OBJECTIVE: To evaluate how epilepsy and intellectual and developmental disabilities (IDD) affect contraceptive provision among females with Medicaid insurance. METHODS: We obtained Medicaid claims data from 2016-2021 for females aged 12-51 years. We excluded individuals with diagnosis codes for menopause and those who underwent sterilization in 2016-2017. Using a validated definition of epilepsy, we identified females who met the criteria for epilepsy in 2016-2017, and we identified a comparison group of females enrolled in 2016-2017 who never met the criteria for epilepsy. We used International Classification of Diseases, Tenth Revision codes from previous claims studies to determine IDD diagnoses. We ascertained contraceptive prescriptions from 2018-2021. To evaluate the effects of epilepsy and IDD and their interaction on contraceptive prescription, we performed a multivariable logistic regression for prescription of any contraceptive method from 2018-2021. We performed similar logistic regressions for prescription of individual contraceptive methods from 2018-2021 among females prescribed any method of contraception. RESULTS: Our final sample included 207,699 females with epilepsy and 3,573,052 females without epilepsy. The logistic regression for contraceptive prescription showed that, compared with females who did not have epilepsy or IDD, females with epilepsy were significantly more likely to be prescribed any contraceptive method (adjusted odds ratio [aOR], 1.05, 95% CI, 1.04-1.06, P<.007), females with IDD were significantly less likely to be prescribed any contraceptive method (aOR, 0.57, 0.56-0.58, P<.007), and there was intermediate likelihood of contraceptive provision to females with co-occurring epilepsy and IDD (aOR, 0.83, 95% CI, 0.81-0.85, P<.007). There were statistically significant differences in prescription patterns for specific contraceptives among females with epilepsy alone, IDD alone, co-occurring epilepsy and IDD, and neither epilepsy nor IDD. CONCLUSION: Epilepsy has a small and statistically significant effect on contraceptive prescription for females with Medicaid insurance, even when adjusting for confounders. There is a statistically significant interaction between epilepsy and IDD that affects overall contraceptive prescriptions and prescriptions for specific methods.

PURPOSE OF REVIEW:To review the effectiveness of pain control methods for outpatient intrauterine device (IUD) insertions and endometrial biopsy (EMB) procedures. RECENT FINDINGS:Several approaches to decreasing pain with ambulatory IUD placement and EMB have been evaluated in the literature. Paracervical blocks, cervical lidocaine spray, nonsteroidal anti-inflammatory drugs (NSAIDs), and anxiety reduction techniques have been shown to decrease pain reported by patients. For both IUD insertion and EMB, evidence regarding NSAIDs for intraprocedural pain is mixed, and they should be advised to decrease postprocedural cramping. A paracervical block with local anesthesia successfully targets pain but can cause discomfort with injection. Misoprostol may improve ease of IUD insertion and thus may be useful in select patients with difficult placements; however, routine use is not recommended because of increased side effects and risk of expulsion. Ultrasound-guided IUD insertion and nitrous oxide administration have also shown efficacy but are limited by cost and logistical barriers. SUMMARY:Pain during IUD placement and EMB is multifactorial and best addressed with use of an individualized, multimodal approach. Shared decision-making should guide clinician and patient discussion for offering strategies such as preprocedural NSAIDs, lidocaine spray, paracervical blocks, and anxiety management to all patients to optimize comfort and procedural experience.

