Long-Acting Reversible Contraception

Mitigating adverse effects of Cu-containing intrauterine devices using a highly biocompatible Cu5Fe alloy

Copper-containing intrauterine devices (Cu-IUD) are adopted by worldwide women for contraception with the advantages of long-term effectiveness, reversibility and affordability. However, adverse effects occur in the initial implantation stage of Cu-IUD in uterine because of the burst release of Cu2+. To minimize the burst release, in this study, we designed a series of Cu-Fe alloys with 0.5 wt%, 1 wt% and 5 wt% Fe and also further produced ultrafine grained (UFG) structure for these alloys via equal-channel angular pressing. The microstructures and properties of the coarse grained (CG) Cu, CG Cu-Fe alloys and UFG Cu-Fe alloys were systematically investigated, including grain structure and phase compositions, metallic ions release behavior, electrochemical corrosion performance, and in vitro cytotoxicity. With careful comparison and selection, we chose the CG Cu-5Fe and UFG Cu-5Fe for in vivo tests using rat model, including tissue biocompatibility, in vivo corrosion behavior, and contraceptive effectiveness. Moreover, the corrosion mechanism of the Cu-5Fe alloy and its improved biocompatibility was discussed. Both CG and UFG Cu-5Fe alloys exhibited dramatic suppression of Cu2+ release in simulated uterine fluid for the long-term immersion process. The in vivo tissue compatibility was significantly improved with both CG and UFG Cu-5Fe alloys implanted in the rats' uterine while the high contraceptive efficacy was well maintained. Due to the superior biocompatibility, the CG and UFG Cu-5Fe alloys can be the promising candidate material for Cu-IUD. STATEMENT OF SIGNIFICANCE: A highly biocompatible Cu-Fe alloy was designed and fabricated for Cu-containing intrauterine devices (Cu-IUD). With 5 wt% Fe, the burst release of Cu2+ is inhibited due to the formed galvanic cell of Cu and Fe, resulting in earlier release of Fe3+. As Fe is the most abundant essential trace element of human body, it can mitigate the toxic effects of Cu2+, thus significantly improving both in vitro cell compatibility and in vivo tissue compatibility. More importantly, the Cu-5Fe alloy exhibits 100 % contraceptive efficiency as the CG Cu, but with greatly reduced adverse effects to the uterus tissues. An advanced Cu-IUD can be developed using Cu-Fe alloys.

Gene expression associated with unfavorable vaginal bleeding in women using the etonogestrel subdermal contraceptive implant: a prospective study

To evaluate gene expression associated with unfavorable vaginal bleeding in users of the Etonogestrel (ENG) contraceptive implant. Prospective study involving 100 women who intended to use the ENG implant. Exclusion criteria included abnormal uterine bleeding, inability to attend a 1-year follow-up, and implant removal for reasons unrelated to vaginal bleeding or loss of follow-up. We obtained endometrial biopsies before implant placement and assessed the expression of 20 selected genes. Users maintained a uterine bleeding diary for 12 months post-implant placement. For statistical analysis, we categorized women into those with or without favorable vaginal bleeding at 3 and 12 months. Women with lower CXCL1 expression had a 6.8-fold increased risk of unfavorable vaginal bleeding at 3 months (OR 6.8, 95% CI 2.21-20.79, p < 0.001), while those with higher BCL6 and BMP6 expression had 6- and 5.1-fold increased risks, respectively. By the 12-month follow-up, women with lower CXCL1 expression had a 5.37-fold increased risk of unfavorable vaginal bleeding (OR 5.37, 95% CI 1.63-17.73, p = 0.006). Women with CXCL1 expression < 0.0675, BCL6 > 0.65, and BMP6 > 3.4 had a higher likelihood of experiencing unfavorable vaginal bleeding at 3 months, and CXCL1 < 0.158 at 12 months. Users of ENG contraceptive implants with elevated BCL6 and BMP6 expression exhibited a higher risk of breakthrough bleeding at the 3-month follow-up. Conversely, reduced CXCL1 expression was associated with an elevated risk of bleeding at both the 3 and 12-month follow-ups.

Contraceptive Method Use Among a Population-Based Cohort During the South Carolina Choose Well Initiative

Importance

Evaluating the impact of statewide contraceptive access initiatives is necessary for informing health policy and practice.

Objective

To examine changes in contraceptive method use among a cohort of women of reproductive age in South Carolina during the Choose Well contraceptive access initiative.

Design, Setting, and Participants

In this cohort study, baseline data from the initial Statewide Survey of Women administered from October 1, 2017, to April 30, 2018, to a probability-based sample of women of reproductive age in South Carolina and a peer state (Alabama) were linked with 3 follow-up surveys given in 2019, 2020, and 2021. Responses about contraception use from the initial survey were compared with responses across follow-up surveys using the regression-based differences-in-differences method. Data analysis was performed from October 2023 to February 2024.

Exposure

The South Carolina Choose Well contraceptive access initiative seeks to fill contraceptive access gaps and increase provision of a full range of contraceptive methods through engagement with a wide range of health care organizations across the state.

Main Outcomes and Measures

Changes in contraceptive method use, including long-acting reversible contraception (LARC), intrauterine devices (IUDs), implants, short-acting hormonal injection, and barrier or other methods between the baseline survey (2017-2018) and 3 subsequent surveys (2019-2021).

Results

A total of 1344 female participants (mean [SD] age, 34 [7] years) completed the first survey (667 in Alabama and 677 in South Carolina). Use of LARC significantly increased in South Carolina (119 [17.6%] to 138 [21.1%]) compared with Alabama (120 [18.0%] to 116 [18.1%]; P = .004). Use of IUDs increased in South Carolina (95 [14.0%] to 114 [17.4%]) compared with Alabama (92 [13.8%] to 102 [15.9%]; P = .003). These associations persisted in the adjusted analysis, with a significant increase in the odds of LARC (adjusted odds ratio, 1.24; 95% CI, 1.06-1.44) and IUD (adjusted odds ratio, 1.19; 95% CI, 1.06-1.32) use at follow-up in South Carolina compared with Alabama.

Conclusions and Relevance

In this cohort study of 1344 participants, increases in the use of IUDs in South Carolina were noted after the implementation of the South Carolina Choose Well initiative that were not observed in a peer state with no intervention. Our findings may provide support in favor of statewide contraceptive access initiatives and their role in promoting access to reproductive health services.

What do women need to know about long-acting reversible contraception? Perspectives of women from culturally and linguistically diverse backgrounds

AIM

To identify components of an online education intervention to improve preference for, and uptake of, long-acting reversible contraception in women from culturally and linguistically diverse backgrounds (CALD).

ISSUE ADDRESSED

Women from culturally and linguistically diverse (CALD) backgrounds have greater rates of unintended pregnancies than those born locally and are less likely to use long-acting reversible contraceptives (LARCs), which are highly effective at reducing unintended pregnancy. Increasing the uptake of LARC in women from CALD backgrounds may reduce the burden of unintended pregnancy in this high-risk group. An online education intervention has been shown to be effective at increasing preference for and uptake of LARC in young women. We aimed to describe what women from CALD backgrounds thought were the potentially effective components of an online education intervention to increase preference for, and uptake of, long-acting reversible contraception.

METHODS

This qualitative study involved semi-structured interviews with six Australian English-speaking women from each of Chinese, Indian, and Middle Eastern cultural backgrounds. Women were recruited through targeted Facebook advertising. Data were analysed using Braun and Clarke thematic analysis.

