Analysing the context and characteristics of legal abortion and comprehensive post-abortion care among adolescents aged 10-14 in a network of sentinel centres in Latin America: a retrospective cross-sectional study, 2016-2020

Pregnancy-related complications are a substantial source of morbidity and mortality among adolescents in low- and middle-income countries. While the youngest adolescents (those aged 10-14) are considered to be at particularly high risk of adverse outcomes, there is little empirical data available on their sexual and reproductive health. Using a unique dataset of clinical records drawn from a regional network of sentinel centres providing legal abortion and comprehensive post-abortion care in 12 Latin American and Caribbean countries, we described the population of adolescents aged 10-14 seeking legal abortion and post-abortion care and calculated institutional rates of complications, using older adolescents (aged 15-19) and young adults (aged 20-24) as comparator groups. We also assessed the quality of care provided as compared to WHO recommendations. Nearly 17% (89 out of 533) of young adolescents sought care when they were already at 15 or more weeks' gestation. Young adolescents were at higher risk of pre-procedure and intra-operative complications than older adolescents and young adults, though the trend is less clear for the most severe complications. In general, the quality of care provided by centres in the network was aligned with WHO recommendations for safe abortion and comprehensive post-abortion care. Taken together, these findings provide insight into the challenges facing the global health community in assuring the sexual and reproductive health and rights of the youngest adolescents, and outline avenues for future research, advocacy, and evidence-based policymaking.

Intrauterine device use is safe among nulligravidas and adolescent girls

The use of intrauterine devices (IUDs), including the copper-bearing device and the levonorgestrel intrauterine system (LNG-IUS), is safe among nulligravidas and adolescent girls. However, several misconceptions limit their use in clinical practice; health-care providers are hesitant to prescribe IUDs, and several myths associated with their usage in nulligravidas and adolescents exist among both providers and women themselves. The high rates of unplanned pregnancies (which in many settings constitute a public health issue, primarily among adolescent females) can be attributed at least partially to lack of awareness and limited use of highly effective contraceptives such as IUDs. In this review, we discuss the role of non-hormonal and hormonal IUDs as effective contraceptives in nulligravidas and adolescent girls. We present a literature review of data that highlight contraceptive efficacy, side effects (including reasons for discontinuation), and continuation rates with the method. We searched the PubMed/MEDLINE, Cochrane Library, Embase, and Scopus databases for all articles published in English between January 1990 through September 2020. A large body of evidence confirmed the effectiveness of IUD/IUS, independent of age and parity. Studies showed a high expulsion rate among adolescents but not among nulligravidas. Additionally, bleeding patterns among adolescents and nulligravidas were similar to those observed among adults and parous women. The high early removal rates observed in adolescents were attributable to bleeding and/or pain, which indicate that compared with adults, adolescents are less likely to accept IUD-induced side effects. IUD placement is an excellent strategy to avoid the high rates of unplanned pregnancies in adolescents and nulligravidas. IUDs are more effective than short-acting reversible contraceptives with failure rates that are equivalent to those observed with permanent contraception. However, few long-term studies have investigated this category of women to definitively establish the role of IUD/IUS as effective means of contraception.

Pregnancy outcomes associated with extended use of the 52-mg 20 μg/day levonorgestrel-releasing intrauterine system beyond 60 months: A chart review of 776 women in Brazil

OBJECTIVE

To assess the contraceptive performance of the 52-mg 20 μg/day levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena; Bayer Oy, Turku, Finland) among women who maintain the same device without changes after 60 months.

STUDY DESIGN

This is a chart review study in which we assessed the charts of 766 women who continue the same LNG-IUS for contraception beyond 60 months. The women were evaluated at the Family Planning clinic, University of Campinas Medical School, Campinas, SP, Brazil, from November 1990 to March 2011. We obtained sociodemographic data, duration of use, continuation and discontinuation rates and reasons, bleeding pattern at the recorded last visit. The statistical analysis was performed using Kaplan-Meier analysis.

