Safety of insertion of the copper IUD and LNG-IUS in nulliparous women: a systematic review.

OBJECTIVE: Intrauterine contraception (IUC) is one of the more effective contraceptive methods for women at highest risk of unintended pregnancy. This includes younger, often nulliparous, women; however, uptake has been relatively low in this group. METHODS: In February 2017 we conducted a systematic review of randomised controlled trials, prospective and retrospective observational studies to identify barriers to IUC use in nulliparous women. RESULTS: Study quality was poor. No differences in rates of infection or expulsions between nulliparous and parous were seen. Fertility rates following removal appeared no different from the general population. Higher rates insertion difficulty, insertion failure and pain during insertion were observed in nulliparous women. CONCLUSION: A long-acting reversible contraceptive method such as IUC reduces the risk of unintended pregnancy since user failure is minimised. Evidence-based information about the advantages and disadvantages of IUC is required to inform decision-making and dispel any myths and misperceptions. Potential barriers to IUC use in nulliparous women, particularly concerns around infection, significantly higher rates of device expulsion and adverse effects on fertility, do not appear to be justified. IUC is appropriate for all medically-eligible women, including nulliparous women, and should be included in the range of contraceptive options discussed during counselling.

Current barriers and potential strategies to increase the use of long-acting reversible contraception (LARC) to reduce the rate of unintended pregnancies in Australia: An expert roundtable discussion.

BACKGROUND: Australia's abortion rates are among the highest in the developed world. Efficacy of the most commonly used form of contraception (oral contraceptives and condoms) relies on regular user compliance. Long-acting reversible contraception (LARC) virtually eradicates contraceptive failure as it is not user-dependent; however, its uptake has been low. AIM: To provide an overview of barriers to LARC use in Australia and potential strategies to overcome these barriers. METHOD: A roundtable of Australian experts was convened to share clinical perspectives and to explore the barriers and potential strategies to increase LARC use. RESULTS: Three broad barriers to LARC uptake were identified. (i) A paucity of Australian research exists that impedes closure of evidence gaps regarding contraceptive prescription and use. Systematic data collection is required. (ii) Within primary care, lack of familiarity with LARC and misperceptions about its use, lack of access to general practitioners (GPs) trained in LARC insertion/removal and affordability impede LARC uptake. Potential strategies to encourage LARC use include, GP education to promote informed choice by women, training in LARC insertions/removals, effective funding models for nurses to perform LARC insertions/removals, and rapid referral pathways. (iii) At the health system level, primary care incentives to provide LARC to women and health economic analyses to inform government policy changes are required. CONCLUSIONS: Although LARC decreases unintended pregnancies by eliminating user compliance issues, its uptake is low in Australia. Strategies that promote LARC uptake by targeting specific barriers may effectively reduce Australia's high unintended pregnancy rate.

Risk of venous thromboembolism in women taking the combined oral contraceptive: A systematic review and meta-analysis.

BACKGROUND: Much scientific, media and patient interest surrounds the risk of venous thromboembolism (VTE) in women taking combined oral contraceptives (COCs). OBJECTIVE: We conducted a systematic review and meta-analysis to assess VTE risk in women taking COCs, focusing on drospirenone. METHODS: Literature searches of clinical studies on COCs in which VTE was reported were undertaken in May 2015. No overall estimate of VTE risk between drospirenone-containing COCs and other COCs was produced because of heterogeneity of the study designs. RESULTS: The final review and meta-analysis included 15 studies. No increased risk of VTE with drospirenone was seen in prospective or case control studies, but the risk of VTE was increased in retrospective cohort and nested case control studies. DISCUSSION: The difference in risk of VTE based on the choice of progestin in COCs is, at worst, very small in absolute terms and should not be the sole factor considered when choosing the 'right' COC for each woman.

The success rate of IVF has significantly improved over the last decade.

AIM: To demonstrate that success rates with in vitro fertilisation (IVF) have been improving despite decreasing the number of embryos transferred. MATERIALS AND METHODS: This was a retrospective cohort study comparing live birth outcomes for women who started IVF between 2001 and 2005 with women who started between 2006 and 2010, using life table analysis to allow for the fact that women had differing number of cycles of treatment. The data were obtained from a single IVF centre, Monash IVF Geelong, Victoria. The 2001-2005 cohort consisted of 233 women, and the 2006-2010 cohort consisted of 453 women who started IVF between the specified dates. The main outcome measure was a live birth. Life table analysis was used to estimate the cumulative probability of a live birth after each cycle. RESULTS: The estimate of cumulative live birth probability demonstrated that the chance of a live birth by cycle five was 75.8% in the 2001-2005 cohort, which significantly increased to 80.1% by cycle five in the 2006-2010 cohort (P = <0.05). There was a mean of 1.8 embryos transferred per embryo transfer in the 2001-2005 cohort, which decreased to a mean of 1.3 embryos transferred per embryo transfer in the 2006-2010 cohort. This was associated with a significant decrease in the multiple birth rate from 24.7% in the 2001-2005 cohort to 7.5% in the 2006-2010 cohort. CONCLUSION: The IVF success rate has significantly improved despite the number of embryos transferred being reduced. This study provides further support for elective single embryo transfers.

