Contraception

Key clinical point: Current use of hormonal contraceptives was associated with lower mean levels of anti-Müllerian hormone compared to levels in women not on contraceptives; the data may guide clinicians in counseling women to continue their contraceptives during evaluation of ovarian reserve.

Major finding: Compared to women not using any contraceptives, mean anti-Müllerian hormone levels were significantly lower in women using a combined oral contraceptive pill (23.68%), vaginal ring (22.07%), hormonal intrauterine device (6.73%), implant (23.44%), or progestin-only pill (14.80%).

Study details: The data come from a cross-sectional study of 27,125 women aged 20-46 years in the United States. The researchers used dried blood spot cards or venipuncture to assess anti-Müllerian hormone levels.

Disclosures: Modern Fertility, manufacturer of the tests used in the study, paid salaries and consulting fees to the study authors. Lead author Dr. Hariton is a paid consultant for Modern Fertility, has stock options in the company, and his spouse is a Modern Fertility employee.

Source: Hariton E et al. Am J Obstet Gynecol. 2021 Jun 12. doi: 10.1016/j.ajog.2021.06.052.

Key clinical point: Current use of hormonal contraceptives was associated with lower mean levels of anti-Müllerian hormone compared to levels in women not on contraceptives; the data may guide clinicians in counseling women to continue their contraceptives during evaluation of ovarian reserve.

Major finding: Compared to women not using any contraceptives, mean anti-Müllerian hormone levels were significantly lower in women using a combined oral contraceptive pill (23.68%), vaginal ring (22.07%), hormonal intrauterine device (6.73%), implant (23.44%), or progestin-only pill (14.80%).

Study details: The data come from a cross-sectional study of 27,125 women aged 20-46 years in the United States. The researchers used dried blood spot cards or venipuncture to assess anti-Müllerian hormone levels.

Disclosures: Modern Fertility, manufacturer of the tests used in the study, paid salaries and consulting fees to the study authors. Lead author Dr. Hariton is a paid consultant for Modern Fertility, has stock options in the company, and his spouse is a Modern Fertility employee.

Source: Hariton E et al. Am J Obstet Gynecol. 2021 Jun 12. doi: 10.1016/j.ajog.2021.06.052.

Key clinical point: Current use of hormonal contraceptives was associated with lower mean levels of anti-Müllerian hormone compared to levels in women not on contraceptives; the data may guide clinicians in counseling women to continue their contraceptives during evaluation of ovarian reserve.

Major finding: Compared to women not using any contraceptives, mean anti-Müllerian hormone levels were significantly lower in women using a combined oral contraceptive pill (23.68%), vaginal ring (22.07%), hormonal intrauterine device (6.73%), implant (23.44%), or progestin-only pill (14.80%).

Study details: The data come from a cross-sectional study of 27,125 women aged 20-46 years in the United States. The researchers used dried blood spot cards or venipuncture to assess anti-Müllerian hormone levels.

Disclosures: Modern Fertility, manufacturer of the tests used in the study, paid salaries and consulting fees to the study authors. Lead author Dr. Hariton is a paid consultant for Modern Fertility, has stock options in the company, and his spouse is a Modern Fertility employee.

Source: Hariton E et al. Am J Obstet Gynecol. 2021 Jun 12. doi: 10.1016/j.ajog.2021.06.052.

Key clinical point: Pregnancy rates were low following placement of an IUD for emergency contraception, including among women who resumed intercourse within days of IUD placement without backup contraception.

Major finding:  No pregnancies were reported among 138 women who received levonorgestrel IUS or among 148 who received copper IUDs who reported intercourse within 7 days of placement, regardless of use of backup contraception.

Study details: The data come from a secondary analysis of 518 participants in a randomized controlled trial of IUDs for emergency contraception; participants received a 52 mg levonorgestrel intrauterine system (IUS) or 380 mm2 copper IUD.

Disclosures: The study was supported in part by the Eunice Kennedy Shriver National Institute of Child Health and Development, the University of Utah Population Health Research (PHR) Foundation, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences of the National Institutes of Health. The Division of Family Planning in the University of Utah's Department of Obstetrics and Gynecology receives research funding from Bayer Women's Health Care, Merck & Co. Inc., Cooper Surgical, Sebela Pharmaceuticals, Femasys, and Medicines 360. Lead author Dr. Fay had no financial conflicts to disclose.

Source: Fay KE et al. Contraception. 2021 Jun 21. doi: 10.1016/j.contraception.2021.06.011.

Key clinical point: Pregnancy rates were low following placement of an IUD for emergency contraception, including among women who resumed intercourse within days of IUD placement without backup contraception.

Major finding:  No pregnancies were reported among 138 women who received levonorgestrel IUS or among 148 who received copper IUDs who reported intercourse within 7 days of placement, regardless of use of backup contraception.

Study details: The data come from a secondary analysis of 518 participants in a randomized controlled trial of IUDs for emergency contraception; participants received a 52 mg levonorgestrel intrauterine system (IUS) or 380 mm2 copper IUD.

Disclosures: The study was supported in part by the Eunice Kennedy Shriver National Institute of Child Health and Development, the University of Utah Population Health Research (PHR) Foundation, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences of the National Institutes of Health. The Division of Family Planning in the University of Utah's Department of Obstetrics and Gynecology receives research funding from Bayer Women's Health Care, Merck & Co. Inc., Cooper Surgical, Sebela Pharmaceuticals, Femasys, and Medicines 360. Lead author Dr. Fay had no financial conflicts to disclose.

Source: Fay KE et al. Contraception. 2021 Jun 21. doi: 10.1016/j.contraception.2021.06.011.

Key clinical point: Pregnancy rates were low following placement of an IUD for emergency contraception, including among women who resumed intercourse within days of IUD placement without backup contraception.

Major finding:  No pregnancies were reported among 138 women who received levonorgestrel IUS or among 148 who received copper IUDs who reported intercourse within 7 days of placement, regardless of use of backup contraception.

Study details: The data come from a secondary analysis of 518 participants in a randomized controlled trial of IUDs for emergency contraception; participants received a 52 mg levonorgestrel intrauterine system (IUS) or 380 mm2 copper IUD.

Disclosures: The study was supported in part by the Eunice Kennedy Shriver National Institute of Child Health and Development, the University of Utah Population Health Research (PHR) Foundation, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences of the National Institutes of Health. The Division of Family Planning in the University of Utah's Department of Obstetrics and Gynecology receives research funding from Bayer Women's Health Care, Merck & Co. Inc., Cooper Surgical, Sebela Pharmaceuticals, Femasys, and Medicines 360. Lead author Dr. Fay had no financial conflicts to disclose.

Source: Fay KE et al. Contraception. 2021 Jun 21. doi: 10.1016/j.contraception.2021.06.011.

Key clinical point: Rates of continuation and satisfaction were high among women who underwent placement of IUDs during cesarean deliveries, with two cases of infection and no cases of perforation or pregnancy reported.

Major finding:  Rates of IUD continuation were 92% at 6 weeks and 71.5% at 6 months; and approximately 85% and 76% of the women reported satisfaction with the devices at 6 weeks and 6 months, respectively.

Study details: The data come from a prospective, observational study of 158 women in Brazil who received copper IUDs during cesarean deliveries, with follow-up at 6 weeks and 6 months after IUD placement.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Uchoa de Albuquerque C et al. Eur J Contracept Reprod Health Care. 2021 Jun 29. doi: 10.1080/13625187.2021.1943739.

Key clinical point: Rates of continuation and satisfaction were high among women who underwent placement of IUDs during cesarean deliveries, with two cases of infection and no cases of perforation or pregnancy reported.

Major finding:  Rates of IUD continuation were 92% at 6 weeks and 71.5% at 6 months; and approximately 85% and 76% of the women reported satisfaction with the devices at 6 weeks and 6 months, respectively.

Study details: The data come from a prospective, observational study of 158 women in Brazil who received copper IUDs during cesarean deliveries, with follow-up at 6 weeks and 6 months after IUD placement.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Uchoa de Albuquerque C et al. Eur J Contracept Reprod Health Care. 2021 Jun 29. doi: 10.1080/13625187.2021.1943739.

Key clinical point: Rates of continuation and satisfaction were high among women who underwent placement of IUDs during cesarean deliveries, with two cases of infection and no cases of perforation or pregnancy reported.

Major finding:  Rates of IUD continuation were 92% at 6 weeks and 71.5% at 6 months; and approximately 85% and 76% of the women reported satisfaction with the devices at 6 weeks and 6 months, respectively.

Study details: The data come from a prospective, observational study of 158 women in Brazil who received copper IUDs during cesarean deliveries, with follow-up at 6 weeks and 6 months after IUD placement.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Uchoa de Albuquerque C et al. Eur J Contracept Reprod Health Care. 2021 Jun 29. doi: 10.1080/13625187.2021.1943739.

Levonorgestrel intrauterine devices (LNG IUD) are a hot topic in contraceptive research. A recent study on LNG IUDs published by Fay KE et al evaluated pregnancy rates in US women who received LNG or copper IUDs for emergency contraception and reported intercourse within 7 days of insertion. Zero pregnancies were reported in women who resumed intercourse within 7 days of IUD insertion for both the LNG IUD and copper IUD, even in women who had multiple unprotected sexual encounters.  LNG IUDs are more readily accessible and better tolerated than their copper IUD counterparts, and expanding their use will only continue to improve access to reliable contraception. Women often resume penetrative intercourse shortly after initiating new contraceptive method despite counseling. Patients can be reassured that placement of a LNG IUD appears to provide immediate contraceptive benefit.

 A new estrogen is on the market for use in combined oral contraceptive pills (COC). Estetrol is a natural estrogen produced by the human fetal liver only found in circulation during pregnancy.  Estetrol was previously studied for use in menopausal hormone therapy as it acts as a mixed agonist and antagonist, offering a potential improved side effect profile with less activity in the breast and liver.  Estetrol (15 mg) was combined with 3 mg of drospirinone for a novel combined oral contraceptive option in a study by Gemzell-Danielsson K et al.  The pregnancy rate was similar to traditional COCs, demonstrating good contraceptive efficacy. Bleeding patterns and side effects were similar to traditional COCs, and one case of venous thromboembolism was reported in the large study population. A phase III trial with similar results has been completed and this new oral contraceptive formulation recently received FDA approval and is now marketed as Nextstellis. This new oral contraceptive pill hopefully represents a novel option for women who desire COCs with a low androgenic profile and VTE risk or have failed other COC formulations.  

Women are increasingly delaying childbearing, utilizing a variety of contraceptive options to avoid pregnancy. Many proactively seek to determine their fertility potential and clinicians often utilize anti-Müllerian hormone (AMH) as the standard biomarker for assessing ovarian reserve, as it is cycle independent and can be drawn at any time during a woman’s clinical assessment.  Hormonal contraception suppresses ovulation by gonadotropin suppression as a means of contraceptive action, and thus could impact an AMH value. A fascinating study by Hariton E et al looked at all contraceptive options and their impact on AMH values. AMH levels were significantly lower in women using COCs, implants, progestin-only pills, and vaginal rings compared to patients not using contraceptives, and AMH levels were slightly lower in women using hormonal IUDs. These results help clinicians counsel patients on expectations for AMH levels while on contraceptives and can guide future research to generate contraceptive-specific ranges. Women using contraceptives should be counseled to retest after stopping if AMH levels are low.

Levonorgestrel intrauterine devices (LNG IUD) are a hot topic in contraceptive research. A recent study on LNG IUDs published by Fay KE et al evaluated pregnancy rates in US women who received LNG or copper IUDs for emergency contraception and reported intercourse within 7 days of insertion. Zero pregnancies were reported in women who resumed intercourse within 7 days of IUD insertion for both the LNG IUD and copper IUD, even in women who had multiple unprotected sexual encounters.  LNG IUDs are more readily accessible and better tolerated than their copper IUD counterparts, and expanding their use will only continue to improve access to reliable contraception. Women often resume penetrative intercourse shortly after initiating new contraceptive method despite counseling. Patients can be reassured that placement of a LNG IUD appears to provide immediate contraceptive benefit.

