University of Southern California Dissertations and Theses

Clinical research in reproductive health

(USC Thesis Other)

Clinical research in reproductive health

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CLINICAL RESEARCH IN REPRODUCTIVE HEALTH

by

Rachel Leah Steward

A Thesis Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(CLINICAL AND BIOMEDICAL INVESTIGATIONS)

May 2011

Copyright 2011 Rachel Leah Steward

ii
Acknowledgements

To the casual observer, a thesis may appear to be solitary work. However, to complete a
clinical research project requires an enormous network of support, and I am indebted to
many people. Chapter One, entitled “Abortion,” would never have been possible without
the generosity of time and knowledge from Dr. Mary Gatter and Dr. Deborah Nucatola at
Planned Parenthood of Los Angeles. Chapter Two “Contraception”, was made possible
by Dr. Daniel Mishell; a mentor to whom I am eternally grateful for wisdom, guidance,
and inspiration. Also, I would like to extend gratitude to my thesis committee, Dr.
Stanley Azen, Dr. Frank Stanczyk and Dr. Melissa Wilson.

iii
Table of Contents

Acknowledgements ii

List of Tables iv

Abstract v

Preface vii

Chapter 1: Abortion 1
Abstract 1
Introduction 2
Materials and Methods 4
Results 7
Figure 1. Frequency of extramural deliveries per 1,000 11
procedures and 95% confidence intervals.
Discussion 11
Chapter 1 References 15

Chapter 2: Contraception 17
Abstract 17
Introduction 18
Materials and Methods 21
Preliminary Results 27
Discussion 28
Chapter 2 References 31

Chapter 3: Conclusion 34

Comprehensive Bibliography 35

Appendix: Sperm-cervical mucus penetration score, 39
WHO sperm cervical mucus classification score,
WHO cervical mucus quality score.

iv
List of Tables

Table 1: Characteristics of individuals who received D&E with 8
digoxin injection between gestational weeks 18 and 24
from 2000 to 2008 (n=4906)

Table 2: Frequency of extramural delivery of subjects who 10
received digoxin injection prior to D&E by year,
estimated gestational age, and race (n = 4,906)

v

Abstract

The work described in this thesis aims to add evidence to current clinical practices in
reproductive health. The first chapter examines the risk of increased maternal morbidity
with the use of digoxin as a feticidal agent when injected prior to a dilation and
evacuation (D&E) procedure. The second chapter is devoted to evaluating the thickening
of cervical mucus as a mechanism of action of combined oral contraceptive pills (COCs).

The first study described is a retrospective cohort study of 4,906 D&E procedures
performed at Planned Parenthood of Los Angeles. Our hypothesis prior to conducting the
study was that injection of digoxin conferred little increase in extramural delivery or
infection when used as a feticidal agent. In this cohort, extramural delivery frequency
was 0.30% and infection frequency was 0.04%. These frequencies are consistent with
published rates for the procedure itself. Our data adds to the growing body of literature
supporting physician discretion to use digoxin as a feticidal agent prior to performing a
D&E.

The second study is an ongoing open-label investigator blinded, randomized controlled
crossover equivalency study comparing in vitro sperm penetrability and quality of
cervical mucus on the last day of the hormone free interval of women assigned to one of
two groups. Our hypothesis is that the cervical mucus of women taking COCs will be of
poor quality compared to their own mid-cycle cervical mucus. We also hypothesize that
the cervical mucus on the last hormone free day of women taking a 21/7 regimen will be

vi
of equivalently poor quality as those on the 24/4 regimen. The data collection for this
study is on-going but our preliminary results are consistent with this hypothesis.

vii
Preface

This thesis is a combination of two research projects in women’s reproductive health.
Though these two studies are very different in subject, design, and application; they are
unified by the fact that they were both executed by the same principal investigator
(myself) with the intention of adding evidence to current clinical reproductive health
practices. They cover the full spectrum of family planning services in that they cover
both abortion and contraceptive practices. One is a retrospective single cohort study, the
other an open-label, investigator-blinded, randomized controlled crossover equivalency
study. One was conducted at Planned Parenthood of Los Angeles (PPLA) on surgical
abortion technique; the other was conducted at the Los Angeles County + University of
Southern California Medical Center (LAC+USC) on women desiring contraception. One
is finished; one is far-from complete. Both studies were simultaneously an exercise in
frustration and gratification; but more importantly helped to cement my understanding of
what it means to undertake clinical research.

The first chapter I have entitled “Abortion.” This chapter is devoted to my study that is
currently in press after being accepted for publication in the journal Contraception. This
is a retrospective cohort study of 4,906 women presenting for Dilation and Evacuation
(D&E) from 18 to 24 estimated gestational weeks who also received Digoxin injection to
induce fetal demise prior to the procedure. When the Partial-Birth Abortion Ban Act was
upheld in 2007, many providers performing second-trimester abortion elected to use a
feticidal agent to ensure compliance with the law. In the published literature, the practice

viii
of inducing fetal demise is neither indicated nor contraindicated for medical reasons.
There is little data to support those providers choosing to administer the medication for
legal reasons.

One related study, published in abstract form only by Dean et al. suggested an increased
risk of infection and extramural delivery following the use of digoxin to induce fetal
demise. Because PPLA had been administering digoxin for non-legal reasons for the past
decade, we decided to collect the data on the frequency of these two outcomes in our
patient population. The abstract was accepted for oral presentation at the Association of
Reproductive Health Providers in September of 2010 in Atlanta, GA. My presentation
was well-received and I was encouraged to write the manuscript to submit for publication.
To me, this study represents the confluence (and occasional juxtaposition) of surgical
abortion care, clinical research, and legal advocacy for women’s rights. I am very proud
that this paper will be published in the coming months.

The second chapter, entitled “Contraception,” I have devoted to my ongoing investigator-
blinded, randomized controlled crossover study. This study aims to evaluate the
thickening of cervical mucus as a mechanism of action of Combined Oral Contraceptive
pills (COCs) and to further examine the potential increase in efficacy of a 24/4 regimen
when compared to a 21/7 regimen.

ix
This study has taught me more than I ever anticipated about the challenges of conducting
clinical research in an academic setting. After one month of enrollment, this study was
suspended by the IRB for an adverse event. After many internal review meetings, I went
before the board to explain how the event occurred and how we could prevent such
events if we were granted permission to continue in the future. After many amendments
to our protocol and informed consent the IRB approved resumption of the study. This
process advanced our time-line by approximately six months.

Since resuming enrollment, we have faced significant challenges recruiting healthy
patients from our predominantly unhealthy county hospital clinic population despite
having actively recruited women through personal solicitation, flyers and newspaper
postings at local universities, and on various websites. In addition, approximately 50% of
our subjects have been non-compliant with protocol visits or study drug regimens despite
rigorous screening questions prior to enrollment. Most recently, I submitted an
amendment that was approved by the IRB to increase the compensation for subject visits
in the hope of increasing our retention of enrolled subjects. This change allowed us to
adequately compensate women for the time and travel associated with participating in
clinical research. I learned if we are to devalue anything in clinical research, it cannot be
the reimbursement of the very women that allow us to complete studies that not only
change practice, but establish our academic careers. To the women who have participated
in my study, I am eternally grateful.

x
Despite the many unpredicted delays that this study has encountered, I am extremely
proud of the work that I am doing. When this study is finished, I am confident that the
results (whether they are in agreement with our hypothesis or not) will have a significant
contribution to the evidence supporting the mechanism of action of COCs. Even more
importantly, I believe the results of this study will help to dispel the myth that COCs act
as abortofacients. Because of this clinical trial, my hope is that more physicians will
provide COCs and more women will use them, thus further decreasing the need for
procedures such as those studied in Chapter One.

