History of contraception

1. History of contraception • Idea is ancient • Egypt • Douched with wine and garlic after sex • Soaked crocodile dung in sour milk and inserted in vagina • Greeks and Romans • Placed absorbent materials within vagina to absorb semen • Penile sheaths as far back as 1350 BC in Egypt • Term condom in 18th century • Originally made of animal intestines • Casanova used condoms • Rubber condoms in late 1840s

2. Selecting a method of contraception • Convenience • Moral acceptability • Cost • Sharing responsibility • Safety/side effects • Reversibility • Protection from STDs • Effectiveness

3. History of fight against contraceptives • Anthony Comstock • Secretary of NY Society for the Suppression of Vice • Lobbied for passage of 1873 federal law (Comstock Law) • Margaret Sanger • Proponent of contraception and information • 1st started magazine called “The Woman Rebel” in 1914 • Founded birth control clinic in 1916, which was shut down by police • She appealed • In 1918, courts ruled in favor of MDs being able to disseminate information that might prevent disease • Today, critics of Sanger persist • Eugenics • Racism

4. Need for contraceptives • Worldwide over 100,000,000 acts of intercourse per day • 910,000 conceptions • 50% planned, 25% unwanted • 356, 000 sexually transmitted bacterial and viral infections • Mythical contraceptives • Nursing an infant • Withdrawal • Douching • Teens—all sorts of ideas

5. Contraceptives around the world • Japan • Oral contraceptives approved in 1999 • About 3% of women take them (compared with 18% in US) • 70% don’t want them • Strategy was to discourage sterilization, IUDs and diaphragms to encourage condom use to decrease STDs • Brazil • Had a trial of a male contraceptive—still refining • Impressive because until 1979 it was illegal to advertise contraceptives • 60% of men express a willingness to take a contraceptive • Sterilization was illegal until 1997—now 40% of married women have undergone this • China • One child policy implemented in 1978 • Expected to remain in place until at least 2020 • Induced abortion is one of the forms of birth control • Requires abortion of a fetus with any abnormality because kids are supposed to care for aging parents • France • French Catholic Bishops—approved of condoms due to STDs

6. Contraceptives around the world • United Nations World Contraceptive Use 2003 • 61 per cent of all women of reproductive age who are married or in a consensual union are using contraception. • More developed regions--69 % • Less developed regions-- 59 % • Africa—27% • Nine out of every 10 women using contraception rely on modern methods. • Traditional methods are more popular in developing countries than in developed countries • The most commonly used traditional methods are: rhythm (periodic abstinence) and withdrawal. • At the world level, these methods are used by 6 per cent of women who are married or in union.

7. The biggest obstacle to contraceptive use in US: Effective planning

8. The pill • Combination pill—synthetic estrogen and progesterone—steady dose, some multiphasic and vary through the month • Mini pill—progestin pill • Pills are used by 28% of women who use reversible contraception • Works by preventing ovulation—fakes pregnancy • Artificially increases estrogen, which prohibits FSH production and inhibits ovulation • Progestin is a backup—keeps cervical mucus thickhard for sperm to get through and changes lining of uterus for a more difficult implantation • When pill is withdrawn, menstruation • Failure rate (pregnancy rate over year) • Perfect user .1%, typical user 3%

9. Side effects • Side effects • Slight increase in diseases of circulatory system—DVT, stroke, heart attack, high bp • No evidence of increase in cervical, uterine, or breast CA • Actually a protectant from endometrial and ovarian CA • Increases susceptibility to vaginitis, gonorrhea, Chlamydia • 20% of users report increased irritability, depression—become worse with time used. • Groups who should not use BCP • Antibiotics may decrease effectiveness • Pill may make some drugs more potent (anxiolytics) • Research on effects on sex interest • There is already research on how male contraceptives affect sex interest, but very little on female contraceptives • Not Now Darling I’m on the Pill • Began with uncontrolled, retrospective study • Then did prospective study • Results—BCP decrease breast pain and bloating but decreases sexual interest

10. The mini pill • Good for women who can’t take combo pill for estrogen reasons • Women with a history of clotting problems • Creates irregular periods • Not sure why they work—40% continue to ovulate • Progestin also fosters male secondary sex characteristics • Acne, facial hair, vaginal dryness, thinning of scalp hair, decreased breast size