 A new estrogen is on the market for use in combined oral contraceptive pills (COC). Estetrol is a natural estrogen produced by the human fetal liver only found in circulation during pregnancy.  Estetrol was previously studied for use in menopausal hormone therapy as it acts as a mixed agonist and antagonist, offering a potential improved side effect profile with less activity in the breast and liver.  Estetrol (15 mg) was combined with 3 mg of drospirinone for a novel combined oral contraceptive option in a study by Gemzell-Danielsson K et al.  The pregnancy rate was similar to traditional COCs, demonstrating good contraceptive efficacy. Bleeding patterns and side effects were similar to traditional COCs, and one case of venous thromboembolism was reported in the large study population. A phase III trial with similar results has been completed and this new oral contraceptive formulation recently received FDA approval and is now marketed as Nextstellis. This new oral contraceptive pill hopefully represents a novel option for women who desire COCs with a low androgenic profile and VTE risk or have failed other COC formulations.  

Women are increasingly delaying childbearing, utilizing a variety of contraceptive options to avoid pregnancy. Many proactively seek to determine their fertility potential and clinicians often utilize anti-Müllerian hormone (AMH) as the standard biomarker for assessing ovarian reserve, as it is cycle independent and can be drawn at any time during a woman’s clinical assessment.  Hormonal contraception suppresses ovulation by gonadotropin suppression as a means of contraceptive action, and thus could impact an AMH value. A fascinating study by Hariton E et al looked at all contraceptive options and their impact on AMH values. AMH levels were significantly lower in women using COCs, implants, progestin-only pills, and vaginal rings compared to patients not using contraceptives, and AMH levels were slightly lower in women using hormonal IUDs. These results help clinicians counsel patients on expectations for AMH levels while on contraceptives and can guide future research to generate contraceptive-specific ranges. Women using contraceptives should be counseled to retest after stopping if AMH levels are low.

Levonorgestrel intrauterine devices (LNG IUD) are a hot topic in contraceptive research. A recent study on LNG IUDs published by Fay KE et al evaluated pregnancy rates in US women who received LNG or copper IUDs for emergency contraception and reported intercourse within 7 days of insertion. Zero pregnancies were reported in women who resumed intercourse within 7 days of IUD insertion for both the LNG IUD and copper IUD, even in women who had multiple unprotected sexual encounters.  LNG IUDs are more readily accessible and better tolerated than their copper IUD counterparts, and expanding their use will only continue to improve access to reliable contraception. Women often resume penetrative intercourse shortly after initiating new contraceptive method despite counseling. Patients can be reassured that placement of a LNG IUD appears to provide immediate contraceptive benefit.

 A new estrogen is on the market for use in combined oral contraceptive pills (COC). Estetrol is a natural estrogen produced by the human fetal liver only found in circulation during pregnancy.  Estetrol was previously studied for use in menopausal hormone therapy as it acts as a mixed agonist and antagonist, offering a potential improved side effect profile with less activity in the breast and liver.  Estetrol (15 mg) was combined with 3 mg of drospirinone for a novel combined oral contraceptive option in a study by Gemzell-Danielsson K et al.  The pregnancy rate was similar to traditional COCs, demonstrating good contraceptive efficacy. Bleeding patterns and side effects were similar to traditional COCs, and one case of venous thromboembolism was reported in the large study population. A phase III trial with similar results has been completed and this new oral contraceptive formulation recently received FDA approval and is now marketed as Nextstellis. This new oral contraceptive pill hopefully represents a novel option for women who desire COCs with a low androgenic profile and VTE risk or have failed other COC formulations.  

Women are increasingly delaying childbearing, utilizing a variety of contraceptive options to avoid pregnancy. Many proactively seek to determine their fertility potential and clinicians often utilize anti-Müllerian hormone (AMH) as the standard biomarker for assessing ovarian reserve, as it is cycle independent and can be drawn at any time during a woman’s clinical assessment.  Hormonal contraception suppresses ovulation by gonadotropin suppression as a means of contraceptive action, and thus could impact an AMH value. A fascinating study by Hariton E et al looked at all contraceptive options and their impact on AMH values. AMH levels were significantly lower in women using COCs, implants, progestin-only pills, and vaginal rings compared to patients not using contraceptives, and AMH levels were slightly lower in women using hormonal IUDs. These results help clinicians counsel patients on expectations for AMH levels while on contraceptives and can guide future research to generate contraceptive-specific ranges. Women using contraceptives should be counseled to retest after stopping if AMH levels are low.

One of the most common reasons patients seek care from an ob.gyn. is for contraceptive counseling and family planning. While prescribing contraceptives for cisgender patients is often part of the daily routine for ob.gyns., many are unfamiliar with counseling and options for patients who identify as transgender. In a survey of practicing ob.gyns. in nine academic centers, 80% did not receive training on caring for transgender patients.¹ Other studies have found that 5.5%-9% of transgender men have reported that a clinician informed them that testosterone was a contraceptive.^2,3

Testosterone is not a reliable form of contraception and, in fact, testosterone is considered category X, as it can induce labial fusion, produce abnormal vaginal development, cause a persistent urogenital sinus, and cause clitoromegaly in the developing fetus. Given the teratogenic effects of testosterone, it is imperative that patients who do not desire pregnancy receive appropriate contraceptive options. Counseling of patients should be individualized and start by taking a comprehensive sexual history. Such strategies include using gender-inclusive language, avoiding assumptions about sexual orientation, and obtaining an anatomic inventory of both the patient and their partner(s).⁴ While a majority of patients achieve amenorrhea while taking testosterone, it is important to discuss the need for contraception if patients are engaging in penile-vaginal intercourse. According to a study of 41 transmasculine patients who achieved pregnancy, one-third of pregnancies were unplanned. Another study reported that 20% of transmasculine patients were taking testosterone and amenorrheic at the time of conception.²

Contraindications to certain types of contraception, such as a history of a thromboembolic event precluding a patient from using combined oral contraceptives, still apply. Transmasculine patients have additional concerns that providers should be aware of and sensitive to when prescribing contraceptives. Gender dysphoria may be exacerbated by contraceptive options that require a pelvic exam or procedure, such as an intrauterine device. For patients that desire an IUD but experience heightened distress in anticipation of the procedure, premedication with anxiolytics or topical anesthetics are reasonable options.⁴ Using an adequate amount of lubricant and a small speculum may also make the exam more comfortable for patients, especially if patients do not engage in receptive frontal intercourse. Of note, certain types of IUDs, such as the Paragard, may cause pelvic cramping or abnormal bleeding, which could be a trigger for dysphoria. Patients may also experience worsening dysphoria by repeatedly taking a medication that is often associated with cisgender women, such as combined oral contraceptives (COCs). Furthermore, patients may want to avoid COCs secondary to concerns about potential feminizing effects of these hormones and their counteraction of masculinizing effects of testosterone. While COCs act to lower androgen levels by increasing sex hormone–binding globulin, which subsequently binds to testosterone, the amount of estrogen in the pill does not contribute significantly to inhibiting masculinization, and patients should be counseled accordingly.^4,5 Side effects such as breast tenderness, which is common among COCs and other estrogen-containing contraceptives, can increase dysphoria and make chest binding more painful. In patients who undergo gender-affirming mastectomies, these effects are less pronounced, however, there may be residual breast tissue left behind which can still produce tenderness and pain.

Sterilization is also a reasonable option in transmasculine patients desiring permanent contraception. Similar to sterilization counseling in cisgender women, a discussion about the irreversibility of the procedure and rates of regret should occur. Transmasculine patients may seek hysterectomy for contraception and to avoid further pelvic exams, cervical cancer screening, pelvic cramping, and/or uterine bleeding. Providers should be knowledgeable about the World Professional Association for Transgender Health standards of care for gender-affirming hysterectomies and counsel patients appropriately.

In summary, transmasculine and all gender-diverse patients deserve the same comprehensive care that their cisgender counterparts receive. Even if the ob.gyn. is not the prescribing physician for testosterone, we all must have a basic understanding of the effects of testosterone and provide appropriate contraceptive services and family planning options to patients when indicated.

Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.

References

1. Unger CA. J Women’s Health. 2015;24(2):114-8.

2. Abern L and Maguire K. Obstet Gynecol. 2018;131:65S.

3. Light A et al. Contraception. 2018;98:266-9.

4. Krempasky C et al. Am J Obstet Gynecol. 2020;222(2):134-43.

5. Goodman NF et al. Endocrin Pract. 2015:21(11):1291-300.
 

One of the most common reasons patients seek care from an ob.gyn. is for contraceptive counseling and family planning. While prescribing contraceptives for cisgender patients is often part of the daily routine for ob.gyns., many are unfamiliar with counseling and options for patients who identify as transgender. In a survey of practicing ob.gyns. in nine academic centers, 80% did not receive training on caring for transgender patients.¹ Other studies have found that 5.5%-9% of transgender men have reported that a clinician informed them that testosterone was a contraceptive.^2,3

Testosterone is not a reliable form of contraception and, in fact, testosterone is considered category X, as it can induce labial fusion, produce abnormal vaginal development, cause a persistent urogenital sinus, and cause clitoromegaly in the developing fetus. Given the teratogenic effects of testosterone, it is imperative that patients who do not desire pregnancy receive appropriate contraceptive options. Counseling of patients should be individualized and start by taking a comprehensive sexual history. Such strategies include using gender-inclusive language, avoiding assumptions about sexual orientation, and obtaining an anatomic inventory of both the patient and their partner(s).⁴ While a majority of patients achieve amenorrhea while taking testosterone, it is important to discuss the need for contraception if patients are engaging in penile-vaginal intercourse. According to a study of 41 transmasculine patients who achieved pregnancy, one-third of pregnancies were unplanned. Another study reported that 20% of transmasculine patients were taking testosterone and amenorrheic at the time of conception.²

Contraindications to certain types of contraception, such as a history of a thromboembolic event precluding a patient from using combined oral contraceptives, still apply. Transmasculine patients have additional concerns that providers should be aware of and sensitive to when prescribing contraceptives. Gender dysphoria may be exacerbated by contraceptive options that require a pelvic exam or procedure, such as an intrauterine device. For patients that desire an IUD but experience heightened distress in anticipation of the procedure, premedication with anxiolytics or topical anesthetics are reasonable options.⁴ Using an adequate amount of lubricant and a small speculum may also make the exam more comfortable for patients, especially if patients do not engage in receptive frontal intercourse. Of note, certain types of IUDs, such as the Paragard, may cause pelvic cramping or abnormal bleeding, which could be a trigger for dysphoria. Patients may also experience worsening dysphoria by repeatedly taking a medication that is often associated with cisgender women, such as combined oral contraceptives (COCs). Furthermore, patients may want to avoid COCs secondary to concerns about potential feminizing effects of these hormones and their counteraction of masculinizing effects of testosterone. While COCs act to lower androgen levels by increasing sex hormone–binding globulin, which subsequently binds to testosterone, the amount of estrogen in the pill does not contribute significantly to inhibiting masculinization, and patients should be counseled accordingly.^4,5 Side effects such as breast tenderness, which is common among COCs and other estrogen-containing contraceptives, can increase dysphoria and make chest binding more painful. In patients who undergo gender-affirming mastectomies, these effects are less pronounced, however, there may be residual breast tissue left behind which can still produce tenderness and pain.

Sterilization is also a reasonable option in transmasculine patients desiring permanent contraception. Similar to sterilization counseling in cisgender women, a discussion about the irreversibility of the procedure and rates of regret should occur. Transmasculine patients may seek hysterectomy for contraception and to avoid further pelvic exams, cervical cancer screening, pelvic cramping, and/or uterine bleeding. Providers should be knowledgeable about the World Professional Association for Transgender Health standards of care for gender-affirming hysterectomies and counsel patients appropriately.

In summary, transmasculine and all gender-diverse patients deserve the same comprehensive care that their cisgender counterparts receive. Even if the ob.gyn. is not the prescribing physician for testosterone, we all must have a basic understanding of the effects of testosterone and provide appropriate contraceptive services and family planning options to patients when indicated.

Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.

