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Contraception Journal
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Contraception Highlights July 2013

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

ONE KEY QUESTION®: Preventive reproductive health is part of high quality primary care
Helen K. Bellanca, Michele Stranger Hunter
Contraception and other reproductive health services have recently gained national attention as part of the core preventive services that should be available to all women as part of health care reform. Oregon has a unique model of health care reform with an emphasis on measuring quality, and sexual and reproductive health advocates in the state have achieved a major milestone: inclusion of a contraception provision as a marker of quality care. This was possible because of the widespread support of an initiative called ONE KEY QUESTION, which was created and developed by the Oregon Foundation for Reproductive Health (OFRH) to address the issue of diminishing access to contraceptive services in primary care. Read more >

Editorial

New guidelines for authors
Carolyn Westhoff, Taylor Bowen
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Clinical Guidelines

Surgical abortion prior to 7 weeks of gestation
E. Steve Lichtenberg, Maureen Paul
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Original Research Articles

Evaluation of e-mail contact to conduct follow-up among adolescent women participating in a longitudinal cohort study of contraceptive use
Sadia Haider, Laura E. Dodge, Beth A. Brown, Michele R. Hacker, Tina R. Raine
Background: The purpose of this study was to determine whether e-mail contact is a viable method for gathering information from adolescent women about contraceptive use.
Conclusions: E-mail follow-up with Web-based surveys was effective amongst adolescent women at risk for unintended pregnancy. This indicates that e-mail contact could be used as a preliminary follow-up strategy to capture a substantial proportion of participants and that standard follow-up can be used as a second-line approach. A two-pronged approach with initial e-mail contact and traditional follow-up for participants who do not respond may be a viable method when evaluating sensitive areas such as contraceptive use.
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Randomized comparison of two Internet-supported fertility-awareness-based methods of family planning
Richard J. Fehring, Mary Schneider, Kathleen Raviele, Dana Rodriguez, Jessica Pruszynski
Background: The aim was to compare the efficacy and acceptability of two Internet-supported fertility-awareness-based methods of family planning.
Conclusion: In comparison with the CMM, the EHFM method of family planning was more effective. All users had an increase in acceptability over time. Results are tempered by the high dropout rate.
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A new experimental three-dimensional, reticular intrauterine device (3-DRIUD) composed of nitinol and silicone rubber
Yi Qiu, Lei-Guang Wang, Mei-Hua Zhang, Yan-Ping Zhang, Ai-Dong Zhang, Dan-Tong Yang
Background: The aim of this study was to explore a new three-dimensional, reticular intrauterine device (3-DRIUD) composed of nitinol and silicone rubber and to observe the contraceptive effect of the device in rats.
Conclusions: The primary contraceptive mechanism effect of the new 3-DRIUD in rodents appears to be a result of occupying physical space in the uterus.
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Intrauterine infusion of lidocaine does not reduce pain scores during IUD insertion
Anita L. Nelson, Jennifer K. Fong
Background: Potential pain with IUD insertion is a concern for women. Studies have found that systemic and local cervical therapies do not reduce pain scores. Since intrauterine infusion of lidocaine may reduce pain with endometrial aspiration, in this pilot study, we tested whether such infusion through an inexpensive endometrial aspirator could reduce IUD insertion pain scores with IUD insertion.
Conclusion: Use of 2% lidocaine administered through an endometrial aspirator did not significantly reduce IUD insertion pain scores in this pilot study.
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Can isosorbide mononitrate be useful in second trimester termination of pregnancies?
Athanasios Mousiolis, Mihalis Sindos, Nikolaos Papantoniou, Aris Antsaklis
Background: Isosorbide mononitrate (IMN) administration is thought to enhance in the cervical ripening process. We sought to identify the clinical usefulness and safety of IMN administration for shortening the time to termination of the second trimester pregnancy procedures when used in addition to misoprostol.
Conclusions: A net benefit after the combined use of IMN and misoprostol was noted. Therefore, we believe that IMN has a clinical role in the ripening process.
