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Reproductive Health |
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Clinical Challenges |
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Pill 'Vacation' Unnecessary A married 24-year-old woman who has been using oral contraceptives (OCs) for several months comes to the clinic for advice. She is happy with her choice of contraceptive method. However, she has heard that she needs to give her reproductive system a "vacation" from OC use, or else she may not be able to "reactivate" it later when she wants to have children. The young woman is thinking of not taking the pills for a while. What should she be counseled to do? Since she is satisfied taking OCs, the woman should be advised to continue using them. Women do not need to periodically stop taking OCs to preserve fertility. Research has shown that contraceptive pills do not cause infertility,1 regardless of duration of use.2 The World Health Organization states that return to fertility is immediate after OC users stop taking the pills.3 However, several studies have shown that OC users may experience a temporary delay in return to fertility.4 Taking a "vacation" from the pill would improve neither this woman's health nor her fertility. But it would increase her risk of unintended pregnancy if she had unprotected sexual intercourse or intercourse using a less effective contraceptive method during this time. Of note, use of OCs can protect against ectopic pregnancy5 that could jeopardize long-term fertility. Can Douching Threaten Fertility? A 23-year-old sexually active, single woman wants to know whether regular vaginal douching is a good practice. Some of her friends and female family members have told her that douching can help protect her from acquiring sexually transmitted infections (STIs), but others have told her that it can be harmful and might even threaten her fertility. Based on the best research to date, should this practice be recommended? Many women douche, believing that the practice is hygienic, healthy,6 and even prevents STI transmission.7 However, douching has not been shown to either protect against STIs or provide other health benefits. Furthermore, a recent cross-sectional analysis found that douching — particularly frequent or recent douching — for symptoms such as vaginal discharge or for hygiene was associated with bacterial vaginosis (BV), an overgrowth of unhealthy bacteria.8 These findings confirm those of several cross-sectional studies9 and a single, small prospective cohort study10 that have shown an association between douching and BV. BV can cause fertility-threatening pelvic inflammatory disease (PID) if either gonorrhea or chlamydial infection is present. It can also harm a pregnancy. A recent meta-analysis of 18 studies involving some 20,000 patients has confirmed that BV, present early in pregnancy, is a strong risk factor for preterm delivery and spontaneous abortion.11 How different douching products affect vaginal health has not been established yet. But, given growing concerns about the adverse health effects of douching, this practice should not be recommended. Of note, some studies have suggested that douching is associated with cervical chlamydial infection and PID.12 However, this association was not observed in the recent study that linked douching with BV. That study, conducted among 1,200 U.S. women at high risk for STIs, found no association between douching and either gonorrhea or chlamydial infection of the cervix.13 Similarly, in a recent randomized study conducted among 1,827 women, the risk of PID for women assigned to use a newly designed douche product was only slightly greater or no greater than for those women assigned to use a cloth towel wipe.14 Vasectomy's Permanency Could Cause Regret A 29-year-old man comes to the family planning clinic with his 25-year-old wife six months after the birth of their second child. They have been discussing their contraceptive options, and wonder whether vasectomy would be a good choice. Struggling financially, they doubt that they will ever be able to afford more children; thus, they are considering a permanent contraceptive method. Would vasectomy be advisable in this case? Vasectomy is a good contraceptive for couples seeking a safe, effective, and permanent method. However, it may not be the best choice for a couple who, in reacting to immediate financial pressures, have not fully considered their ultimate reproductive goals. Since this couple wishes to delay fertility for an indefinite time, a long-acting method — such as the intrauterine device (IUD) — might be a better option. Vasectomy involves a brief surgical procedure in which the vasa deferentia — the two tubes that carry sperm from the testicles to the penis — are interrupted so that sperm can no longer enter the semen. Although vasectomy failure may be more common than previously thought, recent evidence from Nepal still shows pregnancy rates of only 2 percent in the first year and 4 percent in the three years following the procedure.15 New techniques such as cautery and fascial interposition may make vasectomy even more effective.16 Reversing a vasectomy is difficult, expensive, and has no guarantee of success, so it is important that providers counsel clients about the method's permanency.17 To help clients make informed choices, provider-initiated counseling before vasectomy is performed should also include discussion of other long-term but reversible contraceptive options.18 By exploring clients' feelings about ending fertility and their readiness for the procedure, providers can identify clients who have doubts or unrealistic expectations and those who have requested sterilization in response to short-term stresses or external pressure. These are all factors associated with post-operative regret. Young age at sterilization and changes in marital status are also common predictors of sterilization regret.19 — Kathleen Henry Shears and Kim Best References
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