BACKGROUND:There is increasing social media discourse on inadequate pain management during intrauterine device insertion. While a paracervical block has the most evidence for reducing intrauterine device insertion pain in the ambulatory setting, few studies have explored what factors contribute to paracervical block utilization at the level of the individual patient visit. OBJECTIVE:To estimate the utilization rate of pain management techniques, including paracervical block, during intrauterine device insertion and evaluate whether there are patient-based or provider-based factors associated with pain management methods. STUDY DESIGN:We used billing data from January 2021 through December 2021 to identify patients who received contraceptive care in the Obstetrics and Gynecology ambulatory unit of a tertiary academic medical center. We then conducted a retrospective chart review of patients with billing codes indicating an intrauterine device insertion. We describe the prevalence of intrauterine device insertions and receipt of paracervical block according to patient characteristics, as well as other pain management options. The odds of receiving a paracervical block according to patient characteristics were assessed with a multivariable logistic regression model with adjusted odds ratios and 95% confidence intervals of the effect based on parity, presence of gynecologic condition, race/ethnicity, and insurance. RESULTS:Between January 2021 and December 2021, a total of 1464 unique patients accessed contraceptive care during the study period, and 464 patients underwent intrauterine device insertion. Notably, most patients had no documentation of any pain management method provided during intrauterine device insertion (N=339, 73.1%). A paracervical block was used for 12.5% of insertions (N=58). Common pain management options include oral nonsteroidal anti-inflammatory drugs (N=103, 22.2%) and acetaminophen (N=36, 7.8%). In our multivariable model, we observed statistically significant differences in the odds of receiving a paracervical block based on parity and presence of a gynecologic condition, controlling for patient race/ethnicity and insurance; nulliparous patients had over double the odds of receiving a paracervical block compared to multiparous patients (adjusted odds ratio, 2.61; 95% confidence interval, 1.11, 6.90), as did patients with a documented gynecologic condition (adjusted odds ratio, 2.23; 95% confidence interval, 1.15, 4.36). Among 34 clinicians inserting intrauterine devices, only 10 used a paracervical block. Three-quarters of paracervical blocks were performed by 2 providers. CONCLUSION:Pain management options for intrauterine device insertion are broadly underused in an ambulatory tertiary care setting. Paracervical block utilization appears to be associated with specific providers rather than a patient-centered pain management approach. This highlights a need for increased attention to pain control and clinician education for intrauterine device insertion.

Objective: To evaluate contraception use and change among young women with early breast cancer. Design: Secondary analysis of a cluster randomized trial. Subjects: Patients with newly diagnosed breast cancer age <= 45 years enrolled from 54 US oncology practices. Intervention: Sites were randomly assigned to the Young Women's Intervention, an educational intervention for young women with newly diagnosed breast cancer and their oncologists addressing issues specific to this population, including contraception, or a contact-time control physical activity intervention. Participants completed surveys in follow-up, including a 3-month survey regarding contraceptive practices before and after diagnosis. Main outcome measures: Outcomes of interest included young women's contraceptive use and methods before breast cancer diagnosis and 3 months after study enrollment. Logistic regression models assessed factors associated with use of less than highly effective contraceptive methods categorized according to World Health Organization effectiveness tiers and changes in contraceptive methods. Results: Of 312 women included, 258 (83%) reported contraceptive use before breast cancer diagnosis, and 275 (88%) reported contraceptive use after diagnosis. Use of highly effective methods (e.g., vasectomy, non-hormonal intrauterine devices) increased from 39% before diagnosis to 52% after diagnosis. Use of moderately effective methods (e.g., hormonal methods) decreased from 22% before diagnosis to 3% after diagnosis. Use of less effective methods (e.g., condoms, withdrawal) increased from 22% before diagnosis to 34% after diagnosis. On multivariable analysis, factors associated with using less than highly effective contraception after diagnosis included desire for additional children (odds ratio [OR], 6.33; 95% confidence interval [CI], 3.76-10.66) and discussing contraception with a provider (OR, 1.96; 95% CI, 1.12-3.40). After breast cancer diagnosis, 207 patients (66%) reported no change in contraceptive methods. On multivariable analysis, factors associated with contraceptive method change after diagnosis included age <35 years (OR, 2.96; 95% CI, 1.57-5.58) and provider discussion (OR, 3.59; 95% CI, 1.91-6.78). There was no association in either analysis with study arm. Conclusion: Although most patients used contraception after breast cancer diagnosis, nearly half reported using less than highly effective contraceptive methods with higher failure rates, highlighting the need for early and improved contraceptive counseling for young women with breast cancer.