References

1. Unger CA. J Women’s Health. 2015;24(2):114-8.

2. Abern L and Maguire K. Obstet Gynecol. 2018;131:65S.

3. Light A et al. Contraception. 2018;98:266-9.

4. Krempasky C et al. Am J Obstet Gynecol. 2020;222(2):134-43.

5. Goodman NF et al. Endocrin Pract. 2015:21(11):1291-300.
 

One of the most common reasons patients seek care from an ob.gyn. is for contraceptive counseling and family planning. While prescribing contraceptives for cisgender patients is often part of the daily routine for ob.gyns., many are unfamiliar with counseling and options for patients who identify as transgender. In a survey of practicing ob.gyns. in nine academic centers, 80% did not receive training on caring for transgender patients.¹ Other studies have found that 5.5%-9% of transgender men have reported that a clinician informed them that testosterone was a contraceptive.^2,3

Testosterone is not a reliable form of contraception and, in fact, testosterone is considered category X, as it can induce labial fusion, produce abnormal vaginal development, cause a persistent urogenital sinus, and cause clitoromegaly in the developing fetus. Given the teratogenic effects of testosterone, it is imperative that patients who do not desire pregnancy receive appropriate contraceptive options. Counseling of patients should be individualized and start by taking a comprehensive sexual history. Such strategies include using gender-inclusive language, avoiding assumptions about sexual orientation, and obtaining an anatomic inventory of both the patient and their partner(s).⁴ While a majority of patients achieve amenorrhea while taking testosterone, it is important to discuss the need for contraception if patients are engaging in penile-vaginal intercourse. According to a study of 41 transmasculine patients who achieved pregnancy, one-third of pregnancies were unplanned. Another study reported that 20% of transmasculine patients were taking testosterone and amenorrheic at the time of conception.²

Contraindications to certain types of contraception, such as a history of a thromboembolic event precluding a patient from using combined oral contraceptives, still apply. Transmasculine patients have additional concerns that providers should be aware of and sensitive to when prescribing contraceptives. Gender dysphoria may be exacerbated by contraceptive options that require a pelvic exam or procedure, such as an intrauterine device. For patients that desire an IUD but experience heightened distress in anticipation of the procedure, premedication with anxiolytics or topical anesthetics are reasonable options.⁴ Using an adequate amount of lubricant and a small speculum may also make the exam more comfortable for patients, especially if patients do not engage in receptive frontal intercourse. Of note, certain types of IUDs, such as the Paragard, may cause pelvic cramping or abnormal bleeding, which could be a trigger for dysphoria. Patients may also experience worsening dysphoria by repeatedly taking a medication that is often associated with cisgender women, such as combined oral contraceptives (COCs). Furthermore, patients may want to avoid COCs secondary to concerns about potential feminizing effects of these hormones and their counteraction of masculinizing effects of testosterone. While COCs act to lower androgen levels by increasing sex hormone–binding globulin, which subsequently binds to testosterone, the amount of estrogen in the pill does not contribute significantly to inhibiting masculinization, and patients should be counseled accordingly.^4,5 Side effects such as breast tenderness, which is common among COCs and other estrogen-containing contraceptives, can increase dysphoria and make chest binding more painful. In patients who undergo gender-affirming mastectomies, these effects are less pronounced, however, there may be residual breast tissue left behind which can still produce tenderness and pain.

Sterilization is also a reasonable option in transmasculine patients desiring permanent contraception. Similar to sterilization counseling in cisgender women, a discussion about the irreversibility of the procedure and rates of regret should occur. Transmasculine patients may seek hysterectomy for contraception and to avoid further pelvic exams, cervical cancer screening, pelvic cramping, and/or uterine bleeding. Providers should be knowledgeable about the World Professional Association for Transgender Health standards of care for gender-affirming hysterectomies and counsel patients appropriately.

In summary, transmasculine and all gender-diverse patients deserve the same comprehensive care that their cisgender counterparts receive. Even if the ob.gyn. is not the prescribing physician for testosterone, we all must have a basic understanding of the effects of testosterone and provide appropriate contraceptive services and family planning options to patients when indicated.

Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.

References

1. Unger CA. J Women’s Health. 2015;24(2):114-8.

2. Abern L and Maguire K. Obstet Gynecol. 2018;131:65S.

3. Light A et al. Contraception. 2018;98:266-9.

4. Krempasky C et al. Am J Obstet Gynecol. 2020;222(2):134-43.

5. Goodman NF et al. Endocrin Pract. 2015:21(11):1291-300.
 

SACRAMENTO (AP) – California is poised to approve reparations of up to $25,000 to some of the thousands of people – some as young as 13 – who were sterilized decades ago because the government deemed them unfit to have children.

The payments will make California at least the third state – following Virginia and North Carolina – to compensate victims of the so-called eugenics movement that peaked in the 1930s. Supporters of the movement believed sterilizing people with mental illnesses, physical disabilities, and other traits they deemed undesirable would improve the human race.

While California sterilized more than 20,000 people before its law was repealed in 1979, only a few hundred are still alive. The state has set aside $7.5 million for the reparations program, part of its $262.6 billion operating budget that is awaiting Gov. Gavin Newsom’s signature.

California’s proposal is unique because it also would pay women the state coerced to get sterilized while they were in prison, some as recently as 2010. First exposed by the Center for Investigative Reporting in 2013, a subsequent audit found California sterilized 144 women between 2005 and 2013 with little or no evidence that officials counseled them or offered alternative treatment.

While all of the women signed consent forms, officials in 39 cases did not do everything that was legally required to obtain their permission.

“We must address and face our horrific history,” said Lorena Garcia Zermeño, policy and communications coordinator for the advocacy group California Latinas for Reproductive Justice. “This isn’t something that just happened in the past.”

California’s forced sterilization program started in 1909, following similar laws in Indiana and Washington. It was by far the largest program, accounting for about a third of everyone sterilized in the United States under those laws.

California’s law was so prominent that it inspired similar practices in Nazi Germany, according to Paul Lombardo, a law professor at Georgia State University, Atlanta, and an expert on the eugenics movement.

“The promise of eugenics at the very earliest is: ‘We could do away with all the state institutions – prisons, hospitals, asylums, orphanages,’” Mr. Lombardo said. “People who were in them just wouldn’t be born after awhile if you sterilized all of their parents.”

In California, victims include Mary Franco, who was sterilized in 1934 when she was just 13. Paperwork described her as “feeble minded” because of “sexual deviance,” according to her niece, Stacy Cordova, who has researched her case.

Ms. Cordova said Franco actually was molested by a neighbor. She said her family put Ms. Franco in an institution to protect the family’s reputation.

Ms. Cordova said her late aunt loved children and wanted to have a family. She married briefly when she was about 17, but Ms. Cordova said the marriage was annulled when the man discovered Ms. Franco couldn’t have children. She lived a lonely life in a Mexican culture that revered big families, Ms. Cordova said.

“I don’t know if it is justice. Money doesn’t pay for what happened to them. But it’s great to know that this is being recognized,” said Ms. Cordova, who has advocated for the state to pay survivors. “For me, this is not about the money. This is about the memory.”

Relatives like Ms. Cordova aren’t eligible for the payments, only direct victims are.

Sterilizations in California prisons appear to date to 1999, when the state changed its policy for unknown reasons to include a sterilization procedure known as “tubal ligation” as part of inmates’ medical care. Over the next decade, women reported they were coerced into this procedure, with some not fully understanding the ramifications.

A state law passed in 2014 bans sterilizations for the purpose of birth control at state prisons and local jails. The law permits sterilizations that are “medically necessary,” such as removing cancer, and requires facilities to report each year how many people were sterilized and for what reason.

Questionable sterilizations also occurred in facilities run by local governments. In 2018, the Los Angeles County Board of Supervisors apologized after more than 200 women were sterilized at the Los Angeles–University of Southern California Medical Center between 1968 and 1974.

Those people are not eligible for reparations under California’s program. But advocates say they hope to include them in the future.

“It’s only the beginning,” said state Assemblywoman Wendy Carrillo, a Democrat from Los Angeles who has been advocating for reparations. “I can’t imagine the trauma, the depression, the stress of being incarcerated, being rehabilitated and trying to start your life again in society, wanting to start a family, only to find out that that choice was taken away from you.”

Of the people California sterilized under its old eugenics law, just a few hundred are still alive, according to research conducted by the Sterilization and Social Justice Lab. Including the inmates who were sterilized most recently, advocates estimate more than 600 people would be eligible for reparations.

But finding them will be difficult, with advocates predicting only about 25% of eligible people will ultimately apply for reparations and be paid.

California’s Victim Compensation Board will run the program, with $2 million used to find victims by advertising and poring through state records. The state also set aside $1 million for plaques to honor the victims, leaving $4.5 million for reparations.

A version of this article appeared on Medscape.com.

Associated Press © 2021 

SACRAMENTO (AP) – California is poised to approve reparations of up to $25,000 to some of the thousands of people – some as young as 13 – who were sterilized decades ago because the government deemed them unfit to have children.

The payments will make California at least the third state – following Virginia and North Carolina – to compensate victims of the so-called eugenics movement that peaked in the 1930s. Supporters of the movement believed sterilizing people with mental illnesses, physical disabilities, and other traits they deemed undesirable would improve the human race.

While California sterilized more than 20,000 people before its law was repealed in 1979, only a few hundred are still alive. The state has set aside $7.5 million for the reparations program, part of its $262.6 billion operating budget that is awaiting Gov. Gavin Newsom’s signature.

California’s proposal is unique because it also would pay women the state coerced to get sterilized while they were in prison, some as recently as 2010. First exposed by the Center for Investigative Reporting in 2013, a subsequent audit found California sterilized 144 women between 2005 and 2013 with little or no evidence that officials counseled them or offered alternative treatment.

While all of the women signed consent forms, officials in 39 cases did not do everything that was legally required to obtain their permission.

“We must address and face our horrific history,” said Lorena Garcia Zermeño, policy and communications coordinator for the advocacy group California Latinas for Reproductive Justice. “This isn’t something that just happened in the past.”

California’s forced sterilization program started in 1909, following similar laws in Indiana and Washington. It was by far the largest program, accounting for about a third of everyone sterilized in the United States under those laws.

California’s law was so prominent that it inspired similar practices in Nazi Germany, according to Paul Lombardo, a law professor at Georgia State University, Atlanta, and an expert on the eugenics movement.

“The promise of eugenics at the very earliest is: ‘We could do away with all the state institutions – prisons, hospitals, asylums, orphanages,’” Mr. Lombardo said. “People who were in them just wouldn’t be born after awhile if you sterilized all of their parents.”

In California, victims include Mary Franco, who was sterilized in 1934 when she was just 13. Paperwork described her as “feeble minded” because of “sexual deviance,” according to her niece, Stacy Cordova, who has researched her case.

Ms. Cordova said Franco actually was molested by a neighbor. She said her family put Ms. Franco in an institution to protect the family’s reputation.

Ms. Cordova said her late aunt loved children and wanted to have a family. She married briefly when she was about 17, but Ms. Cordova said the marriage was annulled when the man discovered Ms. Franco couldn’t have children. She lived a lonely life in a Mexican culture that revered big families, Ms. Cordova said.

“I don’t know if it is justice. Money doesn’t pay for what happened to them. But it’s great to know that this is being recognized,” said Ms. Cordova, who has advocated for the state to pay survivors. “For me, this is not about the money. This is about the memory.”

Relatives like Ms. Cordova aren’t eligible for the payments, only direct victims are.

Sterilizations in California prisons appear to date to 1999, when the state changed its policy for unknown reasons to include a sterilization procedure known as “tubal ligation” as part of inmates’ medical care. Over the next decade, women reported they were coerced into this procedure, with some not fully understanding the ramifications.

A state law passed in 2014 bans sterilizations for the purpose of birth control at state prisons and local jails. The law permits sterilizations that are “medically necessary,” such as removing cancer, and requires facilities to report each year how many people were sterilized and for what reason.

Questionable sterilizations also occurred in facilities run by local governments. In 2018, the Los Angeles County Board of Supervisors apologized after more than 200 women were sterilized at the Los Angeles–University of Southern California Medical Center between 1968 and 1974.

