Protecting fertility: contraceptives pose no threat, but STIs do.

Becoming a mother is a woman's passport to adulthood in many settings throughout the world. Motherhood brings pride in continuing the family lineage, the comradery of sharing child-rearing experiences with other adult females in the community, and often better prospects for long-term marital stability and economic security.

"In some cultures, a woman does not achieve full adult status until she is a mother," says Dr. Priscilla Ulin, an FHI senior staff consultant who served as deputy director of the FHI's Women's Studies Project, a multinational effort from 1993 to 1998 to study the impact of family planning on women's lives. (1) "Findings from the Women's Studies Project show us clearly that, throughout much of the world, there is strong desire among women to prove their fertility and to protect their ability to have children."

But a woman's health and well-being, and those of her family, may depend on her being able to delay the birth of her first child or space the births of her children. "And while women are often aware of the benefits of family planning, mistaken fears that contraceptives--particularly hormonal methods and intrauterine devices (IUDs)--could cause infertility sometimes inhibit them from adopting a highly effective contraceptive method or result in them abandoning it," says Dr. Ulin.

Providers working with clients in their peak childbearing years should keep such fears in mind, taking care to dispel myths about an association between contraceptive use and infertility. They should counsel women who highly value their fertility about how to protect themselves against sexually transmitted infections (STIs), some of which can lead to pelvic inflammatory disease (PID), a common cause of infertility (see article, page 16). Meanwhile, providers should be aware that women's fertility goals, sexual behaviors, and needs for contraception and STI protection change throughout their reproductive lives.

REPRODUCTIVE LIFE STAGES

A woman's reproductive years, which typically span almost four decades, can be divided into stages, according to Dr. Jacqueline Darroch of the U.S.-based Alan Guttmacher Institute, who has outlined five such stages: (2)

1. Menarche to intercourse

2. Intercourse to marriage

3. Marriage to first birth

4. First birth to attainment of desired family size

5. Attainment of desired family size to menopause

(Women do not necessarily pass through these stages in sequential order. They may also omit stages or return to earlier stages.)

Each stage is characterized by different priorities for contraception and STI protection. For example, in the second stage--from the time of her first sexual intercourse until marriage--a single woman may have multiple sexual partners. She may want to postpone childbearing while protecting her fertility, but may be at higher risk than women in other stages for both unplanned pregnancy and STI infection. This is largely because her sexual encounters are more likely to be unpredictable and her use of condoms and other contraceptives inconsistent. A nationally representative survey of 2,465 Zimbabwean women ages 15 to 49 years suggests that contraceptive use during the second reproductive stage tends to be low. Only 15 percent of survey respondents ages 30 years or younger reported using contraception during their first sexual encounter, which usually occurred prior to marriage, according to Women's Studies Project research conducted by FHI and the University of Zimbabwe. For this group, the rate of contraceptive use continued to be low--only 11 percent--at the time of marriage. (3)

During the third reproductive life stage, a recently married woman may wish to delay the birth of a first child while preserving her fertility. An increasing number of women in Morocco, for example, are delaying childbearing after marriage, according to a 2001 study based on a 1995 national survey of 4,753 women. Researchers suggested that these delays in childbearing may be related to rising housing costs: Moroccan couples are increasingly beginning married life in their parents' homes rather than establishing their own households. (4)

In the fourth stage, a woman may wish to space the birth of her children while preserving her fertility. Concern about STIs would be expected to be low during a woman's peak childbearing years, but only if partners are monogamous. From first intercourse to attainment of desired family size, providers should consider whether a woman needs protection against STIs because an STI contracted in one stage can affect a woman's fertility during later stages of her reproductive life.

"Throughout Africa, much of providers' time is spent dealing with infertility problems," says Dr. Samuel Sinei, professor of obstetrics and gynecology at the University of Nairobi in Kenya. "Women who are infertile have more unstable marriages and often end up divorced. When this happens, they often have no economic ability to survive on their own. Many become prostitutes, which can lead to acquiring STIs, including HIV. This is unfortunate, especially since infertility is often preventable. Much of infertility is caused by STIs that women acquire in their late teens. By the time they reach full adulthood, they are already infertile.

