• Mohamed Badaou

Does contraception impact my fertility?

If you’ve got ovaries and are over 16, chances are pretty high that you’re on some sort of contraception. Almost 70% of sexually active women between 16 and 49 in the Netherlands use some form of contraception. The most common form of contraception is the pill (including the injectable form, Depo-Prova), after which comes the intrauterine device (IUD) and in third place, the condom. The least used methods of contraception are a pessary and natural methods of contraception (also known as, the pulling out method). (1, 2)

As you can see, a lot of different methods are used, some with hormones and others without, but do you also know how these different methods affect your fertility? I certainly did not know this, which is why I started looking for answers. Think of this blog post as your – no nonsense, no medical lingo – scientific guide that helps you understand the effect of different forms of contraception on your fertility.


Good to know: in this blog post I divide the contraceptives in two groups: hormonal (the pill, the Mirena / Kyleena IUD, implantable-rod) and non-hormonal contraception (sterilisation, natural methods).


Part 1: Hormonal contraception

Oral contraception

Oral contraception is best known as the pill. This form of contraception is one of the most commonly used methods. There are two forms of the pill, the difference between the two lies in the hormones that are used:

  1. Progesterone and estrogen, or;

  2. Progesterone only (commonly known as the mini pill)

Although stories often circulate that the pill would make you less fertile, research actually shows a different pattern. In a study that followed 60,000 women with an active desire to have children who had previously used the pill, about 13-20% of women got pregnant during their first menstrual cycle after stopping the pill, depending on the age. After a year, 60-80% of the women who stopped taking the pill were pregnant (3). It also seems to be the case that women who have used oral contraception for at least 7 years seem to be more fertile than women who have used the pill for 2 years (4). It is still unclear which factors actually caused these women to be more fertile.


Hormonal IUD

The first hormonal IUDs were made in the 1970s, ten years after the first copper IUD was invented (5). The two most well-known and most commonly used hormonal IUDs are the Mirena and Skyla. Both contain levonorgestrel (a hormone related to progesterone). The main difference between Mirena and Skyla is the fact that the Skyla contains less levonorgestrel. This allows the Skyla to be used up to 3 years after insertion, while the Mirena can last up to 7 years. To date, it is not yet clear how an IUD exactly works. Which is absolutely mindblowing to me.


Although the exact mechanism is not known, these IUDs are thought to work in two ways:

  1. By thickening your cervix(6);

  2. Preventing fertilization of your eggs (7)

A 1989 study followed women with an active desire to have children after taking out their IUD and tracked how long it took someone to conceive. This was found to take an average of 4.4 months. After 12 months, about 93% of women had become pregnant. (8)


Another 2015 study found the same relation, in this research women with an IUD were compared to women who did not use an IUD. This study showed that there was no significant difference between the groups. The pregnancy rates after 12 months were virtually the same. However, in this study there were only 17 women who had a hormonal IUD. So because of the small number of women who participated, the evidence of this study is limited. (9)


Implant

The first implant was released in 1983 and has since changed in shape a few times. From 6 rods, to 2 rods, to a single rod. The present version of the implant contains the hormone etonogestrel (progesterone) and is inserted under the skin on the inside of your non-dominant upper arm. After insertion, the implant can continue to work for up to 5 years.


After the implant is taken out, fertility often returns quickly. A 2002 study showed that in most cases, your cycle returns within 3 months. The research also shows that a large proportion of women who remove the implant become pregnant within a year. However, the percentages of women who become pregnant within 12 months of the implant removal differ greatly (76-100%). (10) Another study in which 24 Indian women discontinued the implant showed that about 30% became pregnant within 3 months, 67% within 9 months and 96% within 12 months (11).


The injectable pill (Depo-Prova)

This is a form of birth control that works in the same manner as the oral pill, except you don’t have to think about taking a pill in every day. Instead, you either have to inject yourself every three months or go to the doctor.


Of all forms of contraception, this method has the longest lingering effect. A study involving more than 18,000 women found that after stopping with Depo-Prova, it took at least 5 cycles for the menstrual cycle to get back on track. There were no long-term effects on your fertility based on this research. (12)


Table 1. Summary: average time of fertility return(12)

Part 2: Non-hormonal contraception

Sterilisation

If you're sure you don't want to get pregnant anymore, you can get yourself sterilized at a doctor. An advantage of sterilisation is that you only have to do this once. An important disadvantage is that in many cases you can't reverse this. Once you're sterilised, there is now way of fully going back. (13)


Female sterilisation can be achieved through three different methods

  1. Removing your fallopian tubes

  2. Clenching your fallopian tubes with special rings

  3. Scarring your fallopian tubes with electric current

Because the fallopian tubes are either damaged or removed, the eggs can no longer reach the uterus. Also, the sperm can no longer get to the eggs and therefore no fertilisation can take place.