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Personalized contraceptive assistance and uptake of long-acting, reversible contraceptives by postpartum women: a randomized, controlled trial
Katharine B. Simmons, Alison B. Edelman, Hong Li, Keenan E. Yanit, Jeffrey T. Jensen
Background: Many women who intend to use long-acting, reversible contraceptives (LARCs) postpartum do not follow through with initiating use. The objectives of this study were to determine whether support from a contraceptive personal assistant could increase the uptake of LARCs by 3 months postpartum, and to identify risk factors for nonuptake of LARCs among women who planned LARC use.
Conclusions: Providing telephone assistance to help navigate barriers did not increase postpartum uptake of LARCs. A personal history of clinic visit no-shows and/or infrequent prenatal visits were related to poor uptake of LARCs postpartum.
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Characteristics associated with interest in long-acting reversible contraception in a postpartum population
Jennifer H. Tang, Rosalie Dominik, Sandra Re, Seth Brody, Gretchen S. Stuart
Background: Short interpregnancy intervals lead to adverse perinatal outcomes and could be prevented with increased use of long-acting reversible contraception (LARC) in the postpartum period. The primary objective of this study was to assess which baseline characteristics are associated with the intent to use LARC among postpartum women.
Conclusions: High interest in LARC exists among postpartum women, particularly among women with a recent unintended pregnancy and women who do not desire pregnancy for at least 2 years. Past and future pregnancy intentions should be incorporated into future models and frameworks that evaluate postpartum contraceptive choice. Educational intervention studies are also needed to assess if LARC interest can be increased among postpartum women who are less likely to intend to use LARC but at risk for future adverse perinatal outcomes.
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A modified SILCS contraceptive diaphragm for long-term controlled release of the HIV microbicide dapivirine
Ian Major, Peter Boyd, Maggie Kilbourne-Brook, Gene Saxon, Jessica Cohen, R. Karl Malcolm
Background: There is considerable interest in developing new multipurpose prevention technologies to address women's reproductive health needs. This study describes an innovative barrier contraceptive device — based on the SILCS diaphragm — that also provides long-term controlled release of the lead candidate anti-HIV microbicide dapivirine.
Conclusions: The study demonstrates proof of concept for a dapivirine-releasing diaphragm with daily release quantities potentially capable of preventing HIV transmission. In discontinuous clinical use, release of dapivirine may be readily extended over 1 or more years.
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Factors associated with the use of irreversible contraception and continuous use of reversible contraception in a cohort of HIV-positive women
Nadia Kancheva Landolt, Reshmie Ashmanie Ramautarsing, Nittaya Phanuphak, Nipat Teeratakulpisarn, Suteeraporn Pinyakorn, Piyanee Rodbamrung, Surasith Chaithongwongwatthana, Jintanat Ananworanich
Background: Effective contraception can be lifesaving by reducing maternal mortality linked to childbirth and unsafe abortion and by reducing vertical and horizontal transmission of HIV, in the case of an HIV-positive woman.
Conclusions: Despite high contraceptive use, there are still uncovered contraceptive needs among HIV-positive women in Thailand. HIV-positive women need established specialized family planning services, offering an optimal variety of contraceptive choices and tailored to their individual needs. As sterilization is an irreversible choice, it cannot be a viable alternative for every woman. Due to the positive trend between current and past contraceptive use, we consider that it may be possible to improve family planning programs if they start as early as possible in a woman's life and are continued throughout her sexually active and reproductive years.
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Fertility goal-based counseling increases contraceptive implant and IUD use in HIV-discordant couples in Rwanda and Zambia
Naw H. Khu, Bellington Vwalika, Etienne Karita, William Kilembe, Roger A. Bayingana, Deborah Sitrin, Heidi Roeber-Rice, Emily Learner, Amanda C. Tichacek, Lisa B. Haddad, Kristin M. Wall, Elwyn N. Chomba, Susan A. Allen
Introduction: HIV-discordant heterosexual couples are faced with the dual challenge of preventing sexual HIV transmission and unplanned pregnancies with the attendant risk of perinatal HIV transmission. Our aim was to examine uptake of two long-acting reversible contraceptive (LARC) methods — intrauterine devices (IUD) and hormonal implants — among HIV-discordant couples in Rwanda and Zambia.