Those people are not eligible for reparations under California’s program. But advocates say they hope to include them in the future.

“It’s only the beginning,” said state Assemblywoman Wendy Carrillo, a Democrat from Los Angeles who has been advocating for reparations. “I can’t imagine the trauma, the depression, the stress of being incarcerated, being rehabilitated and trying to start your life again in society, wanting to start a family, only to find out that that choice was taken away from you.”

Of the people California sterilized under its old eugenics law, just a few hundred are still alive, according to research conducted by the Sterilization and Social Justice Lab. Including the inmates who were sterilized most recently, advocates estimate more than 600 people would be eligible for reparations.

But finding them will be difficult, with advocates predicting only about 25% of eligible people will ultimately apply for reparations and be paid.

California’s Victim Compensation Board will run the program, with $2 million used to find victims by advertising and poring through state records. The state also set aside $1 million for plaques to honor the victims, leaving $4.5 million for reparations.

A version of this article appeared on Medscape.com.

Associated Press © 2021 

SACRAMENTO (AP) – California is poised to approve reparations of up to $25,000 to some of the thousands of people – some as young as 13 – who were sterilized decades ago because the government deemed them unfit to have children.

The payments will make California at least the third state – following Virginia and North Carolina – to compensate victims of the so-called eugenics movement that peaked in the 1930s. Supporters of the movement believed sterilizing people with mental illnesses, physical disabilities, and other traits they deemed undesirable would improve the human race.

While California sterilized more than 20,000 people before its law was repealed in 1979, only a few hundred are still alive. The state has set aside $7.5 million for the reparations program, part of its $262.6 billion operating budget that is awaiting Gov. Gavin Newsom’s signature.

California’s proposal is unique because it also would pay women the state coerced to get sterilized while they were in prison, some as recently as 2010. First exposed by the Center for Investigative Reporting in 2013, a subsequent audit found California sterilized 144 women between 2005 and 2013 with little or no evidence that officials counseled them or offered alternative treatment.

While all of the women signed consent forms, officials in 39 cases did not do everything that was legally required to obtain their permission.

“We must address and face our horrific history,” said Lorena Garcia Zermeño, policy and communications coordinator for the advocacy group California Latinas for Reproductive Justice. “This isn’t something that just happened in the past.”

California’s forced sterilization program started in 1909, following similar laws in Indiana and Washington. It was by far the largest program, accounting for about a third of everyone sterilized in the United States under those laws.

California’s law was so prominent that it inspired similar practices in Nazi Germany, according to Paul Lombardo, a law professor at Georgia State University, Atlanta, and an expert on the eugenics movement.

“The promise of eugenics at the very earliest is: ‘We could do away with all the state institutions – prisons, hospitals, asylums, orphanages,’” Mr. Lombardo said. “People who were in them just wouldn’t be born after awhile if you sterilized all of their parents.”

In California, victims include Mary Franco, who was sterilized in 1934 when she was just 13. Paperwork described her as “feeble minded” because of “sexual deviance,” according to her niece, Stacy Cordova, who has researched her case.

Ms. Cordova said Franco actually was molested by a neighbor. She said her family put Ms. Franco in an institution to protect the family’s reputation.

Ms. Cordova said her late aunt loved children and wanted to have a family. She married briefly when she was about 17, but Ms. Cordova said the marriage was annulled when the man discovered Ms. Franco couldn’t have children. She lived a lonely life in a Mexican culture that revered big families, Ms. Cordova said.

“I don’t know if it is justice. Money doesn’t pay for what happened to them. But it’s great to know that this is being recognized,” said Ms. Cordova, who has advocated for the state to pay survivors. “For me, this is not about the money. This is about the memory.”

Relatives like Ms. Cordova aren’t eligible for the payments, only direct victims are.

Sterilizations in California prisons appear to date to 1999, when the state changed its policy for unknown reasons to include a sterilization procedure known as “tubal ligation” as part of inmates’ medical care. Over the next decade, women reported they were coerced into this procedure, with some not fully understanding the ramifications.

A state law passed in 2014 bans sterilizations for the purpose of birth control at state prisons and local jails. The law permits sterilizations that are “medically necessary,” such as removing cancer, and requires facilities to report each year how many people were sterilized and for what reason.

Questionable sterilizations also occurred in facilities run by local governments. In 2018, the Los Angeles County Board of Supervisors apologized after more than 200 women were sterilized at the Los Angeles–University of Southern California Medical Center between 1968 and 1974.

Those people are not eligible for reparations under California’s program. But advocates say they hope to include them in the future.

“It’s only the beginning,” said state Assemblywoman Wendy Carrillo, a Democrat from Los Angeles who has been advocating for reparations. “I can’t imagine the trauma, the depression, the stress of being incarcerated, being rehabilitated and trying to start your life again in society, wanting to start a family, only to find out that that choice was taken away from you.”

Of the people California sterilized under its old eugenics law, just a few hundred are still alive, according to research conducted by the Sterilization and Social Justice Lab. Including the inmates who were sterilized most recently, advocates estimate more than 600 people would be eligible for reparations.

But finding them will be difficult, with advocates predicting only about 25% of eligible people will ultimately apply for reparations and be paid.

California’s Victim Compensation Board will run the program, with $2 million used to find victims by advertising and poring through state records. The state also set aside $1 million for plaques to honor the victims, leaving $4.5 million for reparations.

A version of this article appeared on Medscape.com.

Associated Press © 2021 

Travel distance is an important determinant of access to abortion care in the United States, new findings show.

Increases in median travel distance to the nearest abortion care facility were associated with significant reductions in median abortion rate.

The abortion rate was 21.1 per 1,000 female residents of reproductive age among those who lived less than 5 miles from a facility, but that number dropped to 3.9/1,000 for those living 120 miles or further away.

Overall, in a model of 3,107 U.S. counties that included 62.5 million women of reproductive age, there were an estimated 696,760 abortions (at a mean rate of 11.1/1,000). The authors estimate that if abortion services were integrated into primary care, an additional 18,190 abortions would be performed (mean rate, 11.4/1,000).

Similarly, if telemedicine became widely available in this setting, this would allow approximately 70,920 abortions (mean rate 12.3/1,000). The study was published online in JAMA Open Network.

Reducing travel distances to abortion facilities would increase access, but additional clinics and providers would be needed to meet the demand. But as the population density of many counties with poor access is low, innovative strategies are also needed.

Integrating abortion into primary care or making medication abortion care available by telemedicine may decrease this unmet need, and lead author Kirsten Thompson, MPH, noted that there is growing evidence that both solutions are quite feasible to implement.

“A study published in 2018 has led primary care providers to adopt the same regimen for miscarriage care, showing that they are interested and capable, despite the barriers posed by the mifepristone [Risk Evaluation and Mitigation Strategy] program for these patients,” said Ms. Thompson, who is program and communications director, Bixby Center for Global Reproductive Health, University of California, San Francisco. “Medical education programs designed specifically for primary care providers have trained family medicine and other clinicians in abortion care for over a decade.”

As for telemedicine, Ms. Thompson explained that, during the pandemic, a preliminary injunction in a federal court case and then the Food and Drug Administration suspended enforcement of the in-person requirements of the mifepristone REMS. “In states that allow medical abortion care by telemedicine, providers have been able to offer remote care when medically appropriate, including mailing medical abortion pills to patients at home,” she said. “Researchers have already published evidence on the safety of and patient satisfaction with this approach.”

However, there are two main barriers to the widespread adoption of medical abortion by telemedicine in the United States. “One is the potentially temporary nature of the FDA’s enforcement discretion and second, are the 19 states with laws that ban it, singling out medical abortion as somehow different from other forms of care by telemedicine,” she said.
 

Study details

About one in four women in the United States will terminate a pregnancy during their lifetime, but the issue is highly contentious and many states have implemented policies that restrict access to abortion care. The authors pointed out that studies have documented clinic closures and women being unable to obtain abortion care, with low-income women and non-White women being disproportionately affected. Increased travel to a provider has also been associated with delays in care as well as increased costs and stress.

Prior research has shown that the further a woman lives from a facility, the less likely she is to obtain abortion care. In this study, Ms. Thompson and colleagues examined the association between travel distance to the nearest abortion care facility and the abortion rate, and then modeled the effect of reduced travel distance on rates.

They first conducted a cross-sectional geographic analysis using the American Community Survey and the U.S. Census to calculate county-level abortion rates per 1,000 women aged between 15 and 44 years. The 2015 data covered 1,948 counties in 27 states.

Abortion rates were then estimated for 3,107 counties in 48 states and the effect of different travel distance scenarios on the abortion rate was also estimated by multivariable model. Data were collected from April 2018 to October 2019.

There were 37.3 million women of reproductive age residing in the 27 states, and a total of 428,720 reported abortions (mean rate, 11.5/1,000; median rate, 9.9/1,000 women).

When looking at all 48 states, the population-weighted mean travel distance to the nearest facility was 25.6 miles, with a median travel distance of 8.2 miles.

A multivariable model showed that a greater travel distance was associated with lower abortion rates. When compared with traveling less than 5 miles, the abortion rate declined by 0.05/1,000 for women traveling between 5 to less than 15 miles for care, 0.22 for those traveling 15 to less than 30 miles, 0.34 for 30 to less than 60 miles, 0.43 for 60 to less than 120 miles, and 0.73 for those traveling 120 miles or more.

They estimated that, if all travel was under 30 miles, there would be a 2.6% increase or 18,190 additional abortions. A simulation also showed that there would be a 10.2% increase (70,920 additional abortions) using medication via telemedicine.
 

Solutions are feasible

Approached for an independent comment, Sarah W. Prager, MD, MAS, professor of obstetrics and gynecology and division chief, complex family planning, at the University of Washington, Seattle, agreed that the solutions proposed by the authors were feasible.

“More than a third of abortions that are eligible are now done with medication,” she said, “And 89% of abortions are done in the first trimester.”

What this means is that early first-trimester abortions can conceivably be performed in the primary care setting. “Any primary care clinician – whether it’s a family practice or internal medicine physician, or nurse practitioner or nurse midwife – can all be trained to do aspiration or prescribe medication in the first trimester,” said Dr. Prager. “So it could easily be integrated into primary care settings if there was motivation for that to happen.”

However, she emphasized that more is involved than just training the provider. “The whole clinic has to buy into it,” Dr. Prager explained. “The nurses have to be willing to assist, you need the medical assistants, the scheduler or person who works the front desk – the whole clinic system has to buy into it and that’s where it becomes more challenging.”

The individual provider may be willing, but the system may still not be allowing that to happen. “This is also where telemedicine can come in, where the medication can be mailed so it can circumvent the problem to a certain extent,” Dr. Prager added. “You don’t have to have the infrastructure in the same way.”

But many states already have laws in place to make that illegal, especially for abortion care even if they allow it for similar types of care.

Another expert also weighed in and agreed that these two solutions can potentially be implemented.

“The concept of decreased rates of abortion associated with greater distances traveled is not new, but what is unique to this manuscript is the estimations that the authors conducted in understanding the impact of expanding access to abortion among primary care and telehealth providers,” said Catherine Cansino, MD, MPH, associate clinical professor in the department of obstetrics and gynecology, University of California, Davis.

“The study provides convincing evidence regarding the need to strengthen infrastructures that support expansion of these services in primary care settings, among physicians and advanced care practitioners,” she said. “Training to provide medical abortion and first-trimester surgical abortion is simple. Many primary care providers are already doing gynecologic procedures – IUD insertions, colposcopies, endometrial biopsies.”

Thus, she noted, adding abortion care “to their toolkit isn’t too far of a stretch.”

As for telemedicine, Dr. Cansino pointed out how the COVID-19 pandemic has also expanded what both patients and providers think are safe options for providing and receiving good care. “Consultations through telemedicine coupled with access to medications for medical abortion through local pharmacies or express mail is definitely safe and feasible.”

The study was supported by the William and Flora Hewlett Foundation and by an anonymous foundation for general operating support (Ms Thompson). Ms. Thompson reported receiving personal fees from GenBioPro outside the submitted work. Dr. Cansino and Dr. Prager have no disclosures.

