Banish the myths about fertility, contraception
Review the following scenario: a patient has used oral contraceptives for 15 years, starting her first pill pack at age 28. Now at age 43, she tells you, "I had three children by 28 when I started using the Pill. I got divorced three years ago, and now I'm remarried. Why can't I get pregnant? It must be the Pill." What is your counseling strategy?
Women who have chosen reversible methods to delay pregnancy until they are older may find that they have difficulties in conceiving.1 When discussing the matter with their health care provider, women may attribute the difficulty to the former contraceptive method, when in fact, both aging and parity are the culprits.2-4
There is a large and well-defined body of literature that shows that the use of hormonal contraception does not increase the chance of either primary or second infertility, says Lee Shulman, MD, professor of obstetrics and gynecology at Feinberg School of Medicine at Northwestern University in Chicago.
"I think the first issue that we need to explain to patients is that as we get older, fertility does decrease," observes Shulman. "The fact that time has passed by while using contraception does not mean that contraception has reduced fertility, it is time, which we know does reduce fertility."
Research shows that there is no decrease in fertility after stopping hormonal contraception,2 says Shulman. Use of current intrauterine contraception also does not increase of infertility.5,6
Other medical conditions can impact fertility, including endometriosis, polycystic ovarian syndrome, diabetes, obesity, thyroid dysfunction, and sexually transmitted diseases. Women who seek to become pregnant later in life following use of contraception and who experience problems will need to be evaluated for these and other conditions, with their partners checked as well, says Shulman.
Don't 'take a break'
Another myth encountered in contraceptive counseling sessions involves the belief that users of hormonal methods can protect their future fertility by periodic "breaks" in use. There are no data to support this myth, says Carolyn Westhoff, MD, MSc, professor of obstetrics/gynecology and epidemiology/population and family health at Columbia University in New York City.
Women who think they need to take a "rest" from taking their daily pills risk an unintended pregnancy, state the authors of Contraceptive Technology.7 Fertility resumes promptly after the discontinuation of most hormonal contraceptives.1 While there have been no long-term studies of return to fertility following discontinuation of contraceptive patch or ring use, effects are expected to be similar to those encountered with combination oral contraceptives — about one to three months. In a comparison study of the copper T and levonorgestrel intrauterine devices (IUDs), median time to pregnancy was three months after copper T IUD removal and four months after levonorgestrel IUD removal.8
Women who choose the newly approved single rod implant method Implanon should be counseled about rapid return to fertility upon method discontinuation. In small studies, ovulation and fertility resumed after three months following device removal.9,10
In contrast, the use of the contraceptive injection (depot medroxyprogesterone acetate (DMPA), Depo-Provera, Pfizer, New York City) has been associated with a prolonged contraceptive effect. The median time to conception following method discontinuation is about 10 months.11 Time to conception for women may be delayed for up to two years.1
Women's contraceptive needs change over time: an adolescent may choose a method to delay pregnancy while preserving fertility; a young mother may look for an option to space her family order; an older woman may select a reversible method to protect against pregnancy until menopause. Help women choose contraception with an eye toward individual childbearing goals.
- Shulman LP, Westhoff CL. Return to fertility after use of reversible contraception. Dialogues in Contraception 2006; 10:1-3, 8.
- Vessey MP, Smith MA, Yates D. Return of fertility after discontinuation of oral contraceptives: Influence of age and parity. Br J Fam Plann 1986; 11:120-124.
- Howe G, Westhoff C, Vessey M, et al. Effects of age, cigarette smoking, and other factors on fertility: Findings in a large prospective study. Br Med J (Clin Res Ed) 1985; 290:1,697-1,700.
- Frank O, Bianchi PG, Campana A. The end of fertility: Age, fecundity, and fecundability in women. J Biosoc Sci 1994; 26:349-368.
- Arias RD. Compelling reasons for recommending IUDs to any woman of reproductive age. Int J Fertil Womens Med 2002; 47:87-95.
- Hubacher D, Lara-Ricalde R, Taylor DJ, et al. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001; 345:561-567.
- Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology: 18th revised edition. New York City: Ardent Media; 2004.
- Belhadj H, Sivin I, Diaz S, et al. Recovery of fertility after use of the levonorgestrel 20 mcg/d or copper T 380 Ag intrauterine device. Contraception 1986; 34:261-267.
- Glasier A. Implantable contraceptives for women: Effectiveness, discontinuation rates, return of fertility, and outcome of pregnancies. Contraception 2002; 65:29-37.
- Kiriwat O, Patanayindee A, Koetsawang S, et al. A 4-year pilot study on the efficacy and safety of Implanon, a single-rod hormonal contraceptive implant, in healthy women in Thailand. Eur J Contracept Reprod Health Care 1998; 3:85-91.
- Schwallie PC, Assenzo JR. The effect of depot-medroxy-progesterone acetate on pituitary and ovarian function, and the return of fertility following its discontinuation: A review. Contraception 1974; 10:181-202.
The Washington, DC-based Association of Reproductive Health Professionals offers a freely-reproducible patient information sheet, Which Contraceptive Is Right For You? at its web site, www.arhp.org. Click on "Patient Education," "Resource Centers," "Contraception Resource Center," "Patient Information," and the sheet title. Designed in a chart form, it allows clinicians to review available contraceptive methods; information on return to fertility is included with each method.