Abortion doulas support patients who are receiving abortion care. Understanding the abortion doula landscape is critical for patients, clinicians, doulas, and those interested in expanding programs for doula support. We aimed to describe the state of US-based abortion doula programs through a mapping review of the grey literature, documenting programs' characteristics from their online presence (websites, Facebook, Instagram, X). We identified 17 active abortion doula programs. In addition, we identified 30 programs which appeared either to be inactive or to not provide abortion support, primarily in states with post-Dobbs abortion bans. Most active abortion doula programs are community-based, volunteer-run, and free for patients. Three doula programs have partnerships with local clinics; three clinics have in-house doula programs. Most train their own doulas. Most US-based abortion doula programs independently provide community-based, no-cost, volunteer doula services.

This cohort study examines adoption rates in states with vs without Targeted Regulation of Abortion Providers (TRAP) laws.

Importance The 2022 US Supreme Court decision Dobbs v Jackson Women’s Health Organization overturned federal protections to abortion care, allowing many states to severely restrict or ban access to abortion. Given the implications of the Dobbs ruling, there is a need to understand the full consequences of restricted abortion access. Before 2022, many states restricted access to safe and legal abortions through Targeted Regulation of Abortion Providers (TRAP) laws, which provide a historical mode for estimating the consequences of abortion restrictions. Objective To use TRAP law enactment as a natural experiment to quantify the association between restricted abortion access and foster care entries. Design, Setting, and Participants In this cohort study, data on the enactment of TRAP laws and case-level data on foster care entries were used to estimate the association between restricted abortion access and foster care entries in each of the 50 US states and the District of Columbia. The sample included children conceived between January 1, 1990, and December 31, 2011, who were placed into foster care at any point between January 1, 2000, and December 31, 2020. Data analysis was performed from January 2023 to July 2023. Exposures Restricted abortion access due to state-level TRAP laws during pregnancy. Main Outcomes and Measures The main outcome was the number of children entering foster care in each state, measured by year of child conception. The analysis was performed using a generalized difference-in-differences design, comparing entries into foster care in states with TRAP laws to states without TRAP laws, before and after their implementation. Results This study included 4 179 701 children who were placed into foster care during the study period, with 11 016 561 entries. More than half of the children were male (51.4%), and the mean (SD) age was 7.4 (5.2) years. There was an 11% increase in foster care placement after abortion access was restricted in states with TRAP laws, relative to states without TRAP laws (incidence rate ratio [IRR], 1.11 [95% CI, 1.01-1.23]). These laws had significant consequences for Black children (IRR, 1.15 [95% CI, 1.05-1.28]) and racial and ethnic minority children (IRR, 1.15 [95% CI, 1.02-1.30]). The increase in entries due to TRAP laws was particularly attributable to housing inadequacy (IRR, 1.21 [95% CI, 1.11-1.32]). Conclusions and Relevance Restricted abortion access can have numerous consequences, and these findings reveal a heightened strain on the US foster care system, particularly affecting marginalized racial and ethnic communities and financially vulnerable families. These placements have been shown to have lifelong consequences for children and substantial costs for both states and the federal government. To further examine the widespread implications of the overturning of Roe v Wade , future studies should forecast the expected increase in foster care entries and estimate the expenditure needed to support these children.

ObjectivesTo measure plasma concentrations of medroxyprogesterone acetate (MPA) in users with epilepsy treated with anti-seizure medications and compare these to MPA concentrations in those without epilepsy.MethodsFor this multi-site cross-sectional study, we obtained a single blood sample from those with epilepsy treated with various anti-seizure medications (n=18) within the week before their next depot medroxyprogesterone (DMPA) injection. Among the participants without epilepsy (n=20), 10 similarly were scheduled within the week prior to the next injection, and 10 were scheduled at earlier intervals to attempt to balance the time intervals between groups. MPA concentrations were determined by a validated assay.ResultsMPA concentrations were similar among those with epilepsy and controls, and between groups with and without use of enzyme-inducing medications. The lowest MPA concentrations, under 0.07 ng/mL, were observed among two of eight using enzyme-inducing anti-seizure medications; one of 10 using non-inducing medications, and one of 19 controls had concentrations below 0.2 ng/mL.ConclusionsIn this exploratory study, lower MPA concentrations in some participants using enzyme-inducing anti-seizure medications suggest a potential interaction that could reduce DMPA efficacy.

