FERTILITY AND STERILITYt
VOL. 70, NO. 5, NOVEMBER 1998
Copyright 1998 American Society for Reproductive Medicine
Published by Elsevier Science Inc.
Printed on acid-free paper in U.S.A.
Received March 20, 1998;
revised and accepted June
3, 1998.
Supported by Family
Health International (FHI)
and the Andrew Mellon
Foundation, although the
views expressed in this
article do not necessarily
reflect those of FHI and the
Mellon Foundation.
Reprint requests: Carlos
Petta, M.D., Caixa Postal
6181, 13081-970,
Campinas, SP, Brazil
(FAX: 55-19-2892440;
E-mail: gpetta@turing.
unicamp.br).
* Depo-Provera, Upjohn
Co., Kalamazoo, Michigan.
Departamento de
Tocoginecologia,
Universidade Estadual de
Campinas.
time during the menstrual cycle if service pro-
Clinical Trials Division,
Family Health International.
0015-0282/98/$19.00
PII S0015-0282(98)00309-4
Timing of onset of contraceptive
effectiveness in Depo-Provera users.
II. Effects on ovarian function*
Carlos A. Petta, M.D., Anibal Faundes, M.D., Thomas R. Dunson, M.S.,
Marcia Ramos, B.Sc., Mara DeLucio, B.Sc., Daniel Faundes, M.D., and
Luis Bahamondes, M.D.
Departamento de Tocoginecologia, Universidade Estadual de Campinas, Campinas, Brazil; and Clinical Trials
Division, Family Health International, Research Triangle Park, North Carolina
Objective: To determine the timing of onset of contraceptive effectiveness after the first injection of 150 mg of depot
medroxyprogesterone acetate (DMPA) administered between days 8 and 13 of the menstrual cycle.
Design: Descriptive, prospective study.
Setting: A tertiary university referral center.
Patient(s): Thirty healthy women between 18 and 40 years of age.
Intervention: Volunteers were injected with DMPA between days 8 and 13 (5 women on each day) of the menstrual cycle.
Main Outcome Measure(s): Ovarian function determined by serum levels of E2 and progesterone and follicular devel-
opment evaluated by vaginal ultrasound.
Result(s): In nine (30%) of 30 women studied, DMPA did not prevent ovulation. All ovulations occurred in women
receiving DMPA between days 10 and 13 of the cycle. No woman who received injections on day 8 or 9 ovulated. Ovulation
suppression was more effective in women with low ovarian activity. All ovulation occurred within 3 days after the injection.
Conclusion: A back-up contraceptive method, used after the 7th day of the menstrual cycle, is recommended for up to 7
days after the first injection of DMPA. (Fertil Sterilt 1998;70:81720. 1998 by American Society for Reproductive
Medicine.)
Key Words: Depo-Provera, ovulation, contraception, back-up contraception, progesterone, estradiol
Depot medroxyprogesterone acetate (DMPA) the changes in ovarian function when the first
is a highly effective contraceptive method injection of DMPA is provided after the 7th
when the first injection is administered within day of the menstrual cycle became highly rel-
the first 7 days of the menstrual cycle. The evant. These changes must be correlated di-
principal mechanism of action is inhibition of rectly to the time a woman needs to use a
ovulation (1). However, in one study (2), when back-up method or observe sexual abstinence
DMPA was administered on days 9 and 11 it after the administration of DMPA.
did not prevent ovulation in five of 24 women. The first report of this study (4) focused on
On the basis of these findings, it has been the effect of a first injection of 150 mg of
recommended that the first injection of DMPA
DMPA administered on days 8 to 13 of the
be administered within the first 7 days of the menstrual cycle on the cervical mucus, and this
menstrual cycle. second report addresses the changes in ovarian
This practice recently has been considered function.
as a barrier to free access by women to this
contraceptive method, and consequently it was
suggested that DMPA can be initiated at any
MATERIALS AND METHODS
Study Population
viders can be reasonably sure that the woman is The study was performed at the Department
not pregnant (3). of Obstetrics and Gynecology, Universidade
In view of this new policy, the evaluation of Estadual de Campinas, Campinas, Brazil. Thirty
817
healthy women aged 18 40 years were enrolled in the study
between February 1995 and February 1996. Criteria for entry TABLE 1
into the study included a normal medical history and phys- Distribution of cases according to day of menstrual cycle,
ical examination, no use of hormonal contraception in the 4 E2 level, and follicle diameter at baseline; P level; and
months before entrance into the study, and no recent history ovulation status at US evaluation.
of pregnancy or breastfeeding. Subjects were required to be
between days 8 and 13 (inclusive) of their current menstrual Baseline Follicle Day 7 Follicle
Case Day of level of E2 diameter P level rupture on
cycles, with five women at each of these days of the cycle.
no. cycle (pg/mL) (mm) (ng/mL) US*
Their mean (6SD) age was 33.0 6 2.4 years.