RESULTS

A total of 18 participants were interviewed. We have demonstrated the importance of messages tailored to cultural values, translating the video, widening the target audience to both men and women and using specific social media platforms. For all women, the video needs to highlight the covertness of contraceptive methods, alongside stating cost and approach to access. For Indian women, the video needs to highlight the effect of LARC methods on the menstrual period for Indian women and include basic information on women's health. For Middle Eastern women the video should be explicit about LARC not equating to abortion and emphasise the low efficacy of natural contraceptive methods. For Chinese women, the video should address the misconception that hormones damage the body. Regarding delivery of the video, it should be translated and delivered by a female doctor from the same culture. For Chinese women, the video should include women from the same culture sharing anecdotes and use WeChat and Chinese schools as a platform for dissemination. For Middle Eastern and Indian women government websites should be used for dissemination. The video should be made available to all decision-makers in the reproductive planning process including male partners of Middle Eastern women, parents and peers of Chinese women, and for Indian women the male partner, family, and community leaders.

CONCLUSIONS

There is a wide range of cultural adaptations that can be made to the online education videos about LARCs to improve uptake of LARCs and hence reduce the burden of unintended pregnancy in women from CALD grounds. SO WHAT?: Our findings will be used to modify an online education video about LARCs so that it is culturally appropriate for women from CALD backgrounds.

Etonogestrel-releasing subdermal contraceptive implant: Budget impact analysis based on the Brazilian private healthcare system

High rates of unplanned pregnancies persist despite pharmacological developments and advancements in contraceptive methods. Here, we demonstrate that the etonogestrel-releasing subdermal contraceptive implant (IMP-ETN) may be an appropriate and cost-effective alternative to levonorgestrel-releasing intrauterine systems (LNG-IUSs) for women in Brazil. For our pharmacoeconomic analysis, we reviewed the literature on IMP-ETN regarding its acceptance, eligibility criteria, choice, relations with age, adverse events and, finally, the unmet need in the fee-for-service private healthcare sector. We considered qualitative observations in combination with quantitative analysis and performed a deterministic sensitivity analysis to investigate whether this technology can be self-sustainable over a period of five years. The target population for this analysis comprised 158,696 women. Compared with the continued use of LNG-IUSs, adopting the IMP-ETN can result in a cost avoidance of $ 7.640.804,02 in the first year and $ 82,455,254.43 in five years. Disseminating information among physicians will promote this change and strengthen the potential cost avoided by private health system payers. These savings can be used to improve other healthcare programs and strategies. Moreover, the principles of care can be promoted by improving and adapting healthcare systems and expanding treatment and follow-up strategies. This would also provide support to women's reproductive rights and improve their quality of life. Our results suggest that the IMP-ETN has a favorable cost-effectiveness profile. Given all its advantages and negative incremental cost impact over a period of five years, the IMP-ETN may be a more favorable alternative to LNG-IUSs. Therefore, it should be offered to beneficiaries with a private healthcare plan. This analysis overcomes previous barriers to the use of cost-benefit models, and our results may help balance decision-making by policymakers, technical consultants, and researchers.

Acceptability and continuation of use of the subdermal contraceptive implant among adolescents and young women in Argentina: a retrospective cohort study

A new public policy was instituted in Argentina for free distribution of subdermal contraceptive implants to women aged 15-24 years old in the public healthcare system. The objective of this study is to determine the extent to which this population adhered to the implant, as well as predictors of continuation. The retrospective cohort study was based on a telephone survey of a random sample of 1101 Ministry of Health-registered implant users concerning the continuation of use, satisfaction with the method and side-effects, and reasons for removal. Descriptive statistics and multivariate regression analysis were used to explore the association between adherence and having received contraceptive counselling, satisfaction, and side effects. We found high levels of adherence (87%) and satisfaction (94%). Common reported side effects were amenorrhoea or infrequent bleeding, perceived weight gain, increased menstrual bleeding and headaches. Multivariate regression analysis indicates that, among adolescents, having received contraceptive counselling increased comfort, while frequent bleeding at six months hindered trust. Participants who had a history of a prior delivery or who had themselves primarily chosen the method were less likely to request the removal of the implant. Our results support the public policy of free implant distribution in the public health sector. This is a sustainable public policy that contributes to equity and access to effective contraception. It is appropriate for adolescents and young women and will also reduce unintended pregnancies. Our results suggest that counselling patients is key prior to insertion of the implant, as it improves acceptability and continuation.

Assessing readiness to implement long-acting injectable HIV antiretroviral therapy: provider and staff perspectives

BACKGROUND

Long-acting injectable antiretroviral therapy (LAI-ART) represents the next innovation in HIV therapy. Pre-implementation research is needed to develop effective strategies to ensure equitable access to LAI-ART to individuals living with HIV.

METHODS

We conducted focus group discussions (FGDs) with providers and staff affiliated with HIV clinics in San Francisco, Chicago, and Atlanta to understand barriers to and facilitators of LAI-ART implementation. Participants also completed a short survey about implementation intentions. FGDs were held via video conference, recorded, transcribed, and thematically analyzed using domains associated with the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Between September 2020 and April 2021, we led 10 FDGs with 49 participants, of whom ~60% were prescribing providers. Organizational readiness for implementing change was high, with 85% agreeing to being committed to figuring out how to implement LAI-ART. While responses were influenced by the unique inner and outer resources available in each setting, several common themes, including implementation mechanisms, dominated: (1) optimism and enthusiasm about LAI-ART was contingent on ensuring equitable access to LAI-ART; (2) LAI-ART shifts the primary responsibility of ART adherence from the patient to the clinic; and (3) existing clinic systems require strengthening to meet the needs of patients with adherence challenges. Current systems in all sites could support the use of LAI-ART in a limited number of stable patients. Scale-up and equitable use would be challenging or impossible without additional personnel. Participants outlined programmatic elements necessary to realize equitable access including centralized tracking of patients, capacity for in-depth, hands-on outreach, and mobile delivery of LAI-ART. Sites further specified unknown logistical impacts on implementation related to billing/payer source as well as shipping and drug storage.

CONCLUSIONS

Among these HIV care sites, clinic readiness to offer LAI-ART to a subset of patients is high. The main challenges to implementation include concerns about unequal access and a recognition that strengthening the clinic system is critical.

Spatial distribution and multilevel analysis of factors associated with long-acting reversible contraceptive use among sexually active women of reproductive age in Nigeria

BACKGROUND

Long-acting reversible contraceptives (LARCs), including hormonal implants and intrauterine devices, are highly effective pregnancy prevention methods. Aside its advantages over other hormonal methods, LARCs are cost-effective, easy to maintain, and have a low risk of non-compliance-related method failure. Besides, LARCs are also relatively safe for all sexually active women in the postpartum or post-abortion period. However, despite its effectiveness, most sexually active women use other short-term methods, such as condoms and contraceptive pills, which are associated with high discontinuation rates. Thus, this study examines the spatial distribution and multilevel factors associated with LARC use among sexually active reproductive-age women in Nigeria.

METHODS

This is a cross-sectional analysis of a population-based study from the 2018 Nigeria Demographic Health Survey (NDHS). The NDHS is a nationally representative survey that collects data on socio-demographic characteristics, sexual and reproductive health-related indicators such as contraceptive use and child & maternal health. A sample of 3,978 sexually active reproductive-age women (15-49 years) in Nigeria was used in the analysis. Frequency distribution and spatial analysis of LARC use were displayed with tables and maps, respectively, while multilevel analysis at a 95% confidence interval (CI) and a p-value of less than 0.05 was used to determine factors associated with LARC use among the sample.

