Two year continuation rates of contraceptive methods in France: a cohort study from the French national health insurance database.

OBJECTIVE: The aim of this study was to evaluate the continuation rates of reimbursed contraceptive methods in French real-world conditions. METHODS: A retrospective cohort study using a representative sample of the national health insurance database, the General Sample of Beneficiaries (Echantillon Généralistes des Bénéficiaires [EGB]), was performed between 2006 and 2012. Selected women were ≥15 years of age and had started a reimbursed contraceptive method between 2009 and 2012 without prior reimbursement for an implant or an intrauterine contraceptive method between 2006 and 2008. The outcome of interest was the continuation rates, defined as the probability of women initiating a contraceptive method and continuing to use the same method over time. Continuation rates were assessed for up to 2 years. Only the first contraceptive method used during the study period was considered in the analysis. Non-parametric Kaplan-Meier survival analysis was used to assess continuation rates. RESULTS: A population of 42,365 women representative of the 4,109,405 French women initiating any reimbursed method between 2009 and 2012 was identified in the EGB: 74.5% of women used oral contraceptives, 12.8% the levonorgestrel-releasing intrauterine system (LNG-IUS), 9.2% the copper intrauterine device (Cu-IUD) and 3.5% the subdermal etonogestrel (ENG) implant. The 2 year continuation rates varied from 9.1% for progestin-only oral contraceptives, 27.6% for first to second generation combined oral contraceptives (COCs) and 33.4% for third generation COCs to 83.6% for the ENG implant, 88.1% for the Cu-IUD and 91.1% for the LNG-IUS. CONCLUSION: This study conducted in real-world conditions showed that long-acting reversible contraceptive (LARC) methods remain rarely used in France despite high continuation rates over 2 years. Increasing the use of LARC methods is therefore a public health priority.

[Contraception for transgender men: A case report and review]. / La contraception d'un homme transgenre : à propos d'un cas et revue de la littérature.

All methods of contraception used by a cisgender woman can theoretically be used by a transgender man. In practice, some contraceptives can aggravate gender dysphoria and should be discarded. On the other hand, contraceptives which make it possible to consolidate amenorrhea or to accentuate the virilization induced by taking testosterone will be better tolerated.

[The contraception consultation: CNGOF Contraception Guidelines]. / Consultation en contraception. RPC Contraception CNGOF.

OBJECTIVE: Determine the most accurate information to give to women, the most efficient way of doing it, the physical examination during a contraceptive visit and the most appropriate follow-up. METHODS: A systematic review of French-speaking or English-speaking evidence-based literature about contraception and its visit was performed using Pubmed, Cochrane and international recommendations. RESULTS: Showing a contraceptive preference decreases women's satisfaction (EL1) and may decrease contraceptive persistence (EL4). A GATHER's like structured consultation is recommended (Grade A). It allows a contraceptive choice improvement (EL2). Contraceptive knowledge improvement associated with a structured consultation allows a decrease in unplanned pregnancies (EL1) compared to a traditional non-personalized consultation. The main expectations of women are slightly different from what is expected by practitioners (EL2). The main topics to be addressed are efficiency, risks, cost, duration of action and practicality (EL2). The quality of interpersonal communication could allow greater contraceptive persistence (EL2). A careful behavior at the beginning of the consultation and facilitating the expression of the woman's point of view could increase the persistence of the initially prescribed contraception (EL2). Explaining the chosen contraception's adverse effect is recommended because it could allow a better persistence (Grade B). Decision aids has shown interest in the therapeutic choice (EL1). Computerized modules or slide shows in the waiting room before consultation could make the contraceptive choice easier (EL2). The presentation of contraception by effectiveness categories is better than pregnancy numbers for comparing the methods (EL1). Performing a blood pressure measurement prior to an estroprogestative contraception prescription is recommended (Grade C). In women without risk factors, literature data do not allow specific recommendations regarding breast, pelvic examination, laboratory screening and follow-up (Professional agreement).

[Intrauterine contraception: CNGOF Contraception Guidelines]. / Contraception intra-utérine. RPC Contraception CNGOF.