After sterilization, a woman is generally not fertile anymore, but in some cases women are still able to become pregnant. This happens to 5 out of 1,000 women.


Copper IUD

The copper IUD is a variant of the hormonal IUD, only without the hormones. The copper in the IUD functions as a toxic material against the sperm cells. The effect of the copper IUD on your fertility is no different than the hormonal spiral. Research shows that women who have had an IUD became pregnant as quickly and easily as women who have not had an IUD (14).


Periodic abstention

This category is a collection of all natural ways of contraception, think of tracking your fertile days or measuring your temperature. These methods are becoming increasingly popular through the usage of different apps (think: Natural Cycles & Daysy)

Because these methods are natural and therefore not affected by hormones, your fertility is not negatively affected.


Although non-hormonal contraception is not the first thing you think about when hearing contraception, they are becoming increasingly popular. Some forms are permanent and others are temporary. Fortunately, there is plenty to choose from if you want to use contraception.

References

  1. Geboorteregeling; anticonceptiemethode en leeftijd van de vrouw, 1993-2013 [Internet]. Opendata.cbs.nl. 2020 [cited 26 December 2020]. Available from: https://opendata.cbs.nl/#/CBS/nl/dataset/37459/table

  2. NHG Richtlijn Anticonceptie [Internet]. Richtlijnen.nhg.org. 2020 [cited 26 December 2020]. Available from: https://richtlijnen.nhg.org/standaarden/anticonceptie#volledige-tekst-figuur1

  3. Cronin M, Schellschmidt I, Dinger J. Rate of Pregnancy After Using Drospirenone and Other Progestin-Containing Oral Contraceptives. Obstetrics & Gynecology. 2009;114(3):616-622.

  4. Mikkelsen E, Riis A, Wise L, Hatch E, Rothman K, Toft Sorensen H. Pre-gravid oral contraceptive use and time to pregnancy: a Danish prospective cohort study. Human Reproduction. 2013;28(5):1398-1405.

  5. Thiery M. Pioneers of the intrauterine device. The European Journal of Contraception & Reproductive Health Care. 1997;2(1):15-23.

  6. Sivin I, Stern J, Coutinho E, Mattos C, El Mahgoub S, Diaz S et al. Prolonged intrauterine contraception: A seven-year randomized study of the levonorgestrel 20 mcg/day (LNg 20) and the Copper T380 Ag IUDS. Contraception. 1991;44(5):473-480.

  7. Hatcher R. Contraceptive technology. 2011.

  8. Gupta B. Return of fertility in various types of IUD users. International Journal of Fertility. 1989;34(2).

  9. Ortiz M, Croxatto H. Copper-T intrauterine device and levonorgestrel intrauterine system: biological bases of their mechanism of action. Contraception. 2007;75(6):S16-S30.

  10. Glasier A. Implantable contraceptives for women: effectiveness, discontinuation rates, return of fertility, and outcome of pregnancies. Contraception. 2002;65(1):29-37.

  11. Bhatia P, Nangia S, Aggarwal S, Tewari C. Implanon: Subdermal Single Rod Contraceptive Implant. The Journal of Obstetrics and Gynecology of India. 2011;61(4):422-425.

  12. Yland J, Bresnick K, Hatch E, Wesselink A, Mikkelsen E, Rothman K et al. Pregravid contraceptive use and fecundability: prospective cohort study. BMJ. 2020;:m3966.

  13. Ik denk na over een sterilisatie (vrouw) | Thuisarts [Internet]. Thuisarts.nl. 2020 [cited 26 December 2020]. Available from: https://www.thuisarts.nl/sterilisatie-bij-vrouw/ik-ben-vrouw-en-overweeg-sterilisatie

  14. Stoddard A, Xu H, Madden T, Allsworth J, Peipert J. Fertility after Intrauterine Device Removal: A Pilot Study. The European Journal of Contraception & Reproductive Health Care. 2015;20(3):223-230.

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