharge differed according to the department group studied. In the experimental departments, the women were younger than those in the control departments and had fewer sexual partners. In contrast to the results obtained for women, no behavioural changes were observed among men with a discharge. CONCLUSIONS: The results may indicate a decreased risk in spread of infection. Methodological problems associated with such a design are discussed. There is a need to develop specific messages aimed at changing male sexual behaviour. The study design has implications for the best strategy in delivering prevention messages to the general population which are relevant to the present AIDS epidemic.

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.

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.

The prevention of sexually transmitted diseases which affect fertility: methodological problems and initial results.

Sexually transmitted diseases and their consequences for fertility are currently a major preoccupation in public health. A joint research project is being carried out in France to develop an STD prevention program and then to implement it experimentally to evaluate its efficiency. It includes 2 phases: a feasibility phase, currently concluded, and an active phase, a community randomized trial. The aim of the feasibility phase was to test the research methods and tools and to act as a basis for the design of the prevention program. It measured the incidence of discharge (men and women) at a one-year interval and patient characteristics. Participating physicians were GPs in a French administrative department near Paris. Between the two measurements, information and sensitization actions were carried out in the same department among health professionals and the general public. The results show that the incidence of discharge (chosen here as indicators of STDs) in daily general medical practice is low, of the order of 6 cases per 1000 consultations. The community randomized trial will now be conducted in 6 French administrative departments, randomly divided into 3 treated departments, benefiting from a prevention campaign, and 3 controls, where no actions will be undertaken, and its results will be used in a national STD prevention campaign.

PIP: The complications of sexually transmitted diseases -- epididymitis in men and pelvic inflammatory disease in women -- result in 12,000 cases of infertility a year in France. It is therefore necessary to implement a program for the prevention of sexually transmitted diseases in France. The 1st step in such a program must be a feasibility study to determine the level of participation of general practitioners and the suitability of the questionnaires. The feasibility study was carried out in 2 steps, one in 1984 and a similar one in 1985. In each year, during a 4-week period, 57 participating doctors filled out questionnaires for each patient consulting for leucorrhea or urethral discharge. During the year between the studies, information brochures on sexually transmitted diseases were produced for doctors and the public. In 1984, the physicians noted 154 cases of leucorrhea and urethral discharge; in 1985, they noted 121 cases, an average of 6 cases/1000 patients. Of the 275 cases, 141 were in men, 134 in women. Only 4% of the men and 9% of the women were under 20, indicating that young patients go to a free health clinic rather than to private practitioners. Over 1/2 of the men, but only 1/5 of the women had multiple sexual partners, and 1/2 the patients were consulting for a recurrence. Bacteriological screening showed that the commonest organisms in the male infections were Gonococcus and Chlamydia trachomatis, while in women mycoses were more prevalent. The feasibility study showed that general practitioners cooperated and that the quality of the data was good. The 2nd phase of the study, a community randomized trial, is currently being conducted in 6 French administrative departments, 3 for treatment and 3 to act as controls. In each department 50 physicians are participating. All available information will be disseminated in the 3 treatment departments for 3 months after beginning the experiment.

[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.

[Ectopic pregnancy: factors related to ovum anomalies?]. / Grossesse extra-utérine : des facteurs liés à des anomalies de l'oeuf?

Identified risk factors for ectopic pregnancy (prior pelvic inflammatory disease, smoking at the time of conception, intrauterine device, obstetrical and surgical history) explain from 60 to 65% of the cases. Egg anomalies may also be a risk factor as it is likely that the transport of an abnormal egg along the uterine tube is less efficient than a normal one. We tested this hypothesis with data from two case-control studies with the same design covering a total of 1955 women. The risk of ectopic pregnancy increased specifically with age, which is compatible with our hypothesis. We also studied the associations with spontaneous abortion, considered to be a marker of the risk of pregnancies involving chromosomal malformations. We observed an association between ectopic pregnancy and spontaneous abortions (especially recurrent abortions), not explained by other known risk factors. Although our data do not supply a single definitive demonstration, our results converge to suggest that egg chromosomal anomalies may play a part in ectopic pregnancy aetiology.

[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.

[Epidemiologic aspects of extrauterine pregnancy]. / Aspects épidémiologiques des grossesses extra-utérines (GEU).

Looking over the last twenty years, the increase in the numbers of ectopic pregnancies has become an important health issue. It is necessary to find out the principal causes for the rise if preventive action is to be taken. Different publications have widely different views about the incidence of the condition and how the increase came about. This variation is due to the diversity of the places and of the different populations that have been studied (age, the way the populations were recruited) as well as the frequencies that have been calculated (according to the number of pregnancies, according to the number of deliveries or according to the number of women of reproductive age in a population). All the same, the trend can be noted. These are: the doubling or tripling in the last two decades of the incidence in industrialised countries. The results of certain epidemiological studies undertaken to seek out the risk factors (mainly based on case histories) have to be interpreted carefully because of the differences in methodology and particularly in the choice of control groups (there seems to be some failure to take into account confounding factors). The chief of the risk factors for extra-uterine pregnancy which are now considered important are the increase in sexually transmitted diseases and in particular in Chlamydia trachomatis. The role played by tubal sterilisation and by some contraceptive measures such as intra-uterine contraceptive device and the progestational mini-pill in the causation of extra-uterine pregnancy can be explained by the fact that these methods are better at preventing intra-uterine pregnancy than extra-uterine pregnancy, although they to diminish the risk of these as well. Furthermore, spontaneous abortions, abdominal surgery and, above all, terminations of pregnancy which had been said to be conductive to the causation of extra-uterine pregnancies, seem to do this by the fact that they are associated with pelvic inflammatory disease. Finally, the role of in vitro fertilisation, and of vaginal irrigation, as well as of nicotine, should be sought out when further studies are carried out.