OBJECTIVE: To provide national clinical guidelines focusing on intrauterine contraception. METHODS: A systematic review of available literature was performed using Pubmed and Cochrane libraries. American, British and Canadian guidelines were considered as well. RESULTS: Intrauterine contraception (IUC) displays a wide panel of indications, including adolescents, nulliparous, patients living with HIV before AIDS (Grade B) and women with history of ectopic pregnancy (Grade C). Cervical cancer screening should not be modified in women with IUC (Grade B). Bimanual examination and cervix inspection are mandatory before device insertion (Grade B). Patients should not systematically undergo screening for sexually transmitted infections (STI) before device insertion (Grade B). Screening for STI should be preferably done before insertion but it can be performed at the time of device insertion in asymptomatic women (Grade B). Routine antibiotic prophylaxis and premedication are not recommended before insertion (Grade A). A follow-up visit may be offered several weeks after insertion (Professional consensus). Routine pelvic ultrasound examination in not recommended after device insertion (Grade B). In patients with IUC, unscheduled bleeding, when persistent or associated with pelvic pain, requires further investigation to rule out complication (Professional agreement). Suspected uterine perforation warrants radiological workup to locate the device (Professional consensus). Laparoscopic approach should be preferred for elective removal of intrauterine device from abdominal cavity (Professional consensus). In case of accidental pregnancy with intrauterine device in situ, ectopic pregnancy should be excluded (Grade B). In case of viable and desired intrauterine pregnancy, intrauterine device removal is recommended if the strings are reachable (Grade C). Detection of Actinomyces-like organisms on pap smear in asymptomatic patients with intrauterine contraception does not require further intervention (Grade B). Immediate removal of intrauterine device is not recommended in case of STI or pelvic inflammatory disease (Grade B). Device removal should be considered in the absence of clinical improvement after 48 to 72 hours of appropriate treatment (Grade B). CONCLUSION: Intrauterine contraception is a long-acting and reversible contraception method displaying great efficacy and high continuation rate. In contrast, complication rate is low. It should thus be offered to both nulliparous and multiparous women.

[Contraception: CNGOF Guidelines for Clinical Practice (Short Version)]. / Contraception : Recommandations pour la Pratique Clinique du CNGOF (texte court).

The French College of Obstetrics and Gynecology (CNGOF) releases its first global recommendations for clinical practice in contraception, to provide physicians with an updated synthesis of available data as a basis for their practice. The French Health Authority (HAS) methodology was used. Twelve practical issues were selected by the organizing committee and the task force members. The available literature was screened until December 2017, and allowed the release of evidence-based, graded recommendations. This synthesis is issued from 12 developed texts, previously reviewed by experts and physicians from public and private practices, with an experience in the contraceptive field. Male and female sterilization, as well as the use of hormonal treatments without contraceptive label were excluded from the field of this analysis. Specific practical recommendations on the management of contraception prescription, patient information including efficacy, risks, and benefits of the different contraception methods, follow up, intrauterine contraception, emergency contraception, local and natural methods, contraception in teenagers and after 40, contraception in vascular high-risk situations, and in case of cancer risk are provided. The short/mid-term future of contraception mostly relies on improving the use of currently available methods. This includes reinforced information for users and increased access to contraception for women, whatever the social and clinical context. That is the goal of these recommendations.

[Hysteroscopic fallopian tube sterilization procedure: feasibility and one-year follow-up]. / Stérilisation tubaire par voie hystéroscopique: faisabilité et évaluation à un an.

OBJECTIVES: Hysteroscopic flexible micro-insert (Essure) is an ambulatory improvement of fallopian tube sterilization, which is a deliberated suppression of fertility. The aim of this study was an evaluation of feasibility (learning curve) and the first year outcome of this method. PATIENTS AND METHODS: This prospective study, carried out between February 2002 and March 2003, included patients who were matching with manufacturer recommendations. One surgeon only realized all the device placements. RESULTS: Fifty patients were included (one year follow-up). Mean age was 41 (+/-3.3), mean parity was 2.7 (+/-0.8). Mean time needed for device placement was 26 minutes (+/-6.5) and was reduced with increased experience. Six failures of placement (12%) were related, because of submucus leiomyomas, proximal tubal stenotic disease or too retroverted uterus. Only 5 patients (11,4%) described intensive pelvic pain during the placement. The only case of device expulsion benefited from a successful second placement. The one-year follow-up showed no significant difference of body weight increasing, duration or quantity of menstruation, neither significant pelvic pain nor vaginal bleeding. Tolerance was rated at least at "somewhat satisfied". There have been no pregnancies reported in 670 woman-months of effectiveness. DISCUSSION AND CONCLUSION: Our results agree in any point with those of larger studies. We think that hysteroscopy micro-insert placement is not only reserved to specialized centers but also to any gynecologist who is used to performing hysteroscopy because of its feasibility.

