Frequently asked questions

There are a few different avenues you can take:

• If you have a family physician, OBGyn or other physician, request a referral by giving them this form. Since your physician will be involved in follow-up care, we like to involve them at the start of the process.
• If you are currently receiving care at another clinic, you can request a chart transfer or a second opinion. Please email us to learn more.
• If you do not have a physician, please email us so that we can discuss the options for you to see an Anova fertility specialist.

Once a referral has been received, we will reach out to you via phone and/or email to schedule your appointment. We aim to respond within two business days. Typically, we are able to see new fertility patients within four weeks of receiving a referral. If you believe you were referred, please feel free to email us about the status of your referral. It’s helpful if you include the details of the referring physician.

Here are some ways to prepare for the initial consult with your physician:

• Submit the patient intake form and take some time to browse the available resources on our website.
• For virtual appointments:
  • Check to ensure you have a strong internet connection and an audio/video component to your computer, tablet or smartphone.
  • Sit in a private, quiet and comfortable place for the meeting.
  • If there is an issue with the call quality, the physician will call you via telephone. It will appear on your phone as an unknown caller.
• Physician schedules can run behind due to unforeseen circumstances. Please be patient and allocate some extra time for your appointment in case it begins late.

You will usually be asked to come into the clinic to have testing done to support the fertility assessment. An Anova team member will be here to answer any questions and to help schedule any necessary testing.

Recurrent pregnancy loss (RPL), or recurrent miscarriage, is the occurrence of two or more consecutive pregnancy losses. If this describes you, we will gladly support you through your investigations and treatment. 

Our medical team will carry out a series of investigations along with close surveillance pregnancy monitoring to ensure our patients feel well supported during this sensitive time. Investigations may include:

• Assessment of the woman’s uterine cavity (sonohysterogram)
• Chromosome/karyotype testing
• Thrombophilia testing
• Endometrial biopsy
• Hormone profile
• Product of conception testing

To become a patient, please have your physician send us a referral form, along with any supporting documentation.

Polycystic ovary syndrome (PCOS) is an endocrine disorder common among women of reproductive age. It affects 8% of women. Though the signs, symptoms and severity of PCOS vary, they may include:

• Infrequent, prolonged menstrual periods
• Weight gain
• Acne
• Excess male hormone (androgen) levels
• Excessive hair growth
• Numerous ovarian cysts
• Failure to ovulate

Unfortunately, over 50% of PCOS patients don’t get diagnosed or receive the treatment they need. They often receive a diagnosis only after they are struggling to get pregnant. Raising awareness of PCOS and its treatment options will help improve diagnosis rate, patient experience and outcome.  

Here at Anova, we do have a dedicated PCOS endocrinology program, and our specialists can address your questions and concerns around fertility and PCOS.

We commonly hear from patients how important a support network outside of the clinic can be. Although it is not mandatory except in certain situations*, we highly recommend that patients participate in individual or couples counselling. To ensure that all the Anova community is supported, we also facilitate support groups that are moderated by a trained counsellor. These occur in person and virtually, creating a safe environment for patients to be open and honest about their fertility experience. 

 

If you are already a patient, you can join our closed Facebook support group. If you would like to join a virtual support group, please contact us. 

*Counselling is a mandatory component for patients proceeding with third party reproduction.

If you are an Ontario resident with a valid OHIP number and are under the age of 43, then you may qualify for Ontario Fertility Program funding. This is a special program offered by the Ministry of Health and Long Term Care. It does have a limited yearly funding allocation, meaning that in a typical year, there are more patients requesting funding than the Ontario Fertility Program can accommodate. Anova is one of the fertility clinics in Ontario that receives a funding allocation, and our waitlist is currently around 18-24 months. Please note that you must be under the care of an Anova physician in order to be added to our waitlist. To learn more about Ontario Fertility Program eligibility, click here.

The wait time for each of our specialists varies. Our medical director, Dr. Dixon, has the longest wait time. It is about two months to have your initial visit with her. We have other knowledgeable and compassionate fertility specialists that are able to see you within two or three weeks. Our highly skilled physician team members have the same specialized training and work very closely together to ensure optimal patient care. Meet our medical team here.

