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Contraception Journal
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Contraception Highlights April 2013

Thinking (Re)Productively
Expert analysis on pressing issues from the Association of Reproductive Health Professionals

Why bold policies for family planning are needed now
Malcolm Potts, Rachel Weinrib, Martha Campbell

Last spring at a Technology, Entertainment, Design (TED) talk in Berlin, Melinda Gates used this phrase, “The most transformative thing you can do is to give people access to birth control.” She expressed similar sentiments at the London Summit on Family Planning on in July 2012, an event that represented a new focus on international family planning after nearly 20 years of collapsed budgets. Read more>

Editorial

What the world needs now…is more access to the levonorgestrel IUD
David K. Turok
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Original research articles

Endothelial function in women using levonorgestrel-releasing intrauterine system (LNG-IUS)
Mohamed Fouad Selim, Adnan Fathey Hussein
Background: Oral levonorgestrel has been linked to increased cardiovascular risk, but currently, no information is available on the effect of the levonorgestrel-releasing intrauterine system (LNG-IUS) on endothelial dysfunction. The objective of this study was to assess endothelial function in LNG-IUS users.
Conclusions: A nonsignificant change detected in endothelial function in LNG-IUS indicates that it has no increased cardiovascular risk.
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Cost analysis of immediate postabortal IUD insertion compared to planned IUD insertion at the time of abortion follow up
Jennifer Salcedo, Andrea Sorensen, Maria I. Rodriguez
Background: Immediate postabortal intrauterine device (IUD) insertion decreases rates of repeat abortions. However, only one third of high-volume, non-hospital abortion providers in the United States offer immediate postabortal IUD placement.
Conclusion: Immediate postabortal IUD insertion is cost saving from a public payer perspective, compared to planned insertion at the time of follow up. These savings are seen over a wide range of model inputs.
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Five-year follow-up of levonorgestrel-releasing intrauterine system versus thermal balloon ablation for the treatment of heavy menstrual bleeding: a randomized controlled trial
Agnaldo L. Silva-Filho, Francisco de A.N. Pereira, Sérgio S. de Souza, Luciano F. Loures,  Ana Paula C. Rocha, Carolina N. Valadares, Márcia M. Carneiro, Rubens L.C. Tavares, Aroldo F. Camargos
Background: The study was conducted to compare 5-year follow-up of levonorgestrel-releasing intrauterine system (LNG-IUS) or thermal balloon ablation (TBA) for the treatment of heavy menstrual bleeding (HMB).
Conclusion: Five-year follow-up of HMB treatment with LNG-IUS was associated with higher efficacy and satisfaction ratings compared to TBA.
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Fertility in older women following removal of long-term intrauterine devices in the wake of a natural disaster
Huili Zhu, Haike Lei, Wei Huang, Jing Fu,  Qiushi Wang, Licong Shen, Qiuyi Wang, Jie Ruan, Dong Liu, Hao Song, Lina Hu
Background: In order to evaluate the effect of long-term intrauterine device (IUD) use on female fertility, we interviewed 2301 women who lost children in the 2008 Wenchuan earthquake in China, which prompted IUD removal.
Conclusion: Long-term IUD use in older women had a high rate of pregnancy after removal of IUD, but with an increased risk of fertility problems.
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The effect of nitroprusside on IUD insertion experience in nulliparous women: a pilot study 
Paula H. Bednarek, Elizabeth A. Micks, Alison B. Edelman, Hong Li, Jeffrey T. Jensen
Background: Concern about pain during placement of an intrauterine device (IUD) represents a barrier to use, especially among nulliparous women. We hypothesized that nitroprusside gel applied intracervically prior to IUD placement would reduce insertion-related pain.
Conclusions: Intracervical administration of 10-mg nitroprusside gel immediately prior to IUD insertion does not appear to provide a clinically relevant improvement in patient-reported pain with IUD insertion among nulliparous women.
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Temporal changes in cervical mucus after insertion of the levonorgestrel-releasing intrauterine system
Melissa F. Natavio, DeShawn Taylor, Radha A. Lewis, Paul Blumenthal,  Juan C. Felix, Alexander Melamed, Elisabet Gentzschein, Frank Z. Stanczyk, Daniel R. Mishell
Background: The major contraceptive action of the levonorgestrel-releasing intrauterine system (LNG-IUS) is cervical mucus (CM) thickening, which prevents sperm penetration. No study to date has examined the temporal relationship between the insertion of the LNG-IUS and changes in CM quality and sperm penetration.
Conclusion: Significant changes in quality of CM and sperm penetration were observed shortly after LNG-IUS insertion; however, CM can remain penetrable for up to 5 days when the LNG-IUS is inserted midcycle.
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Contraceptive vaginal ring effectiveness is maintained during 6 weeks of use: a prospective study of normal BMI and obese women
Monica Dragoman, Kelsey Petrie, Anupama Torgal, Tiffany Thomas,  Serge Cremers, Carolyn L. Westhoff
Background: A single study shows that contraceptive vaginal ring (CVR) use for up to 35 days in women with a normal body mass index (BMI) maintains serum hormone levels sufficient to suppress ovulation. This study is intended to confirm those results and to evaluate prolonged CVR use up to 42 days in both normal BMI and obese women.
Conclusions: A single CVR used for 6 weeks demonstrates therapeutic serum levels of EE and ENG among women with normal and obese BMI. Women who forget to remove the CVR at day 21 may well have continued contraceptive protection during the next 3 weeks.
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Perceived susceptibility to pregnancy and its association with safer sex, contraceptive adherence and subsequent pregnancy among adolescent and young adult women
Mahbubur Rahman, Abbey B. Berenson, Sandra R. Herrera
Background: The study was conducted to examine the hypotheses that adolescent and young adult women who perceived they are susceptible to pregnancy when birth control is not used are less likely to practice unsafe sex, discontinue oral contraception (OC) and become pregnant during a 12-month follow-up period.
