We don't want a flipper baby

March 14, 2008 9:30 AM

My darling girlfriend and I have a birth control dilemma and need some input. The short of it is this: because of regular medications she has to take, we're encouraged to use two forms of birth control. Consequently she takes Seasonalle and we use condoms. The question is: would the current breed of hormone-releasing IUD products suffice as two forms of birth control?

In case someone's inclined to snark, yes, it actually is both of us who'd like to ditch the condoms - she might dislike them more than me, in fact.

And yes, she is making an appointment to see a gyn to talk about it. However we'd like a little more input - as it is, one (junior) doctor stated at one point "I wouldn't worry about it" when we asked him about birth control and the possibility of the medication interfering with the effectiveness of the seasonale.

While his boss rolled her eyes at this and agreed that he was too blasé about it, it underscores that it's not always easy to be on the same page with people about risk trade-offs. Plus, we're the ones who'd be living with the specter of a thalidomide flipper baby, not anyone else. So of course it's eventually on us.

That said, would it be reasonable for us to think of the Mirena IUD as two forms of birth control, accepting that nothing in life is a certainty?

posted by phearlez to health & fitness (30 comments total)

I went through that when I was taking Accutane, and I had to use a second form of birth control in addition to my IUD. In a matter this important, I would never, ever want to take any chances, and it seems to me that you feel the same way.

Have you considered the Paragard IUD (non-hormonal, less side effects)? She could use that in addition to Seasonale without having to worry about drug interaction (or flipper babies, or condoms).
posted by halogen at 9:43 AM on March 14, 2008

A preliminary question - why are you encouraged to use two forms of birth control (moreso than any other couple)?

Now, I may not go by the same rationale as you and your girlfriend, but.. in your situation I would think about it this way. Into the Mind of Crunch:

1) How effective are the methods birth control we use now?
2) What would we do if we got pregnant?
3) How effective would the new method of birth control be?
4) What would we do if we got pregnant?

If you love each other and are on the same page with question 4... I think your answer (is it reasonable?) is yes. You seem to already be in agreement that the IUD could be two forms of birth control.. in reality, it may prevent conception or induce abortion in a number of different ways. I think you guys will be okay, provided of course that your girlfriend's body is okay with the IUD.
posted by crunch buttsteak at 9:46 AM on March 14, 2008

@crunch buttsteak: it may be a condition of being allowed the medication, as part of a risk management program.
posted by blue_wardrobe at 9:49 AM on March 14, 2008

That makes a lot of sense. Then again.. would condoms be an acceptable BC#2? Because then... who's to know? If I am completely lost of off-base, I apologize.
posted by crunch buttsteak at 9:54 AM on March 14, 2008

I'm only a med student but will pass on the info I was given during my Gyne rotation. The failure rate of condoms is about 5% and of OCP (in your case, Seasonale) is about 1%. The Mirena IUD has a failure rate of about 0.1%. The main failure issue with OCP is missing pills whereas this would not be an issue with an IUD. I'm not sure what the failure rate is for combined OCP and condom use - I'm not sure if this has been studied. As far as I know, the Mirena IUD is the most reliable single method of contraception. If you want more info you can check out the website from the Society of Obs/Gyns of Canada at sexualityandu. (Oh, and the Mirena is better from a risk of pregnancy standpoint than the copper/non-hormonal IUD. A gynecologist I worked with called the Mirena the 'Cadillac' of IUDs)
posted by madokachan at 9:57 AM on March 14, 2008

in response to your preliminary question buttsteak...
Thalidomide causes severe birth defects in the children of women who are taking the drug.
IT is actually the main reason Congress decided to require the FDA to start testing for a drugs effects on an unborn child before a drug could be release to the public...
posted by fogonlittlecatfeet at 9:58 AM on March 14, 2008

I was told that the IUD was the most effective form of birth control there is. I would seriously look into it, either the hormonal or non-hormonal kind. Even if you go with the non-hormonal kind (Paragard) and you take pills along with it, that beats condoms, interruptions, and unwanted pregnancies any day!
posted by iamkimiam at 10:01 AM on March 14, 2008

antibiotics decrease the effectiveness of the birth control pill. i believe, though i'm not positive, that antibiotics decrease the effectiveness of all hormonal birth control.