Absolutely. Your cryopreserved eggs, sperm and embryos can be easily moved between clinics, but it does require the use of couriers who are familiar with the shipment of cryogenically stored products. We have a team member who works closely with patients and other facilities to safely move products from one facility to the next. It does take some planning to facilitate, so it is best to move the required samples before starting any treatment cycles. The costs associated with the shipment would be the patient’s responsibility. The clinic where your items are currently stored may also charge an administration fee to prepare the sample. If this is something you are considering, we can have someone reach out to you with additional details about the process.

For a patient wanting to retrieve eggs, our upper age limit is 44 years, 12 months, equal to their 45 birthday. We are unable to provide this service to patients after their 45th birthday. As with any retrieval, proceeding with a cycle is at the specialist’s discretion and requires a set of tests to ensure viability. For a patient wanting to carry a pregnancy and therefore go through a transfer cycle, we will transfer embryos into a patient up to the age of 50 years, 12 months. In other words, we are not able to perform transfers on patients after their 51st birthday.

At Anova, our BMI upper limit for our IVF program is 40. Our goal is to ensure every patient’s safety and to optimize their chances for success. Should a patient need support in reaching a BMI goal, we are happy to help with resources.

IVF includes the process of stimulating and retrieving multiple eggs from a patient’s uterus and fertilizing them with sperm to create embryos. The cost is $13,999 (not including medication, the cost of which could range from $5,000-$9,000+).

A sonohysterogram, commonly called a sono, is a procedure that examines the uterus and the uterine cavity. This is performed using a transvaginal ultrasound probe and a saline solution that safely expands the uterus and endometrial cavity. The purpose of this test is to detect any structural abnormalities. The sono procedure is typically booked between days six and 10 of your cycle. The sonohysterogram is a very safe procedure that is performed by a physician. It may cause some cramping, spotting and vaginal discharge. Some may experience cramping for several hours after the procedure, and patients are often recommended to take ibuprofen beforehand. You might find this link from the American Society of Reproductive Medicine useful.

As 1/3 of infertility diagnoses are related to the male partner, performing a semen analysis is an important part of the fertility assessment. This test measures the count, motility and morphology of the sperm. The analysis must be performed on a fresh sperm sample, which can be collected either at home or at the clinic, though there are very specific instructions about transport if the sample is collected at home. It is recommended to abstain from ejaculation for two to four days before your test. 

To schedule a complimentary consultation about semen analysis, you’ll just need a referral. Click here if you have a referral. Click here if you’d like help getting a referral.

This test measures the level of anti-mullerian hormone (AMH) in your blood. It’s part of a standard fertility assessment. Knowing your AMH level helps us to understand your ability to produce eggs that can be fertilized for pregnancy. Along with other tests, it will provide your physician with a clearer picture of your ovarian reserve, as well as how you may respond to certain fertility medications. This test is not covered by OHIP and has a fee of $130.

You will need to have a full bladder for your first visit, which can be booked between cycle days two and five (even if it is referred to as day three cycle monitoring). During this first cycle monitoring appointment, the ultrasound technician will perform a pelvic and transvaginal ultrasound. Having a full bladder is needed to help clearly show the appearance of the ovaries and uterus. You will be asked to drink one liter of water one hour before your appointment. The scan should take about 30 minutes. Cycle monitoring appointments at later days in your cycle will not typically require a full bladder.

Whether your insurance, benefit or healthcare spending account covers fertility medications or other aspects of fertility care, such as egg freezing, is very plan specific. Often, we see a specified amount of medications being covered during the lifetime of a patient. This is important to consider, as you may need multiple rounds of medication along your fertility journey. Anova is not able to charge your benefits provider directly, though we are here to help you navigate your coverage. If you are asked to purchase medications, you will be provided with a detailed receipt including the drug identification numbers to submit to your plan provider. We are happy to work with you to understand if your benefits provider has fertility medication coverage. 

Absolutely. Your cryopreserved eggs, sperm and embryos can be easily moved between clinics, but it does require the use of couriers who are familiar with the shipment of cryogenically stored products. We have a team member who works closely with patients and other facilities to safely move products from one facility to the next. It does take some planning to facilitate, so it is best to move the required samples before starting any treatment cycles. The costs associated with the shipment would be the patient’s responsibility. The clinic where your items are currently stored may also charge an administration fee to prepare the sample. If this is something you are considering, we can have someone reach out to you with additional details about the process.