[Surgical methods of abortion]. / Interruption volontaire de grossesse instrumentale.

OBJECTIVE: A state of the art of surgical method of abortion focusing on safety and practical aspects. MATERIAL AND METHODS: A systematic review of French-speaking or English-speaking evidence-based literature about surgical methods of abortion was performed using Pubmed, Cochrane and international recommendations. RESULTS: Surgical abortion is efficient and safe regardless of gestational age, even before 7 weeks gestation (EL2). A systematic prophylactic antibiotics should be preferred to a targeted antibiotic prophylaxis (grade A). In women under 25 years, doxycycline is preferred (grade C) due to the high prevalence of Chlamydia trachomatis. Systematic cervical preparation is recommended for reducing the incidence of complications from vacuum aspiration (grade A). Misoprostol is a first-line agent (grade A). When misoprostol is used before a vacuum aspiration, a dose of 400 mcg is recommended. The choice of vaginal route or sublingual administration should be left to the woman: (i) the vaginal route 3 hours before the procedure has a good efficiency/safety ratio (grade A); (ii) the sublingual administration 1 to 3 hours before the procedure has a higher efficiency (EL1). The patient should be warned of more common gastrointestinal side effects. The addition of mifepristone 200mg 24 to 48hours before the procedure is interesting for pregnancies between 12 and 14 weeks gestations (EL2). The systematic use of nonsteroidal anti-inflammatory drugs is recommended for limiting the operative and postoperative pain (grade B). Routine vaginal application of an antiseptic prior to the procedure cannot be recommended (grade B). The type of anesthesia (general or local) should be left up to the woman after explanation of the benefit-risk ratio (grade B). Paracervical local anesthesia (PLA) is recommended before performing a vacuum aspiration under local anesthesia (grade A). The electric or manual vacuum methods are very effective, safe and acceptable to women (grade A). Before 9 weeks gestation, the manual vacuum aspiration could have a subjective interest (grade B). The electric vacuum aspiration is recommended after 9 weeks gestation (best practice agreement). For a pregnancy of unknown location, the success of the procedure can reasonably be determined if hCG drops more than 50 % on day 5 and 80 % on day 7 (NP3). After a surgical abortion, paracetamol or addition of paracetamol and codeine is not recommended (grade B).

[Induced abortion: Guidelines for clinical practice - Text of the Guidelines (short text)]. / L'interruption volontaire de grossesse : recommandations pour la pratique clinique ­ Texte des recommandations (texte court).

