How common is natural conception in women who have had a livebirth via assisted reproductive technology? Systematic review and meta-analysis.

STUDY QUESTION: What is the proportion of women who experience natural conception after a livebirth via assisted reproductive technology (ART)? SUMMARY ANSWER: Current evidence suggests that natural conception pregnancy may occur in at least one in five women after having a baby via IVF or ICSI. WHAT IS KNOWN ALREADY: It is widely known that some women having babies via ART go on to conceive naturally. This reproductive history is of media interest and often described as 'miracle' pregnancies. STUDY DESIGN, SIZE, DURATION: A systematic review with meta-analysis was carried out. Ovid Medline, Embase, and PsycINFO were searched until 24 September 2021 for English language, human studies from 1980. Search terms were used for the concepts of natural conception pregnancy, assisted reproduction, and livebirth. PARTICIPANTS/MATERIALS, SETTING, METHODS: The inclusion criterion was studies with an outcome measure of the proportion of women experiencing natural conception pregnancy after an ART livebirth. Quality of studies was assessed using the Critical Appraisal Skills Programme cohort study checklist or AXIS Appraisal tool for cross-sectional studies, and a risk of bias assessment was carried out. No studies were excluded based on quality. Random-effects meta-analyses were adopted to produce a pooled effect estimate of the proportion of natural conception pregnancy after ART livebirth. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 1108 distinct studies were identified, resulting in 54 studies after screening by title and abstract. Eleven studies including 5180 women were selected for this review. The included studies were mostly of moderate quality with a maximum follow-up period ranging from 2 to 15 years. Four studies reported natural conception livebirths which were used as known underestimates of natural conception pregnancies. The pooled estimate for the proportion of women having natural conception pregnancies after ART livebirth was 0.20 (95% CI, 0.17-0.22). LIMITATIONS, REASONS FOR CAUTION: The studies varied widely according to methodology, population, cause of subfertility, type and outcome of fertility treatment, and length of follow-up, leading to potential bias relating to confounding, selection bias, and missing data. WIDER IMPLICATIONS OF THE FINDINGS: Current evidence suggests that contrary to widely held views, natural conception pregnancy after ART livebirth is far from rare. National, data-linked studies are needed to provide more accurate estimates of this incidence and analysis of associated factors and trends over time to facilitate tailored counselling of couples considering further ART. STUDY FUNDING/COMPETING INTEREST(S): This work was conducted as part of an academic clinical fellowship awarded to AT by the National Institute for Health Research (NIHR). NIHR has had no input into the study design, data collection, and analysis, nor the writing of this study. No authors have any conflicts of interest. REGISTRATION NUMBER: PROSPERO (CRD42022322627).

Contraception after in vitro fertilisation (IVF): a qualitative study of the views of women who have had spontaneous pregnancies after successful IVF.

BACKGROUND: The use of in vitro fertilisation (IVF) has increased rapidly since its inception in 1978. Women seeking IVF have a wide range of subfertility causes including unexplained subfertility. A growing subgroup of women seek treatment for other reasons than fertility problems, for example, women in same sex relationships and single women. This study aims to better understand the contraceptive needs of women after successful IVF pregnancy in order to improve service delivery and prevent unplanned and rapid-repeat pregnancies. METHODS: A qualitative study of views of women who have had spontaneous pregnancies after successful IVF. Participants were recruited using purposive and snowballing sampling methods from social media and peer networks. The framework method was used for analysis using NVivo12. RESULTS: The sample comprised 21 interviewees from the United Kingdom (UK), having a range of spontaneous pregnancy outcomes, including single and multiple livebirths, miscarriage, ectopic pregnancy and termination of pregnancy. Contraceptive choices were subject to a complex and dynamic interaction of influencing factors including beliefs regarding subfertility, desire for children and views on contraception. None of the women recalled receiving any information or useful counselling about contraception during fertility or maternity care. After IVF pregnancy, most women (n = 16) used no or ineffective contraception. Spontaneous pregnancy was not universally welcomed in this group and inter-pregnancy intervals were often short (n = 16, less than 18 months). Even after subsequent spontaneous pregnancy, use of contraception and the most effective methods remained low. Women held persistent beliefs regarding their subfertility despite subsequent spontaneous pregnancy. They associated aspects of the IVF process with a sense of personal failure, despite an ultimately "successful" outcome of livebirth. These aspects may reinforce their self-belief in subfertility. Other barriers to contraception use in women having IVF included: lack of knowledge of likelihood of spontaneous pregnancy, lack of contraceptive experience and inherent incentives towards shorter inter-pregnancy intervals. CONCLUSIONS: The contraceptive needs of women having IVF pregnancies are real and are being overlooked. Fertility services should take responsibility for providing information on the risks of subsequent spontaneous pregnancy. Maternity and community healthcare professionals must address women's perceptions of their fertility in order to engage them in contraception counselling.

Women who have difficulty getting pregnant may choose to use fertility treatment to help. Fertility treatment known as 'in vitro fertilisation', or IVF, was developed around 40 years ago and has been increasingly used ever since. Over 8 million babies have been born this way around the world. There are many different reasons why women can have problems getting pregnant and in a quarter of cases the cause is never found. We know that some women, who have babies using IVF, get pregnant again afterwards without fertility treatment. Getting pregnant again quickly, or when a woman isn't ready, can be worse for the health of the mother and child. Therefore, this study aims to understand what contraception women need after IVF to plan and space their future pregnancies. We spoke to 21 women who became pregnant without fertility treatment after having their first babies using IVF. Although most of these women had not been using contraception after their first baby, they were shocked to get pregnant again as they firmly believed they could not get pregnant without fertility treatment. Most of these pregnancies had happened quickly and not all the women were happy to be pregnant again. These women were not given the information they needed about their chances of getting pregnant after IVF without fertility treatment. Fertility and maternity services must close this gap. Health professionals also need to explore women's beliefs about their own fertility after IVF before they can start to have helpful conversations about contraception.