Travel distance is an important determinant of access to abortion care in the United States, new findings show.

Increases in median travel distance to the nearest abortion care facility were associated with significant reductions in median abortion rate.

The abortion rate was 21.1 per 1,000 female residents of reproductive age among those who lived less than 5 miles from a facility, but that number dropped to 3.9/1,000 for those living 120 miles or further away.

Overall, in a model of 3,107 U.S. counties that included 62.5 million women of reproductive age, there were an estimated 696,760 abortions (at a mean rate of 11.1/1,000). The authors estimate that if abortion services were integrated into primary care, an additional 18,190 abortions would be performed (mean rate, 11.4/1,000).

Similarly, if telemedicine became widely available in this setting, this would allow approximately 70,920 abortions (mean rate 12.3/1,000). The study was published online in JAMA Open Network.

Reducing travel distances to abortion facilities would increase access, but additional clinics and providers would be needed to meet the demand. But as the population density of many counties with poor access is low, innovative strategies are also needed.

Integrating abortion into primary care or making medication abortion care available by telemedicine may decrease this unmet need, and lead author Kirsten Thompson, MPH, noted that there is growing evidence that both solutions are quite feasible to implement.

“A study published in 2018 has led primary care providers to adopt the same regimen for miscarriage care, showing that they are interested and capable, despite the barriers posed by the mifepristone [Risk Evaluation and Mitigation Strategy] program for these patients,” said Ms. Thompson, who is program and communications director, Bixby Center for Global Reproductive Health, University of California, San Francisco. “Medical education programs designed specifically for primary care providers have trained family medicine and other clinicians in abortion care for over a decade.”

As for telemedicine, Ms. Thompson explained that, during the pandemic, a preliminary injunction in a federal court case and then the Food and Drug Administration suspended enforcement of the in-person requirements of the mifepristone REMS. “In states that allow medical abortion care by telemedicine, providers have been able to offer remote care when medically appropriate, including mailing medical abortion pills to patients at home,” she said. “Researchers have already published evidence on the safety of and patient satisfaction with this approach.”

However, there are two main barriers to the widespread adoption of medical abortion by telemedicine in the United States. “One is the potentially temporary nature of the FDA’s enforcement discretion and second, are the 19 states with laws that ban it, singling out medical abortion as somehow different from other forms of care by telemedicine,” she said.
 

Study details

About one in four women in the United States will terminate a pregnancy during their lifetime, but the issue is highly contentious and many states have implemented policies that restrict access to abortion care. The authors pointed out that studies have documented clinic closures and women being unable to obtain abortion care, with low-income women and non-White women being disproportionately affected. Increased travel to a provider has also been associated with delays in care as well as increased costs and stress.

Prior research has shown that the further a woman lives from a facility, the less likely she is to obtain abortion care. In this study, Ms. Thompson and colleagues examined the association between travel distance to the nearest abortion care facility and the abortion rate, and then modeled the effect of reduced travel distance on rates.

They first conducted a cross-sectional geographic analysis using the American Community Survey and the U.S. Census to calculate county-level abortion rates per 1,000 women aged between 15 and 44 years. The 2015 data covered 1,948 counties in 27 states.

Abortion rates were then estimated for 3,107 counties in 48 states and the effect of different travel distance scenarios on the abortion rate was also estimated by multivariable model. Data were collected from April 2018 to October 2019.

There were 37.3 million women of reproductive age residing in the 27 states, and a total of 428,720 reported abortions (mean rate, 11.5/1,000; median rate, 9.9/1,000 women).

When looking at all 48 states, the population-weighted mean travel distance to the nearest facility was 25.6 miles, with a median travel distance of 8.2 miles.

A multivariable model showed that a greater travel distance was associated with lower abortion rates. When compared with traveling less than 5 miles, the abortion rate declined by 0.05/1,000 for women traveling between 5 to less than 15 miles for care, 0.22 for those traveling 15 to less than 30 miles, 0.34 for 30 to less than 60 miles, 0.43 for 60 to less than 120 miles, and 0.73 for those traveling 120 miles or more.

They estimated that, if all travel was under 30 miles, there would be a 2.6% increase or 18,190 additional abortions. A simulation also showed that there would be a 10.2% increase (70,920 additional abortions) using medication via telemedicine.
 

Solutions are feasible

Approached for an independent comment, Sarah W. Prager, MD, MAS, professor of obstetrics and gynecology and division chief, complex family planning, at the University of Washington, Seattle, agreed that the solutions proposed by the authors were feasible.

“More than a third of abortions that are eligible are now done with medication,” she said, “And 89% of abortions are done in the first trimester.”

What this means is that early first-trimester abortions can conceivably be performed in the primary care setting. “Any primary care clinician – whether it’s a family practice or internal medicine physician, or nurse practitioner or nurse midwife – can all be trained to do aspiration or prescribe medication in the first trimester,” said Dr. Prager. “So it could easily be integrated into primary care settings if there was motivation for that to happen.”

However, she emphasized that more is involved than just training the provider. “The whole clinic has to buy into it,” Dr. Prager explained. “The nurses have to be willing to assist, you need the medical assistants, the scheduler or person who works the front desk – the whole clinic system has to buy into it and that’s where it becomes more challenging.”

The individual provider may be willing, but the system may still not be allowing that to happen. “This is also where telemedicine can come in, where the medication can be mailed so it can circumvent the problem to a certain extent,” Dr. Prager added. “You don’t have to have the infrastructure in the same way.”

But many states already have laws in place to make that illegal, especially for abortion care even if they allow it for similar types of care.

Another expert also weighed in and agreed that these two solutions can potentially be implemented.

“The concept of decreased rates of abortion associated with greater distances traveled is not new, but what is unique to this manuscript is the estimations that the authors conducted in understanding the impact of expanding access to abortion among primary care and telehealth providers,” said Catherine Cansino, MD, MPH, associate clinical professor in the department of obstetrics and gynecology, University of California, Davis.

“The study provides convincing evidence regarding the need to strengthen infrastructures that support expansion of these services in primary care settings, among physicians and advanced care practitioners,” she said. “Training to provide medical abortion and first-trimester surgical abortion is simple. Many primary care providers are already doing gynecologic procedures – IUD insertions, colposcopies, endometrial biopsies.”

Thus, she noted, adding abortion care “to their toolkit isn’t too far of a stretch.”

As for telemedicine, Dr. Cansino pointed out how the COVID-19 pandemic has also expanded what both patients and providers think are safe options for providing and receiving good care. “Consultations through telemedicine coupled with access to medications for medical abortion through local pharmacies or express mail is definitely safe and feasible.”

The study was supported by the William and Flora Hewlett Foundation and by an anonymous foundation for general operating support (Ms Thompson). Ms. Thompson reported receiving personal fees from GenBioPro outside the submitted work. Dr. Cansino and Dr. Prager have no disclosures.

Travel distance is an important determinant of access to abortion care in the United States, new findings show.

Increases in median travel distance to the nearest abortion care facility were associated with significant reductions in median abortion rate.

The abortion rate was 21.1 per 1,000 female residents of reproductive age among those who lived less than 5 miles from a facility, but that number dropped to 3.9/1,000 for those living 120 miles or further away.

Overall, in a model of 3,107 U.S. counties that included 62.5 million women of reproductive age, there were an estimated 696,760 abortions (at a mean rate of 11.1/1,000). The authors estimate that if abortion services were integrated into primary care, an additional 18,190 abortions would be performed (mean rate, 11.4/1,000).

Similarly, if telemedicine became widely available in this setting, this would allow approximately 70,920 abortions (mean rate 12.3/1,000). The study was published online in JAMA Open Network.

Reducing travel distances to abortion facilities would increase access, but additional clinics and providers would be needed to meet the demand. But as the population density of many counties with poor access is low, innovative strategies are also needed.

Integrating abortion into primary care or making medication abortion care available by telemedicine may decrease this unmet need, and lead author Kirsten Thompson, MPH, noted that there is growing evidence that both solutions are quite feasible to implement.

“A study published in 2018 has led primary care providers to adopt the same regimen for miscarriage care, showing that they are interested and capable, despite the barriers posed by the mifepristone [Risk Evaluation and Mitigation Strategy] program for these patients,” said Ms. Thompson, who is program and communications director, Bixby Center for Global Reproductive Health, University of California, San Francisco. “Medical education programs designed specifically for primary care providers have trained family medicine and other clinicians in abortion care for over a decade.”

As for telemedicine, Ms. Thompson explained that, during the pandemic, a preliminary injunction in a federal court case and then the Food and Drug Administration suspended enforcement of the in-person requirements of the mifepristone REMS. “In states that allow medical abortion care by telemedicine, providers have been able to offer remote care when medically appropriate, including mailing medical abortion pills to patients at home,” she said. “Researchers have already published evidence on the safety of and patient satisfaction with this approach.”

However, there are two main barriers to the widespread adoption of medical abortion by telemedicine in the United States. “One is the potentially temporary nature of the FDA’s enforcement discretion and second, are the 19 states with laws that ban it, singling out medical abortion as somehow different from other forms of care by telemedicine,” she said.
 

Study details

About one in four women in the United States will terminate a pregnancy during their lifetime, but the issue is highly contentious and many states have implemented policies that restrict access to abortion care. The authors pointed out that studies have documented clinic closures and women being unable to obtain abortion care, with low-income women and non-White women being disproportionately affected. Increased travel to a provider has also been associated with delays in care as well as increased costs and stress.

Prior research has shown that the further a woman lives from a facility, the less likely she is to obtain abortion care. In this study, Ms. Thompson and colleagues examined the association between travel distance to the nearest abortion care facility and the abortion rate, and then modeled the effect of reduced travel distance on rates.

They first conducted a cross-sectional geographic analysis using the American Community Survey and the U.S. Census to calculate county-level abortion rates per 1,000 women aged between 15 and 44 years. The 2015 data covered 1,948 counties in 27 states.

Abortion rates were then estimated for 3,107 counties in 48 states and the effect of different travel distance scenarios on the abortion rate was also estimated by multivariable model. Data were collected from April 2018 to October 2019.

There were 37.3 million women of reproductive age residing in the 27 states, and a total of 428,720 reported abortions (mean rate, 11.5/1,000; median rate, 9.9/1,000 women).

When looking at all 48 states, the population-weighted mean travel distance to the nearest facility was 25.6 miles, with a median travel distance of 8.2 miles.

A multivariable model showed that a greater travel distance was associated with lower abortion rates. When compared with traveling less than 5 miles, the abortion rate declined by 0.05/1,000 for women traveling between 5 to less than 15 miles for care, 0.22 for those traveling 15 to less than 30 miles, 0.34 for 30 to less than 60 miles, 0.43 for 60 to less than 120 miles, and 0.73 for those traveling 120 miles or more.

They estimated that, if all travel was under 30 miles, there would be a 2.6% increase or 18,190 additional abortions. A simulation also showed that there would be a 10.2% increase (70,920 additional abortions) using medication via telemedicine.
 

Solutions are feasible

Approached for an independent comment, Sarah W. Prager, MD, MAS, professor of obstetrics and gynecology and division chief, complex family planning, at the University of Washington, Seattle, agreed that the solutions proposed by the authors were feasible.

“More than a third of abortions that are eligible are now done with medication,” she said, “And 89% of abortions are done in the first trimester.”

What this means is that early first-trimester abortions can conceivably be performed in the primary care setting. “Any primary care clinician – whether it’s a family practice or internal medicine physician, or nurse practitioner or nurse midwife – can all be trained to do aspiration or prescribe medication in the first trimester,” said Dr. Prager. “So it could easily be integrated into primary care settings if there was motivation for that to happen.”

However, she emphasized that more is involved than just training the provider. “The whole clinic has to buy into it,” Dr. Prager explained. “The nurses have to be willing to assist, you need the medical assistants, the scheduler or person who works the front desk – the whole clinic system has to buy into it and that’s where it becomes more challenging.”

The individual provider may be willing, but the system may still not be allowing that to happen. “This is also where telemedicine can come in, where the medication can be mailed so it can circumvent the problem to a certain extent,” Dr. Prager added. “You don’t have to have the infrastructure in the same way.”

