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Overview of contraception Overview of contraception Presentation Transcript

  • OVERVIEW OFOVERVIEW OF CONTRACEPTIONCONTRACEPTION DR SHABBIR AHMADDR SHABBIR AHMAD SHEIKHSHEIKH PENSYARAH (UNISZA)PENSYARAH (UNISZA) Dan PAKAR O&G (HSNZ)Dan PAKAR O&G (HSNZ)
  • INTRODUCTIONINTRODUCTION • According to figures from the population Reference Bureau, there are 8300 million humans on the planet. • There are 42 births and 17 deaths every 10 seconds, a net gain of 25 extra people somewhere on the globe every 10 seconds.
  • INTRODUCTIONINTRODUCTION • According to UN figures, out of about 180 million conceptions each year, at least 75 million are unwanted. • This results in about 50 million abortions. • Around 600 000 women die each year (one woman/min)- killed by pregnancies. • 200 000 would not die if adequate services/contraception make available to them
  • CHOOSING CONTRACEPTIVE METHOD • Individual general health • Frequency of sexual relationship • Consideration for adolescent women • Number of partners • Considerations for women who have recently given birth • Considerations for women near menopause Religion and Moral belief
  • COUNSELLING • Mode of action • Effectiveness • Side effects • Benefits • How to use the method
  • TYPES OFTYPES OF CONTRACEPTIONCONTRACEPTION
  • Types of contraceptionTypes of contraception 1.1. Oral contraceptionOral contraception  Combined oral contraceptiveCombined oral contraceptive  Progestogen–only pills/ Mini- PillProgestogen–only pills/ Mini- Pill 2. Injectable contraception2. Injectable contraception  Progestogen only injectablesProgestogen only injectables • DMPA : Depo-provera (depot medroxyprogesterone acetate)DMPA : Depo-provera (depot medroxyprogesterone acetate) • NET-EN : norethisterone enantateNET-EN : norethisterone enantate  Combined injectable contraceptiveCombined injectable contraceptive • Cyclofem/ LunelleCyclofem/ Lunelle • MesignaMesigna 3. Implant3. Implant  Implanon (etonogestrel implant)Implanon (etonogestrel implant)  Norplant/ Jadelle (levonorgestrel implant)Norplant/ Jadelle (levonorgestrel implant) 4. Intrauterine devices4. Intrauterine devices  LNG IUD : MIRENALNG IUD : MIRENA  Copper IUDCopper IUD
  • Types of contraceptionTypes of contraception 5. Combined Hormonal Patch : EVRA5. Combined Hormonal Patch : EVRA 6. Combined Hormonal Ring : Nuva Ring6. Combined Hormonal Ring : Nuva Ring 7. Barrier methods7. Barrier methods - Male condom- Male condom  DiaphragmDiaphragm  Cervical capCervical cap  Sponges & spermicidesSponges & spermicides 8. Periodic abstinence8. Periodic abstinence  CalenderCalender  Ovulation methodOvulation method  Sympto-thermalSympto-thermal  Hormone monitoringHormone monitoring 9. Sterilisation9. Sterilisation  Female : BTLFemale : BTL  Male : VasectomyMale : Vasectomy
  • USED OF CONTRACEPTION IN UKUSED OF CONTRACEPTION IN UK METHOD OF CONTRACEPTION USE (%) Combined oral contraceptive pill 36 Condoms 28 Intrauterine contraception (copper device & Mirena®) 7 Injectable medroxyprogesterone acetate (DMPA or Depo-Provera®) 4 Withdrawal (coitus interruptus) 4 Natural family planning 3 Implanon® 2 Diaphragms <1 Sterilization 11 Vasectomy 13
  • COMBINED HARMONALCOMBINED HARMONAL CONTRACEPTIVESCONTRACEPTIVES
  • PreparationsPreparations  COCP (The Pill)COCP (The Pill)  InjectablesInjectables  Patch - EVRAPatch - EVRA®®  Vaginal ring – NUVA RINGVaginal ring – NUVA RING®®
  • 1. COMBINED ORAL1. COMBINED ORAL CONTRACEPTIVE PILLCONTRACEPTIVE PILL (THE PILL)(THE PILL)
  • The PillThe Pill • Oral contraceptives have gone through many changes through the years since they were introduced in the 1960s. • When taken regularly and according to the directions, birth control pills are 98% to 99% effective in preventing pregnancy
  • Combined oral cont racept ive pills • “The pill” contains combination of two hormones - Synthetic oestrogen - Synthetic progesterone
  • FORMULATIONSFORMULATIONS Low dose, 2Low dose, 2ndnd generation Pillsgeneration Pills 1.1.EE (20mcg) + NET (1mg)EE (20mcg) + NET (1mg)  LoestrinLoestrin 2.2.EE (20mcg) + LNG (100mcg)EE (20mcg) + LNG (100mcg) LoetteLoette Low dose, 3rLow dose, 3rdd generation Pillsgeneration Pills 1.1.EE (20mcg) + Desogestrel 150mgEE (20mcg) + Desogestrel 150mg MercilonMercilon 2.2.EE (20mcg) + Gestodene 75mcgEE (20mcg) + Gestodene 75mcg MalianeMaliane Low dose, 4Low dose, 4thth generation Pillsgeneration Pills 1. EE (20mcg) + Drospirenone 3mg1. EE (20mcg) + Drospirenone 3mg YAZYAZ
  • FORMULATIONSFORMULATIONS Standard dose, 2Standard dose, 2ndnd generation Pillsgeneration Pills 1.1.EE (30mcg) + LNG (150mcg)EE (30mcg) + LNG (150mcg) NordetteNordette Standard dose, 3rStandard dose, 3rdd generation Pillsgeneration Pills 1.1.EE (30mcg) + Desogestrel 150mcgEE (30mcg) + Desogestrel 150mcg MarvelonMarvelon 2.2.EE (30mcg) + Gestodene 75mcgEE (30mcg) + Gestodene 75mcg MinuletMinulet Standard dose, 4Standard dose, 4thth generation Pillsgeneration Pills 1. EE (30mcg) + Drospirenone 3mg1. EE (30mcg) + Drospirenone 3mg YasminYasmin
  • FORMULATIONSFORMULATIONS High dose, 2High dose, 2ndnd generation Pillsgeneration Pills 1.1.EE (35mcg) + LNGEE (35mcg) + LNG  TrinordiolTrinordiol High dose EE + Anti-androgenHigh dose EE + Anti-androgen 1.1.EE (35mcg)+Ciproterone acetate 2mgEE (35mcg)+Ciproterone acetate 2mgDiane35Diane35 New COCPNew COCP Estradiol + dienogestEstradiol + dienogest  QlairQlair
  • Who Should Not UseWho Should Not Use the Pillthe Pill
  • WHO medical eligibity criteriaWHO medical eligibity criteria for contraception use.for contraception use.
  • Who Should Not Use the PillWho Should Not Use the Pill 1. A history of pulmonary embolism or genetic disorders that could cause thrombosis (blood clots). 2. Uncontrolled hypertension 3. A history of stroke or heart attack 4. Severe liver disease 5. Migraine headaches with a neurological component
  • Who Should Not Use the PillWho Should Not Use the Pill 6. Diabetes with retinopathy or kidney problems (diabetes alone does not prevent the use of the pill) 7. Estrogen-dependent cancer of the breast or endometrium
  • Mode of Action COCPMode of Action COCP  Suppression of ovulationSuppression of ovulation  By prevention of ovarian follicular maturationBy prevention of ovarian follicular maturation  By interrupting the oestrogen-mediated positiveBy interrupting the oestrogen-mediated positive feedback on the hypothalamic-pituitary axis thusfeedback on the hypothalamic-pituitary axis thus preventing LH surgepreventing LH surge  Thicken the cervical mucusThicken the cervical mucus  reduce sperm penetrabilityreduce sperm penetrability  Thinning of the endometriumThinning of the endometrium  reducing likelihood of implantationreducing likelihood of implantation
  • When to take the pill?When to take the pill? In principal: at any time if it is reasonably certain that the woman is not pregnantIn principal: at any time if it is reasonably certain that the woman is not pregnant
  • How to take the pill?How to take the pill?  1 pill is taken every day for 21 days and followed by 71 pill is taken every day for 21 days and followed by 7 days of pill free period, during which the women will havedays of pill free period, during which the women will have a ‘withdrawal bleed’.a ‘withdrawal bleed’. For YAZ , 24days & 4 days pill freeFor YAZ , 24days & 4 days pill free period.period.  Timing is not as critical as it is with POPs, but it is a goodTiming is not as critical as it is with POPs, but it is a good practice to get into habit of taking the pill at a similar timepractice to get into habit of taking the pill at a similar time every day.every day.