RESULTS

A total of 776 charts were identified of women who used the LNG-IUS beyond 60 months. The mean age (±S.E.M.) at LNG-IUS placement was 32.0±0.2 years (ranged 15 to 44 years; median was 32 years). The distribution of number of pregnancies was 0-1 (45%); 2-4 (54.1%) and≥5 (0.9%). The median length of the LNG-IUS' use was 73 months after placement (ranged 61-184 months). Zero pregnancies were reported and the main reasons for discontinuation were expiration of approved effective lifespan, menopause and planning pregnancy. The cumulative women-years (W-Y) of exposure were 967 and 1403 up to seven and 15 years, respectively. The main bleeding pattern reported by the women was amenorrhea.

CONCLUSIONS

The 52-mg 20 μg/day LNG-IUD (Mirena) showed continue contraceptive efficacy beyond 5 years of use with no pregnancies detected over 967 and 1403 W-Y up to seven and 15 years after placement.

IMPLICATIONS STATEMENT

The 52-mg 20 μg/day LNG-IUD presented a very high contraceptive efficacy beyond the first 5 years of lifetime labeled. Increasing data support that efficacy beyond 5 years of use, and new data suggested efficacy as long as 15 years. Healthcare professionals, policy makers and stakeholders could take advantage of the present information to decide to maintain the same device at least up to seven years. Furthermore, amenorrhea could be a good indicator of contraceptive effect.

A prospective, open-label, single arm, multicentre study to evaluate efficacy, safety and acceptability of pericoital oral contraception using levonorgestrel 1.5 mg

STUDY QUESTION

Will the use of levonorgestrel (LNG) 1.5 mg taken at each day of coitus by women who have relatively infrequent sex be an efficacious, safe and acceptable contraceptive method?

SUMMARY ANSWER

Typical use of LNG 1.5 mg taken pericoitally, before or within 24 h of sexual intercourse, provides contraceptive efficacy of up to 11.0 pregnancies per 100 women-years (W-Y) in the primary evaluable population and 7.1 pregnancies per 100 W-Y in the evaluable population.

WHAT IS KNOWN ALREADY

LNG 1.5 mg is an effective emergency contraception following unprotected intercourse. Some users take it repeatedly, as their means of regular contraception.

STUDY DESIGN, SIZE, DURATION

This was a prospective, open-label, single-arm, multicentre Phase III trial study with women who have infrequent coitus (on up to 6 days a month). Each woman had a follow-up visit at 2.5, 4.5 and 6.5 months after admission or until pregnancy occurs if sooner, or she decided to interrupt participation. The study was conducted between 10 January 2012 and 15 November 2014.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 330 healthy fertile women aged 18–45 years at risk of pregnancy who reported sexual intercourse on up to 6 days a month, were recruited from four university centres located in Bangkok, Thailand; Campinas, Brazil; Singapore and Szeged, Hungary to use LNG 1.5 mg pericoitally (24 h before or after coitus) as their primary method of contraception. The participants were instructed to take one tablet every day she had sex, without taking more than one tablet in any 24-h period, and to maintain a paper diary for recording date and time for every coital act and ingestion of the study tablet, use of other contraceptive methods and vaginal bleeding patterns. Anaemia was assessed by haemoglobin evaluation. Pregnancy tests were performed monthly and pregnancies occurring during product use were assessed by ultrasound. At the 2.5-month and final visit at 6.5 months, acceptability questions were administered.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 321 women included in the evaluable population (which includes all eligible women enrolled), with 141.9 woman-years (W-Y) of observation and with a rate (95% confidence interval [CI]) of 7.1 (3.8; 13.1) pregnancies per 100 W-Y of typical use (which reflects use of the study drug as main contraceptive method, but also includes possible use of other contraceptives from admission to end of study) and 7.5 (4.0; 13.9) pregnancies per 100 W-Y of sole use. In the primary evaluable population (which includes only eligible enrolled women <35 years old), the rate was 10.3 (5.4; 19.9) pregnancies per 100 W-Y of typical use, and 11.0 (5.7; 13.1) pregnancies per 100 W-Y of sole use. There were three reported severe adverse events and 102 other mild adverse events (most common were headache, nausea, abdominal and pelvic pain), with high recovery rate. The vaginal bleeding patterns showed a slight decrease in volume of bleeding and the number of bleeding-free days increased over time. There was only one case of severe anaemia, found at the final visit (0.4%). The method was considered acceptable, as over 90% of participants would choose to use it in the future or would recommend it to others.

