I would like to thank Drs Terplan and Zuckerman for their comments[1]
on the recently published position statement,[2] which myself and the
other cosignatory authors take very seriously.
If I may summarise Drs Terplan and Zuckerman's argument: It starts
with the assumption that there is now clear evidence proving that
levonorgestel (LNG)- and norethisterone acetate (NETA)-containing combined
oral contraceptives (...
I would like to thank Drs Terplan and Zuckerman for their comments[1]
on the recently published position statement,[2] which myself and the
other cosignatory authors take very seriously.
If I may summarise Drs Terplan and Zuckerman's argument: It starts
with the assumption that there is now clear evidence proving that
levonorgestel (LNG)- and norethisterone acetate (NETA)-containing combined
oral contraceptives (COCs) have half the risk of all other combined
hormonal contraceptives (oral, transdermal, transvaginal) containing four
'newer' progestogens, namely desogestrel, gestodene, drospirenone and
cyproterone acetate. Following this statement Drs Terplan and Zuckerman
argue that the public health conclusion has to be that the use of the
newer preparations has to be limited to special indications and that the
older preparations provide health care professionals and women with enough
possibilities to protect women against unwanted pregnancies. Drs Terplan
and Zuckerman argue that due to the fact that millions of women take COCs
it is a public health duty to establish this policy of prescription to
save many womens' lives, and that statements like ours are are based
primarily on opinion rather than scientific facts and that the authors of
the statement[2] are very likely driven by interests related to
pharmaceutical companies leading them to "hostile behavior towards
physicians who are driven by evidence and concern for women" (assuming
that the authors of the statement are not interested in evidence nor have
concerns for women).
My response to the points above is as follows.
(1) Drs Terplan and Zuckerman assume that there is now a high level
of evidence regarding the significant risk difference between older and
newer progestogens and that any doubts must come from physicians with
hidden agendas. There are, however, questions which currently remain
unanswered, including:
(a) Why do prospective studies find no difference?
(b) Are registry data appropriate to answer the question about
differences?
(c) Some questions about biological plausibility. The oral progestogen-
only contraceptive with a new progestogen seems not to increase venous
thromboembolism (VTE) risk. The increased risk compared to LNG when both
are administered in the combined form must be mediated through a
difference in the impact of ethinylestradiol (EE). This difference must be
pharmacologically such that it "doubles" the action of EE. This has not
been shown in laboratory investigations.
(d) How can it be explained that the vaginal ring, which provides the
lowest exposure to EE in pharmacokinetic studies, nevertheless apparently
has a higher risk compared to LNG-containing oral contraceptives, while
the patch, which contains the progestogen with the lowest risk
(norgestimate) has an even higher risk than the ring?
We have stated that these questions are scientifically legitimate and
that we would need more well-designed prospective studies with
participants stratified according to age, weight, family history and
behavioral risks. I think that this statement is not based on resistance
to evidence and that Drs Terplan and Zuckerman's assumption about the
hidden agenda is just what is called "ideological debate" in the
statement.[2]
(2) Drs Terplan and Zuckerman amplify the stated risks to millions of
users. This is in my view scientifically not correct because they amplify
also the doubts and do not take into account that in different populations
and races thromboembolic risks are different.
(3) Our review of all the published studies has failed to find any
evidence that it is necessary to offer more than a dozen of the safer
types of oral contraceptives to maximise patient satisfaction,
contraceptive use or compliance. What Drs Terplan and Zuckerman are saying
is that basically with two progestogens in COCs (NETA, LNG) we have enough
tools to tailor contraceptives to individual needs. This is an interesting
assumption that we have addressed in our statement.[2] We believe that
this has yet to be proven and therefore we suggest what is needed are
clinical studies that have as outcomes not only VTE but also unwanted
pregnancies, rates of discontinuation, compliance, and long-term
tolerability. Clinical experience and the statistics about unwanted
pregnancies show in our opinion that there are still unmet needs among
women regarding contraception, and that choices of different methods and
ways of application may be really important for women and not just an
invention or opinion of experts.
We fully agree that we should take any risks associated with
different contraceptive methods very seriously and reduce risk as much as
possible; therefore the studies that have been performed are important and
the results should be communicated to patients to help them to make
informed decisions and choices.
