FERTILITY AND STERILITY”

VOL.. 69, NO. 2, FEBRUARY 1998

Copyright 01998 American Society for Reproductive Medicine
Published by Elwier Science Inc.
Printed on acid-free paper in U.S.A.

Is there any evidence for a post-tubal

sterilization syndrome?
Gwen P. Gentile, M.D.,* Steven C. Kaufman, M.D.,t and Donald W. He/big, M.D.”
State University of New York Health Science Center at Brooklyn, New York, and National Institutes of Child
Health and Human Development, Bethesda, Maryland

Objective: To review the literature on menstrual and hormonal changes in women who undergo tubal sterilization.
Design: A systematic review through MEDLINE and a literature search identified more than 200 articles in the English
literature from which the most relevant were selected for this review.
Result(s): Many authors have investigated the sequelae of female sterilization. Increased premenstrual distress, heavier and
more prolonged menstrual bleeding, and increased dysmenorrhea have been reported. However, failure to control for age,
parity, obesity, previous contraceptive use, interval since sterilization, or type of sterilization may have affected study
results. Most studies that have controlled for these important variables have not reported significant changes, except in
women who undergo sterilization between 20 and 29 years of age
Conclusion(s): Tubal sterilization is not associated with an increased risk of menstrual dysfunction, dysmenorrhea, or
increased premenstrual distress in women who undergo the procedure after age 30 years. There may be some increased risk
for younger women, although they do not appear to undergo significant hormonal changes. (Fertil Sterile 1998;69:179-86.
01998 by American Society for Reproductive Medicine.)
Key Words: Post-tubal ligation syndrome, post-tubal sterilization syndrome, luteal phase defect, menstrual blood loss,
laparoscopic tubal sterilization, contraception

Received May 6, 1997.
Supported in part by the
National Institutes of Child
Health and Human
Development, NOl-HD-
2908, Washington, DC.
Reprint requests: Gwen P.
Gentile, M.D., State
University of New York
Heaith Science Center at
Brooklyn, Box 24,450
Clarkson Avenue, Brooklyn,
NY 11203 (FAX: 717-385
1634).
??Department of Obstetrics
and Gynecology, State
University of New York
Health Science Center at
Brooklyn.
t Contraceptive Research
and Evaluation Branch,
National Institutes of Child
Health and Human
0015-0282/98/$19.00
PII so01 5-0292(97)00229-x
Tubal sterilization is the most popular
method of contraception in the world (1) and
among U.S. women over age 30 years (2). For
all ages combined, it is the second most com-
mon form of contraception in this country,
where an estimated 10 million women age 15
to 44 years used it for contraception in 1988
(3). Roughly 640,000 U.S. women underwent
tubal sterilization in 1987 (4).
As these women age and seek gynecologic
care, they will have menstrual complaints that
many will ascribe to their sterilization. The
phrase “post-tubal ligation syndrome” was
coined to describe a variety of symptoms that
have been reported to occur after female ster-
ilization. For some investigators, this describes
only abnormal bleeding and/or pain. For oth-
ers, it may include changes in sexual behavior
and emotional health, exacerbation of premen-
strual symptoms, and menstrual disturbances
significant enough to lead to further gyneco-
logic surgery, including hysterectomy or tubal
reanastomosis.
The occurrence of abnormal bleeding after
tubal sterilization first was described in 1951
by Williams et al. (5). They reviewed the
records of 200 women who had undergone
tubal sterilizations of unspecified type and
compared them with 1,994 gynecologic and
3,222 obstetric patients. These women were
observed for 1 to 10 years. Compared with
19% of the gynecologic and 5% of the obstetric
control subjects, 24% of the women who had
undergone sterilization had abnormal bleeding
(defined as increased intermenstrual bleeding
and increased menstrual flow).
Additional data were reported in 1972 by
Muldoon (6), who questioned 374 women who
had undergone sterilization between 1955 and
1960. He reported that 43% needed further
gynecologic treatment, 19% required a hyster-
ectomy, and 6% required some other major
gynecologic surgery. Studies such as these
prompted many physicians to recommend that
women undergo hysterectomy instead of tubal
sterilization. However, many of the women
who underwent sterilization in the 1950s and
1960s had sought termination of childbearing
capacity because of significant gynecologic
and medical illnesses. Some of these illnesses