  • Missed pillsMissed pills  PrincipalPrincipal  It takes 7 consecutive pills to ensure thatIt takes 7 consecutive pills to ensure that ovulation has been suppressedovulation has been suppressed  It is thus vital to avoid lengthening the pill freeIt is thus vital to avoid lengthening the pill free week to more than 7 daysweek to more than 7 days
  • Missed 1Missed 1stst weekweek  If pills are missed in the FIRST 7 DAYS ofIf pills are missed in the FIRST 7 DAYS of pill taking, the ovaries will not have 7pill taking, the ovaries will not have 7 consecutive pills to ensure suppression ofconsecutive pills to ensure suppression of ovulation following pill-free week THUSovulation following pill-free week THUS emergency contraception should be givenemergency contraception should be given if necessary and EXTRA PRECAUTIONSif necessary and EXTRA PRECAUTIONS used until seven further pills have beenused until seven further pills have been taken without a breaktaken without a break
  • Missed 2Missed 2ndnd weekweek  If pills are missed in the SECOND 7 DAYSIf pills are missed in the SECOND 7 DAYS of the packet then the ovaries will have atof the packet then the ovaries will have at least 7 pills to ensure suppression ofleast 7 pills to ensure suppression of ovulationovulation THUS theoreticallyTHUS theoretically emergencyemergency contraception and extra precautioncontraception and extra precaution SHOULD NOT BE NEEDED.SHOULD NOT BE NEEDED.
  • Missed 3Missed 3rdrd weekweek  If pills are missed in the THIRD 7 DAYS of pillIf pills are missed in the THIRD 7 DAYS of pill taking the next packet of pills should be startedtaking the next packet of pills should be started WITHOUT having PILL FREE WEEKWITHOUT having PILL FREE WEEK  This is again to ensure that seven consecutiveThis is again to ensure that seven consecutive days of pill taking is achieved before allowing 7days of pill taking is achieved before allowing 7 days free from the pilldays free from the pill  IN PRACTICE women will find it easier to have 1IN PRACTICE women will find it easier to have 1 set of rules to cover all eventualitiesset of rules to cover all eventualities
  • Missed pillsMissed pills
  • When to stop?When to stop?  In a fit and healthy womanIn a fit and healthy woman with no contraindications towith no contraindications to taking the pill, there is no need to stop just because oftaking the pill, there is no need to stop just because of age.age.  However, with regular bleeds and normal levels ofHowever, with regular bleeds and normal levels of oestrogen, theoestrogen, the onset of the menopause will be maskedonset of the menopause will be masked..  It is wise toIt is wise to choose the age of 50 to stop the COCchoose the age of 50 to stop the COC pillpill and use another method of contraceptionand use another method of contraception  Taking COCP would mask common bld markers of theTaking COCP would mask common bld markers of the menopause such as oestradiol and FSH levels – thismenopause such as oestradiol and FSH levels – this effect disappears after 6 weekseffect disappears after 6 weeks and levels of theseand levels of these markers can be relied on.markers can be relied on.
  • AdvantagesAdvantages  High efficacyHigh efficacy  Failure rate (pearl index) 0.1-1/100 woman yearsFailure rate (pearl index) 0.1-1/100 woman years  ReversibleReversible  Prompt return to ovulation with 70% of women ovulating inPrompt return to ovulation with 70% of women ovulating in the 1the 1stst cycle and 98% by the 3cycle and 98% by the 3rdrd cyclecycle  Not related to intercourseNot related to intercourse  Reduction in menstrual blood flowReduction in menstrual blood flow  Reduced the menstrual blood flow by 50%Reduced the menstrual blood flow by 50% especially with YAZespecially with YAZ
  • AdvantagesAdvantages  Less dysmenorhoeaLess dysmenorhoea  Reduce menstrual prostaglandin release thus reducingReduce menstrual prostaglandin release thus reducing uterine contractility and dysmenorrhoeauterine contractility and dysmenorrhoea  Predictability of mensesPredictability of menses  Treats PMS/PMDD,Treats PMS/PMDD, especially with YAZ.especially with YAZ.  Reduction in benign breast diseaseReduction in benign breast disease  Reduction in functional ovarian cystReduction in functional ovarian cyst  Reduction in PIDReduction in PID  Due to progesterone effect on cervical mucus- increase viscosityDue to progesterone effect on cervical mucus- increase viscosity impedes ascent of pathogens and may confer protective effect.impedes ascent of pathogens and may confer protective effect.  Lower menstrual flow also reduces bacterial growthLower menstrual flow also reduces bacterial growth
  • AdvantagesAdvantages  Reduction in ectopic pregnancy rateReduction in ectopic pregnancy rate  All forms of contraception reduce the incidence of ectopicAll forms of contraception reduce the incidence of ectopic pregnancypregnancy  Risk of ectopic pregnancy in COCP users is 0.005 per 1000Risk of ectopic pregnancy in COCP users is 0.005 per 1000 woman years, comparable to that associated with vasectomywoman years, comparable to that associated with vasectomy and lower than the risk associated with barrier contraception,and lower than the risk associated with barrier contraception, IUCD or tubal ligationIUCD or tubal ligation  Reduction in ovarian and endometrial cancerReduction in ovarian and endometrial cancer  COCP use for 4 and 8 years associated with 40% and 51% reduction inCOCP use for 4 and 8 years associated with 40% and 51% reduction in risk of ovarian cancer respectivelyrisk of ovarian cancer respectively  COCP use for 4 and 8 years associated with 54% and 66% reduction inCOCP use for 4 and 8 years associated with 54% and 66% reduction in risk of endometrial cancer respectivelyrisk of endometrial cancer respectively
  • DisadvantagesDisadvantages  Cardiovascular effectCardiovascular effect  VTEVTE  Myocardial infarctionMyocardial infarction  Cerebrovascular accidentsCerebrovascular accidents  Raised blood pressureRaised blood pressure  Breast cancerBreast cancer  Cervical cancerCervical cancer  Compared with never users of oral contraceptives, the relative risksCompared with never users of oral contraceptives, the relative risks of cervical cancer increased with increasing duration of useof cervical cancer increased with increasing duration of use  Liver adenoma or carcinomaLiver adenoma or carcinoma  CholestasisCholestasis  GallstonesGallstones
  • 2.INJECTABLE COMBINED2.INJECTABLE COMBINED CONTRACEPTIVESCONTRACEPTIVES
  • Injectable combined contraceptiveInjectable combined contraceptive 1. Cyclofem/ Lunelle .1. Cyclofem/ Lunelle . (25mg Medroxyprogesterone25mg Medroxyprogesterone acetate & 5mg oestradiol cypionate)acetate & 5mg oestradiol cypionate) 2. Mesigyna .2. Mesigyna . (Norethisterone enantate & estradiolNorethisterone enantate & estradiol valerate)valerate) Given once monthly by intramuscular injection –Given once monthly by intramuscular injection – every 4 weeks +/- 7 daysevery 4 weeks +/- 7 days Advantages over IM depo:Advantages over IM depo:  Improved bleeding patterns and swift return ofImproved bleeding patterns and swift return of fertility on discontinuationfertility on discontinuation
  • 3. COMBINED3. COMBINED CONTRACEPTIVE PATCHCONTRACEPTIVE PATCH
  • ORTHO EVRAORTHO EVRA  ContainsContains 6mg norelgestromin6mg norelgestromin and 0.75mg ethinyl oestradioland 0.75mg ethinyl oestradiol  20 cm squared trans-dermal system –apply at upper20 cm squared trans-dermal system –apply at upper outer arm, abdomen, buttock and backouter arm, abdomen, buttock and back  The patch isThe patch is changed every 7 dayschanged every 7 days for 3 weeks with afor 3 weeks with a drug-free 7 day intervaldrug-free 7 day interval  Patient compliance is significantly higher with the contraceptive patch compared to oral contraceptive pills But expensive.  Pearl index = 0.88. In comparativePearl index = 0.88. In comparative trials, efficacy better, efficacy better than COCPthan COCP
  • Transdermal ContraceptiveTransdermal Contraceptive System: DescriptionSystem: Description • 3-patch system – Apply 1 patch each week for 3 weeks – Apply each patch the same day of the week • 1 week is patch-free Week 1 Week 2 Week 3 Week 4 Patch #1 Patch #2 Patch #3 28-day cycle Patch-free Week 5 Start next cycle 28-day cycle Abrams LS, et al. J Clin Pharmacol. 2001;41:1232-1237, 1301-1309; Abrams LS, et al. Contraception. 2001;64:287-294; Creasy GW, et al. Semin Reprod Med. 2001;19:373-380; Audet MC, et al. JAMA. 2001;285:2347-2354; Smallwood GH, et al. Obstet Gynecol. 2001;98:799-805.
  • Transdermal Contraceptive Patch:Transdermal Contraceptive Patch: ApplicationApplication • Size: 20 cm2 • Composed of 3 layers: – a release liner removed at the moment of application – a medicated adhesive layer – An outer protective polyester layer • Applied to the buttocks, upper outer arm, lower abdomen, or the upper torso (excluding the breast) Keder LM. J Pediatr Adolesc Gynecol. 2002;15:179-181.