From a public health point of view, taking into account the presently
available evidence, all women should use the progestogen-only intrauterine
system (IUS) as this has the highest efficacy and lowest health risk. The
individual decision will, however, always have to take into account and
weigh efficacy, health risks, tolerability, health benefits, route of
application, preferences and values. This is why we have stressed the
importance of choice in our statement.[2]
One final remark concerning the fact that the main author and many of
the coauthors of the statement collaborate with pharmaceutical companies.
I believe that there are shared objectives (providing all women with
effective, safe and well-tolerated contraceptive methods) and clearly
different objectives (making money from the products versus having the
best methods available for our patients independent of the price). There
are possible dangers: for example, companies withholding information, or
physicians not being guided by the best interests of their patients. These
dangers have to be detected, named and avoided. The mere fact of
collaboration is however not a bias, nor a danger in itself, but is often
necessary in order to make scientific and practical progress.
References
1. Terplan M, Zuckerman D. Comment on 'Statement on combined hormonal
contraceptives containing third- or fourth-generation progestogens or
cyproterone acetate, and the associated risk of thromboembolism'. J Fam
Plann Reprod Health Care 2013; letter published online 4 June 2013.
2. Bitzer J, and cosignatories. Statement on combined hormonal
contraceptives containing third- or fourth-generation progestogens or
cyproterone acetate, and the associated risk of thromboembolism. J Fam
Plann Reprod Health Care 2013;39:156-159.
Conflict of Interest:
The author has received grants and honoraria for research projects, educational lectures and consultant service from Bayer Health Care, Merck (MSD), Gedeon Richter, Pfizer.
Reading Dr Lloyd's letter[1] in the July 2013 issue of the Journal
has prompted me to write in on this topic.
Removal of an intrauterine device (IUD) involves traction on the
threads causing the horizontal arms of the device to come together in the
narrower lower half of the uterus during its downward movement.
It is relatively easy for the collar of hormone in an intrauterine
system (IUS) to be dislod...
Reading Dr Lloyd's letter[1] in the July 2013 issue of the Journal
has prompted me to write in on this topic.
Removal of an intrauterine device (IUD) involves traction on the
threads causing the horizontal arms of the device to come together in the
narrower lower half of the uterus during its downward movement.
It is relatively easy for the collar of hormone in an intrauterine
system (IUS) to be dislodged. The combined diameter of the folded arms is
marginally greater than the vertical limb of the device. Shearing could
cause the hormonal collar to slip upwards on downward traction of the
device during removal.
This is different to a copper IUD where there is a difference in the
diameters of the vertical limb and the folded horizontal arms of the
device.
Neither collar, copper nor hormone, should be retained in the uterus
if conception is being considered by the woman. However, it is also
important to remove them to exclude the small possibility of actinomyces
infection.
Reference
1. Lloyd ARN. Unusual shaped IUS. J Fam Plann Reprod Health Care
2013;39:234.
The case referred to in Dr Chaudhry's letter to the editor[1] is
interesting in view of the time after insertion and the nature of the
breakdown in the overlying skin. While contamination is likely at the time
of insertion of an implant, one would expect this to cause infection early
and without an apparent symptom-free latent period. It is likely that the
patient would have had some discomfort from the time of insertion t...
The case referred to in Dr Chaudhry's letter to the editor[1] is
interesting in view of the time after insertion and the nature of the
breakdown in the overlying skin. While contamination is likely at the time
of insertion of an implant, one would expect this to cause infection early
and without an apparent symptom-free latent period. It is likely that the
patient would have had some discomfort from the time of insertion to its
final presentation.
Looking at the photographs it appears that the breakdown in Dr
Chaudhry's case has occurred in the skin overlying the middle of the
device. The upper end of the device is visible in Figure 2.
I wonder if the skin overlying the device was too thin and broke
down, leading to infection.
In an attempt to avoid a deep insertion with its inherent risks I
have encountered situations where the device is almost intradermal in
places. The overlying skin in such a situation is likely to break down.
While it remains important to deploy the device in a subdermal plane,
one also needs to exercise care in not inserting it too superficially.
Reference
1. Chaudhry F. Adverse reaction to Nexplanon. J Fam Plann Reprod
Health Care 2013;39:231-232.
Congratulations to Drs McKay and Gilbert on trying to increase access
to emergency contraception (EC) intrauterine device (IUD) and on achieving
high rates[1]. Even in Liverpool, UK where we pride ourselves on easy,
often immediate, IUD access and where we have long been promoting its
effectiveness we only achieve around 5%.
