Newer techniques of sterilization & contraception ,injectable contraceptives

&emergency contraceptives

by Dr.surendra babu (pg 1st yr)

Moderator: Dr.Prof, O.P. Panigrahi

RISUG (Reversible Inhibition of Sperm Under Guidance)

• A local anaesthetic is applied to the scrotum at the injection site.

• The vas deferens—the tube that sperm pass through on their way from the testes to the penis—is extracted through the scrotum and injected with a polymer made from styrene maleic anhydride (SMA) and dimethyl sulfoxide(DMSO).

• On the market, this non-toxic polymer is known as Vasalge. The process is then repeated on the other side with the second vas deferens

Adiana sterilization system :

• A clinician delivers a catheter through a hysteroscope into the fallopian tube & uses the cathter to apply low level radio frequency energy ,followed by an insertion of a matrix (polymer implant,smaller than grain of rice )

• The matrix is left in the fallopian tube and the surrounding tissue will grow into it causing permanent blockage

• Failure rate :0.2 per 100 women years

• US FDA approval recently

ESSURE :

• The Essure is a permanent birth control (female sterilization) by, an occlusion of the fallopian tubes with the use of trans-cervical bilateral insertion of blocking coils directly into the lumen of the tubes

• . The device itself is made from dual coils that expand into the tubal lumen when deployed. Its fibers stimulate occlusive tissue growth over a 3 month period.

• Successful placement and tubal occlusion is confirmed by hysterosalpingography

• It is irreversible Removal of the micro-inserts requires surgery. Its hould not be considered 100% effective.

Approved by FDA in 2002

Advantages :

• No incision

• No hormones

• No anaesthesia

• outpatient

• EffectiveThe one-year and two-year failure rates established in the Essure clinical trials were both 0%.

• Rapid recovery

• High patient satisfaction

Complications :

• Complications include device expulsion, tubal perforation, and pregnancy.

• Unlike laparoscopic sterilization, it is not immediately effective

• The highly charged polymer attaches to the inner walls of the vas deferens, and

when it comes in contact with the negatively charged sperm, ruptures their tails so

that they are incapable of fertilizing eggs

• This is what separates RISUG from a vasectomy—sperm can still be expelled

from the scrotum, but cannot reach and fertilize an egg

• The procedure typically lasts no more than a few minutes

• The reversal process is also simple, with a quick injection of water and baking

soda to flush out the Vasalgel.

• The side effects of the procedure are minimal, and may including swelling at the

injection site.

What’s New in Contraception?

Factors to consider:

• Innovative methods

• Longer term

• Reduced dosing

• Reduced risks

• Quick reversibility

• Equally as effective as OCP

• Less reliant on the user

Methods of Contraception

Methods of Contraception

I. Combined

Hormonal

Oral contraceptive pills

Depot medroxyprogesterone acetate injections

Transdermal patches and Vaginal rings,

II. Barrier

and

Behavioral

Male condoms, Diaphragms

Caps, Female condoms, Spermicides

Withdrawal, Fertility awareness method,

Natural family planning

III. Longer TermProgestin implants and Intrauterine devices

IV. Sterilization Female sterilization and Vasectomy

What’s new? Contraceptive patch ( Ortho Evra )

Vaginal ring ( Nuvaring )

Intrauterine system ( Mirena )

Progestogen-only Implants ( Implanon )

Transcervical sterilization methods

Yasmin Seasonale

Male contraceptive method

Transdermal patch :

It is a beige-colored patch applied once a week to the abdomen,buttock, upper outer arm, or upper torso (excluding breasts).

The patch releases 150 mcg of norelgestromin and 20 mcg of ethinylestradiol to the bloodstream daily to inhibit ovulation.

3 consecutive 7-day patches (21 days) are applied, followed by 1patch-free week per cycle. The patch contains 9 days of medication.

Advantages:

Very effective

Rapidly reversible

Excellent cycle control by 3 months of use

Easy to use, start, and stop

Extra protection built in; serum hormone levels will remain in the contraceptiverange for up to 2 additional days

Disadvantages:

Requires a prescription

Concern about visibility of patch for some women

Possible skin reactions

Slight increase in risk of VTE compared with COCs

Lack of protection against STIs

Vaginal ring (nuva ring )

Vaginal ring is a thin, transparent, flexible ring that containsoestrogen/progestogen hormones that are absorbed through vaginal mucosa.

The ring is 92% to 99% effective for pregnancy prevention (typical toperfect use).

It stops ovulation and thickens the cervical mucus.

Worn continuously for three weeks followed by a week off, each vaginalring provides one month of birth control.

Advantages: Easy to use

Can be worn for three weeks

Effects fertility one month at a time

Disadvantages: Does not protect against sexually transmitted infections, including HIV/

AIDS

Spotting

Increased vaginal discharge

Adverse effects

• Vaginitis (14.1%)

• Headache (9.8%)

• URTI (8%)

• Leukorrhea (5.8%)

• Nausea (5.2%)

• Weight gain (4.9%)

• Expulsion & Coital problems (2.6%)

Prostogen only implant

This is a matchstick-size, flexible rod that is put under the skin of the upper arm.

• It is often called by its brand name, Implanon.

• The rod releases a progestin, which causes changes in the lining of the uterus and the cervical mucus to keep the sperm from joining an egg.