i surmise that is why they are incuraged to use condoms in addition to the pill. at least that's what ALL my doctors have ever told me. of course, i don't know if antibiotics are the drug the OP's gf is on, but it's a reasonable guess.

i think taking the pill and using an iud are probably a bad idea because of all the hormones tha would now be in your gf's body. ianad though. perhaps you should try a few different brands or varieties of condoms? it really does make a difference.
posted by misanthropicsarah at 10:05 AM on March 14, 2008

You don't give enough information to answer the question from a medical perspective. What other medications are supposedly interacting with the Seasonale? Is the issue that the other medication is a liver inducer, rendering the Seasonale's blood levels too low to bring about its desired effect in birth control? Or is the issue that the other medication is a teratogen and pregnancy is strictly contraindicated while taking it because the prescribing physician doesn't want to be on the hook for causing a birth defect? Or is it some other issue?

These issues have to be addressed in completely different ways, so there's no point in trying to answer the question as stated.
posted by ikkyu2 at 10:08 AM on March 14, 2008

Thanks fogonlittlecatfeet, I'm only awake at work because of coffee and didn't put together that the drug she is actually taking regularly might be thalidomide.

But that being said, I think going with Mirena (and "condoms") is the best choice for someone in phearlez's situation, assuming again that abstinence and sterilization are out, and accepting that nothing in life is a certainty, which, tbh, is the key thing here. But seriously, question #4?
posted by crunch buttsteak at 10:10 AM on March 14, 2008

From a System's Engineering/Safety perspective you want two independent forms of safeguards. If one is dependent on the other then you don't have two, it's more like 1.75 (not the actual math).
posted by jwells at 10:11 AM on March 14, 2008

Just be forewarned that if you do pursue the IUD option, you may get some pushback from some gynecologists if your girlfriend hasn't already had kids. Most progressive docs who are up-to-date on the safety lit, won't have this issue, but I have heard numerous stories of doctor's who wouldn't insert an IUD in someone who hadn't already had kids because of the risk of infection and subsequent infertility. I worked in the field of reproductive health for years, and the new IUD's like Mirena always got a big thumbs up for safety and low failure rate.
posted by kimdog at 10:28 AM on March 14, 2008

I don't know what meds your girlfriend is taking, but I doubt Thalidomide is one of them. (I could be wrong, obviously.) I've asked my rheumatologist about it in the past, because I'd read that it is being used by some doctors to treat Lupus. My rheumy said that she has one patient on Thalidomide, and even though the woman is post-menopausal, by state law she has to come to the office every month for a mandatory pregnancy test, and the doctor has to send the results to Lansing.

Adding hormones on top of hormones doesn't sound safe to me. Maybe she could consider a cervical cap or a diaphragm instead.
posted by Oriole Adams at 10:51 AM on March 14, 2008

I'm sorry, my tendancy to be glib and say "thalidomide flipper baby" is probably inappropriate at the best of times, but here it's also inaccurate and sabotaging my own question. Bad phear, no donut.

The issue at hand is two-fold. The medications my darling girlfriend takes

a) potentially cause birth defects
b) potentially reduce the effectiveness of hormonal birth control.

Thus, we use two forms of birth control. Seasonalle with condoms as a backup.

We would like to not have to continue to use condoms. Whether that means Seasonalle and a different secondary or a hormone-releasing IUD that, in theory, operates as a primary and a secondary all in one, is the decision.
posted by phearlez at 10:58 AM on March 14, 2008

Most progressive docs who are up-to-date on the safety lit, won't have this issue, but I have heard numerous stories of doctor's who wouldn't insert an IUD in someone who hadn't already had kids because of the risk of infection and subsequent infertility.

That isn't the only issue. In a woman who has never had a child, it can be (based on my own experience in trying - and failing - to have an IUD inserted as a nullapara) a very difficult and painful process to physically insert the thing.
posted by anastasiav at 10:59 AM on March 14, 2008

Vasectomy?
posted by Marky at 11:08 AM on March 14, 2008 [1 favorite has favorites]

I don't know the answer to your question, but I think I can clarify it for people who seem to be confused.

Ok, so the Mirena FAQ makes it sound as if they're not really sure how it works. It's pretty frustratingly blase about it:

Q. How does Mirena work?

A. There is no single explanation of how Mirena works.

Mirena may:

* Block sperm from reaching or fertilizing your egg
* Make the lining of your uterus thin (this may also result in benefits like less menstrual bleeding over time)
* Stop the release of your egg from your ovary (but this may not be the way it works in most cases)

It is believed that all 3 of these actions may work together to prevent pregnancy.

