Levonorgestrel IUD: is there a long-lasting effect on return to fertility?

What Do the General Public Know about Infertility and Its Treatment?

Rates of infertility are rising, and informed decision making is an essential part of reproductive life planning with the knowledge that ART success decreases dramatically while a woman's age increases and that high costs can often be incurred during fertility treatment. We aimed to determine the current knowledge of infertility and its treatments in the general public through an online survey. We received 360 complete responses. The average age of respondents was 35 years with most respondents being female (90%), heterosexual (88%), white (85%) and university educated (79%). Of the total, 49% had children and 23% had a condition that affects their fertility; 41% had concerns about future fertility and 78% knew someone who had had fertility treatment. Participants' understanding of basic reproductive biology and causes of infertility varied with correct responses to questions ranging from 44% to 93%. Understanding of IVF outcomes was poorer with only 32% to 55% of responses being correct, and 76% of respondents felt that their education in fertility was inadequate. This survey highlights the inconsistencies in the general public's understanding of infertility in this relatively educated population. With increasing demands on fertility services and limited public funds, better education is essential to ensure patients are fully informed with regard to their reproductive life planning.

A Social Media Survey of US Adolescent Preferences for Menstrual Bleeding Patterns

STUDY OBJECTIVE

To assess preferences for menstrual pattern and acceptability and knowledge about the safety of induced amenorrhea among adolescents and young adults METHODS: We conducted a cross-sectional online survey of US residents aged 14-24 years at least 1 year post-menarche. Online recruitment was conducted via the social media platform TikTok on a teen reproductive health channel. Survey questions focused on menstrual history, menstrual pattern preferences, and demographic characteristics. The primary outcome was the proportion of postmenstrual individuals who would prefer amenorrhea vs scheduled bleeding.

RESULTS

From 5113 potential respondents who accessed the eligibility screening, 3001 completed surveys and met the inclusion criteria. Most were aged 14-18 (63.7%), distributed proportionally among all US Census regions. When asked if they could pick their period-bleeding style without any permanent impacts, almost three-quarters chose no bleeding at all (amenorrhea; 71.5%) compared with scheduled periods (28.5%). However, 63.7% agreed or were uncertain when faced with the statement "It might be unsafe if hormone medications stop your period bleeding." After adjusting for age, gender expression, race, religion, heavy bleeding, and frequent bleeding, factors associated with preference for amenorrhea vs regular bleeding were younger age, masculine gender expression, White race, and non-Christian religious background. Baseline bleeding amount and frequency were not associated with preference for amenorrhea.

CONCLUSION

More than two-thirds of US adolescents and young adults indicated a preference for medication-induced amenorrhea if the method was assured to not have any permanent effects on the body, despite highly prevalent misconceptions about health and safety.

Platelet-rich plasma infusion as an adjunct treatment for persistent thin lining in frozen embryo transfer cycles: first US experience report

PURPOSE

To study effect of intrauterine infusion of platelet-rich plasma (PRP) on endometrial growth in the setting of thin endometrial lining in patients with prior cancelled or failed frozen embryo transfer (FET) cycles.

MATERIALS AND METHODS

Single-arm cohort study of forty-six patients (51 cycles) with endometrial lining thickness (EMT) < 6 mm in prior cancelled or failed FET cycles requesting intrauterine PRP treatment in upcoming FET cycle. The primary outcomes were final EMT in FET cycle and change in EMT after PRP. The secondary outcomes were overall pregnancy rate, clinical pregnancy rate, miscarriage rate, ongoing pregnancy, and live birth rates.

RESULTS

The mean pre-PRP EMT in all FET cycles was 4.0 ± 1.1 mm, and mean post-PRP EMT (final) was 7.1 ± 1.0 mm. Of 51 cycles, 33 (64.7%) reached ≥ 7 mm after PRP administration. There was a significant difference between pre-PRP EMT and post-PRP EMT in all FET cycles, with mean difference of 3.0 ± 1.5 mm. Three cycles were cancelled for failure to reach adequate lining. Total pregnancy rate was 72.9% in our cohort of 48 cycles that proceeded to transfer. Clinical pregnancy rate was 54.2% (26/48 FET cycles); clinical miscarriage rate was 14.3% (5/35 pregnancies). Twenty six women had live birth (18 with EMT ≥ 7 mm and 8 with EMT < 7 mm). Response to PRP was not correlated with any pre-cycle characteristics.

CONCLUSION

We demonstrate a significant improvement in lining thickness and pregnancy rates in this challenging cohort of women after PRP infusion, with no adverse events. Cost-effectiveness of PRP with benefits and alternatives should be carefully considered.

