CONTRACEPTIVE DEVICES

Dr ATHIRA M
POST GRADUATE, PSM
 CONTRACEPTION
 Preventive measures for unwanted
pregnancies

 Temporary and permanent methods

Cafeteria approach
 Emphasizes on limitation of family size rather than contraception
 Provides clients with a basket of choices (5 methods)
Female, male sterilization
IUCD
OCP
Condoms
Evaluation of contraceptive methods

Evaluated based on their effectiveness, expressed as failure rate per

100 women years of exposure

Pearl Index:

 Number of failures per 100 women years

 Failure rate per HWY = Total accidental pregnancies x 1200

Total months of exposure

 Pearl index of 20 → 20 out of 100 women will become pregnant of
that particular method is used for that particular year
 Terminal
Spacing methods
methods

Male Female
Barrier Hormonal Post conceptional
methods
IUDs methods methods
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Physical
methods

Chemical
methods

Combined
methods
 SPACING METHODS

 Birth spacing : time interval between 2

successive pregnancies (at least 24
months)
Barrier methods

 Prevent live sperm from meeting the ovum

 Contraceptive advantage :absence of side effects related to pills or

IUD

 Non contraceptive advantage: some protection against STDs,CA

cervix, reduction in incidence of PID
Barrier methods contd...

Physical methods:

Male condom :

• In India - NIRODH

• Effectiveness increased by spermicidal gels

• Benefits : inexpensive, easy to use,easily available, protection from unwanted

pregnancies, STDs

• Disadvantages : may slip off or tear

• Failure rate : 2-14 per hundred women years

Vaginal Sponge:

 Made of polyurethane, 1gm of

nonoxynol-9
 Placed over cervix, once
applied should not be
removed for 6 hours
 Side effects : Allergic reaction,
TSS, vaginal irritation, fungal
infection
 Failure rate : 20-40 per HWY
 Diaphragm

• Vaginal barrier,
• Fits over cervix, prevents sperm entry to
uterus
• Inserted before coitus and held for not
more than 6hrs
• Adv: almost total absence of risks and
medical C/I
• Disadv: practice at insertion,
privacy,facilitates for washing and storing
the diaphragm - extent of use not so great
• Failure rate :6-12 per HWY
 Female condom

• Pouch made of polyurethane

• Worn inside vagina similar to tampon
or menstrual cup
• 2 rings – thick inner ring with closed
end , thin outer ring
• Non reusable, should be removed
immediately after use
• Failure rate : 5-21 per HWY
• Prevents pregnancy, STDs
Chemical methods

Spermicides: Foams (foam tablets, foam aerosols), Creams,

jellies, pastes,Suppositories
• Attach to spermatozoa, inhibits oxygen uptake and kills sperms
Drawbacks :
• High failure rate
• May cause mild irritation or burning sensation
• No spermicide which is safe to use has yet been found
effective in preventive pregnancy
• Used in conjuction with barrier methods
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 IUD

Non medicated (1st gen) Medicated

Copper based (2nd gen)

Hormone based(3rd gen)

1st generation IUDs:
• Inert or non-medicated devices
Lippes loop:
• Double S shaped, polyethylene
• Has barium sulphate, tail made of nylon
• 4 sizes (A,B,C,D)
• A - great antifertility effect, lower
expulsion rate
• C,D - Multiparous women
2nd generation IUDs
• Earlier devices: Cu-7, Cu T 200 (4yrs)
• Newer devices: CuT 220C, CuT 380A
(10yrs), Nova T (5yrs) ,ML-Cu250, ML
Cu 375
• Radio opaque copper wire is wrapped
around the stem and arm of a
polypropylene frame
• Failure rate : 0.8 per HWY
3rd generation IUDs:
• Progestasert : T shaped, 38mg progesterone -
releases 65mcg daily, should be changed every year
• LNG-20 (Mirena) - T shaped, releases 15-20mcg
Levonogestrel
Failure rate : 0.2 per 100 women
7-10 years life
MOA:

• Foreign body reaction - cellular and biochemical changes in

endometrium and uterine fluids - impairs viability of the gamete

• Cu ions : alters biochemical composition of cervical mucus- affects

sperm motility,capacitation and survival

• Hormones: increases viscocity of cervical mucus- prevents sperm

entry to cervix, maintains high level of progesterone and low
relatively levels of estrogen
Advantages: No complex procedure/hospitalisation
Stays in place
Reversible contraceptive effect on removal
Almost free from systemic side effects
Inexpensive