I guess the question is, which of those things are a result of the hormones in Mirena, and if any of them are not a result of hormones, is that enough to prevent pregnancy if the effectiveness of the hormones is reduced?

And yeah, I've never had a kid and have a Mirena, and the insertion was not fun. It took my doc three tries to get it in, and she's preformed a lot of insertions. However, I love it and will be getting another one when this one's all used up.

From what I understand, if she has heavy flow or cramps, the paraguard may make them a lot worse. Other than that, it doesn't seem like there would be a problem using the pill and the paraguard together.
posted by amarynth at 11:30 AM on March 14, 2008

You don't give enough information to answer the question from a medical perspective.

True, but that was deliberate. For one, I figure this is a generic issue that comes up for people who are in a much less rare circumstance than my darling is - antibiotics takers, for example, as several here have identified. For another.... I don't expect anyone to give me exact medical advice here. You're a doctor but not MY doctor, you know?

However, my darling girlfriend has been willing to discuss this freely with others in the past and I just cleared it with her, SO:

Susan has an optical condition known as one of the white dot syndromes. In this case, Punctate Inner Choroiditis. * (That link is not HER case, by the way - to the best of my knowledge she's never had Chlamydia :) We're fortunate to live in the DC area and have good insurance, so she's getting care from a great bunch of folk at the Wilmer Eye Institute in Baltimore.

The medications she's currently because of this are mycophenolate mofetil (CellCept®)[pdf] (in an off-label use to reduce further lesions) and a small dose of prednisone.

Initially it was just the cellcept because the lesions that has caused her visual disturbances were inactive, however she had another crop up some months ago, thus the predisone. They've tapered her back down on the prednisone (which was really only used because it's faster acting than the cellcept, so increasing the dose there, which they also did, would have less immediate response).

So, the cellcept is the issue both for potential birth defects and reducing birth control effectiveness. Even putting aside the defects, many women have onsets of these syndromes during pregnancy. To me that makes pregnancy unacceptable since it not only increases the chance of more lesions but also reduces treatment options during that time. We're both perfectly fine with adoption - Susan is herself adopted - so why risk it?

Which of course brings up vasectomy, as Marky mentions, and in fact I proposed it some time ago. She's highly resistant to it, however (We're atypical in many ways!), so for the moment it's not an option.

* There's not a lot of info out there on PIC, so if someone were to come across this during a Google search for other information, by all means feel free to use the email address in my profile and I'll put you in touch with Susan. She's always glad to answer questions about it, to the best of her ability.
posted by phearlez at 11:38 AM on March 14, 2008

Do not get a vasectomy, unless you are 100% certain you don't want to have kids and 100% certain you won't be with a woman (Susan or a different one) who wants to have their own kids at some point down the line. Adoption is a great option, one my wife and I may consider down the road after having our own two.

My doctor made it abundantly clear that vasectomy reversals are not very reliable, even if the plumbing does get hooked back up and running.
posted by shinynewnick at 11:47 AM on March 14, 2008

I would compare the failure rate of the methods you use now (I think that would be just multiplying the failure rate of condoms by the failure rate of Seasonale, if possible modifying the latter to reflect the true failure rate of Seasonale for people on the same medication as your girlfriend) to the failure rate of the IUD. IIRC, the failure rate for IUDs is so low that the failure rate for the IUD alone might be lower than the failure rate of using two methods.

Common potential downsides to IUDs: worse period cramps and iron-deficiency anemia. They are also a bitch going in.
posted by Jacqueline at 12:24 PM on March 14, 2008

Oh, and if she knows that she never wants to be pregnant, why doesn't she get sterilized? There is a new sterilization method for women now that doesn't involve surgery, they just basically jack you up and stick plugs in your fallopian tubes. I forget the name of it but a gynecologist should know.
posted by Jacqueline at 12:29 PM on March 14, 2008

One reason, Jacqueline, is that it's almost impossible for women who haven't had children to get sterilized. Most doctors will refuse to do it, on the ridiculous grounds that, "You'll change your mind and sue me later."
posted by agregoli at 2:08 PM on March 14, 2008

I'm in a similiar situation with medication that would cause birth defects, and I don't use anything more than an paraguard IUD. In my mind, an abortion would be a back-up birth control. Because the failure rate of the IUD is so low, I really don't expect that to have to happen, but I'll do it if I have to. And then I'd get my tubes tied.