179
progressed to the point of requiring major cures, resulting in
high rates of further treatment and surgery. In addition, at
that time, tubal sterilization was a major undertaking, requir-
ing a laparotomy and a lengthy hospitalization. A supracer-
vital hysterectomy did not require much more effort, which
made it a viable alternative to tubal sterilization,
Contraception before the 1960s also was a cumbersome
process. Couples were restricted to coitally related meth-
ods that, because of the high level of commitment re-
quired for successful use, frequently were accompanied
by user-related failure. Failure meant having an infant or
obtaining an illegal abortion in most instances; a legal
abortion was difficult or impossible to obtain. The advent
and widespread use of oral contraceptives (OCs) and
intrauterine devices (IUDs) in the 196Os, with their high
levels of effectiveness and non-coitally related use, freed
couples for the first time from the fear of pregnancy that
had held their parents in thrall.
In the 197Os, with the popularization of laparoscopy,
termination of childbearing capacity became much easier.
One or two small incisions replaced the large laparotomy
scar. Women were in and out of the hospital in hours instead
of spending the better part of a week. Equally important,
barriers to obtaining sterilization involving age, parity, and
partner’s consent began to disappear. In the early 1970s in
the United States, more than 500,000 women per year un-
derwent sterilization, double the number a decade earlier.
Further, many more women than men underwent steriliza-
tion, in a complete reversal of the pre-1970s trend (7). As the
number of women undergoing sterilization increased, reports
started to appear concerning the possible long-term sequelae
of the procedure, including menstrual symptoms, hormonal
and other physical characteristics, and the risk of hysterec-
tomy after an essentially minor elective procedure.
The mechanism for the occurrence of post-tubal ster-
ilization syndrome long has been a matter of conjecture. It
has been hypothesized that the destruction of the fallopian
tube and, in many procedures, the concomitant destruction
of portions of the mesosalpinx, alters the blood supply to
the ovary. Theoretically, this would reduce the gonado-
trophin signal to the ovary, with resultant impairment of
follicular growth and corpus luteum function. Ovarian
hormone levels would be affected and a variety of men-
strual disorders would ensue. Some of these would be
manifested by minor changes, but major changes might be
significant enough to warrant major therapeutic interven-
tions, including surgery.
RISK OF HYSTERECTOMY AFTER
TUBAL STERILIZATION
Hysterectomy was perceived as an indicator of men-
strual dysfunction or gynecologic problems after steriliza-
tion, a perspective that had been set by Muldoon (Table 1)
180 Gentile et al. Post-tubal sterilization syndrome
(6). In uncontrolled studies, 1.6% to 3.4% of women who
underwent sterilization subsequently underwent hysterec-
tomy (8, 11, 14). None of these figures approached the
19% found by Muldoon (6). Further, two of these studies
reported that most (11) or all (14) of the hysterectomies
were performed for organic disease that often had existed
before the sterilization.
In studies that included a control group, there appeared to
be an increased risk of hysterectomy in women who had
undergone sterilization when compared with control sub-
jects. None of these studies controlled for the prior use of
OCs in the women who underwent sterilization or the fre-
quency of use of OCs in the control subjects, which would
limit the risk of menstrual disorders.
Four studies (9, 10, 13, 16) showed a significantly in-
creased incidence of hysterectomy in women who had un-
dergone sterilization when compared with a control group,
and one of the studies found no increase in menstrual dis-
orders. Of even greater interest, three studies indicated that
women who had undergone sterilization at a younger age
were at significantly greater risk for hysterectomy than
women who had undergone sterilization later in life. The risk
was significantly elevated for women who had undergone
hysterectomy before age 29 years in two studies and before
age 24 years in another (12, 15, 17).
It is generally accepted that the risk of hysterectomy is
higher among women who have undergone sterilization
than in the general population. In older studies, much of
this could be explained by the fact that sterilization pro-
cedures had been performed for medical reasons and
preexisting gynecologic disorders contributed to the hys-
terectomy rate. Regardless of whether sterilization pro-
duced the problems that led to hysterectomy in more
recent studies, it apparently produced an increased de-
mand for surgery. Once childbearing no longer is desired,
the presence of the uterus is much less important to many
women and menstrual disorders are not tolerated as will-
ingly. Self-selection also may play a role, because women
who seek surgery for contraception probably are more
likely to accept or seek surgery to alleviate gynecologic
complaints.
SUBJECTIVE CHANGES IN MENSTRUAL
SYMPTOMS AFTER STERILIZATION
Numerous investigators (18 -2 1) have evaluated men-
strual symptoms after tubal sterilization. Several have not
controlled for OC use or menstrual pattern before steril-
ization (Table 2). This is particularly relevant for the
millions of women who used OCs, many of whom did so
to ensure menstrual regularity and decrease menstrual
bleeding and pain. As these women elected to undergo
sterilization, they discontinued the use of OCs and began
to experience heavier, more irregular, and more painful
Vol. 69, No. 2, February 1998
Outcome of hysterectomy after tubal sterilization.

