Mechanisms of action of emergency contraception

Knowledge, Attitudes, and Practice About Emergency Contraception Among Saudi Women of Childbearing Age of Eastern Region in Saudi Arabia

Background and aim Emergency contraception (EC) refers to methods of contraception that are used within 72 hours up to 120 hours after unprotected intercourse to prevent unintended pregnancy. It can postpone ovulation, stopping fertilization. Ella® (progestin receptor modulator), plan B, birth control tablets, and the copper intrauterine device (IUD) are examples of emergency contraception. The aim of the study is to evaluate knowledge, attitudes, and practices of emergency contraception among Saudi women of childbearing age in the eastern province of Saudi Arabia. Methods It is a descriptive cross-sectional study conducted in the eastern region of Saudi Arabia. Data was collected through a pretested online questionnaire after approval from an ethical committee and women's consent to participate in the study. Women between 18 and 49 years old were included in the study. Women aged under 18 and over 49 years were excluded from the study to make the sample population more homogenous. Participants were provided a link to a questionnaire form to be completed from their devices (phone or laptop). Results A total of 648 childbearing Saudi women completed the survey. The majority were between 18 and 25 years old. Approximately 263 (40.6%) had no children, and 348 (53.7%) earned less than 5,000 SAR monthly. Four hundred and sixty-seven (72%) of the participants had never used emergency contraception. Four hundred and seventy-eight (73.8%) did not know the maximum acceptable time for using EC. Three hundred and fourteen (48.5%) did not know the potential risks to the baby in case of failure of emergency contraception. Two hundred and twenty-three (34%) patricians wrongly believed that there would be a potential risk to the baby if the patient got pregnant after using emergency contraception. Three hundred and eight (47.5%) participants supported the idea of the availability of emergency contraception without a prescription, and a majority believed that they would not feel shy in asking for emergency contraception. Five hundred and seventy-one (88%) participants did not visit any family planning clinic last year. A significant source of EC information was a doctor or a family planner, 206 (31.8%). A considerable barrier to EC use was fear of side effects and health risks, as reported by 382 (59%) respondents. Conclusions The current study reveals that participants have positive attitudes towards emergency contraception, but use is deficient because of poor knowledge and lack of awareness. Our study urges the urgent need for awareness campaigns by health professionals to improve learning and remove wrong fears and beliefs about emergency contraception.

Practice Bulletin No. 152: Emergency Contraception

Emergency contraception, also known as postcoital contraception, is therapy used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. Common indications for emergency contraception include contraceptive failure (eg, condom breakage or missed doses of oral contraceptives) and failure to use any form of contraception (). Although oral emergency contraception was first described in the medical literature in the 1960s, the U.S. Food and Drug Administration (FDA) approved the first dedicated product for emergency contraception in 1998. Since then, several new products have been introduced. Methods of emergency contraception include oral administration of combined estrogen-progestin, progestin only, or selective progesterone receptor modulators and insertion of a copper intrauterine device (IUD). Many women are unaware of the existence of emergency contraception, misunderstand its use and safety, or do not use it when a need arises (). The purpose of this Practice Bulletin is to review the evidence for the efficacy and safety of available methods of emergency contraception and to increase awareness of these methods among obstetrician-gynecologists and other gynecologic providers.

Physicians' information to patients and prescription of the emergency contraceptive pill according to their personal experience of using the method and perception of its mechanism of action

OBJECTIVES

The aim of the study was to evaluate the association between physicians' understanding of the mechanism of action of the emergency contraceptive pill (ECP), their personal use of it, and their practice in informing their patients about the method and in prescribing it.

METHODS

The study was carried out in a sample of 3337 obstetrician-gynaecologists who responded to a mailed questionnaire. Bivariate analysis was used to test the association between physicians' personal use of the ECP, their understanding of its mechanism of action, and their practice in informing their patients about the method and in prescribing it. Multiple Poisson regression analysis was carried out to identify variables independently associated with the two dependent variables.