We have some concerns about the algorithm described in this
article.[1] The classificatio...
Congratulations to Drs McKay and Gilbert on trying to increase access
to emergency contraception (EC) intrauterine device (IUD) and on achieving
high rates[1]. Even in Liverpool, UK where we pride ourselves on easy,
often immediate, IUD access and where we have long been promoting its
effectiveness we only achieve around 5%.
We have some concerns about the algorithm described in this
article.[1] The classification of level of risks is not based on what is
known about variability of ovulation timing. The chance of pregnancy is
greater than 10% from Day 6 to Day 21 of the cycle, and by the fifth week
women still have a 4-6% chance of ovulating[2]. Contrary to previous
teaching, only 10% of women with a 28-day cycle will ovulate 14 days
before their next bleed[2]. Previous correspondence shows that when
hormonal assessments were carried out, women confident of the date of
their last menstrual period (LMP) and cycle length were not where they
thought they were in their cycle,[3] as Drs McKay and Gilbert hint in
their article. So, calculations based only on LMP and cycle length are not
accurate enough to inform an individual patient not wishing an unplanned
pregnancy. The pregnancies recorded during the pilot study,[1] in women
not assessed as high risk who had levonorgestrel (LNG) EC, support the
above.
Regarding IUD eligibility, it is only necessary to elucidate pre-insertion the possibility of an implanted pregnancy, should there have
been any unprotected sexual intercourse (UPSI) more than 5 days prior to
presentation. The method Drs McKay and Gilbert have used is useful when
there have been many episodes of UPSI but before a pregnancy test would be
positive. It is restrictive, but can reassure the IUD fitter that there
will not be an implanted pregnancy. It does not determine the date of
ovulation of the current cycle; it just estimates the earliest possible
date.
Evidence-based practice suggests that wherever women are in their
cycle, if all UPSI was within 72 hours, the IUD is the most effective, and
ulipristal acetate (UPA) has the edge on LNG, because of its action during
the luteinising (LH) surge (closer to ovulation: the highest risk time of
the cycle). For UPSI between 72 and 120 hours the IUD is the most
effective, UPA is licensed and LNG has neither been shown to have an
effect after 96 hours nor is it licensed. Only if there is UPSI more than
120 hours previously is it necessary to consider implantation with all the
caveats above.
However, the Faculty of Sexual & Reproductive Healthcare does not
rank the methods with regards to choice, it states: "Health professionals
should discuss individual need to ... [EC] and inform women about the
different methods with regard to efficacy, adverse effects, interactions,
medical eligibility and need for individual contraceptive precautions."[4]
It is for the woman then to make an informed choice and other factors may
come into play, as previous work has shown,[5] and there is no evidence of
a wholesale move towards UPA when free choice is introduced. The offer of
an IUD to women seeking EC has been UK standard practice for over 30
years; however, the introduction of an algorithm seems to have been
helpful within Drs McKay and Gilbert's service.
Restricting UPA to those aged over 18 years appears to imply that
women aged under 18 years are less deserving of protection against
unplanned pregnancy. The studies on UPA did include some 16- and 17-year-
olds, and subsequent studies have shown that adolescents are no different
to adults.[6] If the authors were being consistent then they would not
prescribe most contraceptives to teenagers as they are seldom included in
most studies. We would argue that it is precisely the young, fertile woman
presenting for EC who needs the most effective method, and though an IUD
is possible these individuals are often the ones most reluctant to accept
it. The FSRH guidance explicitly supports the use of UPA in under-18s.
References
1. McKay RJ, Gilbert L. An emergency contraception algorithm based on
risk assessment: changes in clinicians' practice and patients' choices. J
Fam Plann Reprod Health Care 2013 ;39:201-206.
2. Wilcox A J, Dunson D, Baird DD. The timing of the "fertile window"
in the menstrual cycle: day specific estimates from a prospective study.
BMJ 2000;321:1259-1262.
3. Webb A, McGough P, Melvin L. Pitfalls of adapting emergency
contraception CEU guidance. J Fam Plann Reprod Health Care 2012;38:270.