RESULTS

The spatial distribution of LARC use among sexually active women of reproductive age in Nigeria ranges between 20 and 34.8%. Fifteen of the 36 states (excluding the Federal Capital Territory, FCT) recorded low utilization of LARCs. These states include Adamawa, Lagos, Ogun, Enugu, Anambra, Imo, Abia, Rivers, Kogi, Taraba, Yobe, Gombe, Jigawa, Borno, and Kebbi. Besides, the likelihood of LARC use was lower among participants with a prior history of pregnancy termination [aOR = 0.62; 95%(CI = 0.48-0.80)] compared to their counterparts without pregnancy termination history. Also, participants with no fertility intention had a higher likelihood of using LARCs [aOR = 1.65; 95%(CI = 1.30-2.08)] compared to those with fertility intention. At the community level, women with higher socioeconomic status were less likely to use LARCs [aOR = 0.66; 95%(CI = 0.45-0.97)] compared to women with lower socioeconomic status.

CONCLUSIONS

This study showed a relatively low utilisation of LARC among sexually active reproductive-age women in Nigeria. Notably, this low utilisation is also common in states that could be described as cosmopolitan, indicating a need for closer investigation to understand context-specific factors associated with LARC use. Population-specific family planning education and counselling for this population are important to address common misconceptions about LARCs in particular and modern contraceptive use in general.

Real-world satisfaction and menstrual bleeding pattern with available LNG-IUD among Spanish young women

OBJECTIVE

The aim of this study was to evaluate the satisfaction and menstrual bleeding pattern with levonorgestrel-releasing intrauterine systems (LNG-IUD) in young women.

METHODS

A prospective, multicentre, non-interventional study with 1-year follow-up was conducted in Spain. Participants were women between 18 and 30 years old who freely choose any available LNG-IUD for contraception. Satisfaction with LNG-IUD was measured with a 5-point Likert scale. Type of LNG-IUD, menstrual bleeding pattern and satisfaction with it, easiness of insertion and pain during procedure were collected.

RESULTS

A total of 555 women (37.3% parous, 62.7% nulliparous) (mean age 25.8 ± 3.5) completed the study. After 12 months, 92.4% of women were satisfied or very satisfied with the LNG-IUD, with no differences by parity status, type of IUD or baseline menstrual bleeding pattern. Satisfaction with the LNG-IUD correlated with satisfaction with menstrual bleeding pattern at 12 months. Up to 88.7% of women were satisfied or very satisfied with their menstrual bleeding pattern at 12 months in comparison to 41.5% at baseline (p < 0.001). Adverse events (AE)-related discontinuation rate was low (2.2%).

CONCLUSIONS

Satisfaction with LNG-IUD is very high among young Spanish women, regardless of parity and menstrual bleeding pattern at baseline.

Prevalence and factors associated with the use of long-acting reversible and permanent contraceptive methods among women who desire no more children in high fertility countries in sub-saharan Africa

BACKGROUND

The proportion of women with family planning needs increased from 74 to 76% between 2000 and 2019, and this improvement has not transcended to a fertility rate stall or decrease in sub-Saharan Africa (SSA). In the face of a continuous increase in the fertility rate in SSA, population experts agreed that the efficient use of reliable family planning methods such as long-acting reversible and permanent contraceptive methods (LARC/PMs) could help reduce the high fertility rate and associated adverse reproductive health outcomes in the region. However, despite the effectiveness of LARC/PMs, its use remains elusive in SSA. Thus, this study examines the prevalence and factors associated with the use of LARC/PMs among women who desire no more children in high-fertility countries in SSA.

METHODS

Secondary datasets from the demographic health surveys conducted in 20 countries in SSA between 2010 and 2019 were included in the study. A total sample size of 46,290 sexually active women of reproductive age who desire no more children and who met the study inclusion criteria was pooled and analysed. Prevalence of LARC/PMs use was displayed using a graph whilst binary logistic regression was used to determine the associated factors, and results were presented as unadjusted odds ratio and adjusted odds ratio with a statistical significance of p < 0.05.

RESULTS

The prevalence of LARC/PMs use among women who desire no more children was 7.5%. Ranging from 20.9% in Senegal and as low as 0.4% in Congo. Women within the richest wealth index [aOR = 1.18, 95% CI = 1.03-1.36] and those exposed to mass media [aOR = 1.54, 95% CI = 1.41-1.68] had higher odds of LARC/PMs use among sexually active women of reproductive age who desire no more children compared to those within poorest wealth index and women with no mass media exposure.

CONCLUSION

The study concluded that LARC/PMs use among sexually active women who desire no more children was very low, and women within the richest wealth index and those with mass media exposure were likely to use LARC/PMs. Interventions that will encourage using LARC/PMs should be prioritised to reduce fertility rates in SSA.

Evaluating the impact of three progestin-based hormonal contraceptive methods on immunologic changes in the female genital tract and systemically (CHIME Study): a prospective cohort study protocol

BACKGROUND

Gonadal hormones can modify immune function, which may impact susceptibility to infectious diseases, including Human Immunodeficiency Virus (HIV). There is limited knowledge about how hormonal contraceptives (HC) influence the immune response during the course of use. The CHIME study aims to evaluate the effect of long-acting progestin-based hormonal contraceptives (depot medroxyprogesterone acetate, etonogestrel implant, and levonorgestrel intrauterine device) on immunologic changes in the female genital tract (FGT) and systemic compartment.

METHODS

CHIME is an observational cohort study where participants attend 2 visits prior to initiating the HC method of their choice, and then attend 6 visits over 12 months with biological sampling (vaginal swabs, cervicovaginal lavage, cytobrush and blood) for immunological, bacteriological, and virological analyses at each visit. Immune profiling will be evaluated by multi-color flow cytometry to determine how different T-cell subsets, in particular the CD4 T-cell subsets, change during the course of contraceptive use and whether they have different profiles in the FGT compared to the systemic compartment. The study aims are (1) to characterize the alterations in FGT and systemic immune profiles associated with three long-acting progestin-only HC and (2) to evaluate the vaginal microenvironment, determined by 16 s rRNA sequencing, as an individual-level risk factor and moderator of genital and systemic immune profile changes following exposure to three commonly used HC. Data collection started in March 2019 and is scheduled to be completed in October 2024.

DISCUSSION

The CHIME study aims to contribute to the body of research designed to evaluate the comparative impact of three long-acting progestin-only HC on innate and adaptive immune functions to understand how immunologic effects alter STI and HIV susceptibility.

[Worldwide contraception]

The latest statistics concerning contraceptive use in the world have been published in 2019 by the United Nations. Among the 1.9 billion of women of reproductive age (15-49 years), 1.1 billion have a need for family planning. Among them, 190 millions are not using any contraception, although they wanted to avoid a pregnancy. There is a significant discrepancy among continents concerning the percentage of contraceptive use and the distribution of the different types of contraception. Female sterilization is the most widespread method of contraception since it represents 24% of all contraception methods used. Male condoms is used by 21% of couples. Thus, progress is still needed to disseminate effective, well tolerated and potentially reversible methods of contraception. Education of females, couples, medical and paramedical staff is one of the priority targets to improve contraception throughout the world.

The Intrauterine Device Experience Among Transgender and Gender-Diverse Individuals Assigned Female at Birth

INTRODUCTION

The intrauterine device (IUD) is a long-acting and highly efficacious form of contraception that can also be used for menstrual suppression. Although IUD use is increasing, the type chosen, appeal, and satisfaction among individuals who are transgender and gender diverse and assigned female at birth (TGD-AFAB) is unknown. The purpose of this study is to evaluate IUD usage among TGD-AFAB individuals.

METHODS

TGD-AFAB individuals who had an IUD for a minimum of 6 months at the time of completing the survey or had one in the past completed an anonymous online survey. Descriptive statistics were used to analyze the data.

