ABSTRACTS OF INVITED SPEAKERS

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Acknowledgements: Support for the development of The Population Council CVRs has been received from USAID, NICHD, BMGF, IPM, CONRAD, UNFPA, WHO.

IS-22 Availability and accessibility of contraception in Europe

B. Pinter

Division of Ob/Gyn, University Medical Centre Ljubljana, Ljubljana, Slovenia

Objective(s): Effective contraceptive utilisation is influenced by many factors on the micro level (patient, provider) and macro level (health system and political/legal framework). Availability refers to whether the method is present on the market; it is influenced by the socio-economic system and legal and political framework of the country. Accessibility describes how a patient can get the method and what are the costs; it is influenced by the health politics and health system of the country (e.g., reimbursement) and by the professional status and competency of the provider. Availability and accessibility of contraception in Europe are presented.

Design and methods: The data were derived from The Reproductive Health Report (The state of sexual and reproductive health within the European Union), reports from professionals in particular countries, and from searches of medical literature.

Results: In the majority of countries, contraception is allowed, and not prohibited by law. But, in some countries sterilisation of healthy women or men is restricted below a certain age limit. In most countries hormonal emergency contraception is available (exceptionally not), often accessible over the counter (OTC) in pharmacies , rarely free of charge. Different hormonal contraceptives are more or less presented on the markets, mainly prescribed by mandatory prescription by the physicians, rarely by trained nurses or midwives. The reimbursements for hormonal contraception vary from none to full reimbursement, or reimbursement only for therapeutic indications such as acne. Intrauterine devices (IUDs) are available in most countries and mainly accessible via- and prescribed by physicians; IUDs are reimbursed in some countries; more often hormone releasing-intrauterine systems are reimbursed for medical conditions. Regarding the barrier methods, in some countries female condoms, diaphragms and spermicides are not/no longer on the market. The competence of a provider, as an important factor influencing the accessibility of contraception, was difficult to assess. Namely, the competence is not only evident in the traditional role of the provider (physician) as a medical expert, but also in a role as communicator, collaborator, manager, health advocate, scholar and professional (by CanMEDS).

Conclusions: Availability and accessibility of contraception in Europe differ from country to country and are influenced by several background factors.

IS-23 The role of policies in the area of sexual and reproductive health in accelerating progress in improving access and quality of services

G. Lazdane

WHO Regional Office for Europe

Following the International Conference on Population and Development (ICPD) in Cairo in 1994, many countries developed national sexual and reproductive health policies based on the analysis of needs and the human rights principle. Some of them defined concrete goals and objectives, but only a few included ways of monitoring the progress in the implementation of these national policy documents.

More than 15 years have passed and soon, in 2015, the global community will evaluate the achievements of the implementation of the Programme of Action of ICPD and Millennium Declaration. This leads to the question as to whether international and national strategies and action plans have influenced practices in family planning and contraception use and whether they have played a role in improving the sexual and reproductive health.

In 2004, more than 190 countries represented by ministries of health approved the Global Reproductive Health Strategy. Every two years the World Health Assembly discusses the progress made, based on the results of answers to a questionnaire sent by the WHO Secretariat to Member States to evaluate the impact in five core areas of the strategy: (1) improvement of maternal and perinatal health, (2) family planning and (3) sexual health, (4) prevention of unsafe abortions and (5) sexually transmitted infections including HIV and cervical cancer. The impact of the global and national reproductive health strategies differs between countries.

Most of the 53 countries in the WHO European Region have revised or developed national policies, but a quarter of those whose representatives replied to the questionnaire do not have comprehensive national reproductive health policies, but focus more on prevention of HIV or cervical cancer. Less than half have national committees or task groups that monitor implementation of their national reproductive health strategies or progress towards the Millennium Development Goals including the achievement of target 5B ‘universal access to reproductive health’. One of the conclusions is that professional societies and civil-society organisations have an important role in ensuring that policies are developed based on the analysis of the needs of population, including different age and social groups. Health professionals are the best informed, but their knowledge has to be summarised and linked with monitoring of the implementation of the national strategies and action plans and revision of their priorities or methods of achievement.