LIMITATIONS, REASONS FOR CAUTION

This was a single-arm study with small sample size, without a control group, designed as a proof of concept study to explore the feasibility of this type of contraception.

WIDER IMPLICATIONS OF THE FINDINGS

A larger clinical study evaluating pericoital contraception with LNG is feasible and our data show that this method would be acceptable to many women.

STUDY FUNDING/COMPETING INTEREST(S)

This study received partial financial support from the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR) and the World Health Organization. Gynuity and the Bill and Melinda Gates Foundation (BMGF) provided financial support for project monitoring. HRA Pharma donated the LNG product. N.K. was the initial project manager when she was with WHO/HRP and was employed by HRA Pharma, which distributes LNG for emergency contraception. The other authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

This study was registered on ANZCTR, Trial ID ACTRN12611001037998.

TRIAL REGISTRATION DATE

4 October 2011.

DATE OF FIRST PATIENT'S ENROLMENT

10 January 2012.

Prevalence of Low Bone Mass and Osteoporosis in Long-Term Users of the Injectable Contraceptive Depot Medroxyprogesterone Acetate

BACKGROUND

Bone mineral density (BMD) loss among depot medroxyprogesterone acetate (DMPA) users is a controversial issue. Aspects under debate include whether the number of years of use has any effect on continuous BMD loss, whether this loss will stabilise over the years of use or if it will progress to low bone mass, osteoporosis and an increased fracture risk. The aim of this study was to compare the difference in osteoporosis and low bone mass between DMPA and copper intrauterine device (Cu-IUD) users.

METHODS

This was a cross-sectional study that evaluated BMD at the lumbar spine and femoral neck in 47 long-term DMPA users and 41 Cu-IUD users as control group. BMD was measured by dual-energy X-ray absorptiometry. The participants were 27 to 57 years of age, had used either DMPA or a Cu-IUD uninterruptedly for at least ten years, had initiated use of the method prior to 40 years of age and had follicle stimulating hormone values <40 mIU/mL.

RESULTS

Findings showed that 68.1% and 36.6% of the DMPA and Cu-IUD users, respectively, had low bone mass and 29.8% and 2.4% of DMPA and Cu-IUD users, respectively, had osteoporosis. BMD decreased as the number of years of DMPA use increased.

CONCLUSION

Long-term DMPA use was associated with low bone mass and osteoporosis in women who had used the method for 10 years or more. DMPA users with longer time of use showed a greater bone mass loss.

Effect of vaginal administration of misoprostol before intrauterine contraceptive insertion following previous insertion failure: a double blind RCT

STUDY QUESTION

Is pretreatment with misoprostol useful in insertion of intrauterine contraceptives (IUCs) after insertion failure at the first attempt?

SUMMARY ANSWER

Pretreatment with intravaginal administration of 200 mcg of misoprostol after IUC insertion failure 10 and 4 h before the second attempt of IUC placement was significantly better than placebo at facilitating the insertion of an IUC.

WHAT IS KNOWN ALREADY

One of the reasons for low use of IUCs is the concept that insertion is difficult. Misoprostol was used in several randomized clinical trials (RCT) before IUC insertion to facilitate the insertion. In general, the results showed no significant differences when compared with placebo. However, most previous studies have been carried out among unselected women whereas the present study is among women with previous insertion failure.