Objective Systemic rheumatic conditions affect reproductive‐aged patients and often require potentially teratogenic medications. We assessed the feasibility and impact of a standardized pregnancy intention screening question (One Key Question [OKQ]) in a large academic rheumatology practice. Methods This 6‐month pilot quality improvement initiative prompted rheumatologists to ask female patients aged 18 to 49 years about their pregnancy intentions using OKQ. We administered surveys to assess rheumatologists’ barriers to and comfort with reproductive health issues. We performed chart reviews to assess uptake and impact on documentation, comparing charts with OKQ documented with 100 randomly selected charts eligible for pregnancy intention screening but without OKQ documented. Results When we compared 32 of 43 preimplementation responses with 29 of 41 postimplementation responses, the proportion of rheumatologists who reported they were very comfortable with assessing their patients’ reproductive goals increased (31%‐38%) and the proportion reporting obstetrics and gynecology (OB/GYN) referral challenges as barriers to discussing reproductive goals decreased (41%‐21%). During the implementation period, 83 of 957 (9%) eligible patients had OKQ documented in their chart. Female providers were more likely to screen than male providers (odds ratio 2.42, 95% confidence interval 1.21‐4.85). Screened patients were more likely to have their contraceptive method documented (P < 0.001) and more likely to have been referred to OB/GYN for follow‐up (P = 0.003) compared with patients who were not screened with OKQ. Conclusion Although uptake was low, this tool improved provider comfort with assessing reproductive goals, the quality of documentation, and the likelihood of OB/GYN referral. Future studies should examine whether automated medical record alerts to prompt screening increase uptake.

Objective: Prior work shows that ads related to abortion services often feature crisis pregnancy centers instead of abortion providers. We investigated whether a change in Google's advertising policy that re-quired advertisers to disclose whether they provided abortion services increased the proportion of ads facilitating abortion self-referral.Study Design: We used a standardized protocol to search online for abortion services before, during, and after the policy change; we performed searches in August 2016 to June 2017, June 2019, and October 2019, respectively, using Google, Bing, and Yahoo search engines. We performed searches for the 25 most populous U.S. cities and the 43 state capitals not already included. We classified up to the first 5 ads as facilitating abortion referral, hindering abortion referral, or providing neutral content. We compared search engine results using a chi-square test.Results: Among ads returned by Google, those shown after the policy change were significantly more likely to facilitate abortion self-referral (66.7% vs. 44.2%; p = 0.003) and slightly less likely to hinder abortion self-referral (33.3% vs. 40.6%; p = 0.33) compared to before the change. These findings were reversed for ads shown by Bing and Yahoo; ads returned after the change were significantly less likely to facilitate abortion self-referral (24.6% vs. 32.8%; p = 0.01) and significantly more likely to hinder self -referral (28.3% vs. 21.6%; p = 0.03) compared to before the change.Conclusion: A policy requiring advertisers to disclose whether they provide abortion services was associated with increasing the proportion of ads facilitating self-referral. Similar policies should be considered by all search engines.Implications: While the internet is a convenient source of information that individuals often use to locate abortion providers, the information may not actually lead searchers to services. Search engines should consider restricting abortion-related advertising to organizations that provide abortion services in order to ensure that individuals searching online for abortion services are able to locate services in a direct and timely manner. (c) 2022 Elsevier Inc. All rights reserved.

Objective: We calculated the prevalence of contraindications to progestin-only pills (POPs) among reproductive age women to evaluate the safety of over the counter provision. Study Design: This descriptive study queried a multi-institution US database to identify women ages 10 to 45 presenting for preventive care, and a subset of this initial cohort also presenting for contraceptive services, to estimate the prevalence of contraindications to POPs using diagnosis and procedure codes. Results: Among 813,888 females seeking preventive care between 2009 and 2015, 4.36% had a condition associated with a potential risk or unacceptable risk for initiation of POPs, compared to 2.29% of the 71,216 women seeking both preventive care and contraceptive services. Current breast cancer, the only condition classified as an unacceptable risk for initiation, was listed as a diagnosis for 2.67% and 0.57% in each respective group. Conclusion: The prevalence of contraindications to POPs among reproductive age women is low. This finding supports the relative safety of an over the counter progestin-only contraceptive pill. (C) 2021 Elsevier Inc. All rights reserved.

