CONTRACEPTION

Associate Prof Dr Hanifullah Khan

ultrasound scan of IUCD in situ

Objectives

Understand the definition, classification & terminology

Understand the reason for contraception

Know the advantages & side-effects

Know the proper use of each method

To be able to advise on the use

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Introduction

Definition – any method used to prevent pregnancy

• Allows to choose whether & when to

have a child

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Reproduction

Ovulation

Fertile period

Fertilisation

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Female Contraception

Reversibl Non-

Hormon Non-

CO

PO

IU

Barrie

Spermicide

Tubal

PO

Injectable

Implant

Emergenc

Miren

COMBINED CONTRACEPTION

• BENEFICIAL EFFECTS ON FUTURE FERTILITY

– ↓ ASCENDING INFECTION & PID (PROGESTOGENIC EFFECT)

PROGESTOGEN ONLY CONTRACEPTION

● POP ● SUBDERMAL

IMPLANTS ● INJECTABLES ● COMBINED

INJECTABLES ● EMERGENCY

CONTRACEPTION

Emergency Contraception Levonorgestrel 0.15 mg +ethinyl estradio

Nordette (light orange tablets)

4 tablets/dose

2 doses

Levonorgestrel 0.75 mg

Plan B 1 tablet/dose

2 doses First dose within 72 hours of unprotected intercourse; second dose

• COPPER-CONTAINING

INTRAUTERINE DEVICE (IUD)

INSERTED WITHIN 120 HOURS OF

UNPROTECTED INTERCOURSE TO

PREVENT PREGNANCY

• A SHORT COURSE

– EITHER A HIGH-DOSE

COMBINATION OF ESTROGEN & PROGESTIN OR

– PROGESTIN-ONLY

– USED WITHIN 72 HOURS OF

UNPROTECTED INTERCOURSE TO PREVENT PREGNANCY

• TAKEN AFTER SI BUT BEFORE

IMPLANTATION • MORE

EFFECTIVE THE SOONER THEY ARE INITIATED

AFTER SI.

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NATURAL METHODS

Avoid sex at the fertile times

Unsuitable for:

Women who can't check their temperature and cervix every day

Couples who are even slightly disorganised

Women with very irregular periods

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Methods

Coitus Interruptus

Rhythm Method

Calendar

BBT

Cervical Mucous (Ovulation)

Symptothermal

Ovulation Predictor Kits

Abstinence

Lactational Amenorrhoea Method

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Shortest cycle (S) minus 18 = Last infertile day of the pre-ovulatory phase

Longest cycle (L) minus 11 = Last fertile day

For example:- Length of cycles during last six months = 28, 29, 28, 27, 30, 28

(S = 27) S - 18 = Last infertile day 27 - 18 = 9

(L = 30) L - 11 = Last fertile day 30 - 11 = 19

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Basal Body Temperature Method

Keeping track of body temperature

Body temperature rises two days prior to ovulation.

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Ovulation (Billing) Method

Requires feeling and observing the cervical mucus to determine the time of ovulation.

Note the production of clear, watery mucus in the days immediately before ovulation

To avoid pregnancy, intercourse is avoided for several days following change in the color and consistency of cervical mucus.

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Sensation at Vulva Finger Test Appearance

Moist orSticky

Early Mucus Scanty Thick WhiteSticky Holds its shape

Wetter

Transitional Mucus Increasing Amounts Thinner Cloudy Slightly Stretchy

Slippery

Highly Fertile Mucus ProfuseThin TransparentStretchy (like raw egg white)

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Mucus changes throughout the cycle

Complete cycle showing typical pattern of menstruation, pre-ovulatory dry days, mucus days with increasingly fertile characteristics approaching peak day, the abrupt change back to less fertile characteristics, the count of four after peak day and post-ovulatory dry days

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Interpretation of the Sympto-Thermal Chart

This sympto-thermal chart shows the correlation between all indicators of fertility

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Fertility Chart

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Ovulation Predictor Kits

used to test urine to identify hormones that indicate ovulation is about to occur

electronic fertility computer tells a woman which days she is fertile

Persona: fertile days are indicated with a red light and infertile days with a green light

failure rate as low as 6% among women who abstain on fertile days as indicated by the device

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LAM

Conditions to be fulfilled

Fully BF

No periods

Recommended up to 6 months - the longer LAM is used, the more likely it is that ovulation will precede the first menses

INTRAUTERINE DEVICES

Copper IUDs: Mechanisms of Action

Interfere with reproductive process before ova reach

uterine cavity

Thicken cervical mucus

Interfere with ability of sperm to pass through

uterine cavity

Change endometrial lining

IUDs: Who Should Not Use (WHO Class 4)

IUDs should not be used if woman:

Is pregnant (known or suspected)

Has unexplained vaginal bleeding until the cause is determined and any serious problems are treated

Has current, recent PID

Has acute purulent (pus-like) discharge

Has distorted uterine cavity

Has malignant trophoblast disease

Has genital tract cancer

Has an active genital tract infection (e.g., vaginitis, cervicitis)19 May 07 67Source: WHO 1996.

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IUDs: Common Side Effects

Copper-releasing:

Heavier menstrual bleeding

Irregular or heavy vaginal bleeding

Intermenstrual cramps

Increased menstrual cramping or pain

Vaginal discharge

Progestin-releasing:

Amenorrhea or very light menstrual bleeding/spotting

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IUDs: Possible Other Problems

Missing strings

Slight increased risk of pelvic infection (up to 20 days after insertion)

Perforation of the uterus (rare)

Spontaneous expulsion

Ectopic pregnancy

Spontaneous abortion

Partner complains about feeling strings

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Failure rates

Implants, IUDs and LNG-IUS - <1% #

Contraceptive pills - 5% #

Male condoms - 14% #

Diaphragm with spermicide - 20% #

Cap with spermicide - 20-40% #

'Natural' methods - 35% #

Withdrawal - 19%

KEY POINTS

Contraception provides an effective means to plan a family

Many methods are available -

suitability has to be decided based on a proper history & examination

Pregnancy should be ruled out first

You should know the advantages & side effects

Contraception also provides non-contraceptive benefits

Further reading

Cleland et al. Family Planning as a cost saving preventive health service. NEJM April 20, 2011.

Trussell J. Update on the cost effectiveness of contraceptives in the United States. Contraception 2010;82:391.

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