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Fertility Following Oral Contraceptives
Abstract & Commentary
By Alison Edelman, MD, MPH, Assistant Professor, Assistant Director of the Family Planning Fellowship, Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, is Associate Editor for OB/GYN Clinical Alert.
Dr. Edelman has served on an advisory board and as an Implanon® trainer for Schering-Plough and receives grant/research support from the Society for Family Planning.
Synopsis: Oral contraceptive use does not appear to adversely or beneficially affect fertility following discontinuation.
Source: Barnhart KT, Schreiber CA. Return to fertility following discontinuation of oral contraceptives. Fertil Steril 2009;91:659-663.
A review of any publication from 1960 to 2007 with the main outcome of time to fertility following oral contraceptive discontinuation was performed. Return to fertility within 12 months of oral contraceptive discontinuation was similar (72-94%) to fertility following discontinuation of intrauterine devices, progestin-only pills, condoms, and natural family planning. Additionally, fertility after prolonged use of cyclic oral contraception was not affected. Although the research is not extensive, continuous or extended dosing of oral contraceptives appears equivalent to cyclic dosing in regard to fertility return following discontinuation.
Fertility issues weigh heavily on the minds of most of our patients; whether they are trying to prevent it or pursue it. Women choosing reversible contraception want assurance that their fertility will be unaffected by their choice in contraceptive method — not an unreasonable expectation. Conflicting myths abound regarding fertility following the birth control pill, including that the pill causes infertility, improves fertility, a break from the pill is needed to retain fertility (only if you want to be pregnant NOW!), and even increases the likelihood of multiples. Most of the concern regarding pill-induced fertility impairment was generated from higher-dose pills and also from the use of pills in women with pre-existing menstrual dysfunction.1 Barnhart and Schreiber present a comprehensive evaluation of the literature regarding fertility following discontinuation of the birth control pill. In addition, they also specifically look at fertility following chronic pill use (1 year) and continuous-dosing (longer than 28 days of active pills). As the most popular form of contraception in the United States,2 it is important to reassure ourselves and our patients of the pill's reversibility and to dispel these myths.
This review reports the aggregate conception rates at 12 months following oral contraceptive (cyclic dosing) discontinuation as compared to discontinuation of other common contraceptive methods. Oral contraceptives were found to have very similar conception rates (72-94%) as compared to the levonorgestrel-releasing intrauterine device (75-79%), the copper intrauterine device (71-92%), and barrier methods (95%). In addition, the authors found several studies demonstrating no ill effects of chronic use of oral contraceptives on fertility. Although not statistically significant, one study even demonstrated increased fertility with 1-2 years of oral contraceptive use (97%) as compared to 6 months or less (84%).2 Finally, continuous and/or extended dosing of oral contraceptives has not been found to impair fertility. Now this review mainly focused on fertility over a 12-month period; however, they did mention that when looking at the first 3 months after oral contraceptive discontinuation there may be a slight delay in fertility.
We can continue to be reassured that oral contraceptives do not impair fertility even if used for an extended duration or if dosed continuously. "Taking a break" from oral contraceptives isn't a good plan unless a pregnancy is desired or a woman wants to/needs to switch birth control methods. That being said, oral contraceptives do not protect women from a major cause of infertility — chlamydia. Women and providers do not seem to be as concerned with one of the most common sexually transmitted diseases. An obscene number of opportunities are missed for testing (over 80%).3 Use your patient's concern regarding fertility issues to reassure her regarding her birth control, but also as an opportunity to discuss how to prevent, diagnose, and treat an actual cause of infertility.