No. of tubal No. of

sterilization control Reported hysterectomy outcomes
First author* Year cases subjects Follow-up? after tubal sterilization

Muldoon (6) 1972 374 0 120 to 180 19% had hysterectomies

Stock (8) 1978 278 0 12 to 36 5 (2%) had hysterectomies
Templeton (9) 1982 6,260 7,612 12 to 48 Annual rate of 9.3 per 1,000 in women with tubal
sterilization; 2.5 per 1,000 in control subjects?
Cooper (10) 1983 588 365,000 6 to 72 20 in women with tubal sterilization (3.4% ); 8,130
in control subjects (2.2%)$
Kendrick (11) 1985 4,002 0 1 to 15 64 (1.6%) had hysterectomies, 41 of whom had
preexisting organic pelvic disease
Cohen (12) 1987 4,374 6,835 24 to 96 Women aged 230 years had no increased risk;
relative risk (RR) 1.6 (95% confidence interval
[CI]: 1.2 to 2.3) in women aged 25 to 29 years
Kjer (13) 1990 10,104 847,012 48 to 84 RR of having a hysterectomy after tubal sterilization,
3.4
Koetswang (14) 1990 499 0 48 to 144 17 (3.4%) had hysterectomies, none for menstrual
disorders
Stergachis (15) 1990 7,414 25,736 60 to 200 Women 230 years had no increased risk; RR 3.4
(95% CI: 2.4 to 4.7) in women aged 25 to 29
years
Rulin (16) 1993 500 466 Pre and 8 4.6% in women with tubal sterilization; 2.17% in
36 to 54 control subjects, despite no increase in menstrual
disorders
Goldhaber ( 17) 1993 39,502 40,505 84 to 204 RR 2.4 if aged <24 years; RR 1.4 if aged 135 years
* Reference numbers are in parentheses.
t Values are months after tubal sterilization unless otherwise noted.
$ Cases were older and more parous than control subjects, who were not controlled for oral contraceptive use.

menstrual periods, which would have occurred regardless
of whether the sterilization had been performed.
In 1976, Chamberlain and Foulkes (22) were the first to
report the effect of prior contraceptive practices on men-
strual symptoms after tubal sterilization. They sent question-
naires to women who had undergone abdominal or laparo-
scopic tubal sterilization 2 to 3 years earlier. They found a
significant increase in both pain and bleeding after steriliza-
tion in the 74 women who had been using OCs. For the 37
women who had been using IUDs, sterilization led to a
significant reduction in the length and heaviness of the
menstrual period. For the 76 women who had used no
contraception, there was no significant change in the dura-
tion or amount of menstrual bleeding.

Change in menstrual symptoms after tubal sterilization not controlled for prior contraceptive use.

No. of tubal
sterilization No. of control
First author* Year cases subjects Follow-up? Findings after sterilization

Williams (5) 1951 200 1,994 gynecologic; 12 to 120 24% of women with tubal sterilization, and 19% of
3,222 obstetric gynecologic and 5% of obstetric control subjects
had abnormal bleeding
Neil (18) 1975 420 143 10 to 28 Increased menstrual pain and bleeding for unipolar
cautery, but not for interval laparotomy
Poma (19) 1980 514 514 24 to 84 22 women with tubal sterilization and 2 control
subjects were hospitalized for abnormal bleeding
Alder (20) 1980 43 45 Unknown Increased menstrual blood loss was reported
Shy (21) 1992 7,253 25,448 12 to 180 No increased risk of hospitalization for menstrual
disorders based on matched pairs, but relative
risk 2.4 (95% confidence interval 2.0 to 2.9) in
population-based comparison
* Reference numbers are in parentheses.
$ Values are months after tubal sterilization

FERTILITY & STERILITY@ 181

Change in menstrual symptoms after tubal sterilization controlled for prior contraceptive use.

