CONTRACEPTION
CONTRACEPTIVE EFFECTIVENESS
Pearl index = No. of unintended pregnancies x 1200
No. of women observed x months of use
METHODS OF CONTRACEPTION
Contraception
Short acting reversible Long acting Permanent
contraception reversible methods
contraception
Hormonal methods • Intrauterine • Female
Non Hormonal methods
devices sterilisation
• Combined oral contraceptive • Condom • Implants • Male
pills • Diaphragm sterilisation
• Progesterone only pills • Cervical cap
• Injectible progesterone • Femidom
• Injectible combined hormonal
contraceptives
• Vaginal rings
• Transdermal patches
THE GATHER APPROACH
Used for family planning counselling- is popular from 1980’s
• G - Greet Build a rapport.
• A - Ask Ask questions
• T - Tell Tell the relevant regarding method of contraception
• H - Help Help the client to reach a decision
• E - Explain Explain about the method
• R - Return Return for ongoing contraceptive method is advised.
A note about TRADITIONAL METHODS
Also called fertility awareness methods (FAMS)
• Rhythm method/ Calendar method
• Basal Body temperature method
• Cervical mucus method/ Billing’s method
Requires motivated women with
• Sympto-thermal method regular cycles and co – operation of
• Standard days method using Cycle beads both partners
• Two day method
• Ovulation detection
• Coitus interruptus
• Lactational Amenorrhoea
• Abstinence
•Rhythm method /Calendar method:
• Abstain between the duration
most effective is symptothermal
▪ Shortest cycle - 18 : first day of fertile period
method-
▪ Longest cycle - 11 : last day of fertile period failure rate: 2 /HWY
• Basal Body Temperature Method:
• Based on rise in body temp(0.5- 0.8 degree F) due to thermogenic effect
of progesterone
• Intercourse only 3 days after rise
• Cervical mucus/ Billing’s/ Ovulation method:
• Based on change in vaginal secretions from scant- to profuse and sticky- lasts for 3
days
• To abstain 3 days after the last WET day
• Symptothermal method:
• Combines BBT and Billing’s method + manifestations of fertile period
LACTATIONAL AMENORRHEA (LAM)
• Based on the antifertility effects of prolactin
✔ Inhibits LH - decreases ovarian response to gonadotrophins
✔ Initiation must satisfy the Bellagio criteria:
✔ Menstrual cycles have not resumed
✔ Infant is fully or nearly fully breast fed, day and night
✔ Infant is under 6 months of age
In amenorrheic women who fully or partially breastfeed,
pregnancy rates are 1 HWY in the first 6 months
Fertil Steril 2008
SHORT ACTING REVERSIBLE
CONTRACEPTIVES
Includes
• Combined oral contraceptive pills
• Progesterone only pills
• Injectible progesterone
• Injectible combined hormonal contraceptives
• Vaginal rings
• Transdermal patches
FOUR GENERATIONS OF OCP’S
Evolution of OCP’s
Characteristi First Second Third Fourth
cs generation generatio generation generation
n
Estrogen Ethinyl estradiol(EE) EE EE EE/Estradiol valerate (EV)
Progesterone Norethindrone Norgestrel Desogestrel(DSG Drospirenone(DRS)
acetate(NE) Levonorgestrel ) Dienogest
Ethynodiol (LNG) Gestodene(GSD) Nestorone
Lynestrenol Norgestimate Nomegestrol acetate
Side effects:
Nausea/vomiting ++ + - -
Headache/ HTN ++ + - -
VTE + + ++ ++
Acne/hirsutism/ ++ + - decrease
weight gain
Altered lipids + + - -
Faculty of Sexual and Reproductive Healthcare, 2007.
NEWER CLASSIFICATION FOR OCPs
• Constant dose of both E2 & P4 in each of the hormonally active pills
Monophasic throughout the entire cycle (21 days of active pills)
pills
• Change the level of P4 once (halfway)during the menstrual cycle.
Biphasic • Jenest ,Mircette ,Nelova ,Necon
pills
• Contain three different doses of P4 in the active pills (changing every 7
days during the first 3 weeks of pills).
Triphasic • Ex: Necon,Nortrel,Ortho Tricyclen ,Ortho Tricyclen Lo ,Ortho-Novum ,Tri-
pills Levlen ,TriNessa
DEPOT MEDROXY PROGESTERONE ACETATE
Injectable, progestin-only Grace period: 2 weeks
contraceptive. Do UPT after 15 weeks: next
dose + back up contraception
150 mg/1 mL – i.m. Injection- every 3 x 7d
months
104 mg/0.65 ml - s.c. injection. (Sayana
Press)
• Subcutaneous: 30 % lower dose,
slower, ↑ sustained absorption . No indication for BMD testing on
• Same duration of action, equal prolonged use
efficacy, less painful may be self ACOG Committee Opinion 415, 2008
administered.
