This counseling should include the expected failure rates of contraceptive options and the anticipated maternal and fetal risks of unplanned pregnancy, with these issues revisited on a regular basis. Contraceptive choices include combined hor- monal (estrogen/progesterone) contraception, progesterone-only agents, intrauterine devices, barriermethods,andpermanentsterilization.Low- dose combination oral contraceptive ( 20 mcg of ethinyl estradiol) is an option except in women who are at increased risk of thrombosis.S3.13.2-4 Medroxyprogesterone acetate is a less effective method of contraception, and the potential for fluid retention must be considered.S3.13.2-5 Intra- uterine devices are highly effective methods of contraception; however, women may experience vasovagal reactions at the time of implant. Tubal ligation is generally safe with recognized risks associated with anesthesia and abdominal insuf- flation. An efficacious option is a vasectomy for the male partner; however, the long-term prog- nosis of the female patient with CHD must be considered and discussed openly. In the case of unplanned pregnancy with desire for termination, the morning-after pill (levonorgestrel) is safe for women, but acute fluid retention is a risk to be considered. 2. Women with CHD who are at high risk of throm- bosis include those with cyanosis, Fontan physi- ology, mechanical valves, prior thrombotic events, and PAH. In women who are at high risk of throm- bosis and who receive warfarin, there are no data on which to base a recommendation or coun- seling as to whether it is safe to use estrogen- containing contraception. It is unclear whether the use of warfarin offsets adequately the addi- tional risk of thrombosis related to pregnancy in high-risk patients. 3.13.3. Infertility Treatment Menstrual cycle disorders are not uncommon in women with CHD. 