  • Transdermal Contraceptive Patch:Transdermal Contraceptive Patch: AdvantagesAdvantages • Weekly application encourages compliance • Easy verification of presence reassures user of continued protection • Does not require vaginal insertion • Contraceptive effects are rapidly reversible • Excellent cycle control after 3 months
  • Transdermal Contraceptive Patch:Transdermal Contraceptive Patch: DisadvantagesDisadvantages • Application site reactions • Not as effective in women weighing >198 pounds • Side effects are similar to oral contraceptives except for: - higher rates of breast pain during first 2 months - higher rates of dysmenorrhea • May be difficult to conceal • No protection against HIV or other sexually transmitted infectionsZieman M, et al. Fertil Steril. 2002;77(Suppl 2):S13-S18.
  • Transdermal Contraceptive Patch: PooledTransdermal Contraceptive Patch: Pooled Analysis of EfficacyAnalysis of Efficacy Through 13 CyclesThrough 13 Cycles 22,160 Cycles Number of Pregnancies Probability of Pregnancy* Method Failure 12 0.8% User Failure 3 0.6% *Kaplan-Meier estimates of the cumulative probabilities of pregnancy. Zieman M, et al. Fertil Steril. 2002;77(Suppl 2):S13-S18; Smallwood GH, et al. Obstet Gynecol. 2001;98(Pt 1):799-805; Audet MC, et al. JAMA. 2001;285:2347- 2354; Hedon B, et al. Int J Gynaecol Obstet. 2000:70(suppl 1):78.
  • Efficacy of the Contraceptive PatchEfficacy of the Contraceptive Patch Versus an Oral ContraceptiveVersus an Oral Contraceptive Cycle s No. of Pregnancies Probability of Pregnancy Pearl Index Metho d failure User failure Metho d failure Overal l Method * Overall † Patch (n=811 ) 5,240 4 1 1.1 1.3 0.99 1.24‡ OC (n=605 ) 4,167 4 3 1.3 1.8 1.25 2.18‡ Patch = Ortho Evra® transdermal patch; OC = Triphasil® oral contraceptive * Failure when taken as directed † User failure plus method failure ‡ The difference in efficacy was not statistically significant Audet MC, et al. JAMA. 2001;285:2347-2354.
  • Transdermal Contraceptive Patch:Transdermal Contraceptive Patch: Most Common Adverse EventsMost Common Adverse Events Audet MC, et al. JAMA. 2001;285:2347-2354. Adverse Event Number of Patients (%) Ortho Evra® Patch (n=812) Oral Contraceptiv e (n=605) P Value Headache 178 (21.9) 134 (22.1) 0.95 Nausea 166 (20.4) 111 (18.3) 0.34 Application site reaction 164 (20.2) – – Breast discomfort* 152 (18.7) 35 (5.8) <0.001 Upper respiratory infection 108 (13.3) 108 (17.9) 0.02 Dysmenorrhea 108 (13.3) 58 (9.6) 0.04 Abdominal pain 66 (8.1) 51 (8.4) .85 * Reported only during the first 2 study cycles.
  • Transdermal Contraceptive Patch:Transdermal Contraceptive Patch: Patient Counseling on Usage and DisposalPatient Counseling on Usage and Disposal • Application: – Use a new location for each patch – Apply to clean, dry skin – Apply where it won’t be rubbed by clothing: on buttocks, abdomen, upper outer arm, upper torso – Do not use on irritated or abraded skin – Do not use on the breasts – Avoid oils, creams, or cosmetics until after patch placement – Bathe and swim as usual • Anticipate more breast discomfort during the first 2 months • Store at room temperature • Do not cut, alter or damage the patch as if may alter contraceptive efficacy • Do not flush a used patch into the water system; fold the used patch in half and place in the trash
  • Transdermal Contraceptive Patch:Transdermal Contraceptive Patch: Patient Counseling on Basic InstructionsPatient Counseling on Basic Instructions • If switching from an oral contraceptive, apply the patch as soon as withdrawal bleeding begins (Day 1 Start) - Sunday Start: use backup protection for 7 days unless Sunday is the first day of the menstrual cycle • Wear each patch for 7 days; subsequent patch changes are made on the same day of the week • No more than 7 days should lapse between the application of the last patch of the prior 21-day cycle and the first patch of the next 21-day cycle • For partial or full detachment, make sure the exposed undersurface of the patch is clean and adherent; press it into place for 10 seconds; if the patch does not adhere completely, remove it and replace it with another patch
  • 28-Day Cycle (Days 1-28) Patch #1 Days 1-7 Patch #2 Days 8-15 Patch #3 Days 16-21 No Patch Next 28-Day Cycle (Days 29-56) This patch was not applied: • Apply a new patch immediately; this is the new “patch change day” • Use backup protection for 7 days • Consider emergency contraception Patch application is 1 to 2 days late: • Apply new patch immediately; Make this the new “patch change day” • No backup protection is required Patch application is >2 days late: • Immediately start new 21-day application cycle •Use backup protection for 7 days •Consider emergency contraception Patch #1 This patch was not removed: • Remove immediately • Start cycle on day 29 Transdermal Contraceptive Patch:Transdermal Contraceptive Patch: Managing Missed or Late ApplicationsManaging Missed or Late Applications
  • Contraception During Perimenopause:Contraception During Perimenopause: Transdermal PatchTransdermal Patch Available methods (Failure rates)* • Ethinyl estradiol/norelgestromin patch (8%) Prevents unintended pregnancy Yes Minimizes hormonal fluctuations Yes Provides additional health benefits • Bone protection • Cycle control Grimes DA, Wallach M, eds. Modern Contraception: Updates from The Contraception Report. 2007; Hatcher RA, Nelson AL. In: Contraceptive Technology. 2004:391-460.
  • Transdermal Contraceptive Patch:Transdermal Contraceptive Patch: Risk for Venous ThromboembolicRisk for Venous Thromboembolic Events*Events* Jick SS, et al. Contraception. 2006;73:223-228; Cole JA, et al. Obstet Gynecol. 2007;109:339-346. Relevant Studies Odds Ratio (95% Confidence Interval) Jick SS, et al., 2006 0.9 (0.5–1.6) Cole JA, et al., 2007 2.4 (1.1–5.5) *Women should be counseled that all combined contraceptive products increase the risk of venous thromboembolic events; use of these products should be discontinued if a patient becomes immobilized.
  • 4. COMBINED4. COMBINED CONTRACEPTIVECONTRACEPTIVE VAGINAL RINGVAGINAL RING
  • NUVANUVA ringring • It is made of latex-free plastics. • Diameter : 54 mm • CONTAINS ethinyl estradiol 15 ug and etonorgestrel 120 ug. • The ring is worn for 21 days and removed for 7 days to allow withdrawal bleedings. • Same risks and benefits as COC but is more expensive. • Cycle control is better & breakthrough bleeding is less common. • Efficacy is 99.4%. • If remain inserted >4wks backup contraception untill new ring has been in place for 7 days.