11. Morning after pill • Stops fertilization or implantation • Take within 72 hours • New York Times poll—65% consider this birth control, 20% abortion • High dosage of estrogen and progesterone—not tested long term • As of 2002, France—girls under 18 are eligible for free pills, must speak with pharmacist, no script necessary • In US, costs $10-$70—over 17, no script, under need prescription

12. The patch • 2010 Ortho Evra patch approved • It is a transdermal estrogen/progestin drug system • It is applied to the lower abdomen, buttocks, or upper body every week for 3 weeks. The fourth week is patch-free to allow menses. • Risks and effectiveness are similar to oral combination contraceptive pills. • Less than 2% of these patients discontinued the patch due to effects, less effective in those weighing over 200 lbs • Costs about $30/month, just like pill

13. Vaginal ring • 2010 NuvaRing approved • It is a flexible polymer 2.1” ring that is colorless and transparent—releases estrogen and progesterone • The patient inserts the ring in the vagina on day 5 of her cycle and leaves it in place for 3 weeks. • Effectiveness takes 7 days, requiring abstinence or a backup contraceptive method. The ring is removed to allow menses (1 week hormone-free similar to the pill and patch • Efficacy and side effects are similar to oral contraceptives • Compliance rates of about 91% • The ring may accidentally be expelled if not inserted correctly • Cost for is about $45

14. Other hormonal methods • Monthly shots—Depo Provera, Lunelle--progesterone • Implanon—implantable, in arm • Estrogen, progesterone • Good for three years • Costs $400-$800 for implantation • Highly effective—failure rate of less than 1%

15. IUD • Both hormonal (Mirena-progesterone) and non-hormonal (ParaGard) methods • Small t-shaped piece of plastic or copper • Left in place for 1 to 5 years • Common in China (1/3 of married women)—only about 3% here • Not exactly sure how non-hormonal method works • Mirena also decreases menstrual flow and can be used to treat excessive menstrual bleeding • Quite effective—1-2% failure rate—usually due to expulsion • Major side effect—PID—pelvic inflammatory disease • Others—menstrual cramps, irregular bleeding, increased menstrual flow in 10-20% of women • Initial cost--$175-$650

16. Diaphragm and cervical cap • Diaphragm • Fewer than 5% of married women use • Circular, dome-shaped piece of thin rubber with rubber covered rim of flexible material • Contraceptive jelly on edge • Can be inserted 6 hours before sex. Must be there 6 hours after • Typical user failure rate—18%, perfect user 6% • Fit is key—refit after birth, abortion, weight gain or loss or more than 10 lbs • Few side effects • Cost $10 plus office visit, should last 2 years • No effect on hormones • Cervical cap • Newer • Fits snugly on cervix • Used with spermicide • 18% for nulliparous, 36% for parous

17. Spermicides • Use no more than 60 minutes before sex • Jellies, foams, creams, suppositories, film • Work by coating cervical opening • Typical user failure rate—as high as 21% • Foams are better than creams or jellies • Better when combined with condom or diaphragm

18. Male condom • Old idea • New one for every act of intercourse • Must be put on before intercoursepre-ejaculate contains sperm • Typical user failure rate 12%, perfect user 3% • FDA regulates only US made condoms • Animal skin—not as effective in preventing STDs

19. Female condom • Can be inserted as much as 8 hrs before sex • Typical user failure rate of 21%, perfect user failure of 5% • Early material made lots of crinkling noise, but newer materials do less of this • $2.50 to $5 each

20. Non-contraceptives • Douching • 40% failure rate • Withdrawal • 20% at best

21. Fertility awareness • Major advantage—sanctioned by RCC • Involves abstaining from sex around ovulation • Calendar method—based on ovulation day 13-15 • Basal body temp—good only after ovulation • Cervical mucus • Home ovulation kits • Saliva ovulation test • Sympto-thermal—both mucus and temp • Effectiveness • Typical user—20% typical user • Perfect user 1% home ovulation, 9% calendar