STUDY DESIGN, SIZE, DURATION

This was a double blind RCT conducted between February 2013 and October 2014. Participants were 104 women who requested an insertion of an IUC and the insertion failed at the first attempt. After insertion failure, the women received a sealed envelope with misoprostol or placebo. The randomization system (1: 1) in one block size was computer-generated.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study was conducted at a tertiary care centre. The women were instructed to insert vaginally one tablet of misoprostol 200 µg (Prostokos, Hebron, Cariacica, PE, Brazil) or placebo 10 and 4 h before the woman returned to the clinic for a new insertion attempt. The outcomes were successful IUC insertion and the use of a cervical dilator immediately prior to the insertion procedure.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 2639 women requested the insertion of an IUC during the study period. The IUC was inserted at the first attempt in 2535 women (96%) and 104 women in whom we were unable to insert the device were eligible to participate in the RCT. Four women declined and 100 women were randomized (55 for the misoprostol group and 45 for the placebo group). From the 100 participating women, the levonorgestrel-releasing intrauterine system (LNG-IUS) was chosen by 55 and 37 women and the TCu380A intrauterine device (Cu-IUD) was chosen by none and 8 women in the misoprostol and placebo group, respectively. Seven and three women allocated to misoprostol and placebo, respectively, never returned to the clinic after randomization. We placed the IUC in 42 (87.5%) out of the 48 women and in 26 (61.9%) out of the 42 women randomized to misoprostol and placebo, respectively (P = 0.0066). Regarding the Evaluable Population the relative risk (RR) of successful insertions was 1.41 (95% confidence interval (CI) for absolute difference (8.2, 43.0), P = 0.0066); in the Intent-to-Treat Population the RR (95% CI) was 1.32 (0.3, 36.9). Multiple regression analysis showed that the significant variables associated with the insertion failure were the number of Caesarean section ≥1 (P = 0.020) and the use of placebo (P = 0.026). Dilators were used in 21 (43.7%) out of the 48 and 21 (50%) out of the 42 women randomized to misoprostol and placebo, respectively (P = 0.804).

LIMITATIONS, REASONS FOR CAUTION

The limitations were that the majority of the women chose the LNG-IUS, and consequently the data for the Cu-IUD were limited, and there was a small number of nulligravidas.

WIDER IMPLICATIONS OF THE FINDINGS

The results show that IUC insertion difficulties and failures are not common. Pretreatment with intravaginal misoprostol facilitated IUC insertion after failure of insertion at the first attempt, and insertion failure was associated with number of Caesarean sections.

STUDY FUNDING/COMPETING INTERESTS

This study received partial financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), grant # 2012/10085-0, and from the National Research Council (CNPq), grant #573747/2008-3. All the TCu380A IUDs were donated by Injeflex, São Paulo, Brazil, and all the LNG-IUS were donated by the International Contraceptive Access Foundation (ICA), Turku, Finland. Both donations were provided in the form of unrestricted grants. The authors declare that there are no conflicts of interest associated with this study.

TRIAL REGISTRATION NUMBER

ClinicalTrial.gov NCT01754649.

Estimated disability-adjusted life years averted by long-term provision of long acting contraceptive methods in a Brazilian clinic

STUDY QUESTION

What is the contribution of the provision, at no cost for users, of long acting reversible contraceptive methods (LARC; copper intrauterine device [IUD], the levonorgestrel-releasing intrauterine system [LNG-IUS], contraceptive implants and depot-medroxyprogesterone [DMPA] injection) towards the disability-adjusted life years (DALY) averted through a Brazilian university-based clinic established over 30 years ago.

SUMMARY ANSWER

Over the last 10 years of evaluation, provision of LARC methods and DMPA by the clinic are estimated to have contributed to DALY averted by between 37 and 60 maternal deaths, 315-424 child mortalities, 634-853 combined maternal morbidity and mortality and child mortality, and 1056-1412 unsafe abortions averted.

WHAT IS KNOWN ALREADY

LARC methods are associated with a high contraceptive effectiveness when compared with contraceptive methods which need frequent attention; perhaps because LARC methods are independent of individual or couple compliance. However, in general previous studies have evaluated contraceptive methods during clinical studies over a short period of time, or not more than 10 years. Furthermore, information regarding the estimation of the DALY averted is scarce.

STUDY DESIGN, SIZE AND DURATION

We reviewed 50 004 medical charts from women who consulted for the first time looking for a contraceptive method over the period from 2 January 1980 through 31 December 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women who consulted at the Department of Obstetrics and Gynaecology, University of Campinas, Brazil were new users and users switching contraceptive, including the copper IUD (n = 13 826), the LNG-IUS (n = 1525), implants (n = 277) and DMPA (n = 9387). Estimation of the DALY averted included maternal morbidity and mortality, child mortality and unsafe abortions averted.