For a patient wanting to retrieve eggs, our upper age limit is 44 years, 12 months, equal to their 45 birthday. We are unable to provide this service to patients after their 45th birthday. As with any retrieval, proceeding with a cycle is at the specialist’s discretion and requires a set of tests to ensure viability. For a patient wanting to carry a pregnancy and therefore go through a transfer cycle, we will transfer embryos into a patient up to the age of 50 years, 12 months. In other words, we are not able to perform transfers on patients after their 51st birthday.

At Anova, our BMI upper limit for our IVF program is 40. Our goal is to ensure every patient’s safety and to optimize their chances for success. Should a patient need support in reaching a BMI goal, we are happy to help with resources.

IVF includes the process of stimulating and retrieving multiple eggs from a patient’s uterus and fertilizing them with sperm to create embryos. The cost is $13,999 (not including medication, the cost of which could range from $5,000-$9,000+).

There is a lot you can do to take care of yourself during this time. Remember, the healthier you are when you start your cycle the better

• Overall, you do want to ensure you are maintaining a healthy weight
• Eat a well-balanced diet; find time for regular daily physical activity. The silver lining is that you have more time now to do both
• Take prenatal vitamins (Vitamin D, CoQ10 and Folic Acid), and remember that a different mix of prenatal vitamins for men might be improve sperm quality as well
• As always, quit smoking and avoid alcohol
• An important one right now is your mental health as well; do try to manage your anxiety and stress levels during this challenging time. The Anova Wellness team is doing virtual consultations

While they won’t help you to necessarily get pregnant, there are a couple other things you can do to have your proverbial ducks in a row for when we can resume creation pregnancies. If you have questions on anything I’m about to say, please email the clinic:

• Get all the routine testing up to date so that it is ready when we reopen
• Ensure the paperwork is complete (mainly consent forms)
• Get in contact to learn about the different financial options that exist, such as payment plans and financing options.

AND MOST IMPORTANTLY do your part to flatten the curve. Stay home, be diligent about your social distancing, wash your hands often, and minimize chances of exposure.

Unfortunately, it is too early to tell what government officials will do after the crisis is over. It would make sense that if you weren’t able to access your funded cycle, you could use it later. However, this pandemic will have substantial financial implications on the Ministry of Health, and we don’t know at this point what will be done to minimize the health, economic, and social impacts of this rapidly evolving public health issue. It is important to note that the waitlist for funded cycles maybe even longer post-COVID-19. Waiting longer for some women means that they will have to rethink their fertility treatment route and consider switching to paid cycles to increase their chances of getting pregnant. Time matters, and the best care plan for you may mean paying privately sooner rather than waiting for a funded cycle.

At Anova, we take pride in our personalized approach. Once resumed, our doctors will review the list of our patients and see what order will give you the best chances, age will be a factor – but we will also try and respect the order that was established before COVID-19 interrupted the plans. We are currently evaluating how we can increase the number of IVF treatments we can offer per month to help couples get back on track. We are currently trying to get in contact with women who had been notified of a funded cycle, as well as any patient who was prepared to pay privately for their IVF treatment. If you haven’t heard from us yet, please email us.

First, we need to turn to international recommendations from the governing medical bodies when facing times of uncertainty – it’s why they exist. According to CFAS and ASRM guidelines, until more is known about the virus, and while we remain in this public health emergency, it is best to avoid the initiation or creation of a pregnancy. COVID-19 is a new virus, and there is still not enough research to understand its impacts on embryogenesis, fetal development, and pregnancy complications, so we need to be cautious. In addition, prescribing ovulation induction drugs to a patient without the appropriate monitoring is NOT safe. Patients can hyper-stimulate on ovary stimulation drugs. They can get ten follicles on each one of these drugs, and without proper monitoring, there is no way to know how many follicles were created. Conceiving naturally, with this many follicles, significantly increases the risk for multiple pregnancies, which is considered to be higher risk pregnancy and can be dangerous for both mom and babies. Even if we can’t see you at the clinic right now (though we are still seeing patients virtually!), we are still responsible for your health, and responsible for every prescription we prescribe. Therefore, Anova fertility will NOT prescribe these medications or refills during this time.