RESULTS

Multiple regression analysis showed that the percentage of physicians who had informed their patients about the ECP was significantly lower among those who had needed it themselves but had not used it and among those living in the northeast of Brazil. A significantly higher percentage of female than male physicians had provided information on the ECP. The percentage of physicians who had prescribed the ECP was significantly lower among those who had needed it themselves but had not used it and among those who believed that it caused a mini-abortion. The proportion of physicians who had ever-prescribed the ECP was greater among those who worked exclusively in private practice and among those who worked in a state capital.

CONCLUSIONS

The misconception that emergency contraception could cause a mini-abortion was associated with its denial to potential users, while physicians' personal experience of needing to use it favoured the likelihood of their informing potential users about it and prescribing it.

Emergency contraception: What is new?

Unintended pregnancy rates remain high throughout the World and increase the risk of poor maternal and infant outcomes. Most of unintended pregnancies occur in women who were not using contraception or who became pregnant despite the reported use of contraception. Women who have had recent unprotected intercourse including those who have had another form of contraception fail are potential candidates for this intervention. Currently used emergency contraceptive methods are pills that contain combined estrogen-progesterone, only progestin, antiprogestins and copper intrauterine devices. The most common form of this type of contraception is oral progestin-only pills (levonorgestrel). The most effective method is copper intrauterine devices followed by anti-progestins and oral progestin-only pills. The major pathogenesis of oral emergency contraceptives is the prevention or delay of ovulation. Although conception is possible on only a few days of the cycle, emergency contraception is offered when indicated without regard to the timing of the menstrual cycle because of uncertainty in the timing of the ovulation. Levonorgestrel and E/P regimes are most effective as soon as possible after unprotected sexual intercourse. A linear relationship has been shown between effectiveness and the time of dose. The effectiveness continues for 120 h, but it is recommended to be used within 72 h after intercourse. Intrauterine devices may prevent pregnancy when 5 d after ovulation.

Repeated use of pre- and postcoital hormonal contraception for prevention of pregnancy

BACKGROUND

Repeated use of postcoital hormonal contraception is not currently recommended due to the higher risk of side effects and lower contraceptive effectiveness compared to other modern methods of contraception. However, emerging evidence indicates renewed interest in a regular coitally-dependent method of oral contraception. We evaluated the existing data on safety and effectiveness of pericoital use of levonorgestrel and other hormonal drugs to prevent pregnancy.

OBJECTIVES

To determine the effectiveness and safety of repeated use of pre- and postcoital hormonal contraception for pregnancy prevention.

SEARCH METHODS

We searched until 1 September 2014 for trials that tested repeated pre- and postcoital use of hormonal drugs for pregnancy prevention. Databases included CENTRAL, MEDLINE, and POPLINE. We searched for current trials via ClinicalTrials.gov and ICTRP. For the initial review, we also searched EMBASE, CINAHL, and LILACS, and wrote to researchers to identify other trials.

SELECTION CRITERIA

We considered published and unpublished studies of repeated postcoital or immediately precoital use of hormonal drugs for contraception with pregnancy as an outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently confirmed eligibility and extracted data from the included studies. We calculated confidence intervals (CI) around individual study Pearl indices using a Poisson distribution. We presented individual study estimates and pooled estimates and their 95% CI, where appropriate.

MAIN RESULTS

We found 22 trials that evaluated pericoital use of LNG and other hormonal drugs on a regular basis to prevent pregnancy. The studies included a total of 12,400 participants, and were conducted in Europe, Asia, and the Americas. The drugs and doses evaluated included levonorgestrel (LNG) 0.75 mg (11 studies), LNG in doses other than 0.75 mg (4 trials), and hormones other than LNG (7 trials). Outcomes included pregnancy rates, discontinuation, side effects, and acceptability.Pericoital levonorgestrel was reasonably efficacious and safe. The pooled Pearl Index for the 0.75 mg dose of LNG was 5.4 per 100 woman-years (95% CI 4.1 to 7.0). The pooled Pearl Index for all doses of LNG was 5.0 per 100 woman-years (95% CI 4.4 to 5.6). Other hormonal drugs appeared promising but most of them were not studied extensively. Menstrual irregularities were the most common side effects reported. However, the studies provided no consistent evidence of a relationship between bleeding abnormalities and either frequency of pill intake or total dose of the drug. Non-menstrual side effects were reportedly mild and not tabulated in most studies. Most women liked the pericoital method in spite of frequent menstrual irregularities.

