Humans have a long history of attempting to manipulate their fertility and so control the timing of the birth of their children. As knowledge around the biology of the menstrual cycle evolved, so too did the advice given to women about when intercourse was most likely to result in conception – followers of Hippocrates, widely considered the father of Western medicine, believed the fertile period directly followed menstruation.1 Other ancient writings refer to the enduring technique of ‘coitus interruptus’ and barrier methods such as vaginal pessaries – often soaked in various substances thought to have spermicidal qualities – were most commonly used by women.1 For women living in the middle ages, the use of oral agents, including arsenic and strychnine, frequently had lethal consequences.2 In the more recent past, recognition of the ovulation suppression effects of exogenous oestrogen and progesterone came about partly through the work of 1950s American gynaecologist John Rock, who was injecting women with high doses of synthetic hormone hoping to increase fertility by stimulating a rebound effect after cessation of treatment.2
The ‘modern woman’ with the array of safe and effective contraceptives available to her, can almost divide her life into phases based on reproductive choices. The early adult ‘trying not to get pregnant’ years, followed by the ‘having a family’ years, and finally the ‘don’t have to worry about that any more’ years.
But despite all the modern medicine available, pregnancies don’t always happen when we want them to and the consequences can be devastating.
I was recently reminded of the potential for a pregnancy at an unexpected time to completely alter a life’s trajectory as I sat in the consulting room with a nauseous 16-year-old, who thought she’d used a condom, and watched the second line on the urine test light up. In our society, she still has choices, and I hope I was able to help her make the right choice, for her, at this time in her life.
In general practice we are ideally placed to help our patients take control of their reproductive health and, as much as possible, get the timing right for them. Perhaps if I’d come across my young patient earlier, her painful situation could have been avoided with some timely contraceptive counselling. In this issue of Australian Family Physician, Katrina Allen from SHine SA shares her pearls of wisdom on that very subject, with some practical advice on managing the various contraceptive methods, including long acting, reversible methods and their particular use in younger women.3
Another important area in young women’s reproductive health is polycystic ovary syndrome (PCOS). Its prevalence and the importance of early diagnosis to try to minimise not only the potential reproductive difficulties but also those in the areas of metabolic and emotional health, is being increasingly recognised. The evidence based guidelines4 released last year are an excellent reference for general practitioners and in this issue, Jacqueline Boyle and guideline project director Helena Teede, provide a summary article on the latest evidence for the diagnosis and management of PCOS.5
As our patients move into the ‘having a family’ stage, it can be the absence rather than the presence of that second line on the urine test that brings the emotional turmoil. Fortunately, we’ve come a long way since the days of John Rock and have an ever-expanding armoury of assisted reproductive technologies that can help our patients – male and female – who are having difficulty conceiving. In her article, ‘Assisted reproductive technology: what’s new and what’s important?’,6 Kate Stern discusses the major issues in fertility treatment today and provides a comprehensive summary of available technologies, as well as their limitations and Eric Chung shifts our focus to the male perspective with an approach to infertility assessment and treatment as well as a brief summary of erectile dysfunction and testosterone replacement therapies.7
But it is important to remember the limitations of all this technology when discussing family planning with our patients. While there is much we can manipulate and change to achieve the desired reproductive outcomes, we don’t yet have the ability to turn back the clock on fertility.
Time is still, of the essence.