IS-24 Clinical practice: Who, what and how? The Swedish model

C. Zätterström

Family planning clinics and Youth Clinics in SLSO South-West of Stockholm, Sweden

Historical retrospect: In the beginning of the 1960s, combined contraceptive pills were introduced in Sweden like in many other countries. Before the pill, family planning mainly consisted of using condoms and diaphragms. Since 1948, midwives at Maternity Care centres were obliged by the parliament to assist women in fitting the diaphragms free of charge. At that time the demand for a liberalised abortion law increased. In 1974, the new Swedish Abortion law was introduced which entitled women to have a pregnancy terminated on request until the end of the 18th week of pregnancy. Before this new law was implemented in 1975 there was a huge concern about a possible rapid increase of abortions. How could this be prevented? As midwives were involved in family planning since 1948, it was not totally strange to make them responsible for contraception counselling in an attempt to make it easily accessible to all women. RFSU, a NGO like IPPF, supported this reform and started educating midwives. Since 1972, a midwife has the right to give contraceptive counselling. In 1970, the first Swedish Youth Clinic started.

Aim: To describe contraceptive counselling – the Swedish model.

Who: In Sweden we have a long tradition of cooperation between gynaecologists/obstetricians and midwives. The midwife will take care of the healthy woman's normal pregnancy and childbirth while obstetricians will be responsible for the unhealthy women and everything abnormal. In practice, the midwife will counsel healthy women about contraception whereas women with health disorders are referred to the gynaecologist.

We have Youth Clinics almost all over the country. The staff consists of social workers, midwives, doctors and sometimes psychologists. The Youth Clinics are open to all young people from the age of 13 up to 20–23. Women over the age of 20–23 mainly come to the antenatal-family planning clinics for contraceptive counselling. The first caregivers at both the Youth Clinic and the family planning clinic are midwives. In Sweden midwives also are responsible for the Pap smear-testing among women aged 23–60 years.

What: Contraceptive counselling given by midwives includes prescription of hormonal contraceptives, insertion of IUDs and subdermal implants, fitting of diaphragms and talking about and giving out condoms. The midwife will also offer STI-testing.

How: Most members of staff at the primary health clinics have been trained in Motivational Interviewing (MI). Motivational interviewing is a client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

The primary health clinics are usually only open from Monday to Friday. Most have drop-in consulting, some daily and some only once a week. The overall goal is that all women should be able to get an appointment within a week.

Discussion: Advantages/disadvantages of the Swedish model; abortion rate; the link between midwives-gynaecologists at the primary care units; midwives as researcher and research consumers; the lack of monitoring; the role of media; sex education in schools.

IS-25 The ‘big five’. Learning from the Dutch Sexual Health Promotion Programme

W.L. Gianotten

The Netherlands

Originally, sexual health was described as a condition without the disturbance of undesired pregnancy and STI. Organisations promoting sexual health usually were concerned with only one of those areas. When hormonal contraception became widely available in the Netherlands, the Dutch pragmatic attitude led to the rejection of abstinence-based- and fear-based sex education. As a result, the Netherlands had much lower undesired pregnancy rates and abortion rates than most other Western countries.

When in the 1980s, next to STIs and pregnancy, sexual abuse was ‘discovered’, new stakeholders entered the arena of sexual health. But those three areas were not integrated, and neither was their financing. In the last decades, ongoing investment in sexual health promotion caused gradual changes based on three different aspects: the scientific base, widening of the scope and integrating the various topics.

(1) The scientific base: The pragmatic and relative liberal attitude in the Netherlands allowed us to scientifically approach the health promotion aspects in the area of MSM (men who have sex with men) and HIVAIDS. That gradually resulted in the theory- and evidence-based development of ‘Intervention Mapping’. This is a protocol for effective behaviour change interventions in (sexual) health promotion.

(2) Widening of the scope: After undesired pregnancy and STIs, sexual abuse was the third major area of concern in sexual health promotion. Although still a ‘negative topic’ (i.e., ‘something to be prevented’), health promotion on the subject of sexual abuse can carry ‘positive elements’ (in the form of respect for self and other). Change ‘to the positive’ is more present in the fourth topic: homophobia. Next to aspects of prevention, there is more room here for ‘positive messages’ concerning accepting diversity. The fifth major topic is pleasure. Not only an important (and frequently not addressed) element, but also a strong motivator to reach groups with unmet needs, especially adolescents. So the ‘preventing unhealth’ is increasingly overtaken by ‘promoting health’.

