Contraception

Editorial Board

2012-02-01

Pregnancy outcomes with an IUD in situ: a systematic review

2011-08-17

Abstract: Background: While intrauterine devices (IUDs) provide highly effective contraception, pregnancies among IUD users do rarely occur. The objective of this systematic review is to assess the evidence about risks for adverse pregnancy outcomes among women who conceive with an IUD in situ.Methods: We searched MEDLINE, POPLINE, EMBASE and LILACS databases from inception through April 2011 for peer-reviewed articles containing evidence related to pregnancy outcomes among women who conceived while using copper (Cu) and levonorgestrel-releasing (LNG) IUDs.Results: Nine articles met our inclusion criteria. Women with retained IUDs were at the greatest risk of adverse pregnancy outcomes, including spontaneous abortion, preterm delivery, septic abortion and chorioamnionitis. Cu-IUD removal decreased risks but not to the baseline risk of pregnancies without an IUD. One case series examined the LNG-IUD; when left in situ, 8 in 10 ended in spontaneous abortions.Conclusion: Pregnancies complicated by a remaining IUD in situ were at greater risk of adverse pregnancy outcomes. Early IUD removal appeared to improve outcomes but did not entirely eliminate risks.

Feticidal digoxin injection before dilation and evacuation abortion: Evidence and ethics

David A. Grimes, Gretchen S. Stuart, Elizabeth G. Raymond — 2011-05-27

Feticidal injection of digoxin before dilation and evacuation (D&E) abortion has become common in recent years and is now a standard policy at some abortion clinics. The procedure entails amniocentesis and administration of digoxin into the amniotic fluid or fetus before uterine evacuation. Two new reports in this issue of the journal present conflicting views about its safety .

Safety of digoxin for fetal demise before second-trimester abortion by dilation and evacuation

2011-07-11

Abstract: Background: Digoxin is used to induce fetal demise before dilation and evacuation (D&E) abortion. Published data on the safety of digoxin in abortion care are limited.Study Design: We conducted a retrospective cohort study with historical controls at a large family planning center. We reviewed the records of patients at 18 to 24 weeks' gestation who received digoxin before D&E from May 15, 2007 (date the center initiated digoxin use), through March 31, 2008. We also reviewed the records of patients who presented for D&E without digoxin from February 22, 2006, through May 12, 2007. We compared the rates of immediate complications.Results: We included 566 digoxin patients and 513 controls. Eleven spontaneous abortions occurred in the digoxin cohort; none occurred among controls (p<.001). We found 19 cases of infection in the digoxin cohort and three among controls (odds ratio 5.91; 95% confidence interval 1.74–20.07). Eleven digoxin patients were admitted to a hospital after the preoperative visit; no controls were admitted (p<.001).Conclusions: Patients who received digoxin before D&E were more likely to experience spontaneous abortion, infection and hospital admission than controls who underwent D&E without digoxin.

Infection and extramural delivery with use of digoxin as a feticidal agent

Rachel Steward, Alexander Melamed, Renita Kim, Deborah Nucatola, Mary Gatter — 2011-02-21

Abstract: Background: Many abortion providers use digoxin to induce fetal demise prior to dilation and evacuation (D&E). Our primary objective was to examine the frequency of infection and extramural delivery following digoxin use.Study Design: We conducted a retrospective single-cohort study. Inclusion criteria were all women between 18 and 24 weeks of estimated gestational age who received digoxin in preparation for D&E at our outpatient facility. We queried two electronic databases to collect data on the frequency of extramural delivery and the rate of perioperative infection.Results: From January 1, 2000, to December 31, 2008, 4906 abortions were performed between 18 and 24 weeks of estimated gestation with digoxin injection administered as feticidal agent 1 day prior to D&E. Extramural delivery frequency was 0.30%, and infection frequency was 0.04%. There were no significant differences in the frequency of extramural deliveries across procedure year (p=.2), estimated gestational age (p=.3), race/ethnicity (p=.2) or maternal age (p=.3).Conclusion: Rates of extramural delivery and infection are acceptably low following digoxin use prior to scheduled D&E.