Frontal Fibrosing Alopecia and Reproductive Health: Assessing the Role of Sex Hormones in Disease Development

Frontal Fibrosing Alopecia (FFA) is a distinctive form of cicatricial alopecia characterized by gradual hairline recession, predominantly affecting postmenopausal individuals, thus implying a potential hormonal origin. This narrative review, spanning 2000 to 2023, delves into PubMed literature, focusing on the menopausal and hormonal status of women with FFA. The objective is to unravel the intricate nature of FFA and its plausible associations with hormonal dysregulations in women. While menopause remains a pivotal demographic characteristic linked to FFA, existing data suggest that its hormonal imbalances may not fully account for the development of FFA. Conversely, substantial evidence indicates a strong association between a reduction in fertile years, particularly through surgical interventions leading to an abrupt hormonal imbalance, and FFA in women. Additionally, exposure to hormone replacement therapy or oral contraceptives has shown varying degrees of association with FFA. Gynecologists should maintain a heightened awareness regarding the ramifications of their interventions and their pivotal role in overseeing women's fertility, recognizing the potential influence on the progression of FFA. The recurrent theme of hormonal disruption strongly implies a causal connection between alterations in sex hormones and FFA in women. Nevertheless, this relationship's extent and underlying mechanisms remain subjects of ongoing debate.

Nanomaterials Solutions for Contraception: Concerns, Advances, and Prospects

Preventing unintentional pregnancy is one of the goals of a global public health policy to minimize effects on individuals, families, and society. Various contraceptive formulations with high effectiveness and acceptance, including intrauterine devices, hormonal patches for females, and condoms and vasectomy for males, have been developed and adopted over the last decades. However, distinct breakthroughs of contraceptive techniques have not yet been achieved, while the associated long-term adverse effects are insurmountable, such as endocrine system disorder along with hormone administration, invasive ligation, and slowly restored fertility after removal of intrauterine devices. Spurred by developments of nanomaterials and bionanotechnologies, advanced contraceptives could be fulfilled via nanomaterial solutions with much safer and more controllable and effective approaches to meet various and specific needs for women and men at different reproductive stages. Nanomedicine techniques have been extended to develop contraceptive methods, such as the targeted drug delivery and controlled release of hormone using nanocarriers for females and physical stimulation assisted vasectomy using functional nanomaterials via photothermal treatment or magnetic hyperthermia for males. Nanomaterial solutions for advanced contraceptives offer significantly improved biosafety, noninvasive administration, and controllable reversibility. This review summarizes the nanomaterial solutions to female and male contraceptives including the working mechanisms, clinical concerns, and their merits and demerits. This work also reviewed the nanomaterials that have been adopted in contraceptive applications. In addition, we further discuss safety considerations and future perspectives of nanomaterials in nanostrategy development for next-generation contraceptives. We expect that nanomaterials would potentially replace conventional materials for contraception in the near future.

Long-Term Retained Lippes Loop Intrauterine Device Causes Vesicouterine Fistula

This case report discusses a 77-year-old female patient who presented to an outpatient clinic with urinary symptoms and recurrent UTIs. Imaging revealed a foreign body, which was later confirmed as a retained intrauterine device (IUD) that had caused a vesicouterine fistula (VUF). The patient had a medical history of cervical cancer treated with radiation therapy, during which her IUD's string could not be located, leading to the decision to proceed with radiation therapy without removing the IUD. The patient opted to manage her condition medically rather than undergo surgical removal due to concerns about worsening the vesicouterine fistula. This case highlights the potential risks and complications of retained IUDs, and the importance of careful consideration and communication among clinical teams and patients when managing these situations.

Hormonal contraceptives and the brain: A systematic review on 60 years of neuroimaging, EEG, and biochemical studies in humans and animals

Hormonal contraception has been widely prescribed for decades. Although safety and efficacy are well-established, much uncertainty remains regarding brain effects of hormonal contraception. We systematically review human and animal studies on the brain effects of hormonal contraception which employed neuroimaging techniques such as MRI, PET and EEG, as well as animal studies which reported on neurotransmitter and other brain biochemical effects. We screened 1001 articles and ultimately extracted data from 70, comprising 51 human and 19 animal studies. Of note, there were no animal studies which employed structural or functional MRI, MRS or PET. In summary, our review shows hormonal contraceptive associations with changes in the brain have been documented. Many questions remain and more studies are needed to describe the effects of hormonal contraception on the brain.

Thin endometrial lining: is it more prevalent in patients utilizing preimplantation genetic testing for monogenic disease (PGT-M) and related to prior hormonal contraceptive use?

STUDY QUESTION

Is a thin endometrial lining before ovulation triggering more prevalent in patients utilizing preimplantation genetic testing for monogenic disease (PGT-M) compared to the regular IVF/ICSI population and is this associated with prior hormonal contraceptive use?

