Review articleFertility after discontinuation of contraception: a comprehensive review of the literature☆
Introduction
Women's reproductive goals and contraceptive practices change depending on their life situation. The ability to control fertility with highly effective reversible contraceptives has emancipated many women to choose to become pregnant by choice not chance. An essential feature of any reversible method of contraception is that it should not adversely affect future fertility—often an important concern for women [1]. Any fertility delay or impairment following the cessation of a given contraceptive method may be associated with reduced use and poor user satisfaction especially in young women [2], where misconceptions and lack of information [2], [3] add to their general distrust of effective contraceptive methods.
In the 1960s, following discontinuation of oral contraceptives, initial reports suggested a syndrome of anovulation and infertility in some women who previously had regular menses [4], [5], [6], [7]. Clinicians feared that long-term ovulation suppression with oral contraceptives could lead to a state of prolonged ovulatory suppression where return to normal menstruation was delayed resulting in some women remaining amenorrheic for more than 1 year. This so-called postpill amenorrhea syndrome has been subsequently refuted [8]. Nonetheless, the effect of long-term oral contraceptive use on reproductive function and fertility, particularly as it may affect adolescent maturation and reproductive development, continues to be of concern to some clinicians [3].
Fertility is a complex issue that depends on a number of factors (both male and female) including underlying reproductive potential, behavioral/lifestyle and environmental factors. The negative association between age and fecundity is generally well accepted [9], [10] and is related to reduced coital frequency [11], [12], a decline in fertility [10], [13] and increased prevalence of underlying gynecological disease [14]. In addition, smoking in women has been associated with impaired fertility [15], [16], [17], as has obesity [18] and exposure to a number of environmental toxins (including pesticides, solvents and chlorinated hydrocarbons) [19], [20], [21]. Consequently, studies assessing pregnancy rates or time to pregnancy following cessation of contraceptive use may be influenced by a number of underlying factors specific to the population under study.
The aim of this article was to systematically review the available literature comparing pregnancy rates in women who wanted to become pregnant after discontinuing various contraceptive methods. While there have been recent reviews focusing on this aspect for individual methods such as oral contraceptives [22] and copper intrauterine devices (IUDs) [23], there have been no comprehensive reviews covering most reversible methods of contraception. This information will be useful when counseling individuals or couples about the impact of contraceptive use on their future fertility, especially for those who have not yet completed their families.
Section snippets
Methods
We performed a computerized literature search of Medline® and Embase® using the Ovid interface system to retrieve relevant articles published up to 30 September 2009. The combined search terms used were (where $ represents truncation of a word that allows all possible suffix variations of a root word to be retrieved; for example, the search “discontin$” would retrieve documents with “discontinue,” discontinuing,” “discontinuation” etc.): return to fertility; return of fertility; time to
Results
We identified and extracted information from 17 prospective studies (studies assessing more than one method are only counted once) reporting pregnancy rates following cessation of reversible contraceptive use to become pregnant (see Appendix A). Two studies were excluded because they included a mixture of both prospective and retrospective data or included women who tried to conceive following an interval after discontinuation of a contraceptive method [24], [25]. Of the studies included, 3
Discussion
This comprehensive review shows that there is wide overlap in the reported 1-year pregnancy rates after the cessation of various methods of contraception. The baseline prevalence of infertility will influence the fertility rates of women seeking pregnancy following discontinuation of a contraceptive method. The ranges of the 1-year pregnancy rates for oral contraceptives, copper IUDs and the LNG-IUS broadly overlap those reported in retrospective studies of women wishing to conceive following
Acknowledgments
Medical writing support for the development of this manuscript was provided by Richard Glover of InScience Communications, a Wolters Kluwer business, with the financial support of Bayer HealthCare Pharmaceuticals.
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Conflicts of interest: Dr Mansour has received support to undertake research, attend clinical meetings and scientific advisory boards from Bayer HealthCare Pharmaceuticals; Dr Gemzell-Danielsson has participated on scientific advisory boards, clinical trials and has been a speaker for Bayer HealthCare Pharmaceuticals; Dr Pirjo Inki is an employee of Bayer HealthCare Pharmaceuticals; and Dr Jensen has participated on scientific advisory boards, received research support and been a speaker for Bayer HealthCare Pharmaceuticals.