Revival of the intrauterine device: increased insertions among US women with employer-sponsored insurance, 2002–2008

Xin Xu, Maurizio Macaluso, Lijing Ouyang, Andrzej Kulczycki, Scott D. Grosse — 2011-08-01

Abstract: Background: Use of the intrauterine device (IUD) in the United States has recently increased. New evidence for women with employer-sponsored health insurance permits analysis of variation and trends in such use.Study Design: A retrospective analysis of annual IUD insertion rates between 2002 and 2008 was conducted by evaluating claims from the MarketScan® Commercial Research Databases for US women insured by plans that covered IUD insertions. Estimates were weighted to be nationally representative.Results: IUD insertion rates increased from 1.6/1000 women of reproductive age to 9.8/1000 over 2002–2008 and varied substantially by state. Insertion rates of the levonorgestrel-releasing intrauterine system (LNG-IUS) increased from 0.4/1000 to 7.7/1000, whereas the insertion rates of copper T380A IUD (copper IUD) increased from 0.6/1000 to 1.5/1000. IUD insertions, which are most common among women aged 25–34 years, increased at roughly the same rate across all age groups.Conclusions: The sixfold increase in IUD insertion rates between 2002 and 2008 was accompanied by an increase in the share IUD use with the LNG-IUS from 40% to 85%. Substantial geographic and age variations existed.

Does the provision of free intrauterine contraception reduce pregnancy rates among uninsured low-income women? A cohort study a two North Carolina clinics

Nicole Fanarjian, Christina Drostin, Joanne Garrett, Arlin Montalvo — 2011-07-15

Abstract: Background: Low-income women are disproportionately affected by unintended pregnancy. The Access to Resources in Contraceptive Health Foundation was established to provide free levonorgestrel intrauterine contraceptive systems to uninsured women who meet specific socioeconomic eligibility criteria. The aim of this study was to evaluate the effectiveness of this program at reducing pregnancies among uninsured women attending two North Carolina clinics.Study Design: This was a retrospective cohort study including uninsured women (aged 15–44 years) who desired contraception, were deemed eligible for the program and attended one of two North Carolina clinics between January 1, 2003, and June 30, 2009. The primary outcome was pregnancy. Pregnancy rates were compared between those women who had a program-approved intrauterine device placed (exposed group) and those women who were eligible for the program, but did not have a device placed (the unexposed group). Questionnaires were used to determine the numbers of pregnancies (and dates of conception), the types of alternative contraception being used and basic demographic information about program participants. The data were analyzed using survival analysis of time to pregnancy. A Cox proportional hazards model was used to estimate a hazard ratio.Results: We attempted to reach 321 patients and obtained 104 responses. After exclusions, data from 90 participants were analyzed. Sixty-five women received a levonorgestrel device, and 25 eligible women did not. Seven pregnancies occurred in the exposed group (11%), all after the IUD was removed; three of these pregnancies were planned. Eight pregnancies occurred in the unexposed group (32%). The median follow-up time was 2.4 years (range: 0.75–4 years) and 1.8 years (0.05–4 years) in the exposed and unexposed groups, respectively.Conclusions: Provision of a levonorgestrel-releasing device was associated with significantly lower risk of pregnancy than was use of alternative or no contraception. If these data from North Carolina are representative of experience nationwide, then the public health benefit of the Foundation's philanthropy may be large.

Access to contraception after health care reform in Massachusetts: a mixed-methods study investigating benefits and barriers

2011-08-05

Abstract: Background: In 2006, Massachusetts passed sweeping health care reform legislation aimed at improving access to health care for residents. This study investigates how this landmark legislation affected contraceptive access for low-income women.Study Design: This study included (a) 16 in-depth interviews with family planning providers, (b) 9 focus group discussions with 52 low-income English- and Spanish-speaking women, (c) 10 self-administered surveys of family planning administrators and (d) a systematic review of Web sites for government-subsidized insurance plans.Results: Findings from all study components were highly consistent. We found that while most low-income women in Massachusetts continue to regularly obtain contraception, challenges such as maintaining insurance coverage, understanding benefits, securing an appointment with a provider and obtaining prescriptions were identified post reform. Findings about contraceptive affordability under reform were mixed.Conclusion: Though health care reform legislation has benefited many women, barriers remain to ensuring consistent access to contraception for low-income women.