But many states already have laws in place to make that illegal, especially for abortion care even if they allow it for similar types of care.

Another expert also weighed in and agreed that these two solutions can potentially be implemented.

“The concept of decreased rates of abortion associated with greater distances traveled is not new, but what is unique to this manuscript is the estimations that the authors conducted in understanding the impact of expanding access to abortion among primary care and telehealth providers,” said Catherine Cansino, MD, MPH, associate clinical professor in the department of obstetrics and gynecology, University of California, Davis.

“The study provides convincing evidence regarding the need to strengthen infrastructures that support expansion of these services in primary care settings, among physicians and advanced care practitioners,” she said. “Training to provide medical abortion and first-trimester surgical abortion is simple. Many primary care providers are already doing gynecologic procedures – IUD insertions, colposcopies, endometrial biopsies.”

Thus, she noted, adding abortion care “to their toolkit isn’t too far of a stretch.”

As for telemedicine, Dr. Cansino pointed out how the COVID-19 pandemic has also expanded what both patients and providers think are safe options for providing and receiving good care. “Consultations through telemedicine coupled with access to medications for medical abortion through local pharmacies or express mail is definitely safe and feasible.”

The study was supported by the William and Flora Hewlett Foundation and by an anonymous foundation for general operating support (Ms Thompson). Ms. Thompson reported receiving personal fees from GenBioPro outside the submitted work. Dr. Cansino and Dr. Prager have no disclosures.

The contraceptive needs of women who have had in vitro fertilization (IVF) pregnancies are real but are being overlooked, according to study data presented at the Royal College of Obstetricians & Gynaecologists (RCOG) Virtual World Congress 2021.

The interview-based study found that women report not being routinely informed about the chance of spontaneous pregnancy after IVF. “There is scope to follow-up with women after IVF … but information about the chances of spontaneous births and need for contraception isn’t given,” said lead researcher Annette Thwaites, MD, an academic clinical fellow and a senior registrar in Community Sexual and Reproductive Health at Kings College Hospital, London.

“Fertility services, maternity services, and community services could all do more to give women information on contraception postnatally,” Dr. Thwaites said.

“Even if a woman has had IVF previously, a woman shouldn’t lose the right to plan the rest of her family,” she added. “We need to stop shielding these women from the information they really do need.”

Dr. Thwaites first came across the issue around contraception after IVF pregnancy while talking to new mothers in a postnatal ward for another study. Ward staff told her not to enter the rooms with women who had had IVF births, with the implication that these women would not need or want contraception.

With this in mind, Dr. Thwaites and colleagues aimed to better understand the contraceptive needs of women after successful IVF pregnancy to improve service delivery and prevent unplanned and rapid-repeat pregnancies after IVF.

The researchers interviewed 21 women who had spontaneous pregnancies after successful IVF. Participants were aged 35-50 years, the majority were White, British, professional, married for at least 10 years, and living in nuclear families.

Of the spontaneous post-IVF pregnancies in these women, outcomes included single (11) and multiple live births (1 twin), miscarriage (1), ectopic (1) termination of pregnancy (1), and three ongoing pregnancies.  

After IVF pregnancy, most women said that they used no contraception or ineffective contraception and had never had a conversation around contraception after IVF.

The women also reported that spontaneous pregnancy was shocking and not universally welcomed, and interpregnancy intervals were often short.

In addition, comments by these women suggested certain aspects of the IVF experience reinforced their perceptions of subfertility. One is quoted as saying, “It seemed to be this big failure if you were having IVF.” Another said, “It’s bad enough that I’m having to conceive my baby like this.”
 

An unmet need

In her 30 years of practice, Melanie Davies, MD, has seen many women who experience natural pregnancy after IVF. She agrees it is important to address these women’s contraceptive needs but stresses that it needs to be approached carefully.

“It can stir up sensitivities to discuss this issue after having an IVF pregnancy,” said Dr. Davies, a consultant obstetrician and gynecologist at University College London Hospitals, London. “I think many women genuinely think that contraception after IVF just doesn’t apply, but lots of women do have natural pregnancies after IVF. I think women do need this information, but we need to be aware of the sensitivities around this issue, so the way we deliver it is crucial.”

Gwenda Burns, chief executive of the National Patient Charity Fertility Network UK, which supports people before, during, and after fertility treatment, agrees that the process leading up to a successful IVF birth can have lasting effects.

“Fertility struggles and going through fertility treatment can put an enormous strain on both physical and mental health and can have a long-lasting impact,” Ms. Burns said when asked to comment on the new study.

“It is vital that patients receive the right support, guidance, and advice following treatment, including when natural conception may still be possible,” Ms. Burns continued.
 

Growing population

Given the increasing use of IVF in recent years, Dr. Thwaites said the importance of understanding and meeting the contraceptive needs of women post-IVF is increasingly important. Also, people are turning to it earlier and for other reasons, such as women in same sex relationships, single women, pre-implantation genetic testing, and surrogates.

“During the recruitment process for the current study, I came across women who said since their IVF pregnancies they had no idea what they should do about contraception,” Dr. Thwaites said.

But she empathizes with health care professionals too. “I genuinely feel that health care professionals just don’t know how to advise women in this setting, so they avoid the topic of contraception altogether with these women. They are concerned about making women feel awkward or upsetting them. In my experience, there is very little said about IVF and contraception in the same breath.”
 

Women believe subfertility always persists after IVF

Among participants in the study, the causes of the women’s subfertility were wide-ranging and included tubal, anovulatory, male factor, joint, and unexplained, the latter of which affects 25% of couples with fertility issues. In the cohort, women had taken up to 9 years to conceive their first child and one had a donor egg conception.

After IVF, the chance of pregnancy will depend on the reason for the couple’s subfertility. “Given that a huge number of patients these days have unexplained subfertility. This is when there is no absolute cause of infertility identified, and it might not prevent a pregnancy but slows it down,” Dr. Davies said in an interview. “Such couples still have a chance of natural pregnancy.”

Polycystic ovary syndrome as a cause of subfertility is often associated with improvement in fertility after IVF, Dr. Davies noted. “This can improve after a spontaneous pregnancy or after IVF, even if the IVF is not a success, and this is possibly due to needling the ovary.”

Dr. Thwaites added that challenging women’s perceptions of their subfertility is critical if headway is to be made on this topic. Many women have persistent views concerning their subfertility after successful IVF, which may be rooted in previous failed treatment; need for repeat cycles or intracytoplasmic sperm injection (ICSI); low numbers of eggs collected; poor quality embryos; and pregnancy complications, to note some of the most common reasons.

“So many [women] feel that they are very lucky to have had a pregnancy because their journey has been difficult. They might have had a successful pregnancy, but they still hold a sense of personal failure,” said Dr. Thwaites. “Even after spontaneous pregnancy some women said it was a miracle or freak event. [Yet two of these] women had two spontaneous pregnancies.”

Remarkably, even after subsequent spontaneous pregnancy, use of contraception and the most effective methods remained low among participants.

As well as fixed beliefs concerning their subfertility, other barriers to contraception use included a lack of knowledge of likelihood of spontaneous pregnancy; lack of contraceptive experience; and inherent incentives towards shorter interpregnancy intervals (e.g., the convenience and privacy of undergoing further IVF while still on maternity leave and availability of frozen embryos).

Looking ahead, Dr. Thwaites says there is a clear need to link and/or expand the maternity services dataset to uncover the true rates of post-IVF spontaneous pregnancy.

Dr. Thwaites and Dr. Davies have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The contraceptive needs of women who have had in vitro fertilization (IVF) pregnancies are real but are being overlooked, according to study data presented at the Royal College of Obstetricians & Gynaecologists (RCOG) Virtual World Congress 2021.

The interview-based study found that women report not being routinely informed about the chance of spontaneous pregnancy after IVF. “There is scope to follow-up with women after IVF … but information about the chances of spontaneous births and need for contraception isn’t given,” said lead researcher Annette Thwaites, MD, an academic clinical fellow and a senior registrar in Community Sexual and Reproductive Health at Kings College Hospital, London.

“Fertility services, maternity services, and community services could all do more to give women information on contraception postnatally,” Dr. Thwaites said.

“Even if a woman has had IVF previously, a woman shouldn’t lose the right to plan the rest of her family,” she added. “We need to stop shielding these women from the information they really do need.”

Dr. Thwaites first came across the issue around contraception after IVF pregnancy while talking to new mothers in a postnatal ward for another study. Ward staff told her not to enter the rooms with women who had had IVF births, with the implication that these women would not need or want contraception.

With this in mind, Dr. Thwaites and colleagues aimed to better understand the contraceptive needs of women after successful IVF pregnancy to improve service delivery and prevent unplanned and rapid-repeat pregnancies after IVF.

The researchers interviewed 21 women who had spontaneous pregnancies after successful IVF. Participants were aged 35-50 years, the majority were White, British, professional, married for at least 10 years, and living in nuclear families.

Of the spontaneous post-IVF pregnancies in these women, outcomes included single (11) and multiple live births (1 twin), miscarriage (1), ectopic (1) termination of pregnancy (1), and three ongoing pregnancies.  

After IVF pregnancy, most women said that they used no contraception or ineffective contraception and had never had a conversation around contraception after IVF.

The women also reported that spontaneous pregnancy was shocking and not universally welcomed, and interpregnancy intervals were often short.

In addition, comments by these women suggested certain aspects of the IVF experience reinforced their perceptions of subfertility. One is quoted as saying, “It seemed to be this big failure if you were having IVF.” Another said, “It’s bad enough that I’m having to conceive my baby like this.”
 

An unmet need

In her 30 years of practice, Melanie Davies, MD, has seen many women who experience natural pregnancy after IVF. She agrees it is important to address these women’s contraceptive needs but stresses that it needs to be approached carefully.

“It can stir up sensitivities to discuss this issue after having an IVF pregnancy,” said Dr. Davies, a consultant obstetrician and gynecologist at University College London Hospitals, London. “I think many women genuinely think that contraception after IVF just doesn’t apply, but lots of women do have natural pregnancies after IVF. I think women do need this information, but we need to be aware of the sensitivities around this issue, so the way we deliver it is crucial.”

Gwenda Burns, chief executive of the National Patient Charity Fertility Network UK, which supports people before, during, and after fertility treatment, agrees that the process leading up to a successful IVF birth can have lasting effects.

“Fertility struggles and going through fertility treatment can put an enormous strain on both physical and mental health and can have a long-lasting impact,” Ms. Burns said when asked to comment on the new study.

“It is vital that patients receive the right support, guidance, and advice following treatment, including when natural conception may still be possible,” Ms. Burns continued.
 

Growing population

Given the increasing use of IVF in recent years, Dr. Thwaites said the importance of understanding and meeting the contraceptive needs of women post-IVF is increasingly important. Also, people are turning to it earlier and for other reasons, such as women in same sex relationships, single women, pre-implantation genetic testing, and surrogates.

“During the recruitment process for the current study, I came across women who said since their IVF pregnancies they had no idea what they should do about contraception,” Dr. Thwaites said.

But she empathizes with health care professionals too. “I genuinely feel that health care professionals just don’t know how to advise women in this setting, so they avoid the topic of contraception altogether with these women. They are concerned about making women feel awkward or upsetting them. In my experience, there is very little said about IVF and contraception in the same breath.”
 

Women believe subfertility always persists after IVF

Among participants in the study, the causes of the women’s subfertility were wide-ranging and included tubal, anovulatory, male factor, joint, and unexplained, the latter of which affects 25% of couples with fertility issues. In the cohort, women had taken up to 9 years to conceive their first child and one had a donor egg conception.

After IVF, the chance of pregnancy will depend on the reason for the couple’s subfertility. “Given that a huge number of patients these days have unexplained subfertility. This is when there is no absolute cause of infertility identified, and it might not prevent a pregnancy but slows it down,” Dr. Davies said in an interview. “Such couples still have a chance of natural pregnancy.”

Polycystic ovary syndrome as a cause of subfertility is often associated with improvement in fertility after IVF, Dr. Davies noted. “This can improve after a spontaneous pregnancy or after IVF, even if the IVF is not a success, and this is possibly due to needling the ovary.”