1 8 48 7 1.0 No
Volunteers had to have been abstinent for 48 hours before 10 8 28 6 0.3 No
injection and had to agree to abstain from coitus or to use a 27 8 70 9 0.4 No
nonspermicidal condom for the duration of the study. 29 8 66 9 0.6 No
30 8 39 16 0.4 No
This study was approved by the institutional review board 2 9 66 12 0.3 No
of the University of Campinas. After being informed about 4 9 41 5 0.2 No
the purpose of the study and the risks and benefits associated 5 9 95 8 0.5 No
with the use of DMPA, all patients gave informed consent. 9 9 80 14 0.5 Yes
22 9 80 11 0.2 No
3 10 39 8 0.4 No
Subject Assessments 6 10 107 10 0.2 No
All subjects made up to seven visits (screening, admis- 7 10 63 8 0.4 No
sion, and five follow-up visits). The admission visit took 8 10 150 13 3.4 Yes
place within 8 13 days after the onset of menses. A pelvic 11 10 80 11 0.3 No
13 11 120 18 4.2 Yes
ultrasonogram was obtained to measure follicular size, and 18 11 36 5 1.1 No
the level of serum E2 was determined to assess ovarian 19 11 160 6 0.7 No
activity. Each subject received 150 mg of DMPA at time 0 20 11 160 19 10.0 Yes
and returned to the clinic at 24 hours and on days 3 and 7 24 11 420 20 9.0 Yes
after injection for an ultrasound (US) and for blood sampling 12 12 90 11 2.0 No
15 12 36 11 0.5 No
to determine the E2 and LH levels. 25 12 107 NA 0.4 NA
The serum P level served as a primary parameter for 26 12 70 18 0.4 Yes
28 12 250 20 9.0 Yes
determining whether ovulation had occurred and was mea-
14 13 NA 15 2.8 Yes
sured in samples drawn on day 7 after injection. Progester- 16 13 190 16 7.5 Yes
one levels of .2.5 ng/mL in subjects with follicle develop- 17 13 150 19 0.5 Yes
ment followed by apparent rupture were considered to 21 13 100 18 2.7 Yes
indicate ovulation. A subject was considered to have com- 23 13 240 18 4.6 Yes
pleted the study if she returned to the clinic for her day 7 Note: NA 5 not available.
* Follicles disappeared or were abruptly reduced in size ($50%) after
follow-up visit and completed the procedures at this visit.
reaching a diameter of 15 mm.

Hormone Assays
Hormonal measurements were performed using commer-
cial kits for solid-phase I125 RIA (Diagnostic Products Corp.,
Los Angeles, CA). For E2 analysis, the intra-assay coeffi-
cient of variation (CV) was between 4.0% and 7.0% and the
interassay CV was 4.2% 8.1%. For progesterone analysis,
the intra-assay CV was 2.7% 8.8% and the interassay CV
was 3.9%9.7%. Quality control was performed by the
World Health Organization.
Vaginal Ultrasound
Examinations were performed using Ultramark-4 equip-
ment (Advanced Technology Laboratories, Inc., Tampa, FL)
with a real-time scanner and a vaginal probe of 5 MHz. The
technique for performing the measurements has been de-
scribed elsewhere (5, 6, 7). Briefly, the follicle measurement
was made in three diameters and the mean was noted.
Follicles that disappeared or that were abruptly reduced in
size by $50% after reaching a diameter of 15 mm were
considered to have ruptured.
RESULTS
Table 1 shows the distribution of cases according to the
day of the cycle when DMPA was injected as well as
selected parameters used in this study. No ovulation was
observed when the injection was administered on day 8 or 9
of the menstrual cycle, and only 1 of the 5 subjects treated on
day 10 ovulated. On the other hand, all but 1 subject treated
on day 13 and 4 of 10 of those receiving injections on day 11
and 12 showed evidence of ovulation.
Ovuluation was detected in 9 (30%) of 30 cases. All cases
in which ovulation was detected by P levels were confirmed
by follicle rupture at US evaluation, but there were three

818 Petta et al. Timing of effectiveness of Depo-Provera II Vol. 70, No. 5, November 1998
 the patients in this study. This finding is in agreement with
TABLE 2 earlier studies on the capacity of DMPA to suppress ovula-
Estradiol levels and follicle diameter in ovulating and
tion when injected after day 7 of the menstrual cycle (2). The
nonovulating women before DMPA injection. ovulation suppression effect was related to the stage of
follicle development at the time of the injection.
Follicular diameter
Ovulation E2 level (pg/mL) (mm) Ovulation did not occur when the injection was adminis-
tered on days 8 and 9 of the menstrual cycle; it was first
Yes 203.8 (100420) 17.4 (1320) noted after injection on day 10 and occurred in all but one
No 73.5 (28160) 10.2 (519)
subject on day 13. In addition, no patient had E2 levels of
Note: Values are means, with ranges in parentheses.