No. of tubal No. of

sterilization control
First author* Year cases subjects Follow-up? Findings after sterilization

Chamberlain (22) 1976 187 0 24 to 36 Prior oral contraceptive users had

significantly increased and prior
intrauterine device users had significantly
decreased bleeding and pain; those
without prior contraceptive use had no
significant menstrual changes
Lieberman (23) 1978 504 Self Pre, 6, and 12 No significant menstrual changes noted
Rubinstein (24) 1979 147 Self <l and 12 to 28 No significant menstrual changes noted
Kwak (25) 1980 1,303 Self Pre, 6, 24, and 24 to No significant menstrual changes noted
120
Reidel (26) 1981 644 0 Significantly fewer menstrual complaints for
endocoagulation than for unipolar cautery
Bhiwandiwala (27) 1983 9,994 Self Pre, 6, and 12 No significant menstrual changes noted
DeStefano (28) 1983 2,456 Self Pre and 24 Cycle length and days of menstrual bleeding
significantly decreased in women with
tubal sterilization; significant increase in
pain only when tubal sterilization was
done by unipolar cautery
Vessey (29) 1983 1,817 3,551 12 to 96 No significant menstrual changes noted
Bledin (30) 1985 138 135 Pre, 6, and 12 No significant menstrual changes noted
DeStefano (31) 1985 719 1,083 6 to 84 Among women with normal cycles at
baseline; those with tubal sterilization had
significantly more cycle abnormalities 22
years after the procedure
Foulkes (32) 1985 415 135 12 to 24 No significant menstrual changes noted
Rulin (33) 1985 389 40 6and12 No significant menstrual changes noted
Shain (34) 1989 225 219 Pre and 12 Significant menstrual changes and more
pain for bipolar cautery or Pomeroy
procedure, but not for Falope ring
procedure
Wilcox (35) 1992 5,070 Self Pre and 60 Increased menstrual pain and bleeding 5 y
after tubal sterilization
Rulin (16) 1993 500 466 Pre, 6 to 10, and 36 No significant menstrual changes noted
to 54
* Reference numbers are in parentheses.
t Values are months after tubal sterilization unless otherwise noted.

Most studies also found no significant changes in men- 7 19 women had undergone tubal sterilization and 1,083
strual symptoms after controlling for contraceptive use were the partners of men who had undergone vasectomy.
before sterilization (Table 3) (23-27, 29, 30, 32, 33). The authors adjusted for age, prior contraceptive use,
Some studies found significant changes associated with gravidity, and body mass index. Less than 2 years after
some sterilization techniques, but not with sterilization in sterilization, the women had no significant menstrual
general. For example, increased menstrual pain or men- changes when compared with control subjects. More than
strual irregularity has been observed in subgroups of 2 years after sterilization, the women who previously
women undergoing sterilization by unipolar (26, 28) or had had normal cycles had a significantly increased risk
bipolar cautery (34), but no statistically significant men- of abnormal menstrual cycle length and menstrual irreg-
strual changes have been observed in the group as a ularity.
whole. The Collaborative Review of Sterilization (CREST), a
In response to concern about the long-term effects of large, multicenter, prospective study of female steriliza-
tubal sterilization, DeStefano et al. (31) evaluated 1,802 tion in the United States, reported on changes in the
women who had been followed up for 6 months to 8 years menstrual cycles of 5,070 women who had undergone
in the Walnut Creek Contraceptive Drug Study. Of these, sterilization. At 5 years after sterilization, they noted

182 Gentile et al. Post-tubal sterilization syndrome Vol. 69, No. 2, February 1998
Nonhormonal objective measures of menstrual changes.