(3) Integrating the various topics: Proper sexual health education should integrate attention for each of these five elements: Pregnancy, STI, sexual abuse, diversity and pleasure.

This government-sponsored move from Sex Education to Sexual Health Education apparently is the reason that, in happiness research, Dutch youngsters are found to be the happiest of all.

IS-26 Noncontraceptive benefits of permanent contraception

L.P. Shulman

The Anna Ross Lapham Professor in Obstetrics and Gynecology, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA

The non-contraceptive benefits of reversible and highly effective hormonal and intrauterine contraceptives have been well described and are generally recognised and taken into consideration, along with the inherent risks of these techniques, when contraception is provided. However, the non-contraceptive benefits of permanent sterilisation techniques are not as well recognised and are frequently minimised in the wake of the fundamental principle of permanent sterilisation, which is to prevent pregnancy in sexually active women or men who no longer wish to procreate. With regard to permanent male sterilisation (vasectomy), there do not appear to be any non-contraceptive health benefits associated with vasectomy except for some positive impact in sexuality, likely the result of reduced anxiety concerning pregnancy. Extensive studies have shown that vasectomy has no untoward health effects including heart disease, prostate or testicular cancer, immune complex disorders, impotence or other sexual difficulties, or other pathophysiological conditions. Current approaches to female sterilisation include tubal-disruptive (e.g., Filshie Clip, Falope Ring, Pomeroy procedure) and tubal-occlusive (e.g., Essure, Adiana) techniques. There is essentially no information on the non-contraceptive benefits of the tubal-occlusive techniques; accordingly, the clinical effects presented here are associated solely with tubal-disruptive techniques.

Similar to male sterilisation techniques, there appears to be no overall detrimental effect on female sexuality, with some evidence of a positive effect on sexuality, again likely the result of reduced anxiety concerning unintended pregnancy. However, unlike male sterilisation techniques, tubal-disruptive techniques have been shown to be associated with noncontraceptive benefit; specifically, a considerably reduced risk of ovarian epithelial cancer (OEC). Originally presumed to be the result of a reduction in blood supply to the ovaries, recent information concerning the tubal origin of ‘ovarian’ cancer, especially among the highest risk women (those who carry a BRCA1/2 mutation), indicates that the actual disruptive effect on the tube is likely the source of the consistent reduction in OEC among all women of all risk categories. As with vasectomy, studies have found no adverse effects on women's health resulting from tubal-disruptive techniques, including menstrual abnormalities and the onset of menopause. Consideration of permanent contraception must first and foremost be for those who no longer desire to have children. However, women will also gain a profound reduction in the risk for OEC if they choose a tubal-disruptive procedure to obtain that permanent contraception.

IS-27 Contraception during the reproductive life-cycle

T. Bombas¹, B. Pinter²

¹Obstetric Unit, Hospital Universitário de Coimbra, Coimbra, PortugalDivision of Ob/Gyn, University, ²Medical Centre Ljubljana, Slajmerjeva 3, 1000 Ljubljana, Slovenia

Background: In the reproductive life-cycle, the woman (and her partner) transit through different needs, opportunities and obstacles regarding contraception. Counselling must be adapted to the needs and expectations during the different phases of the life-cycle. In each phase, efficacy, safety, compliance, accessibility and availability of each contraceptive method determine its use.

Content: The reproductive life-cycle could be divided into adolescence, early adulthood, adulthood, postnatal period, premenopause and menopause. For each period the same questions arise, but the importance and weight of each one could vary. The questions for each period are expected to be answered by the participants of the workshop:

Sexual activity and behaviour in this period?

The risk of unwanted pregnancy in this period?

The risk of STIs in this period?

Options of contraception for this period?

Health risks of contraceptive use in this period?

Non-contraceptive health benefits in using contraception in this period?

Special needs in contraception in this period?

Barriers to accessibility of contraceptives in this period?

Compliance with contraceptive use in this period?

