Fertility Regulation

Interventions to Reduce Unintended Pregnancies Among Adolescents

Intervention programmes did not decrease the number of pregnancies in adolescent women, but they might increase the pregnancy rates in abstinence programmes. In addition, such programmes did not delay the initiation of sexual intercourse or increase the use of contraception by young people of either gender.

Interventions to reduce unintended pregnancies among adolescents: systematic review of randomised controlled trials DiCenso A, Guyatt G, Willan A, Griffith L. Interventions to reduce unintended pregnancies among adolescents: systematic review of randomised controlled trials. British Medical Journal, 2002;324(7351):1426-1430.

Interventions for Emergency Contraception

Levonorgestrel and mifepristone offer the highest efficacy with an acceptable side-effect profile. One disadvantage of mifepristone is that it causes delays in onset of subsequent menses which may induce anxiety in users.

Evidence Summary

This review analyzed data form 48 trials including 33110 women using different methods of emergency contraception in varying doses including high dose estrogens, the Yuzpe regimen (estrogen +progestogen), progestogen alone (levonorgestrel), danazol, mifepristone in varying doses, and mifepristone with anordrin, misoprostol or tamoxifen and intra-uterine device. Most (37/48) of these trials are from China. Comparative evaluation of different interventions found that any form of emergency contraception is better than no intervention or placebo. levonorgestrel and mifepristone had higher efficacy and fewer side effects than the Yuzpe regimen and danazol; independent of time elapsed since intercourse.

Antibiotic prophylaxis for intrauterine contraceptive device insertion

Prophylactic use of antibiotics to reduce of the risk of upper genital infection after IUD insertion yields no benefit with respect to pelvic inflammatory disease or IUD continuation rates.

Evidence Summary

This review concludes that at the present time there is no scientific basis for recommending the routine use of prophylactic antibiotics to reduce of the risk of upper genital infection after insertion of an intrauterine device (IUD). The methodology appears to be appropriate.

Immediate postabortal insertion of intrauterine devices

IUD insertion immediately after abortion—whether induced or reported as "spontaneous"—is both safe and practical. IUD expulsion rates are higher after second-trimester abortions than after first-trimester abortions. In postabortion IUD insertion, it is important first to rule out current genital tract infection, risk of infection or haemorrhage and genital tract injury.

Evidence Summary

The review included nine randomized controlled trials. All but one compared different intrauterine devices (IUDs) inserted immediately following an induced abortion. Only one trial evaluated the safety and efficacy of immediate versus interval (that is, few weeks after abortion) insertion. Overall, the review found immediate post abortion insertion of the IUDs to be safe and effective. Pregnancy rates observed in the trials that compared different IUDs for immediate insertion were about the same when compared with interval insertion (i.e. during or immediately after menses, usually few weeks after an abortion) as well as the occurrence of serious events such as perforation and pelvic inflammatory diseases. However, the expulsion rate of Copper 7 IUD was higher with immediate insertion when compared to interval insertion (Odds ratio: 2.9; 95% Confidence interval: 1.0 - 8.7).

Immediate post-partum insertion for intrauterine devices

For women with limited access to medical care, the time of delivery offers a unique opportunity to address the need for contraception if the delivery takes place in a health centre. The popularity of the IUD and its use in the immediate postpartum period in countries like China, Egypt, and Mexico reflects the practicality of this approach.

Evidence Summary

The review assesses the safety and efficacy of immediate postpartum insertion of the intrauterine device (IUD). The a priori hypothesis was that this practice is safe but associated with a higher expulsion rate than interval insertion. There were no trials comparing various timings (immediate postpartum, delayed postpartum and interval) of IUD insertion. Eight trials that compared different IUDs or modifications of IUDs to aid retention in utero were included. The principle outcome measures included pregnancy, spontaneous expulsion and continuation rates.

Combined hormonal versus

Choices of contraception may be limited for lactating women due to concerns about hormonal effects. Ideally, the contraceptive method chosen should not interfere with lactation. Additionally, because the return of menstruation and ovulation can be unpredictable in breastfeeding women, the timing of contraception initiation is important.

Evidence Summary

This review analysed data from 5 trials that compared: (i) combined hormonal with progesterone-only contraceptive pills (1 WHO trial conducted in Hungary and Thailand); (ii) combined hormonal contraception with a placebo (2 trials, conducted in the USA and Germany); (iii) progestin-only pill with a placebo (1 trial conducted in Mexico); and (iv) 2 different initiation timings for the progestin-only pill (1 trial from Kenya). Overall, the methodological quality of all included trials was poor. Sample sizes ranged from 20 to 200 women, and for 3 trials the trial duration was especially short (10–21 days). Finally, loss to follow-up was higher than 30% in the 2 larger trials (sample sizes 171 and 200), which seriously undermined the trial validity. As indicated by the reviewers, milk volume measurements might not have been optimal in the trials, and women were not always fully breastfeeding, with supplemental foods to infants being potential confounders. The reviewers' conclusions are straightforward

Minilaparotomy and endoscopic techniques

Major morbidity is a rare with minilaparotomy and laparoscopy, but culdoscopy is associated with serious complications. The choice between minilaparotomy and laparoscopy can be made based on the surgeon's preference, but culdoscopy is not recommended.

Evidence Summary

The primary purpose of this review is to compare operative morbidity and mortality associated with three alternative surgical approaches (minilaparotomy, laparoscopy, and culdoscopy) for entering the abdominal cavity to perform tubal sterilization. As the authors note, the surgical approach to entering the abdominal cavity is but one major determinant of the safety of tubal sterilization – others include the technique of anaesthesia and the method of tubal occlusion. This review concludes that major morbidity seems to be a rare outcome when minilaparotomy and laparoscopy are used as the surgical approach and that there is no difference in risk of major morbidity between the two groups, although the included studies had little power to detect potentially important differences. Culdoscopy was associated with more major complications than minilaparotomy and more minor complications than laparoscopy. The choice between minilaparotomy and laparoscopy can be made on preferences, but culdoscopy is not recommended.

Techniques for the interruption of tubal patency for female sterilisation

Compared with tubal ring and other methods, electrocoagulation was associated with less morbidity. However, the risk of burns to the small bowel might be a serious criticism of the approach. Aspects such as training, costs and maintenance of the equipment may be important factors in deciding which method to choose.

Evidence Summary

The review compares various techniques of tubal interruption, such as tubal rings, clips, electrocoagulation and the modified Pomeroy method for female sterilization. Nine randomized controlled trials conducted between 1976 and 1991 have been included. Clips were compared with tubal rings (three trials) and with the Pomeroy method (one trial). Electrocoagulation was compared with the Pomeroy method (two trials) and with tubal rings (two trials). In one trial, Filshie clips was compared with Hulka-Clemens clips.

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