Conclusions: Perceived susceptibility to pregnancy, an important component of the health belief model, does not seem to have any impact on use of birth control methods, safer sex or rate of subsequent pregnancy among low-income adolescent and young adult women.
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Cilostazol blocks pregnancy in naturally cycling mice
Ahmed M. Taiyeb Albarzanchi, Christie M. Sayes, Mundhir T. Ridha Albarzanchi, Virginia R. Fajt, W. Les Dees, Duane C. Kraemer
Background: Administration of a phosphodiesterase three enzyme inhibitor (PDE3-I) in rodents and primates results in ovulation of immature oocytes. Concerns regarding inhibition of PDE3 enzymes that are expressed in heart and blood vessels discouraged further development of PDE3-Is as nonsteroidal contraceptives. Cilostazol (CLZ) is a PDE3A-I that is approved for medical indications in humans and has an additional effect of adenosine uptake inhibition that is believed to counterbalance the undesirable outcomes resulting from PDE inhibition.
Conclusion: CLZ is a potential nonsteroidal contraceptive agent that merits further evaluation in other mammals.
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The impact of an educational text message intervention on young urban women's knowledge of oral contraception
Kelli Stidham Hall, Carolyn L. Westhoff, Paula M. Castańo
Background: Oral contraceptive (OC) knowledge deficits may contribute to OC discontinuation. We examined the effect of an innovative educational intervention on young women's OC knowledge.
Conclusion: Daily educational text messages can modestly improve knowledge of OCs, which may promote successful contraceptive outcomes.
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Lower risk for Down syndrome associated with longer oral contraceptive use: a case–control study of women of advanced maternal age presenting for prenatal diagnosis
Gyula Richárd Nagy, Balázs Győrffy, Bálint Nagy, János Rigó
Background: Maternal trisomy 21 ovarian mosaicism might provide the major causative factor for fetal Down syndrome. The small proportion of trisomy 21 oocytes thought to be retarded in their maturation in comparison to normal disomic ones, and the maternal age effect can be based on an accumulation of trisomy 21 oocytes in the ovarian reserve. By lowering the number of unnecessary ovulations, a greater portion of disomic oocytes might be saved.
Conclusion: We found that a history of longer oral contraceptive pill use and fewer ovulatory cycles were associated with fewer common trisomies of the fetus. Additional research is needed to rule out potential confounding factors, but our results are consistent with the maternal ovarian mosaicism causal model.
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Pre-teen literacy and subsequent teenage childbearing in a US population
Ian M. Bennett, Rosemary Frasso, Scarlett L. Bellamy, Stanton Wortham, Kennen S. Gross
Background: While literacy is a key factor in health across the life course, the association of literacy and teenage childbearing has not been assessed in the US.
Conclusions: Literacy strongly predicts risk of teenage childbearing independent of confounders. The effects of literacy were stronger among girls with Hispanic or African American race/ethnicity.
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Reasons for using contraception: perspectives of US women seeking care at specialized family planning clinics
Jennifer J. Frost, Laura Duberstein Lindberg
Background: The availability and use of contraception to prevent unintended pregnancy has had profound and positive impacts on the lives of American women. This study looks beyond the aggregate benefits of contraceptive use to examine the individual-level benefits and reasons for using contraception reported by women themselves.
Conclusions: Women value the ability to plan their childbearing and need continued access to contraception and contraceptive services, allowing them to realize the benefits that accrue when unintended pregnancies are avoided.
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Development and implementation of a quality assurance program for a hormonal contraceptive implant
Derek H. Owen, David Jenkins, Aida Cancel, Eli Carter, Laneta Dorflinger, Jeff Spieler, Markus J. Steine
Background: The importance of the distribution of safe, effective and cost-effective pharmaceutical products in resource-constrained countries is the subject of increasing attention. FHI 360 has developed a program aimed at evaluating the quality of a contraceptive implant manufactured in China, while the product is being registered in an increasing number of countries and distributed by international procurement agencies. The program consists of (1) independent product testing; (2) ongoing evaluation of the manufacturing facility through audits and inspections; and (3) post-marketing surveillance.
Conclusions: The quality assurance program developed for this contraceptive implant has helped ensure that a safe product was being introduced into developing country family planning programs. This program provides a template for establishing quality assurance programs for other cost-effective pharmaceutical products that have not yet received stringent regulatory approval and are being distributed in resource-poor settings.
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A randomized clinical trial comparing the short-term side effects of sublingual and buccal routes of misoprostol administration for medical abortions up to 63 days’ gestation
Joyce Chai, Ching Yin Grace Wong, Pak Chung Ho
Background: Buccal misoprostol 800 mcg and sublingual misoprostol 800 mcg show high efficacy when used with 200 mg mifepristone for early pregnancy termination but have different side effect profiles. This is the first double-blind randomized trial comparing the side effect profiles of these two routes of administration of misoprostol when used with mifepristone for termination of pregnancies up to 63 days’ gestation.
Conclusions: When combined with mifepristone for termination of pregnancy up to 63 days, both the buccal and sublingual routes are effective routes of administration. The sublingual route tended to be associated with more side effects.
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Review article