Continuation of contraceptive use in this period?

Possible reasons for less effective use of contraception in this period?

Conclusions: It is expected that the findings of the workshop will show the diversity of the needs and possible solutions for each period of life-cycle.

IS-28 Forum: Communicating about sexuality: A matter of fun or fear

O. Loeber¹, S. Reuter²

¹Rutgershuis Oost, Arnhem, the Netherlands, ²Contraception & Sexual Health Service, Nottinghamshire Community Health, Swansea, UK

Reproductive health, contraception, problems in the reproductive organs etc., are all related to sexuality and sexual activity. Women and men may step into your office with questions about this in mind without having the nerve to ask about it. In this forum we would like to discuss with all of you how and when you talk about sexuality in your office. For instance, when 14-year-old Anna comes for the pill, or Jamie, 23, who had 12 partners, comes for STI testing, Mrs Peterson, 45, has had a mastectomy for breast cancer, since then she complains of dyspareunia, Mr Davies, 53, does not like his anti-hypertensive medication or Mrs Jones, 54, who complains of frequent UTI.

Only few of us have been trained to do so and many of us may think this is not our duty. Even more debatable: should we, as professionals, address the fun part of sexuality? If we should do so, when is it appropriate and when intrusive? Many among the current generation of doctors, nurses and midwives have not been trained to talk about sexuality: we may talk in a very abstract way about coitus and dyspareunia, infertility, and sexually transmitted infections. Whether we are able to address sexuality in a natural way has a lot to do with our practice in talking about it. So aside of discussing the aspects of our daily work, we shall address the way sexuality education has been done, by whom and how it should be done, and how we should learn communicating about sexuality.

IS-29 Online abortion – safe or unsafe?

K. Guthrie¹, A. Verougstraete²

¹Hull and East Riding Sexual and Reproductive Healthcare Partnership, UK ²Sjerp-Dilemma – Dutch-speaking Free University of Brussels (VUB), Belgium

What are the potential risks?

Online pharmacies have popped up to sell ‘abortion kits’ online.

(1) There is no guarantee that the pills bought online have the proper composition.

(2) These online pharmacies have no helpdesk in case of problems.

(3) Medical risks: if women take the pills without knowing the duration of pregnancy, they could be confronted with heavy bleeding or dangerous complications.

(4) Abortion is reimbursed in a lot of European countries; online abortion could be more expensive.

(5) After the abortion, women will get no help to find a contraception that suits them.

(6) Abortion pills could be misused (administered to a woman who does not want an abortion.

Conclusion: We need to lift barriers so that women have an easy access to safe and legal abortion. Then women will not need risky online abortions.

IS-30 Vaginal hormonal contraception combined with new microbicides: A giant step or a myth?

R. Sitruk-Ware¹, B. Variano¹, D. Tolenaar¹, D. Weber²

¹Population Council New York, NY, ²International Partnership for Microbicides, Silver Spring, MD, USA

There is an urgent need, especially in less developed countries, to help women protect themselves against sexually transmitted infections, in particular HIV/AIDS, and to prevent unwanted or mistimed pregnancies. Several organisations are currently developing vaginal rings that deliver both levonorgestrel (LNG), a well-known contraceptive steroid, and an antiretroviral agent (ARV), including tenofovir, Dapivirine, or MIV-150. The feasibility of a LNG-contraceptive ring has been clearly demonstrated by previous clinical studies conducted by the WHO. The protective benefit of the antiretroviral agents against HIV has been demonstrated for some agents, in particular tenofivir in the CAPRISA 004 trial.

Contraceptive Research and Development (CONRAD) has developed a vaginal ring which delivers a low dose of levonorgestrel (LNG) and tenofovir (TFV) for at least 90 days. The Population Council in collaboration with the International Partnership for Microbicides, developed a combination vaginal ring releasing LNG and Dapivirine. The in vitro drug release from single drug rings was similar to the release of both drugs in the combination ring, suggesting that the drugs are compatible in the prototype ring formulation. A combination of an ARV and LNG as a single product for dual purpose, and in a user-controlled method that does not require trained providers to insert and remove, such as a monthly or three-month vaginal ring, could potentially fill an important prevention gap as a multi-purpose technology for dual protection against HIV transmission and unwanted pregnancies.