MAIN RESULTS AND THE ROLE OF CHANCE

We obtained 29 416 contraceptive segments of use including 25 009 contraceptive segments of use from 20 821 new users or switchers to any LARC method or DMPA with at least 1 year of follow-up. The mean (± SD) age of the women at first consultation ranged from 25.3 ± 5.7 (range 12-47) years in the 1980s, to 31.9 ± 7.4 (range 16-50) years in 2010-2011. The most common contraceptive chosen at the first consultation was copper IUD (48.3, 74.5 and 64.7% in the 1980s, 1990s and 2000s, respectively). For an evaluation over 20 years, the cumulative pregnancy rates (SEM) were 0.4 (0.2), 2.8 (2.1), 4.0 (0.4) and 1.3 (0.4) for the LNG-IUS, the implants, copper IUD and DMPA, respectively and cumulative continuation rates (SEM) were 15.1 (3.7), 3.9 (1.4), 14.1 (0.6) and 7.3 (1.7) for the LNG-IUS, implants, copper IUD and DMPA, respectively (P < 0.001). Over the last 10 years of evaluation, the estimation of the contribution of the clinic through the provision of LARC methods and DMPA to DALY averted was 37-60 maternal deaths; between 315 and 424 child mortalities; combined maternal morbidity and mortality and child mortality of between 634 and 853, and 1056-1412 unsafe abortions averted.

LIMITATIONS, REASONS FOR CAUTION

The main limitations are the number of women who never returned to the clinic (overall 14% among the four methods under evaluation); consequently the pregnancy rate could be different. Other limitations include the analysis of two kinds of copper IUD and two kinds of contraceptive implants as the same IUD or implant, and the low number of users of implants. In addition, the DALY calculation relies on a number of estimates, which may vary in different parts of the world.

WIDER IMPLICATIONS OF THE FINDINGS

LARC methods and DMPA are highly effective and women who were well-counselled used these methods for a long time. The benefit of averting maternal morbidity and mortality, child mortality, and unsafe abortions is an example to health policy makers to implement more family planning programmes and to offer contraceptive methods, mainly LARC and DMPA, at no cost or at affordable cost for the underprivileged population.

STUDY FUNDING/COMPETING INTERESTS

This study received partial financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), grant # 2012/12810-4 and from the National Research Council (CNPq), grant #573747/2008-3. B.F.B., M.P.G., and V.M.C. were fellows from the scientific initiation programme from FAPESP. Since the year 2001, all the TCu380A IUD were donated by Injeflex, São Paulo, Brazil, and from the year 2006 all the LNG-IUS were donated by the International Contraceptive Access Foundation (ICA), Turku, Finland. Both donations are as unrestricted grants. The authors declare that there are no conflicts of interest associated with this study.

Body weight and body composition of depot medroxyprogesterone acetate users

OBJECTIVES

Weight gain is a concern with the contraceptive depot-medroxyprogesterone acetate (DMPA); however, this issue remains controversial. The objective of this study was to compare body weight (BW) and body composition (BC) in DMPA and copper intrauterine device (IUD) users at baseline and after one year of use.

STUDY DESIGN

We enrolled new DMPA users and age and weight matched new IUD users into this prospective study. Weight and height were measured, BC (fat and lean mass) was evaluated using dual-energy X-ray absorptiometry, and physical activity was assessed at baseline and at 12 months. Student's paired t test and the Wilcoxon paired test for matched samples were used.

RESULTS

Ninety-seven women were enrolled for the study; 26 matched pairs continued using the initial method for at least one year, and completed the baseline and 12 month assessments. An increase of 1.9 kg occurred in BW (p=.02) in DMPA users at 12 months of use, resulting from an increase in fat mass of 1.6 kg (p=.03). Weight remained stable in IUD users; however, there was an increase in lean mass at 12 months of use (p=.001). The number of women practicing physical activity increased in this group. There was a significant difference between the groups regarding the variation in the percentage of central fat (p=.04).

