**Contraceptive Methods and the Subsequent Search for a Pregnancy a Pregnancy**

**Contraceptive Methods and the Subsequent Search for** 

DOI: 10.5772/intechopen.72525

Blanca Patricia Bautista Balbás, Luis Alfredo Bautista Balbás and Alicia Pouso Rivera Luis Alfredo Bautista Balbás and Alicia Pouso Rivera

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.72525

Blanca Patricia Bautista Balbás,

#### **Abstract**

Many women are concerned about their future fertility, about pregnancy complications and about the health of their future child when choosing a contraceptive method and sometimes women want to interrupt the contraception – maybe after years of use – in order to attempt pregnancy. Return to fertility, has been thoroughly analyzed in the literature. This chapter provides evidence-based information and discusses the potential doubts of women. Return to fertility has been consistently found to be sure, albeit sometimes slightly slow in the short term: pregnancy rates after 1 year of contraceptive interruption are 79–95% for oral contraceptives, 79–96% for levonorgestrel IUD, 71–91% for copper IUDs, around 80% for implants and 75–80% for injectable contraceptives. About 50% women are pregnant 3–6 months after contraceptive discontinuation; around 90–95% of women had achieved pregnancy 2 years after stopping their contraceptive method. Some studies have found associated risks of fetal malformations when women take oral contraceptive pills *after* conception (though other studies disputed these results). However the offspring of women who used oral contraceptives *before* conception does not show an increased risk of fetal death, miscarriage, gestational hypertension, major newborn structural defects or hypospadias. The effect on birth weight seems small and inconclusive.

**Keywords:** return to fertility, contraceptive, UID, copper, pill, contraceptive implant, hormonal contraceptive, injectable, depot, pregnancy rate

#### **1. Introduction**

Contraceptive methods are the instrument that women use to control their fertility at any given time in their lives so that the pregnancy would be produced by choice and not by

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chance. In any case, women's reproductive goals change at any moment of the woman's fertile life; this is why the reversibility of the chosen method is especially important for them [1].

the birth control implant. The pregnancy rates in these methods are comparable to sterilization. IUD risks include uterus perforation, IUD loss, pelvic inflammatory disease, pregnancy during IUD use, etc. [11] Depot medroxyprogesterone acetate intramuscular injection (DMPA) was approved by the FDA in 1992 and became the most common injectable method in use in the USA [12]. LARC has been described to be more cost-effective than COCs, even at 1 year of use [13]. Women's preferences for anticonception have varied between different countries and generations [14, 15]. As a documented example for these variations, in the USA the Centre for Disease Control has published several periodic reports on contraception use. Apparently in the 2006–2010 report [16] a slight decrease in condom usage and an increase in intrauterine

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The 2011–2013 National Survey of Family Growth reported that oral contraceptives (OCs) were the most commonly used contraceptive method in the United States (16% of women aged 15–44), followed by female sterilization (15.5%), male condom (9.4%) and long-acting reversible contraceptives (7.2%). The use of sterilization declined and the use of OCs increased with greater educational level and the use of long-acting reversible contraceptives was higher

This chapter focuses on a particular clinical situation: those women who are using a contraceptive method and want to conceive a child. These future mothers are often worried about when they will be able to conceive and about the health of the future child. With the advent of the Internet and information technologies the access to information has become less of a problem compared to the information overload [18] and the abundance of lesser quality information. Generally speaking openness of information is positive for patients, but many issues. Some women might have heard reports of secondary effects of contraceptive methods and they might become concerned about this; on the Internet many women talk and discuss reproductive issues via women's forums or family planning forums and this might exacerbate some natural fears of mothers. In these cases it is especially important to expose medical evidence-based facts clearly: many contraceptive methods have been available for decades and there is abundant evidence and clinical experience with them. More than 150 million women around the world use the IUD [15] and clinical studies with contraceptive methods have involved thousands of patients [1]. Case reports are seen as particularly weak evidence when compared to other studies, and personal experiences shared via the Internet should not be considered a reliable source of information. For example, a former user of IUD could have a miscarriage and she could link these two circumstances; attempts to rationalize this situation are normal part of the grief and emotional healing process in many women. However miscarriages are very common (some authors have calculated a rate of >20 miscarriages/1000 women/week in the first 8 weeks [5]) and she might just be experiencing a fortuitous event. Press and internet newspapers can act as an immediately available and quite reliable bridge between authoritative media sources and women. Reports on contraceptive methods sometimes include expert opinion and consensus statements [19]; information presented this way could be helpful for women. Media sources also usually include noteworthy journalists' opinion articles on reproductive issues [20]; in these the separation between facts and beliefs could be less clear. Experienced midwifes and doctors can also act as a reliable bridge for women with reproductive health doubts; they can provide objective evidence-based objective infor-

devices (IUD) was observed compared to 1995 data.

among women aged 25–34 (11.1%) compared to other age groups [17].

mation and statements that can be very helpful for women.

