1. Doctors' Voices Generate Support for Abortion Care: Results from a Nationally Representative Survey
Physicians who provide abortion face complex issues around the public discourse on abortion. Facing potential stigma, threats, and safety concerns, these doctors may choose to remain silent, but the authors of this study hypothesized that their voices could have an important impact on audiences. They aimed to explore effective modes of communication for physicians who provide abortion, hoping to set the groundwork for communication guidelines that are both effective and acknowledge the complexity of abortion. For this study, the authors surveyed more than 1,200 participants who watched videos of doctors speaking about their work as abortion providers. The “doctor-messengers” in these videos were not given scripts and were encouraged to speak about their roles as caregivers, focus on patient care and its complexity, and discuss politics only as it affects their patients. The authors found that by centering this approach, viewers responded favorably and ultimately felt more supportive of abortion itself. This study provides an initial framework for communication around abortion and can be used as a reference point for abortion providers who choose to discuss their work publicly.
2. Efficacy of medication abortion with concurrent initiation of progestin contraceptives: a retrospective cohort study
Medication abortion, which is most effective when administered as a combination of mifepristone and misoprostol, can be offered safely to patients through no-touch or virtual delivery methods. Alternatively, patients may have a single in-person visit and instructions for virtual or self-managed follow-up. The majority of abortions in the US are medication abortions, and in an increasingly restrictive landscape, the convenience of these types of delivery cannot be overstated. As a result, many patients opt to receive contraception at the same visit. However, due to mifepristone’s mechanism of action as a selective progestin antagonist, there is concern that progestin-containing contraceptives may interfere with its efficacy. Prior randomized controlled trials (RCTs) have suggested that, while the implant can be safely placed at the time of medication abortion initiation, depot medroxyprogesterone acetate (DMPA), a.k.a. the shot, significantly increased the risk of ongoing pregnancy in patients undergoing medication abortion. The authors of this study expanded this to a real-world population by performing a retrospective cohort study to determine whether same-day implant or DMPA at the time of medication abortion provision would affect abortion efficacy. They found that consistent with prior data, DMPA appeared to result in decreased medication abortion efficacy, while the implant did not change the efficacy when administered at the same time as mifepristone. These results reaffirm earlier data and can be used to bolster counseling.
3. Risk of teratogenicity in continued pregnancy after gestational exposure to mifepristone and/or misoprostol: a systematic review and meta-analysis
Medication abortion using mifepristone followed by misoprostol is an extremely safe and effective form of abortion care, with success rates usually quoted in the high 90th percentile when used as directed. However, a small percentage of patients may still have an ongoing pregnancy after using these medications, and an even smaller percentage of these patients may consider continuing those pregnancies. In this meta-analysis of 13 studies on the effects of mifepristone and/or misoprostol exposure on fetuses or neonates, the authors found that the use of misoprostol alone in early pregnancy was associated with increased risk of fetal malformations, including hydrocephalus, Mobius syndrome, and transverse limb defects. They did not find evidence of increased teratogenicity with mifepristone alone or an additive risk of mifepristone when combined with misoprostol. However, the authors note that there is insufficient evidence to conclude that mifepristone is not teratogenic, as there are relatively few studies of mifepristone exposure alone. Patients who consider continuing a pregnancy after exposure to medication abortion should be thoroughly counseled about the possibilities of congenital anomalies and the lack of high-quality safety data.
4. Maximizing the effectiveness of 1.5 mg levonorgestrel for emergency contraception: The case for precoital use
Oral emergency contraception with 1.5mg of levonorgestrel (LNG EC), often known by its brand name of “Plan B”, is a safe and effective way for patients to reduce the risk of pregnancy when taken after sex when another method of contraception is not used. The sooner LNG EC is taken, the more effective it is, but it may be used up to 120 hours after sex and works through delaying ovulation. No type of EC has any effect on an established pregnancy. Given that LNG EC is most effective and is recommended as soon as possible after sex, many reproductive health experts advocate for patients who anticipate possible unprotected sex to have a ready supply of the medication. In this mathematical modeling study, the authors analyze whether taking LNG EC a few hours before unprotected sex could improve the effectiveness of pregnancy prevention. In their modeling, the authors concluded that taking LNG EC could theoretically reduce the risk of unintended pregnancy by 91%, though they note that real-world usage in research studies used in the model would change effectiveness levels; accounting for this, they conclude that if half of patients took the medication three hours before sex, actual effectiveness levels would range from 70-81%. While the authors caution that patients should not routinely rely on precoital use of LNG EC to effectively avoid unintended pregnancy, this research suggests that patients who do use LNG EC could further reduce their chance of unintended pregnancy by using the medication in advance of unprotected sex.
5. Hormone-related side effects in new users of a levonorgestrel 52 mg intrauterine device
The levonorgestrel (LNG) IUDs are a highly effective form of reversible contraception that can be used safely by virtually all patient populations. While patients’ systemic exposure to LNG is very low, especially in comparison to other forms of hormone-containing contraception, some patients do report hormone-related side effects; however, it is less clear whether these side effects may actually be due to patients switching from another form of hormonal contraception. In this evaluation of a subset of more than 1,700 patients in a Phase 3 study of a 52mg LNG IUD, the authors compared reported hormone-related side effects between patients previously using combined hormonal versus non-hormonal forms of birth control. They noted that hormone-related side effects aside from acne were rare, reported less than 3% of days in the first six months, and discontinuation due to these side effects was low in both groups. Patients who switched from combined hormonal contraception were significantly more likely to report acne and orgasm/libido problems after switching to the LNG IUD than those who switched from non-hormonal contraception. These findings demonstrate that hormone-related side effects from LNG IUD are uncommon and rarely bothersome enough to lead to discontinuation and suggest that providers should counsel patients who are discontinuing combined hormonal contraception and who have had past issues with acne or orgasm/libido issues about the on the possible recurrence of the issues.