OBJECTIVE: Develop recommendations for the practice of induced abortion. MATERIALS AND METHODS: The Pubmed database, the Cochrane Library and the recommendations from the French and foreign Gyn-Obs societies or colleges have been consulted. RESULTS: The number of induced abortions (IA) has been stable for several decades. There are a lot of factors explaining the choice of abortion when there is an unplanned pregnancy (UPP). Early initiation and choice of contraception in connection to the woman's life are associated with lower NSP. Reversible contraceptives of long duration of action should be positioned fist in line for the teenager because of its efficiency (grade C). Ultrasound before induced abortion must be encouraged but should not be obligatory before performing IA (Professional consensus). As soon as the sonographic apparition of the embryo, the estimated date of pregnancy is done by measuring the crown-rump length (CRL) or by measuring the biparietal diameter (BIP) from 11 weeks on (grade B). Reliability of these parameters being±5 days, IA could be done if measurements are respectively less than 90mm for CRL and less than 30mm for BIP (Professional consensus). A medical IA performed with a dose of 200mg mifepristone combined with misoprostol is effective at any gestational age (EL1). Before 7 weeks, mifepristone followed between 24 and 48hours by taking misoprostol orally, buccally sublingually or eventually vaginally at a dose of 400 ug possibly renewed after 3hours (EL1, grade A). Beyond 7 weeks, misoprostol given vaginally, sublingually or buccally are better tolerated with fewer side effects than oral route (EL1). It is recommended to always use a cervical preparation during an instrumental abortion (Professional consensus). Misoprostol is a first-line agent for cervical preparation at a dose of 400 mcg (grade A). Aspiration evacuation is preferable to curettage (grade B). A perforated uterus during an instrumental suction should not be considered as a scarred uterus (Professional consensus). IA is not associated with increased subsequent risk of infertility or ectopic pregnancy (EL2). The pre-abortion medical consultations does not affect, most of the time, the decision to request an IA. Indeed, a majority of women is quite sure of her choice during these consultations. Acceptability of the method of IA and satisfaction appears to be larger when they are able to choose the abortion method (grade B). There is no relationship between an increase in psychiatric disorders and IA (EL2). Women with psychiatric histories are at increased risk of mental disorders after the occurrence of an UPP (EL2). In case of instrumental abortion, oral estrogen-progestogen contraceptives and the patch should be started from the day of the abortion, the vaginal ring inserted within 5 days of IA (grade B). In case of medical abortion, the vaginal ring should be inserted within a week of taking mifepristone, oral estrogen-progestogen contraceptives and the patch should be initiated on the same day or the day after taking prostaglandins (grade C). In case of instrumental abortion, the contraceptive implant may be inserted on the day of the abortion (grade B). In case of medical abortion, the implant can be inserted on the day of mifepristone (grade C). The copper Intrauterine Device (IUD) and levonorgestrel should be inserted preferably on the day of instrumental abortion (grade A). In case of medical abortion, an IUD can be inserted within 10 days following mifepristone after ensuring by ultrasound of the absence of intrauterine pregnancy (grade C). CONCLUSION: The implementation of these guidelines may promote a better and more homogenous care for women requesting IA in our country.

[Sperm hyperactivated motility: influence of the capacitation medium]. / Cinétique spermatique d'hyperactivation: influence du milieu de capacitation.

OBJECTIVE: Hyperactivation-associated motility is an important marker of capacitation and a prerequisite to fertilization. Computer-Assisted Sperm Analysis (CASA) is a reproducible method that can be used to predict fertilization success, in addition to the migration and survival test. However, published data are contradictory and preparation methods are heterogeneous. Changing one element in the sperm preparation (capacitation medium) may alter its kinetic parameter values. MATERIAL AND METHOD: This prospective study with two paired series was performed on sperm considered as normal. The sperm preparation was identical up to the second centrifugation, and there after the centrifugate was divided into two groups and suspended either in the capacitating medium Upgraded B2 INRA Medium(R), or in Ferticult Flushing Medium. Measurements were carried out with a Hamilton Thorne Research Analyzer (IVOS v10.9i). RESULTS: The analysis of the 87 sperm samples included in the study showed differences between the averages of Straight Line Velocity (SLV, p=0.02), Curvilinear Velocity (CLV, p<0.0001), Amplitude of Lateral Head Displacement (ALH, p<0.0001), and algorithmic calculation of the examined hyperactivation (Hyper 5, p<0.0001). CONCLUSION: The diagnostic validity of hyperactivation motility cannot be dissociated from the preparation conditions. A standardised preparation is a prerequisite for scientific evaluation and validation of this technique. Although higher motility characteristics seem to be desirable in a therapeutic environment, results will have to be validated by clinical tests.

[Delayed versus immediate pushing in the second stage of labor for nulliparous parturients with epidural analgesia: a meta-analysis of randomized trials]. / Poussée retardée versus poussée immédiate lors de la seconde phase du travail chez les nullipares sous anesthésie péridurale.