AUTHORS' CONCLUSIONS

The studies of pericoital LNG regimens provided promising results but many had serious methodological issues. Most reports were decades old and provided limited information. However, we considered the evidence to be moderate quality because of the large number of participants from diverse populations, the low pregnancy rates, and the consistent results across studies. Rigorous research is still needed to confirm the efficacy and safety of pericoital use of LNG as a primary means of contraception among women with infrequent intercourse. If the method is shown to be efficacious, safe and acceptable, the results may warrant revision of the current World Health Organization recommendations and marketing strategies.

Update on emergency contraception

Emergency contraception (EC) is any method used after sexual intercourse to prevent pregnancy. This article provides an overview of the history of EC methods and describes the current availability of oral and intrauterine EC. Oral forms include the Yuzpe regimen (combining ethinyl estradiol and levonorgestrel), levonorgestrel-only pills, and ulipristal acetate, which is a new emergency contraceptive drug recently approved by the US Food and Drug Administration. The copper T-380A intrauterine device can also be used for EC. Information about dosing, timing, access, and other considerations in the provision of EC is covered. Clinicians should be aware of all available options in order to counsel women in need of EC appropriately.

Adolescent contraception: review and guidance for pediatric clinicians

The objectives of this article are to review current contraceptive methods available to adolescents and to provide information, guidance, and encouragement to pediatric clinicians to enable them to engage in informed up-to-date interactions with their sexually active adolescent patients. Pregnancy prevention is a complex and dynamic process, and young people benefit from having a reliable authoritative source for information, counseling, and support. Clinicians who provide services for adolescents have a responsibility to develop their skills and knowledge base so that they can serve as that source. This review begins with a discussion about adolescent sexuality and pregnancy in the context of the adolescent developmental stages. We discuss approaches to introduce the topic of contraception during the clinic visit and contraceptive counseling techniques to assist with the discussion around this topic. In addition, information is included regarding confidential services, support of parental involvement, and the importance of male involvement in contraception. The specific contraceptive methods are reviewed in detail with the adolescent patient in mind. For each method, we discuss the mechanism of action, efficacy, contraindications, benefits and risks from the medical perspective, advantages and disadvantages from the patient's perspective, side effects, patient adherence, patient counseling, and any medication interactions. Furthermore, we have included a section that focuses on the contraceptive management for the adolescent patient with a disability and/or chronic illness. The article concludes with an approach to frequently asked or difficult questions. This section largely summarizes subsections on specific contraceptive methods and can be used as a quick reference on particularly challenging topics. Finally, a list of useful contraceptive management resources is provided for both clinicians and patients.

Repeated use of pre- and postcoital hormonal contraception for prevention of pregnancy

BACKGROUND

Repeated use of postcoital hormonal contraception is not currently recommended due to the higher risk of side effects and lower contraceptive effectiveness compared to other modern methods of contraception. However, emerging evidence indicates renewed interest in a regular coitally-dependent method of oral contraception. We re-evaluated the existing data on safety and effectiveness of pericoital use of levonorgestrel and other hormonal drugs to prevent pregnancy.

OBJECTIVES

To determine the effectiveness and safety of repeated use of pre- and postcoital hormonal contraception for pregnancy prevention

SEARCH STRATEGY

We searched the computerized databases MEDLINE, POPLINE, CINAHL, LILACS, EMBASE and CENTRAL for trials that tested repeated pre- and postcoital use of hormonal drugs for pregnancy prevention. We also searched for current trials via ClinicalTrials.gov and ICTRP.

SELECTION CRITERIA

Published and unpublished studies in any language of repeated postcoital or immediately precoital use of hormonal drugs for contraception with pregnancy as an outcome

DATA COLLECTION AND ANALYSIS

Two authors independently confirmed the eligibility and extracted data from the included studies. We calculated confidence intervals (CI) around individual study Pearl indices using a Poisson distribution. We presented individual study estimates and pooled estimates and their 95% CI, where appropriate.