For many authors, infertility refers to the inability of a couple to conceive after having 12 months of regular sexual intercourse without using any contraceptive method; some authors emphasize intercourse "in the fertile phase of the menstrual cycles" [2]. Infertility rate is better estimated by prospective studies; around 80% women become pregnant in the first cycles and approximately, 85–90% couples will conceive within 1 year if they have regular unprotected sex. 50% of couples who did not manage to conceive after 12 months (infertility definition) will manage to conceive spontaneously in the next 36 months; after this time point spontaneous conception in infertile couples is considered only sporadic [2]. Infertility (both male and female) is influenced by many reproductive or lifestyle factors. Physical causes of female infertility include alterations in ovulation and abnormal functioning or structures of reproductive organs, as well as age and lifestyle-related risk factors: alcohol or drug use, obesity, tobacco habit, exposure to a range of environmental toxins, etc. [3, 4] Consequently, studies assessing pregnancy rates or time to pregnancy following cessation of contraceptive use may be influenced by many underlying factors specific to the population under study.

Future pregnancy complications and pregnancy outcome is another important concerning issue of women who want to become pregnant; these events can happen in any pregnancy. Spontaneous abortion is one of the most common pregnancy complications; abortion rates are especially high in the weeks [5]. 14% of pregnancies end with fetal loss, with rates varying between 9% and 75% or more depending on the age, population and other factors [6, 7]. Ectopic pregnancy incidence rates vary between 1 and 2% of live births in developed countries, maybe reaching up to 4% in women subject to assisted reproductive treatments [8]. Preterm birth rates range from 5% of babies in European Countries to 18% in African countries [9]. Induced abortion rates also vary greatly depending in many psychosocial factors [7].

At the time of choosing a contraceptive method, women value aspects such as effectiveness, comfort, price, safety and early recovery of fertility after ceasing using this method. Past experiences with contraception and future fertility intentions also can play a role in this decision. Quite often the reversibility of the method is an important concern for women; the lack of information plus the acquisition of misconceptions about methods can increase general mistrust in long-acting contraceptive methods and lead to reduced use of these. The midwife can exert an important role solving women doubts, considering their concerns and helping them choose the most suitable contraceptive method in each case.

**Male condom** was the mainstay of contraception for several decades, being also immediately reversible and effective at preventing sexually transmitted diseases (STDs). **Combined Oral Contraceptive (COC) Pill**, which contains estrogens and progesterone, was first approved for contraceptive use in the United States in 1960. Combined hormonal methods also include patches and vaginal rings. Unlike combined methods, **progesterone-only** contraceptive methods are not associated with cardiovascular risk or deep-vein-thrombosis risk. These methods are monophasic and can be administered subcutaneously or orally (progesterone-only pills, POP). They lack adverse effects on lactation but cycles and menstrual bleeding become more irregular [10].

**Long-acting reversible contraception** methods are highly-effective reversible contraceptive methods that last for years and are easy to use. These include the intrauterine device (IUD) and the birth control implant. The pregnancy rates in these methods are comparable to sterilization. IUD risks include uterus perforation, IUD loss, pelvic inflammatory disease, pregnancy during IUD use, etc. [11] Depot medroxyprogesterone acetate intramuscular injection (DMPA) was approved by the FDA in 1992 and became the most common injectable method in use in the USA [12]. LARC has been described to be more cost-effective than COCs, even at 1 year of use [13].

chance. In any case, women's reproductive goals change at any moment of the woman's fertile life; this is why the reversibility of the chosen method is especially important for them [1].