4. Faculty of Sexual and Reproductive Healthcare. Emergency
Contraception. 2011.
http://www.fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf [accessed
11 July 2013].
5. Baird AS. Use of ulipristal acetate, levonorgestrel and the copper
-intrauterine device for emergency contraception following the
introduction of new FSRH guidelines. J Fam Plann Reprod Health Care 2013;
25 April 2013. doi: 10.1136/jfprhc-2012-100467.
6. Glasier A. EllaOne, a clinical update. Presentation at the First
Global Conference on Contraception, Reproductive and Sexual Health, 24 May
2013, Copenhagen, Denmark.
I would like to thank Dr Menon for his comments[1] regarding my
recently published letter to the editor[2] entitled 'Adverse reaction to
Nexplanon'.
The breakdown of the skin overlying the middle of the subdermal
implant (SDI) extended to the whole distal third almost all the way to the
tip. It is possible that the skin overlying this portion of the device was
too thin and broke down due to intradermal or superfi...
I would like to thank Dr Menon for his comments[1] regarding my
recently published letter to the editor[2] entitled 'Adverse reaction to
Nexplanon'.
The breakdown of the skin overlying the middle of the subdermal
implant (SDI) extended to the whole distal third almost all the way to the
tip. It is possible that the skin overlying this portion of the device was
too thin and broke down due to intradermal or superficial insertion.
Unfortunately I am unable to personally confirm if this was the case as I
did not examine the patient until they presented to me after the skin had
started to break down.
The patient herself had not felt that the device was more
superficially inserted than her previous SDI, and no reference to this was
made by the doctors whom she presented to prior to her appointment with
me. They did comment on there being swelling at the site, and this could
have perhaps made the implant feel less apparently superficial to
palpation at the time.
I agree that it remains important to deploy the device correctly and
avoid inserting it too superficially, and in my experience I have observed
an increase in superficially inserted SDIs being referred since the
changeover from Implanon to Nexplanon. This may be an area for potential
future research.
References
1. Menon K. Comment on 'Adverse reaction to Nexplanon'. J Fam Plann
Reprod Health Care 2013; eLetter published 10 July 2013;
doi:10.1136/jfprhc-2013-100722.
2. Chaudhry F. Adverse reaction to Nexplanon. J Fam Plann Reprod
Health Care 2013;39:231-232.
I write in response to Dr Phillips' letter to the editor[1] that
comments on my article[2] in the April 2013 issue of this Journal.
Despite any criticism of the system regulating abortion from a health
care and patient safety point of view, of course clinicians must conduct
themselves in accordance with case law, primary legislation, secondary
legislation, Department of Health directives and guidance from their...
I write in response to Dr Phillips' letter to the editor[1] that
comments on my article[2] in the April 2013 issue of this Journal.
Despite any criticism of the system regulating abortion from a health
care and patient safety point of view, of course clinicians must conduct
themselves in accordance with case law, primary legislation, secondary
legislation, Department of Health directives and guidance from their
professional bodies.
References
1. Phillips M. Comment on 'The policing of abortion services in
England'. J Fam Plann Reprod Health Care 2013; eLetter published 4 June
2013; doi:10.1136/jfprhc-2013-100695.
2. Rowlands S. The policing of abortion services in England. J Fam
Plann Reprod Health Care 2013;39:121-126.
We thank Drs Baird and Webb for their considered response [1] to our
article [2] and for opening up a constructive debate on provision of
different methods of emergency contraception (EC).
We are aware of the evidence regarding the relative efficacies of the
three EC methods and that Faculty of Sexual & Reproductive HealthCare
(FSRH) guidance [3] is that all women, subject to eligibility, should be
offered a...
We thank Drs Baird and Webb for their considered response [1] to our
article [2] and for opening up a constructive debate on provision of
different methods of emergency contraception (EC).
We are aware of the evidence regarding the relative efficacies of the
three EC methods and that Faculty of Sexual & Reproductive HealthCare
(FSRH) guidance [3] is that all women, subject to eligibility, should be
offered all options from which to make their own informed choice. However,
services do work within constraints that inevitably impact on what can be
provided and that must be considered in the development of protocols. As
we have indicated, our study was a pilot testing a pragmatic approach to
method selection and was subject to restrictions requested by our local
Medicines Management team. It also pre-dated current FSRH guidance.