MAIN RESULTS

We found 21 trials that evaluated pericoital use of LNG and other hormonal drugs on a regular basis to prevent pregnancy. Pericoital levonorgestrel (LNG) was reasonably efficacious and safe. The pooled Pearl Index for the 0.75 mg dose of LNG was 5.1 per 100 woman-years (WY) (95% CI 3.8 to 6.7). The pooled Pearl Index for all doses of LNG was 4.9 per 100 WY (95% CI 4.3 to 5.5). Other hormonal drugs appeared promising but most of them were not studied extensively. Most women liked the pericoital method in spite of frequent menstrual irregularities.

AUTHORS' CONCLUSIONS

The studies of pericoital LNG regimens provided promising results but had a number of serious methodological limitations. A pressing need exits to conduct a rigorous research to confirm the efficacy and safety of pericoital use of LNG as a primary means of contraception among women with infrequent intercourse. If the method is shown to be efficacious, safe and acceptable, the results may warrant revision of the current WHO recommendations and marketing strategies.

Pregnancy outcome after levonorgestrel-only emergency contraception failure: a prospective cohort study

BACKGROUND

Levonorgestrel (LNG), as a dedicated emergency contraception (EC) product, has been available over-the-counter in China for 10 years. Until now, only a small number of deliveries after LNG-EC failure have been documented.

METHODS

This study was a prospective comparative cohort study. A group of 332 pregnant women who had used LNG-EC during the conception cycle was recruited, and matched to a group of 332 pregnant women without the exposure to LNG. Congenital malformations, perinatal complications and delivery circumstances were investigated in this study.

RESULTS

There were 31 pregnant women in the study group and 28 in the comparison group miscarried within 14 weeks of gestation. In the study and comparison groups, four malformations were found in each group. In the study group, both birthweight (3416 versus 3345 g, P = 0.040) and the sex ratio of birth (boys/girls, 1.14 versus 0.90, P = 0.153) were higher than in the comparison group. There were no statistically significant differences in the incidence of miscarriage or malformation or in the neonatal outcome between the two groups.

CONCLUSIONS

There was no association between the use of LNG-EC pills and the risk of major congenital malformations, pregnancy complications or any other adverse pregnancy outcomes in our study.

Levonorgestrel administration in emergency contraception: bleeding pattern and pituitary-ovarian function

BACKGROUND

This study was conducted to evaluate the effects of levonorgestrel administration for emergency contraception (EC) on bleeding pattern and pituitary-ovarian function.

STUDY DESIGN

In 69 women with a reported stable menstrual cycle length of 24-34 days, we investigated bleeding patterns following EC administration in the follicular (n=26), periovulatory (n=14) and luteal (n=29) phase. In a subgroup of 8 women, hormonal evaluation and ultrasonography were performed.

RESULTS

EC taken in the follicular, but not in the periovulatory or luteal phase, significantly shortened cycle length by 10.9+/-1 days. The subsequent cycle was not affected. EC taken in the late preovulatory phase, prior to the gonadotrophin surge, suppressed ovulation (n=7), while ovulation was not blocked when EC was given during an ongoing luteinizing hormone (LH) pulse (n=1).

CONCLUSIONS

Our data indicate that EC given before the onset of the luteinizing hormone (LH) surge inhibits ovulation and hastens the end of the current menstrual cycle. Subsequently, the length of the following menstrual cycle returned as prior to treatment. By contrast, levonorgestrel administered after the expected ovulation has no effect on menstrual cycle length.

Emergency contraception, myths and facts

Emergency contraception has the potential to reduce the United States unintended pregnancy rate by half. This article discusses the evidence on the safety and efficacy of emergency contraception, its side effects, as well as its mechanisms of action. Emergency contraception availability presents many opportunities for enhanced contraceptive care, beyond the obvious lapse in condom use, and evidence is lacking for contraindications to this expanded role. This article concludes that clinicians caring for women of reproductive age should recognize the importance of ready access to this medication to help prevent unintended pregnancies.