22. Sterilization • 39% married women under 45, 15% of men • Vasectomy • Severs vas deferens • Takes 20 min in drs office • No physical changes that interfere with erection • .1% failure • 50% pregnancy rate after reversal • Female sterilization • Tubal ligation • Takes 10-20 min in hospital • Doesn’t interfere with ovaries • .4% failure rate • 45-80% pregnancy rate after reversal

23. Abortion • Each year, nearly 1 million girls 15-19 get pregnant • About 30% end in abortion, 50% live birth, rest miscarriage • 27% white teen girls, 35% black teen girls report no contraceptives • 37 million abortions worldwide each year • 90% during first trimester • In US, rates range from about 3 per 1000 (Idaho) women to 37 per 1000 (DC) • Average of about 14.1 per 1000 women overall per year

24. Abortion around the world • Canada • All remaining restrictions struck down in 1988 • No reporting requirements, but about 19% of all known pregnancies • 90% are in the 1st trimester • 2/3 on young, unmarried • China • 13 million annually (China Daily) (Compared to 20 million births each year) • 62 percent of the women who have abortions are between 20 and 29 years old, and most are single • Additional 10 million abortion pills are distributed yearly • 70% are due to contraceptive failure • Ireland • Abortion is completely illegal • Estimated that over 125,000 have traveled to England for abortions since 1985 • Iran • Abortion is only legal if mother’s life is in danger

25. Abortion around the world • Egypt • Abortion is illegal unless mother’s life is in danger • Commonly performed by midwives • Sweden • Up to 12 weeks upon request • 12-18 weeks on consult with MD and counselor • After 18 weeks with approval of Nat’l Board of Health and Welfare • Free • One of the lowest abortion rates in the world • US • 90% in first 12 weeks • States can regulate in 2nd and 3rd trimester • 2nd to assure safety • 3rd may prohibit

26. US Attitudes • Majority support Roe v. Wade • 22% say should be allowed under all circumstances • 18% say should never be allowed • 1998 Poll—32% said that abortion is murder, but still sometimes the best option • 2009—Gallup Poll—47% describe selves as pro-life, 46 as pro-choice • Other polls show more of a spread—52 to 41 • Republicans more pro-life • Those for whom religion is more important are more pro-choice, but not all religions • Younger more pro-choice (64% of college students) • % of obstetricians willing to perform abortions is dropping—33% in 1995 • Since 1980, about 550 hospitals have stopped performing them

27. Methods • Vacuum aspiration • Up to 14 weeks gestation • 90% of abortion • Outpt with local, takes 10 min • Dilate cervix, tube is inserted, and the other end is attached to suction • Complications are rare • D&C—Dilation and Curettage • 8-20 weeks • Dilate cervix, scrape uterus • Hospital with general • Rare for abortion • More common now for gynecological problems

28. Methods • D&E—Dilation and Evacuation • 2nd trimester • Similar to vacuum aspiration, but then uterus is scraped • Induced labor by amniotic infusion—saline • 2nd trimester • 1% of abortions • Hysterotomy • Essentially a c-section from 16-24 weeks • More complications • Expensive—over $1000 • Intact Dilation and Extraction • Partial birth abortion • .17% of all abortions

29. Mifeprestone • RU-486 • Within 49 days of LMP • Blocks progesterone, thus not allowing ovum to implant • Requires physician’s script • Requires 3-4 drs visits • Nausea, vomiting, diarrhea, headache, dizziness, and fatigue may occur. • Bleeding and cramping are expected • Bleeding and spotting may last up to 30 days, and may be greater than a normal, heavy period. In a very few cases, this bleeding will need to be stopped by performing a surgical procedure

30. Psychological consequences of abortion • Major et al 2000 • 72% were satisfied • 69% would do it again • All of these women had agreed to be contacted 2 yrs post • What about the 15% who didn’t? • 300,000 women per year would not do it again • Hollander 2001 • 16% regretted decision • 67% would do it again • 20% met criteria for depression • Fergussen et al 2009 • High rates of both positive and negative emotions • 90% believed it was necessary • But—rates of mental illness 1.4-1.8 times higher than those not having abortion • Distress is related to being younger, unmarried, not given birth previously, culture, religion • What about those denied an abortion? • Studies from 1960s and 1970s suggest increased risk to the children—poor social adjustment, etc • However, others argue that these studies did not control for other factors (SES, etc) and when these are controlled, those risks are diminished