RESULTS

One hundred and five TGD-AFAB individuals completed the survey. Among participants who were sexually active, 88% reported they were in a relationship in which it was possible to get pregnant. There were 85 individuals who currently had an IUD: 62 (73%) chose a 52-mg levonorgestrel (LNG) IUD, 5 (6%) chose a lower-dose LNG IUD, 17 (20%) chose the copper IUD, and one chose an IUD unavailable in the United States. Menstrual suppression was the primary reason for choosing a 52-mg LNG IUD (58%). Most individuals who opted for a copper IUD did so to avoid hormonal contraception (71%). Participants reported experiencing IUD side effects; however, few desired removal. Among the 36 respondents who had an IUD in the past, the most frequent reasons for removal were expiration of the device (LNG IUDs) and undesired side effects (copper IUD). Approximately half of participants who had an IUD removed had it replaced with another IUD.

DISCUSSION

Pregnancy can occur among TGD-AFAB individuals even if they are on testosterone and amenorrheic. IUDs are well tolerated in this population, with few current users desiring removal for unwanted side effects. Clinicians should counsel TGD-AFAB individuals about the contraceptive and noncontraceptive benefits of IUDs and expected side effects.

Advances in long-acting injectables, implants, and vaginal rings for contraception and HIV prevention

Worldwide, women face compounding reproductive health risks, including human immunodeficiency virus (HIV), sexually-transmitted infections (STIs), and unintended pregnancy. Multipurpose prevention technologies (MPTs) offer combined protection against these overlapping risks in singular prevention products that offer potential for simplified use, lower burden, higher acceptability, and increased public health benefits. Over the past decade, substantial progress has been made in development of extended-release MPTs, which have further potential to grant sexual and reproductive health autonomy to women globally and to offer choice for women to accommodate varying needs during their reproductive lives. Here, we highlight the advances made in injectable, implant, and ring delivery forms, and the importance of incorporating end-user preferences early in the research and development of these products.

Effective easing of the side effects of copper intrauterine devices using ultra-fine-grained Cu-0.4Mg alloy

Copper intrauterine device is one of the most adopted contraceptive methods with high effectiveness (over 99 %), low cost, spontaneous reversibility and long-lasting usage. However, the side effects induced from the initial burst release of copper ions (Cu²⁺) hinder the continuation of the Cu-IUD made of Coarse-Grained Copper (CG Cu). We proposed to tailor the bio-corrosion behaviors of better control of Cu²⁺ release via the addition of bioactive Mg into the Ultra-Fine Grained (UFG) Bulk Cu. Thus, UFG bulk Cu with 0.4 wt.% Mg was produced via equal-channel angular pressing. The microstructures of the UFG Cu-0.4Mg was observed using electron backscatter diffraction and transmission electron microscopy techniques. The in vitro long-term corrosion behaviors in simulated uterine fluid, cytotoxicity to four cell lines, in vivo biocompatibility and contraceptive efficacy were all studied on CG Cu, UFG Cu and UFG Cu-0.4Mg materials. The results demonstrate that both the ultrafine grains and the addition of bioactive Mg into Cu contribute to the suppression of the burst release of Cu²⁺ in the initial stage and the maintenance of high level Cu²⁺ in long-term release. Moreover, the UFG Cu-0.4Mg also exhibited much improved cell and tissue biocompatibility from both the in vitro and in vivo evaluations. Therefore, the contraceptive efficacy of UFG Cu-0.4Mg is still maintained as high as the CG Cu and UFG Cu while the side effects are significantly eased, suggesting the high potential of the UFG Cu-0.4Mg alloy as a new upgrading or alternative material for Cu-IUD. STATEMENT OF SIGNIFICANCE: The side effects from burst release of Cu²⁺ at the initial implantation stage of Cu-containing intrauterine devices (Cu-IUD) is one of the main drawbacks of these devices. In this work, an ultra-fine-grained Cu (UFG Cu) alloyed with a low amount of bioactive Mg was used for a Cu-IUD. The UFG Cu-0.4Mg alloy exhibited suppressed burst release of Cu²⁺ at initial implantation, while active Cu²⁺ release for long-term usage was maintained, comparable to coarse-grained pure Cu. Furthermore, the UFG Cu-0.4Mg alloy displayed significantly improved biocompatibility with human uterus cells and a much decreased inflammatory response within the uterus. Therefore, the side effects from Cu-IUD were eased, while high antifertility efficacy of the UFG Cu-0.4Mg alloy was maintained. The UFG Cu-0.4Mg alloy is promising for Cu-IUD.

[Long-acting reversible contraception methods in women under 26 years of age]

OBJECTIVES

Long-acting reversible contraception (LARC) methods have proven their high safety and efficacy for pregnancy prevention and they are specially indicated in young and vulnerable population, but their use encounter barriers both between providers and users due to lack of information or to the economic cost. The aim of this study was to assess the use of two LARC methods, intrauterine device (IUD) and implant, in minors under 26 years old after giving an adequate contraceptive advice and subsidizing them in vulnerability situations. To analyze the population that chooses them, the side effects, the reasons for abandoning and the permanence time.

MATERIAL AND METHODS

Retrospective descriptive study of IUD and implants inserted to minors under 26 years old from January 2016 to December 2019 at the Municipal Health Center of Usera belonging to Madrid Salud. Data is collected from n=266 women who started using IUD or implant. 87 copper IUD, 37 medicated IUD and 142 implants have been placed.

RESULTS

Increased prescription of both methods, with significant implant use in the last year of the study. There has been vulnerability in 91.7% of women. The average age of IUD users is about 21.4 years, almost 2 years older than that of the implant and they have more children. The side effects frequency has been similar with both methods, being abnormal bleeding as the most frequent side effect. 31% of copper IUD, 32% of medicated IUD and 12% of implants have been removed early. The average permanence time was 19.3 months (SD=13.3), 89.1% remained at the end of the first year, 81.2% at two years and 77.4% at three years.

CONCLUSIONS

An adequate contraceptive advice and free access are essential keys for increasing the LARC methods use in this particularly vulnerable population. Few and minor side effects and high continuity rate have been found, especially for the implant.

Engineered drug delivery devices to address Global Health challenges

There is a dire need for innovative solutions to address global health needs. Polymeric systems have been shown to provide substantial benefit to all sectors of healthcare, especially for their ability to extend and control drug delivery. Herein, we review polymeric drug delivery devices for vaccines, tuberculosis, and contraception.

Free Access to a Broad Contraceptive Method Mix and Women's Contraceptive Choice: Evidence from Sub-Saharan Africa

Financial barriers may restrict women's ability to use their preferred contraceptive methods, especially long-acting reversible contraceptives (LARC). Providing free access to a broad contraceptive method mix, including both LARC and short-acting reversible contraceptives (SARC), may increase contraceptive use, meet women's various fertility needs, and increase their agency in contraceptive decisions. Linking facility and individual data from eight countries in sub-Saharan Africa, we use a propensity score approach combined with machine learning techniques to examine how free access to a broad contraceptive method mix affects women's contraceptive choice. Free access to both LARC and SARC was associated with an increase of 3.2 percentage points (95 percent confidence interval: 0.006, 0.058) in the likelihood of contraceptive use, driven by greater use of SARC. Among contraceptive users, free access did not prompt women to switch to LARC and had no effect on contraceptive decision-making. The price effects were larger among older and more educated women, but free access was associated with lower contraceptive use among adolescents. While free access to contraceptives is associated with a modest increase in contraceptive use for some women, removing user fees alone does not address all barriers women face, especially for the most vulnerable groups of women.