Dr. Thwaites added that challenging women’s perceptions of their subfertility is critical if headway is to be made on this topic. Many women have persistent views concerning their subfertility after successful IVF, which may be rooted in previous failed treatment; need for repeat cycles or intracytoplasmic sperm injection (ICSI); low numbers of eggs collected; poor quality embryos; and pregnancy complications, to note some of the most common reasons.

“So many [women] feel that they are very lucky to have had a pregnancy because their journey has been difficult. They might have had a successful pregnancy, but they still hold a sense of personal failure,” said Dr. Thwaites. “Even after spontaneous pregnancy some women said it was a miracle or freak event. [Yet two of these] women had two spontaneous pregnancies.”

Remarkably, even after subsequent spontaneous pregnancy, use of contraception and the most effective methods remained low among participants.

As well as fixed beliefs concerning their subfertility, other barriers to contraception use included a lack of knowledge of likelihood of spontaneous pregnancy; lack of contraceptive experience; and inherent incentives towards shorter interpregnancy intervals (e.g., the convenience and privacy of undergoing further IVF while still on maternity leave and availability of frozen embryos).

Looking ahead, Dr. Thwaites says there is a clear need to link and/or expand the maternity services dataset to uncover the true rates of post-IVF spontaneous pregnancy.

Dr. Thwaites and Dr. Davies have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The contraceptive needs of women who have had in vitro fertilization (IVF) pregnancies are real but are being overlooked, according to study data presented at the Royal College of Obstetricians & Gynaecologists (RCOG) Virtual World Congress 2021.

The interview-based study found that women report not being routinely informed about the chance of spontaneous pregnancy after IVF. “There is scope to follow-up with women after IVF … but information about the chances of spontaneous births and need for contraception isn’t given,” said lead researcher Annette Thwaites, MD, an academic clinical fellow and a senior registrar in Community Sexual and Reproductive Health at Kings College Hospital, London.

“Fertility services, maternity services, and community services could all do more to give women information on contraception postnatally,” Dr. Thwaites said.

“Even if a woman has had IVF previously, a woman shouldn’t lose the right to plan the rest of her family,” she added. “We need to stop shielding these women from the information they really do need.”

Dr. Thwaites first came across the issue around contraception after IVF pregnancy while talking to new mothers in a postnatal ward for another study. Ward staff told her not to enter the rooms with women who had had IVF births, with the implication that these women would not need or want contraception.

With this in mind, Dr. Thwaites and colleagues aimed to better understand the contraceptive needs of women after successful IVF pregnancy to improve service delivery and prevent unplanned and rapid-repeat pregnancies after IVF.

The researchers interviewed 21 women who had spontaneous pregnancies after successful IVF. Participants were aged 35-50 years, the majority were White, British, professional, married for at least 10 years, and living in nuclear families.

Of the spontaneous post-IVF pregnancies in these women, outcomes included single (11) and multiple live births (1 twin), miscarriage (1), ectopic (1) termination of pregnancy (1), and three ongoing pregnancies.  

After IVF pregnancy, most women said that they used no contraception or ineffective contraception and had never had a conversation around contraception after IVF.

The women also reported that spontaneous pregnancy was shocking and not universally welcomed, and interpregnancy intervals were often short.

In addition, comments by these women suggested certain aspects of the IVF experience reinforced their perceptions of subfertility. One is quoted as saying, “It seemed to be this big failure if you were having IVF.” Another said, “It’s bad enough that I’m having to conceive my baby like this.”
 

An unmet need

In her 30 years of practice, Melanie Davies, MD, has seen many women who experience natural pregnancy after IVF. She agrees it is important to address these women’s contraceptive needs but stresses that it needs to be approached carefully.

“It can stir up sensitivities to discuss this issue after having an IVF pregnancy,” said Dr. Davies, a consultant obstetrician and gynecologist at University College London Hospitals, London. “I think many women genuinely think that contraception after IVF just doesn’t apply, but lots of women do have natural pregnancies after IVF. I think women do need this information, but we need to be aware of the sensitivities around this issue, so the way we deliver it is crucial.”

Gwenda Burns, chief executive of the National Patient Charity Fertility Network UK, which supports people before, during, and after fertility treatment, agrees that the process leading up to a successful IVF birth can have lasting effects.

“Fertility struggles and going through fertility treatment can put an enormous strain on both physical and mental health and can have a long-lasting impact,” Ms. Burns said when asked to comment on the new study.

“It is vital that patients receive the right support, guidance, and advice following treatment, including when natural conception may still be possible,” Ms. Burns continued.
 

Growing population

Given the increasing use of IVF in recent years, Dr. Thwaites said the importance of understanding and meeting the contraceptive needs of women post-IVF is increasingly important. Also, people are turning to it earlier and for other reasons, such as women in same sex relationships, single women, pre-implantation genetic testing, and surrogates.

“During the recruitment process for the current study, I came across women who said since their IVF pregnancies they had no idea what they should do about contraception,” Dr. Thwaites said.

But she empathizes with health care professionals too. “I genuinely feel that health care professionals just don’t know how to advise women in this setting, so they avoid the topic of contraception altogether with these women. They are concerned about making women feel awkward or upsetting them. In my experience, there is very little said about IVF and contraception in the same breath.”
 

Women believe subfertility always persists after IVF

Among participants in the study, the causes of the women’s subfertility were wide-ranging and included tubal, anovulatory, male factor, joint, and unexplained, the latter of which affects 25% of couples with fertility issues. In the cohort, women had taken up to 9 years to conceive their first child and one had a donor egg conception.

After IVF, the chance of pregnancy will depend on the reason for the couple’s subfertility. “Given that a huge number of patients these days have unexplained subfertility. This is when there is no absolute cause of infertility identified, and it might not prevent a pregnancy but slows it down,” Dr. Davies said in an interview. “Such couples still have a chance of natural pregnancy.”

Polycystic ovary syndrome as a cause of subfertility is often associated with improvement in fertility after IVF, Dr. Davies noted. “This can improve after a spontaneous pregnancy or after IVF, even if the IVF is not a success, and this is possibly due to needling the ovary.”

Dr. Thwaites added that challenging women’s perceptions of their subfertility is critical if headway is to be made on this topic. Many women have persistent views concerning their subfertility after successful IVF, which may be rooted in previous failed treatment; need for repeat cycles or intracytoplasmic sperm injection (ICSI); low numbers of eggs collected; poor quality embryos; and pregnancy complications, to note some of the most common reasons.

“So many [women] feel that they are very lucky to have had a pregnancy because their journey has been difficult. They might have had a successful pregnancy, but they still hold a sense of personal failure,” said Dr. Thwaites. “Even after spontaneous pregnancy some women said it was a miracle or freak event. [Yet two of these] women had two spontaneous pregnancies.”

Remarkably, even after subsequent spontaneous pregnancy, use of contraception and the most effective methods remained low among participants.

As well as fixed beliefs concerning their subfertility, other barriers to contraception use included a lack of knowledge of likelihood of spontaneous pregnancy; lack of contraceptive experience; and inherent incentives towards shorter interpregnancy intervals (e.g., the convenience and privacy of undergoing further IVF while still on maternity leave and availability of frozen embryos).

Looking ahead, Dr. Thwaites says there is a clear need to link and/or expand the maternity services dataset to uncover the true rates of post-IVF spontaneous pregnancy.

Dr. Thwaites and Dr. Davies have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Frequency or timing of unprotected intercourse within 14 days before IUD placement had no impact on pregnancy if a preplacement pregnancy test was negative, based on data from 655 women who received IUDs.

Many women present for emergency contraception with a history of unprotected intercourse, often beyond the 5-day guidelines for emergency contraception recommended by the World Health Organization, wrote Abena BakenRa, MD, of the University of California, Berkeley, and colleagues. “As such, we lack data on situations in which multiple episodes of unprotected intercourse occurred in the same menstrual cycle of use, especially episodes occurring more than 5 days before emergency contraception use,” the researchers said.

To determine pregnancy risk during a longer period before IUD placement, the researchers reviewed secondary data from a randomized trial of 655 women who received the copper T380A IUD or levonorgestrel 52-mg intrauterine system for emergency contraception. The women were aged 18-35 years and were enrolled at one of six family planning clinics in Utah between August 2016 and December 2019.

In a study published in Obstetrics & Gynecology, the researchers assessed pregnancies at 1 month after IUD placement. All of the women had a confirmed negative urine pregnancy test result immediately before IUD placement.

Overall, 286 women (43.7%) reported multiple episodes of unprotected intercourse, with a median of three episodes. A total of 95 women (14.4%) reported at least one unprotected intercourse episode at 6 days or more prior to IUD placement. No pregnancies were reported among women in either of these categories (0.0% for both). Pregnancy risk was 0.2% among those who reported unprotected intercourse within 5 days of IUD placement.

No pregnancies occurred in those who reported additional episodes of unprotected intercourse at 6-7 days, 6-10 days, or 6-14 days before IUD placement (0% for all).

In both the copper IUD and levonorgestrel groups, 68% and 74%, respectively, of the women reported that all fertile-window unprotected intercourse events occurred in the 5 days prior to IUD placement.

The study findings were limited by several factors including the lack of power for analysis of certain categories of assessment, such as pregnancy rates by timing or frequency, the inclusion of patients only from the state of Utah, and the potential underreporting of unprotected intercourse, the researchers noted. However, the findings were strengthened by the relatively large sample size, and by data on unprotected intercourse before IUD placement in a randomized, controlled trial that included two types of IUDs, they said.

“For these situations with multiple unprotected intercourse episodes and extended time between unprotected intercourse and emergency contraception request, potential users should be informed of the evidence of IUD emergency contraception efficacy, compared with the current state of uncertain data for oral emergency contraception methods,” the researchers said.

“Given the multitude of barriers that may impede timely presentation to care (insurance and cost concerns, difficulty finding a capable health care professional, or sexual assault trauma), these data are critical to patient-centered family planning care,” they concluded.

Data support IUD placement in practice

“Understanding potential barriers to placement of long-acting reversible contraception such as IUDs is essential to expanding access to contraception,” Iris Krishna, MD, of Emory University, Atlanta, said in an interview.

“This study is a secondary analysis of a randomized trial that compared copper versus levonorgestrel IUD placement for emergency contraception. Investigators were able to evaluate frequency and timing of unprotected intercourse up to 14 days prior to IUD placement and prospectively collect data assessing pregnancy risk 1 month after IUD placement,” she said.

The study findings suggest that the risk of pregnancy with unprotected intercourse within 14 days of IUD placement is low overall, and that this risk does not appear to increase with multiple episodes of unprotected intercourse during this time period, Dr. Krishna said. “In general, insertion of an IUD may occur at any time during the menstrual cycle as long as pregnancy may be reasonably excluded and clinicians are encouraged to initiate and place long-acting reversible contraceptives in a single visit, if possible,” she noted. However, “there is a paucity of data on risk of pregnancy when assessing efficacy of IUDs as emergency contraception with episodes of unprotected intercourse more than 5 days prior to IUD placement,” she added.

The study results also suggest that pregnancy risk is similar between women who reported unprotected intercourse within 5 days prior to IUD placement and those who reported unprotected intercourse up to 14 days prior to IUD placement, said Dr. Krishna. “These findings are clinically significant, as they add to our understanding of risk of pregnancy with unprotected intercourse up to 14 days prior to placement of an IUD,” she emphasized.

In practice, the study results “will help clinicians counsel patients on risk of pregnancy after IUD placement for emergency contraception,” said Dr. Krishna. “More studies evaluating risk of pregnancy after IUD placement for emergency contraception with episodes of unprotected intercourse more than 5 days prior to placement are needed to further assess the potential to expand the time frame for IUD use as emergency contraception,” she said. “Reducing barriers to IUD access, especially in setting of emergency contraception, is essential to lowering unintended pregnancy rates in the United States.”

The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, as well as the University of Utah Population Health Research Foundation, the National Center for Research Resources, and the National Center for Advancing Translational Sciences at the National Institutes of Health. Several coauthors disclosed grant support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Office of Research on Women’s Health of the National Institutes of Health. The researchers, as well as Dr. Krishna, had no financial conflicts to disclose.

