CONTRACEPTION

1. CONTRACEPTION

2. DEFINITION • Any methods or system that allow inter course yet prevent conception called contraception. • IDEAL CONTRACEPTIVE: • Safe • Effective • Acceptable • Simple to administer • Inexpensive • Reversible • Independent of coitus • Long lasting

3. Present approach to the family planning programme is the cafeteria approach. Measurement of contraceptive efficiency Pearl index;This is expressed pregnancy rate per 100 women years and is calculated by the formula. Pregnancy rate per HWY= total accidental pregnancies×1200÷total months of exposure to un intended pregnancy. Total month of exposure is obtained by deducting from the period under review those methods during which for extrinsic reasons contraception was not possible. 10 months are deducted from the a full term pregnancy and 4 months from abortion. Life table technique: To over come the bias of the pearl index this is used. This estimates probability of being pregnant while using any methods during the fixed period. Pregnancy rate is expressed as X per HWY. This method gives information about the method failure and patient failure.

4. FAILURE RATES OF VARIOUS METHODS

5. MEDICAL ELIGIBILITY CRITERIA • WHO in 2004 published this for initiation and continuing use of contraceptives on the basis of the thorough review of the latest clinical and epidemiological information taking into account the risks and benefits of using such method. • Eligibility criteria for reversible contraceptives • Category 1- no restrictions for use. • Category2-advantages of using this over weigh the theoretical or proven risks. • Category3-therotical or proven risks out weigh the advantages of this method. • Category4-use of this methods presents un acceptable health risks.

6. METHODS OF CONTRACEPTION A) TEMPORARY METHODS • Natural methods • Barrier methods • IUCDS • Steroidal contraceptives B) PERMANENT METHODS • Female: Tubal occlusion • Male: Vasectomy

8. Natural methods of contraception • DEFINITION : methods that do not use the application of medicine. • FERTILITY AWARENESS BASED METHODS • Method of planning and preventing pregnancy by observing signs and symptoms of the fertile phase and voidance of the coitus during the fertile phase if pregnancy to be avoided. • METHODS ARE: • Rhythm method • Basal body temperature method • Cervical mucus method • Sympothermal method • Standard days method

9. Rhythm method/Calendar method • Based on OGINOS theory that ovulation takes place between 14+2 days that is between D7-D21 • Irregular cycles (shortest cycle-18) and (longest cycles-11) • Basal _Body Temperature Method • Principle: There is the rise in BBT soon after the ovulation due to progesterone rise. • Rise in temp 0.5-0.8˚F/0.2-0.4˚C.. • Couples are advised to avoid coitus 3 day after the temp rise in the post- ovulatory period. • preovulatory safe period cannot be decided so this is not effective.

10. Cervical mucus method/Ovulationmethod/ BILLINGS METHOD • PRINCIPLE: Changes in the cervical mucus is due to oestrogen and progesterone. • Due to oestrogen mucus appear profuse slippery discharge. • Progesterone produces scanty and thick mucus. • Inter course can be practiced during mensturation and alternate days following mensturation ie during the dry days. The couple should abstain as soon as the first mucus appears in the pre ovulatory phase and during the wet days in the ovulatory phase days)and 3 days after the peak mucus day.(last day of the wet mucus is called the peak day). • This method is un suitable for those with abnormal white discharge.

11. SYMPTO THERMAL METHOD • Observation of the basal body temperature, cervical mucus changes, and the manifestations of the fertile period such as the mid cycle pain ,mid cycle light spotting breast tenderness. • Noted in the sympto thermal chart. • The practice of the inter course is same as that Billings method. • STANDARD DAY METHODS • By using cycle beads(string of colour coded beads that represent a woman's menstural cycle) • 1 day black thread across the red bead /every day one bead will be added/when the ring is on the brown beads pregnancy is unlikely/white beads chance to become pregnant • It also helps to calculate the length of her cycle • If she gets period before moving to the brown beads her cycle is less than 26 days. • If moves to the last baeds then also period has not yet started her cycle is longer than 32 days.