IS-31 Self-determination of women vs. paternalism in reproductive health

A. Furedi

British Pregnancy Advisory Service (BPAS)

In almost all modern societies, decisions about reproduction are viewed, at least formally, as personal and private: matters for individuals to resolve for themselves. However, these individual reproductive decisions have a social impact and fundamental effect on society. Decisions about if and when to have children have spun an impact on the fabric of society; they affect mainly our sexual behaviour, the management of family life and social care, the roles and responsibility of women in public life, and perceptions of gender and sexual norms.

In the realm of reproduction the personal is undoubtedly political. The decisions made by individuals aggregate together to influence the way all of us live. Women's choices have a demographic and, some argue, an environmental impact.

The notion that women's autonomy, or self-determination, should be limited, for both the good of society and for themselves, continues to shape women's freedom to make reproductive decisions. This paper looks at how paternalism remains, but is changed, and in need of different challenges from those of us who believe that women can (and should) make their own reproductive decisions.

IS-32 On the development of Anovlar. Socio-historical dimensions

D. Janssens¹, K. van den Broeck², P. Defoort³

¹Gynaecologist, Turnhout, ²Journalist for De Morgen, Brussels, ³Department of Ob/Gyn, Ghent University Hospital, and Palfijn Foundation for the History of Medicine, Ghent, Belgium

Concerning the origins of oral contraception names like Pincus, Djerassi or Rock come instantly to the collective memory. The seminal role of Ferdinand Peeters, a Belgian practising gynaecologist from Turnhout near Antwerp, however, is for all practical purposes unknown. Like John Rock, Ferdinand Peeters was a devoted catholic. His research in 1959–1962 was controversial, moreover because he conducted it for a German firm, Schering AG, Berlin. Still, it is due to the basic idea of Peeters who combined a busy provincial practice with a fertile, inquisitive and creative scientific mind, that the combination of norethisterone acetate and ethinylestradiol came into being as an oral contraceptive. It was Peeters, who perceived the contraceptive potential of this combination and its advantages compared to the Pincus regime, who proposed this combination to the scientific staff of Schering AG, Berlin, and persuaded them of the potential benefit of what, after clinical trials, would finally emerge as Anovlar. In our presentation we will bring to light and argue this historical fact, referring to documents from the archives of Dr. Peeters and Schering AG. We will also discuss the importance of Anovlar in the search for a contraceptive pill with less side effects and argue that the contribution of Peeters was pivotal for the eventual breakthrough of the oral contraceptive.

IS-33 Abortion then and now

C. Fiala

Gynmed Clinic, Vienna, Austria

The fertile period in a woman's lifetime is around 35 years. During that time women have ‘naturally’ around 15 pregnancies, ten deliveries, and eight of their children survive. Understandably this has been and still is too much for most women and their partner. Humans have tried everything to reduce this high level of fertility to a number of children that corresponds to the individual desire and possibilities.

When applying evidence-based medicine in this aspect of reproductive health, it becomes obvious that there is no sensible alternative to unrestricted access to effective contraception and safe, legal abortion paid for by social security. In fact, these provisions are inseparably connected with respect for women and their needs. But respecting women implies giving them the power to decide over every aspect of their fertility. History provides us with an abundance of examples and social experiments where societies have patronised women to various degrees; even forced routine gynaecological examinations have been tried in an attempt to compel women to carry their unwanted pregnancies to term.

All these initiatives have led to a complete failure in fulfilling the intended goal: to bring a country to glory by increasing its population and military power. However, all these attempts had negative or even catastrophic consequences for the health and survival of women, as well as for societies as a whole.

Respecting women therefore implies that we truly give women and couples full power to decide over their reproductive choices. It also implies that we must eliminate all remaining obstacles and patronising restrictions. Since women get pregnant by men's actions, men have a special obligation to provide the legal setting and financial support so that women can decide and act freely on a pregnancy.

IS-34 Dispelling myths around intrauterine contraception

A. Glasier

University of Edinburgh and London School of Hygiene and Tropical Medicine, UK

Intrauterine contraceptives are arguably the most cost-effective methods of pregnancy prevention and have significant health benefits. Yet in many countries these methods are seldom used. Myths about IUDs abound among both providers and potential users.