  • Progestogen-onlyProgestogen-only Hormonal contraceptionHormonal contraception
  • 1.Progestogen only Pill1.Progestogen only Pill (mini-pill)(mini-pill)
  • FormulationsFormulations  Ethynodiol diacetate 500mcgEthynodiol diacetate 500mcgFFemulenemulen  Norethisterone 350mcgNorethisterone 350mcgNoriday / MicronorNoriday / Micronor  Levonorgestrel 30mcgLevonorgestrel 30mcg MicrovalMicroval  Norgestrel 75mcgNorgestrel 75mcg  NeogestNeogest  DesogestrelDesogestrel  CerazetteCerazette
  • Progestogen-only PillsProgestogen-only Pills  Suitable for women with VTE, migraine, olderSuitable for women with VTE, migraine, older women who smoke, women with hypertension,women who smoke, women with hypertension, valvular heart disease and diabetes mellitus –valvular heart disease and diabetes mellitus – avoids oestrogenic S/E of COCPavoids oestrogenic S/E of COCP  ContraindicationsContraindications  PregnancyPregnancy  Undiagnosed vaginal bleedingUndiagnosed vaginal bleeding  Severe arterial diseaseSevere arterial disease  Liver adenomaLiver adenoma
  • AdvantagesAdvantages  Failure rate 0.3-3/100 women yearsFailure rate 0.3-3/100 women years  Effective when used correctlyEffective when used correctly  well toleratedwell tolerated  No artificial oestrogen component thus all of the s/eNo artificial oestrogen component thus all of the s/e related to oestrogen e.g. risk of circulatory disease arerelated to oestrogen e.g. risk of circulatory disease are potentially absentpotentially absent  Readily reversible method of contraceptionReadily reversible method of contraception  Efficacy increases with age and may be reduced ifEfficacy increases with age and may be reduced if weight > 70kgweight > 70kg  Do not affect the raised FSH and oestradiol levelsDo not affect the raised FSH and oestradiol levels associated with menopause thus reduce the problems ofassociated with menopause thus reduce the problems of diagnosing the menopause on hormonal contraceptiondiagnosing the menopause on hormonal contraception
  • DisadvantagesDisadvantages  Strict adherence to the rules of pill takingStrict adherence to the rules of pill taking is essentialis essential  Pattern of bleeding is unpredictablePattern of bleeding is unpredictable  Associated with increased incidence ofAssociated with increased incidence of ovarian follicular cysts and increased riskovarian follicular cysts and increased risk of ectopic pregnancy (compared toof ectopic pregnancy (compared to COCP)COCP)
  • Mode of actionMode of action  Main effect : Thicken cervical mucus thusMain effect : Thicken cervical mucus thus decreased sperm penetrability of cervixdecreased sperm penetrability of cervix  Reduce receptivity of endometrium toReduce receptivity of endometrium to implantationimplantation  Reduction in ovulationReduction in ovulation  Suppress ovulation inSuppress ovulation in ~~40%, this is unpredictable and varies40%, this is unpredictable and varies between cycles resulting in irregular menstruationbetween cycles resulting in irregular menstruation  10-15% of women have complete inhibition of ovarian activity10-15% of women have complete inhibition of ovarian activity and are amenorrhoeicand are amenorrhoeic  50%have regular ovulatory cycles with normal luteal phase50%have regular ovulatory cycles with normal luteal phase and a normal menstrual cycleand a normal menstrual cycle  Reduce fallopion tube motilityReduce fallopion tube motility
  • How to take?How to take?  One tablet daily taken on day 1 of cycle and takenOne tablet daily taken on day 1 of cycle and taken continuously without a breakcontinuously without a break  Should be taken at the same time every day andShould be taken at the same time every day and within 3 hrs at the mostwithin 3 hrs at the most  If pill missed for more than 3 hrs, additionalIf pill missed for more than 3 hrs, additional precautions needed for following 2 days –precautions needed for following 2 days – An estimatedAn estimated 48hrs of POP use was deemed necessary to achieve the contraceptive effects on48hrs of POP use was deemed necessary to achieve the contraceptive effects on cervical mucuscervical mucus  Maximal effect on cervical mucus is at 4 hrs after pillMaximal effect on cervical mucus is at 4 hrs after pill takingtaking  The only antibiotics that would reduce the efficacy ofThe only antibiotics that would reduce the efficacy of the POP are the enzyme inducer such as rifampicin orthe POP are the enzyme inducer such as rifampicin or griseofulvingriseofulvin
  • When to take the pill?When to take the pill?  POP can be started at any time ifPOP can be started at any time if pregnancy can be excludedpregnancy can be excluded  First day or two of menses, if started laterFirst day or two of menses, if started later than this – extra precautions needed forthan this – extra precautions needed for following 7 daysfollowing 7 days  Can be started immediately following aCan be started immediately following a miscarriage or termination of pregnancymiscarriage or termination of pregnancy  When changing from COCs, an immediateWhen changing from COCs, an immediate switch is recommendedswitch is recommended
  • CerrazetteCerrazette®®  Released in 2003Released in 2003  Contain 3Contain 3rdrd generation of progestogen –generation of progestogen – desogestrel 75mcgdesogestrel 75mcg  Evidence show that it inhibits ovulation in 97% ofEvidence show that it inhibits ovulation in 97% of cyclescycles  Window period of 12 hoursWindow period of 12 hours instead of 3 hoursinstead of 3 hours  Taken every day with no breakTaken every day with no break  Useful for younger women who cannot or do notUseful for younger women who cannot or do not wish to take oestrogen containing products orwish to take oestrogen containing products or women who cannot tolerate other POPs.women who cannot tolerate other POPs.
  • 2. INJECTABLE2. INJECTABLE PROGESTOGENSPROGESTOGENS
  • INJECTABLESINJECTABLES  PreparationsPreparations • DMPA : Depo-provera (depotDMPA : Depo-provera (depot medroxyprogesterone acetate)medroxyprogesterone acetate) • NET-EN : norethisterone enantateNET-EN : norethisterone enantate  Main effect : inhibition of ovulationMain effect : inhibition of ovulation  Also has effect on endometrial and cervical mucusAlso has effect on endometrial and cervical mucus
  • Depo-proveraDepo-provera®®  Depo-Depo- medroxyprogesteronemedroxyprogesterone acetate 150mgacetate 150mg  Deep im injectionDeep im injection  Every 3 months +/- 2Every 3 months +/- 2 weeksweeks  Failure rate 0.25-0.5/100Failure rate 0.25-0.5/100 woman yearswoman years  Use of broad spectrumUse of broad spectrum antibiotics do notantibiotics do not compromised efficacycompromised efficacy since the route does notsince the route does not depend on absorptiondepend on absorption from the gutfrom the gut
  • BenefitsBenefits  Suitable for womenSuitable for women  who forget to take pills, particularly travellers, due to frequent changeswho forget to take pills, particularly travellers, due to frequent changes in time zones, missed pills are likely or where suboptimal compliance isin time zones, missed pills are likely or where suboptimal compliance is expectedexpected  Who wish for a secret or ‘private’ methodWho wish for a secret or ‘private’ method  In whom oestrogen is contraindicated:In whom oestrogen is contraindicated: mild to moderate hypertension,diabetesmild to moderate hypertension,diabetes mellitus in the absence of vascular disease, age >35yo & smoking)mellitus in the absence of vascular disease, age >35yo & smoking)  Associated with reduction in sickling crises in sufferers ofAssociated with reduction in sickling crises in sufferers of sickle cell disease and reduced frequency of seizures insickle cell disease and reduced frequency of seizures in epileptic women having cyclical attacksepileptic women having cyclical attacks  Does not have any effect on the risk of ovarian andDoes not have any effect on the risk of ovarian and endometrial cancerendometrial cancer  Little or no association with stroke, MI or VTE .Little or no association with stroke, MI or VTE .
  • Side effects & RisksSide effects & Risks  Menstrual disturbances are likely with irregular frequent vaginalMenstrual disturbances are likely with irregular frequent vaginal bleedingbleeding  Amenorrhoea becomes more likely with repeated dosesAmenorrhoea becomes more likely with repeated doses • 30% after 130% after 1stst dosedose • 55% after 455% after 4thth dosedose  Weight gainWeight gain  3-19% of users may develop headaches, dizziness, breast3-19% of users may develop headaches, dizziness, breast tenderness and mood changestenderness and mood changes  Associated with delay in return to normal fertilityAssociated with delay in return to normal fertility  On average following a final injection of DMPA, ovulation returnsOn average following a final injection of DMPA, ovulation returns after 4-5 months, may be as long as 24 monthsafter 4-5 months, may be as long as 24 months  78% had conceived by 12 months and over 92% had conceived78% had conceived by 12 months and over 92% had conceived by 24 months following discontinuationby 24 months following discontinuation  Thought to be due to slow metabolism of the drug from theThought to be due to slow metabolism of the drug from the microcrystalline deposits in muscle tissuemicrocrystalline deposits in muscle tissue