.100 pg/mL on days 8 and 9, which is evidence of low
ovarian activity. However, the sample size was small, and
cases of apparent follicle rupture in which a subsequent thus our data do not permit us to conclude that the injection
increase in P levels was not observed (cases 9, 17, and 26). window of DMPA can be widened up to day 9 of the
Ovulation occurred only among women who had E2 lev- menstrual cycle. In addition, the day of the cycle is not a
els of $100 pg/mL and who had a leading follicle diameter good ovarian activity predictor because of the wide variation
of .13 mm at the time of DMPA injection. The mean E2 of cycle length among women. Consequently, E2 levels or
level was nearly threefold higher and the follicular diameter follicle size is a better parameter to evaluate the risk of
was almost twice as great in the group of women who ovulation.
ovulated compared with the group of women whose P values
The absence of ovulation as detected by P levels among
remained low (Table 2). For all subjects who ovulated, as
women with E2 levels of ,100 pg/mL at the time of the
confirmed by P concentration on day 7, follicle rupture was
injection shows that DMPA inhibits ovulation more often in
detected by the 3rd day after the injection, independent of the
women with low ovarian function. Estrogen level was a
day of the cycle on which DMPA was administered (Table
more precise indicator than follicle size, considering that 2 of
3).
11 subjects with an initial follicle size of $15 mm at injec-
In general, a good correlation between follicular diameter tion did not ovulate, according to P levels. However, it is not
(.13 mm) and E2 levels ($ 100 pg/mL) measured before practical to measure E2 levels or to obtain an US to deter-
injection was observed, with few exceptions (cases 30, 19, 9, mine ovarian activity before administration of DMPA.
and 26). Two of the three cases in which follicle rupture was
All women who ovulated, as determined by follicle rup-
documented but was not followed by an increase in P level
ture, did so within 3 days after the injection. It is possible
are among these exceptions. These two patients (patient 9
that DMPA injected close to the time of ovulation can trigger
and 26) had low E2 levels (,100 pg/mL) despite having
the ovulatory mechanism (7). Several studies (8 10) evi-
follicular diameters of .13 mm.
denced the importance of a progestational signal after an E2
level increase in triggering the LH peak. Further evidence
DISCUSSION
shows that administration of mifepristone in the late follic-
Injection of DMPA between the 8th and 13th days of the ular phase delays the midcycle gonadotropic peak and ovu-
menstrual cycle did not inhibit ovulation in 30% (9/30) of lation by suppressing the progestational signal (1114). This
evidence could explain the occurrence of ovulation soon
after injection in this study.
TABLE 3
A study of levonorgestrel implants that had the same
Follicle diameters for the nine subjects who ovulated after design that the present study had showed that levonorgestrel
injection of DMPA. could not prevent ovulation in 40% of the subjects studied.
However, all LH peaks were observed within 2 days after
Follicle diameter on US (mm)
implant insertion (V. Brache, personal communication).
Case Day of Day Considering that the oocyte is no longer viable after 24 hours
no. injection 0 Day 1 Day 3 of ovulation (15), it is recommended that a back-up method
be used for a maximum of 3 days when implant insertion is
8 10 13 14 Rupture
13 11 18 Rupture performed after day 7 of the menstrual cycle (V. Brache,
20 11 19 20 Rupture personal communication).
24 11 20 22 Rupture
28 12 20 Rupture In the case of DMPA, we can be reasonably sure that
14 13 15 14 Rupture women will not become pregnant if they abstain or use a
16 13 16 16 Rupture back-up method during the first 4 days after the DMPA
21 13 18 20 Rupture injection, assuming that a viable oocyte would last only 24
23 13 18 19 Rupture
hours.

FERTILITY & STERILITYt 819

 In a previous report (4), which focused on the changes in
cervical mucus in the same group of women, we noted that
1 of the 30 subjects had a good cervical mucus score and
good sperm penetration 3 days after DMPA injection; hence,
the recommendation was to use a back-up method for 7 days
after the injection. However, findings reported in the current
article indicate that the first DMPA injection achieves con-
traceptive effect, in terms of effect on ovarian function, in 4
days.
We conclude that a back-up contraceptive method used
for 4 days after the injection will provide sufficient protec-
tion when the contraceptive is used after the 7th day of the
cycle. However, this 4-day duration of protection is based on
the uncertain assumption of short viability of the human
oocyte. Considering that DMPA also is used in rural areas of
developing countries, it should be easier for providers and
clients to remember to use 1 week of a back-up method or
abstinence; this would leave a safety cushion of 2 or 3 days
for those who fail to follow the abstinence or back-up
method recommendation.
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Vol. 70, No. 5, November 1998