Menstrual cup and risk of IUD expulsion - a systematic review.

BACKGROUND: The menstrual cup is a safe, cost-effective, and environmentally friendly menstrual product which is increasing in usage, especially in younger women. The potential risk for concomitant menstrual cup use to increase IUD expulsion has been raised over the last 10 years, however, few studies assess this. This systematic review aims to identify, appraise and synthesize the current specific evidence on menstrual cup use and risk of partial or total IUD expulsion. METHODS: PubMed, and the Cochrane Library were searched for publications available in English, until February 20th, 2021. Quantitative and qualitative studies, systematic reviews and case series reports were included. Websites of menstrual cup manufacturers LenaCup®, DivaCup®, Lunette®, AllMatters® and Saalt® were searched for warnings relevant to IUD expulsion. RESULTS: Seven studies were included in this review, comprising 73 partial or total IUD expulsion events in patients with IUD contraception using menstrual cups. The case study reports included two individuals who each experienced two and three expulsions respectively. Of the seven publications, three reported expulsion rates of 3.7%, 17.3% and 18.6%. Time to expulsion ranged from less than one week to two and a half years. These three studies disagree on whether there is a statistically significant association between menstrual cup use and IUD expulsion. CONCLUSION: There is a possible association between menstrual cup use and increased risk of IUD expulsion and this information should be shared with patients. However evidence is scarce and high-quality randomised controlled trials are needed to address this risk and the impact of factors such as age, menstrual cup removal technique, pelvic anatomy, IUD type, and measures such as cutting the IUD strings short or delaying menstrual cup use for a period post-insertion. This research gap is limiting patients' ability to make informed choices regarding intrauterine contraception and menstrual management and must urgently be addressed in the context of rising IUD and menstrual cup use, particularly among a younger demographic who are seeking highly effective contraception.

Women's and healthcare professionals' views on immediate postnatal contraception provision: a literature review.

OBJECTIVES: Provision of immediate postnatal contraception, including long-acting reversible contraceptive (LARC) methods, is increasingly identified and endorsed as a key strategy for reducing unplanned and rapid repeat pregnancies. This literature review aims to evaluatethe views of women and healthcare professionals regarding the receipt, initiation or delivery of these services. METHODS: Databases (Embase, Medline, CINAHL, HMIC) were searched for relevant English language studies, from January2003 to December 2017. In addition, Evidence Search, Google Scholar and Scopus (citation search) were used to identify further literature. Other relevant websites were accessed for policies, guidance and supplementary grey literature. RESULTS: There is clear guidance on how to deliver good-quality postnatal contraception to women, but the reality of service delivery in the UK does not currently meet these aspirations, and guidance on implementation is lacking. The available evidence on the provision of immediate postnatal contraception focuses more on clinical rather than patient-centred outcomes. Research on postnatal women's views is limited to receptivity to LARC and contraception counselling rather than what influences their decision-making process at this time. Research on views of healthcare professionals highlights a range of key systemic barriers to implementation. CONCLUSIONS: While views of postnatal women and healthcare professionals are largely in support of immediate postnatal contraception provision, important challenges have been raised and present a need for national sharing of service commissioning and delivery models, resources and evaluation data. Provider attitudes and training needs across multidisciplinary groups also need to be assessed and addressed as collaborative working across a motivated, skilled and up-to-date network of healthcare professionals is viewed as key to successful service implementation.

Contraception for adolescents with disabilities: taking control of periods, cycles and conditions.

The onset of puberty, periods and sexual relationships can be difficult for adolescents and parents. Adolescents with disabilities face a wide range of additional challenges (physical, mental, social and intellectual), which may impact the quality of their lives and those of their families and carers. Research on the use of contraception in young women with disabilities is limited, and clinicians have little practical guidance for best practice. This review article aims to summarise and assess the evidence and guidance for the use of contraception in this group, particularly with regard to management of menstrual and cyclical problems. Multidisciplinary teamwork is important for recognising and addressing the concerns of patients and their carers effectively. The legal and ethical considerations are also highlighted here, as this group of adolescents is highly vulnerable to sexual exploitation and abuse.

Immediate postnatal contraception: what women know and think.

INTRODUCTION: Postpartum women are at risk of rapid repeat, unplanned pregnancy with associated adverse outcomes for mother and child. We aimed to better understand their contraceptive needs to improve delivery of services and prevent unplanned pregnancies. METHODS: A cross-sectional survey of women on the postnatal ward of an inner-city hospital was administered over a 6-week period in June and July 2017 to determine their level of knowledge, intentions and preferences regarding postnatal contraception. RESULTS: 272 women were surveyed: 86% of all women on the postnatal ward during the study period. 10% (26/272) had never used any method of contraception previously and 22% (59/272) had ever used a long-acting reversible contraception (LARC) method. 18% (48/272) recalled a health professional speaking to them about contraception at any point during their pregnancy and 32% (87/272) said they needed more information to decide on their postnatal contraceptive method. 54% (147/272) of women did not think any LARC methods were safe immediately postnatally, rising to 71% (194/272) if breastfeeding. However, 47% (129/272) of women said that they would prefer to get their contraception from the ward before discharge and 46% (126/272) were likely to accept LARC, if safe, in this setting. CONCLUSIONS: Almost half the women in our survey would welcome provision of postnatal contraception, including LARC, on the postnatal ward but the women surveyed currently lack the knowledge to make informed choices in this setting. There is therefore a need for effective, tailored contraceptive choices discussions with every woman during pregnancy, as well as integrated planning for postnatal provision of the woman's chosen method.