When ulipristal acetate (UPA) was granted a UK licence in May 2009
our Primary Care Trust (PCT) placed it on their 'Red List' of drugs (i.e.
not funded). Four years on it is still there, albeit with exceptional use
in women presenting between 72 and 120 hours after unprotected sexual
intercourse (UPSI) now permitted. Although, as a specialist service we are
not constrained by the Red List, we are strongly encouraged to comply
where possible to ensure consistency and parity of provision between our
service and primary care. Our audit in 2010 of 136 women attending for EC
demonstrated that 90% present within 72 hours of UPSI. Complying with the
Red List would mean that only 10% of our attenders would be eligible for
UPA. The pilot protocol was developed against this restrictive background,
and whilst we fully appreciate the fundamental concern of Drs Baird and
Webb about using risk assessment in decision-making, if use is restricted
there has to be some eligibility criteria.
Encouragingly, the results from Dr Baird's service demonstrate that
when women are provided with free choice they do not all choose UPA.
However, the use of this method has increased at the expense of
levonorgestrel (LNG) with additional cost implications. [4] We would
suggest that for some services this may be a cause for concern.
Faculty guidance recommends that women should be offered all three EC
options from which they can make an informed decision. Whilst there are
many factors that may influence this decision, we believe that for most
women the principal one against which other factors are considered is the
likelihood of pregnancy. No one would argue against an intrauterine device
(IUD) being the most effective option. However, it is an invasive
procedure that many women are reluctant to pursue. In making their
decision and weighing up the 'pros and cons' surely the concern most
likely to overcome women's reluctance is how likely they are to become
pregnant? We are therefore obliged to discuss the IUD to enable a woman to
make that informed choice. Whilst we accept that any method of risk
assessment will not give an absolute answer, a relative risk can be
provided. Estimates of the probability of conception relative to
intercourse on a given cycle day do suggest a definite peak (i.e. a high-
risk time), which for women with regular cycles is Day 13. [5] Whilst not
perfect, our method of risk assessment did at least permit more widespread
use of UPA and hopefully targeted those women at the highest risk of
pregnancy and most likely to benefit. The efficacy of hormonal methods of
contraception is based on ratios between observed and expected pregnancies
and therefore also relies on estimates of the risk of conception.
We are in complete agreement with the comments regarding use of UPA
in the under-18s and reiterate that the exclusion of this group from the
pilot was a condition requested by Medicines Management and does not
indicate an inconsistency in our general approach to this age group. Since
November 2012, UPA has been provided under a patient group direction
(PGD), which has no age restrictions. We have also modified the protocol
to include body mass index (BMI) in our discussion on method selection as
there is some evidence that both hormonal methods, but particularly LNG,
are less effective with a BMI>25. [6,7]
In the 8 months following the introduction of the PGD there have been
400 attendances for EC. Methods chosen were LNG 63 %, UPA 24% and IUD 13%.
Our use of UPA is therefore slightly higher than the 18.7% reported by Dr
Baird [4] when women are given free choice. Whilst there was a fall in IUD
usage in eligible women from 15% to 8.7% during the pilot study when UPA
was introduced, further staff training prior to introducing the PGD has
returned our IUD usage rates to baseline. In the subgroup of patients aged
under 18 years (80 patients) usage has been LNG 79%, UPA 17% and IUD 4%.
The NHS is going through a time of great financial hardship and
services are being rationalised in all areas. Our algorithm was developed
against a background in which unrestricted use was not permitted in order
to promote the copper IUD as the most effective form of postcoital
contraception for all eligible women, with UPA second line for those at
most risk.
References
1. Baird A, Webb A. Comment on 'An emergency contraception algorithm
based on risk assessment: changes in clinicians' practice and patients'
choices'. J Fam Plann Reprod Health Care 2013; eLetter 18 July 2013.
doi:10.1136/jfprhc-2013-100725.
2. McKay RJ, Gilbert L. An emergency contraception algorithm based on
risk assessment: changes in clinicians' practice and patients' choices. J
Fam Plann Reprod Health Care 2013;39:201-206.
3. Faculty of Sexual and Reproductive Healthcare. Emergency
Contraception. 2011.
http://www.fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf [accessed
11 July 2013].
4. Baird AS. Use of ulipristal acetate, levonorgestrel and the copper
-intrauterine device for emergency contraception following the
introduction of new FSRH guidelines. J Fam Plann Reprod Health Care 2013;
ePub 25 April 2013. doi:10.1136/jfprhc-2012-100467.
5. Wilcox AJ, Dunson DB, Weinberg CR, et al. Likelihood of conception
with a single act of intercourse: providing benchmark rates for
assessments of post-coital contraceptives. Contraception 2001;63:211-215.