This thesis reflects my passions as a reproductive health provider. I believe first and
foremost in preventative medicine. I believe that with sound evidence and increased
access, women will have the opportunity to plan their own reproduction. However, in the
face of increased political opposition to women’s rights and the lack of federal support
for preventative intervention; I believe even more passionately, in the right of women to
utilize abortion services. It is my dream that every woman wanting to prevent a
pregnancy can do so in a safe and efficacious manner. Yet, for every woman who cannot;
it is my realistic mission to provide safe and accessible abortion care. This thesis is the
representation of my academic pursuit with the underlying clinical theme to provide
comprehensive reproductive care to all of my patients

1
Chapter 1: Abortion

1.1 Abstract

Background: Many abortion providers use digoxin to induce fetal demise prior to
dilation and evacuation (D&E). Our primary objective was to examine the frequency
of infection and extramural delivery following digoxin use.

Study design: We conducted a retrospective single cohort study. Inclusion criteria were
all women between 18 and 24 weeks estimated gestational age who received digoxin in
preparation for D&E at our outpatient facility. We queried two electronic databases to
collect data on the frequency of extramural delivery and the rate of peri-operative
infection.

Results: From January 1, 2000, to December 31, 2008, 4906 induced abortions were
performed between 18 and 24 weeks estimated gestational age with digoxin injection
administered as a feticidal agent one day prior to D&E. Extramural delivery frequency
was 0.3% and infection frequency was 0.04%. There were no significant differences in
the frequency of extramural deliveries across the 9 procedure years (p=0.2), estimated
gestational age (p=0.3), race/ethnicity (p=0.2), or maternal age (p=0.3).

Conclusion: Rates of extramural delivery and infection are low following digoxin use
prior to scheduled D&E.

2

1.2 Introduction

The safety of induced abortion in the second trimester has been well established [1]. In
the United States, dilation and evacuation (D&E) is the most common method of
pregnancy termination beyond 13 weeks estimated gestational age, with more than
140,000 procedures performed annually [2]. In recent years, the practice of inducing fetal
demise prior to the procedure has become more common for a variety of reasons. Passage
of the Partial-Birth Abortion Ban Act of 2003 made it a violation to perform an abortion
in which a “living fetus” is delivered vaginally “deliberately and intentionally” past
certain anatomical landmarks, before fetal demise occurs [3]. When the law was upheld
in 2007, many providers performing second-trimester abortion elected to use a feticidal
agent to ensure that the law would not be violated because the fetus was no longer
“living” when the procedure commenced.

There are several techniques that can be used for induction of fetal demise prior to a
termination of pregnancy including cardiac puncture and exsanguination, air
embolization, and umbilical cord transection [4]. Currently, in the United States,
pharmacologic agents are the most commonly used method [4]. For many years prior to
the 2007 legislation, clinicians at our site had been using digoxin to facilitate second-
trimester termination of pregnancy for other potential benefits. It is believed by some
clinicians that digoxin injection results in softer, macerated fetal tissues that may ease
evacuation of the fetus and potentially decrease procedure time and risk of complications

3
[5,6]. Finally, research has shown that some patients prefer the induction of fetal demise
prior to the abortion procedure [7].

Data on the side effect profile of digoxin, when used as a feticidal agent, are scarce.
Other than extramural delivery, there have been no reports of complications associated
with digoxin use for this indication. One study of eight women who received 1.0 mg of
digoxin intraamniotically showed no adverse maternal cardiovascular effects [8]. Another
study evaluating digoxin doses of 0.125-1.0 mg administered either intraamniotically or
intrafetally supported its maternal safety [9]. Only one study employed post-injection
maternal electrocardiographic monitoring, during which no arrhythmias were noted [8].

In reference to the specific outcomes of infection and extramural delivery following
digoxin injection, there is still a paucity of data. The only cases of infection documented
in patients who received a feticidal injection were with the use of potassium chloride
(KCl) intrafunic, intracardiac, and transcervically, respectively [10 -12]. There are several
case series that examine the rate of extramural delivery after iatrogenic fetal demise.
Molaei et al. [9] specifically examined the safety of digoxin as an agent to induce fetal
demise. In this series, there were 1796 cases, of which nine women who received a
digoxin injection experienced spontaneous contractions and were sent to the hospital
prior to the scheduled return visit (0.5%). Seven women had received intrafetal and two
had received intraamniotic digoxin [9].

4
In August of 2009, Dean et al. [13] published in abstract form only, a retrospective
double cohort study, consisting of 566 patients in Cohort A who received digoxin prior to
D&E and 513 patients in the control group, Cohort B. They found that digoxin injection
prior to D&E was associated with increased rates of spontaneous abortion (1.9% vs. 0%)
and infection (1.2% vs. 0.2%) when compared to controls who did not receive digoxin.
The purpose of conducting the current study was to add to the growing body of evidence
evaluating digoxin’s safety when used to induce fetal demise. We hypothesized that study
subjects who were administered digoxin intrafetally or intraamniotically would have a
small absolute risk of extramural delivery and an infection frequency consistent with
historical norms for the procedure itself.

1.3 Materials and methods

Our clinic uses an electronic practice management (EPM) system to track all procedures
performed. Data collected includes patient demographics and estimated gestational age as
obtained by ultrasound examination. We also maintain a second electronic database of all
adverse events experienced by patients including but not limited to: hospital transfers, out
of office deliveries, and post-operative infections requiring hospitalization or IV therapy.
Collection and documentation of these events is by clinic staff or providers from outside
institutions reporting on our patients presenting to them for care. These reports are
documented contemporaneously with the occurrence of each event.

Multiple prior internal quality-assurance studies have been completed as process
measures to ensure that these databases are reliable and usable sources of information.

5
One hundred fifteen charts were randomly selected from six outpatient sites to analyze
whether the gestational age determined by ultrasound examination and documented by
the clinician at the time of the procedure, matched what was recorded in the EPM system.
All gestational ages reported by the database matched the charts to within one week. Our
adverse event database was verified by a separate audit of 100 randomly selected charts.
We reviewed all charts for any documentation of infection defined as temperature greater
than or equal to 100.4˚F, clinical suspicion of infection, treatment with an antibiotic other
than doxycycline or metronidazole (which are given as routine prophylaxis), or transfer
to a hospital. There were no cases that met infection-defining criteria identified by the
chart review, which accurately corresponded to our adverse event database.

We searched our EPM system for all abortion procedures between 18 and 24 weeks
estimated gestational age and retrieved demographic information on these women. We
then searched our adverse event database to identify patients that met our inclusion
criteria. The aforementioned electronic databases were queried using the SQL Server .05
for CPT code 59841 to obtain a list of all surgical abortions performed from January 1,
2000, to December 31, 2008. We then searched within that list for all patients who
received digoxin by using billing code x6082. All women included in the study were
between 18 and 24 weeks estimated gestational age and all received 1.0 mg digoxin per
clinic protocol, injected either intraamniotically or intrafetally shortly after laminaria
placement one day prior to the D&E procedure. Digoxin was used for abortions
performed between 18 - 20 weeks gestation only from May 2007 to August 2008. While

6
the clinic protocol utilized digoxin injection for all procedures performed at 20 weeks or
greater since 1999, the starting gestational age was decreased to 18 weeks in response to
the Partial Birth Abortion Act, which became effective in 2007. Digoxin use for the 18 -
20 week gestational age was discontinued in August 2008 secondary to two out-of-office
deliveries in this gestational age group.