Keith et al, Savana press
review,Contraception 2014
TRANSDERMAL HORMONAL
CONTRACEPTIVES
• Highly effective, long acting reversible
contraceptive
• ↑ Compliance, coitus independent
• Ortho Evra: only brand available
• 20 x 20 mm Increased risk
• Daily release: 20 mcg EE +150 mcg norelgestromin (metabolite
of VTE is aof
concern with
norgestimate) use of non
• Duration: 1 patch/week x 3 wk. oral CHC
Long acting reversible contraceptives (LARC)
⚫ Includes
⚫ Intrauterine devices (IUDs)
( Cu T, LNG – IUD)
⚫ Subdermal implants
(Implanon/Nexplanon)
⚫ Not user-dependent
⚫ Very low failure rates – 0.27 /HWY Launched by ACOG in 2008
with aim to reduce unintended
Winner et al, N Eng J Med , 2012 pregnancy and increase
access to LARC methods
Intrauterine contraceptive devices
• 1 generation : Lippes Loop
st
• 2nd generation : Copper containing
• 3rd generation : Progesterone containing
• Microcrystallized progesterone: Progestasert
• Levonorgestrel : Mirena
• 4th generation : frameless IUD
• GyneFix (copper)
• FibroPlant ( levonorgestrel)
Copper IUD’s Hormone releasing IUD’s
• CuT 380A • Progestasert
• CuT-380Ag • LNG - 20 (Mirena)
CuT 380 slimline Newer – Lilleta/ Skyla
Multiload 375
Nova T
LNG IUD
Mirena(Bayer) Liletta(medicines Skyla(Bayer)
52 mg LNG 360) Contains 13.5 mg LNG
Releases 20 mcg/ d 52 mg LNG Releases 14 mcg/ day
effective for 5 yrs Releases 18.6 mcg/ d effective for 3 yrs
32 x 32 mm effective for 3 yrs smaller 28 x 30 mm
Rate of amenorrhea after 32 x 32 mm Contains silver core
1 year- 20% Similar rates of Rate of amenorrhea after
amenorrhea as mirena 1 yr of use- 6%
IUD INSERTION
• Timing : 1st 7 d of menses, post abortal- immediate – 1 wk, post partum-
immediate - 48 hours or after 6 wks.
• Back up contraception x 7 d : • >7d of menstrual cycle
• Post abortal
• PP- < 21d , not lactating
• Cervical inspection and bimanual examination is mandatory.
• Prophylactic antibiotics not recommended for IUD insertion.
• Standard practice cleansing the cervix and sterilizing instruments.
• Routine follow up not required.
• NO TOUCH TECHNIQUE, WITHDRAWL METHOD.
CuT 380A has ↑ efficacy than Multiload 375.
No difference in side effect profile, ease of insertion.
Cochrane systematic review 2007
• Older implants: IMPLANTS
• Norplant: 36mg/rod, 6 LNG rods
• Jadelle : 75mg two LNG rods
• Implanon: marketed as Nexplanon- bioequivalent- has I rod of 68 mg
etonorgestrel- releases 60 mcg/ day
⚫ Has 99% contraceptive efficacy over 3 years
Graessel et al,Eur J Contracept Reprod Health Care. 2008
• Nexplanon:
⚫ radiopaque,
⚫ with easier insertion
EMERGENCY CONTRACEPTION
INDICATIONS
• When contraceptive method NOT used
• Sexual assault
• During contraceptive failure or incorrect use, including:
⚫ Condom breakage, slippage or incorrect use.
⚫ 3 or more consecutively missed COCs.
⚫ POP > 3 hours late, DMPA > 4 weeks late.
⚫ Dislodgment, delay in placing, or early removal of a contraceptive hormonal
ring or skin patch;
⚫ Failed withdrawal, miscalculation of fertile periods..
⚫ Expulsion of IUD or implant.
• LNG- I PILL
✔ Single dose regimen LNG- 1.5 mg
• more convenient than split dose regimen
• as effective as a split dose, without increasing the frequency of side effects
✔ Interval between 2 doses of LNG can be lengthened to 24 hours apart
without changing efficacy
Hansen et al,Pharmacotherapy. ,2007
• MIFEPRISTONE
✔ 25/50 mg stat dose- even 10 mg dose is accepted
✔ prevents 92–100% of pregnancies with an acceptable side-effect profile
✔ In a comparative study of 4136 healthy women,( single dose of 10 mg
mifepristone vs 1.5 mg levonorgestrel vs 2 doses of 0.75 mg
levonorgestrel 12 h apart) pregnancy rates 1.5% :mifepristone & single
dose of levonorgestrel ,1.8% :split dose LNG
•Copper intrauterinecontraception (IUD)
Most effective method of emergency contraception
Advantages:
✔continuing contraception after initial IUD placement
✔more effective than oral regimens, especially
in overweight/obese women
Sample :1963 women, 18–44 years for EC
Results :No pregnancies occurred prior to or at the first follow-up visit, making CuT380A 100%
effective as emergency contraception.
✔The pregnancy rate over the 12-month period was 0.23 per 100 women.