No.of tubal No. of

sterilization control
First author* Year cases subjects Follow-up Measures Findings after sterilization

Kasonde (38) 1916 25 Self Pre, 6, and 12 Volume of menstrual No change in menstrual blood loss before
blood and within 1 y of tubal sterilization
Donnez (39) 1981 58 65 6 Endometrial biopsy 5 Retarded endomettial biopsy samples in
to 10 d before cautery and Pomeroy groups but not in
next expected clip and control groups
menstrual period
El-Mahgoub (40) 1984 109 10 8 to 58 Midluteal phase No abnormalities noted in endometrial
endometrial biopsy biopsy samples 24 to 58 mo after tubal
sterilization, but retarded within 24 mo
Hague (41) 1987 72 32 Unknown Luteal phase Luteal phase endometrial biopsy samples
endometrial biopsy showed no luteal phase defect in
women with tubal sterilization or
control subjects
* Reference numbers are in parentheses.
t Values are months after tubal sterilization unless otherwise noted.

significant menstrual function changes (heavier menstrual
flow and increased dysmenorrhea) when compared with
the baseline and l-year data. Because each woman served
as her own control, the degree to which aging affected
these complaints could not be assessed (35).
One serious consideration is the potentially increased
risk of menstrual disorders among women who undergo
sterilization at a young age. One study (21) found such an
increase using automated discharge data over a 15year
period in a population-based cohort of 7,253 women who
had undergone sterilization and 25,448 age-matched con-
trol subjects aged 20 to 49 years. Compared with the
women who had not undergone sterilization, the relative
risk of hospitalization for menstrual disorders was 2.4 for
all the women who had undergone sterilization and 6.1 for
those aged 20 to 24 years (95% confidence intervals, 2.0
to 2.9 and 1.9 to 19.6, respectively).
However, data on contraceptive use were not avail-
able and might have accounted for at least part of
the effect observed. In analyzing menstrual pattern
changes, both Cole et al. (36) and Martinez-Schnell et al.
(37) noted a significant correlation between the existence
of menstrual abnormalities before tubal sterilization and
the presence of significant menstrual dysfunction after-
ward.
OBJECTIVE MEASURES OF
MENSTRUAL CHANGES
In an attempt to define the cause of menstrual changes,
many investigators have evaluated various objective pa-
rameters during the menstrual cycle. These include hor-
monal analyses, endometrial biopsy, and measured blood
loss.
One of the earliest attempts to measure menstrual
changes objectively was made by Kasonde and Bonnar in
1976 (Table 4) (38). By extracting menstrual blood from
tampons and sanitary napkins, they measured blood loss
by the Oxford method for three consecutive cycles before
tubal sterilization and for six consecutive cycles after-
ward in 25 women. In 10 of the women, alternate men-
strual periods were measured for 6 to 12 months after
surgery. These authors concluded that tubal occlusion did
not increase menstrual bleeding in the first year after
surgery.
At least three studies (39-41) have reported the results
of endometrial biopsy in women who have undergone
sterilization and in control subjects who have not. One
showed no endometrial abnormalities (41). Another dem-
onstrated normal endometrium more than 24 months after
sterilization, despite evidence of retardation shortly after
sterilization (40). The third study showed retardation
of the endometrium consistent with a luteal phase de-
fect (39).
In 1978, Berger et al. (42) found significantly lower
midluteal phase P levels in 10 patients who requested rever-
sal of sterilization when compared with 19 partners of infer-
tile men. They hypothesized that these levels were compat-
ible with luteal insufficiency.
Since that time, many authors have reported levels of P
and other ovarian and pituitary hormones (Tables 5 and
6). Many of the studies were performed in women who
requested reversal of sterilization or women who had
significant menstrual abnormalities. Their findings were

FERTILITY & STERILITY@ 183

Hormonal measures in women with menstrual changes after tubal sterilization.

No. of tubal No. OP

sterilization control
First author* Year cases subjects Follow-up? Measures Findings after sterilization

Hargrove (43) 1981 29 11 12 to 144 Midluteal P, E,, PRL Significantly lower midluteal phase
P and higher E, in women with
tubal sterilization
Radwanska (44) 1982 23 28 12 to 96 LH, follicle-stimulating Significantly lower midluteal phase
hormone, P, E,, P in women with tubal
every 2 to 3 d for sterilization and menstrual
one cycle disturbances
Cattanach (45) 1988 112 55 >24 24-h urine for estrogen Significantly lower midluteal phase
and pregnanediol 7 d urinary estrogen in women with
before next expected tubal sterilization
menstrual period
Rivera (46) 1989 65 26 Pre, 1, 3, 6, and Luteal P on menstrual When tubal sterilization was done
12 days 15, 20, and 25 by Yoon band, longer menstrual
interval but no significant
change in P
Rojansky (47) 1991 25 53 24 to 260 Midfollicular and late No significant change except lower
luteal phase F,, P, midfollicular phase E, in women
PRL, TSH, T, with tubal sterilization attending
a premenstrual syndrome clinic
* Reference numbers are in parentheses.
$ Values are months after tubal sterilization unless otherwise noted.