SUMMARY ANSWER

Thin (<8 mm) endometrial lining is more prevalent in PGT-M patients compared to the regular IVF/ICSI population and is associated with both longer prior hormonal contraceptive use and a shorter cessation interval of hormonal contraceptives before IVF/ICSI treatment.

WHAT IS KNOWN ALREADY

Thin endometrial lining has been associated with lower pregnancy rates in IVF/ICSI cycles and increased chances of miscarriage and low birth weight. Endometrial thinning and atrophy occur during hormonal contraceptive use. Patients utilizing PGT-M typically use hormonal contraceptives up until treatment to avoid the risk of conception of a genetically affected child. Whether this could negatively affect endometrial thickness achieved during subsequent IVF/ICSI cycles is not known.

STUDY DESIGN, SIZE, DURATION

A retrospective case control study was performed, including all PGT-M patients attending the University Medical Centre Groningen (cases), between 2009 and 2018. The control group consisted of two non-PGT IVF/ICSI patients for each PGT-M patient, matched for age and treatment period.

PARTICIPANTS/MATERIALS, SETTING, METHODS

First cycles of 122 PGT-M patients and 240 controls were included. Cessation interval of hormonal contraceptives was categorized as late cessation (cessation <1 year prior to treatment) or early cessation (>1 year prior to treatment). Endometrial thickness was routinely measured on the day of hCG triggering or 1 day prior. The prevalence of an endometrial lining <8 mm was compared between PGT-M patients and controls. Hormonal contraceptive use (both duration and cessation interval) was compared between both groups. Univariable and multivariable regression analyses were performed to identify risk factors for thin endometrial lining. In addition, cycle and pregnancy outcomes were compared within control/PGT-M groups between patients with endometrial lining > or <8 mm.

MAIN RESULTS AND THE ROLE OF CHANCE

Thin endometrial lining on the day of hCG triggering was found significantly more often in the PGT-M group, compared to controls: 32% vs 11% (mean difference 21.0%, 95% CI: 11.7, 30.3%). As expected, more patients in the PGT-M group ceased their hormonal contraception late (<1 year): 64% vs 2% in the control group (mean difference 61.9%, 95% CI: 53.0, 70.8%). Average duration of hormonal contraceptive use was 10.6 years in the PGT-M group vs 9.3 years in controls (mean difference 1.3 years, 95% CI: 0.2, 2.3 years). Multivariable logistic regression analysis identified late cessation (OR: 6.0, 95% CI: 1.9-19.2) and duration of prior hormonal contraceptive use (OR per year increase 1.1, 95% CI: 1.0-1.2) as significant independent risk factors for a thin endometrial lining. In relation to outcome, we found a statistically significant increase in miscarriage rate in PGT-M patients with an endometrial lining <8 mm compared to those with an endometrial lining >8 mm (20.0% vs 1.7%, mean difference 18.3%, 95% CI: 2.3, 34.3%). A trend towards lower birth weight and gestation- and gender-adjusted birth weight (z-score) was also found in this group. No statistically significant differences were detected in pregnancy rate, live birth rate, or incidence of preterm delivery or SGA. Within the control group, no statistically significant differences were found in outcomes between patients with an endometrial lining <8 compared to an endometrial lining >8 mm.

LIMITATIONS, REASONS FOR CAUTION

The study is retrospective. Various types of hormonal contraceptives were reported which possibly exert different effects on the endometrial lining. In relation to pregnancy outcome measures, numbers were very limited; therefore, no firm conclusions should be drawn.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides further insight into the role of prior hormonal contraceptive use as a possible contributor to the occurrence of thin endometrial lining during ART treatment. Future studies should provide more information on its clinical relevance, to determine whether PGT-M patients can be reassured, or should be counselled to stop hormonal contraceptive use and change to an alternative contraceptive method prior to PGT treatment.

STUDY FUNDING/COMPETING INTERESTS

No specific funding was used and no conflicts of interests are declared.

TRIAL REGISTRATION NUMBER

N/A.

Long-acting intrauterine systems: Recent advances, current challenges, and future opportunities

Levonorgestrel intrauterine systems (LNG-IUSs) are complex drug-device combination products designed to release a hormonal contraceptive drug for up to 7 years. These drug delivery systems offers a great promise as a modern method of long-acting reversible contraceptives (LARCs) to improve women's health. Unfortunately, there are some scientific challenges associated with the development of these products which are among the major reasons contributing to the availability of relatively few IUS products on the market. This review summarizes the formulation considerations (drug and excipient attributes), manufacturing methods, advances in characterization and in vitro drug release testing of IUSs, as well as factors influencing drug release from IUSs. A critical discussion on the major challenges to IUS product development is presented. Specifically, insights on bioequivalence evaluation, in vitro-in vivo correlation (IVIVC) establishment, and regulatory challenges are detailed. Lastly, methodological tools to overcome some of these hurdles to product development are proposed. The knowledge furnished through this review will be helpful towards obtaining better product understanding. Such understanding will facilitate the development of these complex drug products, as well as their regulatory approval process.