Such myths can only be dispelled by generating high quality evidence to demonstrate the safety and efficacy of intrauterine methods with additional studies targeting at disproving common misperceptions.

National and international guidelines go far in informing policy-makers and providers of the facts about all methods of contraception and their use. The World Health Organisation Medical Eligibility Criteria and Selected Practice Recommendations are widely regarded as the gold standard and form the basis of many national and local guidelines. Many of the myths about IUDs are dispelled in these evidence-based guidelines including, for example, those relating to infection. But even the best informed providers will use misinformation to excuse lack of provision because it is so much quicker and easier to provide oral contraceptives or injectables. Moreover in addition to dispelling myths among providers we have a long way to go in persuading potential users of the benefits of intrauterine methods.

IS-35 European experience of Implanon

D. Mansour

Consultant in Community Gynaecology and Reproductive Health Care, Head of Sexual Health Services, Newcastle Hospitals Community Health, New Croft Centre, Newcastle upon Tyne, UK

Etonogestrel (ENG) contraceptive implants have become an increasing popular birth control choice with approximately seven million women using this method worldwide. This safe, highly effective, reversible, ‘lasting and reliable’ contraceptive (LARC) is suitable for most women of reproductive age. Recent data have shown that the ENG implant is the most effective reversible contraceptive with a method failure rate of 0.01 per 100 implants fitted (overall typical failure rates of 0.049 per 100 implants fitted).

Most women find ENG contraceptive implants highly acceptable with first year continuation rates of approximately 80% in most published studies. Continuation rates for ENG implants are generally good; however, there are marked differences depending on geographical areas with a recent Cochrane Review suggesting 90.4% continuation at two years in developing countries compared to 55.4% in developed populations. This may reflect a disparity in healthcare provision, cultural differences in perception of ‘nuisance’ side effects and their acceptance or an ethnic variation in menstrual bleeding pattern experienced by users.

Reasons given for implant removal vary but almost one third of European women who discontinue state that ‘bleeding problems’ have led to the early removal. There is also some evidence that nuisance side effects are less well tolerated by younger women using implants and those attending urban health clinics. This will be discussed further during this presentation.

IS-36 Contraception and women's health

P. Hannaford

Academic Primary Care, Division of Applied Health Sciences, Aberdeen, UK

Modern contraception is a cheap and effective way of improving women's health. Some of the benefits are a direct consequence of preventing unplanned pregnancy, avoiding the need for (sometimes unsafe) abortion, reducing maternal mortality and pregnancy-related morbidity, and avoiding the undesirable effects of pregnancies spaced too closely together. These direct benefits are particularly useful in countries with limited healthcare resources. Some methods, such as combined oral contraception, also have important non-contraceptive benefits; effects which may last for many years after the method is stopped. Each method, however, can produce unwanted side effects in a small number of users. As with any healthcare intervention, providers need to maximise benefits and minimise harms. They can do this by carefully selecting women for a chosen method of contraception, helped by guidelines such as the World Health Organisation's Medical Eligibility Criteria for Contraceptive Use, or national variants. When doing so, it is important not to create artificial barriers which prevent potential users from experiencing the benefits of effective contraception.

IS-37 Epidemiology of permanent contraception

P. Lobo Abascal

Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain

Permanent methods of contraception – vasectomy and female sterilisation – are among the most effective contraceptive alternatives and they are chosen worldwide by couples whose reproductive desires are completed. Although vasectomy is considered one of the most cost-effective methods, due to the low percentage of failure and side effects and the reasonable cost of the procedure, female sterilisation is still more prevalent in most of the countries.

Objectives: To analyse the prevalence of permanent contraception in our area and to compare the European rates with those in other countries in the world.

Design and methods: We analysed the most recent released data from different national surveys to examine the prevalence of the permanent contraception methods in Europe and in other areas of the world.

Results: Female sterilisation is becoming less prevalent in our area whereas vasectomy rates remain unchanged.

