Contraceptives and Abortifacients

So, originally this week I was going to write about some of the developmental delays I've been seeing this past week in clinic. But after multiple Supreme Court rulings on the contraceptive mandate, I decided I really can't stay quiet about this.

For those of you who haven't heard of these rulings, allow me to summarize them for you.

First, we have Burwell vs. Hobby Lobby. Hobby Lobby is an arts and crafts store owned by the Green family, who are devout Christians. Their argument was that their corporation remains a family owned business, and they should be able to run that corporation in line with their religious beliefs. The particular argument was that the contraceptive mandate of the ACA (the section that required insurers to cover at no additional cost all 20 FDA approved contraceptives) violated their religious beliefs because 4 of the contraceptives covered (two forms of IUDs and two forms of 'emergency contraception') are abortifacients, that is, they have an action that may prevent implantation and thus result in 'abortion' of a fertilized egg.

A linked case, Conestoga vs. Burwell, had a similar argument. The Hahn family is the sole owner of the company and also believe that these four contraceptives are abortifacients.

In these cases, the Supreme Court voted 5-4 in favor of the companies. It should be noted that all three female justices voted against this decision.

Wheaton College vs. Burwell was not decided this week, but was allowed to abstain from the contraceptive mandate until they can gather arguments to go in front of the Supreme Court in the future.

I see multiple issues with these decisions, but for now am only going to focus on the medical aspect: Whether these contraceptives are abortifacients or not.

Before we get into how these contraceptives work, here's a crash course on what needs to happen for pregnancy.

First, there needs to be a viable egg. Each month, roughly, an egg is released from the ovary following a hormonal signal called the LH surge. This is referred to as ovulation. The egg then travels down the Fallopian tube towards the uterus (you can view of diagram of this here, if you're more of a visual person). Somewhere in this Fallopian tube, it is met by the sperm released after sex. The sperm fight to be the first inside the egg, and the now fertilized egg (soon to be an embryo) travels down to the uterus, where it implants in the rich lining and starts to form an actual baby. Progesterone, another hormone, is produced by the ovary following ovulation to promote the growth of the lining of the uterus until the placenta (the direct connection between baby and mama) forms and can produce this hormone on its own.

You'll note that I said the sperm meet the egg in the Fallopian tube. Sperm can live inside the female body for up to 5 days after sex. The egg can only survive without being fertilized for 24 hours or so after ovulation. So the most fertile time for women is actually having sex prior to ovulation so that the sperm can already be present when the egg is released.

When the embryo does not implant, there is obviously no development of a placenta, so after a period of time (usually 2 weeks), the ovary stops producing progesterone, and the uterine lining sheds, resulting in a period. Birth control pills work by supplying the body with a continuous dose of progesterone (and some estrogen, yet another hormone), so the body thinks its pregnant and doesn't release another egg. Thus, when you are on the placebo pill week, you have your period because you are not producing progesterone.

Onto the 'emergency contraceptives'. Plan B, Plan B One-Step, and Next Choice are levonorgestrel, a progesterone-like hormone. Thus, it acts like progesterone by preventing ovulation. As already described, progesterone is necessary to keep the uterine lining intact for the developing embryo. So, if this pill was taken after ovulation, the ovary would continue to produce progesterone, allowing the implantation of the embryo into the uterine lining. This is taken after sex, so it wouldn't prevent the sperm from getting into the Fallopian tube in the first place (as daily birth control pills might). The only way it would prevent pregnancy is if it prevents ovulation. So, not an abortifacient.

Now, an aside, taking the pill after ovulation doesn't mean you'll get pregnant. Everything else has to go right for that to happen. Successful implantation is estimated to occur in 15-30% of natural cycles. Many miscarriages are not realized because the body simply rejects the embryo before the woman knows she's pregnant. Most of the time, this is because there is some major genetic issue--an extra set of chromosomes, or something of that nature. Trust me, after studying genetics and embryology, I was amazed that this process worked at all.

There are some studies showing that there may be some changes in the uterine lining following administration of loveonorgestrel, but as far as I can tell, these studies were all done in the 80s, and much more recent studies have shown that there is little to no effect on the lining. Medications have also changed a great deal in that time.

Ella, ulipristal acetate, is another pill form of emergency contraception. It acts as a mixed progesterone receptor agonist and antagonist, which means it sometimes acts like progesterone and sometimes blocks the action of progesterone. Its effect is determined by the timing of the cycle. It can prevent the LH surge if given early enough, but can also block the effect of the LH surge (ovulation) if given after this hormonal signal. Essentially, it directly delays ovulation, ideally long enough so that the sperm are no longer viable. If given after ovulation, though, it diminishes the ability for the ovary to produce progresterone, thus affecting the uterine lining. Because of this action, I can see its potential for 'abortion', by preventing implantation. Ella is a relatively new contraceptive medication, so there are relatively few studies out there--it was difficult for me to pin down its exact mechanism of action.

Intrauterine Devices (IUDs) are implants placed by an OB/GYN or another clinician trained in the insertion that are used for long-term contraception. Historically, they were thought to have effects primarily in the post-fertilization phase of pregnancy, but other evidence now suggests otherwise.

There are two types available on the market today. First is the copper IUD. This one has been around forever. There is no hormonal effect to this contraceptive, and it is cited as an effective emergency contraception. It seems the effect is primarily toxic to the sperm as they move through the uterus, but it also produces an inflammatory response in the uterus which may affect implantation. So, potentially disrupts implantation.

The second type of IUD is the hormonal IUD, such as Mirena or Skylar. It is a small plastic device that contains progesterone, which acts in much the same way that the progesterone pills function. They are effective for about 3-5 years after insertion and prevent 99% of pregnancies. In theory, these can cause a foreign body reaction in the uterus that prevents implantation, but women can still get pregnant using this device, and it's not very effective as an emergency contraception, so it doesn't seem that this is an active issue. Therefore, I say it's not an abortifacient.

Conclusions: Hobby Lobby may have had a case. As I mentioned, I disagree with the decision on multiple fronts, and this was only the start of it. At minimum, they should not be permitted to object to Plan B and hormonal IUDs on the basis of them being abortifacients, because the science indicates that they are not, and thus it is a flawed argument. Ella and other similar oral emergency contraceptives need to be studied more before we determine for certain whether they result in decreased implantation of a viable embryo. Copper IUDs likely produce an environment that is hostile to life in general in the uterus, and thus potentially disrupt implantation.

There is some disagreement about the term 'abortifacient' as well, since by definition an abortion is the termination of a pregnancy, and a pregnancy can only occur if there is implantation of the embryo, but I chose not to get into this discussion for now.

Thoughts? Questions? Concerns? Feel free to comment or use the contact me form located at the top of the blog. See you next week!