Adolescência e contracepção de emergência: Fórum 2005

OBJETIVO: Relatar os resultados do Fórum "Adolescência e Contracepção de Emergência", que teve como proposta trazer maiores esclarecimentos sobre a contracepção de emergência (CE), além de apoio ético e técnico para sua prescrição, a partir da análise de três vertentes principais de discussão: o perfil da clientela adolescente; as questões éticas que envolvem a CE; a eficácia e o risco do método. FONTES DE DADOS: Discussão dos temas propostos a partir da literatura atual sobre o tema do Fórum organizado em 2005, que envolveu a participação de pediatras, ginecologistas, profissionais ligados a Comissões de Bioética, ao Conselho Federal de Medicina e ao Ministério da Saúde, advogados e juízes. SÍNTESEDOS DADOS: A adolescência caracteriza-se por mudanças, transformações e experimentações que vinculam essa fase da vida à vulnerabilidade e risco. Alguns desses riscos estão relacionados ao exercício inadvertido ou impensado da sexualidade, cujas conseqüências são bem conhecidas: gravidez precoce, aborto e doenças sexualmente transmissíveis, entre as quais HPV e AIDS. É fundamental, portanto, que a assistência a essa faixa etária inclua o enfoque de prevenção, na qual a educação sexual seja vista como um processo do qual é parte relevante a orientação anticoncepcional, incluindo-se nesta a contracepção em situações de emergência. CONCLUSÕES: O artigo apresenta as conclusões resultantes das discussões realizadas durante esse evento. Seu principal desdobramento foi a Resolução do Conselho Federal de Medicina: a CE não é abortiva e pode ser usada em qualquer etapa da vida reprodutiva.

In vivo assessment of the human sperm acrosome reaction and the expression of glycodelin-A in human endometrium after levonorgestrel-emergency contraceptive pill administration

BACKGROUND

The objectives were firstly to assess acrosome reaction (AR) status of spermatozoa following uterine flushing, secondly to measure levonorgestrel (LNG) levels in serum and in uterine flushing fluid and finally to measure endometrial glycodelin-A expression after administration of LNG as a form of emergency contraception (EC).

METHODS

Forty-eight experiments were conducted on 15 regularly menstruating women. Four groups were formed based on different intercourse to treatment interval and treatment to recovery of spermatozoa and the biopsies.

RESULTS

Twenty-four and forty-eight hours after treatment, there were 14.5 +/- 3.9 x 10(6) and 17.3 +/- 6.8 x 10(6) sperm recovered from the uterus, respectively. There were no differences between the AR rate and the endometrial glycodelin-A staining intensity in an LNG or placebo treated cycles. The LNG in uterine flushing medium represented 1.38% of the values observed in serum 24 h after the LNG intake.

CONCLUSIONS

Twenty-four and forty-eight hours after administration of EC, neither the proportion of AR sperm, nor the glycodelin-A level was influenced by 1.5 mg of LNG. LNG did not impair the cervical mucus either because viable spermatozoa were found in the genital tract 36-60 h after coitus and 24-48 h after LNG intake. The mechanism of action of LNG as EC remains unknown.

Current issues in emergency contraception: an overview for providers

Emergency contraception has the potential to greatly reduce the number of unintended pregnancies occurring each year in the United States. Emergency contraception is a safe and effective intervention to which all women should have easy access in the event of an act of unprotected intercourse. Methods of emergency contraception include combined hormone oral contraceptive pills, progestin-only oral contraceptive pills, a dedicated progestin-only emergency contraceptive product, and insertion of a copper intrauterine device. Barriers exist to the increased use of emergency contraception, including the prescription-only status of all of the methods and lack of accurate knowledge on the part of health care providers and consumers. This article provides an overview of the clinical management of emergency contraception.