• Less often, it stops the ovaries from releasing eggs.

Advantages :

It is affective for 3 years

Disadvantages :

• May cause side effects, including irregular bleeding. Doesn't protect against STIs.

Female CondomFemale barrier method

A lubricated polyurethane pouch that is inserted inside the vagina during intercourse.

Advantages: Prevents the transmission of HIV and other STDs No hormonal side effects Can be used by people with latex sensitivities

Does not affect future fertility

Disadvantages: Sometimes difficult to insert or use Friction/noise during intercourse Loss of sensation

Can break or leak

Emergency contraception :

• It is a method of contraception used to prevent pregnancy ,also known as “morning after pill” or postcoital contraception

• A woman who had an unprotected sex & want to prevent pregnancy can use emergency contraception in following circumstances

Unprotected intercourse

Rape ,sexual assault ,incest

Failure of contraceptive method

this method can save the lady from agony & embracement of restoring illegal abortion even suicide

• This method is recommended with in 48 to 72 hrs of unprotected intercourse

• They act by stopping ovulation or by interfering with implantation of the ovum

High dose progesterone

High dose estrogens Estrogen –progesterone combination (yuzpe)

Content Levonorgestrel 1.5 mg (i-pill)One pill to be taken preferably with in 12hrs & not later than 72 hrs & 2nd pill to be taken witin 12 hrsafter the 1st pill

Diethylstilbestrol 50 mgmfor 5 daysEthinyl estradiol 05mgm for 5 days

100 mgm estrogen&1mgm progestrogen(Mala-N & mala-D)

Failure rate < 1% 0.2 to 2%

Side effects Nausea ,vomiting ,headache & breast

Severe & high due to high doses of estrogen

Due to high doses of estrogen

Recent advances in emergency contraception :

Danazol :it is progestogen only with anti-gonadotropic activity

Mechanism of action :Prevents implantation by making unfavourable endometrium

Dose : 2 doses of 400 mgm each at 12 hrs interval

This method is more effective than yuzpe regimen

Mifepristone :(RU486 )it is anti progesterone

Mechanism of action :Prevents ovulation & hinders development of endometrium

Dose :600 mg stat with in 120 hrs

This method is more effective than yuzpe & danzol

Mechanical method of emergency contraception :

• This consists of insertion of cooper IUD within 3 to 5 days of unprotected intercourse

• Mechanism of action :prevents implantation of embryo &embryo toxic effect by cooper ions

• This is useful particularly when hormonal pills are contraindicated

• Contraindication :in woman who are at risk of STD because of rape

• This is more effective than hormonal method as emergency contraceptive

Method & Dose Time after Intercourse Failure rate (%) Comments

High dose estrogenDiethyl stilbestrol 50mg or Ethinyl Estradiol 5mg X 5 days

< 72 hours0.3-1.6 severe nausea & vomiting,

failure to complete regimen

Yuzpe’s Regime (E+P) - EthinylEstradiol 100 µg + Levonorgestrel 0.5 m

<72 hrs., repeat after 12 hrs. O.2-3.2 (75-80% effective

risk of estrogen uselow efficacy

Danazol 800mgm X 3 doses 1200mg X 2doses

72 hrs 0.8-1.7 androgenic effect on repeated use

IUD (CuT) 5 days <1

risk of PID, unsuitable for nullipara,infrastructure & training required

Centchroman 50mg 2 tablets 72-120 hrs repeat after 12 hrs to be evaluated menstrual delay

Levonorgestrel - 0.75 mg X2 1.5 mg X 1

upto 120 hrs, 0.75mg (two doses 12 hrs apart) or 1.5mg (single dose)

1.1safe & effectivecheap

Anti-Progestin RU 486 (Mifepristone) 10mg single dose

120 hrs 1.1-1.3menstrual delay,risk of ectopic pregnancy

Injectable contraceptives :• They are called as “depot formulations” or “slow release formulations”

• These are formulations containing only synthetic progesterone which is released over long period of time ,thus providing long lasting hormonal contraceptive activity

Most widely used injectables are DMPA & NET-EN

Injectable contraceptives :• They are called as “depot formulations” or “slow release formulations”

• These are formulations containing only synthetic progesterone which is released over long period of time ,thus providing long lasting hormonal contraceptive activity

Most widely used injectables are DMPA & NET-EN

DMPA (depot medroxy progesterone

acetate)

NET-EN (norethisterone ethnalthate )

Suspension Micro crystalline suspension Oily suspension

Route of administration Deep intramuscular once in 3 months Deep intramuscular once in 2 months

Dose 150mgm of progestin (synthetic

progesterone)

200 mgm synthetic progesterone

Duration of protection 3 months 2 months

Return of fertility 4 to 6 months ,after stoppage of drugs Same

Merits :

• very safe ,affective ,convenient & reversible

• Does not interfere with lactation & sex

• Can be used by women of any age in the reproductive period

• Helps prevent ectopic pregnancies,endometrial cancer & uterine fibroids

Demerits :

Menstrual cycle become irregular

Weight gain 1or 2kg per year

Head ache ,breast tenderness ,mood changes

Postpartum use : if used with in 6 wks of delivery ,it may result in heavy bleeding

Contraindications :

• Suspected malignancy

• PID

• Bleeding disorders