We abstracted maternal age, estimated gestational age, race, ethnicity, procedure date,
occurrence of infection, and occurrence of extramural delivery from our databases. The
following maternal age categories were employed in analysis: 0-12, 13-15, 16-20, 21-25,
26-30, 31-35, 36-40, 41-45, and 46+. Race and ethnicity were combined into a single
race/ethnicity variable by categorizing any subject with Hispanic ethnicity as Hispanic,
and all non-Hispanics as Asian/Pacific Islander, Black, Native American/Alaskan Native,
White or other/unknown. We calculated annual, race-specific, age-specific, estimated-
gestational-age-specific and overall frequencies of extramural deliveries. Since only two
infectious complications occurred over the study period, we were unable to perform
stratified analysis for infections. Infection rates were compared to published historical
norms (ranging from 0.05% to 2.00%) following second-trimester abortion [14]. We
calculated exact binomial 95% confidence intervals. The presence of differences in event
frequencies across age group, race/ethnicity, and year were assessed with the Fisher exact
test. Linear trends in event frequency across time and gestational age were evaluated by
visual inspection and Poison regression. Statistical analysis was carried out using SAS
9.2 (SAS Institute Inc, Cary, NC,) and Excel 2003 (Microsoft Corp, Redmond WA).

7
Institutional Review Board approval was obtained from an Independent Review
Committee located in San Anselmo, California.

1.4 Results

Between 2000 and 2008, there were 4,906 D&Es performed after digoxin was
administered. Characteristics of the patients who underwent this procedure are shown in
Table 1. Of these patients, 12 experienced definite extramural deliveries. An additional
three patients failed to return after laminaria placement and despite rigorous attempts to
contact them, were subsequently lost to follow-up. Assuming these three patients did go
into spontaneous labor, at most 15 women experienced extramural deliveries (0.3%, 95%
CI 0.2 – 0.5), and two patients had a peri-operative infection (0.04%, 95% CI 0.0 – 0.2).
One patient was a 19-year-old with a history of one prior cesarean section who presented
in December of 2002 at 22 weeks estimated gestation for a D&E and was administered
digoxin per protocol. On the second day after her uncomplicated D&E procedure, she
called the clinic stating her temperature was 102.9. She was referred to the nearest
hospital emergency department where she was admitted, treated with intravenous
antibiotics, and recovered completely. The second patient was a 17-year-old at 20 weeks
estimated gestation who presented on the day of her procedure complaining of fevers and
chills. Her heart rate was in the 120’s and her temperature prior to D&E was 100.4. She
had an uncomplicated procedure and was treated with Ceftriaxone post-operatively.

8
Table 1. Characteristics of individuals who received D&E
with digoxin injection between gestational weeks
18 and 24 from 2000 to 2008 (n=4906)

Characteristic n (%)
Year
2000 349 (7.1)
2001 269 (5.5)
2002 306 (6.2)
2003 326 (6.6)
2004 451 (9.2)
2005 784 (16.0)
2006 674 (13.7)
2007 900 (18.3)
2008 847 (17.3)

Gestational age, weeks
18 148 (3.0)
19 194 (4.0)
20 1077 (22.0)
21 1189 (24.2)
22 1062 (21.7)
23 929 (18.9)
24 307 (6.3)

Race/Ethnicity
Asian/Pacific Islander 295 (6.0)
Black 866 (17.7)
Hispanic 2479 (50.5)
Native American/Alaskan Native 31 (0.6)
White 807 (16.5)
Other/Unknown 428 (8.7)

Age group, years
13 to 15 142 (2.9)
16 to 20 1784 (36.4)
21 to 25 1565 (31.9)
26 to 30 701 (14.3)
31 to 35 409 (8.3)
36 to 40 238 (4.9)
41 to 45 62 (1.3)
46+ 5 (0.1)

9
The frequency of extramural delivery by year of the procedure, estimated gestational age,
and race/ethnicity are shown in Table 2. There were no significant differences in the
frequency of extramural deliveries across procedure year (p = 0.2) (see Fig 1), estimated
gestational age (p = 0.3), race/ethnicity (p = 0.2), or maternal age (p = 0.3). No secular
trends in frequency of extramural deliveries were apparent (p for linear trend = 0.2), nor
was there a significant linear trend in the frequency of extramural delivery for increasing
gestational age (p for trend = 0.9).

10
Table 2. Frequency of extramural delivery of subjects
who received digoxin injection prior to D&E by year,
estimated gestational age, and race (n = 4,906)

Procedures Extramural
deliveries
Frequency of extramural
delivery, percentage (95% CI)
Year
2000 345 4 1.2 (0.3 – 3.0)
2001 269 0 0 (0 – 1.4)
2002 306 0 0 (0 – 1.2)
2003 324 2 0.6 (0.1 – 2.2)
2004 451 0 0 (0 – 0.8)
2005 784 2 0.3 (0 – 0.9)
2006 674 1 0.1 (0 – 0.8)
2007 900 3 0.3 (0.1 – 1.0)
2008 847 3 0.4 (0.1 – 1.0)

Gestational age, weeks
18 148 2 1.3 (0.2 – 4.8)
19 194 0 0 (0 – 1.9)
20 1077 3 0.3 (0.1 – 0.8)
21 1189 3 0.3 (0.1 – 0.7)
22 1062 2 0.2 (0 – 0.7)
23 929 3 0.3 (0.1 – 0.9)
24 307 2 0.7 (0.1 – 2.3)

Procedures Extramural
deliveries
Frequency of extramural
delivery, percentage (95% CI)
Race/Ethnicity
Asian 295 3 1.0 (0.2 – 2.9)
Black 866 2 0.2 (0 – 0.8)
Hispanic 2472 7 0.3 (0.1 – 0.6)
American Indian /
Alaskan Native
31 0 0.3 (0 – 11.2)
White 807 2 0.2 (0 – 0.9)
Other 427 1 0.3 (0 – 1.3)

Total 4,906 15 0.3 (0.2 – 0.5)

11
Figure 1. Frequency of extramural deliveries
per 1,000 procedures (●) and 95% confidence intervals ( I ).

1.5 Discussion

These results are reassuring in regards to patient safety. For practitioners who wish to
achieve fetal demise prior to performing a D&E procedure, this study shows that use of
digoxin does not cause maternal adverse events in nearly all cases. Because digoxin
injection may confer a small additional risk of extramural delivery, beyond that inherent
in the D&E procedure itself, the possibility should be addressed with patients. This
discussion should include an individualized plan of where to present should labor begin
at home. If, however, the injection has been effective at inducing fetal demise, care is

12
often facilitated more smoothly at outside institutions by eliminating the debate of
whether to resuscitate a peri-viable fetus.

There are many limitations to our study. Unfortunately, our EPM system was initiated
shortly before our use of digoxin, and, as a result, we have no appropriate control group.
In addition, although we have data for patients undergoing procedures from 18 to 24
weeks estimated gestational age, our facility only administered digoxin prior to 20 weeks
for a short time (May 2007 to August 2008). As mentioned previously, this practice was
discontinued secondary to two out-of-office deliveries in this earlier gestational age
group. As expected, secondary to the small number of patients in this estimated
gestational age range, the two out-of-office deliveries did not reach a statistically
significant increase from prior years where its use was performed only more than 20
weeks estimated gestational age.

Our study is also limited by our electronic databases. Demographic data were obtained
from our EPM system, which was originally intended for billing purposes only. Ideally,
we would have preferred to look for an association of extramural delivery with gravidity
and parity. Unfortunately, this clinical data is not easily obtained using the current EPM
system.

