Nadine Job-Spira

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.

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.

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.

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.

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.

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.

Caractéristiques des utilisatrices de pilule du lendemain, en France

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 ECE. 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. Seventy-one percent of women know ECP and 9% had ever used ECE. ECP users were younger more often single but no important difference was round 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 sexually 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 round 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. 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. (authors)

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 peoples 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 womans 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.

The hidden side of ectopic pregnancy : the hormonal factor

As discussed by James (19%) in his opening article, epidemiological studies have provided evidence that several factors may be involved in the etiology of ectopic pregnancy. These studies focused on infectious risk factors as assessed by past history of pelvic inflammatory disease, tubal surgery and Chlamydia trachomatis serology (Coste et al, 1991a). In terms of population attributable risk, approximately one out of three ectopic pregnancies is due, directly or indirectly, to these infectious factors (Coste et al, 1994). Among the other risk factors of ectopic pregnancy, cigarette smoking and induced conception cycles suggest a functional disturbance of the genital tract by a modification of oestrogens on the smooth muscle activity. In these conditions, some ectopic pregnancies could be caused by an abnormal increase or decrease in oestrogen concentrations. There is a strong evidence that smoking affects ovarian function. Smokers were three or four times more likely than non smokers to conceive within 12-24 months (Rosevear et al, 1992). There is a positive correlation between smoking and the risk of ectopic pregnancy even after adjustment for identified confounding variables (Coste et al, 1991b). A suggested mechanism for subfertiliry is inhibition of steroidogenesis by cigarette smoke constituents. Women smokers have lower endogenous oestrogen concentrations. In ovulation induction for assisted reproductive techniques, the serum oestradiol concentrations were significantly lower in smokers than in non-smokers with fewer eggs retrieved (Van Voorhis et al, 1992). This last observation is in relationship, with the presence of cotinine in preovulatory follicular fluid. Nicotine and arabinase inhibit granulosa aromatase which catalyses production of oestrogens from their steroid precursors in a dose-dependent manner. Nicotine and its metabolite cotinine inhibit 11 P-hydroxylase and could contribute to this altered pattern of oestradiol observed in smokers. One consequence of a low oestrogen concentration is diminished tubal contractility. Low oestrogen concentrations and alteration of egg quality in women smokers are associated with an alteration of tubal motility and ciliary function by a toxic effect of nicotine.

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.