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ectopic pregnancy, especially after ultrasound documentation of an intrauterine pregnancy, laparoscopy is not indicated. The incidence of heterotopic pregnancy, in which intrauterine and extrauterine implantation occur, is no higher than approximately 1 in 2500 pregnancies. 427. The answer is a. (Mishell, 3/e, p 288. Ransom, 1997, p 95. Ransom, 2000, p 12.) All spermicides contain an ingredient, usually nonoxynol-9, that immobilizes or kills sperm on contact. Spermicides provide a mechanical barrier and need to be placed into the vagina before each coital act. Their effectiveness increases with increasing age of the women who use them, probably due to increased motivation. The effectiveness of spermicides is similar to that of the diaphragm, and increases with the concomitant use of condoms. Although it has been reported that contraceptive failures with spermicides may be associated with an increased incidence of congenital malformations, this finding has not been confirmed in several large studies and is not believed to be valid. Levonorgestrel is a synthetic progestational agent found in several combination oral contraceptive pills. 428. The answer is e. (Mishell, 3/e, pp 179–181.) Masters and Johnson have shown that the size of the clitoris bears no relation to increased orgasmic capacity. Similarly, the distance between the clitoris and the vaginal introitus makes little difference, because clitoral stimulation during coitus is provided largely by traction on the clitoral hood via the labia minora, which are moved during penile thrusting. Direct clitoral stimulation is achieved by the lateral and female superior coital positions. Erection of the clitoris is likewise not related to orgasmic capacity. 429. The answer is b. (Mishell, 3/e, pp 179–182.) Many factors can contribute to the development of primary orgasmic dysfunction in women. By definition, these women will not have been able to achieve orgasm through any means at any time in their lives; reasons for their dysfunction can include the influence of orthodox religious or rigid familial beliefs, dissatisfaction with their partners’ behavioral or social traits, or past trauma such as rape. Sexual dysfunction, particularly premature ejaculation in a male partner, can reinforce a woman’s orgasmic dysfunction. 430. The answer is e. (Mishell, 3/e, pp 179–182.) The response of women to sexual stimulation is generalized and affects many different organ sys-