Our study has many strengths. To verify our results we used multiple process measures to
ensure our data collection was accurate. Though we are dependent upon outside

13
institutions reporting back to us when our patients present for care with clinical signs of
infection, this communication occurs with great regularity for other complications not
included in this study. In addition, though there is a possibility that our infection rate is an
underestimation, the cases that we may have missed are likely post-operative rather than
a result of the digoxin injection. Any patient infected by the injection itself would likely
have had clinical signs or symptoms one day later upon presentation for the D&E. We are
confident that our occurrence log captured all cases of out of office delivery as our staff
employ rigorous means to contact all patients who have previously undergone laminaria
placement and digoxin injection.

The question remains as to why our data differs from that reported by Dean et al. [13].
Our rates of extramural delivery and infection are similar to the control group in their
study. Possible explanations for the difference include variations in digoxin injection
technique, variations in cervical preparation technique, underlying differences in
population characteristics, sample size, and variations in procedure length (i.e., one
versus two days of cervical preparation prior to D&E procedure). In addition, definition
of “spontaneous abortion” in our study is an “out-of-office delivery” as opposed to the
inclusion by Dean et al. of patients who delivered in the office prior to their procedure.
Unfortunately, data on the rate of extramural delivery following preparation for D&E
consisting of laminaria alone (no digoxin) has not been published.

14
It is possible that any subclinical infection that may result from digoxin administration
would be treated with the doxycycline that is routinely used prior to any D&E procedure.
To date, there is insufficient data to determine whether second-trimester abortion is made
safer by using digoxin to induce fetal demise prior to the procedure. To justify the
potential increase in spontaneous labor and out-of-office delivery, an increase in safety
would seem warranted. The induction of fetal demise remains largely a decision based on
practitioner and patient preference. However, for those providers who choose to employ
the technique, this data adds to the growing body of literature that supports the minimal
risk inherent in digoxin injection when used as a feticidal agent.

15
Chapter 1 References

[13] Dean G, Lunde B, Colarossi L, Jacobs A, Porsch L, Paul M. The safety and efficacy
of digoxin as a feticidal agent prior to second trimester abortion by dilation and
evacuation. Contraception 2009; 80:197 (abstract).

[8] Drey EA, Thomas LJ, Benowitz NL, Goldschlager N, Darney PD. Safety of
intraamniotic digoxin administration before late second-trimester abortion by dilation and
evacuation. Am J Obstet Gynecol 2000; 185: 1063-6.

[1] Grimes DA, Schulz KF. Morbidity and mortality from second-trimester abortions. J
Reprod Med 1985; 30: 505-14 [Evidence Grade: III].

[4] Induction of fetal demise before abortion. SFP Guideline 20101. Release January
2010. Contraception 2010; 81:462-473.

[7] Jackson RA, Teplin VL, Drey EA, et al. Digoxin to facilitate late second-trimester
abortion: a randomized, masked, placebo-controlled trial. Obstet Gynecol 2001; 97: 471-
76.

[2] Koonin LM, Strauss LT, Chrisman CE, Montalbano MA, Bartlett LA, Smith JC.
Abortion surveillance – United States, 1996. MMWR Morb Mortal Wkly Rep
1998:48:1-42.

[10] Li Kim Mui SV, Chitrit Y, Boulanger MC, et al. Sepsis due to Clostridium
perfringens after pregnancy termination with feticide by cordocentesis: a case report.
Fetal Diagn Ther 2002; 17: 124-6 [Evidence Grade: III]

[11] Lipitz S, Shalev E, Meizner I, et al. Late selective termination of fetal abnormalities
in twin pregnancies: a multicentre report. Br J Obstet Gynaecol 1996; 103:1212-6
[Evidence Grade: III].

[9] Molaei M, Jones HG, Weiselberg T, McManama M, Bassell J, Westhoff C.
Effectiveness and safety of digoxin to induce fetal death prior to second-trimester
abortion. Contraception 2008; 77:223-5. [Evidence Grade II-3].

[6] Nucatola D, Roth N, Gatter M. A randomized pilot study on the effectiveness and
side effect profiles of two doses of digoxin as a feticide when administered
intraamniotically or intrafetally prior to second-trimester surgical abortion. Contraception
2010; 81: 67-74.

[3] Partial-birth Abortion Ban Act, U.S.C. 1531. 2003.

16
[5] Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG, Creinin MD.
Management of unintended and abnormal pregnancy. Comprehensive Abortion Care.
Oxford, UK: Wiley-Blackwell; 2009. Chapter 11, p. 166.

[14] Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG, Creinin MD.
Management of unintended and abnormal pregnancy. Comprehensive Abortion Care.
Oxford, UK: Wiley-Blackwell; 2009. Chapter 15, p. 237.

[12] Timor-Tritsch IE, Peisner DB, Monteagudo A, et al. Multifetal pregnancy reduction
by transvaginal puncture: evaluation of the technique used in 134 cases. Am J Obstet
Gynecol 1993: 168:799-804 [Evidence Grade: III].

17
Chapter 2: Contraception

2.1 Abstract

Background: The main contraceptive effect of Combined Oral Contraceptive pills
(COCs) is inhibition of the mid-cycle LH surge to prevent ovulation; however, the
percent of ovulatory cycles in patients using low dose COCs ranges between 1.5 and 16.8
percent. Another potential progestin related mechanism of contraceptive action is
thickening of cervical mucus. Prior studies have examined the changes in cervical mucus
quality and sperm penetrability in women using progestin only methods, but few studies
have evaluated this mechanism in users of COCs.

Objectives: The primary objective of this study is to compare the effect upon sperm
penetration of the cervical mucus on the last hormone free day of users of a 24/4 regimen
to that of users of a 21/7 regimen. The secondary objective of this study is to quantify and
compare levels of ethinyl estradiol (EE) and norethindrone (NET) in the blood and
cervical mucus of participants on the last hormone free day when taking the 24/4 and the
21/7 regimens.

Methods: This is an open-label, investigator-blinded, randomized controlled crossover
equivalency study comparing the in vitro sperm penetrability and quality of cervical
mucus using WHO grading criteria on the last day of the hormone free interval of women
assigned to one of two groups. Healthy, reproductive age women are randomized by a
computer generated system to receive a 20µg EE and 1mg NET-acetate formulation in a

18
21/7 day regimen, or in a 24/4 day regimen. After two months of each regimen, subjects
present on the last day of the hormone free interval for cervical mucus sampling and
venipuncture to measure estradiol, EE, progesterone, and NET levels. Linear sperm
penetration, penetration density, and motility are graded on a scale of 0-3 to calculate the
Sperm Penetration Meter Score (SPMS) validated by Eggert-Kruse et al. (1989).

Results: Of the 31 subjects screened, 5 were excluded for inability to comply with
protocol, pregnancy, or insufficient cervical mucus. Six patients are currently pending
enrollment. Of the 20 subjects enrolled, 8 have been discontinued. There are currently 12
active subjects: one subject completed all study visits, 8 are within their first two months
of study participation, and 4 have started the second arm. Data collection is ongoing.

Conclusion: There are many misperceptions regarding the mechanism of action of COCs
that contribute to low use in certain areas of the United States, including the
misperception that they act as abortifacients. This study aims to further clarify the action
of COCs on the cervical mucus to confirm that inhibition of sperm transport prevents
fertilization to provide contraceptive action even with possible ovulation.

2.2 Introduction

The main contraceptive effect of Combined Oral Contraceptive pills (COCs) is inhibition
of the mid-cycle LH surge to prevent ovulation. However, several studies have shown the
percent of ovulatory cycles in patients using low dose combined contraceptive pills

19
ranges between 1.5 and 16.8 percent [1,2,3,4,5,6,7,8]. With this high rate of ovulatory
cycles in women taking COCs, we would expect the pregnancy rate with COC use to be
much higher than the perfect use failure rate of 0.3% [9] were there not other effective
mechanisms of contraceptive action besides ovulation inhibition. Another potential
mechanism of contraceptive action is the suppression of FSH secretion during the
follicular phase of the cycle, thereby preventing follicular maturation; however, follicular
development has been shown to occur in 23-90% of cycles in women using COCs [1,5,9].
There are also many progestin related mechanisms that likely contribute to the overall
efficacy of the combined contraceptive pills; such as, thickening of cervical mucus,
impairment of tubal mobility and peristalsis, and effects on the endometrial lining,
making it less suitable for implantation.