  • Depo-provera and osteoporosisDepo-provera and osteoporosis  There is evidence that depo-provera causes a significantThere is evidence that depo-provera causes a significant reduction in bone mineral density. This effect may bereduction in bone mineral density. This effect may be more important in adolescents. This reduction appears tomore important in adolescents. This reduction appears to be partly reversible after discontinuation and resumptionbe partly reversible after discontinuation and resumption of ovarian activityof ovarian activity  In adolescentsIn adolescents, it should only be used after other, it should only be used after other methods have been considered and found to bemethods have been considered and found to be unsuitable or unacceptableunsuitable or unacceptable  In all women, careful re-evaluation of risks and benefitsIn all women, careful re-evaluation of risks and benefits of treatment should be undertaken in those who wish toof treatment should be undertaken in those who wish to continue use forcontinue use for longer than 2 yearslonger than 2 years
  • Depo-subQ provera 104Depo-subQ provera 104  A new micronised,A new micronised, subcutaneous formulationsubcutaneous formulation of Depo-proveraof Depo-provera® 104mg® 104mg  Every 12 weeksEvery 12 weeks  Fewer side effects suchFewer side effects such as weight gainas weight gain  The efficacy and delay inThe efficacy and delay in return of fertility is similarreturn of fertility is similar with im depo-provera®with im depo-provera®  Can be self administeredCan be self administered
  • NoristeratNoristerat®®  200mg norethindrone enanthate200mg norethindrone enanthate  Administered every 8 weeks +/- 2 weeksAdministered every 8 weeks +/- 2 weeks  Less effect on bleeding patternLess effect on bleeding pattern  Pearl index 0.4-2.0/100 woman yearsPearl index 0.4-2.0/100 woman years
  • 3. PROGESTOGEN3. PROGESTOGEN IMPLANTSIMPLANTS
  • ImplantImplant  PreparationsPreparations 1.Implanon (etonogestrel1.Implanon (etonogestrel implant)implant) 2.Norplant/ Jadelle2.Norplant/ Jadelle (levonorgestrel implant)(levonorgestrel implant)
  • ImplanonImplanon  68mg68mg etonorgestreletonorgestrel – active metabolite of desogestrel– active metabolite of desogestrel  A single 40 mm rod, just 2 mm in diameter.A single 40 mm rod, just 2 mm in diameter.  Initial release rate of 60-70mcg/day and falls gradually toInitial release rate of 60-70mcg/day and falls gradually to around 25-30mcg at the end of 3 yearsaround 25-30mcg at the end of 3 years  Inserted subdermally in the groove between biceps andInserted subdermally in the groove between biceps and triceps in the non-dominant hand about 8-10cm from thetriceps in the non-dominant hand about 8-10cm from the medial epicondylemedial epicondyle  Can be administered up to day 5 of menses without theCan be administered up to day 5 of menses without the need for additional contraceptionneed for additional contraception  License for 3 years – efficacy may be lower during the 3License for 3 years – efficacy may be lower during the 3rdrd year in overweight womenyear in overweight women  Inhibit ovulation by prevention of LH surge, also affectInhibit ovulation by prevention of LH surge, also affect cervical mucus thickening and endometriumcervical mucus thickening and endometrium
  • Implanon- timing of insertionImplanon- timing of insertion  Day 1 to day 5 of menses. If later than dayDay 1 to day 5 of menses. If later than day 2, recommend additional contraception till2, recommend additional contraception till day 7. If after day 7, must make sureday 7. If after day 7, must make sure abstinence.abstinence.  Immediate after 1Immediate after 1stst trimester abortiontrimester abortion  Day 21 after 2Day 21 after 2ndnd trimester abortion ortrimester abortion or deliverydelivery  During breast feedingDuring breast feeding
  • Implanon- advantages &Implanon- advantages & benefitsbenefits  Feature of ‘forgetability’ / better complianceFeature of ‘forgetability’ / better compliance  Long action plus high continuation ratesLong action plus high continuation rates  Efficacy not being affected by broad-spectrumEfficacy not being affected by broad-spectrum antibioticsantibiotics  Oestrogen free- usable in past VTE, excellentOestrogen free- usable in past VTE, excellent choice for many diabeticschoice for many diabetics  Unchanged blood pressureUnchanged blood pressure  Can use in past ectopicsCan use in past ectopics  Rapidly reversible- after removal 44/47 womenRapidly reversible- after removal 44/47 women will ovulate within 3 weekswill ovulate within 3 weeks  Failure rate fewer than 0.1/100 woman yearsFailure rate fewer than 0.1/100 woman years
  • Implanon- problems &Implanon- problems & disadvantagesdisadvantages  Menstrual disturbancesMenstrual disturbances  Improve over 3-5 monthsImprove over 3-5 months  NSAIDs and low dose COCs are generally effectiveNSAIDs and low dose COCs are generally effective treatment strategies for implanon related bleedingtreatment strategies for implanon related bleeding  Minor general side effects – acne, headache,Minor general side effects – acne, headache, abdominal pain, breast pain, dizziness, moodabdominal pain, breast pain, dizziness, mood changes, reduced libido and hair losschanges, reduced libido and hair loss  Body weight – slight increaseBody weight – slight increase  Possible hypo-oestrogenismPossible hypo-oestrogenism  Local adverse effects – discomfort, expulsion,Local adverse effects – discomfort, expulsion, migration and scarringmigration and scarring
  • Implanon - contraindicationsImplanon - contraindications  Absolute include progestogen dependantAbsolute include progestogen dependant tumour, current severe hepatic disease,tumour, current severe hepatic disease, pregnancy, undiagnosed vaginal bleeding,pregnancy, undiagnosed vaginal bleeding, severe hypersensitivity and acutesevere hypersensitivity and acute porphyriaporphyria  Relative include previous ectopicRelative include previous ectopic pregnancies and liver cirrhosispregnancies and liver cirrhosis
  • Levonorgestrel implantLevonorgestrel implant  Jadelle : 2 rods effective for 5 yearsJadelle : 2 rods effective for 5 years  Norplant :Norplant :  6 capsules labelled for 5 years usage6 capsules labelled for 5 years usage  Released a low dose levonorgestrel at rate ofReleased a low dose levonorgestrel at rate of 30-35mcg/24h after 18 months30-35mcg/24h after 18 months  Failure rate 0.2-1/100 women yearsFailure rate 0.2-1/100 women years  Large studies have found that it is effective forLarge studies have found that it is effective for 7 years (in women <70kg)7 years (in women <70kg)  No more available in UK marketNo more available in UK market
  • 4.INTRAUTERINE4.INTRAUTERINE DEVICESDEVICES
  • LNG IUD : MIRENALNG IUD : MIRENA  Long-acting, rapidlyLong-acting, rapidly reversiblereversible  52mg levonorgestrel52mg levonorgestrel released at the rate ofreleased at the rate of 20mcg/ day20mcg/ day  Frame is rendered radio-Frame is rendered radio- opaque by impregnationopaque by impregnation with barium sulphatewith barium sulphate  Width is 4.8mmWidth is 4.8mm  Licensed forLicensed for contraception for 5 yearscontraception for 5 years
  • LNG IUD : MIRENALNG IUD : MIRENA  The contraceptive effect is achieved byThe contraceptive effect is achieved by  profound endometrial glandular and stromal atrophy,profound endometrial glandular and stromal atrophy, a decidualisation effect and a foreign body effect ina decidualisation effect and a foreign body effect in the uterus rendering the endometrium unresponsivethe uterus rendering the endometrium unresponsive to oestrogento oestrogen  Changes in the cervical mucus which prevent ascentChanges in the cervical mucus which prevent ascent of spermatozoaof spermatozoa  After removal, endometrial morphology returnsAfter removal, endometrial morphology returns to normal with menstruation within 30 daysto normal with menstruation within 30 days  Failure rate of 0.09/100 women yearsFailure rate of 0.09/100 women years
  • When to use?When to use?  May be fitted up to 7 day of menstrual cycleMay be fitted up to 7 day of menstrual cycle without need of additional contraceptionwithout need of additional contraception  Or at any time in the menstrual cycle with barrierOr at any time in the menstrual cycle with barrier contraceptives for the next 7 days, if it iscontraceptives for the next 7 days, if it is reasonably certain that the woman is notreasonably certain that the woman is not pregnantpregnant  It may be fitted at the time of 1It may be fitted at the time of 1stst trimester surgicaltrimester surgical abortionabortion  It is preferable to wait 6 weeks later followingIt is preferable to wait 6 weeks later following late 2late 2ndnd trimester abortiontrimester abortion
  • Benefits including non-Benefits including non- contraceptioncontraception  Return to fertility is rapidReturn to fertility is rapid  Management of menorrhagiaManagement of menorrhagia  Reduction in menstrual blood loss of up to 97% afterReduction in menstrual blood loss of up to 97% after 12 months of use with an increase in serum ferritin12 months of use with an increase in serum ferritin and Hb concentration.and Hb concentration.  DysmenorrhoeaDysmenorrhoea  Low rate of ectopic pregnancyLow rate of ectopic pregnancy  Management of endometrial hyperplasiaManagement of endometrial hyperplasia  Protection against STD- thickening of cervical mucus,Protection against STD- thickening of cervical mucus, inactivation of the endometrium and reduced bleedinginactivation of the endometrium and reduced bleeding  Cost effectiveness – compare to cost of hysterectomy/Cost effectiveness – compare to cost of hysterectomy/ medical treatment for menorrhagiamedical treatment for menorrhagia  Progesteron arm of HRT in perimenopausal women.Progesteron arm of HRT in perimenopausal women.