Impact of etonogestrel-releasing implant and copper intrauterine device on carbohydrate metabolism: a comparative study

2011-09-19

Abstract: Background: We investigated the influence of an etonogestrel-releasing (ETG) implant and copper intrauterine device (IUD) on carbohydrate metabolism.Study Design: In this nonrandomized, open-label, prospective controlled trial, 40 healthy women received an implant or IUD (20 per group). Outcome measures were fasting glucose, fasting insulin, oral glucose tolerance test (OGTT) and glycosylated hemoglobin A1C (HbA1C) levels at baseline and after 6 and 12 months.Results: The groups were similar in age, body mass index and laboratory parameters at baseline. Carbohydrate metabolism was not modified by the ETG implant at baseline and at 6 and 12 months (mean±SD) (fasting glucose: 85.9±5.13, 87.05±5.36, 88.19±5.05; insulin: 7.77±2.42, 10.64±9.4, 8.82±3.73; OGTT: 94.8±25.28, 96.5±19.67, 99.47±24.6; HbA1C: 5.27±.34, 5.55±.39, 5.7±0.37). The same was true for the IUD (fasting glucose: 88.87±7.2, 89.65±5.86, 88.75±4.79; insulin: 7.94±3.6, 8.3±4.1, 7.34±3.02; OGTT: 96.85±15.16, 97.48±13.42, 91.3±22.16; HbA1C: 5.41±.49, 5.75±.41, 5.9±0.73).Conclusions: The ETG-releasing implant did not affect carbohydrate metabolism in normal women after 12 months.

Bioequivalence study of an oral contraceptive containing ethinylestradiol/drospirenone/levomefolate calcium relative to ethinylestradiol/drospirenone and to levomefolate calcium alone

2011-07-20

Abstract: Background: A new tablet formulation containing 0.02 mg ethinylestradiol/3 mg drospirenone/0.451 mg levomefolate calcium (calcium salt containing 0.416 mg L-5-methyltetrahydrofolate) was assessed for bioequivalence compared to the approved oral contraceptive (OC) tablet containing identical amounts of ethinylestradiol and drospirenone and to a tablet containing 0.451 mg levomefolate calcium.Study Design: Forty-four subjects received in an intraindividual crossover design single doses of the new tablet formulation or the established ethinylestradiol/drospirenone tablet or the levomefolate calcium tablet.Results: Bioequivalence was demonstrated for ethinylestradiol, drospirenone and L-5-methyltetrahydrofolate (active moiety of levomefolate calcium) between the investigated tablet formulations. The geometric mean ratios of the AUC(0–tlast) and Cmax values for all three compounds and their 90% confidence intervals were well within the 80%–125% range generally accepted to demonstrate bioequivalence.Conclusion: The rate and extent of absorption of ethinylestradiol and drospirenone were not affected by the concomitant administration of levomefolate calcium and vice versa.

Induced abortion in Canada 1974–2005: trends over the first generation with legal access

Wendy V. Norman — 2011-08-05

Abstract: Background: Canadian women currently entering menopause are the first generation with access to legal induced abortion throughout their reproductive years.Study Design: Statistics Canada data from 1974 to 2005 on age-specific abortion and first-abortion rates were analyzed to determine the proportion of the cohort hypothetically and actually undergoing at least one induced abortion, as well as the age-specific trends.Results: Among Canadian women who turned 45 years old in 2005, 31% had at least one abortion, with a median age at first abortion of 24 years. Since 1997, age-specific induced abortion rates overall and among teenagers have declined significantly, while rates among older women show less decline as age increases. Annually from 1974 to 2005, women aged 20–29 years account for 52% (SD 1.8%) of all abortions in Canada.Conclusions: Induced abortion is a common procedure experienced by nearly a third of Canadian women during their reproductive years. Consistently, half of all women accessing abortion are in their twenties. These findings suggest that Canadian women, particularly those in their twenties, experience a significant unmet need for effective contraception.

Can women accurately assess the outcome of medical abortion based on symptoms alone?