It is known that sperm transport from the vagina to the oviducts is greatly dependent on
the properties of human cervical mucus, including mucus quantity, thickness and
hydration [10]. Beginning at approximately the ninth day of an ovulatory menstrual cycle,
increasing estradiol levels cause an increase in the amount of cervical mucus [11]. The
mucus quality changes and it becomes thin, watery, and allows sperm penetration from
the endocervix into the endometrial cavity. The effect of sperm penetrability increases
and reaches a peak on the day of ovulation. Progesterone is then secreted from the corpus
luteum and causes the cervical mucus to become scant in amount, thick, opaque and
unfavorable to sperm penetration.

20
Prior studies have examined the changes in cervical mucus quality and sperm
penetrability in women using progestin-only pills. Moghissi et al (1971) demonstrated
that microdose norgestrel (75 µg daily) causes alterations of physical and chemical
properties of cervical mucus such that it becomes highly viscous, cellular, and scanty,
exhibits reduced ferning and spinbarkeit, and inhibits sperm transport [12]. Barbosa et al
(1996) examined time to contraceptive effectiveness in users of the single implant
containing 55mg nomegestrol acetate [13]. Cervical mucus and sperm penetration tests
were altered in all subjects within 48 hours after insertion of the implant. Another study
of the same design enrolled thirty women desiring the 150mg DMPA injection and
measured the same parameters of cervical mucus changes [14]. This study showed all
subjects to have cervical mucus quality scores of 0, as determined by WHO criteria, and
sperm penetrability test sufficient to prevent pregnancy by day 7 after the injection.
Lewis et al (2010) demonstrated that mid-cycle mucus of users of the Levonorgestrel
intrauterine system is poor quality and prevents endocervical sperm transport in vitro [15].

Few studies have examined cervical mucus quality in users of combined oral
contraceptive regimens. One study published in 1976 by Elstein et al indicated that
contraceptive action of combined low-dose oral contraceptive is mediated through
suppression of ovulation and by rendering cervical mucus impenetrable to sperm [16].
Another randomized trial of two low-dose COCs by Winfried et al. found the quality and
quantity of cervical mucus to be minimal in the majority of women during treatment
cycles [17].

21

Another topic that this study aims to address is shortening of the pill-free interval with
COCs. Loestrin 24 Fe, trade name for the 24/4 day regimen of norethindrone acetate 1
mg/20 µg ethinyl estradiol was approved in 2006. Initial studies have shown that Loestrin
24 Fe is associated with a cumulative pregnancy risk of 0.9% during the first six cycles of
use and a Pearl Index of 1.79 in women ≤ 35 years old. In addition to a theoretical
improvement in efficacy, a shorter hormone-free interval also has the benefits of
decreasing symptoms such as pelvic pain, headache, breast tenderness and
bloating/swelling, which occur more frequently during this interval than when active pills
are ingested [18,19]. Recently Dinger et al. published a large U.S. Cohort study that
demonstrated a higher contraceptive effectiveness with a 24-day oral contraceptive
regimen compared with conventional 21-day regimen [20].

2.3 Materials and Methods

Design: This is an open-label, investigator-blinded, randomized controlled crossover
equivalency study comparing the in vitro sperm penetrability and quality of cervical
mucus using WHO grading criteria on the last hormone free interval of women assigned
to one of two groups. Otherwise healthy, reproductive-age women with regular menses
who desire initiation of contraceptive pills are enrolled for participation in this study.
They are randomized by a computer-generated system to receive either Loestrin Fe 1/20,
a 21/7-day regimen, or Loestrin 24 Fe, also with 20µg ethinyl estradiol and 1mg
norethindrone acetate, but in a 24/4-day regimen.

22
Participants: Subjects are recruited from the Los Angeles County – USC family
planning clinic by providers. Flyers with Reproductive Research Clinic contact
information have been posted on the University of Southern California Health Sciences
Campus. In addition, there are advertisements on the internet and in print. Inclusion
criteria are healthy women age 18 -39, desiring to initiate COCs. Exclusion criteria are
any contraindications to combined hormonal contraception including pregnancy, breast
feeding, liver disease, vascular or uncontrolled metabolic disorders, smoking greater than
15 cigarettes at age greater than or equal to 35, Body Mass Index (BMI) greater than or
equal to 40, migraine with aura, or untreated cervical dysplasia (LSIL or greater). Women
are excluded if they have used steroid hormone or intrauterine contraception within three
months prior to study enrollment, or six months prior in the case of DMPA. Currently
breastfeeding or patients less than three months post partum of a term pregnancy (or
within 6 weeks of a first trimester loss or termination), are also excluded, as are women
who cannot or will not refrain from intercourse or the use of vaginal douches during the
study period that requires cervical mucus assessment. The principal investigator
personally reiterates the importance of attendance to all scheduled visits. Each subject,
given unforeseen circumstances, must be willing to stay in the Los Angeles area for the
duration of the study and to be available on the specific days as outlined by the protocol.
These dates will be reviewed and confirmed with the subject prior to enrollment. Any
subject not able to commit to these strict stipulations is considered ineligible to
participate.

23
If an initial telephone or in-person screening deems that a woman meets initial inclusion
criteria, she is invited to present for a screening visit which will include informed consent,
provision of screening ID number, collection of demographic information, a complete
history and physical examination, gynecological exam and baseline laboratory testing
(Pap, gonorrhea, Chlamydia, and wet mount), and cervical mucus evaluation. If all
screening tests return negative and she has demonstrated adequate cervical mucus, she is
enrolled in the study and given a study ID number. If the cervical mucus she provides is
not adequate or penetrable, she returns in two days (Day 14 of her cycle). If on her
second collection day, the mucus is still not sufficient, she returns in two days (Day 16)
for a third collection. If after three mucus collections, her mucus is not adequate, she will
be excluded from further participation. Subjects with vaginitis or cervicitis will be treated
and may return for study enrollment in 2-4 weeks if test of cure is negative. Once a
subject is enrolled, she will be started on randomized method as dispensed by the
pharmacy via the “Quick Start” protocol [21].

On the fourteenth day during the active phase of the second month, the patient presents
for her 1
st
cervical mucus analysis and venipuncture. This visit may occur from Day 12 to
Day 16 of a woman’s cycle. The visit includes a gynecological exam with endocervical
mucus sampling using a specialized collection device. Venipuncture for Norethindrone
levels will be obtained. The Kremer Sperm Cervical Mucus Penetration Test will be used
to determine the Sperm Penetration Meter Score. After completing two months of the
COC, the patient returns on the last day of her hormone free interval for cervical mucus

24
sampling. At this visit, she undergoes a venipuncture for Estradiol, Ethinyl Estradiol,
Progesterone, and Norethindrone levels. If the subject does not present for cervical mucus
evaluation, she is given the option of continuing the same pill for an additional month. If
a subject does not present for her visits during the third month, she will be ineligible for
further participation.

Each subject is then switched to the group that she was not originally assigned and begins
taking the second regimen. Mid cycle (Day 12 to Day 16) of her fourth month, the patient
presents for her 3
rd
cervical mucus sampling, along with a measure of serum and mucus
Norethindrone levls. After completing two months of the second regimen of COC use,
the patient returns on the last day of her hormone free interval for her final cervical
mucus sampling and venipuncture. Each subject is compensated $30 for the screening
visit and $20 for each visit thereafter until enrollment. After enrollment, each subject is
compensated $40 for each visit.