This review will clarify the complex relationship of hormonal contraception and mood in women both with and without mood disorders, in adolescents, and in postpartum women. Though the overall effect of hormonal contraception on mood does not appear to have a significant clinical impact, several recent population-based studies suggest adolescents are potentially more vulnerable than adults. Strategic initiation of hormonal contraception may mitigate mood symptoms, with continuous regimens of hormonal therapy demonstrating some benefit over cyclic regimens. Additional rigorous studies are needed to measure the impact of hormonal contraception on mood relative to dose and formulation, particularly in those women with pre-existing mood disorders.

INTRODUCTION: One in six American women experience sexual abuse in their lifetime, which pre-disposes a large percentage of our patients to post-traumatic stress disorder. Patients report being re-traumatized when undergoing exams during childbirth and routine Ob/Gyn visits. Very little is known about whether Ob/Gyn physicians are trained to care for patients who have experienced trauma. METHODS: This study was a cross-sectional survey administered to program directors at all US and Canadian Ob/Gyn Residency programs in September of 2019. RESULTS: At this time, 58 out of 241 (24%) program directors have responded to the survey and represent all ACOG districts. Over 20% of programs have formal training that occurs every year, 63.8% have had some training occur in the past though not on a regular basis, and 15.5% have never had any training. When asked about the primary barrier to providing this training, 27.6% of respondents cited the lack of facilitators to teach it, followed by lack of time within the residency curriculum (17.2%). About 30% of respondents are satisfied with the current training provided at their program. All respondents agree that Ob/Gyn residents need to be trained in trauma informed care, 60.3% believe it should be a CREOG educational objective, and 88% would be somewhat or extremely likely to implement a training program specifically designed for Ob/Gyn residents if one became available. CONCLUSION: Most Ob/Gyn residency programs are providing some training on the care of patients who have experienced trauma, however respondents in our sample are largely unsatisfied with how this occurs.

Objectives: Currently, patients with federally funded insurance are required to sign a sterilization consent form (SCF) at least 30 days prior to sterilization, while privately insured patients are not. Although this policy was designed to protect the reproductive rights of vulnerable populations, it has had the unintended effect of creating a disparity in access to an effective contraceptive method. Our qualitative study aims to clarify the decision-making process surrounding postpartum sterilization and assess if patients perceive that the SCF adds value. Study design: We interviewed 25 women who underwent postpartum sterilization procedures, 10 with private insurance and 15 with Medicaid. Topics discussed included reproductive history, reason for choosing sterilization, decision-making timeline and value of the SCF. We transcribed and coded the interviews and identified themes. Results: Participant responses indicated that decision-making processes were similar between patients with private insurance and those with Medicaid. For most women, the decision to undergo sterilization took place over the course of their reproductive lives. Participants expressed that nonbiased provider counseling, autonomy and information from other women were helpful to their decision making. Most subjects felt that the SCF might benefit other women but did not/would not affect their own decision making. Conclusions: We did not find evidence suggesting that women with private insurance and women with Medicaid should be subjected to disparate restrictions on sterilization based on differences in decision-making processes. Characteristics of the decision-making process that women value, which in this population did not include the SCF, should be prioritized. Implications: Given the potential negative consequences associated with the SCF including its disproportionate burden on women of low socioeconomic status, the lack of value added to the decision-making process for postpartum sterilization reported by our participants provides further evidence for reevaluation of the policy. (C) 2018 Elsevier Inc. All rights reserved.

to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions or ideas contained in the material herein.Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made.Although all advertising material is expected to conform to ethical (medical) standards, inclusion in this publication does not constitute a guarantee or endorsement of the quality or value of such product or of the claims made of it by its manufacturer.