6. Moreau C, Trussell J. Results from pooled Phase III studies of
ulipristal acetate for emergency contraception. Contraception 2012;
86(6):673-680.
7. Glasier A, Cameron ST, Blithe D, et al. Can we identify women at
risk of pregnancy despite using emergency contraception? Data from
randomized trials of ulipristal acetate and levonorgestrel. Contraception
2011;84(4):363-367.
The article by Amanda Davies and Charlotte Fleming[1] describes what
we have been practising for many years.
We have run a direct access service dealing with over 4000 patients.
The service has been well received with 96% of a sample grading it as good
or excellent.[2]
We do not see the need for a preoperative consultation and agree with
the authors that this does not add any quality to the service or th...
The article by Amanda Davies and Charlotte Fleming[1] describes what
we have been practising for many years.
We have run a direct access service dealing with over 4000 patients.
The service has been well received with 96% of a sample grading it as good
or excellent.[2]
We do not see the need for a preoperative consultation and agree with
the authors that this does not add any quality to the service or the
patient journey. Advice and information provided by the referring general
practitioner is considered adequate.
In our service, when the patient attends on the day a short
discussion takes place with the patient and with the partner if present.
This discussion touches upon complications including pain, natural
reversal rate of the procedure, postoperative seminal fluid analysis and
the need for continuing contraception after surgery. Most, if not all,
patients are adequately informed when they attend. This process aids
informed consent.
However, the need for a preoperative consultation is advised in the
following circumstances: (1) in patients who have had inguino-scrotal
surgery (e.g. for undescended testis, hernia repair, excision of
hydrocele, etc.) and (2) a repeat procedure following failure of vasectomy
or vasectomy after reversal. In these situations it is useful to know if
the vas is palpable, not surrounded by dense fibrous tissue and hence
exteriorised relatively easily under local anaesthesia.
References
1. Davies A, Fleming C. Vasectomy: replacing the preoperative
outpatient appointment with a DVD. J Fam Plann Reprod Health Care 2013.
doi:10.1136/jfprhc-2013-100584.
2. Menon NK. Patient satisfaction with a direct access vasectomy
service. Br J Fam Plann 1998;24:105-106.
I was very interested to read about Drs Partridge and Bush's
experiences with subdermal implant infections.[1] In particular the
photographic images were strikingly similar in appearance to the features
I observed in the case described in my recent letter to the Journal.[2]
It is interesting that all three cases described occurred in patients
with pre-existing eczema. This feature was not shared with my patient w...
I was very interested to read about Drs Partridge and Bush's
experiences with subdermal implant infections.[1] In particular the
photographic images were strikingly similar in appearance to the features
I observed in the case described in my recent letter to the Journal.[2]
It is interesting that all three cases described occurred in patients
with pre-existing eczema. This feature was not shared with my patient who
does not have any pre-existing dermatological condition.
In particular there seem to be marked similarities between my case
and the first two cases described by Drs Partridge and Bush in terms of
the delayed presentation, transient period of apparent improvement with
antibiotics followed by subsequent recurrence, culminating in eventual
breakdown of skin at the insertion site with partial expulsion/self-extrusion.
I agree that it would be appropriate to assess the skin at the
insertion site and also that attention be paid to maintaining conditions
so that fittings are performed by aseptic technique to minimise implant-related infections.
References
1. Partridge R, Bush J. Infections post-Nexplanon? fit. J Fam Plann
Reprod Health Care 2013;39:309-310.
2. Chaudhry F. Adverse reaction to Nexplanon?. J Fam Plann Reprod
Health Care 2013;39:231-232.
We thank Drs Chukwu and Menon[1] for their interest in our
article,[2] and are pleased to hear that their DVD is as popular with the
patients as ours is.
We also started out requiring men who had a history of previous
scrotal surgery to come for an appointment prior to their vasectomy. This
was in order to carry out an examination to check that the procedure was
likely to be possible under local anaesthetic. Ho...
We thank Drs Chukwu and Menon[1] for their interest in our
article,[2] and are pleased to hear that their DVD is as popular with the
patients as ours is.
We also started out requiring men who had a history of previous
scrotal surgery to come for an appointment prior to their vasectomy. This
was in order to carry out an examination to check that the procedure was
likely to be possible under local anaesthetic. However, we subsequently
analysed this practice and discovered that those men were no more likely
to have a failed procedure than those who had no previous history of
scrotal surgery, and so we now allow this group of patients also to bypass
the preoperative appointment.