Conclusions: Integrated fertility goal-based family planning counseling and access to LARC methods with reinforcement of dual-method use prompted uptake of IUDs and implants and reduced unprotected sex among HIV-discordant couples in two African capital cities.
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Meeting the need: youth and family planning in sub-Saharan Africa
Ndola Prata, Karen Weidert, Amita Sreenivas
Background: The need for a concerted effort to address the gaps in family planning services for youth in sub-Saharan Africa has been underreported and underexplored.
Conclusion: Our findings support existing literature that calls for a reorientation of family planning policies and programs, especially improved access to modern contraceptive methods among African youth.
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Prescription requirements and over-the-counter access to oral contraceptives: a global review
Kate Grindlay, Bridgit Burns, Daniel Grossman
Background: Since the prescription requirement for oral contraceptives (OCs) can act as a barrier for some women, over-the-counter (OTC) access may improve uptake and continuation. The goal of this study was to ascertain the prescription requirements and informal OTC availability of OCs worldwide.
Conclusions: OCs are available without prescription in the majority of countries. Country experiences with OTC provision may provide evidence about the safety and effectiveness of OTC provision as a strategy to improve access to effective family planning.
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Uptake of the levonorgestrel intrauterine system among recent postpartum women in Kenya: factors associated with decision-making
David Hubacher, Rose Masaba, Carolyne Kemunto Manduku, Valentine Veena
Background: The levonorgestrel intrauterine system (LNG IUS) may become more available in the public sector of resource-poor countries, but it is unclear what product features might be attractive to users and what factors will influence uptake.
Conclusions: The LNG IUS could be an ideal method for increasing uptake of long-acting methods among recent postpartum women. Product attributes and comparisons to other contraceptive options are important factors in decision-making. Even among women comfortable with intrauterine contraception, great distinctions and preferences are apparent. Addressing specific misconceptions and fears with better information can help women make the best personal choices.
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Performance of Sino-implant (II) in routine service delivery in Madagascar
P.J. Feldblum, O. Hanitriniaina, A. Lendvay, K. Hopkins, A. Wheeless, M. Chen, M.J. Steiner
Background: Sino-implant (II) is a low-cost subdermal contraceptive implant containing levonorgestrel that is currently labeled for 4 years of use. Widely used in China and Indonesia, it has been little studied elsewhere. We conducted a prospective study of Sino-implant (II) use by women in Madagascar.
Conclusions: This is the first report on the performance of Sino-implant (II) from outside China and Indonesia and among the first in the English-language literature. These initial data from Madagascar indicate a favorable level of safety, effectiveness and acceptability during the first year of use.
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An exploration of women's reasons for termination timing in the setting of fetal abnormalities
Lori M. Gawron, Kenzie A. Cameron, Ava Phisuthikul, Melissa A. Simon
Background: Over 3% of pregnancies are complicated by a fetal abnormality, of which, approximately 80% are terminated. Despite early screening options, women often present at the cusp of legal limits for termination.
Conclusions: Timing of termination for fetal abnormalities is attributable to multiple issues. Future research should identify optimal prenatal counseling strategies, address systemic barriers, and identify patient decision-making resources.
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Same-day cervical preparation with misoprostol prior to second trimester D&E: a case series
Kathryn A. Maurer, Janet C. Jacobson, David K. Turok
Background: Traditionally, overnight cervical preparation with osmotic dilators has been used for second trimester dilation and evacuation (D&E) procedures. Misoprostol offers an alternative treatment that could shorten cervical preparation time.
Conclusion: Same-day cervical preparation with misoprostol for second trimester D&E is both safe and effective. With the continuing shortage of D&E providers, the resulting increase in travel distance to obtain the procedure, mandatory waiting periods and the capability of having the procedure completed in a single day may increase patient access, reduce cost and improve patient satisfaction.
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Acceptability of home use of mifepristone for medical abortion
Yael Swica, Erica Chong, Tamer Middleton, Linda Prine, Marji Gold, Courtney A. Schreiber, Beverly Winikoff
Background: Most medical abortion protocols require women to take mifepristone in the doctor's office. We assessed the acceptability of home use of mifepristone among women and their providers.