This eResources article provides links to patient education materials that can aid in the selection of a contraceptive method and links to medical guidelines that can help healthcare providers evaluate the safety of specific methods in women with complex medical conditions. BACKGROUND Forty percent of all pregnancies worldwide are unintended (either unplanned or mistimed).1 For women with preexisting medical conditions, unintended pregnancy may worsen their disease, be associated with poor pregnancy outcomes, expose the pregnancy to potentially teratogenic medicines, or render patients ineligible for interventions such as organ transplant. Unfortunately, women who may have increased medical and obstetrical risk in pregnancy have the same rates of unintended pregnancy as the general population.2,3 Most female transplant patients are sexually active, and ovulation and menstruation (although sometimes irregular) usually resume within months after transplant surgery.4-6 The unintended pregnancy rate among transplant patients has been reported as high as 93% and the rate of contraceptive use only 48% to 72%.4,7 To reduce the risks of unintended pregnancy and to address the unmet need for contraception, contraception must be incorporated into the clinical care of transplant patients.8 CONTRACEPTIVE METHODS Modern contraceptive methods vary in their reversibility, mode of delivery, length of use, hormonal composition, and effectiveness at preventing pregnancy. The World Health Organization and the United States Centers for Disease Control provide a patient guide to contraceptive methods listed in tiers according to their effectiveness [A]. Fact sheets are available to educate patients about contraceptive options [B,C], some of which are in Spanish, Chinese, and Portuguese, in addition to English [C]. The Bedsider Web site has an interactive contraception guide that includes photos and video testimonials [D]. Current methods of contraception are briefly described here: Permanent sterilization includes vasectomy, tubal sterilization, and hysteroscopic tubal occlusion, which are highly effective surgical procedures that are irreversible and appropriate only for patients who are certain that they do not desire or have completed childbearing. Long-acting reversible contraception is as effective as sterilization but is not permanent. These are small devices that are inserted either in the uterus or subdermally in the arm and can remain in place for up to several years. The copper intrauterine device (IUD) is hormone-free, whereas the hormonal IUDs and implants deliver a progestin. Progestin injections are used monthly or every 3 months and are highly effective. Combined hormonal contraception includes a daily oral pill, weekly transdermal patch, and monthly vaginal ring, all of which deliver both an estrogen and a progestin. The estrogen component increases risk for venous and arterial thrombosis, especially in women with underlying risk factors. Compared with older formulations, modern versions of the pill contain lower doses of estrogen and therefore carry a lower thrombogenic risk. These methods are less effective than long-acting reversible contraception or injections, primarily because of patient nonadherence. Progestin-only pills require daily administration and do not contain estrogen. Emergency contraception is a pill that may be used within several days of unprotected intercourse to delay ovulation and prevent pregnancy. This Web site can help patients navigate access to emergency contraception [E]. Barrier contraception includes condoms, diaphragms, cervical caps, and spermicide. These methods are used with each episode of coitus and contain no hormones. These are the least effective of the methods presented here; with typical use, 12% to 21% of women relying on these methods will become pregnant within 1 year. CONTRACEPTIVE SAFETY IN TRANSPLANT PATIENTS The World Health Organization publishes evidence-based and consensus guidelines evaluating the relative safety of contraception in women with specific medical conditions (Medical Eligibility Criteria for Contraceptive Use) [F]. Similar guidelines have been adapted and issued in the United States and the United Kingdom [G,H]. A single-page summary chart is also available for easy reference [I]. For each medical condition, contraceptive methods are classified as follows: Category 1: No restriction Category 2: Advantages generally outweigh theoretical or proven risks Category 3: Theoretical or proven risks generally outweigh the advantages Category 4: Unacceptable health risk The US Centers for Disease Control and the UK Medical Eligibility Criteria for Contraceptive Use state that women with uncomplicated solid organ transplants may initiate any method of contraception (barrier methods are category 1, and all nonbarrier methods are category 2). Women with complicated solid organ transplants, defined as acute or chronic graft failure, rejection, or cardiac allograft vasculopathy, may safely initiate the progestin implant, progestin injection, and progestin pills (category 2) and may continue to use IUDs that are already in place (category 2). For complicated transplant patients, inserting a new IUD is not advisable (category 3). Combined hormonal contraception is contraindicated for both women with complicated solid organ transplants and women with Budd-Chiari syndrome (category 4). Clinical studies of contraception in transplant patients are limited in both number and size. In small prospective studies, renal and liver transplant patients using the combined hormonal pill, patch, and ring for more than 12 months did not become pregnant and maintained stable transplant functions.9,10 In one of these studies, antihypertensive regimens did require adjustment in some patients, and 2 patients discontinued the pill because of lower extremity thromboembolism and acute graft rejection.9 Historical concern about IUD use after transplantation stems from case reports of contraceptive failure and bacterial peritonitis in renal transplant patients thought to be linked to chronic immunosuppression.11 However, more recent case series of transplant patients using IUDs demonstrated contraceptive efficacy and safety, with no unintended pregnancies or pelvic infections.12,13 Serum and intrauterine biomarkers measured before and after progestin IUD insertion provide evidence of a local, but not systemic, inflammatory response in both transplant patients and healthy controls.14 Furthermore, more robust clinical literature of HIV patients has shown that the copper IUD is both safe and effective in this immunosuppressed population.15 When choosing appropriate contraception with a transplant patient, comorbidities and medications must be considered along with the patient's clinical status. For example, certain medical conditions, such as uncontrolled hypertension or a history of venous thromboembolism, preclude use of exogenous estrogen, and immunosuppressive therapies may affect or be affected by contraceptive hormone metabolism. GENERAL APPROACH TO CONTRACEPTION FOR THE TRANSPLANT PATIENT For the transplant provider, it is important to address contraception with reproductive-age patients at the pretransplant evaluation, because women must delay pregnancy until at least 1 year after transplant, and at follow-up visits.16 This topic can be introduced with a simple question: "Would you like to become pregnant in the next year?" (This is branded as One Key Question [J], a campaign to encourage physicians to routinely screen patients for contraceptive need.) Depending on the patient's response, she may be referred to a gynecologist or family planning specialist for contraception counseling and provision or to an obstetrics specialist for pregnancy planning and management. Women needing contraception should be encouraged to use barrier methods as a bridge to more effective contraception. Coordination of reproductive care between transplant teams and obstetrician/gynecologists minimizes the unnecessary morbidity of unintended pregnancy and optimizes the safety of intended pregnancy among transplant patients. Links For patients: [A] https://www.cdc.gov/reproductivehealth/unintendedpregnancy/pdf/contraceptive_methods_508.pdf [B] http://www.arhp.org/publications-and-resources/patient-resources/fact-sheets [C] http://www.reproductiveaccess.org/key-areas/contraception/ [D] https://www.bedsider.org/methods [E] http://ec.princeton.edu/providers/index.html For providers: [F] http://www.who.int/reproductivehealth/publications/family_planning/MEC-5/en/ [G] https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6503.pdf [H] https://www.fsrh.org/standards-and-guidance/external/ukmec-2016-digital-version/ [I] https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf [J] http://www.onekeyquestion.org

stable. Tissue immediately next to the fibrosed alginate implant also showed an increased expression of the macrophage marker CD68 and the local inflammation marker TGFβ1 together with a delayed increase in the B cell marker CD19. Removal of innate immune macrophages by clodrosome treatment eliminated the fibrosis of hydrogel alginate. However, clodrosome treatment also eliminated the innate immune population entirely, thus limiting its clinical application. Inhibition of cytokine receptor colony stimulating factor-1 receptor, however, reduced host immune-mediated recognition and propagation of foreign body rejection while preserving essential macrophage functions. These findings provide not only insights into the immunological basis of foreign body responses but may also provide the basis for the development of macrophage-specific agents that may be integrated into drug-elution systems reducing the fibrotic response to implanted medical devices.