12. FAILURE RATES OF NFP METHOD • Calendar method 9% • BBT method 1% • Cervical mucus method 3% • Symptothermal method 2% • SDM 5% • Two day method 5% • ADVANTAGES: • No cost • No contraindications • No systemic side effects. • No effects on lactation. • DISADVANTAGES • Failure rate is high • Requires motivation • No protection against HIV and STD.

18. Lactational amenorrhea methods It is a temporary method of contraception Criteria:1)baby gets 85% feeding from the breast milk And often feeds her baby day and night.2)she is not having mensturation.3)baby is less than 6 months old. Women who do not breast feed the menses can occur as early as 35-40 days after delivery. ovulation can occur in 6% cases before first post partum mensturation Mechanism of action Excessive secretion of prolactin-inhibits pituitary secretion of LH,Partially inhibits ovarian response of LH and FSH-Ovary produces little oestrogen and no progesterone, hence ovulation and mensturation are affected

19. ANTIINFERTILITY EFFECTS OF PROLACTlN • Anovulatory cycles with short luteal cycles, impaired luteal competence, interference with implantation. • Either due to itself or due to suckling induced oxytocin release. • ABSOLUTE CONTRA INDICATION • cannot fully breast fed the baby • Menstruation starts(bleeding for atleast 2 days after 8 weeks of child birth) • Mother treated with mood altering drugs • Viral hepatitis of the mother • Mother has HIV/AIDS • DRAWBACK • Super involution of the uterus • Persistent hyper prolactinemia • Prolonged amenorrhoea/oligo

20. Failure rate-0.5-1.5 % Advantages-Effectively prevents pregnancy -No hormonal side effects Disadvantages-Inconvenient to working mothers -No protection against STD’S WITHDRAWAL WAL METHODS/COITUS INTERRUPTUS Coitus takes place in the normal manner but penis is withdrawn before the ejaculation Failure rate is 25 per 100 women years

21. BARRIER CONTRACEPTIVES Acts as barriers which prevent union of sperms and ovum TYPES • Condoms • Occlusive caps • Vaginal sponge • Spermicides • Female condoms

22. CONDOMS • Types-Fine latex rubber Circular cylinders,15-20cm in length,3-3.5cm diameter,0.003-0.007cm thickness,closed at one end and open at the other end with a rim • Available in dry ; semidry ;prelubricated forms. • Spermicidal condoms are coated with nonoxynol-9 both inner and the outer surfaces. In India dry condoms manufactured and supplied free of cost under the brand name NIRODH. • Non latex condoms. • Made of poly urethane. • Longer shelf life and can be used with oil lubricants which damages latex condoms. • Average life span is 5 years from the date of manufacturer.

23. Advantages • Protection against STDS and AIDS • Following vasectomy for 12 ejaculates • Immunologic infertility in males • In later months of pregnancy protect against amniotic fluid infections. • When used more than 5 years reduces the chance of cervical dysplasia and cervical cancer • Disadvantages • Hyper sensitization • Severe allergy to the latex • Ultra thin condoms prone for breakage Failure rate is 10-14 per HWY due to bursting or slipping or due to compliance.

24. FEMALE CONDOM Soft loose fitting polyurethane sac-15cm long and 7cm diameter lubricated with silicone based lubricant (DIAMETHICONE). It is a woman controlled method. Advantages It is a woman controlled method It prevent STDS and HIV It is not damaged by oils and chemicals. Disadvantages Needs high motivation Intercourse is noisy and slippage can occur It is expensive method. Failure rate-21%

26. OCCLUSIVE CAPS • These provide barrier in the vagina against direct insemination. • This is effective when used along with the spermicides. • TYPES • Dutch cap/diaphragm • Cervical cap • Vault cap • Vinule cap