compared with those of women who were partners of
infertile men, women who had tubal infertility, or some
other control group.
In several of these studies (43-45, 47-50, 54, 57),
evidence of decreased midluteal phase E,, P, or LH was
found. In those studies in which the women served as their
own controls and had preoperative hormone levels as-
sessed, no significant or persistent changes in hormone
levels were demonstrated (46, 51-53, 55, 56, 58). This is
important because these women served as their own con-
trols, obviating the concern for confounding factors other
than aging. The length of follow-up varied from 3 months
to several years.
DISCUSSION
The only consistency in the articles reviewed is their
inconsistency. In one article, the hormone levels were not
changed, but the cycle length was. In another, the cycles
were the same but the hormone levels were different. In
many, there were no significant changes at all. Many of the
earlier, more alarming articles failed to evaluate age, height,
weight, parity, previous contraceptive use, interval since
sterilization, and type of sterilization performed. Control
groups either were not used or were not really comparable to
the study population. Prospective studies that took these
factors into account found small and frequently insignificant
changes. Some of the changes were for the better. In the end,
there appears to be no clear-cut evidence of the existence of
post-tubal sterilization syndrome. As Grimes (59) recently
wrote, “The literature suggests that if post tubal sterilization
syndrome occurs at all, it affects a very small minority of
women.”
However, even a “small minority of women” can be
too many women in a country where 10 million women
have undergone sterilization. There is evidence that the
individuals at highest risk are women in their 20s who
have histories of menstrual dysfunction before their tubal
sterilizations. Young women also are more likely to regret
their decision to undergo tubal sterilization because they
have most of their reproductive lives still ahead of them
and are most likely to undergo the changes in life status
that would lead to the desire for more children (60, 61).
Because these women have opted for surgical approaches
to their contraceptive needs, they may be more likely than
other women to opt for surgical solutions to their men-
strual abnormalities.
Whatever the reasons, the important lesson is not that
women should avoid tubal sterilization because of the small
possibility of increased problems. Rather, they should be
aware of all the risks, as- well as the considerable benefits,
that are associated with this procedure.

184 Gentile et al. Post-tubal sterilization syndrome Vol. 69, No. 2, February 1998
Hormonal measures in women with no menstrual changes after tubal sterilization.

No. of tubal No. of

sterilization control
Author* Year cases subjects Follow-upt Measures Findings

Radwanska (48) 1979 40 24 Unknown One midluteal phase Midluteal phase P significantly
P 5 to 10 d before lower in women seeking
next expected tubal reanastomosis
menstrual period
Alvarez-Sanchez (49) 1981 30 15 1 to 96 LH, P, E, daily from Significantly decreased
day 10 to menses preovulatory LH and E,
Corson (50) 1981 29 19 Unknown E, and P 8 d after Midluteal phase E, significantly
BBT rise lower in women with ring
but not cautery tubal
sterilization procedures
Meldrum (5 1) 1981 25 42 Unknown Midluteal P No significant hormonal change
noted
Helm (52) 1983 12 Self Pre and 3 P every 2 to 3 days No significant hormonal change
for one cycle noted
Alvarez (53) 1989 17 Self Pre, 2, and 6 LH, FSH, E,, P daily Significantly higher P noted
on days 10 to 18 only at second month of
follow-up after Uchida tubal
sterilization
wu (54) 1991 10 10 24 to 120 FSH, LH, PRL, E,, Preovulatory E, peak and LH
P daily for one surge significantly lower
cycle
Garza-Flores (55) 1991 16 Self Pre, 3, 12, and 60 Luteal E, and P No significant hormonal change
every other day noted
Thranov (56) 1992 11 Self Pre, 3, 6, and 12 E,, P, FSH five No significant changes except
times during cycle midluteal phase P lower only
at third month of follow-up
-
* Reference numbers are in parentheses.
t Values are months after tubal sterilization unless otherwise noted.

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Vol. 69, No. 2, February 1998