OBJECTIVES: The main object of this study was to evaluate the effect of delayed pushing on the second phase of delivery and the second one was to analyze the maternal and fetal consequences. MATERIAL AND METHOD: This was a meta-analysis of randomized prospective studies. The inclusion criteria were nulliparous women with epidural analgesia, singleton cephalic presentation at term and a spontaneous or induced labor. RESULTS: There was a significant increase in the number of spontaneous deliveries when pushing was delayed (p=0,019). On the other hand, no significant difference could be found in the incidence of perineal trauma (p=0,64). Post-partum hemorrhage and maternal fever could not be accurately evaluated because of insufficient data in the selected publications. Concerning the neonatal outcomes, the criteria for evaluation were too heterogeneous for analysis. CONCLUSION: In nulliparous parturients under epidural analgesia the fetal descent must be respected, so long as the fetal heart rate is unremarkable, in order to increase the probability of a spontaneous delivery, without apparent adverse consequences for the mother or the neonate.

Experimental therapeutic studies of Solanum aculeastrum Dunal. on Leishmania major infection in BALB/c mice.

OBJECTIVES: Solanum acueastrum Dunal. has been shown to have some chemotherapeutic value. Leaf and berry water and methanol compounds of S. acueastrum were evaluated for possible antileishmanial activity In vivo on BALB/c mice and in vitro against Leishmania major promastigotes, amastigotes and vero cells. MATERIALS AND METHODS: Dry S. aculeastrum berry and leaf material were extracted in methanol and water. L. major parasites were exposed to different concentrations of S. aculeastrum fruit and leaf compounds and the IC50 on the promastigotes, percentage of infection rate of macrophages by amastigotes and the toxicological effect on vero cells were determined. BALB/c mice were infected subcutaneously with 1×10(6) promastigotes and kept for four weeks to allow for disease establishment. Infected mice were treated with fruit and leaf methanolic and water compounds, amphotericin B (AmB), and sterile phosphate buffered saline (PBS). RESULTS: Fruit methanol compound was most effective in inhibiting the growth of promastigotes with IC5078.62 µg/ml. Fruit water compound showed the best activity in inhibiting infection of macrophages by amastigotes. Fruit methanol compound was more toxic at Ld50=8.06 mg/ml to vero cells than amphotericin B. Analysis of variance computation indicated statistically significant difference in lesion sizes between experimental and control mice groups (P=0.0001). Splenic impression smears ANOVA indicated a highly significant difference in parasitic numbers between the experimental and the control groups (P=0.0001). CONCLUSION: The results demonstrate that compounds from S. aculeastrum have potential anti-leishmanial activities and the medicinal use of the plant poses considerable toxicity against dividing vero cells.

[Victims of sexual assault: a routine protocol for better management]. / Constats de violences sexuelles: rédaction d'un protocole d'accueil et mise en pratique.

Caring for victims of sexual assault is a difficult situation where the physician has to simultaneously evaluate the psychological impact and conduct a complete and precise physical examination. To make sure every step of the examination is completed and all samplings are done in the correct order by all physicians, it is useful to have a written routine protocol. We describe step-by-step management procedures for victims of sexual assault, taking into consideration the psychological aspect, the physical examination, the different samplings, and the different emergency treatments. Free download of the entire protocol, with the booklet containing examples of prescriptions, is available at http://www.agof.net/constatviol/.

[Microvolume dosage of lactate in cord blood for the evaluation of the neonatal well-being]. / Evaluation du bien-être néonatal par micro-dosage rapide des lactates au sang du cordon.

A preliminary experience about a new microvolume lactate meter (Lactate Pro) is reported from 200 consecutive term deliveries. Comparison between lactate and pH in umbilical artery revealed a significant negative correlation between the two variables (r=-0.0693; p<0.0001). For the diagnosis of acidosis (pH<7.15) a lactate cutoff value at 6 mmol/l had a sensitivity of 50% and a specificity of 92% in a population with a prevalence of 8%. The study also demonstrated a better correlation between the concentrations of lactate and the base excess from 44 cord blood samples in high risk deliveries (r=0.837; p<0.0001). A lactate value higher than 6mmol/L predicted a metabolic acidosis (BE>- 8 mmol/l) with a sensitivity of 50% and a specificity of 94% from a collective with a prevalence of 16%. Considering the simplicity of the method, lactate measurements in cord blood could be extended to all birth centers for a systematic evaluation of the fetal condition in combination with the APGAR score. According to the minimal sampling volume (5 microliter) and the better prediction of metabolic acidosis this new method could replace the determination of the pH on fetal scalp.