SAN FRANCISCO — Fifty years after the introduction of oral contraceptives, physicians are looking to long-acting removable contraceptives to provide the next leap forward in preventing unintended pregnancy.

Three themes emerged in interviews with multiple physicians who gave separate presentations on contraception in sessions at the annual meeting of the American College of Obstetricians and Gynecologists.

First, nothing in the future of contraception is likely to match the revolutionary impact of oral contraception. Second, the great advances in contraception over the last half-decade still are accompanied by an unacceptably high rate of unintended pregnancies. And third, when asked to imagine what contraception might look like 50 years from now, most physicians looked to greater use of long-acting removable contraception (LARC) such as intrauterine devices (IUDs) or implants.

“The Pill is still one of the most important inventions ever, in terms of advancing not just women's health care but also women's rights and the ability for women to be in the workforce and to contribute in more ways that they want as members of society,” said Dr. Sarah Prager of the University of Washington, Seattle.

Long-acting removable contraception is the wave of the future, she said, because once the devices are inserted, they don't require patient participation in contraception, which has been one of the major stumbling blocks in contraceptive failures.

The next 50 years probably will see improvements in long-acting removable contraceptives, Dr. Prager added. “Our longest-acting LARC method only lasts for 10–12 years,” she noted.

Dr. Joseph Anthony Ogburn of the University of New Mexico, Albuquerque, shared the same vision for the future. “We did better than we did in the past, but we have great room for improvement,” he said. Approximately half of U.S. pregnancies are unintended, giving the United States the worst unintended pregnancy rate among developed countries.

Only about 1%–2% of U.S. women on contraception use an IUD, and less than 1% have a contraceptive implant. “If we could increase those numbers significantly, I think we could have a dramatic impact on the unintended pregnancy rate,” he said. Advances in the next 50 years probably will entail tweaking existing long-acting removable contraceptives to make them more acceptable.

But “I don't see anything as revolutionary as the Pill coming along any time in my lifetime,” he added.

Dr. Pouru Bhiwandi was more enthusiastic. “It's a very, very exciting time for all of contraception,” said Dr. Bhiwandi, an ob.gyn. in Raleigh, N.C., and an international consultant in women's health. “We have so many choices today, which we've never had before.”

Since the first oral contraceptive was approved in 1960, women's options grew with approval of more than 40 birth control pills and the development of other forms of hormonal contraception in transdermal patches, the vaginal ring, implants, and intrauterine devices (IUDs).

Modifications in dosing since the first oral contraceptives, which contained nearly four times the amount of estrogen and nearly 10 times the amount of progestin as today's formulations, have made the Pill safer and more acceptable, as have the development of newer estrogens and progesterones, she added. Newer regimens mean women no longer have to bleed while on hormonal contraception.

On the horizon are “exciting possibilities” for new products in barrier contraception that are both spermicidal and microbicidal to prevent sexually transmitted infections, plus “a whole range of new IUDs, a 1-year vaginal ring with a new progestin, and other products, Dr. Bhiwandi said.

The U.S. should emulate Europe, where longer-acting methods of birth control, including IUDs and contraceptives are much more prevalent, said Dr. Andrew Kaunitz, professor of ob.gyn. at the University of Florida, Jacksonville.

Although U.S. clinical trials report a failure rate of 1%–2% with oral contraceptive use, in “typical practice” it's much higher, Dr. Kaunitz said—around nine women per 100 couples annually have unintended pregnancies on the Pill. “That's too high,” he said.

Dr. Bliss Kaneshiro of the University of Hawaii, Honolulu, noted that long-acting contraceptive devices are expensive and not always covered by insurance. “One of the big challenges, I think, is cost,” she said. “Our challenge for the next 50 years is improving access to those good contraceptive methods.”

Dr. David Plourd of the Naval Medical Center, San Diego, said he hopes to see more options in long-acting removable contraceptives in the next 50 years, such as “a flexible IUD, not the semi-rigid T-shaped ones we have currently.”

The development of contraception methods targeted to men should play more of a significant role, he added.

Dr. Kaunitz disclosed financial relationships with Teva Pharmaceuticals, Bayer, Ortho (Johnson & Johnson), Merck, Procter & Gamble, Becton Dickinson, Sanofi-Aventis, and Medical Diagnostic Laboratories. Dr. Ogburn has been a consultant for Organon/Schering-Plough. Dr. Bhiwandi disclosed financial relationships with Teva Pharmaceuticals, Warner Chilcott, Boehringer Ingelheim, and Watson Pharmaceuticals. Dr. Plourd has been a speaker for Merck, Novartis, Sanofi-Aventis, Graceway, and Warner Chilcott.

Dr. Prager and Dr. Kaneshiro said they have no conflicts of interest.

Long-Acting Implants Are the Frontier for Contraception