Is that an outlook that you and your gf are comfortable with? If so, just do the IUD and relax.
posted by saffry at 2:48 PM on March 14, 2008

I know tons of childless women who have been sterilized. If one doctor refuses, go to another. Get referrals from Planned Parenthood for doctors who will do it without giving her crap about it, or seek out your local No Kidding chapter and ask the women there if they've been sterilized and who did it for them. If she has a medical issue that would make pregnancy harmful to her, and has to take medication for the rest of her life that will cause birth defects, then she's got a great reason to get sterilized.
posted by Jacqueline at 7:14 PM on March 14, 2008

Oh boy this is a toughy.

As a bit of preface, let me first say that I definitely ain't your or her doctor. However I am a doctor who does have a fair bit of experience with Cellcept, used primarily in the setting of solid organ transplantation. I have surprisingly not yet run into the issue of IUDs and Cellcept specifically. Also, in general, I'm a big fan of IUDs, know the general data fairly well, and in an otherwise healthy, never-pregnant woman would have no trouble recommending it depending on the circumstances.

That all said, IUDs and Cellcept are a dicey proposition. There is very, very little data on the combination. One concern is that IUDs may have decreased efficacy in the setting of immunosuppression (which would include Cellcept). This was suggested by some old data on prior generation IUDs in renal transplant patients. I'm not aware of newer data, though perhaps it exists. The second, more general concern is the whole issue of an invasive device being placed while someone's immune system isn't up to snuff. I suspect many physicians wouldn't recommend IUDs in this situation for this reason alone, though again, specific data on the risks are quite lacking. There may be someone out there with more expertise than I on family planning and contraception in the setting of immunosuppression, and I would definitely seek someone like that out. But off the top of my head, I don't know anyone I can refer you to. In your general vicinity, I would maybe hunt down someone on the faculty of UVA, Duke or Hopkins' Gynecology or Women's Health departments and see if you can get a referral. But my suspicion is that noone would feel particularly great about recommending this option for the risks I've outlined.

So the short answer: probably a bad idea, definitely worth getting a real, non-internet expert opinion prior to diving in.

I'd be wary of anyone being ok with placing an IUD in these circumstances without lots of experience with its use in immunosuppressed patients.
posted by drpynchon at 8:23 PM on March 14, 2008

Implanon.

I'm due for what will be my 3rd one, quite shortly :) if that's anything to go by?
The reported failure rate (0.1%) is very encouraging too! (Surgical Sterilization being 0.2%)

(If you want the details of my experiences with it - :) just ask.)
posted by mu~ha~ha~ha~har at 3:57 AM on March 15, 2008

Thanks drpynchon, we'll follow up on that. You might be interested - in doing some looking around to find more information I found mention of a few newer studies than the (I presume) old data in the 1982 publication on renal patients, I found an article that mentions a more current Kenyan study of HIV+ women with IUDs, which the authors claim leads them to conclude that an IUD is not necessarily contraindicated in immunosupressed patients.

here's their footnote:

Sinei SK, Morrison CS, Sekadde-Kigondu C, Allen M, Kokonya D. Complications of use of intrauterine devices among HIV-1-infected women. Lancet. 1998;351:1238-1241.
posted by phearlez at 8:49 AM on March 15, 2008

Thanks for that phearlez. I wasn't aware of it, but I do know that there are currently ongoing trials in the US trying to address the same question. That said, from an immunological standpoint, HIV differs a fair bit from Cellcept and Prednisone, so I wouldn't necessarily extrapolate much from HIV data.
posted by drpynchon at 9:42 AM on March 15, 2008

I wouldn't either, but I only have access to the paper making the assertion, not the paper from the Lancet. Not to mention at best a layman's ability to parse any of those documents...
posted by phearlez at 2:08 PM on March 15, 2008

Do a search for fertility awareness and read up on it. We used it for several years and it was nice not to be on drugs. For awhile we backed it up with condoms, but after a about a year, we became more confident in our ability to gather and interpret the data accurately. A few years after that, when we were "ready" to have kids, the awareness then made it super easy to make that happen too.
posted by markhu at 5:19 PM on March 17, 2008