In addition to the details given to the above question, it is not recommended to start a pregnancy during this time, for the following reasons:

• In the early weeks of pregnancy and throughout the first trimester is when a patient will have their most interactions with the healthcare system. Right now, our healthcare system is trying to adjust, to be able to handle the COVID-19 pandemic. By not creating new pregnancies we are helping to decrease the overall burden on the system and support our healthcare workers.
• As mentioned, the scientific community has not had time to do extensive, robust studies on the impacts of the COVID-19 virus on moms, dads, eggs, sperms, embryos, and babies.
• All pregnant women are, to some extent, considered immunocompromised. Since we know that COVID-19 is more dangerous to certain people, including those that are immunocompromised – we want to avoid getting anyone pregnant and having them be more at risk of severe complications if they develop COVID-19.

We understand and empathize how frustrating this situation is for you and we would like to reassure for you that we are still here for you. The #TTC community is strong, and in our private Facebook peer support group, we are hoping you can lean on each other during these challenging times. To join the group, please email us at info@anovafertility.com

COVID-19 is a new virus, and the data is very limited. Globally, there are not many pregnant women infected with COVID-19. Currently, the data is reassuring and suggests that pregnant women are not at a higher risk of infection, nor at a greater risk of infection, nor a higher risk of severe morbidity (other health concerns) compared to non-pregnant women of the same age. Moreover, the vast majority of infants born to pregnant women infected with COVID-19 have been healthy at birth, with near-term prematurity (preterm birth) being the most commonly reported adverse pregnancy outcome. However, adverse pregnancy outcomes are thought to be proportional to the degree of maternal respiratory illness. You might also want to read this resource from the Centre for Disease Control.

Yes, we are still accepting new referrals, and our physicians are seeing them through virtual consultations. To book your first appointment, reach out to us, and we will get you booked. Now is a good time to learn more about the potential reasons you are facing fertility challenges, and to come up with a care plan moving forwards.

We are getting this one a lot from women who need to postpone their IVF cycle. We have asked all of our patients who are in this situation to call and speak to one of Anova’s nurses. If you haven’t yet, please contact us. Birth control medication (OCPs) allows us to essentially take control of your menstrual cycle. While this may seem counterintuitive, it means that we will be better able to time the start of the IVF treatment once we are allowed to do so. If you are not comfortable taking birth control, that is a personal decision. If you choose to go this route, we are asking for you to call in on the first day of your period to have an update conversation with the nursing team.

The COVID-19 is a new virus, and it is too early to tell as there is not enough data to conclude about vertical transmission, which refers to the transmission of the infection from mother to fetus). According to one study conducted on nine pregnant women in China, there was no evidence of vertical transmission. However, recent study suggests that vertical transmission is possible. For this reason, it is important that pregnant women will practice vigilance and self-isolate as much as possible.

According to public health recommendations by Public Health Ontario, here are some reminders for what you can do to protect yourself and those around you:

• Practise physical distancing. Keep a safe distance of 2 meters away from other people.
• Wash your hands often with soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand sanitizer.
• Avoid touching your eyes, nose, and mouth
• Avoid contact with others. No visitors unless essential (such as care providers), stay away from elderly persons, and people with chronic medical conditions.
• Stay home, and avoid all non-essential trips. Do not go to work, the corner store, or other public places.
• Practice good cough and sneeze etiquette. Cover your mouth and nose every time you cough or sneeze. If you don’t have a tissue, sneeze or cough into your sleeve or arm.
• Clean and disinfect frequently touched objects and surfaces. Think doorknobs, railings, sinks, etc.

The well-being and safety of our patients and staff is our priority. Anova is always on top of all recommendations from Public Health, WHO, ASRM, and CFAS and will follow all the protocols and requirements for returning patients. As the COVID-19 outbreak is evolving, we cannot foresee the future recommendations. Rest assured, we will continue to provide updates as we receive them.

Anova does not foresee a closure like we experienced from March-May, as we are now included as a Phase 1 essential healthcare service able to operate under our Independent Healthcare Facility license. We have a stable stock of PPE, and continue to work with protocols and processes that minimize the risk of exposure for our patients and team members. We will follow and adhere to the guidelines put out by governing bodies, including Public Health, CPSO and CFAS. Please follow us on social media for the most up to date clinic information.