Measures: Sperm analysis is performed on each semen sample by the PI, in coordination
with an experienced technician according to World Health Organization (WHO) criteria.
Semen is obtained frozen from a commercial sperm bank. A single fertile donor,
prescreened for infectious diseases, will be used to provide all semen samples. Samples
will be standardized to a uniform sperm concentration and motility prior to shipping to
this site. The concentration and motility of each semen sample is analyzed post-thaw,
prior to use to insure these parameters remain within normal limits.

25

The Kremer Sperm Cervical Mucus Penetration Test (SCMPT) [22,23,24] will be used to
determine the Sperm Penetration Meter Score and WHO Sperm Cervical Mucus
Classification Score. Cervical mucus is obtained by gentle endocervical aspiration using a
special collection device, and carefully inserted into a specialized flattened capillary tube.
Each tube of fresh cervical mucus is incubated at 37
◦
C in a humidified atmosphere in a
reservoir of semen and analyzed at two and six hours. Depth of linear penetration of the
most advanced sperm, density of penetration and the quality of forward motility is
assessed by phase-contrast microscopy. The principal investigator collects the cervical
mucus. Mucus analysis and analysis of the sperm-cervical mucus penetration test is
performed by the principal investigator who is be blinded to type of COC randomization.

Data collected from the participant, including the initial demographics collected, medical
history and physical exam, is kept in each participant’s file in the research coordinator’s
office, along with all lab slips and reports from all tests. Staff enter data into an Excel
Spreadsheet (using Subject #) so that all participants’ data can be kept together and later
transferred to SPSS for data analysis. Throughout the study period, data entry is
periodically double-checked by the principal investigator. A random sample of values
will be double entered to ensure data quality. All information is kept in a locked file
behind locked doors while not in use. Charts will be retained for 1 year following study
completion. Information stored on the computer is in a locked room that only the staff
and research physicians have access to with appropriate back up and fire walls.

26
The computerized randomization log will be kept by the IDS pharmacy. Medication will
be dispensed only after a subject has demonstrated adequate cervical mucus and been
enrolled. The PI will call the pharmacy directly and the Pharmacist will dispense the
medication according to the randomization log while the PI remains blinded.

Analysis: Statistical consultation will be obtained from the USC Keck School of
Medicine Department of Biostatistics and data will be analyzed using SPSS statistical
software. Linear sperm penetration, penetration density, and motility will each be graded
on a scale of 0-3 to calculate the Sperm Penetration Meter Score (SPMS) validated by
Eggert-Kruse et al. (1989). Period effect, and treatment-period effect will be tested for
using Wilcoxon signed-rank test. If no carryover-effect is detected, an exact 95%
confidence interval will be calculated for the mean within-patient difference in SPMS (δ)
between treatments. Equivalence will be defined at -1 < δ < 1. ANOVA will be used to
compare continuous, normally distributed variable between all different time points at
one. Post-hoc analysis will be used to determine between which groups the differences
lie. Kruskal-Wallis will be used to compare across the various time points for variables
that are not normally distributed.

Recruitment time was originally estimated to be 2-3 subjects per week for 15 weeks.
However, after six months of enrollment, we have found recruitment to be approximately
1 subject per week. The screening and follow-up visits for cervical mucus retrieval are
expected to require a commitment of five months from each subject. We now anticipate

27
subjects will be recruited and data will be collected starting in October 2010, to be
completed by October 2011.

This study is conducted on women, in a primarily underserved Latino population. While
we will not exclude from participation members of other racial or ethnic groups, we
expect that the majority of our subjects will be of Latina descent. In spite of this
limitation, we believe that the findings from this study will be applicable to women from
other minorities. Our informed consents will be written in both Spanish and English. For
participants that do not understand either Spanish or English sufficient to sign consent for
study participation we will be obtaining informed consent via a translator.

2.4 Preliminary Results

Data collection is ongoing. To date we have screened 31 subjects. Of those subjects we
have enrolled 20. Six patients are currently pending enrollment. Of the subjects enrolled,
8 have been discontinued. There are currently 12 active subjects. One subject has
completed all study visits, 4 have been randomized to the second arm, and 8 are within
their first two months of study participation.

Of the subjects screened, 5 were ineligible. 4 subjects did not have adequate mid-cycle
mucus and one subject was pregnant upon presentation for mucus analysis. There are 6
subjects that have presented for the initial screening visit but are awaiting their next
menses so that their mid-cycle mucus may be evaluated.

28
Regarding the subjects that were enrolled but subsequently discontinued: one subject
missed three pills in a row and became pregnant during this time; 5 subjects withdrew
consent for inability to comply with the study drug regimen; and 2 subjects were
completely lost to follow up despite rigorous attempts to make contact by the research
coordinator and principal investigator.

Because only one subject has completed all of the study visits, there is little in the way of
statistical analysis that can be done at this time.

2.5 Discussion

Though data collection is on going, there are considerations that already warrant
discussion. Clinical trials involving daily medication administration are extremely
difficult secondary to dependence upon subject compliance with study drug. In a recent
systematic review of measurement methods for COC use by Hall et al. [25], the authors
found among 38 studies, “a lack of consistent, well-defined measurement of COC use
limits the understanding of contraceptive misuse and related negative outcomes in the
literature.” Of the studies reviewed by Hall et al. >70% relied on self-reporting by the
subjects regarding COC compliance. One benefit of our study design is the mid-cycle
serum measurement of Norethindrone to objectively confirm subjects’ compliance with
study drug regimen.

Another benefit of our study is the crossover design. Because the two COCs being
studied both contain 20µg of ethinyl estradiol and 1mg norethindrone acetate, study

29
subjects should not experience any change in symptoms when being randomized to one
arm from another. Because of the identical hormonal configuration, we were able to
crossover the subjects without a washout period, which would have put all of our subjects
at, risk of unintended pregnancy. The crossover design allows us to use each subject as
her own control, essentially eliminating bias secondary to individual confounders.

One limitation to this study is that we did not include ultrasound examination at each visit
to evaluate follicular development and potential ovulation. Though studies have
demonstrated that between 1.5 and 16.8 percent of women taking COCs ovulate, our
study does not include ovarian follicular measurement, neither mid-cycle nor on the last
day of the pill-free interval. One area for future studies would be to examine the
thickening of cervical mucus in women on COCs with documented follicular
development.

Although evidence suggests that cervical mucus changes are a primary mechanism of
action of progestin-only contraceptives, no study has demonstrated the efficacy of
cervical mucus as a barrier to sperm penetration in users of combined oral contraceptives.
There are many misperceptions regarding the mechanism of action of COCs that
contribute to low use in certain areas of the United States, including the misperception
that they act as abortifacients. This study aims to further clarify the action of combined
oral contraceptive pills on the cervical mucus to confirm that inhibition of sperm
transport prevents fertilization to provide contraceptive action even in the context of

30
potential ovulation. Further more, we hope to elucidate whether shortening of the pill-free
interval maintains the poor quality of mucus providing for increased contraceptive
efficacy.