Emergency Contraception: Access and Challenges at Times of Uncertainty

BACKGROUND

The UN Commission on Life-Saving Commodities for Women's and Children's Health identified emergency contraceptive pills as 1 of the 13 essential underused, low-cost, and high-impact commodities that could save the lives of millions of women and children worldwide. In the US, 2 emergency contraceptive regimens are currently approved, and their most plausible mechanism of action involves delaying and/or inhibiting ovulation.

AREAS OF UNCERTAINTY

Abortion and contraception are recognized as essential components of reproductive health care. In the US, in the wake of the Dobbs v. Jackson Women's Health Organization Supreme Court decision on June 24, 2022, 26 states began to or are expected to severely restrict abortion. It is anticipated that these restrictions will increase the demand for emergency contraception (EC). Several obstacles to EC access have been described, and these include cost, hurdles to over-the-counter purchase, low awareness, myths about their mechanisms of action, widespread misinformation, and barriers that special populations face in accessing them. The politicization of EC is a major factor limiting access. Improving sex education and health literacy, along with eHealth literacy, are important initiatives to improve EC uptake and access.

DATA SOURCES

PubMed, The Guttmacher Institute, Society of Family Planning, American College of Obstetrician and Gynecologists, the World Health Organization, The United Nations.

THERAPEUTIC ADVANCES

A randomized noninferiority trial showed that the 52 mg levonorgestrel intrauterine device was noninferior to the copper intrauterine device when used as an EC method in the first 5 days after unprotected intercourse. This is a promising and highly effective emergency contraceptive option, particularly for overweight and obese patients, and a contraceptive option with a different bleeding profile than the copper intrauterine device.

CONCLUSIONS

EC represents an important facet of medicine and public health. The 2 medical regimens currently approved in the US are very effective, have virtually no medical contraindications, and novel formulations are actively being investigated to make them more convenient and effective for all patient populations. Barriers to accessing EC, including the widespread presence of contraception deserts, threaten to broaden and accentuate the already existing inequities and disparities in society, at a time when they have reached the dimensions of a public health crisis.

Making More Womb: Clinical Perspectives Supporting the Development and Utilization of Mesenchymal Stem Cell Therapy for Endometrial Regeneration and Infertility

The uterus is a homeostatic organ, unwavering in the setting of monthly endometrial turnover, placental invasion, and parturition. In response to ovarian steroid hormones, the endometrium autologously prepares for embryo implantation and in its absence will shed and regenerate. Dysfunctional endometrial repair and regeneration may present clinically with infertility and abnormal menses. Asherman's syndrome is characterized by intrauterine adhesions and atrophic endometrium, which often impacts fertility. Clinical management of infertility associated with abnormal endometrium represents a significant challenge. Endometrial mesenchymal stem cells (MSC) occupy a perivascular niche and contain regenerative and immunomodulatory properties. Given these characteristics, mesenchymal stem cells of endometrial and non-endometrial origin (bone marrow, adipose, placental) have been investigated for therapeutic purposes. Local administration of human MSC in animal models of endometrial injury reduces collagen deposition, improves angiogenesis, decreases inflammation, and improves fertility. Small clinical studies of autologous MSC administration in infertile women with Asherman's Syndrome suggested their potential to restore endometrial function as evidenced by increased endometrial thickness, decreased adhesions, and fertility. The objective of this review is to highlight translational and clinical studies investigating the use of MSC for endometrial dysfunction and infertility and to summarize the current state of the art in this promising area.

Uterine synechiae after intrauterine device use: a case series

PURPOSE

The intrauterine device (IUD) is one of the most effective and safe contraceptive methods. Substantial literature suggests an overall return to normal fertility following IUD removal. However, there are no studies to date that evaluate endometrial function specifically in nulliparous women after levonorgestrel IUD use.

METHODS

We present three nulliparous women with a history of levonorgestrel IUD use who were evaluated for uterine dysfunction at the University of California, San Francisco Center for Reproductive Health. These patients had no other known risk factors or history of uterine manipulation, including prior uterine surgery, pelvic radiation, intrauterine infection, hypothalamic amenorrhea, or uterine anomaly.

RESULTS

Upon evaluation, these patients were found to have uterine synechiae concerning for Asherman syndrome. All three patients were eventually able to conceive through assisted reproductive technology or natural conception.

CONCLUSION

This case series is the first to suggest a possible effect of endometrial dysfunction on fertility resumption following levonorgestrel IUD removal in nulliparous patients. It is possible that a small subset of patients may be at risk for Asherman syndrome after IUD use. Larger prospective trials are needed to explore this possible association.