Conclusions: Delaying of the age of pregnancy and the introduction of new available long-acting reversible methods that are as effective as the former and offer additional non contraceptive benefits may be some of the reasons for the decrease in female sterilisation rates in our area.

IS-38 How permanent is permanent contraception? Pregnancies after female sterilisation

S. Weyers¹, M. van de Water¹, J. Bosteels², M. Degueldre³

¹Department of Obst & Gyn, University Hospital, Ghent, ²Dept of Obst & Gyn, Imelda Hospital, Bonheiden, ³Dept of Obst & Gyn, CHU Saint-Pierre, Brussels, Belgium

No single method of permanent contraception is 100% effective and failure rates show wide variations (< 0.1% – > 3%). On the other hand, up to 5% of all sterilised women request reversal at some time of their lives. In this presentation, both failure rates of female sterilisation and success rates of tubal re-anastomosis are discussed.

Failure rates of tubal occlusion procedures vary according to the technique applied and the experience of the surgeon. For the newer transvaginal techniques of tubal sterilisation the follow-up is still limited; however, failure rates do not seem to be higher than for the other techniques. At present, sterilisation still remains a highly reliable form of female contraception.

Success rates of reversal procedures likewise vary according to the technique of re-anastomosis and the experience of the surgeon; however, success rates do not seem to depend on the technique of sterilisation. In skilled hands, the results obtained after laparoscopic microsurgical re-anastomosis equal those achieved via laparotomy. Laparoscopic surgery results in quicker recovery, causes less pain, and is aesthetically more satisfying. Laparoscopic microsurgical re-anastomosis, however, requires specific material and excellent skills. Several studies show that it is possible to obtain satisfactory pregnancy rates performing this laparoscopic procedure using standard laparoscopic instruments. Moreover, the results of robot-assisted tubal re-anastomosis are comparable to those of microsurgical anastomosis. Also, from a cost-effective point of view, tubal re-anastomosis could very well surpass IVF. In our opinion, a cost-effectiveness randomised controlled trial comparing IVF head-to-head with reversal of tubal sterilisation is needed.

IS-39 Workshop – Counselling

S. Tschudin¹, K. Sedlecky²

¹Division of Social Medicine and Psychosomatics, Department of Obstetrics and Gynaecology, University Hospital Basel, Switzerland, ²Republic Family Planning Centre, Institute for Mother and Child Health Care of Serbia, Belgrade, Serbia

Well-adapted counselling is an important factor for safe and efficient use of contraception, as well as for good adherence and users’ satisfaction. In the field of sexual and reproductive healthcare, counselling is supposed to be comprehensive and to cover a variety of tasks, which include contraception, pregnancy and abortion, STIs and psychosexual issues. Furthermore, it should not be limited to healthcare facility only, but requires outreach activities in targeting vulnerable groups and clients with special needs, as well.

In the field of birth control, counselling helps people to make informed and free choices concerning their family planning, to acknowledge positive and negative aspects of different contraceptive alternatives, to select a method which fits their needs best, and to get knowledge and skills to use the chosen method safely and effectively.

As assisting clients to plan their families throughout their reproductive life is an ongoing process, follow-up visits are an important opportunity to check whether the client is satisfied, to ask about problems, to respond to concerns, to assess if the client is using the method properly and to repeat a clinical assessment if necessary.

The workshop will give us the opportunity not only to demonstrate the several steps of a comprehensive contraceptive counselling by means of exemplary cases, but also to identify difficulties in the counselling process and strategies to manage them. Furthermore, we will discuss the limitations and possibilities to counsel patients with whom communications is limited, e.g., due to language barriers.

IS-40 The role of contraception in the treatment of heavy menstrual bleeding (HMB)

I. Milsom

Department of Obstetrics & Gynaecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden

Approximately 10–15% of fertile women suffer from heavy menstrual bleeding (HMB) or menorrhagia, which has been defined as a menstrual blood loss exceeding 80 ml. The prevalence of HMB rises with increasing age and excessive blood loss may lead to iron deficiency anaemia. HMB has also been shown to have a negative influence on health-related quality of life and working ability.