Absolute C/I : acute PID, CA cervix, previous ectopic pregnancy,

DUB,suspected pregnancy

Relative C/I :Fibroid uterus, congenital malformations, menorrhagia,

purulent cervical discharge
Ideal candidate for IUD insertion:

• At least one kid, No PID, normal cycles,willing to check thread and

follow up exmn, monogamous relationship
Timing of insertion:
• During or within 10days of beginning of menstruation
• Within 1st week of delivery ( ↑ expulsions, perforations)
• 6-8 weeks postpartum aka post puerperal insertion (more
convenient)
• Immediately after medically legal induced 1st trimester abortion
 Follow up :
 Check for thread after first menstruation (expulsion rates high)
followed by third (severe bleeding/abd pain) followed by
6months/1 year intervals
 Warning signs : thread not felt, abdominal pain, foul smelling
vaginal discharge, foul smelling vaginal discharge, fever, chills
Side effects and complications:
 Bleeding
 Pain
 Pelvic infection
 Uterine perforation
 Ectopic pregnancy
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Physical
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Combined
methods
 Hormonal contraceptives

Depot
Oral pills formulations

Progestogen Once-a- Subcutaneous

Combined pill Post-coital pill Male pill Injectables Vaginal rings
only pill (POP) month pill implants
Combined pill:
 21 consecutive days followed by 7 day break
 Bleeding – uterine bleeding from an incompletely formed
endometrium by withdrawal of exogenous hormones (withdrawal
bleed)
 Should be started strictly on 5th day, if she forgets to take the pill-
take it as soon as she remembers and next pill in the usual time
 Mala-D - 0.15mg LNG and 0.03mg EE, free of cost
 Mala-N - 0.3mg Norgestrel and 0.03mg EE, Rs.3/- per pack
 28 pills (21 OCP and 7, 60mg Ferrous fumarate tabs)
 Estrogen inhibits FSH , progesterone inhibits LH surge  prevents
ovulation
 Atrophy of endometrium  prevents implantation
 Thickens cervical mucus
 Failure rate – 0.3 per HWY
 C/I : thromboembolic disorder, CAD, CA breast/uterus, liver
dysfunction or cancer , AUB, DM, HTN, age >35yrs, lactating women
 Non contraceptive uses : dysmenorrhea, hirsuitism, acne,
endometriosis, benign breast cancer
 Side effects: N&V, weight gain, sleep disturbances, mood changes
Progesterone only pills/Micro pill/Mini pill

 Very low doses of progesterone

 Thickens cervical mucus, endometrial atrophy
 Failure rate : 0.3 per HWY (lactating), 0.9 per HWY (non-lactating)
 Benefits : safe for lactating women, HTN, DM, obesity,
thromboembolism
 Can be used where combined OCPs are C/Ied
 Side effects : breakthrough bleeding , headache , mood changes
Emergency contraceptive pills/Post-coital contraception

 To prevent pregnancy due to unprotected intercourse / accidents like

condom rupture or missed pills
 aka morning after pills / post coital pills – not an abortifacient
 Not for regular use  menstrual irregularities
 LNG 0.75mg within 72hrs repeated after 12hrs
OR
 LNG 1.5mg once within 72hrs
OR
 2 COC each containing 100–120 micrograms of ethinyl estradiol and 0.5 mg
of levonorgestrel 12 hrs apart
OR
 4 OCPs containing 30 or 35mcg of EE within 72hrs repeated after 12 hrs
OR

Once a month pill:
 Quinesterol (long acting estrogen) + short acting progesterone
 Pregnancy rate too high, bleeding
Male pill:
 Made of gossypol(cotton seed)
 10% men may develop permanent azoospermia after taking it for 6
months
 Injectables

Depot (slow release

Subdermal implants
formulations)

Vaginal rings
Injectable hormonal contraceptive
Progesterone only injectable
• Depot Medoroxy progesterone acetate (DMPA)
• Norethisterone enanthate (NET-EN)
• Depot Medroxyprogesterone acetate –SC (DMPA –SC)

Combined Injectable
DMPA:
 150mg IM every 3 months
 Safe during lactation
 Side effects: weight gin, irregular cycles, prolonged infertility after use
NET-EN:
 200mg IM every 60days
Administration : within 1st 5 days of cycle, IM gluteus maximus
DMPA-SC 104mg
 Aka Depo-subQprovera 104
 104mg DMPA, SC, every 3 months, upper thigh/abdomen
 MOA: Inhibits ovulation, thickens cervical mucus, endometrial
atrophy
 C/I : thrombophlebitis/ thromboembolism, AUB, liver d/s, CA breast
 Side effects : prolonged bleeding / amenorrhea, weight gain ,
headache, mood swings
Combined injectables:
 Contain progestogen and estrogen
 Monthly intervals
 Suppresses ovulation, thickens cervical mucus, changes in
endometrium
 Eg: Cyclogem, Cycloprovera, Mesigyna
 C/I: pregnancy, thromboembolism, CVA,CAD, CA breast,diabetes
with vascular complications, lactation
Subdermal implants:
 Norplant
 6 silastic capsules with 35mg each
of LNG
 Implanted beneath the skin of
forearm or upper arm
 5 year contraception