Norwegian women's experiences and opinions on contraceptive counselling: A systematic textcondensation study

INTRODUCTION

Contraception plays a pivotal role in most women's lives, from teenage years to the menopause. Contraception and sexual wellbeing are closely related. Ideally, women should be able to access contraception and discuss issues concerning their sexual life during a contraceptive counselling session. Previously, only doctors conducted contraceptive consultations. Increasingly, other healthcare workers are providing contraceptive care. The aim of this study is to explore women's experiences and opinions related to contraceptive counselling.

METHODS

An electronic questionnaire was distributed in 2017-2018. The texts of 308 women's written responses to open-ended questions were analyzed using systematic text-condensation.

RESULTS

The analysis resulted in four themes: 1) Women-centered care, 2) Side-effects of hormonal contraceptives, 3) Non-hormonal methods and male involvement, and 4) Counsellors' professional background. Women wished for a consultation that would lead to the best choice of contraception for them, taking into account their medical history, personal preference and living circumstances. Side-effects of hormonal products were under-communicated, as were non-hormonal methods. Respondents had contradicting opinions about midwives as contraceptive counsellors and were unfamiliar with them in this role.

CONCLUSIONS

The quality of contraceptive counselling in Norway needs to be improved. Women require individualized follow-up, sufficient information and a choice of methods to find the most suitable alternative for them. A good relationship with a health provider they trust could improve contraceptive consultation. Midwives' knowledge and competence in this area need to be made more widely known.

Provision of immediate postpartum contraception to women living with HIV in the Eastern Cape, South Africa; a cross-sectional analysis

BACKGROUND

Universal access to contraception is an important strategy adopted by the South African government to reduce the high rate of unintended pregnancies, especially in women living with HIV. In this article, we describe the choices of contraception and also, examine the influencing factors of the choices of contraception in the immediate postpartum period in parturient women with HIV in the Eastern Cape, South Africa.

METHODS

In this prospective cross-sectional study, 1617 parturient women with HIV completed a survey on the choice of contraception received in the immediate postpartum period (within 72 h) across three large maternity services in the Eastern Cape between September 2015 to May 2016. Additional information was extracted from their medical records. Choices of contraception were categorised as; short-acting (injectables), long-acting reversible (intrauterine device and implants) and permanent contraception (tubal ligation). Adjusted and unadjusted logistic regression models were employed to determine the influencing factors of the choices of contraception received by the cohort.

RESULTS

Participants were predominantly single (69.1%), unemployed (75.1%), had a grade 7-12 level of education (88.4%) and were HIV positive before their index pregnancy (81.3%). The prevalence of immediate postpartum contraception was high (n = 1507; 93.2%) with Injectables being the preferred choice in the majority of the participants (n = 1218; 75.3%). After controlling for all relevant covariates, single marital status was associated with a higher likelihood of immediate postpartum contraceptive initiation (AOR; 1.82 95% CI 1.10-3.03). Overall, women were more likely to initiate a long-acting reversible and irreversible methods when older than 35 years and having had more than two children.

CONCLUSIONS

We found a high prevalence of immediate postpartum contraception with a preference for Injectables in the study setting. Long-term monitoring of this cohort will elucidate on contraceptive discontinuation and risk of unintended pregnancies in the region. Ensuring universal access to contraceptives is an important strategy to reduce the rate of unintended pregnancies at the population level. This strategy was adopted by the South African government with a vision of stemming the tide of unintended pregnancies among women living with HIV. In this study, the choices of contraception adopted by women living with HIV following the delivery of their babies were explored. In addition, the study highlights the factors that predict these choices. Participants were asked the choice of contraception they had received prior to being discharged from the maternity centres where they had delivered their babies. The various types of contraception were then categorised by their duration of action. Three distinct groups emerged; short-acting injectables, long acting reversible contraceptives and permanent methods. Of the 1617 women included in the study, 1117 were single and 1314 knew their HIV status prior to the onset of the index pregnancy. Almost all the women (1507 out of 1617) received one form of contraception before leaving the hospital. Many women (1218 out of 1617) chose injectable contraception (short-acting contraception) over the other types of contraception. Women who were older than 34 years and who had three or more children were more likely to choose a long-acting reversible contraceptive and permanent method over the short-acting contraception or nothing. In conclusion, given the short duration of action of the predominant method adopted by these women, a long-term follow up of the study participants will provide more information on the continued use of contraception and risk for unintended pregnancies.

Long-acting reversible contraception utilization and associated factors among women in extended postpartum period in Hossana town, southern Ethiopia: cross sectional study

Background

In low and middle-income countries, 95% of postpartum women want to avoid a pregnancy for 2 years, but 70% are not using contraception. Delay in use of contraception by couples during postpartum period can result in many unwanted pregnancies. Long-acting reversible contraception (LARC) is ideal for postpartum women. Therefore this study aimed at assessing the prevalence and factors associated with LARC use among postpartum women.

Methods

Facility based cross sectional study was conducted from July 23-Aug 25, 2018. Systematic random sampling technique was employed to recruit a total of 381 women in extended postpartum period visiting Child Immunization service in hosanna health institutions. Pretested structured questionnaire was used for data collection. Data was analyzed by SPSS version 20. Binary and multiple logistic regression analysis was done. The presence and strength of association was determined using AOR with its 95% CI. Variables with P value less than 0.05 were considered as statistical significant.

Results

The prevalence of LARC use was 36.5% (95%CI (33.05–39.95)). The main reason for not using LARC was fear of side effect and false information. Previous use of LARC (AOR = 3.3, 95%CI (1.7–6.5)) and have ever discussed with health providers on LARC (AOR = 2.5, 95%CI (1.1–5.74)) were found to be significantly associated with LARC use.

Conclusions

The utilization of LARC among postpartum women was found to be higher than other studies in Ethiopia. Provision of effective contraceptive counseling during Antenatal, delivery and postnatal care services with emphasis on LARC/Postpartum Intra-Uterine Device is important.

Rheumatology-led pregnancy clinic: enhancing the care of women with rheumatic diseases during pregnancy

The autoimmune rheumatic diseases have a clear predilection for women. Consequently, issues regarding family planning and pregnancy are a vital component of the management of these patients. Not only does pregnancy by itself causes physiologic/immunologic changes that impact disease activity but also women living with inflammatory arthritic conditions face the additional challenges of reduced fecundity and worsened pregnancy outcomes. Many women struggle to find adequate information to guide them on pregnancy planning, lactation and early parenting in relation to their chronic condition. This article discusses the gaps in the care provided to women living with inflammatory arthritis in standard practice and how a rheumatology nurse-led pregnancy clinic would fill such gap, consequently enhance the care provided and ensure appropriate education is provided to these individuals who represent the majority of the patients attending the rheumatology outpatient clinics. Such specialist care is expected to cover the whole journey as it is expected to provide high-quality care before, during and after pregnancy.

Quality of life of women using the etonogestrel long-acting reversible contraceptive implant after abortion for unplanned pregnancy

OBJECTIVES

The aims of the study were to investigate the effect of a subcutaneous etonogestrel-containing contraceptive implant on the quality of life (QoL) and sexual function of women who had undergone termination of an unplanned pregnancy.

METHODS

At pregnancy termination 140 women received contraceptive counselling on the etonogestrel implant. The Short Form-36 questionnaire, the Female Sexual Function Index and the Female Sexual Distress Scale were used to investigate, respectively, the QoL, sexual function and sexual distress of the women at baseline and at 6, 12, 24 and 36 months of follow-up.

