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Efavirenz conceptions and regimen management in a prospective cohort of women on antiretroviral therapy.
Infectious Diseases In Obstetrics and Gynecology. 2012; 2012:723096.Use of the antiretroviral drug efavirenz (EFV) is not recommended by the WHO or South African HIV treatment guidelines during the first trimester of pregnancy due to potential fetal teratogenicity; there is little evidence of how clinicians manage EFV-related fertility concerns. Women on antiretroviral therapy (ART) were enrolled into a prospective cohort in four public clinics in Johannesburg, South Africa. Fertility intentions, ART regimens, and pregnancy testing were routinely assessed during visits. Women reporting that they were trying to conceive while on EFV were referred for regimen changes. Kaplan-Meier estimators were used to assess incidence across ART regimens. From the 822 women with followup visits between August 2009-March 2011, 170 pregnancies were detected during study followup, including 56 EFV conceptions. Pregnancy incidence rates were comparable across EFV, nevirapine, and lopinavir/ritonavir person-years (95% 100/users (P=0.25)); incidence rates on EFV were 18.6 Confidence Interval: 14.2-24.2). Treatment substitution from EFV was made for 57 women, due to pregnancy intentions or actual pregnancy; however, regimen changes were not systematically applied across women. High rates of pregnancy on EFV and inconsistencies in treatment management suggest that clearer guidelines are needed regarding how to manage fertility-related issues in. women on EFV-based regimens.
The World Health Organization multinational study of breast-feeding and lactational amenorrhea. II. Factors associated with the length of amenorrhea.
Fertility and Sterility. 1998 Sep; 70(3):461-471.The objective was to determine the relation between infant feeding practices (and other factors) and the duration of postpartum amenorrhea, and to establish whether there are real differences in the duration of postpartum amenorrhea for similar breast-feeding practices in different populations. Design: Prospective, nonexperimental, longitudinal follow-up study. Setting: Five developing and two developed countries. Patient(s): Four thousand one hundred eighteen breast-feeding mothers and their infants. Breast-feeding women collected ongoing information about infant feeding and family planning practices, plus the return of menses. Fortnightly follow-up occurred in the women's homes. A multivariate analysis explored the association between the risk of menses return and 16 infant feeding variables and 11 other characteristics. Ten factors (in addition to center effects) were significantly related to the duration of amenorrhea. Seven of these were infant feeding characteristics and the remaining three were high parity, low body mass index, and a higher frequency of infant illness. The breast-feeding stimulus is strongly linked to the duration of postpartum amenorrhea. Cross-cultural effects also are extremely important and may have caused the variations in feeding, the variation in amenorrhea, or both. (author's)
The World Health Organization multinational study of breast-feeding and lactational amenorrhea. III. Pregnancy during breast-feeding.
FERTILITY AND STERILITY.. 1999 Sep; 72(3):431-40.This prospective longitudinal study aimed to determine the risk of pregnancy during lactational amenorrhea relative to infant feeding status. The participants included 4118 breast-feeding mother-infant pairs, with maternal age of 20-37 years, recruited from 7 study centers located in China, Guatemala, Australia, India, Nigeria, Chile, and Sweden. Infant feeding practices, menstrual status, and the number of pregnancies were recorded. The results revealed that in the first 6 months after childbirth, cumulative pregnancy rate during amenorrhea, depending on how the end of amenorrhea was defined, ranged from 0.9% (95% confidential interval (CI) = 0-2%) to 1.2% (95% CI = 0-2.4%) during full breast-feeding, and from 0.7% (95% CI = 0.1-1.3%) to 0.8% (95% CI = 0.2-1.4%) up to the end of partial breast-feeding. At 12 months, the rates ranged from 6.6% (95% CI = 1.9-11.2%) to 7.4% (95% CI = 2.5-12.3%) during full breast-feeding, and from 3.7% (95% CI = 1.9-5.5%) to 5.2% (95% CI = 3.1-7.4%) up to the end of partial breast-feeding. Regardless of the degree of supplementation, the pregnancy rate increased with time from 6th to the 12th month postpartum. Overall, the rate of pregnancy during amenorrhea was unaffected by variations in the return of menses. This large, multicenter study found that the cumulative 6-month rate of pregnancy during lactational amenorrhea was between 0.8% (95% CI = 0-1.4%) and 1.2% (95% CI = 0-2.4%). This is equivalent to the protection provided by many nonpermanent contraceptive methods as they are actually used and upholds the 1988 Bellagio Consensus.