  • Side effects/ complicationsSide effects/ complications  Difficulties might be encounter with insertion especially inDifficulties might be encounter with insertion especially in nulliparous womannulliparous woman  Irregular bleeding – takes 3 months for endometrialIrregular bleeding – takes 3 months for endometrial atrophyatrophy  Increased incidence of functional ovarian cystsIncreased incidence of functional ovarian cysts compared to copper IUD userscompared to copper IUD users  AmenorrhoeaAmenorrhoea  unless appropriately counselled, some women may regard thisunless appropriately counselled, some women may regard this as abnormalas abnormal  Occurs in 20% of womenOccurs in 20% of women  Prosgestogenic side effects – oedema/ headache/ breastProsgestogenic side effects – oedema/ headache/ breast tenderness/ acne – subside after a few monthstenderness/ acne – subside after a few months  Expulsion – commonly occurs during first monthExpulsion – commonly occurs during first month following insertionfollowing insertion
  • COPPER IUCDCOPPER IUCD  11stst generationgeneration  Copper sevenCopper seven  Copper T 200Copper T 200  22ndnd generationgeneration  Multiload 250Multiload 250  Nova TNova T  33rdrd generationgeneration  Copper T380Copper T380  Multiload 375Multiload 375
  • Cu T 380Cu T 380  Licensed for 8 years in the UKLicensed for 8 years in the UK  First choice of IUCDFirst choice of IUCD  Low failure rateLow failure rate  1.4-2.2/100 women over 5 years1.4-2.2/100 women over 5 years  Low expulsion rateLow expulsion rate  ~8/100 women over 5 years~8/100 women over 5 years
  • GyneFIX IUCDGyneFIX IUCD  Licensed for 5 yearsLicensed for 5 years  Frameless deviceFrameless device with 6 copper beadswith 6 copper beads wound around a monofilamentwound around a monofilament polypropylene threadpolypropylene thread  Should only be inserted by those whoShould only be inserted by those who have received appropriate traininghave received appropriate training  Has similar efficacy to Cu T 380 but withHas similar efficacy to Cu T 380 but with significantly lower expulsion ratesignificantly lower expulsion rate  3.0/100 women at 3 years3.0/100 women at 3 years vsvs 7.38/100 women7.38/100 women
  • Copper IUDCopper IUD  Efficacy is dependent on the surface areaEfficacy is dependent on the surface area of copperof copper  IUDs fitted after the 40IUDs fitted after the 40thth birthday need notbirthday need not to be changed, since fertility declinesto be changed, since fertility declines rapidly at this age and should be removedrapidly at this age and should be removed 1 year after the menopause1 year after the menopause
  • Complications of Copper IUD useComplications of Copper IUD use  ExpulsionExpulsion  Most occur in the first year, especially in the first 3 monthsMost occur in the first year, especially in the first 3 months  Increased risk of expulsion in woman withIncreased risk of expulsion in woman with • heavy periodsheavy periods • Insertion within 6 weeks post-partumInsertion within 6 weeks post-partum • Previous expulsionPrevious expulsion • Inexperienced operatorInexperienced operator  PerforationPerforation  Risk 1.2/1000 insertionsRisk 1.2/1000 insertions  Pelvic infectionPelvic infection  6 fold increase in risk of developing PID in the first 20 days following insertion compared6 fold increase in risk of developing PID in the first 20 days following insertion compared with any other timewith any other time  Thereafter the risk of infection remains constant at 1.4/1000 womenThereafter the risk of infection remains constant at 1.4/1000 women  Increased menstrual lossIncreased menstrual loss  Abdominal pain/ dysmenorrhoeaAbdominal pain/ dysmenorrhoea  PregnancyPregnancy  Remove device gently if possible as soon as pregnancy is diagnosed : reduces the risk ofRemove device gently if possible as soon as pregnancy is diagnosed : reduces the risk of spontaneous miscarriages by 50%spontaneous miscarriages by 50%  Exclude ectopic pregnancy ( risk 1:25 with IUCD)Exclude ectopic pregnancy ( risk 1:25 with IUCD)
  • WHO Medical Eligibility Criteria for IUD Use inWHO Medical Eligibility Criteria for IUD Use in Women with Certain Medical ConditionsWomen with Certain Medical Conditions Medical Conditions TCu-380A WHO Risk Category* LNG-IUS WHO Risk Category* Hypertension (controlled) 1 1 Multiple cardiovascular risk factors 1 2 History of DVT or pulmonary embolism 1 2 Stroke 1 2 Severe valvular heart disease (complicated) 2 2 HIV infection 2 2 AIDS (clinically well on antiretroviral therapy) 2 2 WHO. Medical Eligibility Criteria for Contraceptive Use. 3rd ed. 2004. Available at: http://www.who.int/reproductive-health/publications/mec/iuds.html. AIDS = acquired immunodeficiency syndrome; DVT = deep vein thrombosis; HIV = human immunodeficiency virus; IUD = intrauterine device; LNG-IUS = levonorgestrel-releasing IUD; TCu-380A = copper-releasing IUD; WHO = World Health Organization *Category 1= there are no restrictions for use of the contraceptive method; Category 2 = the benefits of using the contraceptive method generally outweigh the theoretical or proven risk
  • EMERGENCYEMERGENCY CONTRACEPTIONCONTRACEPTION
  • 1. Yuzpe regime1. Yuzpe regime  EE 100mcg and LNG 500mcgEE 100mcg and LNG 500mcg  Given two tablets BD 12 hours apartGiven two tablets BD 12 hours apart  GivenGiven within 72 hourswithin 72 hours of unprotected intercourseof unprotected intercourse  Is likely to preventIs likely to prevent 6 out of 8 pregnancies6 out of 8 pregnancies
  • 2. Progesterone only2. Progesterone only  TWO regimesTWO regimes 1. Single dose 1.5mg1. Single dose 1.5mg levonorgestrellevonorgestrelEscapelleEscapelle 2. Two doses of 0.75mg2. Two doses of 0.75mg levonorgestrel 12 hours apartlevonorgestrel 12 hours apart LevonelleLevonelle  Is likely to preventIs likely to prevent 7 out of7 out of 8 pregnancies8 pregnancies
  • 3. Progesterone receptor3. Progesterone receptor ModulatorModulator  Ulipristal 30mgUlipristal 30mg  Marketed asMarketed as EllaOneEllaOne  It is used up to 120 hours following unprotected intercourse.  S/E – Vomiting  Not recommended to use >one time per cycle  If breast feeding avoid BF for next 36hrs.
  • 4. Copper IUCD4. Copper IUCD  spermicidal and blastocidal action of copper and thespermicidal and blastocidal action of copper and the prevention of implantationprevention of implantation  Up to 5 days after the first act of unprotected coitusUp to 5 days after the first act of unprotected coitus  Can be removed when menses occurCan be removed when menses occur  Failure rate <1%Failure rate <1%  Main primary complicationsMain primary complications  Uterine cramps/ bleedingUterine cramps/ bleeding  Risk of infectionRisk of infection
  • 5. Mifepristone ( RU486)5. Mifepristone ( RU486)  Not licensedNot licensed for use as emergency contraceptionfor use as emergency contraception  progesterone antagonistprogesterone antagonist  Single dose of 600mg within 72 h of unprotectedSingle dose of 600mg within 72 h of unprotected sexual intercourse is highly effective and nosexual intercourse is highly effective and no pregnancies have been reported in randomisedpregnancies have been reported in randomised trialstrials  Delay in subsequent menses is the main unwantedDelay in subsequent menses is the main unwanted side effect and seems to be dose related.side effect and seems to be dose related.
  • STERILISATIONSTERILISATION Ratio of female to maleRatio of female to male sterilisation is 10:1sterilisation is 10:1
  • STERILISATIONSTERILISATION -intended to be permanent-intended to be permanent  MaleMale  vasectomyvasectomy  FemaleFemale  Mini LaparotomyMini Laparotomy • The Pomeroy methodThe Pomeroy method • The Parkland techniqueThe Parkland technique • The Ushida methodThe Ushida method • The Irving methodThe Irving method • fimbriectomyfimbriectomy  LaparoscopicLaparoscopic • Filshie clipFilshie clip • Hulka clipHulka clip • Falope ringFalope ring  HysteroscopicHysteroscopic • Chemical method: quinacrineChemical method: quinacrine • Mechanical methodMechanical method  OvablocOvabloc®®  Essure® deviceEssure® device
  • VasectomyVasectomy  Local anaesthesiaLocal anaesthesia whenever possiblewhenever possible  Involves division of theInvolves division of the vas deferens.vas deferens.