27. Dutch cap/diaphragm • It is easiest type of cap for use • It fits obliquely just behind the pubic symphysis to the posterior fornix and covers the cervix • It is held in position by the tension of the metal spring. • Contra indications for diaphragm • Prolapse/cystocele/rectocele/ • Recurrent urinary tract infections • allergy to rubber or spermicidal agents Failure rate is 4 per HWY Cervical cap/ check pessary Thimble/dome shaped held in position by the suction Contra indications Chronic cervicitis,cervical erosion, cervical lacerations In a woman with prolapse of uterus or vagina this is preffered to diaphragm

28. Vault cap • Vinule cap:it is useful in patients with cystocele or mild degree of prolapse. • Can be introduced few to 2hrs before the sexual act • After the intercourse it should not be removed before 6-8 hrs of the last act and should be kept for more than 24 hrs Advantages • No medical side effects • No interference with the sexual act Prevent transmission of STDS but AIDS not prevented with these contraceptives Disadvantages • High motivation required • Chances of erosion will be increased • Allergy to rubber and spermicidal agents • Infection may set up if left for a long time • Very rarely produces toxic shock syndrome • Cannot prevent transmission of AIDS

31. VAGINAL SPONGE[TODAY] Soft disposable foam sponge made of polyurethane,saturated with Nanoxynol-9 Attached with nylon loop Effective for 24 hrs\it must be removed and thrown away after 8-24 hrs and not before 6 hrs Disadvantage-High pregnancy rate -Toxic Shock Syndrome Allergic reactions/vaginal dryness/soreness/damage vaginal epithelium and cause transmission of HIV SPERMICIDES Non ionic surfactants which alters sperm surface membrane permeability Contains Nonoxynol-9 Used to improve contraceptive effect of barrier method

32. Types 1.Chemical suppositories 2.Contraceptive creams and jellies 3.Foam tablets 4.Aerosols or Foams 5.C-Films FAILURE RATE-21%

34. INTRAUTERINE DEVICES Categories A.Inert IUCDS’ B.Copper releasing IUCD’S 3.Hormone releasing IUCD’S • Inert IUCD’S:Lippes loop saf –T coil chinese single coil ring mahua ring ota ring Copper carrying devices:cu-7 • Cu-T 200-215/sqmm(124 mg copper released at a rate of 50microgram per 24 hrs) life span is 3 years • ML-cu 250 and ML-cu 375:surface area is 250and 375 Life span is 3 year and 5 year respectively. • Cu-T380A :Surface area is 314/sqmmand 33mm2 on transverse sleeves.life span is 10 years .it is avaliable free of cost through national family health programme. • Nova-T 200:Cut-200along with silver core life span is 5 years • New framelessIUCDS:CU-FIX IUCD/FLEXIGUARD CU-S(CU-SAFE IUCD)

35. Intra uterine devices • They are divided into three groups according to the pregnancy rates • Group I: pregnancy rates more than 2 per 100 women years(lippes loop,CU 7T200) • Group II pregnancy rates less than 2 but more than 1 per 100 women years.Nova-T,MLCu-250,Cu-T220C • Group III pregnancy rates less than 1 per 100 women years.Cu-T380A,CuT380S,ML Cu-375,LNG20

37. HORMONAL IUCDS • PROGESTASERT:38mg releases 65 micrograms per day • Life span is 1 year contraceptive effectiveness is similar to that of CU-T • LNG IUCDS;LENOVA:60mg LNG and releases at a rate of 20 micro gram per day • MIRENA:52 mg LNG releases 20 microgram per day • Advantages are • Decrease bleeding high benefits in patients with DUB and anemia • Reduces pain in endometriosis and adenomyosis • Beneficial in fibroids • Post partum insertion do not effect lactatioin • Dis advantages • Irregular bleeding/ oligo for the first 3 months • Amenorrhoea which affects 20-50% cases in the first one year. • Difficulty in introduction needs most time local anesthesia • Minor side effects