Vaginal rings:
 Ring contains LNG
 Worn in the vagina for 3 weeks of
the cycle, removed on 4th
Non-Hormonal contraceptive pill
Chhaya (Centchroman)
 Non hormonal, non teratogenic, non
steroidal, non carcinogenic
 ↑ Movt of ovum in the fallopian tube into
the uterine cavity before it is ready for
implantation
 Developed indigenously from Central Drug
Research Institute, Lucknow
 Twice a week for 1st 3 months, once a week
thereafter
 On 1st day of cycle OR on the day of abortion
OR within 4 weeks of delivery
 Immediate return of fertility on cessation
 Failure rate : 1-2 per HWY when used
perfectly
 Terminal
Spacing methods
methods

Male Female
Barrier Hormonal Post conceptional Miscellaneou
methods
IUDs methods methods s
sterilizatio sterilizatio
n n

Physical
methods

Chemical
methods

Combined
methods
Post conception methods
Menstrual regulation:
 Aspirate uterine contents 6-14 days of a missed period before confirming pregnancy
 OPD procedure
 Complications: uterine trauma, perforation, risk of future abortion, menstrual
disorders, ectopic pregnancy
Menstrual induction:
 IU application of 1-5mg solution of prostaglandin (PGF2) to induce menstruation
Oral abortifacient:

 Mifepristone (RU 486) 200mg orally on day 1 followed by misoprostol 800mg

vaginally immediately or within 6-8 hrs

 Follow up : 14 days after administration for confirming complete termination of

pregnancy

 Medical abortion failure  surgical termination

 Terminal
Spacing methods
methods

Male Female
Barrier Hormonal Post conceptional
methods
IUDs methods methods
Miscellaneous sterilizatio sterilizatio
n n

Physical
methods

Chemical
methods

Combined
methods
Miscellaneous
 Abstinence
 Coitus interruptus: Male withdraws before ejaculation, failure rate: 25%
 Calendar rhythm method/safe period:
Fertile period : Subtract 18 from total duration of shortest cycle and 11 from longest
cycle in past 1 year
Drawback : cycles not always regular, needs high levels of motivation,compulsory
abstinence
Failure rate : 9 per HWY
 Standard days method :
Regular cycles (26-32 days)
Fertile period – 8th day to 19th day- Consider complete abstinence or other methods
of contraception
Natural family planning methods:

Self recognition of signs and symptoms associated with ovulation to ascertain fertile period

Basal body temperature (BBT):

 Rise of body temp 0.3 to 0.5⁰ C on ovulation ( increased progesterone)
 Temp recorded every morning before getting up from the bed
 Abstinence from 1st to 3 days
 Failure rate : 20 per HWY
Billing’s method/ Cervical mucus secretions :
 Immediately before ovulation (peak day) - clear, slippery, egg white consistency
 After fertile period - thicker mucus
Lactational amenorrhea method (LAM)
 Exclusive breasfeeding --> prolactin -->inhibits ovulation
 Effective until cycle has not returned since delivery
 Terminal
Spacing methods
methods

Male Female
Barrier Hormonal Post conceptional
methods
IUDs methods methods
Miscellaneous sterilizatio sterilizatio
n n

Physical
methods

Chemical
methods

Combined
methods
 Permanent /
Terminal methods

Female sterilisation Male sterilisation

Laparoscopy Minilaparotomy operation

 Female sterilization

 Married, 22-49 yrs. At least 1 kid, no H/O

previous sterilization, mentally fit

 Fallopian tube ligated and cut

Male sterilization

Vasectomy

 1cm of vas cut and ligated

 2 procedures : Incisional vasectomy , No scalpel vasectomy

 Complications: scrotal swelling, pain, hematoma, stitch abscess, orchitis

Post operative advice:

 Can resume to normal work within 48hrs and sexual intercourse in 3days

Another contraceptive to be used for next 3 months or next 30 ejaculations

 Manual labour and strenuous work to avoid for 15days

 To wear scrotal support ot T bandage

 Failure rate : 0.15 per 100 person-years