  • VasectomyVasectomy  Men should be advised to use contraception untilMen should be advised to use contraception until azoospermia is confirmedazoospermia is confirmed 1.1. Testing should be done after 8 weeks of vasectomyTesting should be done after 8 weeks of vasectomy 2.2. 2 samples not less than 4 weeks apart should be clear of2 samples not less than 4 weeks apart should be clear of spermsperm 3.3. International Parenthood Federation suggested at least 20International Parenthood Federation suggested at least 20 ejaculations are required to clear sperm before otherejaculations are required to clear sperm before other contraceptives methods should be discontinuedcontraceptives methods should be discontinued  Failure rates of 1:2000 in comparison to 1:200 in BTLFailure rates of 1:2000 in comparison to 1:200 in BTL  Not associated with testicular cancer or heart diseaseNot associated with testicular cancer or heart disease  Nearly 75% of men who undergo vasectomy will developNearly 75% of men who undergo vasectomy will develop antisperm antibodiesantisperm antibodies
  • ComplicationsComplications  ImmediateImmediate  Haematoma (1-2%)Haematoma (1-2%)  Wound infectionWound infection (up to 5%)(up to 5%)  FailureFailure • Due to failure of otherDue to failure of other contraceptive methods incontraceptive methods in the initial post-op periodthe initial post-op period before azoospermia hasbefore azoospermia has been confirmedbeen confirmed  LateLate  Anti sperm antibody (75%)Anti sperm antibody (75%) • Thought to be in responseThought to be in response to leakage of spermto leakage of sperm • Harmless unlessHarmless unless restoration of fertility isrestoration of fertility is desireddesired  Sperm granulomaSperm granuloma • Presumably also inPresumably also in response to leaked spermresponse to leaked sperm • Painful and persistentPainful and persistent • Can be effectively excisedCan be effectively excised  Chronic testicular painChronic testicular pain • Unknown causeUnknown cause
  • FEMALE STERILIZATIONFEMALE STERILIZATION
  • LAPAROSCOPICLAPAROSCOPIC STERILISATIONSTERILISATION  Filshie clipFilshie clip  Made of Titanium lined by silicone rubberMade of Titanium lined by silicone rubber  Destroyed 4 mm of tubeDestroyed 4 mm of tube  Failure rate 2-3/1000 proceduresFailure rate 2-3/1000 procedures  Hulka – Clemen clipHulka – Clemen clip  A stainless steel spring with 2 plastic jaws made of LexanA stainless steel spring with 2 plastic jaws made of Lexan  Destroyed about 3 mm of tubeDestroyed about 3 mm of tube  1 year pregnancy rate of 2/1000 women1 year pregnancy rate of 2/1000 women  Falope ringFalope ring  Made of silicon rubber and using special design applicatorMade of silicon rubber and using special design applicator  Placed over the loop of tubePlaced over the loop of tube  It destroyed 2-3cm tube and difficult to applied if tube is thick /It destroyed 2-3cm tube and difficult to applied if tube is thick / fibroticfibrotic  Ischemia of loop give significant post op painIschemia of loop give significant post op pain
  • MINI LAPAROTOMYMINI LAPAROTOMY
  • 1.The Pomeroy method1.The Pomeroy method  A loop of the isthmic portion of the tube is elevated usingA loop of the isthmic portion of the tube is elevated using babcock and ligated and cut at its base.babcock and ligated and cut at its base.  The cut ends of the tube are cauterizedThe cut ends of the tube are cauterized
  • 1.The Pomeroy method1.The Pomeroy method
  • 2. The Parkland technique2. The Parkland technique  A 2-3 cm fenestration is made beneath the isthmicA 2-3 cm fenestration is made beneath the isthmic portion of the tubeportion of the tube  Tube is ligated at both sites , 3cm apart.Tube is ligated at both sites , 3cm apart.  3cm portion of the tube is removed3cm portion of the tube is removed  Care must be taken not to pull on the suture duringCare must be taken not to pull on the suture during ligation or during transection of the tube because thisligation or during transection of the tube because this can lead to shearing of the tube from underling mesentrycan lead to shearing of the tube from underling mesentry resulting in bleedingresulting in bleeding
  • 2. The Parkland technique2. The Parkland technique
  • 3.The Uchida method3.The Uchida method  Injection of vaso-constricting solution beneath the serosaInjection of vaso-constricting solution beneath the serosa of the tube about 6 cm from the utero-tubal junction.of the tube about 6 cm from the utero-tubal junction.  The tube is ligated proximally and distally about 3cmThe tube is ligated proximally and distally about 3cm apart and cut.apart and cut.  Ligated proximal stump is allowed to retract into theLigated proximal stump is allowed to retract into the mesosalphinx and tmesosalphinx and the mesosalphinx is closed withhe mesosalphinx is closed with purse-string suture.purse-string suture.  Ligated distal stump remained exteriorized.Ligated distal stump remained exteriorized.
  • 3.The Uchida method3.The Uchida method
  • 4. The Irving method4. The Irving method  A fenestration is made beneath the tube about 4cm fromA fenestration is made beneath the tube about 4cm from the utero-tubal junction.the utero-tubal junction.  The tube is ligated proximally and distally about 3cmThe tube is ligated proximally and distally about 3cm apart and resected.apart and resected.  A deep pocket is created in the myometrium on theA deep pocket is created in the myometrium on the posterior surface of uterus.posterior surface of uterus.  Ligated proximal end of the tube are sutured deep intoLigated proximal end of the tube are sutured deep into the myometrial tunnel.the myometrial tunnel.  Ligated distal stump remained exteriorized.Ligated distal stump remained exteriorized.
  • 4. The Irving method4. The Irving method
  • Reversal of sterilisationReversal of sterilisation  Reversal of female sterilizationReversal of female sterilization  Involves laparotomyInvolves laparotomy  Does not always workDoes not always work  Microsurgical techniques are associated with aroundMicrosurgical techniques are associated with around 70% success70% success  Carries a significant risk of ectopic pregnancy (up toCarries a significant risk of ectopic pregnancy (up to 5%)5%)  Reversal of vasectomyReversal of vasectomy  Technically feasible in many cases with patency ratesTechnically feasible in many cases with patency rates of almost 90%of almost 90%  Pregnancy rates are much less (up to 60%) perhapsPregnancy rates are much less (up to 60%) perhaps as a result of the presence of antisperm antibodiesas a result of the presence of antisperm antibodies
  • HYSTEROSCOPICHYSTEROSCOPIC STERILISATIONSTERILISATION QuinacrineQuinacrine OvablocOvabloc®® EssureEssure®®
  • 1.Quinacrine1.Quinacrine  Blind introduction of pellets of quinacrine into theBlind introduction of pellets of quinacrine into the uterine cavity via an intrauterine device inserter.uterine cavity via an intrauterine device inserter.  The pellets dissolve near the both cornua, withThe pellets dissolve near the both cornua, with some solution entering the tubes and causing asome solution entering the tubes and causing a fibrotic reactionfibrotic reaction  It involves the insertion of 252mg of quinacrineIt involves the insertion of 252mg of quinacrine on two occasions one month aparton two occasions one month apart  Quoted efficacy of 98% at 2 yearsQuoted efficacy of 98% at 2 years
  • 2.Ovabloc2.Ovabloc intra-tubal deviceintra-tubal device  Mainly confined to a few centres in theMainly confined to a few centres in the NetherlandsNetherlands  The procedures involves high pressure injectionThe procedures involves high pressure injection of viscous silicone into the ostium via a catheter.of viscous silicone into the ostium via a catheter.  The silicone conforms to the shape of theThe silicone conforms to the shape of the ampulla of the tube and cures in approximately 5ampulla of the tube and cures in approximately 5 minutes.minutes.
  • 2.Ovabloc2.Ovabloc intra-tubal deviceintra-tubal device  The silicone contains radio-opaque silverThe silicone contains radio-opaque silver powder which enables a radiological check forpowder which enables a radiological check for correct placementcorrect placement  Bilateral placement takes around 30 minutesBilateral placement takes around 30 minutes  The woman is asked to use contraception for 3The woman is asked to use contraception for 3 months, at which point a further plain X-ray ismonths, at which point a further plain X-ray is performed to exclude migration and expulsionperformed to exclude migration and expulsion  Published data reported insertion failure rate atPublished data reported insertion failure rate at 17%17%  In women with a successful insertion the plugIn women with a successful insertion the plug was expelled in 5% of caseswas expelled in 5% of cases
  • EssureEssure®®  The procedure involves the hysteroscopicThe procedure involves the hysteroscopic application of a micro-insert into theapplication of a micro-insert into the intramural portion of the fallopion tubeintramural portion of the fallopion tube  Each device consists of a 4 cm longEach device consists of a 4 cm long nickle-titanium alloy outer coil withinnickle-titanium alloy outer coil within which lie polyethylene terephthalate(PET)which lie polyethylene terephthalate(PET) fibresfibres  The procedure time from insertion toThe procedure time from insertion to removal of the hysteroscope is around 9removal of the hysteroscope is around 9 minutesminutes  Widely used in Australia, USA and theWidely used in Australia, USA and the EuropeEurope
  •  The PET fibres induce a fibrous reaction inThe PET fibres induce a fibrous reaction in the tube whick peaks at around 3 weeks.the tube whick peaks at around 3 weeks.  Patients are instructed to use alternativesPatients are instructed to use alternatives contraception for 3 months after thecontraception for 3 months after the procedure.procedure.  A plain X-ray or HSG is done at this point toA plain X-ray or HSG is done at this point to check continued correct placement.check continued correct placement.  99.74% effectiveness with usage over 599.74% effectiveness with usage over 5 yearsyears
  • BARRIER METHODSBARRIER METHODS • Act by blocking the progress of sperm fromAct by blocking the progress of sperm from male partner to female thereby preventingmale partner to female thereby preventing fertilizationfertilization • Effective in preventing pregnancy and offerEffective in preventing pregnancy and offer protection against STIs and HIVprotection against STIs and HIV
  • Barrier contraception andBarrier contraception and spermicidesspermicides MaleMale  Male condomMale condom  LatexLatex  polyurethanepolyurethane FemaleFemale  Female condomFemale condom  DiaphragmDiaphragm  Cervical capCervical cap  spongesponge
  • 1.Male condom1.Male condom • Estimated 44 million couples use this method • Japan accounts for more than a quarter • Despite the massive problem of HIV/AIDS, condom use remains low in Africa, Latin America and Middle East.