Following the Public Health guidelines, you should isolate and get a COVID-19 test. If the results are negative, and you are symptom free for 48h since getting the test results back, contact the clinic for further instructions. If you do have or develop symptoms, the recommendation is to quarantine for 14 days and be re-tested.

It is critical to be very diligent about behaviours and steps you can take to decrease your exposure risk. This includes of course frequent hand washing and wearing a mask, but also limiting the number of people you physically interact with. The smaller your ‘bubble’, and the fewer trips you make out in public, the less likely you are to come in contact with someone who later tests positive for COVID-19. We are encouraging the entire community to get the flu shot this season.

While many symptoms we are familiar with, they are still potential symptoms of COVID-19. Due to how readily this virus spreads, as a community we need to be cautious with any symptom and get tested. Following the Public Health guidelines, you should isolate and get a COVID-19 test. If the results are negative, and you are symptom free for 48h since getting the test results back, contact the clinic for further instructions. If you do have or develop symptoms, the recommendation is to quarantine for 14 days and be re-tested.

If this happens, please notify our team immediately, so that we are able to identify which staff you may have interacted with on your last visit. As per Public Health guidelines, you need to self-isolate for 14 days regardless of whether you have symptoms, starting from the day you were tested.

To be able to ensure the safety of our patients and our team, there will be new processes and protocols in place, for an overview please click here. At the time of booking your appointment, there will be a verbal COVID-19 pre-screen questionnaire & you will be sent a COVID consent form to complete and return. On the day of your appointment, you will be asked to bring a face mask and to wait in your car until it is time for the appointment. In the lobby you will be greeted by a member of the Anova team. You will need to update your declaration of COVID-19 risk factors, sanitize your hands, wear a sticker, and will be brought to the elevator. At the clinic, the door will be propped open and you will check in with reception before being brought to a clinic room. While we have adjusted the wait room to allow for social distancing, we will be treating it more as a ‘through room’ at this time. After your appointment, you will need to check-out at reception, and leave the building promptly. To decrease exposure risk, we are minimizing the amount of people in the clinic. This includes the restriction that at this time, family, visitors and support people will not be allowed inside the clinic. See more detailed response below.

The entire Anova team is also returning to the clinic under a new set of processes and protocols. All employees will be subject to COVID-19 risk screening before the start of their workday, and will use different PPE as appropriate to their role. They will also be wearing “Completed Screening” stickers, like our patients.

In accordance with the medical guidelines, and to limit the risk of exposure, no visitors or support people will be allowed in the clinic. We will do our best to accommodate ‘virtual visitors’ for OPU and FET procedures. Post-procedure, patients who required sedation will be escorted by an Anova team member to the lobby, where they will be met by their support person.

We will be adjusting the opening hours of the clinic as we work to limit the exposure risk through altered processes and procedures. To be able to ensure that the healthcare providers at Anova remain in full force, they will be working in non-overlapping teams.

There is underground and street parking around 25 Sheppard Ave. West. Street parking with the city’s GreenP App would allow you to manage payment for parking most efficiently.

To limit the amount of people visiting the clinic, we will be continuing with OTN virtual appointments with the physicians whenever possible. Contact reception@anovafertility.com for an appointment The Anova Wellness providers are also seeing patients virtually, you can book with them here.

When COVID-19 vaccines became available to the public, some individuals noticed changes to their menstrual cycle. Some found that their cycles were longer or shorter than usual or noticed slightly more cramping. Researchers sought out to investigate if this was a true phenomenon. A recently-published study by Edelman et al. (2022) did in fact observe a change in the menstrual cycle after vaccination against COVID-19, however the effect was small and only temporary2. On average, the first vaccine dose appeared to be associated with a cycle length increase of 0.71-day and the second dose a 0.91-day increase2. These effects appeared to diminish within two post-vaccination cycles2. While this effect may be negligible for most, this is an important finding for those who rely on accurate menstrual cycle predictions to plan or avoid pregnancy.

Children of any age can become ill with COVID-19, but Ontario hospitals have warned of a recent increase in infant hospitalizations. While infants becoming sick with COVID-19 was a rare occurrence earlier in the pandemic, the surge in cases of the extremely transmissible Omicron variant appears to be affecting more infants and young children. Vigilance in monitoring yourself and your children for COVID-19 symptoms is crucial. For newborns, these symptoms may manifest as a runny nose, sore throat, fever, looking or feeling lethargic, dehydration, sunken eyes or producing less than 5 wet diapers each day. For children over 1 year of age, addition symptoms may include persistent fever, lack of appetite or thirst, vomiting, severe diarrhea, dry mouth and tongue or trouble breathing.