31. Physical consequences • Rates of mortality and complications • .4 -1 per 100,000 abortions—mortality rate • 10x more likely to die from childbirth than abortion • 97% have no complications • Long term effects • 1st trimester—no effect on later childbearing • Later abortions might

32. Conception • Egg is released at day 14 • Makes its way to uterus • Disintegrates in 48 hours if not fertilized • Otherwise takes 5 days • Propelled by cilia

33. Sperm • Sperm • 5 micrometers long (1/5000th in) • Made up of head (chromosomes and acrosome—provides energy for tail), midpiece, and tail • Majority of sperm never make it close to egg • 300 million sperm • Some flow out of vagina, some die in vagina due to acidity, some go up wrong fallopian tube • About 2000 reach tube with egg • 100-200 reach egg • Arrive at egg after 1-1 ½ hrs • Conception occurs in fallopian tube • Egg secretes chemical to attract sperm • Egg is surrounded by gelatinous layer called zona pellucid. Sperm secrete enzyme hyaluronidase to dissolve zona pellucid and allow one sperm to penetrate • Capacitation—sperm become able to penetrate ova after entering uterus/tubes. This is a chemical change • Sperm bearing X are more durable, Y are smaller and faster

34. If you could pick sex of your child, would you? • Recently been separating sperm to get male or female • Success rate is around 80% • Wilcox et al 1995—no association between gender and timing of intercourse in relation to ovulation • Shettler’s Technique • Given assumptions about speed/durability of Y and X, try these. • Claim 80% success. Others say this is too high. • Boy • Sex at ovulation • Decrease acidity • Girl • Sex before ovulation • Increase acidity

35. When conception isn’t easy • Infertility—when failure to conceive has persisted for more than a year • About 15 % of couples have infertility problems • ½ of these will eventually succeed • Infertility is on the rise—in part due to rise in later childbearing • Primary vs secondary • Pregnancy wastage—able to conceive, but unable to carry to term • Attributed to man 40% of time • Attributed to woman 40% • Attributed to both 20%

36. Male infertility • Low sperm count • Azoospermia—no sperm production • Oligospermia—low sperm production • Most common causes • Low sperm motility • Irregularly shaped sperm • Chronic or infectious diseases—diabetes, STDs • Injury to the testes • Pituitary imbalance, thyroid disease • Autoimmune response—body kills own sperm • Enlarged prostate

37. Female infertility • Irregular ovulation • Most common cause • Obstructions of the reproductive tract • Endometriosis • Low estrogen and progesterone that prevent egg from being fertilized or staying implanted • Chemically hostile cervical mucus • High or low body mass • Fibroid tumors—associated with miscarriage

38. Treatment • Artificial insemination • Fertility drugs to increase ovulation • 43% of triplet or higher births due to drugs • Multiple births account for 3.3% of all births • In vitro fertilization • Donor in vitro • Embryonic transfer aka ovum transfer (father’s sperm in surrogate, flushed and implanted) • Surrogacy (artificial insemination of a gestational host) • Adoption

39. Adjustment • VanDenAkker (1997) • 105 infertile respondents • ¾ devastated by diagnosis • 64% women, 47% men could never be happy without a child • ¼ ultimately sought adoption • Peterson et al 2003 • Couples who perceived the stress of infertility at similar levels adjusted better • Daniluk and Tench 2007 • A 33-month longitudinal of 38 infertile couples –unsuccessful treatments • Increased self-esteem and decreased sexual satisfaction were evident over time. • Poorer adjustment was related to having none or few available options, little social support, poor emotional and physical health, and reliance on emotion-focused coping. • Participants who adopted demonstrated better adjustment

40. Fertility services • Of 6.7 million women with fertility problems • 42% received some fertility services • Most of these were low tech • Advice (60%) • Diagnostic testing (50%) • Medical intervention to reduce miscarriage (44%) • Ovulation inducing drugs (35 %) • Those receiving services tend to be older, more educated, more income than those not receiving services