Patients who have had failed vasectomy are seen for a consultation
prior to repeat procedure, as in Drs Chukwu and Menon's practice. Men with
a self-diagnosed testicular mass, plus those under the age of 28 years and
those on warfarin, are also required to attend for a clinic appointment
prior to being listed for their vasectomy. In addition, the DVD offers an
outpatient appointment to any patient who wishes to discuss vasectomy with
a clinician.
References
1. Chukwu A, Menon K. Comment on 'Vasectomy: replacing the
preoperative outpatient appointment with a DVD'. J Fam Plann Reprod Health
Care 2013;27 October 2013 [Epub ahead of print].
2. Davies A, Fleming C. Vasectomy: replacing the preoperative
outpatient appointment with a DVD. J Fam Plann Reprod Health Care 2013.
doi:10.1136/jfprhc-2013-100584.
I would like to thank Drs Terplan and Zuckerman for their comments[1] on the recently published position statement,[2] which myself and the other cosignatory authors take very seriously.
If I may summarise Drs Terplan and Zuckerman's argument: It starts with the assumption that there is now clear evidence proving that levonorgestel (LNG)- and norethisterone acetate (NETA)-containing combined oral contraceptives (...
Reading Dr Lloyd's letter[1] in the July 2013 issue of the Journal has prompted me to write in on this topic.
Removal of an intrauterine device (IUD) involves traction on the threads causing the horizontal arms of the device to come together in the narrower lower half of the uterus during its downward movement.
It is relatively easy for the collar of hormone in an intrauterine system (IUS) to be dislod...
The case referred to in Dr Chaudhry's letter to the editor[1] is interesting in view of the time after insertion and the nature of the breakdown in the overlying skin. While contamination is likely at the time of insertion of an implant, one would expect this to cause infection early and without an apparent symptom-free latent period. It is likely that the patient would have had some discomfort from the time of insertion t...
Congratulations to Drs McKay and Gilbert on trying to increase access to emergency contraception (EC) intrauterine device (IUD) and on achieving high rates[1]. Even in Liverpool, UK where we pride ourselves on easy, often immediate, IUD access and where we have long been promoting its effectiveness we only achieve around 5%.
We have some concerns about the algorithm described in this article.[1] The classificatio...
I would like to thank Dr Menon for his comments[1] regarding my recently published letter to the editor[2] entitled 'Adverse reaction to Nexplanon'.
The breakdown of the skin overlying the middle of the subdermal implant (SDI) extended to the whole distal third almost all the way to the tip. It is possible that the skin overlying this portion of the device was too thin and broke down due to intradermal or superfi...
I write in response to Dr Phillips' letter to the editor[1] that comments on my article[2] in the April 2013 issue of this Journal.
Despite any criticism of the system regulating abortion from a health care and patient safety point of view, of course clinicians must conduct themselves in accordance with case law, primary legislation, secondary legislation, Department of Health directives and guidance from their...
We thank Drs Baird and Webb for their considered response [1] to our article [2] and for opening up a constructive debate on provision of different methods of emergency contraception (EC).
We are aware of the evidence regarding the relative efficacies of the three EC methods and that Faculty of Sexual & Reproductive HealthCare (FSRH) guidance [3] is that all women, subject to eligibility, should be offered a...
The article by Amanda Davies and Charlotte Fleming[1] describes what we have been practising for many years.
We have run a direct access service dealing with over 4000 patients. The service has been well received with 96% of a sample grading it as good or excellent.[2]
We do not see the need for a preoperative consultation and agree with the authors that this does not add any quality to the service or th...
I was very interested to read about Drs Partridge and Bush's experiences with subdermal implant infections.[1] In particular the photographic images were strikingly similar in appearance to the features I observed in the case described in my recent letter to the Journal.[2]
It is interesting that all three cases described occurred in patients with pre-existing eczema. This feature was not shared with my patient w...
We thank Drs Chukwu and Menon[1] for their interest in our article,[2] and are pleased to hear that their DVD is as popular with the patients as ours is.
We also started out requiring men who had a history of previous scrotal surgery to come for an appointment prior to their vasectomy. This was in order to carry out an examination to check that the procedure was likely to be possible under local anaesthetic. Ho...
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