Frequency or timing of unprotected intercourse within 14 days before IUD placement had no impact on pregnancy if a preplacement pregnancy test was negative, based on data from 655 women who received IUDs.

Many women present for emergency contraception with a history of unprotected intercourse, often beyond the 5-day guidelines for emergency contraception recommended by the World Health Organization, wrote Abena BakenRa, MD, of the University of California, Berkeley, and colleagues. “As such, we lack data on situations in which multiple episodes of unprotected intercourse occurred in the same menstrual cycle of use, especially episodes occurring more than 5 days before emergency contraception use,” the researchers said.

To determine pregnancy risk during a longer period before IUD placement, the researchers reviewed secondary data from a randomized trial of 655 women who received the copper T380A IUD or levonorgestrel 52-mg intrauterine system for emergency contraception. The women were aged 18-35 years and were enrolled at one of six family planning clinics in Utah between August 2016 and December 2019.

In a study published in Obstetrics & Gynecology, the researchers assessed pregnancies at 1 month after IUD placement. All of the women had a confirmed negative urine pregnancy test result immediately before IUD placement.

Overall, 286 women (43.7%) reported multiple episodes of unprotected intercourse, with a median of three episodes. A total of 95 women (14.4%) reported at least one unprotected intercourse episode at 6 days or more prior to IUD placement. No pregnancies were reported among women in either of these categories (0.0% for both). Pregnancy risk was 0.2% among those who reported unprotected intercourse within 5 days of IUD placement.

No pregnancies occurred in those who reported additional episodes of unprotected intercourse at 6-7 days, 6-10 days, or 6-14 days before IUD placement (0% for all).

In both the copper IUD and levonorgestrel groups, 68% and 74%, respectively, of the women reported that all fertile-window unprotected intercourse events occurred in the 5 days prior to IUD placement.

The study findings were limited by several factors including the lack of power for analysis of certain categories of assessment, such as pregnancy rates by timing or frequency, the inclusion of patients only from the state of Utah, and the potential underreporting of unprotected intercourse, the researchers noted. However, the findings were strengthened by the relatively large sample size, and by data on unprotected intercourse before IUD placement in a randomized, controlled trial that included two types of IUDs, they said.

“For these situations with multiple unprotected intercourse episodes and extended time between unprotected intercourse and emergency contraception request, potential users should be informed of the evidence of IUD emergency contraception efficacy, compared with the current state of uncertain data for oral emergency contraception methods,” the researchers said.

“Given the multitude of barriers that may impede timely presentation to care (insurance and cost concerns, difficulty finding a capable health care professional, or sexual assault trauma), these data are critical to patient-centered family planning care,” they concluded.

Data support IUD placement in practice

“Understanding potential barriers to placement of long-acting reversible contraception such as IUDs is essential to expanding access to contraception,” Iris Krishna, MD, of Emory University, Atlanta, said in an interview.

“This study is a secondary analysis of a randomized trial that compared copper versus levonorgestrel IUD placement for emergency contraception. Investigators were able to evaluate frequency and timing of unprotected intercourse up to 14 days prior to IUD placement and prospectively collect data assessing pregnancy risk 1 month after IUD placement,” she said.

The study findings suggest that the risk of pregnancy with unprotected intercourse within 14 days of IUD placement is low overall, and that this risk does not appear to increase with multiple episodes of unprotected intercourse during this time period, Dr. Krishna said. “In general, insertion of an IUD may occur at any time during the menstrual cycle as long as pregnancy may be reasonably excluded and clinicians are encouraged to initiate and place long-acting reversible contraceptives in a single visit, if possible,” she noted. However, “there is a paucity of data on risk of pregnancy when assessing efficacy of IUDs as emergency contraception with episodes of unprotected intercourse more than 5 days prior to IUD placement,” she added.

The study results also suggest that pregnancy risk is similar between women who reported unprotected intercourse within 5 days prior to IUD placement and those who reported unprotected intercourse up to 14 days prior to IUD placement, said Dr. Krishna. “These findings are clinically significant, as they add to our understanding of risk of pregnancy with unprotected intercourse up to 14 days prior to placement of an IUD,” she emphasized.

In practice, the study results “will help clinicians counsel patients on risk of pregnancy after IUD placement for emergency contraception,” said Dr. Krishna. “More studies evaluating risk of pregnancy after IUD placement for emergency contraception with episodes of unprotected intercourse more than 5 days prior to placement are needed to further assess the potential to expand the time frame for IUD use as emergency contraception,” she said. “Reducing barriers to IUD access, especially in setting of emergency contraception, is essential to lowering unintended pregnancy rates in the United States.”

The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, as well as the University of Utah Population Health Research Foundation, the National Center for Research Resources, and the National Center for Advancing Translational Sciences at the National Institutes of Health. Several coauthors disclosed grant support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Office of Research on Women’s Health of the National Institutes of Health. The researchers, as well as Dr. Krishna, had no financial conflicts to disclose.

Frequency or timing of unprotected intercourse within 14 days before IUD placement had no impact on pregnancy if a preplacement pregnancy test was negative, based on data from 655 women who received IUDs.

Many women present for emergency contraception with a history of unprotected intercourse, often beyond the 5-day guidelines for emergency contraception recommended by the World Health Organization, wrote Abena BakenRa, MD, of the University of California, Berkeley, and colleagues. “As such, we lack data on situations in which multiple episodes of unprotected intercourse occurred in the same menstrual cycle of use, especially episodes occurring more than 5 days before emergency contraception use,” the researchers said.

To determine pregnancy risk during a longer period before IUD placement, the researchers reviewed secondary data from a randomized trial of 655 women who received the copper T380A IUD or levonorgestrel 52-mg intrauterine system for emergency contraception. The women were aged 18-35 years and were enrolled at one of six family planning clinics in Utah between August 2016 and December 2019.

In a study published in Obstetrics & Gynecology, the researchers assessed pregnancies at 1 month after IUD placement. All of the women had a confirmed negative urine pregnancy test result immediately before IUD placement.

Overall, 286 women (43.7%) reported multiple episodes of unprotected intercourse, with a median of three episodes. A total of 95 women (14.4%) reported at least one unprotected intercourse episode at 6 days or more prior to IUD placement. No pregnancies were reported among women in either of these categories (0.0% for both). Pregnancy risk was 0.2% among those who reported unprotected intercourse within 5 days of IUD placement.

No pregnancies occurred in those who reported additional episodes of unprotected intercourse at 6-7 days, 6-10 days, or 6-14 days before IUD placement (0% for all).

In both the copper IUD and levonorgestrel groups, 68% and 74%, respectively, of the women reported that all fertile-window unprotected intercourse events occurred in the 5 days prior to IUD placement.

The study findings were limited by several factors including the lack of power for analysis of certain categories of assessment, such as pregnancy rates by timing or frequency, the inclusion of patients only from the state of Utah, and the potential underreporting of unprotected intercourse, the researchers noted. However, the findings were strengthened by the relatively large sample size, and by data on unprotected intercourse before IUD placement in a randomized, controlled trial that included two types of IUDs, they said.

“For these situations with multiple unprotected intercourse episodes and extended time between unprotected intercourse and emergency contraception request, potential users should be informed of the evidence of IUD emergency contraception efficacy, compared with the current state of uncertain data for oral emergency contraception methods,” the researchers said.

“Given the multitude of barriers that may impede timely presentation to care (insurance and cost concerns, difficulty finding a capable health care professional, or sexual assault trauma), these data are critical to patient-centered family planning care,” they concluded.

Data support IUD placement in practice

“Understanding potential barriers to placement of long-acting reversible contraception such as IUDs is essential to expanding access to contraception,” Iris Krishna, MD, of Emory University, Atlanta, said in an interview.

“This study is a secondary analysis of a randomized trial that compared copper versus levonorgestrel IUD placement for emergency contraception. Investigators were able to evaluate frequency and timing of unprotected intercourse up to 14 days prior to IUD placement and prospectively collect data assessing pregnancy risk 1 month after IUD placement,” she said.

The study findings suggest that the risk of pregnancy with unprotected intercourse within 14 days of IUD placement is low overall, and that this risk does not appear to increase with multiple episodes of unprotected intercourse during this time period, Dr. Krishna said. “In general, insertion of an IUD may occur at any time during the menstrual cycle as long as pregnancy may be reasonably excluded and clinicians are encouraged to initiate and place long-acting reversible contraceptives in a single visit, if possible,” she noted. However, “there is a paucity of data on risk of pregnancy when assessing efficacy of IUDs as emergency contraception with episodes of unprotected intercourse more than 5 days prior to IUD placement,” she added.

The study results also suggest that pregnancy risk is similar between women who reported unprotected intercourse within 5 days prior to IUD placement and those who reported unprotected intercourse up to 14 days prior to IUD placement, said Dr. Krishna. “These findings are clinically significant, as they add to our understanding of risk of pregnancy with unprotected intercourse up to 14 days prior to placement of an IUD,” she emphasized.

In practice, the study results “will help clinicians counsel patients on risk of pregnancy after IUD placement for emergency contraception,” said Dr. Krishna. “More studies evaluating risk of pregnancy after IUD placement for emergency contraception with episodes of unprotected intercourse more than 5 days prior to placement are needed to further assess the potential to expand the time frame for IUD use as emergency contraception,” she said. “Reducing barriers to IUD access, especially in setting of emergency contraception, is essential to lowering unintended pregnancy rates in the United States.”

The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, as well as the University of Utah Population Health Research Foundation, the National Center for Research Resources, and the National Center for Advancing Translational Sciences at the National Institutes of Health. Several coauthors disclosed grant support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Office of Research on Women’s Health of the National Institutes of Health. The researchers, as well as Dr. Krishna, had no financial conflicts to disclose.

Key clinical point: Women in rural areas were less likely to receive counseling about emergency contraception than urban women, but counseling rates were low for both groups (2% and 3%, respectively). 

Major finding: Between 2006 and 2017, 10% of rural women and 19% of urban women who had ever had sex reported ever using emergency contraception pills, and ever-use of emergency contraception pills more than doubled in both groups between 2006-2008 and 2015-2017.

Study details: The data come from 28,448 teens and women aged 15-44 years who participated in the National Survey of Family Growth between 2006 and 2017.

Disclosures: The study received no outside funding; one coauthor was supported by the Maine Economic Improvement Fund. The other researchers had no financial conflicts to disclose.

Source: Milkowski CM et al. Contracep X. 2021 Feb 8. doi: 10.1016/j.conx.2021.100061. 

Key clinical point: Women in rural areas were less likely to receive counseling about emergency contraception than urban women, but counseling rates were low for both groups (2% and 3%, respectively). 

Major finding: Between 2006 and 2017, 10% of rural women and 19% of urban women who had ever had sex reported ever using emergency contraception pills, and ever-use of emergency contraception pills more than doubled in both groups between 2006-2008 and 2015-2017.

Study details: The data come from 28,448 teens and women aged 15-44 years who participated in the National Survey of Family Growth between 2006 and 2017.

Disclosures: The study received no outside funding; one coauthor was supported by the Maine Economic Improvement Fund. The other researchers had no financial conflicts to disclose.

Source: Milkowski CM et al. Contracep X. 2021 Feb 8. doi: 10.1016/j.conx.2021.100061. 

Key clinical point: Women in rural areas were less likely to receive counseling about emergency contraception than urban women, but counseling rates were low for both groups (2% and 3%, respectively). 

Major finding: Between 2006 and 2017, 10% of rural women and 19% of urban women who had ever had sex reported ever using emergency contraception pills, and ever-use of emergency contraception pills more than doubled in both groups between 2006-2008 and 2015-2017.

Study details: The data come from 28,448 teens and women aged 15-44 years who participated in the National Survey of Family Growth between 2006 and 2017.

Disclosures: The study received no outside funding; one coauthor was supported by the Maine Economic Improvement Fund. The other researchers had no financial conflicts to disclose.

Source: Milkowski CM et al. Contracep X. 2021 Feb 8. doi: 10.1016/j.conx.2021.100061.