41. Pregnancy • Zygote—fertilized egg—travels down fallopian tube • After 36 hours, cell division begins • 1st 8-10 weeks called embryo, after that called fetus • Early signs of pregnancy • Basal temp stays up for 2-3 weeks • Missed periods • Tenderness of the breasts • Morning sickness—related to lower rates of miscarriage and stillbirth • Fatigue • Frequent urination

42. Pregnancy tests • Lab—98-99% accurate after 7 days—urine tests; 1-2% false negative • Blood—more accurate and more expensive • In home—less accurate • Perhaps 25-38% false negative, 16% false positive

43. Miscarriage • Up to 40% • Miscarriage is the spontaneous loss of a pregnancy before the 20th week. • About 10 to 20 percent of known pregnancies end in miscarriage. But the actual number is probably much higher because many miscarriages occur so early in pregnancy that a woman doesn't even know she's pregnant. • Most miscarriages occur because the fetus isn't developing normally.

44. Adjustment to miscarriage • Not much literature relating grief to miscarriage • Reactions that typically are similar to the affective and behavioral reactions after other types of significant losses. • Different, too: emphasis on times ahead rather than remembered • No clear percentage of how common this is • As low as 12% • As high as 96% • Abates after about 6 months or after subsequent pregnancy • Less intense and enduring in men • Some evidence for gestational age being related to grief • Grief doesn’t seem to be related to maternal age • Prior psych problems are related to increased risk

45. Sex during pregnancy • Old fear of causing infection, miscarriage, early delivery—now known to be unfounded • Sex until 4 weeks before delivery is ok • Some say until delivery • Generally drops in frequency in 1st and 3rd trimesters • One study found 90% having sex at 5 months

46. Psychological changes • Genevie and Margolies—35% love pregnancy, 8% hated it, 40% mixed • Physical discomfort influences happiness • Fatigue and nausea prominent in 1st trimester • Fatigue and heartburn prominent in 3rd • 1st trimester—turbulent—many moody, irritable • 2nd—maternity clothes, movement, happier • 3rd—impatient • Routh, 2000—20% experience significant depression • Striegel-Moore, 1996—no huge psychological issues assoc with pregnancy

47. Fathers • Couvade—Brennan et al, 2007 • Industrialized countries • Range of phys and psy sx with no phys basis • Usually in male partners • Other cases (eg., a twin sister) have been reported • Conner and Denson, 1990 • 3 main groups of sx • 1) Nausea, heartburn, abdominal pain, bloating and appetite changes • 2)Upper respiratory disturbances • 3) Psychological symptoms • U-shaped pattern: present in the first trimester, temporarily disappear in the second and reappear in the third trimester • In serious cases in Asia and parts of North and South America—men take to bed, feel all pains of labor, moan, groan • Seeing ultrasound helps fathers feel more involved

48. Prenatal development • During embryonic stage, major organ systems are formed • Inner part of ball of cells differentiates into 2 layers with 3rd layer forming between them • Ectoderm • Endoderm • Mesoderm • Developmental is cephalocaudal • Another group of cells becomes the trophoblast, which will be placenta • Placenta provides cushioning and nourishment • Circulatory system of mother and child are separate • Placenta also secretes estrogen, progesterone, and hcg • Umbilical cord forms in 5th week, attaches to placenta • Amniotic fluid—cushions baby

49. 1st Trimester • By 3rd week, baby is 1/12 in long • During 3rd and 4th week • Head develops • CNS forms • See eyes and ears • Backbone by end of 4th week • Heart beats—4th week • From 4th-8th week—eyes, ears, arms, hands, fingers, legs, feet, toes • End of 7th week—liver, lungs, pancreas, kidneys, intestines, gonads—all present with limited function • 10th week—fingernails • 12th week—looks like small infant, 10cm long

50. 2nd Trimester • End of 14th week—movement can be detected • Woman should feel movement between 16 and 20 weeks • 18th week—physician can hear heartbeat with stethoscope • Week 20—opens eyes • Week 24—sensitive to light and sound • Alternates between wake and sleep • Wrinkled skin, downy hair at end of trimester