Conclusions: Home administration of mifepristone was safe and acceptable to women and providers in our study. Women should be offered this choice to allow more flexibility, comfort and privacy in their abortion experiences.
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Identifying women in need of further discussion about the decision to have an abortion and eventual outcome
Sharon T. Cameron, Anna Glasier
Background: In order to better identify those women requesting abortion who are not certain of their decision and would like more detailed discussion, we piloted use of a self-completed validated questionnaire containing the London Measure of Unintended Pregnancy (LMUP) amongst women requesting an abortion at a hospital clinic in Scotland.
Conclusion: Almost all women requesting an induced abortion had a clearly unintended pregnancy, were certain of their decision and did not wish further counseling. A simple self-completed questionnaire identifies those who may benefit from further discussion. Subjecting women to compulsory counseling about their decision to have an abortion is in conflict with their wishes and wastes resources.
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Search for a potent microbicidal spermicide from the isolates of Shorea robusta resin
Yogesh P. Bharitkar, Maitreyee Banerjee, Shrabanti Kumar, Rupankar Paira, Ravindra Meda, Ketousetu Kuotsu, Nirup B. Mondal
Background: An alarming increase in global population is the root cause of poverty, malnutrition, sexually transmitted infections (STIs) and many other social problems. Microbicidal spermicides possessing dual function of contraception and STI protection can effectively combat this problem, and their development is of utmost importance at present.
Conclusion: Asiatic acid possesses appreciable spermicidal and microbicidal potential and may be explored as an effective microbicidal spermicide.
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Interest in a pericoital pill among women in family planning and abortion clinics
Diana Greene Foster, M. Antonia Biggs, Daniel Grossman, Eleanor Bimla Schwarz Background: The purpose of this study was to determine whether women might be interested in repeated use of a pericoital pill, a pill taken around the time of each act of intercourse.
Conclusion: More work is needed to establish the effectiveness of a pericoital pill and determine how frequently a pericoital pill might be used by women who currently have unprotected intercourse.
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HIV voluntary counseling and testing at an abortion clinic: missed opportunities for diagnosis
Sara J. Newmann, Mi-Suk Kang Dufour, Willi McFarland, Laetitia Oderman, Timothy Kellogg, Brian Louie, Eleanor A. Drey
Background: Most abortion clinics in the US do not provide opt-out HIV testing, and thus women electing abortion may not receive adequate screening for HIV. We sought to determine whether the standard practice of offering voluntary HIV counseling and testing (VCT) services to women electing abortion results in detection of undiagnosed HIV infection.
Conclusions: HIV testing via VCT did not effectively diagnose previously undiagnosed HIV infections among women seeking abortion in this clinical setting.
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Sonographic patterns of the endometrium in assessment of medical abortion outcomes
Chii-Ruey Tzeng, Jiann-Loung Hwang, Heng-Kien Au, Li-Wei Chien
Background: We aimed to define endometrial pattern and endometrial thickness in predicting the outcome of early medical abortion.
Conclusion: Women with a multilayered pattern could be reassured that they have successful medical abortion, while those with a heterogeneous pattern and/or endometrium >http://www.contraceptionjournal.org/webfiles/images/transparent.gif10 mm may need follow-up. Sonographic endometrial pattern and endometrial thickness may serve as objective criteria in the management of early medical abortions.
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The Quick Start Contraception Initiation Method during the 6-week postpartum visit: an efficacious way to improve contraception in Federally Qualified Health Centers
Sharon Stechna, Sally Mravcak, Pamela Schultz, Joaquin Santolaya
Background: About half of all pregnancies in the United States are unplanned, and many start soon after a previous delivery. Our aim was to determine if the implementation of the Quick Start Contraception Initiation Method during the 6-week postpartum evaluation could improve the delivery of contraception.
Conclusion: These findings suggest that the Quick Start Contraception Initiation Method at the time of the 6-week postpartum evaluation improves the delivery of contraception in FQHCs.