214 Family Planning

For many authors, infertility refers to the inability of a couple to conceive after having 12 months of regular sexual intercourse without using any contraceptive method; some authors emphasize intercourse "in the fertile phase of the menstrual cycles" [2]. Infertility rate is better estimated by prospective studies; around 80% women become pregnant in the first cycles and approximately, 85–90% couples will conceive within 1 year if they have regular unprotected sex. 50% of couples who did not manage to conceive after 12 months (infertility definition) will manage to conceive spontaneously in the next 36 months; after this time point spontaneous conception in infertile couples is considered only sporadic [2]. Infertility (both male and female) is influenced by many reproductive or lifestyle factors. Physical causes of female infertility include alterations in ovulation and abnormal functioning or structures of reproductive organs, as well as age and lifestyle-related risk factors: alcohol or drug use, obesity, tobacco habit, exposure to a range of environmental toxins, etc. [3, 4] Consequently, studies assessing pregnancy rates or time to pregnancy following cessation of contraceptive use may be influenced by many underlying factors specific to the population under study.

Future pregnancy complications and pregnancy outcome is another important concerning issue of women who want to become pregnant; these events can happen in any pregnancy. Spontaneous abortion is one of the most common pregnancy complications; abortion rates are especially high in the weeks [5]. 14% of pregnancies end with fetal loss, with rates varying between 9% and 75% or more depending on the age, population and other factors [6, 7]. Ectopic pregnancy incidence rates vary between 1 and 2% of live births in developed countries, maybe reaching up to 4% in women subject to assisted reproductive treatments [8]. Preterm birth rates range from 5% of babies in European Countries to 18% in African countries [9]. Induced abortion rates also vary greatly depending in many psychosocial factors [7].

At the time of choosing a contraceptive method, women value aspects such as effectiveness, comfort, price, safety and early recovery of fertility after ceasing using this method. Past experiences with contraception and future fertility intentions also can play a role in this decision. Quite often the reversibility of the method is an important concern for women; the lack of information plus the acquisition of misconceptions about methods can increase general mistrust in long-acting contraceptive methods and lead to reduced use of these. The midwife can exert an important role solving women doubts, considering their concerns and helping them

**Male condom** was the mainstay of contraception for several decades, being also immediately reversible and effective at preventing sexually transmitted diseases (STDs). **Combined Oral Contraceptive (COC) Pill**, which contains estrogens and progesterone, was first approved for contraceptive use in the United States in 1960. Combined hormonal methods also include patches and vaginal rings. Unlike combined methods, **progesterone-only** contraceptive methods are not associated with cardiovascular risk or deep-vein-thrombosis risk. These methods are monophasic and can be administered subcutaneously or orally (progesterone-only pills, POP). They lack adverse effects on lactation but cycles and menstrual bleeding become more irregular [10].

**Long-acting reversible contraception** methods are highly-effective reversible contraceptive methods that last for years and are easy to use. These include the intrauterine device (IUD) and

choose the most suitable contraceptive method in each case.

Women's preferences for anticonception have varied between different countries and generations [14, 15]. As a documented example for these variations, in the USA the Centre for Disease Control has published several periodic reports on contraception use. Apparently in the 2006–2010 report [16] a slight decrease in condom usage and an increase in intrauterine devices (IUD) was observed compared to 1995 data.

The 2011–2013 National Survey of Family Growth reported that oral contraceptives (OCs) were the most commonly used contraceptive method in the United States (16% of women aged 15–44), followed by female sterilization (15.5%), male condom (9.4%) and long-acting reversible contraceptives (7.2%). The use of sterilization declined and the use of OCs increased with greater educational level and the use of long-acting reversible contraceptives was higher among women aged 25–34 (11.1%) compared to other age groups [17].

This chapter focuses on a particular clinical situation: those women who are using a contraceptive method and want to conceive a child. These future mothers are often worried about when they will be able to conceive and about the health of the future child. With the advent of the Internet and information technologies the access to information has become less of a problem compared to the information overload [18] and the abundance of lesser quality information. Generally speaking openness of information is positive for patients, but many issues.

Some women might have heard reports of secondary effects of contraceptive methods and they might become concerned about this; on the Internet many women talk and discuss reproductive issues via women's forums or family planning forums and this might exacerbate some natural fears of mothers. In these cases it is especially important to expose medical evidence-based facts clearly: many contraceptive methods have been available for decades and there is abundant evidence and clinical experience with them. More than 150 million women around the world use the IUD [15] and clinical studies with contraceptive methods have involved thousands of patients [1]. Case reports are seen as particularly weak evidence when compared to other studies, and personal experiences shared via the Internet should not be considered a reliable source of information. For example, a former user of IUD could have a miscarriage and she could link these two circumstances; attempts to rationalize this situation are normal part of the grief and emotional healing process in many women. However miscarriages are very common (some authors have calculated a rate of >20 miscarriages/1000 women/week in the first 8 weeks [5]) and she might just be experiencing a fortuitous event.