2011-07-15

Abstract: Background: The primary purpose of this study was to evaluate whether women undergoing medical abortion can accurately assess abortion outcome based on symptoms alone. Our secondary aim was to identify predictors of medical abortion failure.Study Design: We conducted a case–control study of women undergoing medical abortion from January 1, 2004, to December 31, 2005, who were 63 days' gestation or less and received 200 mg mifepristone followed by 800 mcg of vaginal misoprostol 6–72 h later. Cases were defined as women who required uterine evacuation for a retained gestational sac or ongoing pregnancy. Separate analyses were conducted for the subset of cases with ongoing pregnancies. Controls were defined as women who successfully expelled the pregnancy without uterine evacuation.Results: During the study period, 53 women had a retained gestational sac (N=26) or ongoing pregnancy (N=27), and a total of 53 controls were selected, matched by site and date of procedure. Case subjects were more likely than controls to report minimal vaginal bleeding and ongoing pregnancy symptoms and to express doubt that they expelled the pregnancy. When predictive modeling was performed, ongoing pregnancy symptoms, minimal bleeding and gestational age as determined by ultrasound measurement of gestational sac or crown-rump length accurately identified only 68% of medical abortion failures. We also found that the odds of medical abortion failure decreased progressively from approximately 4 to 7 weeks' gestational age, was lowest at approximately 7 weeks and increased from 7 to 9 weeks' gestation.Conclusion: Patient symptomatology and self-assessment of complete abortion alone are moderately useful in identifying medical abortion failure. An objective measure of complete abortion, such as a pregnancy test, is still required.

Effect of shared contraceptive experiences on IUD use at an urban abortion clinic

Lyndsey S. Benson, Alissa Perrucci, Eleanor A. Drey, Jody E. Steinauer — 2011-08-17

Abstract: Background: We studied the effect of contraceptive social networking on postabortion intrauterine device (IUD) uptake. This study explores whether women who have heard personal stories of IUD use are more likely to use an IUD for postabortion contraception.Study Design: We surveyed 299 women undergoing induced abortion at San Francisco General Hospital's Women's Options Center before and after contraceptive counseling. Both English- and Spanish-speaking women, aged 15 years and older, were surveyed.Results: Fifty percent of women surveyed chose to use an IUD for postabortion contraception. Women choosing IUDs were more likely than women choosing other contraceptives or no contraceptives to be multiparous, Latina and interested in IUDs prior to contraceptive counseling. Disclosure of personal IUD use by a clinic staff member was independently associated with the decision to use an IUD (odds ratio 8.1, 95% confidence interval 3.8–17.2).Conclusions: Women undergoing abortion in an urban clinic have knowledge and high acceptance of IUDs, and sharing of contraceptive experiences is common among women of all demographics. Controlling for demographics and prior knowledge of IUDs, sharing of personal IUD experiences by providers is significantly associated with IUD use.

Analyzing the impacts of abortion clinic structures and processes: a qualitative analysis of women's negative experience of abortion clinics

Katrina Kimport, Kate Cockrill, Tracy A. Weitz — 2011-08-11

Abstract: Background: In the United States, the social myth that abortion clinics are unsafe, lonely places is pervasive. Little research has investigated the extent to which women's negative experiences of clinic interactions and processes confirm or contest this myth.Study Design: Semistructured interviews with 41 women who received an abortion at a clinic were conducted and analyzed using qualitative analytical techniques in Atlas 5.0.Results: The processes and structures of the abortion clinic necessitated by the realities of antiabortion hostilities lead some women to react negatively to the clinic experience in ways consistent with the social myth of the abortion clinic. Staff interactions can mitigate or alleviate these experiences.Conclusions: Clinic workers and administrators should be aware that safety structures and processes may create negative experiences for some women. Policymakers should be aware of the extent to which public policies and conflict over abortion render the social myth of the clinic a reality.

Mifepristone may shorten the induction-to-abortion time for termination of second-trimester pregnancies by ethacridine lactate

YaLing Zhuang, XiuYing Chen, LiLi Huang — 2011-07-15

Abstract: Background: We reviewed our experience with adding mifepristone to the protocol for the termination of pregnancy up to 24 weeks of gestation by intra-amniotic ethacridine lactate.Study Design: The study consisted of women who presented for the termination of a second-trimester pregnancy between August 2000 and July 2008.Results: Of 1245 women who requested a termination of a second-trimester pregnancy, 744 women underwent the induction of abortion by intra-amniotic ethacridine lactate with mifepristone (mifepristone group), and 501 received intra-amniotic ethacridine lactate alone (control group). The proportion of women who delivered within 24 h was 25.94% in the mifepristone group and 10.18% in the control group (p<.001); the failure rate of abortion was 5.38% in the mifepristone group and 4.99% in the control group (p<.001). There was no significant difference in the complication rate between the two groups. The rate of cervical laceration was 0.54% in the mifepristone group and 0.60% in the control group (p=.9315). The rate of retained placental tissue was 6.99% in the mifepristone group and 6.19% in the control group (p=.1112). Nausea was reported by 34.0% of women in the mifepristone group and none in the control group.Conclusion: The addition of mifepristone to ethacridine lactate may shorten the induction-to-abortion time compared with the use of ethacridine lactate alone without increasing the number of complications.