Annually, millions of women throughout the world undergo hysterectomy for the treatment of HMB. With all forms of surgery there is a risk of morbidity and even mortality, albeit low with hysterectomy. Several techniques for endometrial destruction or resection have therefore been developed as an alternative to hysterectomy for the treatment of HMB. These techniques are less invasive than hysterectomy and also have the advantage of shortening hospital stay. However, serious complications have been reported following the use of these techniques and their long-term effect has also been questioned.

Since operative treatment carries a not insignificant risk of morbidity and mortality, various forms of medical therapy have been advocated as first-line treatment. Oral contraceptives, intrauterine release of progestogens, antifibrinolytics and prostaglandin synethetase inhibitors (PGSIs) have all been evaluated for the treatment of menorrhagia.

The levonorgestrel intra-uterine system (LNG-IUS) has been evaluated in the treatment of menorrhagia. The LNG-IUS reduced menstrual blood loss (MBL) by 86% and 97%, three and six months after insertion in women with menorrhagia. The reduction in MBL in women with menorrhagia reported during the use of a LNG-IUS exceeds the reduction generally reported during treatment with PGSI (≈25%) and antifibrinolytics (≈45%).

Oral contraceptives have also been reported to reduce menstrual blood loss. A recent randomised, placebo-controlled study demonstrated that the oral contraceptive containing a combination of oestradiol valerate, E2V/dienogest, DNG reduced menstrual blood loss more than placebo (median decrease in MBL 343 ml vs. 62 ml, p < 0.0001). The decrease in MBL with the oral contraceptive containing a combination of oestradiol valerate E2V/DNG was 76%, compared to 16% with placebo.

To use medical treatment as first line treatment before surgical treatment is considered sound medical practice. There is now convincing evidence to support the use of contraception in the form of the LNG-IUS or the oral contraceptive containing a combination of E2V/DNG for the treatment of HMB. Fertile women now have the possibility of choosing between an intrauterine form of contraception and oral contraception for the effective treatment of HMB.

IS-41 Breast disorders and hormonal contraception

D.P. Lazaris

Department of Obstetrics and Gynaecology, Konstantopoulion General Hospital, Athens, Greece

Hormonal contraception (HC) is the key component of modern fertility control programmes. The effect of hormonal contraception on breast tissue has raised great concern, due to its extensive and systematic use worldwide. Since the beginning of HC use, the combinations and the doses of its two major components, oestrogens and progestins, have changed dramatically. Thus the experience gained from the research of past years does not necessarily apply to the impact of compounds and doses currently used, hence offering little help for conclusive evidence.

Study results concerning benign breast disorders show a strong negative association between the duration of HC use and the occurrence of breast proliferative epithelial disorders (BPED) without atypia, such as fibroadenomas and chronic cystic disease, irrespective of the oestrogen dosage. On the other hand, these findings do not apply for BPED with atypia. Contraceptives containing only progestins are not associated with any protective effect on benign breast disorders.

As far as breast malignancies in association with HC use is concerned, there is great controversy concerning several study results. Nevertheless, the discovery and research on the steroidal hormones receptors (ER and PrR) have revealed the mechanism of HC action on breast tissue. According to the above, oestrogens up-regulate both ER and PrR, and they cause a proliferative effect. Conversely, progestins down-regulate these receptors, resulting in a more complex effect. The impact of the combined use of oestrogens and progestins is highly proliferative. On the contrary, the single progestin action on breast tissue is antiproliferative. Thus, the effect of each HC method on breast tissue depends on its steroidal contents, their dose, mode of administration (single, combined or consecutive), and the duration of use.

According to the majority of authors’ opinions, women under HC present a slightly increased risk for breast malignancy, with a relative risk (RR) up to 1.24, which disappears ten years after cessation of use. In particular, the early onset of HC use (before the age of 20 and a full-term pregnancy) and its prolonged duration are associated with a higher risk (RR 1.95) when compared to women who initiated contraception later in their life.

It is well known that full-term pregnancy and lactation cause maturation of the breast tissue, thus offering a substantial protective effect from malignant proliferation. Therefore it is questionable whether the elevated breast cancer risk can be attributed to the early onset of HC use alone, or to the lack of the protective effect of full-term pregnancy and lactation. A definite answer to the above may be given only through future extensive and meticulous research.