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Pain at insertion of the levonorgestrel-releasing intrauterine system in nulligravida and parous women with and without cesarean section
Ana Raquel Gouvea Santos, M. Valeria Bahamondes, M. Margarete Hidalgo, Ana Atti, Luis Bahamondes, Ilza Monteiro
Background: Despite the high contraceptive effectiveness and noncontraceptive benefits of the levonorgestrel-releasing intrauterine system (LNG-IUS) in nulligravidas, there are still concerns related to the use of this device. Pain at insertion is one of the limitations to the increased use of intrauterine contraceptives. The aim of the study was to evaluate the ease of insertion and occurrence of pain at insertion of the LNG-IUS in nulligravidas (women who never became pregnant) compared to parous women with and without cesarean section (c-section). We also assessed the difficulty at insertion in each group.
Conclusions: Although almost all women reported pain at insertion, they also reported a willingness to insert a new LNG-IUS if needed. This attitude reflects high satisfaction with the LNG-IUS. The type of difficulty at insertion was related to parity and type of delivery. The LNG-IUS was able to be inserted in all women; however, it was easier to do in parous women without c-section than nulligravid women or those with a prior C-section.
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Weight and body fat changes in postpartum depot-medroxyprogesterone acetate users
Christina M. Nyirati, Diane L. Habash, Lynn E.T. Shaffer
Background: Although postpartum depot-medroxyprogesterone acetate (DMPA) recipients often cite weight gain as the reason for discontinuing DMPA, little is known about body composition changes in postpartum DMPA recipients.
Conclusions: DMPA recipients who were overweight or obese before pregnancy may have greater risk for weight gain in the first year postpartum. However, when counseling women, the risk for DMPA-related weight gain should be balanced against the potential for increased weight from subsequent pregnancies.
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Effect of a combined estrogen and progesterone oral contraceptive on circulating adipocytokines adiponectin, resistin and DLK-1 in normal and obese female rhesus monkeys
Kate A. Shaw, Jon D. Hennebold, Alison B. Edelman
Background: Hormonal contraception is the most common medication used by reproductive aged women but there is little understanding of the impact of hormonal contraception on obesity and metabolism. Adipokine levels (adiponectin, resistin) and markers of adipocyte development (DLK-1) are altered in obese animals and humans and are associated with increased cardiovascular risk. We sought to determine the effect of combined hormonal oral contraceptive pills (COCs) on circulating adiponectin, resistin and DLK-1 levels in obese and normal-weight rhesus macaque monkeys.
Conclusions: COC use may alter metabolic processes via direct (resistin) or indirect (adiponectin) means, while unchanging DLK1 levels suggest they do not affect adipocyte development. COCs may directly increase resistin levels, as observed in both groups. As adiponectin is inversely related to adipocyte mass, increased levels in the obese group are likely attributed to weight loss.
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Association of estrogen receptor alpha gene polymorphisms with autonomic modulation of heart rate in users and nonusers of oral contraceptives
Ana Cristina S. Rebelo, Rozangela Verlengia, Vandeni C. Kunz, Nayara Y. Tamburus, Marcos Felipe Silva de Sá, Rosario D.C. Hirata, Alvaro Cerda, Mario H. Hirata, Ester da Silva
Background: This study examined the association between estrogen receptor α gene (ESR1) polymorphisms and blood pressure (BP), heart rate (HR) and autonomic modulation of HR in a sample population.
Conclusions: ESR1 variants had no effect on the autonomic modulation of HR in young women users and nonusers of OC and may not be implicated in cardiovascular risk in young women.
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Case Report

In situ breakage of Implanon® — two cases of a rare occurrence
Rita Torres, Neuza Mendes, Ana Isabel Machado, Carlos Marques
Background: In situ breakage of Implanon® is a rare occurrence with unknown clinical significance. Authors report two different cases of broken Implanon® of women attended at our Family Planning Clinic.
Conclusion: Currently, the clinical significance of implant breakage remains unknown. The decision to remove a broken or bent implant should be based on clinical judgements considering patients' wishes.
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Letter to the Editor

Types of combined oral contraceptives used by US women
Mitchell D. Creinin
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Response to letter to the editor
Kelli Stidham Hall, James Trussell
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