31
Chapter 2 References

[13] Barbosa IC, Coutinho E, Hirsch C, Ladipo OA, Olssen SE, Ulmsten U. Temporal
relationship between Uniplant insertion and changes in cervical mucus. Contracpetion.
1996 Oct;54(4):213-7

[24] Blasco L. Clinical tests of sperm fertilizing ability. Fertil Steril 1984; 41(2): 177-192

[1] Coney P, Del Conte A. The effects on ovarian activity of a monophasic oral
contraceptive with 100 µg levonorgestrel and 20 µg ethinyl estradiol. Am J Obstet
Gynecol 1999;181:S53-8

[23] Davajan V, Gunitake GM. Fractional in-vivo and in-vitro examination of postcoital
cervical mucus in the human. Fertil and Steril 1969; 20(2): 197-210

[20] Dinger J, Minh T, Buttmann N, Bardenheuer K. Effectiveness of Oral
Contraceptive Pills in a Large U.S. Cohort Comparing Progestogen and Regimen.
Contraception (117) 2011. 33-40

[7] Egarter, M. Putz, H. Strohmer, P. Speiser, R. Wenzl, J. Huber. Ovarian function
during low-dose oral contraceptive use. Contraception, Volume 51, Issue 6, June 1995,
Pages 329-33

[16] Elstein M, Morris SE, Groom GV, Jenner DA, Scarisbrick JJ, Cameron EH. Studies
on low-dose oral contraceptives: cervical mucus and plasma hormone changes in relation
to circulating D-norgest and 17alpha ethynyl-estradiol concentrations. Fertil Steril. 1976
Aug; 27(8): 892-9

[11] Gorodeski GI. Estrogen increases the permeability of the cultured human cervical
epithelium by modulating cell deformability. American Journal of Physiology. 275(3 Pt
1):C888-99, 1998 Sep.

[5] Grimes DA, Godwin AJ, Rubin A, Smith JA, Lacarra M. Ovulation and follicular
development associated with three low-dose oral contraceptives: a randomized controlled
trial. Obstet Gynecol 1994;83:29-34

[25] Hall KS, White KO, Reame N, Westhoff C. Studying the use of oral contraception:
a review of measurement approaches. J Womens Health (Larchmt). 2010 Dec: 19(12):
2203-10

[6] Hamilton & Hoogland. Am J Obstet Gynecol. 1989; 161: 1159-62

32
[4] Janneke van der Does, Niek Exalto, Thom Dieben, Herjan Coelingh Bennink. Ovarian
activity suppression by two different low-dose triphasic oral contraceptives.
Contraception, Volume 52, Issue 6, December 1995, Pages 357-361

[8] Klipping C, Duijkers I, Trummer D, Marr J. Suppression of ovarian activity with a
drospirenone-containing oral contraceptive in a 24/4 regimen. Contraception, Volume 78,
Issue 1, July 2008, Pages 16-25

[22] Kremer J. A simple sperm penetration test. Int J Fertil 1965; 10(3): 209-215

[15] Lewis R, Taylor D, Natavio M, Melamed A, Felix J, Mishel D. Effects of the
levonorgestrel-releasing intrauterine system on cervical mucus quality and sperm
penetrability. Contraception (82) 2010. 491-196

[19] Mishell Jr. D. Rationale for decreasing the number of days of the hormone-free
interval with use of low-dose oral contraceptive formulations. Contraception
2005;71(4):304-5

[12] Moghissi KS, Marks C. Effects of microdose norgestrel on endogenous
gonadotropic and steroid hormones, cervical mucus properties, vaginal cytology, and
endometrium. Fertil Steril 1971; 22(7): 424 – 434

[10] Ola B, Afnan M, Papaioannou S, Sharif K, Bjorndahl L, Coomarasamy A. Accuracy
of sperm-cervical mucus penetration tests in evaluating sperm motility in semen: a
systematic quantitative review. Hum Reprod. 2003 May;18(5):1037-46

[14] Petta CA, Faundes A, Dunson TR, Ramos M, DeLucio M, Faundes D, Bahamondes
L. Timing of onset of contraceptive effectiveness in Depo-Provera users: Part I. changes
in cervical mucus. Fertil Steril. 1998 Feb;69(2): 252-7

[2] Pierson RA, Archer DF, Moreau M, Shangold GA, Fisher AC, Creasy GW. Ortho
Evra™/Evra™ versus oral contraceptives: follicular development and ovulation in
normal cycles and after an intentional dosing error. Ortho Evra™/Evra™ 008 Study
Group Fertility and Sterility - July 2003 Vol. 80, Issue 1,34-42,

[3] Spona J, Elstien M, Feichtinger W, Sullivan H, Ludicke F, Muller U, Dusterberg B.
Shorter pill-free interval in combined oral contraceptives decreases follicular
development. Contraception 1996;54(2):71-7

[18] Sulak P, Scow R, Preece C, Riggs MW, Kuehl TJ. Hormone withdrawal symptoms
in oral contraceptive users. Obstet Gynecol 2000;95:261-6

33
[9] Trussell J. Contraceptive efficacy. In Hatcher RA, Trussell J, Nelson AL, Cates W,
Stewart FH, Kowal D. Contraceptive Technology: Nineteenth Revised Edition. New York
NY: Ardent Media, 2007

[21] Carolyn Westhoff, Jennifer Kerns, Chelsea Morroni, Linda F. Cushman, Lorraine
Tiezzi, Patricia Aikins Murphy Contraception - September 2002 (Vol. 66, Issue 3, Pages
141-145)

[17] Winfried G, Rossmanith, Steffens D, Schramm G. A Comparative Ranomized Trial
on the Impact of Two Low-Dose Oral Contraceptives on Ovarian Activity, Cervical
Permeability, and Endometrial Receptivity. Contraception (56) 1997. 23-30

34
Chapter 3: Conclusion

Through my entire academic career, I have dabbled in research without feeling fully
comfortable in my understanding of the material. During my undergraduate work at
Haverford College, I majored in Russian Literature and Pre-med and spent my time
translating Chekov and Nabokov instead of learning about Biostatistics and
Epidemiology. My medical school didactics were cursory in terms of research and though
we read articles and “interpreted findings,” I always felt I was outside of my comfort
zone. During my Ob/Gyn residency, we had “Journal Club” monthly, during which, we
made a point of finding study design flaws; but again, my participation felt superficial
and lacking true insight.

It wasn’t until I had the opportunity of pursuing this Master’s in clinical research that I
was able to finally understand what my previous twelve years of education had been
culminating towards. It is not that my career has been redirected toward research; I don’t
anticipate ever leaving clinical patient care. However, I have no doubt, the additional
education I have gained through the Master’s of Clinical Investigations will make me a
better educator, a better doctor, and a better person. I am most grateful for this incredible
learning journey.

35
Comprehensive Bibliography

Barbosa IC, Coutinho E, Hirsch C, Ladipo OA, Olssen SE, Ulmsten U. Temporal
relationship between Uniplant insertion and changes in cervical mucus. Contracpetion.
1996 Oct;54(4):213-7

Blasco L. Clinical tests of sperm fertilizing ability. Fertil Steril 1984; 41(2): 177-192

Coney P, Del Conte A. The effects on ovarian activity of a monophasic oral contraceptive
with 100 µg levonorgestrel and 20 µg ethinyl estradiol. Am J Obstet Gynecol
1999;181:S53-8

Davajan V, Gunitake GM. Fractional in-vivo and in-vitro examination of postcoital
cervical mucus in the human. Fertil and Steril 1969; 20(2): 197-210.

Dean G, Lunde B, Colarossi L, Jacobs A, Porsch L, Paul M. The safety and efficacy of
digoxin as a feticidal agent prior to second trimester abortion by dilation and evacuation.
Contraception 2009; 80:197 (abstract).

Dinger J, Minh T, Buttmann N, Bardenheuer K. Effectiveness of Oral Contraceptive
Pills in a Large U.S. Cohort Comparing Progestogen and Regimen. Contraception (117)
2011. 33-40.