[Risk factors of ectopic pregnancy. A case-control study at 7 maternity units in the Paris area]. / Facteurs de risque de la grossesse extra-utérine. Etude cas-témoins dans 7 maternités de la région parisienne.

A case-control study was conducted in seven maternity hospitals in the Paris area in 1988 to evaluate the role of several risk factors in ectopic pregnancy (EP). A total of 279 cases and 307 controls were compared for sociodemographic characteristics, cigarette smoking, sexual reproductive and surgical histories and for the conditions under which conception occurred. Many factors were found to be associated with an increased risk of EP: cigarette smoking related to the number smoked at the time of conception (Odds Radio (OR) 1.26 to 2.72), appendicectomy (OR 1.25, 95% CI = 1.02-1.56), prior tubal surgery (OR = 2.42, 95% CI = 1.37-4.22), prior use of intrauterine devices (OR = 1.34, 95% CI = 1.02-1.80), induced ovulation cycle (OR = 1.66, 95% CI = 1.01-2.74) and prior EP (OR = 3.90, 95% CI = 2.27-6.75). Chlamydia trachomatis seropositivity was associated with an increased risk of EP (OR = 1.50, 95% CI = 1.04-2.13), but clinically reported pelvic inflammatory disease was not. Maternal age, parity, previous induced abortion and previous spontaneous abortion were not associated with EP. Use of an intrauterine device, progestagen micro-pill or the combined oestrogen/progestagen pill at the time of conception were associated with a lower risk of intrauterine pregnancy than of EP. These findings confirm the importance of several of the previously reported risk factors for EP; STD's, previous EP and cigarette smoking. They also identify new risk factors: appendicectomy, induced ovulation cycle, and showed that the combined oestrogen/progestagen pill does not prevent ectopic pregnancy as effectively as it prevents intrauterine pregnancy.

[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.

[Sexually transmitted diseases in free sexual practice. Epidemiological aspects]. / Les maladies sexuellement transmissibles en pratique libérale. Aspects épidémiologiques.

One of the major public health preoccupations at present is the incidence of sexually transmissible diseases and their consequences for fertility. At present there is a programme of combined research by the National Institute of Health and the Medical Research (INSERM U 292) and the Director-General of Health (DGS) and the French Committee for Education in Health Matters (CFES). The object of the exercise is to produce a programme for preventing sexually transmissible diseases and then to put in into action in order to find out how practical it is. The programme consists of two phases, the first which has already been completed was to assess how practical the exercise is, and the second phase which is the active pursuit of the enquiry in a random attempt to change things, and this started in November 1986. The first phase tried to test the methods and see whether they were useful forms of research, and also to serve as a base for the programme of prevention. This consists in looking twice a year at the incidence of discharges in men and in women and the characteristics of the patients who are affected. The consultants were a representative sample of general practitioners who work in the Hauts-de-Seine Department. They gave the information voluntarily. There were two measures carried out in the same region of France. The first was informing the public and making the professionals aware of the situation.(ABSTRACT TRUNCATED AT 250 WORDS)

[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.

[Appendectomy, a risk factor for ectopic pregnancy]. / L'appendicectomie, facteur de risque de grossesse extra-utérine.

As part of a case-control study of ectopic pregnancy, we evaluated the potential etiological role of appendectomy. Previous appendectomy was associated with an increased risk of ectopic pregnancy (adjusted Odds-ratio: 2.2; 95 percent CI: 1.5-3.2). Ruptured appendix did not appear to be more strongly associated with an increased risk of ectopic pregnancy than unruptured appendix. Such confounding factors as absence of pathological diagnosis of appendicitis and relationship between age of appendectomy and age of first sexual intercourse are discussed. This study provides an additional argument in favor of laparoscopy in childbearing age to diagnose appendicitis and salpingitis.

[Incidence of extra-uterine pregnancy and characteristics of treated patients. First results of the Auvergne registry]. / Fréquence de la grossesse extra-utérine et caractéristiques des femmes traitées. Premiers résultats du registre d'Auvergne.

OBJECTIVES: To evaluate the course and frequency of ectopic pregnancy in a single population for a prolonged period in order to study the simultaneous changes in distribution of risk factors, identify new risk factors and evaluate the effect of new diagnostic and therapeutic methods on subsequent fertility and the effectiveness of preventive measures. METHODS: All women residing in the Registry zone and treated surgically or medically for ectopic pregnancy were included in the study and followed to the age of 45 years. RESULTS: In 1992, the incidence of ectopic pregnancy was 20.2 per 1,000 live births (n = 160). At least one currently recognized risk factor was found in 80% of the women. A past history of salpingitis was noted in 13% and nearly one half smoked or had smoked at the time of conception. Nineteen percent had a past history of pelvic surgery and 19% had a history of infertility. The ectopic pregnancy recorded was the second one in 9%. Nearly one-third of the ectopic pregnancies recorded (31%) were diagnosed in patients with a intrauterine device. None of these latter patients had other risk factors. Vaginal echography was used for diagnosis in 75% of the cases. Surgery was used as first intention treatment in 94% and medical treatment (methotrexate) was used in 6%.