"For this reason, providers need to give women information about how to preserve their fertility," Dr. Sinei emphasizes. "One way would be to promote condom use with the reasoning that it can help preserve fertility. This might motivate couples to use condoms regularly."

CONDOMS AND FERTILITY

When used consistently and correctly, condoms are effective contraceptives. They also provide protection against HIV infection and gonorrhea, and are presumed to protect against other STIs that can lead to infertility. (5) Untreated gonorrhea and chlamydial infections are associated with fertility impairment or infertility in both men and women. (6) These and other STIs --particularly herpes and syphilis--are also associated with adverse pregnancy outcomes, including spontaneous abortion, premature birth, and stillbirth. (7) For this reason, providers should consider each client's risk of STI and HIV infection (as assessed by STI prevalence in the community and a woman's specific risk behaviors) and, if that risk is substantial, promote condom use. At-risk women should be encouraged to use condoms for disease prevention even if they are using another method for contraception.

Providers should emphasize consistent and correct use of condoms. The likelihood of a woman acquiring gonorrhea or syphilis from an infected partner is about 50 percent for each act of unprotected sexual intercourse. (8) The probability that she will acquire gonorrhea from an infected partner is about double her risk of becoming pregnant during each unprotected sexual act, even when she is most fertile. (Her probability of acquiring chlamydial infection or viral STIs, especially HIV, during each unprotected coital act may be somewhat lower. (9))

Dr. Ward Cates, president of FHI's Institute for Family Health, a division of FHI, notes that encouraging condom use during high-risk situations could result in more consistent use than counseling clients to use condoms during all sexual encounters. "Counseling women to use condoms during every sexual encounter may seem too unrealistic to them and result in abandoning condom use altogether, while promoting condom use in high-risk situations may ultimately end up in more protected sexual acts."

Some researchers have suggested that encouraging contraceptive use--ideally, condoms--in conjunction with early resumption of sexual relations after childbirth may reduce men's unprotected extramarital affairs during this period and thus protect their wives from fertility-threatening STIs. In Cote d'Ivoire, the belief that sperm may poison breastmilk prevents many couples from resuming sexual relations soon after the birth of a child. But men practicing such postnatal abstinence were twice as likely to engage in unprotected extramarital sex as men who were not, a 2001 study based on the 1994 Cote d'Ivoire Demographic and Health Survey found. Condoms, the researchers noted, could be promoted with the idea that they would protect against the poisoning of breast-milk. (10) A 2002 study conducted in Nigeria found similar beliefs about sperm poisoning breastmilk and similar behavioral patterns among Nigerian men during pregnancy and the period of postpartum abstinence. (11)

HORMONAL METHODS AND FERTILITY

Hormonal contraceptives are among the most effective contraceptives available, but concerns about their effect on fertility may prevent some women from using them. Nearly half of 498 female Nigerian university students believed that oral contraceptives (OCs) could damage the uterus, and 41 percent believed they could cause infertility, a 1993 study showed. These mistaken fears may have discouraged students from adopting this method, since three-quarters expressed a lack of desire to do so. (12) Similar fears were reported by 40 ethnic Chinese-Canadian women recruited from two Canadian abortion clinics to participate in a 2002 study to identify barriers to the use of OCs. A common fear was that the pills could cause permanent infertility. (13) Even some providers mistakenly fear that hormonal methods such as depot medroxy-progesterone acetate (DMPA) may cause infertility, a survey conducted from 1993 to 1995 among more than 1,000 Northern European and U.S. clinicians found. (14)

Use of hormonal methods does not threaten fertility. However, these methods may cause menstrual bleeding disturbances that can make women wonder whether their fertility is in jeopardy. Providers need to reassure clients that such side effects are predictable and normal and that neither the health nor fertility of clients is threatened. In fact, studies have found that fertility returns quickly after the discontinuation of hormonal methods. (The exceptions are the progestin-only injectables DMPA and norethisterone enanthate [NET-EN]. Return of fertility may be delayed by six to 10 months from the date of the last injection, but there is no permanent damage to fertility.) A 1997 study among 70 Brazilian, Chilean, Colombian, and Peruvian women using the once-a-month, combined injectable Cyclofem found fertility restored by one month following discontinuation, with more than half of the women becoming pregnant six months after discontinuation. Eighty-three percent were pregnant one year after discontinuation, and 94 percent of these pregnancies resulted in a live birth. Fertility returned so quickly that researchers have recommended that providers bring this to the attention of Cyclofem users so as to prevent unplanned pregnancies shortly after discontinuation. (15)

