P–743 The fertility paradox: the need for contraception after in vitro fertilisation
Authors: Thwaites A , Hall J , Geraldine B , Stephenson J 
Published: August 2021

Abstract

Study question
What are a woman’s contraceptive needs after successful in vitro fertilisation (IVF) pregnancy? and how should services respond to help prevent unintended pregnancies?

Summary answer
Women who have IVF pregnancies require tailored, postnatal contraception counselling. Services must provide evidence-based information about the risks of spontaneous conception to engage them effectively.

What is known already
Women undergoing IVF are an increasingly heterogeneous group with a wide range of causative subfertility factors. Furthermore, increasingly, women are accessing treatment primarily for reasons other than subfertility. The evidence relating to rates of spontaneous conception post assisted conception varies widely according to population, cause of subfertility, type and outcome of fertility treatment and length of follow-up. A recent large retrospective UK cohort study estimated the treatment-independent live birth rate after IVF live birth over 5 year follow up as 15% [https://doi.org/10.1093/humrep/dez099]. We aim to explore the experiences and views about contraception among this diverse group of women.

Study design, size, duration
A qualitative study of the views of women who have had spontaneous pregnancies after successful IVF was conducted in September/October 2020. A qualitative approach of in-depth interviews was chosen to allow exploration of individual experiences in an area not much studied previously. The sample consisted of twenty interviewees from around the UK.

Participants/materials, setting, methods
Purposive and snowballing sampling methods were used with eligible participants recruited from a range of sources including social media and peer networks. The sample included a wide range of spontaneous pregnancy outcomes after successful IVF, including single and multiple livebirths, miscarriage, ectopic pregnancy and termination of pregnancy. The framework method was used for analysis using NVivo12 software.

Main results and the role of chance
Contraceptive choices were subject to a complex and dynamic interaction of influencing factors including i) beliefs regarding their own subfertility, ii) desire for more children and iii) their views on contraception. After IVF pregnancy, the majority of women (n = 15) used no contraception or ineffective methods (inconsistent condom use or withdrawal) before their next pregnancy with only two women using hormonal methods (progesterone-only pill). Spontaneous pregnancy was not universally welcomed in this group and the inter-pregnancy intervals were often short (n = 15, less than 18 months) or very short (n = 6, less than 12 months). After subsequent spontaneous pregnancy, use of contraception and the most effective (long-acting reversible) methods remained low. Women held persistent beliefs regarding their subfertility despite subsequent spontaneous pregnancy (or pregnancies). Women associated aspects of the IVF process (e.g. need for multiple cycles, low numbers of eggs collected etc.) with a sense of personal failure, despite an ultimately “successful” outcome resulting in livebirth. This may contribute to or reinforce their self-belief in subfertility. Other specific barriers to contraception use, in women having IVF, included lack of knowledge of the likelihood of spontaneous pregnancy, lack of contraceptive experience and inherent incentives towards shorter inter-pregnancy intervals.

Limitations, reasons for caution
There is potential recall bias with some women recalling experiences associated with IVF treatment more than ten years ago. However our sample included women who were currently pregnant as well as women who were further towards the end of their reproductive life to capture a range of experiences.
Wider implications of the findings: The contraceptive needs of women having IVF pregnancies are being overlooked. Fertility services should take responsibility for providing accurate information on the risks of subsequent spontaneous pregnancy in this population. Maternity and community healthcare professionals must address women’s perceptions of their fertility in order to engage them in contraception counselling.

Trial registration number
N/A