41. MECHANISM OF ACTION • Foreign body renders uterine contractility and tubal peristalsis • So that the fertilized ovum propelled down the fallopian tube and it reach the uterine cavity before the development of the chorionic villi • Intense inflammatory reaction interfere with the enzymes in the uterus and also DNA of the endometrial cells glycogen metabolism and estrogen uptake by the uterine mucosa. • Sperm motility and capacitating affected by the biochemical Changes in the cervical mucus . • Phagocytosis of both egg and the sperm • Act ,mostly by preventing sperm from fertilizing ovum impendeing their transport and inhibiting their capacity to fertilize ovum • Progesterone IUCDS:Alteration of the cervical mucus • It causes endometrial atrophy • It prevents ovulation in 40%

42. Patient selection • Low risk STDS • Monogamous relationship • Multiparous women • Long term reversible method required • Unreliable user of OCPS/barrier methods • Uses of IUCDS • Contraception • Emergency contraception • After excision of the uterine septum/ asherman syndrome • Hormonal IUCDS menorrhagia/DUB • CONTRINDICATIONS • Suspected pregnancy • Pelvic inflammatory disease • Fibroids • Diabetic women • Heart disease

44. Previous ectopic • scarred uterus • In nulliparous due to high risk of PID • LNG IUCD in breast cancer • Timing for insertion of IUCDS • Mensturation :soon after it • Post coital; emergency contraception up to 5 days. • Post abortal:following MTP/spontaneous abortion m/c after first trimester abortion but not after the second trimester . • Post partum:6 weeks after the normal vaginal delivery and 1-2 months after the c section other wise high rate of expulsion. • Insertion of IUCDS

45. Before insertion counsel the patient • Method is no touch technique • That is loading the IUCD into the inserter without opening the sterile packet • Not touch the speculum and the posterior vaginal wall • First do the pelvic examination • Inspect vagina and the cervix calculate the length of the uterine cavity with the uterine sound.

47. Directions to be given to the patient • Detect expulsion she should feel the tail of the loop at least for the next three periods • Heavy cycles may be there for three or more cycles • Inter menstrual bleeding • Report if • Fail to feel the loop part of the loop in the vagina/expelled the loopheavy bleeding persistent/irregular bleeding • Severe pain abdomen • Amenorrhoea • Abnormal vaginal discharge • Routine check up after the next period

48. Indications for removal • pelvic pain/cramping • Abnormal excessive persistent bleeding • Expiry of the effective life span . • Displacement of the devices either inside the uterus or outside • Menopause 1 year after • Uterine or cervical malignancy • Desire for pregnancy • Complications • Immediate: cramp like pain • syncopal attack • Partial or complete perforation • Remote :pain • abnormal menstural bleeding • Pelvic infection • Spontaneous expulsion • Perforation of the uterus

49. Menstrual problem Increased bleeding: normal loss is 30-40ml Inert loss up to 70-80ml Cu-T 50-60ml Removal in about 2-10/100 women years Due to increase in the plasminogen activating enzymes /increased vascularity/hormonal asynchronisationInter menstrual bleeding due to the damage to the endometrium Scanty bleed with LNG-20 • Pain Due to uterine cramp subsides in a week Persistent pelvic pain:PID/ectopic abnormal position perforation expulsion disparity between uterine size and IUCD Investigate and remove the IUCD

50. Expulsion • Most common in the nulliparous women • ,, ,, lippes loop than with cu-t • Immediate post partum • Technical fault • High expulsion the first three months high during mensturation • MOA due to contraction of the uterus and disparity in the size • Cousel the patient to check the thread • Clinician should feel the thread with the uterine sound if the tail is not visible • Ski graph/usg if the tail is not felt in the uterus • If expelled it should be re inserted the there is high chance for retainment