One of the best ways for parents to protect themselves and their child from COVID-19 is by getting vaccinated. This is especially the case for pregnant or breastfeeding mothers, as antibodies from the COVID-19 vaccine can pass to the baby through the umbilical cord and breastmilk to allow for some protection against the virus3.

The best time to get the COVID-19 vaccine during pregnancy is now! Recent studies have found that pregnant individuals that are fully vaccinated (2 doses) pass COVID-19-fighting antibodies to their baby at the time of delivery, regardless of when they got their first dose4,5. Those who received a booster in addition to their vaccinations demonstrated the highest levels of antibodies in the blood and umbilical cord. Although some individuals feel that they should wait until the third trimester to get vaccinated so that the antibodies are more “recent” when they give birth, studies have found that this is not factual. In fact, experts suggest that it is not advisable to wait until the 3rd trimester to get vaccinated. Individuals who received two doses of the vaccine early in their pregnancy appeared to have more antibodies (and are better protected) than those who only received one dose in the third trimester.

Absolutely! Studies have found that the COVID-19 vaccine does not pose a risk to individuals who are trying to conceive or already pregnant or their babies. There is no evidence that the COVID-19 vaccination has any effect on male or female fertility, now or in the future. It is recommended that all individuals who are trying to conceive get vaccinated to protect themselves and their future baby from known adverse outcomes associated with contracting a COVID-19 infection. Vaccination builds antibodies that can not only decrease your risk of getting a severe infection but can also be passed to your baby through the umbilical cord and breastmilk for their protection upon delivery.

While mRNA vaccines are considered to be safe, most study participants for both the Pfizer-BioNtech and Moderna vaccines experienced mild side effects similar to influenza-like illness symptoms following vaccination.

 

While mRNA vaccines are not considered live virus vaccines, they are not hypothesized to be a risk to pregnant or breastfeeding women. However, it is important to note both pregnant and breastfeeding women were excluded from the COVID-19 vaccine trials. Therefore, there is not enough data to suggest or deny efficacy or safety during pregnancy or breastfeeding.

According to an SOGC: “While there have been no red flags or hypothesized mechanisms for potential harm associated with administration of an mRNA vaccine during pregnancy until more data is available, the potential risks of vaccination to a pregnant individual and fetus remain unknown.”

While most pregnant women who become infected with SARS-CoV-2 will have mild-to-moderate symptoms, and many can be asymptomatic, some pregnant women are at high mobility risk. Risk factors for severe morbidity from COVID-19 include maternal age over 35 years old, asthma, obesity, pre-existing diabetes, pre-existing hypertension, and heart disease. For individuals at high risk of infection and/or morbidity from COVID-19, the SOGC states that the documented risk of not getting the COVID-19 vaccine outweighs the theorized and undescribed risk of being vaccinated during pregnancy or while breastfeeding, and therefore, vaccination should be offered to them.

In any case, pregnant and breastfeeding people should consult their prenatal care provider, who could weigh in their individual risk factors versus benefits and help them make an informed decision that is right for unique circumstances.

According to the SOGC recommendations, individuals planning a pregnancy, can complete the entire COVID-19 vaccination series (where possible) to achieve maximal vaccine efficacy ahead of pregnancy. However, it is not yet known whether an individual should delay pregnancy following receipt of the vaccine. If you are trying to conceive you should discuss your potential risks vs. benefits with your health care provider.

When COVID-19 vaccines became available to the public, some individuals noticed changes to their menstrual cycle. Some found that their cycles were longer or shorter than usual or noticed slightly more cramping. Researchers sought out to investigate if this was a true phenomenon. A recently-published study by Edelman et al. (2022) did in fact observe a change in the menstrual cycle after vaccination against COVID-19, however the effect was small and only temporary2. On average, the first vaccine dose appeared to be associated with a cycle length increase of 0.71-day and the second dose a 0.91-day increase2. These effects appeared to diminish within two post-vaccination cycles2. While this effect may be negligible for most, this is an important finding for those who rely on accurate menstrual cycle predictions to plan or avoid pregnancy.