Ovulation also returns shortly after stopping the use of OCs. "The return is quicker with today's low-dose pills than with higher-dose pills used in the past," notes Dr. David Grimes, FHI vice president of biomedical affairs. In fact, fertility may return all too quickly if oral contraceptive pills are abandoned or missed. A 1995 study found that women who missed one or more pills per cycle were nearly three times as likely to experience an unplanned pregnancy than were women who took the pills consistently. (16)

IUDS AND FERTILITY

The IUD is a highly effective reversible contraceptive used by more than 106 million women worldwide. (17) Since it can be used safely for 10 years or more, it is also economical.

Some women erroneously associate the IUD with PID and subsequent infertility, but use of the copper IUD (the most common type of IUD now being inserted) in itself does not pose a significant risk to a woman's fertility. (18) Rather, bacteria are the culprits in the development of PID and associated infertility. (19) If a woman has an STI at the time an IUD is inserted, the process of IUD insertion can introduce STI-causing bacteria from the cervix into the uterus and fallopian tubes, which can later cause PID. For this reason, providers should attempt to identify women with cervical infections or those who are at increased risk of such infections. The World Health Organization (WHO) medical eligibility criteria for safe use of contraceptives state that current infection with an STI contraindicates IUD use, as does any previous pelvic infection or STI that has not been cured for at least three months. The WHO criteria also state that IUD use is not usually recommended for women at increased STI risk unless other more appropriate methods are not available or not acceptable. (20) Research suggests, however, that even when cervical infection is present at the time of IUD insertion, only a small percentage of women subsequently develop PID. (21)

While little risk of infection exists after IUD insertion if women are screened carefully and IUDs are correctly inserted in an antiseptic environment, providers need to be aware of the signs of PID infection and educate users to recognize and report any symptoms of infection. Patients with PID may have lower abdominal pain, chills and fever, menstrual disturbances, cervical discharge containing pus, and cervical tenderness. They should be treated with antibiotics as soon as possible, and their sexual partners should be examined and treated appropriately. (22)

Meanwhile, other mistaken beliefs about IUDs persist. Myths and fears were the biggest barriers to IUD use reported by 30 El Salvadorian Ministry of Health clinic providers who were interviewed by FHI researchers in 1999. Among the most common fertility-related fears was the belief that an IUD could become embedded in a woman's uterus. (23) Although possible, this is rare. "The slight indentation in the lining of the uterus caused by this event should resolve with IUD removal and have no ultimate effect on a woman's fertility," says Dr. Grimes.

Research has found that women who understand that IUD use in itself poses no threat to fertility can confidently use the method for delaying, spacing, or limiting childbirth. (24) "I had it for two years, maybe longer," said one of 18 IUD users who participated in a focus group discussion during FHI's IUD study in El Salvador. "It was inserted, and I didn't feel anything that would hinder me, not a string hanging, nothing. When I decided to have it removed, [it] was because I wanted to have another child."

This study also found that providers who dispel infertility myths about IUDs help women make informed contraceptive choices. As one user explained, "I attended a talk where they said there was a possibility of you becoming pregnant [during IUD use]. The baby could be born with the IUD, and it would need an operation. I spoke to the doctor about that and was told, `No, that is not possible.'" At that point, the woman said she chose to have an IUD inserted.

REFERENCES

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(16.) Rosenberg MJ, Waugh MS, Meehan TE. Use and misuse of oral contraceptives: risk indicators for poor pill taking and discontinuation. Contraception 1995;51(5):283-88.

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(19.) 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(8):561-67.

(20.) World Health Organization. Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use, Second Edition. Geneva: World Health Organization, 2000.

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(24.) Katz.