RESULTS

The study group comprised 86 (61.4%) women who chose to use the contraceptive implant. The control group comprised 28 (20.0%) women who chose to use short-acting reversible contraception (SARC) and 26 (18.6%) women who chose not to use hormonal contraception. In the women not using hormonal contraception there were 23 (88.5%) unintended pregnancies before the end of the 3 year study period. QoL, sexual function and sexual distress improved in the study group from the 6 months follow-up until the end of the study (p < 0.001). QoL (p < 0.02) and sexuality (p < 0.001) gradually improved in the control group after 24 and 12 months of follow-up, respectively. None of the women using the etonogestrel implant became pregnant during the study. Inter-group analysis showed better improvement in QoL, sexual function and sexual distress in the study group than in the control group from 6 months (p < 0.004) until the end of the study (p < 0.001).

CONCLUSION

Compared with SARC and non-hormonal contraception, the contraceptive implant promoted better QoL and sexuality in users and reduced the incidence of unplanned pregnancy. However, the women who opted for SARC or non-hormonal contraception did so because of the lower cost compared with that of the contraceptive implant.

Impact of product design parameters on in vitro release from intrauterine systems

Polydimethylsiloxane (PDMS)-based levonorgestrel intrauterine systems (LNG-IUSs) contain a large amount of potent LNG, and therefore it is important to understand the impact of product design parameters on the in vitro and in vivo performance to ensure safety and efficacy, as well as to avoid serious side effects resulting from dose dumping. LNG-IUS is a complex drug-device combination product, and its formulation design, requires consideration of additional factors such as device configuration and dimensions, in addition to formulation and processing parameters. In this study, ten qualitatively (Q1) and quantitatively (Q2) equivalent LNG-IUSs were manufactured with differences in source (supplier) and dimensions (i.e., thickness) of the outer membrane, drug particle size, dimensions of the drug reservoir (i.e., inner diameter), as well as configuration of the entire IUS. A real-time in vitro release testing method was developed for the LNG-IUSs. In addition, an accelerated release testing method was developed using hydro-alcoholic media in order to reduce the time associated with formulation design. Source variations and thickness of their outer membranes had a great impact on the in vitro drug release from the LNG-IUSs. It was demonstrated that the thicker the outer membrane, the slower the drug release rate. The physicochemical properties of the outer membranes obtained from different sources were characterized to understand their impact on the in vitro drug release of the LNG-IUSs. The composition and mechanical strength may play a role in differences in drug release. The LNG-IUS formulation prepared with the larger drug particle size showed a slightly slower daily release rate. The drug release rates from the compositionally equivalent LNG-IUSs linearly correlated to the surface area of the corresponding drug reservoirs. Another factor that affected the drug release rate was the configuration of the entire IUS. It was shown that the placement of the outer membrane was significant, i.e. whether the ends of the drug reservoir were covered or not. It is important to note that real-time release showed zero-order release kinetics over the test period of approximately 900 days. The current study provides a comprehensive understanding of the impact of product design parameters on the in vitro drug release of LNG-IUSs. In addition, the developed real-time and accelerated release testing methods showed good discriminatory ability for compositionally equivalent LNG-IUSs prepared using different product design parameters.

Disorders of Puberty: Pharmacotherapeutic Strategies for Management

During puberty, with activation of the hypothalamic pituitary axis that has been quiescent since the neonatal period, linear growth accelerates, secondary sexual characteristics develop, and adult fertility potential and bone mass are achieved, together with psychosocial and emotional maturation.Disordered pubertal onset and progress, either early or late, presents frequently for endocrine care. Where a disorder is found, due either to a central hypothalamic pituitary cause or to primary gonadal failure, pharmacotherapeutic interventions are required to alter the trajectory of disturbed pubertal onset or progress and for maintenance of adolescent and adult sex hormone status. This paper describes pharmacologic interventions used for pubertal disorders but is not intended to address the diagnostic cascade in detail.

Long-acting reversible contraception: A route to reproductive justice or injustice

This article presents information on unintended pregnancies and the ongoing efforts of policy makers to promote long-acting reversible contraception (LARC) to reduce the numbers of such pregnancies. Also discussed is the tension between the encouragement of LARC to promote the public's interests in achieving that goal versus the need to assure that all women can decide about their bodies and reproductive needs. Our discussion includes information, primarily from the United States, on (a) risks associated with unintended pregnancies, (b) LARC devices approved in the United States (copper intrauterine devices (IUDs), hormone IUDs, and implants), (c) public and social benefits of increasing the use of LARC, (d) disadvantages and barriers to using LARC, (e) dangers of promoting LARC in unjust ways, and (f) the meaning of reproductive justice and its connection to social justice. By sharing the information with the audience of this journal, we hope that it will be integrated into clinical work and research on mental health and development. We also hope that experts in those fields will become discussants in the conversation regarding women's reproductive health and social justice that is taking place in the United States and elsewhere.

Using the theory of planned behavior and self-identity to explore women's decision-making and intention to switch from combined oral contraceptive pill (COC) to long-acting reversible contraceptive (LARC)

Background

\Most college women use the combined oral contraceptive pill (COC) despite more effective long-acting reversible contraceptive (LARC) methods (e.g., IUDs and implant) being available. Resistance to change methods may be impacted by how a woman identifies with being a COC-user.

Methods

Data were collected via 186 web-based surveys distributed to female students attending a university in the southeastern United States (Mean age = 20.0 ± 1.; range = 18–22). Structural equation modeling (SEM) determined TPB fit in understanding LARC intention.

Results

SEM results received acceptable fit (χ2 (670, N = 186) p < 0.01, Comparative Fit Index (CFI) of 0.84, and Normative Fit Index (NFI) of 0.75). A Root Mean Square Error of Approximation (RMSEA) of 0.09 was produced, with a 90% confidence interval of 0.08 to 0.09. Including self-identity in the model yielded similar fit, with χ2 (866, N = 186) p < 0.01, CFI of 0.83, and NFI of 0.73. Self-identity and attitude pathways were significant (p < 0.01) toward intention, extending the TPB model.

Conclusions

The TPB proved to be acceptable in understanding COC users’ intention to obtain LARC. Results provide direction for LARC messaging tailored toward COC users and self-identity.

Electronic supplementary material

The online version of this article (10.1186/s12905-019-0772-8) contains supplementary material, which is available to authorized users.

Physiologically based pharmacokinetic modelling prediction of the effects of dose adjustment in drug-drug interactions between levonorgestrel contraceptive implants and efavirenz-based ART

Background

HIV-positive women receiving efavirenz-based ART and levonorgestrel contraceptive implants are at risk of low levonorgestrel exposure and unintended pregnancy.

Objectives

To investigate clinically applicable dose-adjustment strategies to overcome the known drug-drug interaction (DDI) between levonorgestrel and efavirenz, using a physiologically based pharmacokinetic (PBPK) modelling-based approach.

Methods

A PBPK model was qualified against clinical data to predict levonorgestrel plasma concentrations when standard-dose (150 mg) levonorgestrel implants were administered alone (control group), as well as when standard-dose or increased-dose (300 mg) levonorgestrel implants were coadministered with either 600 or 400 mg of efavirenz.

Results

No difference was seen between in vivo clinical and PBPK-model-simulated levonorgestrel plasma concentrations (P > 0.05). Simulated levonorgestrel plasma concentrations were ∼50% lower at 48 weeks post-implant-placement in virtual individuals receiving standard-dose levonorgestrel with either 600 or 400 mg of efavirenz compared with the control group (efavirenz:control geometric mean ratio = 0.42 and 0.49, respectively). Conversely, increased-dose levonorgestrel in combination with either 600 or 400 mg of efavirenz was sufficient to restore levonorgestrel concentrations to levels similar to those observed in the 150 mg levonorgestrel control group 48 weeks post-implant-placement (efavirenz:control geometric mean ratio = 0.86 and 1.03, respectively).