Press and internet newspapers can act as an immediately available and quite reliable bridge between authoritative media sources and women. Reports on contraceptive methods sometimes include expert opinion and consensus statements [19]; information presented this way could be helpful for women. Media sources also usually include noteworthy journalists' opinion articles on reproductive issues [20]; in these the separation between facts and beliefs could be less clear. Experienced midwifes and doctors can also act as a reliable bridge for women with reproductive health doubts; they can provide objective evidence-based objective information and statements that can be very helpful for women.

Over the course of many decades contraceptive methods have deeply improved. Secondary effects of oral contraceptives have been detected and lower dose formulations have been developed. Many studies have assessed long-term effects of OCs on various aspects of women's health [14, 21], including their future reproductive health. In some topics conflicting evidence is available as the results and conclusions of some studies differ from others. This is not the case for contraceptive reversibility (which has consistently been observed for decades in many studies and is remarked in NICE [13] and WHO [22] guidelines, as we will discuss later), but for some rare pregnancy events (twin pregnancy, preterm birth). Obtaining contradicting results is not uncommon in clinical research and does not necessarily imply there was a flaw conducting the study [23]. Publishing these studies is not a mistake, but inadequately interpreting them could be. Conflicting and inconclusive evidence should be treated with special caution; unconfirmed results or contradictory results are not ground for evidence-based recommendations.

endometrial thickness and long-term COC usage: Talukdar et al. studied the effect long-term use of combined oral contraceptives on endometrial thickness. They gathered 137 women between 30 and 45 years old subject to frozen embryo transfer cycles and determined the endometrial thickness on day 10. The group with endometrium thin than 7 mm (n = 30, a proposed threshold for successful implantation) had longer COC usage compared to the rest of the women. Authors this could be mediated by the effects of OCs on stem cells in an inactive endometrium. In particular, some authors have said this effect after long-term use of OCs is "infrequent but persistent" [28]. These results should be taken cautiously and require further confirmation in larger groups of healthy women in prospective studies; as we will discuss

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The effects of COCs on gonadotropins have also been studied: Compared to women who never used COCs, women using them showed similar or slightly lower FSH levels, whereas women who used them showed slightly higher FSH levels that seemed to wane over time. (LH showed a similar pattern, but it was only significant in one of the two study groups). The authors attributed this to a possible rebound effect of gonadotropins after withdrawing the hormonal COC and a suppression of endogenous estrogen and progesterone [29]. After withdrawal of COCs normal physiology is gradually restored: in a study with 24 women it was observed that the first cycle is longer and with lower gonadotrophin levels compared to the third cycle; ovulation changes were observed in 17/24 women in the first cycle and in 21/24 women in the third cycle [30]. Recent use of OCs and their long-term use have been associated with longer follicular phases (longer time to ovulation) by some authors, but they acknowledged there are conflicting results on this issue in the literature and many women might choose to start using OCs to help regulate their cycles, which

Estrogens are known to stimulate prolactin production. Some reports associated post-pill amenorrhea and galactorrhea and serum prolactin is elevated in OC users; this is more pronounced in women who use high-dose OCs but not significant association was found with long-term usage [32]. However prolactin levels do not seem to be altered in women who

Despite these described biochemical or histological findings, the reversibility of OCs has been clinically observed for decades and across many different ethnic groups (**Table 1**); many studies have reported 1 year pregnancy rates between 70 and 90% and 2 years pregnancy rates of

In the 1960s, the "postpill amenorrhea syndrome" was described as amenorrhea, anovulation and reduced reproductive fecundity for more than 1 year following discontinuation of OCs in some women who previously had regular menstruation. Some authors noted that many women with this syndrome exhibited oligomenorrhea before starting oral contraceptive usage [35]. It was thought that the exogenous administration of hormonal therapy with OCs delayed the return to normal function of the hypothalamic-pituitary-ovary axis [36]. Some authors advocated "watchful waiting" in women not seeking pregnancy, mentioning that regular menses tend to reappear after 12–18 months, and emphasized the importance of ruling

later infertility has not been associated to OC.

might already be longer [31].

previously used COCs [33].

**2.3. Return to fertility**

80–90% [1, 34].

In this chapter we will analyze the reversibility of physiological changes, the observed fertility changes and the future pregnancy complications of several contraceptive methods: OCs (including progestin only pill and emergency contraception), injectables, implants and IUDs.