Drey EA, Thomas LJ, Benowitz NL, Goldschlager N, Darney PD. Safety of
intraamniotic digoxin administration before late second-trimester abortion by dilation and
evacuation. Am J Obstet Gynecol 2000; 185: 1063-6.

Egarter, M. Putz, H. Strohmer, P. Speiser, R. Wenzl, J. Huber. Ovarian function during
low-dose oral contraceptive use. Contraception, Volume 51, Issue 6, June 1995, Pages
329-33

Elstein M, Morris SE, Groom GV, Jenner DA, Scarisbrick JJ, Cameron EH. Studies on
low-dose oral contraceptives: cervical mucus and plasma hormone changes in relation to
circulating D-norgest and 17alpha ethynyl-estradiol concentrations. Fertil Steril. 1976
Aug; 27(8): 892-9

Gorodeski GI. Estrogen increases the permeability of the cultured human cervical
epithelium by modulating cell deformability. American Journal of Physiology. 275(3 Pt
1):C888-99, 1998 Sep.

Grimes DA, Schulz KF. Morbidity and mortality from second-trimester abortions. J
Reprod Med 1985; 30: 505-14 [Evidence Grade: III].

36
Grimes DA, Godwin AJ, Rubin A, Smith JA, Lacarra M. Ovulation and follicular
development associated with three low-dose oral contraceptives: a randomized controlled
trial. Obstet Gynecol 1994;83:29-34

Hall KS, White KO, Reame N, Westhoff C. Studying the use of oral contraception: a
review of measurement approaches. J Womens Health (Larchmt). 2010 Dec: 19(12):
2203-10.

Hamilton & Hoogland. Am J Obstet Gynecol. 1989; 161: 1159-62

Induction of fetal demise before abortion. SFP Guideline 20101. Release January 2010.
Contraception 2010; 81:462-473.

Jackson RA, Teplin VL, Drey EA, et al. Digoxin to facilitate late second-trimester
abortion: a randomized, masked, placebo-controlled trial. Obstet Gynecol 2001; 97: 471-
76.

Janneke van der Does, Niek Exalto, Thom Dieben, Herjan Coelingh Bennink. Ovarian
activity suppression by two different low-dose triphasic oral contraceptives.
Contraception, Volume 52, Issue 6, December 1995, Pages 357-361

Klipping C, Duijkers I, Trummer D, Marr J. Suppression of ovarian activity with a
drospirenone-containing oral contraceptive in a 24/4 regimen. Contraception, Volume 78,
Issue 1, July 2008, Pages 16-25

Koonin LM, Strauss LT, Chrisman CE, Montalbano MA, Bartlett LA, Smith JC.
Abortion surveillance – United States, 1996. MMWR Morb Mortal Wkly Rep
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Kremer J. A simple sperm penetration test. Int J Fertil 1965; 10(3): 209-215

Lewis R, Taylor D, Natavio M, Melamed A, Felix J, Mishel D. Effects of the
levonorgestrel-releasing intrauterine system on cervical mucus quality and sperm
penetrability. Contraception (82) 2010. 491-196

Li Kim Mui SV, Chitrit Y, Boulanger MC, et al. Sepsis due to Clostridium perfringens
after pregnancy termination with feticide by cordocentesis: a case report. Fetal Diagn
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Lipitz S, Shalev E, Meizner I, et al. Late selective termination of fetal abnormalities in
twin pregnancies: a multicentre report. Br J Obstet Gynaecol 1996; 103:1212-6
[Evidence Grade: III].

37
Mishell Jr, D. Rationale for decreaseing the number of days of the hormone-free interval
with use of low-dose oral contraceptive formulations. Contraception 2005;71(4):304-5

Moghissi KS, Marks C. Effects of microdose norgestrel on endogenous gonadotropic and
steroid hormones, cervical mucus properties, vaginal cytology, and endometrium. Fertil
Steril 1971; 22(7): 424 – 434.

Molaei M, Jones HG, Weiselberg T, McManama M, Bassell J, Westhoff C. Effectiveness
and safety of digoxin to induce fetal death prior to second-trimester abortion.
Contraception 2008; 77:223-5. [Evidence Grade II-3].

Nucatola D, Roth N, Gatter M. A randomized pilot study on the effectiveness and side
effect profiles of two doses of digoxin as a feticide when administered intraamniotically
or intrafetally prior to second-trimester surgical abortion. Contraception 2010; 81: 67-74.

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39
Appendix: Sperm-Cervical Mucus Penetration Score,
WHO Spermcervical Mucus Classification Score,
WHO Cervical Mucus Quality Score

Sperm Penetration Meter Score
SCORE 0 1 2 3
Migration
Distance
<15mm 15-29mm 30-44mm ≥45mm
Density of
Penetration at
10mm and
45mm
0-9 sperm/LPF 10-49
sperm/LPF
50-99
sperm/LPF
≥100
sperm/LPF
Motility Grade
at 45mm
Immotile In-situ Motility
“Shaking”
Slow Forward
Motility
Highly
Propulsive
Motility
Maximum Score: 9/9 “Excellent” 6/9 “Good” 3/9 “Fair” 0/9 “Poor”

WHO Sperm Cervical Mucus Classification Score
Migration
Distance (mm)
Penetration
Density
(sperm/LPF)
Migration
reduction from
10 to 45 mm
(ranked order)
Duration of
progressive
movement in
cervical mucus
(hrs)
Classification
10 0 -- -- “Negative”
<30 <10 >3 <2 “Poor”
All
combinations
of tests results
not
classified into other category “Fair”
45 >50 <3 >24 “Good”

WHO Criteria for Cervical Mucus Evaluation
SCORE 0 1 2 3
Volume 0mL .1mL .2mL .3+mL
Consistency Thick, highly
viscous
Intermediate
viscosity
Mildly viscous Normal mid-
cycle pre-
ovulatory
mucus
Ferning No
crystallization
Atypical
ferning
Primary and
secondary stem
ferning
Tertiary and
quaternary
stem ferning
Spinnbarkeit <1cm 1-4cm 5-8cm ≥9cm
Cellularity ≥11cells/HPF 6-20cells/HPF 1-5cells/HPF 0 cells/HPF
Scoring: ≥ 10/15 indicative of good cervical mucus favoring sperm penetration

Abstract (if available)

Abstract The work described in this thesis aims to add evidence to current clinical practices in reproductive health. The first chapter examines the risk of increased maternal morbidity with the use of digoxin as a feticidal agent when injected prior to a dilation and evacuation (D&E) procedure. The second chapter is devoted to evaluating the thickening of cervical mucus as a mechanism of action of combined oral contraceptive pills (COCs).

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Asset Metadata

Creator Steward, Rachel Leah (author)

Core Title Clinical research in reproductive health

School Keck School of Medicine

Degree Master of Science

Degree Program Medicine

Publication Date 04/27/2011

Defense Date 03/25/2011

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag birth control pills,Digoxin,OAI-PMH Harvest,reproductive health

Place Name California (states), Los Angeles (city or populated place), USA (countries)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Azen, Stanley Paul (committee chair), Mishell, Daniel R., Jr. (committee member), Stanczyk, Frank Z. (committee member), Wilson, Melissa (committee member)

Creator Email rachel.steward@usc.edu,rachelst@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m3790

Unique identifier UC1474861

Identifier etd-Steward-4405 (filename),usctheses-m40 (legacy collection record id),usctheses-c127-458851 (legacy record id),usctheses-m3790 (legacy record id)

Legacy Identifier etd-Steward-4405.pdf

Dmrecord 458851

Document Type Thesis

Rights Steward, Rachel Leah

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Repository Name Libraries, University of Southern California

Repository Location Los Angeles, California

Repository Email cisadmin@lib.usc.edu