To the Editor --
I enjoyed reading the Spring 2000 issue of the Journal, especially the Editor's Comments. I would like to speak in more detail about another article on page 57 entitled "Emergency Contraception Research and Demonstration Project." As a member of the Ethics Committee at Kaiser Permanente Santa Clara, I think a more accurate description of the effects of the hormones administered to the patients in the study is necessary. Attempts at contraception after intercourse with hormone therapy could potentially block the sperm's passage through the cervix, prevent sperm migration to the ovum in the distal Fallopian tube, or prevent sperm capacitation (cleavage to and penetration of the ovum). Studies show that, at peak phase during ovulation, it takes an average of 90 seconds for the sperm to penetrate the cervix and another four to five minutes to reach the distal Fallopian tube with capacitation following a short time later. Due to the usual delay in taking emergency contraceptive pills (ECP) none of these potential effects would take place in a timely fashion. Use of the hormones would, however, increase the transport time of the embryo to the uterine cavity by reducing tubal motility and prevent implantation of the embryo into the uterine wall. Wyeth's data on the estrogenic component of the ECPs do not demonstrate any convincing evidence that ECPs prevent ovulation in this situation. In spite of ACOG's recent change in terminology, conception takes place at fertilization, usually in the distal tube, and not at implantation. I agree that ECPs will reduce the number of unplanned pregnancies from unprotected intercourse but what the patient has the right to know is that this is not a contraceptive but an abortifacient effect of ECPs. As with other medications, procedures, and treatments, the patient has a right toand we have a legal and ethical obligation toinformed consent.

Dave Hammons, MD
Kaiser Permanente, Santa Clara, CA

In Reply --
Dr Hammons correctly describes the several mechanisms of action of hormonal EC. These mechanisms are described in the Provider Service Manual, in the patient information brochure, and in the Healthphone script developed by the Project.

The Provider Service Manual contained the following statement (p. 4) about these mechanisms of action:

".since some people will consider interference with a fertilized, not yet implanted egg as an induced abortion, the potential mode of action must be made clear to all members who might elect this treatment." (p. 4)

and the following recommendations to providers (p. 6) about counseling:

"Due to various definitions of pregnancy and abortion, the mode of action should be clearly explained to members as part of their decision-making process." (p. 6)

In the patient brochure, the statement below follows the description of the mechanisms of action of ECPs:

"Because a fertilized egg may be prevented from growing by this treatment, ECPs are considered an abortion by some people. If you would not use a treatment that would interfere with an already fertilized egg, then ECPs may not be a good choice for you."

Finally, providers who considered ECPs to be abortion were permitted to opt out of providing of ECPs.

The EC Research and Demonstration Project was grounded in respect for differences in beliefs about abortion, and took seriously the obligation to provide information about ECPs that would permit informed decision-making.

Diana Petitti, MD
Kaiser Permanente, Pasadena, CA