Effectiveness of levonorgestrel emergency contraception given before or after ovulation--a pilot study

BACKGROUND

Although widely used, the mechanisms of action of the levonorgestrel emergency contraceptive pill (LNG ECP) are still unclear. There are increasing data to indicate that LNG is particularly effective as an ECP by interrupting follicular development and ovulation. An important outstanding question is whether it has any effect on fertilization or implantation.

METHOD

Ninety-nine women participated; they were recruited at the time they presented with a request for emergency contraception. All women took LNG 1.5 mg in a single dose during the clinic consultation. A blood sample was taken immediately prior to ingestion of the ECP for estimation of serum LH, estradiol and progesterone levels to calculate the day of ovulation. The specimens were analyzed in a single batch. Based on these endocrine data, we estimated the timing of ovulation to be within a +/-24-h period with an accuracy of around 80%. Women were followed up 4-6 weeks later to ascertain pregnancy status. The effectiveness of ECP when taken before and after ovulation was determined.

RESULTS

Three women became pregnant despite taking the ECP (pregnancy rate, 3.0%). All three women who became pregnant had unprotected intercourse between Days -1 and 0 and took the ECP on Day +2, based on endocrine data. Day 0 was taken as ovulation day. Among 17 women who had intercourse in the fertile period of the cycle and took the ECP after ovulation occurred (on Days +1 to +2), we could have expected three or four pregnancies; three were observed. Among 34 women who had intercourse on Days -5 to -2 of the fertile period and took ECP before or on the day of ovulation, four pregnancies could have been expected, but none were observed. We found major discrepancies between women's self-report of stage of the cycle and the dating calculation based on endocrine data.

CONCLUSION

These data are supportive of the concept that the LNG ECP has little or no effect on postovulation events but is highly effective when taken before ovulation.

Knowledge, Attitudes, and Use of Emergency Contraception Among Rural Western North Carolina Women

BACKGROUND

To determine the knowledge, attitudes and self-reported usage of emergency contraception (EC) in rural western North Carolina women.

METHODS

Using a cross-sectional survey, with a convenience sample, participants self-administered the survey in waiting rooms of eight medical clinics in three counties in western North Carolina. Participants included 401 English-speaking women of childbearing age (18-44 years old) presenting for routine medical care during a three-month period in 2004.

RESULTS

Of the 70.5% who responded, almost all (97%) were sexually active and most (92%) perceived an unintended pregnancy to be a problem. A majority of the participants (72%) were aware of EC, but only 7.5% of women reported usage in the last year. More than 80% of the surveyed women were uncertain if EC was the same as the abortion pill, RU-486. While only 16% of respondents indicated they had discussed EC with a doctor or another health professional, most women (89%) reported that doctors or other health professionals would be their first choice for accurate information about EC pills.

CONCLUSIONS

Among western North Carolina women of childbearing age, EC is rarely used, perhaps because of confusion about its mechanism of action. Furthermore, EC is infrequently discussed with doctors. Since women indicate that health care providers would be their preferred choice for accurate information about EC, improved patient education by physicians about EC would be a first step in increasing knowledge among patients.

Nonprescription Availability of Emergency Contraception in the United States: Current Status, Controversies, and Impact on Emergency Medicine Practice

In October 2004, the American College of Emergency Physicians Council joined more than 60 other health professional organizations in supporting the nonprescription availability of emergency contraception. This article reviews the history, efficacy, and safety of emergency contraception; the efforts toward making emergency contraception available without a prescription in the United States; the arguments for and against nonprescription availability of emergency contraception; and the potential impact nonprescription availability could have on the practice of emergency medicine in the United States.

Bleeding patterns after use of levonorgestrel emergency contraceptive pills

OBJECTIVE

The objective of this study was to describe bleeding after use of an emergency contraceptive pill (ECP) regimen consisting of 1.5 mg of levonorgestrel in a single dose.

METHODS

We asked 120 women who had been treated with the regimen to keep daily bleeding diaries for 9 weeks. We compared bleeding patterns observed after treatment with usual patterns reported by the participants and with patterns observed in a prior study on women who had not taken ECPs.