A life-threatening ectopic pregnancy with etonogestrel implant

Julie Bouquier, Virginie Fulda, Anne-Sophie Bats, Fabrice Lécuru, Cyrille Huchon — 2011-09-15

Abstract: Background: Etonogestrel contraceptive implant is a highly effective subdermal method of long-acting hormonal contraception for women.Case: We describe a case of ruptured ectopic pregnancy occurring in a patient with an etonogestrel contraceptive implant (Implanon®). The only factor predisposing to a failure in this case is a moderately elevated body mass index of 29. However, the implant was in place for less than 2 years, and the plasma levels of etonogestrel were within the expected range.Conclusion: This case report emphasizes the fact that ectopic pregnancy should not be formally ruled out in women using this contraceptive, and it highlights the need for further study of the effect of body weight on this contraceptive method.

Update on and correction to the cost effectiveness of contraceptives in the United States

James Trussell — 2011-08-16

In , we update our results on the cost effectiveness of contraceptives in the United States to reflect recent increases in the average wholesale price (AWP) of the Mirena IUS to $844 (an increase of 44% over the AWP of $586 in the original paper) and of the ParaGard IUD to $718 (an increase of 45% over the AWP of $494 in the original paper). We also correct an error in the annualized cost of the Mirena IUS in years 2–5 in a previous update; we are grateful to Anna Filonenko and Amy Law for pointing out this error.

Mifepristone+misoprostol vs. misoprostol alone for early medical abortion

Thoai D. Ngo, Min Hae Park — 2011-08-01

Ngoc et al. , in their double-blind randomized placebo-controlled trial, show that mifepristone+misoprostol is more efficacious than misoprostol-only for early medical abortion. The study was conducted from August 2007 to March 2008 at a tertiary hospital in Vietnam.

Response to Letter to the Editor

2011-08-05

We thank Ngo and Park for their comments to our paper, “Comparing two early medical abortion regimens: mifepristone+misoprostol vs. misoprostol alone” . We agree in principle that misoprostol is the only available medical abortifacient for many women in countries with restrictive access to abortion and no access to mifepristone. Yet, we caution about misinterpretation of our results as not being representative of potential outcomes with misoprostol-only regimens in a range of settings. Indeed, although Ngo and Park cite a paper in 2003 reporting a 90% efficacy rate , as they note in their letter, the largest study of 2066 women completed in 2007 reports efficacy rates in the high 70% and low 80% , which are consistent with our results (showing 76.2% efficacy with misoprostol-only) .

Contraception

Editorial Board

Contents

Pregnancy outcomes with an IUD in situ: a systematic review

Feticidal digoxin injection before dilation and evacuation abortion: Evidence and ethics

Safety of digoxin for fetal demise before second-trimester abortion by dilation and evacuation

Infection and extramural delivery with use of digoxin as a feticidal agent

Revival of the intrauterine device: increased insertions among US women with employer-sponsored insurance, 2002–2008

Does the provision of free intrauterine contraception reduce pregnancy rates among uninsured low-income women? A cohort study a two North Carolina clinics

Access to contraception after health care reform in Massachusetts: a mixed-methods study investigating benefits and barriers

Impact of etonogestrel-releasing implant and copper intrauterine device on carbohydrate metabolism: a comparative study

Bioequivalence study of an oral contraceptive containing ethinylestradiol/drospirenone/levomefolate calcium relative to ethinylestradiol/drospirenone and to levomefolate calcium alone

Induced abortion in Canada 1974–2005: trends over the first generation with legal access

Can women accurately assess the outcome of medical abortion based on symptoms alone?

Effect of shared contraceptive experiences on IUD use at an urban abortion clinic

Analyzing the impacts of abortion clinic structures and processes: a qualitative analysis of women's negative experience of abortion clinics

Mifepristone may shorten the induction-to-abortion time for termination of second-trimester pregnancies by ethacridine lactate

A life-threatening ectopic pregnancy with etonogestrel implant

Update on and correction to the cost effectiveness of contraceptives in the United States

Mifepristone+misoprostol vs. misoprostol alone for early medical abortion

Response to Letter to the Editor