✔The main side-effects were increased menstrual bleeding and menstrual disturbances
✔ The 12-month post insertion continuation rate was 94.0 per 100 woman-years.
Ulipristal acetate : 30 mg UPA stat dose
within 120 hrs
is a SPRM- inhibits ovulation
Contraindications :
•Suspected pregnancy
•Poorly controlled asthma
•Hepatic dysfunction.
MEC1 MEC2 MEC3 MEC4
Hormonal •Rape •Severe cardiovascular
methods •h/o ectopic disease
(E+P, P) •Repeated use •Severe liver disease
/UPA •Breastfeeding •Migraine
•Angina
Cu IUD Rape- ↑ risk Pregnancy
STD
HOW TO USE?
• Vomiting Within 3 Hours of Taking ECPs: Repeat dose
± antiemetic.
U. S. S.P.R. for Contraceptive Use 2013.
• EC failure: No ↑ ectopic pregnancy, few cases
reported.
Cleland K et al Am J Obstet Gynecol 2010.
• EC failure: No ↑ congenital malformations.
Zhang L et al, Hum Reprod 2009.
MALE CONTRACEPTION: RECENT
ADVANCES
Includes:
• Barrier methods:Condoms
• Hormonal/non hormonal preparations
• Immunocontraceptive
• RISUG
MALE CONDOMS
NEWER CONDOMS
Polyurethane: Avanti, Supra
Styrene based plastic: Tactylon
Polyisoprene: Skyne (thinnest)
Polyurethane condom vs. latex condom
Pregnancy rates : 5.4% with latex
9% with polyurethane
Advantages: More resistant to heat & oxidation
Thinner material; can be used with any
lubricant
Disadvantages: Higher risk of breakage, lesser STI protection,
costlier.
(Cochrane database systemic Rev 2006)
HORMONAL PREPARATIONS
• Inhibits release of LH and FSH thereby decreasing
intratesticular testosterone levels
• Single agent
⚫ Testosterone enanthate(TE)- 200 mg i.m./ week
Testosterone is available in
the form of injections/
⚫ Testosterone undecanoate(TU)-depot i.m./1-2 month
implants(6 monthly)/
• Dual agent transdermal patches(3
monthly)/gels
⚫ Testosterone +progestin(DMPA/levonorgestrol/etonogestrel/norethisterone
enanthate/cyproterone acetate)
⚫ Synthetic agents
7a-Methyl-19-nortestosterone (MENT) is a selective androgen receptor modulator
(SARM) and is effective orally, is usually combined with progestins
Kogan et al. Male Contraception History and Development Urol Clin N Am 41 2014
IVD(Intra vas devices)
• Intra-vas implants like Intavas( a urethane device filled with
nylon threads) blocks sperm but allows the passage of fluid
• Inserted through a small scrotal incision identical to that
used for vasectomy
• Success rate : 94.3% at 12 months compared with 98.6% for
vasectomy .
Song et al.Int J Androl 2006
RISUG is
currently
RISUG undergoing
phase III trials .
• Reversible Inhibition of Sperm Under Guidance.
• Developed by Dr. Sujoy Guha.
• Technique: injection of styrene maleic anhydride (SMA) dissolved in dimethyl
sulfoxide (DMSO) into the vas under direct visualization through a small incision
100% reversibility achieved using:
❑ progressive percutaneous
Another similar alternative is the squeezing of the vas
VASAGEL( polymer gel)- which is
currently awaiting FDA approval ❑electrical stimulation,
for human trials
❑digital rectal massage
of the ampullary vas
Lohiya et al. contraception 1998
PERMANENT METHODS OF
CONTRACEPTION
• Female sterilisation
⚫ Minilaparotomy
⚫ Laparoscopic
⚫ Hysteroscopic
• Male sterilisation
⚫ Traditional vasectomy
⚫ No scalpel vasectomy
Indian guidelines for sterilisation
MEC for sterilisation
WHO 2004
SPECIAL CASES: CATEGORY D
In females In males
⚫ Acute DVT ⚫ Local infection
⚫ Puerpural / post abortion sepsis/ ⚫ Current systemic infection
⚫ Severe PPH
⚫ Ischemic Heart Disease
⚫ Unexplained vaginal bleeding
⚫ Genital malignancies
⚫ Acute PID
⚫ Acute respiratory/ GI illness
⚫ Severe anemia< 7 g/ dl
Standards for female and male sterilisation. MOHFW, 2006
WHAT’S NEW:
HYSTEROSCOPIC STERILISATION
• Involves placement of metal coil in the tubal ostia (Essure) through
hysteroscope
• Approved by the US (FDA) in 2002
• Requires interim contraception for 3 months followed by HSG to confirm
bilateral occlusion.
ACOG committee opinion 2012
• Benefits – faster recovery
• Drawbacks-
⚫ Not effective immediately,
⚫ Higher chance of ectopic pregnancy if fails
⚫ Can be associated with new onset pain or a worsening of a pre-
existing painful gynecologic condition although both are very rare.
Kamecic H et al J Minim Invasive Gynecol 2016
Thank you all !