Conclusions

These results suggest that the clinically significant DDI between efavirenz and levonorgestrel is likely to persist despite efavirenz dose reduction, whereas dose escalation of implantable levonorgestrel may represent a successful clinical strategy to circumvent efavirenz-levonorgestrel DDIs and will be of use to inform clinical trial design to assess coadministration of efavirenz and levonorgestrel implants.

Helping patients select long-acting reversible contraceptives

To reduce the rate of unintended pregnancies, patients should select a contraceptive option that fits their needs and lifestyle. Long-acting reversible contraceptives (LARCs) are a relatively safe and effective option. This article outlines the characteristics of available LARCs and identifies the appropriate method for specific patient populations.

Porous scaffolds from droplet microfluidics for prevention of intrauterine adhesion

Severe intrauterine adhesions (IUAs) have a great negative impact on women's psychological and reproductive health. It remains a significant challenge to prevent postoperative IUAs because of the complications of various clinical preventive measures and incompatibility of uterine cavity morphology. Herein, we present a new drug-loadedporous scaffold based on a microfluidic droplet template, which combines the characteristics of the artificial biocompatible material GelMA and the natural polysaccharide material Na-alginate. By changing the containers that collect the microfluidic droplets, the porous scaffold conforming to the shape of the uterine cavity could be obtained. The porous structure, mechanical property, and flexibility impart the scaffold with compressibility and send it to the uterus through the vagina. In addition, the external-internal connected open structures could load and control the release of drugs to repair the damaged region continuously in vivo. To verify the antiadhesion and repair of drug-loaded porous scaffolds, we tested the system in the rat model of IUAs, and it was demonstrated that the system had the ability to improve neovascularization, cellularize the damaged tissue, and repair the endometrium. These features provide the drug-loaded porous scaffolds with new options for the improvement of postoperative IUAs. STATEMENT OF SIGNIFICANCE: Intrauterine adhesions are caused by various causes of damage to the endometrial basal layer, thus leading to part or entire adhesions in the cervical or uterine cavity. Clinically, various preventive measures reach the barrier effect through the physical barrier, which are difficult to further promote the repair of the damaged endometrium, and most of them have apparent side effects. This study aims to prepare compressible and biodegradable three-dimensional porous drug-loading biological scaffolds. GelMA and Na-alginate have desirable biocompatibility. The interconnect porous scaffolds, which were prepared through the combination of biomaterials and single emulsion microfluidics, not only have compressibility but also provide space for drug delivery and release. This system can further promote the repair of the endometrium while preventing adhesion.

Free contraception and behavioural nudges in the postpartum period: evidence from a randomised control trial in Nairobi, Kenya

Background

Short birth intervals are a major risk factor for poor maternal and newborn outcomes. Utilisation of modern contraceptive methods during the postpartum period can reduce risky birth intervals but contraceptive coverage during this critical period remains low.

Methods

We conducted a randomised controlled experiment to test whether vouchers for free contraception, provided with and without behavioural ‘nudges’, could increase modern contraceptive use in the postpartum period. 686 pregnant women attending antenatal care in two private maternity hospitals in Nairobi, Kenya, were enrolled in the study. The primary outcomes were the use of modern contraceptive methods at nearly 3 months and 6 months after expected delivery date (EDD). We tested the impact of a standard voucher that could be redeemed for free modern contraception, a deadline voucher that expired 2 months after delivery and both types of vouchers with and without a short message service (SMS) reminder, relative to a control group that received no voucher and no SMS reminder.

Results

By nearly 6 months after EDD, we find that the combination of the standard voucher with an SMS reminder increased the probability of reporting utilisation of a modern contraceptive method by 25 percentage points (pp) (95% CI 6 pp to 44 pp) compared with the control group. Estimated impacts in other treatment arms were not statistically significantly different from the control group.

Conclusions

Reducing financial barriers to postpartum contraception alone may not be enough to encourage take-up. Programmes targeting the postpartum period should consider addressing behavioural barriers to take-up.

Correlates of long-acting reversible contraception uptake among rural women in Guatemala

OBJECTIVE

In many low-resource settings around the world utilization of long-acting reversible contraception (LARC) is low, in part due to access barriers. We sought to explore LARC utilization patterns as well as factors associated with LARC initiation by women seeking contraception in rural Guatemala from a program working to reduce contraception access barriers.

STUDY DESIGN

We analyzed data from a program that provides family planning in six remote, primarily indigenous, villages in Guatemala with limited access to alternative health services. Methods are free and delivered directly within villages by culturally competent providers. We conducted a retrospective chart review of all 288 women who initiated a contraceptive method over a 16-month period and conducted a logistic regression to obtain adjusted odds ratios (OR) for predictors of LARC uptake.

RESULTS

Overall 79.2% of women elected a LARC method. More than half of women (49.8%) switched to LARC from short-acting hormonal methods. In the univariate analysis prior use of short-acting method (p = 0.014), number of prior methods (p = 0.049), and current contraceptive use (p<0.01) were significantly associated with choosing a LARC. In the logistic regression model current use of contraception remained significant (OR 3.29, 95% CI 1.67-8.04). Report of abnormal bleeding or other side effects from prior short-acting method use did not predict LARC uptake (p = 0.82 and p = 0.079).

CONCLUSIONS

Most women in this marginalized population opted for a LARC method.

IMPLICATIONS

Low utilization of LARCs may be related to service delivery factors. Further research is needed to validate these conclusions prospectively and in less selected populations.

Levonorgestrel-releasing intra-uterine systems as female contraceptives

INTRODUCTION

The availability and use of long-acting reversible contraceptives (LARCs), such as levonorgestrel intrauterine systems (LNG-IUSs), have increased in recent times.

AREAS COVERED

The authors provide a narrative review of the LNG-IUSs currently available worldwide as female contraceptives (LNG-IUS 13.5, 19.5 and 52 mg). Specific features of the devices and their parameters of efficacy and tolerability were considered as outcomes.

EXPERT OPINION

The one-handed 3.8-mm-diameter inserter of LNG-IUS 13.5 mg and 19.5 mg may be particularly suitable in nulliparous women. While LNG-IUSs 13.5, 19.5 mg and LNG 52 mg should be used by women simply looking for an effective contraceptive method for up to 3, 4 or 5 years, LNG-IUS 52 mg has also been approved for the treatment of heavy menstrual bleeding and endometrial protection during hormone replacement therapy. LNG-IUS 52 mg is ideal for women who are experiencing a certain hyperestrogenic hormonal environment, with heavy menstrual bleeding due to hormonal imbalances, adenomyosis or fibroids, in the case of symptomatic endometriosis or for endometrial protection during hormone estrogenic replacement therapy in non-hysterectomized women.

[Intrauterine device and pelvic inflammatory disease: Myth or reality?]

INTRODUCTION

Intrauterine device (IUD) is a reliable contraceptive method that is long term reversible, and well tolerated. Numerous studies prove its efficiency and report rare complications that are attributed to it. However, its use is limited due to fear that it can cause a pelvic inflammatory disease (PID). This is based on historical data on infections related to the "Dalkon Shield", which was removed from the market in 1974.

METHOD

The analyzed articles were extracted from PUBMED database between 2000 and 2016. In total, 22 studies were retained. A meta-analysis was not possible due to the methodological diversity among the selected articles contributing to this narrative review of the literature.

RESULTS

After analysis, the following factors influence the risk of PID linked to IUDs: an advanced age and sexually transmitted infections.

CONCLUSION

The risk of PID linked to IUDs is lower than 1%. This is explained by new models of IUD, better screening tests, more frequent follow-up of the patients and the improvement of care PID patients. In the light of our results, the threat of pelvic inflammatory disease should not hinder the use of IUDs.