RESULTS

Treatment in the first 3 weeks of the menstrual cycle significantly shortened that cycle as compared both with the usual cycle length and with the cycle duration in a comparison group. The magnitude of this effect was greater the earlier the pills were taken. In contrast, the duration of the first menstrual period after treatment increased significantly with cycle week of treatment and was longer in women who used the treatment than in those who did not. Intermenstrual bleeding occurred in only 5% of women in the first cycle after treatment.

CONCLUSIONS

The effect of the single-dose levonorgestrel ECP regimen on the timing and duration of the next menstrual period depends on when during the cycle the pills are taken. Intermenstrual bleeding following treatment is uncommon.

The in vitro effect of emergency contraception doses of levonorgestrel on the acrosome reaction of human spermatozoa

INTRODUCTION

The aim of this study was to evaluate the effect of three concentrations of levonorgestrel (LNG) comparable to the levels found in serum following ingestion of LNG as emergency contraception (EC) on the acrosome reaction (AR) of capacitated and noncapacitated spermatozoa of fertile men.

MATERIALS AND METHODS

A total of 24 semen samples from three fertile men were evaluated. The spermatozoa were selected by Percoll gradient. Twelve samples were subsequently incubated with human tubal fluid medium supplemented with bovine serum albumin (HTF/BSA) for 20 h under capacitating conditions. The capacitated spermatozoa and the spermatozoa from the remaining 12 samples were exposed to LNG at 1, 10 and 100 ng/mL, to follicular fluid (FF) (20 %v/v) and to HTF medium. The ratio of live to dead spermatozoa was assessed after 1, 2 and 3 h of incubation at 37 degrees C and 5% CO2. After 30 min of exposure to the different LNG concentrations, aliquots were divided into two parts. In the first part, spermatozoa were immediately stained with Hoescht 33258 and fluorescein isothiocyanate-pisum sativum agglutinin (FITC-PSA) in order to assess AR rate and to repeat evaluation of the live-to-dead ratio. After 3 h of incubation, the remaining part of the aliquots were submitted to the same procedures. Each concentration of LNG was then compared with FF and HTF medium as positive and negative controls, respectively.

RESULTS

The results showed that in vitro exposure to the three different LNG concentrations did not induce AR.

CONCLUSION

This study failed to show any in vitro effect on AR of LNG concentrations similar to those found in serum following intake of LNG as EC. If this effect exists or if there is any other that influences sperm fertilizing capacity, in vitro experiments are probably not an appropriate way of testing it.

Cost savings from use of emergency contraceptive pills in Australia

BACKGROUND

Emergency contraception, which prevents pregnancy after unprotected sexual intercourse, has the potential to reduce significantly the incidence of unintended pregnancy and the consequent need for abortion and to reduce medical care costs.

AIM

To determine the savings generated by use of Postinor-2, the levonorgestrel regimen of emergency hormonal contraception, in Australia.

METHODS

We modelled the cost savings when women obtain Postinor-2 directly from a pharmacist where cost savings are measured as the cost of pregnancies averted by use of Postinor-2 per dollar spent on Postinor-2.

RESULTS

Each dollar spent on a single treatment with Postinor-2 saves A$2.27-A$3.81 in direct medical care expenditures on unintended pregnancy depending on assumptions about savings from costs avoided by preventing mistimed births. Postinor-2 is cost-saving even under the least favourable assumption that mistimed births when prevented today occur 2 years later. Results are robust even to large changes in model input parameters.

CONCLUSION

Emergency contraception is cost saving. More extensive use of emergency contraception could save considerable medical and social costs by reducing unintended pregnancies, which are expensive.

Failure of the emergency contraceptive levonorgestrel and the risk of adverse effects in pregnancy and on fetal development: an observational cohort study

OBJECTIVE

To determine pregnancy and neonatal outcome after the failure of levonorgestrel as an emergency contraceptive.

DESIGN

A retrospective observational cohort study.

SETTING

Telephone consultations concerning reproductive risk factors conducted by Telefono Rosso-Teratology Information Service, Catholic University of Sacred Heart, Rome, Italy.

PATIENT(S)

Women exposed to levonorgestrel (36 cases) compared with a control group (80 cases).

