Women Not Told About Need for Contraception After IVF Births

Becky McCall

June 29, 2021

The contraceptive needs of women who have had in vitro fertilization (IVF) pregnancies are real but are being overlooked, according to study data presented at the Royal College of Obstetricians & Gynaecologists (RCOG) Virtual World Congress 2021.

The interview-based study found that women report not being routinely informed about the chance of spontaneous pregnancy after IVF. "There is scope to follow-up with women after IVF…but information about the chances of spontaneous births and need for contraception isn't given," said lead researcher Annette Thwaites, MD, an academic clinical fellow and a senior registrar in Community Sexual and Reproductive Health at Kings College Hospital, London, UK.

"Fertility services, maternity services, and community services could all do more to give women information on contraception postnatally," Thwaites said.

"Even if a woman has had IVF previously, a woman shouldn't lose the right to plan the rest of her family," she added. "We need to stop shielding these women from the information they really do need."

Thwaites first came across the issue around contraception after IVF pregnancy while talking to new mothers in a postnatal ward for another study. Ward staff told her not to enter the rooms with women who had had IVF births, with the implication that these women would not need or want contraception.

With this in mind, Thwaites and colleagues aimed to better understand the contraceptive needs of women after successful IVF pregnancy to improve service delivery and prevent unplanned and rapid-repeat pregnancies after IVF.

The researchers interviewed 21 women who had spontaneous pregnancies after successful IVF. Participants were aged 35-50 years, the majority were White British, professional, married for at least 10 years, and living in nuclear families.

Of the spontaneous post-IVF pregnancies in these women, outcomes included single (11) and multiple live births (1 twin), miscarriage (1), ectopic (1) termination of pregnancy (1), and three ongoing pregnancies.  

After IVF pregnancy, most women said that they used no contraception or ineffective contraception and had never had a conversation around contraception after IVF.

The women also reported that spontaneous pregnancy was shocking and not universally welcomed, and interpregnancy intervals were often short.

In addition, comments by these women suggested certain aspects of the IVF experience reinforced their perceptions of subfertility. One is quoted as saying, "It seemed to be this big failure if you were having IVF." Another said, "It's bad enough that I'm having to conceive my baby like this."

An Unmet Need

In her 30 years of practice, Melanie Davies, MD, has seen many women who experience natural pregnancy after IVF. She agrees it is important to address these women's contraceptive needs, but stresses that it needs to be approached carefully.

"It can stir up sensitivities to discuss this issue after having an IVF pregnancy," said Davies, a consultant obstetrician and gynecologist at University College London Hospitals, London. "I think many women genuinely think that contraception after IVF just doesn't apply, but lots of women do have natural pregnancies after IVF. I think women do need this information, but we need to be aware of the sensitivities around this issue, so the way we deliver it is crucial."

Gwenda Burns, chief executive of the National Patient Charity Fertility Network UK, which supports people before, during, and after fertility treatment, agrees that the process leading up to a successful IVF birth can have lasting effects.

"Fertility struggles and going through fertility treatment can put an enormous strain on both physical and mental health and can have a long-lasting impact," Burns said when asked to comment on the new study.

"It is vital that patients receive the right support, guidance, and advice following treatment, including when natural conception may still be possible," Burns continued.

Growing Population

Given the increasing use of IVF in recent years, Thwaites said the importance of understanding and meeting the contraceptive needs of women post-IVF is increasingly important. Also, people are turning to it earlier and for other reasons such as women in same sex relationships, single women, pre-implantation genetic testing, and surrogates.

"During the recruitment process for the current study, I came across women who said since their IVF pregnancies they had no idea what they should do about contraception," Thwaites said.

But she empathizes with healthcare professionals too. "I genuinely feel that healthcare professionals just don't know how to advise women in this setting, so they avoid the topic of contraception altogether with these women. They are concerned about making women feel awkward or upsetting them. In my experience, there is very little said about IVF and contraception in the same breath."

Women Believe Subfertility Always Persists After IVF

Among participants in the study, the causes of the women's subfertility were wide-ranging and included tubal, anovulatory, male factor, joint, and unexplained, the latter of which affects 25% of couples with fertility issues. In the cohort, women had taken up to 9 years to conceive their first child and one had a donor egg conception.

After IVF, the chance of pregnancy will depend on the reason for the couple's subfertility. "Given that a huge number of patients these days have unexplained subfertility. This is when there is no absolute cause of infertility identified and it might not prevent a pregnancy but slows it down," Davies told Medscape Medical News. "Such couples still have a chance of natural pregnancy."

Polycystic ovary syndrome as a cause of subfertility is often associated with improvement in fertility after IVF, Davies noted. "This can improve after a spontaneous pregnancy or after IVF, even if the IVF is not a success, and this is possibly due to needling the ovary."

Thwaites added that challenging women's perceptions of their subfertility is critical if headway is to be made on this topic. Many women have persistent views concerning their subfertility after successful IVF, which may be rooted in previous failed treatment; need for repeat cycles or intracytoplasmic sperm injection (ICSI); low numbers of eggs collected; poor quality embryos; and pregnancy complications, to note some of the most common reasons.

"So many [women] feel that they are very lucky to have had a pregnancy because their journey has been difficult. They might have had a successful pregnancy but they still hold a sense of personal failure," said Thwaites. "Even after spontaneous pregnancy some women said it was a miracle or freak event. [Yet two of these] women had two spontaneous pregnancies."

Remarkably, even after subsequent spontaneous pregnancy, use of contraception and the most effective methods remained low among participants.

As well as fixed beliefs concerning their subfertility, other barriers to contraception use included a lack of knowledge of likelihood of spontaneous pregnancy; lack of contraceptive experience; and inherent incentives towards shorter interpregnancy intervals (eg, the convenience and privacy of undergoing further IVF while still on maternity leave and availability of frozen embryos).

Looking ahead, Thwaites says there is a clear need to link and/or expand the maternity services dataset to uncover the true rates of post-IVF spontaneous pregnancy.

Thwaites and Davies have disclosed no relevant financial relationships.

RCOG Virtual World Congress 2021. Poster: Contraception after In Vitro Fertilisation. Annette Thwaites, Jennifer Hall, Geraldine Barrett and Judith Stephenson. Presented June 9-12, 2021.

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