Transfer of a selected single blastocyst optimizes the chance of a healthy term baby: a retrospective population based study in Australia 2004-2007.

BACKGROUND: The practice of single embryo transfer (SET) is highly accepted by clinicians in Australia. This study investigates whether the SET of blastocysts results in optimal perinatal outcomes. METHODS: This retrospective population-based study included 34 035 single or double embryo transfer cycles in women who had their first fresh autologous treatment in Australia during 2004-2007. Pregnancy, live delivery and 'healthy baby' (live born term singleton of > or = 2500 g birthweight and survived for at least 28 days without a notified/reported congenital anomaly) rates per transfer cycle were compared in four groups: selective single embryo transfer (SSET), unselective single embryo transfer (USSET), selective double embryo transfer (SDET) and unselective double embryo transfer (USDET). Live delivery and 'healthy baby' rates per transfer following SSET were further compared by number of embryos available. The analysis was stratified by woman's age and stage of embryo development. RESULTS: The highest rates of live delivery and 'healthy baby' per transfer cycle (46.2 and 38.0%) were achieved with transfer of a single blastocyst in women aged younger than 35 years. In women aged younger than 40 years, SSET had a significantly higher rate of 'healthy baby' per transfer cycle than did SDET regardless of stage of embryo development. In woman aged younger than 35 years who had SSET, there was no significant difference in live delivery and 'healthy baby' rates per transfer cycle whether two, three, four or five embryos were available. For all of these women, SSET of a cleavage embryo had significantly lower rates of live delivery and 'healthy baby' per transfer cycle compared with SSET of a blastocyst where only two blastocysts were available. CONCLUSIONS: Consultation with the patient with respect to the advantage of extended culture and selective single blastocyst transfer will result in better success rates following assisted reproductive technology treatment in Australia.

Management of the infertile couple.

BACKGROUND: With the further development of reproductive technology over the past 2 decades, options for subfertile couples have greatly increased. OBJECTIVE: This article discusses the assessment of common male and female causes of infertility and describes a logical routine for the investigation and treatment of the subfertile couple using a flow chart approach. DISCUSSION: We suggest an approach to assessment for general practitioners, and outline the likely course of more sophisticated testing and treatments that their patients may then experience.

Incidence of polycystic ovaries and polycystic ovary syndrome amongst women in Melbourne, Australia.

BACKGROUND: The incidence of polycystic ovaries (PCO) in the Australian population is unknown. AIMS: To determine the incidence of PCO in a random population of Melbourne women. METHODS: A retrospective survey of the transvaginal ultrasound of female partners of sterile males was undertaken. RESULTS: Twenty-three percent of subjects had polycystic ovaries on ultrasound criteria, 17% bilateral and 6% unilateral. CONCLUSIONS: The incidence of PCO in Australian women is similar to that of other Caucasian populations.

Preliminary report: Correct diagnosis of sex in fetal cells isolated from cervical mucus during early pregnancy.

The aim of this study was to determine the accuracy of sexing fetal cells isolated from cervical mucus. Immunopositive cells identified using a fetal-specific antibody were isolated and subjected to genetic analysis. Fetal sex was predicted in all 22 samples, as confirmed by analysis of the corresponding placental tissue. This study validates the accuracy of our test for sex diagnosis and confirms the ability to effectively recover and analyse fetal cells from the cervical mucus during early pregnancy.

Replacement of one selected embryo is just as successful as two embryo transfer, without the risk of twin pregnancy.

The transition of in vitro fertilization from research to standard clinical practice has, to a great extent, been as a result of the use of controlled ovarian hyper stimulation. A disadvantage of the availability of multiple embryos has been the replacement of several embryos leading to an epidemic of multiple pregnancies. This retrospective review of 2606 fresh embryo transfers between 2001 and 2003, where either one or two selected embryos were replaced from an available cohort of at least four, shows that single embryo transfers have a similar pregnancy rate without the risk of multiple pregnancy.