INTERVENTION(S)

Teratological counseling.

MAIN OUTCOME MEASURE(S)

The rate of congenital anomalies, the prepartum or peripartum complications, and the pregnancy outcomes.

RESULT(S)

Twenty-five exposed newborns with length and weight identical to that of the control group were shown to be without increased risk of congenital malformation. No statistical differences were observed in terms of spontaneous or legal abortion and pregnancy and neonatal complications, and there was no ectopic pregnancy in either group.

CONCLUSION(S)

Although the sample size was small, in our experience, the failure of levonorgestrel as an emergency contraceptive was not associated with an increased risk of major congenital malformations, prepartum or peripartum complications, or an adverse pregnancy outcome.

In vitro effect of levonorgestrel on sperm fertilizing capacity and mouse embryo development

The objectives of this study were to assess the expression of alpha-d-mannose binding sites in human spermatozoa, human sperm-oocyte interaction and the development of early stages of mouse embryo in the presence of levonorgestrel (LNG). Semen samples were obtained from 16 normozoospermic men. Spermatozoa were separated by Percoll gradient and incubated overnight for capacitation. The kinetic analysis of the expression of alpha-D-mannose binding sites was determined at 0, 4 and 22 h and in 22 h-capacitated spermatozoa that had been exposed to 1, 10 or 100 ng/mL of LNG or to a control medium for 30 min. Sperm binding sites for alpha-D-mannose were detected using commercial alpha-D-mannosylated bovine serum albumin conjugated with fluorescein isothiocyanate. To evaluate sperm-oocyte interaction, each oocyte was placed in a 100-microL droplet containing one of the three doses of LNG or control medium and inseminated with 1.0 x 10(5) motile spermatozoa/mL, after which the number of bound spermatozoa was evaluated. A total of 157 two-cell embryos recovered from eight mice was pooled and assigned randomly to treatment (1, 10 or 100 ng/mL of LNG) or control groups. There was a significant increase in the expression of specific alpha-d-mannose binding sites (Patterns II and III) during the incubation of spermatozoa under capacitating conditions. In the presence of LNG, results showed that there was no significant difference in the expression of specific alpha-d-mannose binding sites (Patterns II and III) at any LNG concentration tested compared with those spermatozoa in control medium. None of the LNG concentrations were capable of modifying the number of spermatozoa tightly bound to the human zona pellucida. There was no association between the presence or absence of LNG or the different doses of LNG evaluated and mouse embryo development. In conclusion, the hypothesis that in vitro exposure to LNG could interfere with sperm function and could contribute to the mechanism of action of this form of contraception was not confirmed but cannot be ruled out by the results of this study.

Emergency contraceptive pills: a review of the recent literature

PURPOSE OF REVIEW

The purpose of this review is to inform the reader of new information published since early 2003 about emergency contraception, with a particular focus on issues of access.

RECENT FINDINGS

Research continues to document low but increasing levels of knowledge about emergency contraception, increasing use, and more positive attitudes towards emergency contraception by both patients and healthcare providers. Additional information is available about efficacy and mechanisms of action. More reports of side-effects have been published, as have studies relating to the impact of emergency contraception on sexual and contracepting behaviors. Advance provision, provision by pharmacists, and over-the-counter status have been studied as ways to improve access to emergency contraception.

SUMMARY

Knowledge about the efficacy, safety, types and use of emergency contraception continues to increase. Although patients have greater awareness of and more access to emergency contraception, there are still numerous barriers to its use even in countries where it is available over the counter. Healthcare providers must continue to educate themselves and their patients about emergency contraception even when it becomes available over the counter. In countries where emergency contraception is only available by prescription, providers should offer an advance prescription or supply (where available), and use newer dosing regimens for levonorgestrel-only emergency contraception to increase adherence and efficacy. Developing collaborative practice agreements with pharmacists to increase access is also recommended. Patients should be counseled to seek follow-up if no menses occurs within 3 weeks of taking emergency contraception or if symptoms such as lower abdominal pain occur after the use of emergency contraception.