CONCLUSION

Weight gain in the DMPA group after the first year of use resulted from an increase in fat mass. Weight remained stable in the IUD group; however, an increase in lean mass and a reduction in localized abdominal fat mass occurred, possibly because more users were practicing physical activity.

IMPLICATIONS STATEMENT

There was a greater increase in body weight in DMPA users compared to TCu380A IUD users in the first year of use of the contraceptive method. Furthermore, the weight increase in users of DMPA occurred principally as the result of an increase in fat mass. Physical activity probably could increase the lean mass in the users of TCu380A IUD.

New and emerging contraceptives: a state-of-the-art review

Background

The first hormonal contraceptive was introduced onto the market in several countries 50 years ago; however, the portfolio of contraceptive methods remains restricted with regards to their steroid composition, their cost, and their ability to satisfy the requirements of millions of women/couples in accordance with their different reproductive intentions, behaviors, cultures, and settings.

Methods

A literature review was conducted using Medline, Embase, and Current Contents databases, up to September 1, 2013 to identify publications reporting new contraceptives in development using combinations of the search terms: contraception, contraceptives, oral contraceptives, patch, vaginal ring, implants, intrauterine contraceptives, and emergency contraception (EC). Also, several experts in the field were also consulted to document ongoing projects on contraception development. Additionally, the Clinicaltrial.gov website was searched for ongoing studies on existing contraceptive methods and new and emerging female contraceptives developed over the past 5 years. Information was also obtained from the pharmaceutical industry.

Results

Early sexual debut and late menopause means that women may require contraception for up to 30 years. Although oral, injectable, vaginal, transdermal, subdermal, and intrauterine contraceptives are already available, new contraceptives have been developed in an attempt to reduce side effects and avoid early discontinuation, and to fulfill women’s different requirements. Research efforts are focused on replacing ethinyl-estradiol with natural estradiol to reduce thrombotic events. In addition, new, less androgenic progestins are being introduced and selective progesterone receptor modulators and new delivery systems are being used. In addition, research is being conducted into methods that offer dual protection (contraception and protection against human immunodeficiency virus transmission), and contraceptives for use “on demand.” Studies are also investigating non-hormonal contraceptive methods that have additional, non-contraceptive benefits.

Conclusion

The most pressing need worldwide is, first, that the highly effective contraceptive methods already available should be affordable to most of the population and also that these methods should fulfill the needs of women of different ages and with different reproductive requirements. The development of new contraceptive methods should also take advantage of the knowledge obtained over the past 30 years on gamete physiology and gamete interaction to avoid the use of steroid compounds.

[Intrauterine contraception in nulliparous women as a strategy to reduce unplanned pregnancies in Latin America]

Due high rates of unplanned pregnancy and unsafe abortion in young women in Latin America intrauterine contraception, by its great contraceptive efficacy, should be offered by the public services of health in a more generalized way. However, some negative prejudices prevail over the perception of its benefits. The aim of this article was to explore the most relevant myths around this contraceptive method in Latin America and make a review of the literature to allay the fears of their use by young and nulliparous women.

METHODS

Descriptive and retrospective study. Search for information in Embase and PubMed with emphasis on clinical randomized studies, studies of cases and controls, meta-analyses and systematic reviews which show risks and benefits of intrauterine contraception.

RESULTS

Evidence shows that intrauterine contraception has few contraindications for young women and nulliparous; for this reason it must be as an effective public health strategy to reduce unplanned pregnancies and unsafe abortions.

CONCLUSIONS

We identified the major barriers to the use of intrauterine contraception in Latin America and evidence for each one of them in the bibliography. Doctors of first contact in health systems should now recognize that intrauterine contraception is safe and effective.

Pain at insertion of the levonorgestrel-releasing intrauterine system in nulligravida and parous women with and without cesarean section

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.

METHODS

Three groups of new acceptors of the LNG-IUS were studied: one with 23 nulligravida women, one with 28 parous women who had undergone at least one c-section and one with 23 parous women who had no previous c-section. Pain at insertion was evaluated by using a pain visual analogue score (VAS). The ease of insertion was defined as easy or difficult by health care providers (HCPs) and classified according to the cause of difficulty: tight cervix, anatomically distorted uterus or pain.