Sexual function and quality of life of women adopting the levonorgestrel-releasing intrauterine system (LNG-IUS 13.5 mg) after abortion for unintended pregnancy

PURPOSE

The aim of the study was to investigate the impact of the long-acting reversible contraception (LARC) levonorgestrel-releasing intrauterine system (LNG-IUS 13.5 mg) on sexual function and quality of life (QoL) in women after having undergone abortion for unintended pregnancy.

METHODS

In a prospective controlled study, 128 women aged 16-35 years received counseling to adopt LNG-IUS contraception after termination of pregnancy. The Visual Analog Scale (VAS), the Short Form-36 questionnaire (SF-36), the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (FSDS) were used to investigate, respectively, pelvic pain levels, QoL, sexual function and sexual distress of these women at baseline (T0) and at 6 (T1) and 12 (T2) months after LNG-IUS placement.

RESULTS

Sixty-six (51.6%) women adopted a SARC method, mainly because of the cost of the LNG-IUS. They constituted the control group. The study group consisted of 62 (48.4%) women. Improvement of QoL was observed at T1 (p < .05) and T2 (p < .01). Moreover, sexual function improved and dyspareunia decreased over the study period compared to baseline (p < .001). Dysmenorrhea measured by VAS improved at T1 and at T2 (p < .001). The women of the control group did not experience statistically significant changes at T1 and T2 compared to T0 (p = NS).

CONCLUSIONS

Women who underwent termination of pregnancy experienced positive changes in QoL and sexual function during LNG-IUS use. These results have to be confirmed in larger studies. However, not all women could adopt the LNG-IUS because of the cost of the contraceptive.

Clinically advancing and promising polymer-based therapeutics

In this review article, we will examine the history of polymers and their evolution from provisional World War II materials to medical therapeutics. To provide a comprehensive look at the current state of polymer-based therapeutics, we will classify technologies according to targeted areas of interest, including central nervous system-based and intraocular-, gastrointestinal-, cardiovascular-, dermal-, reproductive-, skeletal-, and neoplastic-based systems. Within each of these areas, we will consider several examples of novel, clinically available polymer-based therapeutics; in addition, this review will also include a discussion of developing therapies, ranging from the in vivo to clinical trial stage, for each targeted area of treatment. Finally, we will emphasize areas of patient care in need of more effective, accessible, and targeted treatment approaches where polymer-based therapeutics may offer potential solutions.

Temporal Trends in the Uptake and Continuation of the Etonogestrel Implant in a Large Private Practice Setting

OBJECTIVE

To assess temporal trends in the uptake and continuation of the etonogestrel subdermal implant in a large private practice setting.

METHODS

This was a retrospective cohort study based on billing records from a large multispecialty private practice in Las Vegas, Nevada. We looked at women of all ages seeking long-acting reversible contraception (LARC) between January 1, 2013, and December 31, 2016. The main outcome measure was uptake of the etonogestrel subdermal implant, expressed as a fraction of all insertions of LARC across four calendar years (2013-2016). The Kaplan-Meier method was used to estimate 12-month continuation stratified by year of insertion.

RESULTS

There were 3477 total LARC insertions across the 4-year study period. In unadjusted analyses, the uptake of the etonogestrel implant increased from 3.0% of LARC insertions in 2013 to 9% in 2016 among women aged 30 years and older. For women younger than 30 years, the uptake of the implant stayed stable from 2013 to 2015 (22.8%, 21.7%, and 22.4%, respectively), but increased to 30.9% in 2016. We modeled the uptake of the implant as a function of year of insertion adjusted for age (continuous) and insurance status (private vs. Medicaid), and we stratified the models by age (younger than 30 years, 30 years, and older than 30 years). The positive association between year of insertion and uptake of the implant was significantly stronger for women aged 30 years and older, compared to women younger than 30 years. There was a progressive decrease in the 12-month continuation of implant from 2013 (95.7%) to 2015 (57.7%).

CONCLUSIONS

In this large private practice setting, among women aged 30 years and older, we observed a threefold increase in the uptake of the subdermal implant from 2013 to 2016. We also observed a significant decrease in the 12-month continuation of the implant over time. Further studies of implant uptake and continuation in the private practice setting are needed.

Minimally invasive probes for programmed microfluidic delivery of molecules in vivo

Site-specific drug delivery carries many advantages of systemic administration, but is rarely used in the clinic. One limiting factor is the relative invasiveness of the technology to locally deliver compounds. Recent advances in materials science and electrical engineering allow for the development of ultraminiaturized microfluidic channels based on soft materials to create flexible probes capable of deep tissue targeting. A diverse set of mechanics, including micro-pumps and functional materials, used to deliver the drugs can be paired with wireless electronics for self-contained and programmable operation. These first iterations of minimally invasive fluid delivery devices foreshadow important advances needed for clinical translation.

Socioeconomic Status As a Risk Factor for Unintended Pregnancy in the Contraceptive CHOICE Project

OBJECTIVE

To evaluate the association of low socioeconomic status as an independent risk factor for unintended pregnancy.

METHODS

We performed a secondary analysis of data from the Contraceptive CHOICE project. Between 2007 and 2011, 9,256 participants were recruited and followed for up to 3 years. The primary outcome of interest was unintended pregnancy; the primary exposure variable was low socioeconomic status, defined as self-report of either receiving public assistance or having difficulty paying for basic necessities. Four contraceptive groups were evaluated: 1) long-acting reversible contraceptive method (hormonal or copper intrauterine device or subdermal implant); 2) depot medroxyprogesterone acetate injection; 3) oral contraceptive pills, a transdermal patch, or a vaginal ring; or 4) other or no method. Confounders were adjusted for in the multivariable Cox proportional hazard model to estimate the effect of socioeconomic status on risk of unintended pregnancy.

RESULTS

Participants with low socioeconomic status experienced 515 unintended pregnancies during 14,001 women-years of follow-up (3.68/100 women-years; 95% CI 3.37-4.01) compared with 200 unintended pregnancies during 10,296 women-years (1.94/100 women-years; 95% CI 1.68-2.23) among participants without low socioeconomic status. Women with low socioeconomic status were more likely to have an unintended pregnancy (unadjusted hazard ratio [HR] 1.8, 95% CI 1.5-2.2). After adjusting for age, education level, insurance status, and history of unintended pregnancy, low socioeconomic status was associated with an increased risk of unintended pregnancy (adjusted HR 1.4, 95% CI 1.1-1.7).

CONCLUSION

Despite the removal of cost barriers, low socioeconomic status is associated with a higher incidence of unintended pregnancy.

LNG-IUS 12: a 19.5 levonorgestrel-releasing intrauterine system for prevention of pregnancy for up to five years

INTRODUCTION

Globally, intrauterine devices (IUDs) are the second most commonly used form of reversible contraception because of their high efficacy, safety, convenience and cost effectiveness. The levonorgestrel releasing intrauterine system with daily average release of 20 mcg (LNG-IUS 20) is the popular choice because of its favorable bleeding patterns and many noncontraceptive benefits. A three year (LNG-IUS 8) became available three years ago. More recently, the LNG-IUS 12 was added. This new IUD shares a smaller frame, narrow inserter and lower rate of amenorrhea with the LNG-IUS 8, but it offers the five years of contraceptive protection of the LNG-IUS 20. Areas covered: This article provides information on the contraceptive efficacy, safety and tolerability of this new IUS based on approximately 60,000 cycles of use. Where available, the impacts of subject age, parity and body mass index (BMI) on study outcomes are reported. Expert opinion: This new LNG-IUS 12 with mid-dose hormone levels, smaller frame and longer effective life fills a niche that may better meet the needs of women who might appreciate the narrow insertion tube and/or the lower rates of amenorrhea. Cost will ultimately help determine success.