6. Complications of vasectomy: results from a prospective audit of 105,393 procedures
Vasectomy provides a highly effective, permanent form of contraception and is considered both safer and more reliable than bilateral tubal ligation/salpingectomy. However, patients considering vasectomy may be deterred by possible complications, long-term consequences, and/or failure rates; the possibility of these issues has been difficult to quantify in the literature. In this large prospective research study, the authors collected data from more than 100,000 vasectomy procedures performed by more than 150 UK surgeons. In their analyses, the authors determined that vasectomy failure was rare, with only 0.93% of patients with motile sperm seven months after vasectomy and 0.04% with a reported failure after having been cleared to discontinue other contraception. Complications were also rare, with postoperative infection reported in 1.22%, hematoma in 1.56%, and post-vasectomy pain syndrome in 0.14%. Providers counseling patients on the option of vasectomy can confidently quote very low likelihoods of complications or vasectomy failures with this procedure.
7. Common misperceptions and public knowledge about intrauterine devices among US-based online respondents
Both hormonal and non-hormonal IUDs are safe and highly effective forms of reversible contraception and help users avoid pregnancy by inhibiting sperm migration and viability and (in the case of the hormonal IUD) by making cervical mucus impenetrable to sperm. However, misperceptions about how the IUD prevents pregnancy and how common IUD side effects are can influence patients in their contraception decisions. In this cross-section research survey, the authors queried approximately 1,600 US adults about their understanding of IUD mechanisms and side effects. Most respondents did not know the primary mechanism of pregnancy prevention, with the majority answering that IUDs prevent embryo implantation; further, 11-15% of respondents reported that IUDs worked by causing miscarriage/abortion, and 10-12% reported they worked through causing permanent infertility. Misperceptions were also common regarding IUD complications and side effects; failure, weight gain, uterine perforation, and expulsion were all cited as health risks likely to occur >5% of the time by 55%, 42%, 34%, and 38% of participants, respectively. Women respondents were more likely to perceive IUDs as higher risk than men. The authors conclude that misperceptions about IUD mechanisms and safety are common in the general populace and call for greater efforts to disseminate accurate IUD information in visible arenas, including clinical spaces as well as online forums.
8. The influence of lifestyle factors on serum etonogestrel concentrations among contraceptive implant users
The etonogestrel implant (Nexplanon) is a highly safe, effective form of long-acting reversible contraception. However, awareness of pharmacokinetics is necessary when counseling patients about this method, as its efficacy may be affected by certain medications. Since variable lifestyle factors, including diet, exercise and substance intake, can affect metabolism of other medications, the authors of this study sought to understand the effect of these factors on serum etonogestrel for implant users. They performed a cross-sectional analysis of 115 participants, focusing on diet, exercise and alcohol, tobacco and marijuana use. All users had had their implant in place for more than 12 months, leading to a hormonal steady state, and completed surveys regarding their lifestyle habits. The authors found that none of the studied lifestyle factors had a significant association with etonogestrel levels, though increased caloric intake had inconsistent associations. This suggests that these lifestyle factors can be excluded from any concerns about etonogestrel levels in implant users.
9. The association of insertion methods on immediate postpartum intrauterine device expulsion rates: a retrospective cohort study
In order to eliminate barriers to access, it is standard to offer intrauterine device (IUD) placement immediately after delivery or within 10 minutes of placental expulsion. However, the risk of IUD expulsion is elevated for patients who choose immediate post-placental IUDs, and there are no standardized methods of placement. The authors of this study wanted to determine whether the method of post-placental IUD placement influences subsequent expulsion. They performed a retrospective cohort study to evaluate expulsion rates, comparing patients whose post-placental IUDs were placed with ring forceps to those whose IUD was placed manually (i.e., by hand). Patients were included in the study if they followed up within six weeks after delivery so that their IUD placement could be evaluated. The authors found that IUD placement with ring forceps had a significant association with IUD expulsion when compared to manual placement (34.6% vs 20%). These results suggest a need for further study and may also be incorporated into provider technique when considering placement of a post-placental IUD.
10. An Exploration of Contraceptive Choice Pathways in Adolescents and Young Adults
Decisions around contraception are influenced by numerous factors that may include side effect concerns, privacy, and convenience. For adolescents and young adults (AYA), these considerations may also include relationship status and the experiences and recommendations of friends. To better understand these nuances, the authors of this study analyzed contraceptive choice pathways in AYA designated female at birth. The study participants were patients at a contraception clinic in a Midwestern children’s hospital ages 14 - 24 who presented over the course of six years. Their decision-making process was visually represented through a Sankey diagram, which is a way of depicting the flow from one choice to another. The authors found that there was a robust relationship between desired and chosen methods for AYA patients, but that undecided AYA had the possibility of choosing all available methods. These results further support the utility of patient-centered contraception counseling and suggest that undecided AYA may especially benefit from a broad overview of all available contraceptive options.