RESULTS

Almost all women reported pain at insertion, regardless of parity and form of delivery. The mean VAS was 6.6 for nulligravida women, 5.2 for parous women with c-section and 5.9 for parous women with no c-section. Although 93% of the women reported pain at insertion, they also reported a willingness to insert a new LNG-IUS again if needed. The most common difficulties were a tight cervix in nulligravidas, an anatomically distorted uterus in parous women with c-section and pain in parous women without c-section. There was no failure of insertion in any group. HCPs reported that it was easier to perform insertion in parous women who had undergone only vaginal deliveries than nulligravid women or parous women with a prior c-section.

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.

Assessment of the use of two new low-dose levonorgestrel-releasing intrauterine systems as contraceptives

Evaluation of: Gemzell-Danielsson K, Schellschmidt I, Apter D. A randomized, Phase II study describing the efficacy, bleeding profile, and safety of two low-dose levonorgestrel-releasing intrauterine contraceptive systems and Mirena. Fertil. Steril. 97(3), 616-622.e3 (2012). A randomized, open-label, Phase II study was conducted in 37 centers in five European countries to assess the optimal dose for a new contraceptive levonorgestrel intrauterine system (LNG-IUS). Overall, 742 parous or nulliparous women aged 21-40 years were allocated to receive a LNG-IUS that initially releases 12 µg/day (LNG-IUS(12)) or 16 µg/day (LNG-IUS(16)) in vitro or the currently available device that releases 20 µg/day (LNG-IUS(20)). The two new devices are shorter than the current one. Pearl Indices of 0.17, 0.82 and 0.00 for the LNG-IUS(12), LNG-IUS(16) and LNG-IUS(20), respectively, reflect the contraceptive efficacy of these devices. The mean number of bleeding and spotting days decreased in all three groups; however, this decrease was more significant in LNG-IUS(20) users. Placement of the new shorter devices was considered simple by providers, while patients reported significantly less pain with the two new devices compared with the current one. This study provided further insight into the development of two new LNG-IUS devices as contraceptives, with the additional possibility of using them to treat heavy menstrual bleeding or as endometrial protection during estrogen therapy.

Use of a lactic acid plus lactoserum intimate liquid soap for external hygiene in the prevention of bacterial vaginosis recurrence after metronidazole oral treatment

OBJECTIVE

To determine the recurrence of bacterial vaginosis (BV) after the use of a lactic acid plus lactoserum liquid soap starting immediately after the treatment with oral metronidazole and the quality of life of the participants.

METHODS

A total of 123 women with diagnosis of BV with at least three of the following criteria: 1) homogeneous vaginal discharge without inflammation of the vagina or vulva; 2) vaginal pH ≥ 4.5; 3) positive Whiff test; and 4) "clue cells" in more than 20% of the epithelial cells in the vagina. A Nugent score ≥ 4 in the vaginal bacterioscopy was also used. After BV diagnosis, metronidazole 500 mg was administered orally bid during 7 days. Patients cured of BV were then instructed to use 7.5 to 10 mL of a lactic acid plus lactoserum liquid soap once-a-day for hygiene of the external genital region. Three subsequent control visits after starting the hygiene treatment (30, 60, and 90 days; ± 5 days) were scheduled. A questionnaire was applied in the form of visual analogue scale (VAS) in all the visits regarding: 1) level of comfort at the genital region; 2) malodorous external genitalia; 3) comfort in sexual intercourse; 4) satisfaction with intimate hygiene; and 5) self-esteem.

RESULTS

Ninety two (74.8%) women initiated the use of a lactic acid plus lactoserum liquid soap at visit 1. At visit 2, 3, and 4 there were 84, 62 and 42 women available for evaluation, respectively. The rate of recurrence of BV was 19.0%, 24.2% and 7.1%, respectively in the three visits and vaginal candidiasis was observed in five treated women. Quality of life was evaluated in the 42 women who completed the four visits schedule and there were significant improvement in the five domains assessed.