Hemoglobin and serum ferritin levels in women using copper-releasing or levonorgestrel-releasing intrauterine devices: a systematic review
Richard F. Lowe, Ndola Prata
Background: The use of intrauterine devices as a contraceptive method has been steadily growing in developing countries. Anemia in reproductive-age women is a growing concern in those settings.
Conclusion: Decreases in hemoglobin mean values in copper IUD users were not sufficient to induce anemia in previously nonanemic women. Women who are borderline anemic would likely benefit from using the LNG IUS.
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Commentary

Controversies in family planning: postabortal pelvic inflammatory disease
Jennefer A. Russo, Sharon Achilles, Teresa DePineres, Laura Gil
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Letters to the Editor

Cost-effectiveness of increased access to emergency contraceptive pills: probably not
Elizabeth G. Raymond, James Trussell, Chelsea B. Polis
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Response to Letter to the Editor
Lisa L. Bayer, Alison B. Edelman, Aaron B. Caughey, Maria I. Rodriguez
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Another flawed database study
Anne Szarewski, Diana Mansour, Samuel Shapiro
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Response to the letter from Dr. Szarewski
Stephen Sidney
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Mifepristone vs. osmotic dilator insertion for cervical preparation prior to surgical abortion at 14–16 weeks: a randomized trial
Mitchell D. Creinin
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Response to Letter to the Editor
Lynn Borgatta, Alice Mark
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