CONCLUSION

A lactic acid plus lactoserum liquid soap for external intimate hygiene may be an option for the prevention of BV recurrence after treatment and cure with oral metronidazole.

In vitro assessment of some sperm function following exposure to levonorgestrel in human fallopian tubes

BACKGROUND

The mechanism of action of levonorgestrel (LNG) as emergency contraception (EC) remains a subject of debate and its effect on sperm function has been only partially explained. The aim of this study was to assess whether LNG at a similar dose to those found in serum following oral intake for EC could affect spermatozoa when exposed to human fallopian tubes in vitro.

METHODS

Fifteen mini-laparotomies were performed, the side on which ovulation occurred was recorded, and both tubes were removed and perfused with a suspension containing 1 × 10(6) motile spermatozoa, with or without LNG. Following 4-hour incubation, the tubes were sectioned to separate the isthmus and the ampulla. Each segment was flushed and the material was evaluated to quantify the number of motile sperm, the number of spermatozoa adhering to the oviductal epithelium and the acrosome reaction (AR) rate.

RESULTS

The addition of LNG did not significantly alter the number of recovered motile spermatozoa either at the isthmus or at the ampulla, nor did it have any effect on the number of recovered spermatozoa adhered to the human tubal epithelium. Furthermore, LNG did not affect the AR rate. No significant differences were found even when the side on which ovulation occurred was taken into account.

CONCLUSIONS

In a similar dose to that observed in serum following oral intake for EC, LNG had no effect on the number of motile spermatozoa recovered from the human fallopian tubes in vitro, on their adhesion to the tubal epithelium, distribution or AR rate. The possible effect of LNG as EC on sperm function remains poorly understood.

Length of the endometrial cavity as measured by uterine sounding and ultrasonography in women of different parities

BACKGROUND

In view of current controversies regarding the need for new, shorter intrauterine devices (IUDs) that would reduce expulsion rates in nulligravida, endometrial cavity length was measured in women of different parities using uterine sounding and ultrasonography.

STUDY DESIGN

A cross-sectional descriptive study was performed including 570 women of 17-52 years of age, 260 of whom were nulligravida and 310 parous.

RESULTS

The difference in mean length between measurements taken by uterine sounding and ultrasonography was 0.28 cm. Mean endometrial cavity length was 3.84+/-0.03 cm (mean+/-S.E.M.) in nulligravida and 4.25+/-0.03 cm in parous women according to uterine sounding (p<.001) and 3.70+/-0.03 cm and 3.84+/-0.03 cm, respectively, according to ultrasonography (p=.006).

CONCLUSIONS

By either technique, mean length of the endometrial cavity was >3.6 cm, the length of the most common IUDs, the TCu380A and the levonorgestrel-releasing intrauterine system. Therefore, the issue appears controversial for developing new, shorter IUDs, since current models fit most women, including nulligravida, albeit one third of the women of our sample showed endometrial length shorter than 3.2 cm.

High rate of unintended pregnancy among pregnant women in a maternity hospital in Córdoba, Argentina: a pilot study

BACKGROUND

Although Argentina has a new law on Reproductive Health, many barriers continue to exist regarding provision of contraceptive methods at public healthcare facilities.

METHODS

We asked 212 pregnant women selected at random at the Maternity and Neonatal Hospital, Córdoba, Argentina, to participate in our descriptive study. Women were asked to complete a structured questionnaire. The objectives were to determine the rate of unintended pregnancies, reasons for not using contraception, past history of contraceptive use, and intended future use.

RESULTS

Two hundred women responded to the questionnaire. Forty percent of the women stated that they had never used contraception and pregnancy was declared unintended by 65%. In the unintended pregnancy group, almost 50% of women said that they had not been using a contraceptive method because they were "unaware about contraception", and 25% stated that their contraceptive method had failed. Almost 85% of women stated that they intended to use contraception after delivery.

CONCLUSION

Approximately two-thirds of all pregnancies in this sample were unintended. Although the data is limited by the small sample size, our findings suggest that our government needs to invest in counseling and in improving the availability and access to contraceptive methods.