  • Male condomMale condom • To control HIV/AIDS epidemic, it was calculated, 24 billion condoms need to be used/year, this figure not yet reached 10 billion
  • Male condomMale condom  Failure rate reduce significantly when used correctly byFailure rate reduce significantly when used correctly by well motivated individualwell motivated individual  Failure rate 2-15/100 women yearsFailure rate 2-15/100 women years  Men complain that they dislike condoms due to lack ofMen complain that they dislike condoms due to lack of sensitivity around glans of penissensitivity around glans of penis  Advantages of Polyurethane condomsAdvantages of Polyurethane condoms  are baggier and less restrictive around the glans of the penis,are baggier and less restrictive around the glans of the penis, giving more sensationgiving more sensation  Not affected by fat soluble products like baby oils which wouldNot affected by fat soluble products like baby oils which would cause breakage of latex condomcause breakage of latex condom
  • 2. Female condom2. Female condom  FemidomFemidom  Made of polyurethaneMade of polyurethane  Come in 1 sizeCome in 1 size  Lines the vaginaLines the vagina  An internal ring in the closedAn internal ring in the closed end of the pouch covers theend of the pouch covers the cervix and an external ringcervix and an external ring remains outside the vagina,remains outside the vagina, partially covering the perineumpartially covering the perineum  Prelubricated with silicone andPrelubricated with silicone and spermicide need not to bespermicide need not to be usedused  Design for single use and isDesign for single use and is expensiveexpensive  Failure rate is 5 – 20 per100Failure rate is 5 – 20 per100 women yearwomen year
  • 3. Diaphragm3. Diaphragm  Consist of thin, latex rubber hemisphere, rimConsist of thin, latex rubber hemisphere, rim reinforced by flexible flat or coiled metalreinforced by flexible flat or coiled metal springspring  Should lie diagonally across cervix reachingShould lie diagonally across cervix reaching post vaginal fornix to behind symphysis pubispost vaginal fornix to behind symphysis pubis covering the cervix.covering the cervix.  Causes of failure areCauses of failure are  Poor motivationPoor motivation  Incorrect insertionIncorrect insertion  Displacement during SIDisplacement during SI  To increase effectiveness use withTo increase effectiveness use with spermicidal is advised (Smith et al 1995)spermicidal is advised (Smith et al 1995)  Failure rateFailure rate  With spermicidal is 4-8 per 100 womenWith spermicidal is 4-8 per 100 women yearsyears  Without spermicidal is 10-18 per 100Without spermicidal is 10-18 per 100 women yearswomen years
  • 4. Cervical cap4. Cervical cap FEMCAPFEMCAP  Need not to be used withNeed not to be used with spermicidespermicide  Made of nonallergic siliconeMade of nonallergic silicone rubber.rubber.  Shaped like an American sailor’sShaped like an American sailor’s hathat  Design to conform to the naturalDesign to conform to the natural shape of the cervix; the brimshape of the cervix; the brim around the cap helps to create aaround the cap helps to create a seal around the vaginal wall,seal around the vaginal wall, stopping the sperm from enteringstopping the sperm from entering the cervixthe cervix  3 sizes3 sizes  22mm suitable for nulliparous22mm suitable for nulliparous  26mm suitable for woman who26mm suitable for woman who have been pregnant beforehave been pregnant before  30mm suitable for women have30mm suitable for women have had a vaginal deliveryhad a vaginal delivery  Failure rate is 8 – 20 per 100Failure rate is 8 – 20 per 100 women yearswomen years
  • DiaphragmDiaphragm CapCap FemaleFemale condomcondom Insertion beforeInsertion before coitus no longercoitus no longer thanthan 6 hrs6 hrs 6 hrs6 hrs 8 hrs8 hrs After coitusAfter coitus should be left inshould be left in place forplace for 6 hrs6 hrs 8 hrs8 hrs -- Maximal wearMaximal wear timetime 24 hrs24 hrs 48hrs48hrs 8hrs8hrs
  • 5.Vaginal sponge5.Vaginal sponge  Marketed asMarketed as ProtectaidProtectaid  Can be inserted into the vagina up to 6 hours beforeCan be inserted into the vagina up to 6 hours before sexual intercourse and can be left for a maximum of 12 hsexual intercourse and can be left for a maximum of 12 h  Impregnated with a spermicide called F-5gelImpregnated with a spermicide called F-5gel  efficacy of 90% with careful and consistent useefficacy of 90% with careful and consistent use  Should be inserted 15 min prior to sexual intercourseShould be inserted 15 min prior to sexual intercourse  Sexual intercourse may take place more than onceSexual intercourse may take place more than once without the need to replenish the spermicidewithout the need to replenish the spermicide  Should be left in situ for 6 h after the last episode ofShould be left in situ for 6 h after the last episode of sexual intercoursesexual intercourse
  • 6.SPERMICIDES6.SPERMICIDES  A type of contraceptive agentA type of contraceptive agent that work by killing sperm.that work by killing sperm.  It need to be in place in aIt need to be in place in a woman's vagina beforewoman's vagina before intercourse if they are tointercourse if they are to prevent viable sperm fromprevent viable sperm from reaching her uterus.reaching her uterus.  It come in a wide variety ofIt come in a wide variety of forms, including pessaries,forms, including pessaries, creams, foams.creams, foams.  The active ingredient in allThe active ingredient in all spermicides isspermicides is Nonoxynol-9.Nonoxynol-9.
  • Traditional MethodsTraditional Methods 1.1. Periodic abstinencePeriodic abstinence 2.2. Coitus interruptusCoitus interruptus 3.3. Harmonal monitoringHarmonal monitoring 4.4. Cervical mucus method (billingCervical mucus method (billing method)method) 5.5. Sympto-thermal method (basal bodySympto-thermal method (basal body temp)temp)
  • 1. PERIODIC A1. PERIODIC ABSTINENCEBSTINENCE  Also known asAlso known as ovulation method, Rhythm method orovulation method, Rhythm method or Calender method or Fertility awareness methodCalender method or Fertility awareness method  Based on the assumption that menstrual cycle relativelyBased on the assumption that menstrual cycle relatively constant and the viability of sperm in the femaleconstant and the viability of sperm in the female reproductive tract (2-7 days) and the life span of ovum(1-reproductive tract (2-7 days) and the life span of ovum(1- 3 days)3 days)  Pregnancy rate of 40 per 100 women yearsPregnancy rate of 40 per 100 women years  General ruleGeneral rule  To estimate the beginning of fertile period by substracting 18To estimate the beginning of fertile period by substracting 18 days from the length of the shortest cycledays from the length of the shortest cycle  To estimate the end of fertile period by substracting 11 days fromTo estimate the end of fertile period by substracting 11 days from the longest cyclethe longest cycle  Example is if cycles of 28-32 days, periodic abstinence shouldExample is if cycles of 28-32 days, periodic abstinence should be from day 10 to day 21be from day 10 to day 21
  • 2. Coitus interruptus2. Coitus interruptus  Means withdrawal of the penis from vagina justMeans withdrawal of the penis from vagina just before ejaculation to prevent pregnancy.before ejaculation to prevent pregnancy.  But it is not reliable as pre-ejaculatory secretionsBut it is not reliable as pre-ejaculatory secretions may contain millions of sperm.may contain millions of sperm.
  • 3. Hormone monitoring3. Hormone monitoring PERSONAPERSONA  A hand held monitor with disposable urine dip stickA hand held monitor with disposable urine dip stick  Measures levels of LH and oestrogen in early morningMeasures levels of LH and oestrogen in early morning urineurine  The ratio between the 2 hormones is used to defined theThe ratio between the 2 hormones is used to defined the start and the end of fertile phasestart and the end of fertile phase  A red light is displayed on days when intercourse shouldA red light is displayed on days when intercourse should be avoidedbe avoided  Need to be programmed for 3 months ( test urine for 16Need to be programmed for 3 months ( test urine for 16 days in the first month and 8 days in subsequentdays in the first month and 8 days in subsequent months) before device can be relied uponmonths) before device can be relied upon  Failure rateFailure rate ~6/100 woman years with perfect use.~6/100 woman years with perfect use.
  • 3. Hormone monitoring3. Hormone monitoring PERSONAPERSONA  Not suitables for:Not suitables for:  Cycle length <23 days or > 35 daysCycle length <23 days or > 35 days  PCOSPCOS  BreastfeedingBreastfeeding  Menopausal symptomsMenopausal symptoms  Women taking hormonal medicationWomen taking hormonal medication
  • 4. Cervical mucus method4. Cervical mucus method  Also known asAlso known as Billing methodBilling method  Requires sensing and observing the cervical mucusRequires sensing and observing the cervical mucus changes over timechanges over time  Oestrogen induced changes at mid cycle: Increase inOestrogen induced changes at mid cycle: Increase in amount of clear, thin and stringy mucusamount of clear, thin and stringy mucus  With ovulation and in the presence of progesterone,With ovulation and in the presence of progesterone, mucus becomes opaque, sticky and much less stretchymucus becomes opaque, sticky and much less stretchy or disappear all togetheror disappear all together  The of ovulation correspond closely to the day of peakThe of ovulation correspond closely to the day of peak mucusmucus  Intercourse is permitted on theIntercourse is permitted on the 44thth day after the last dayday after the last day of sticky, wet mucusof sticky, wet mucus
  • 5.Sympto-thermal method5.Sympto-thermal method  Basal body temperatureBasal body temperature  It is recorded before getting out of bed (early in the morning)It is recorded before getting out of bed (early in the morning)  Progesterone secretion is associated with a rise in basal bodyProgesterone secretion is associated with a rise in basal body temperature of about 0.5temperature of about 0.5°C°C  Prior to ovulation the temp is usually below normal bodyPrior to ovulation the temp is usually below normal body temperaturetemperature  If practice alone, it requires abstinence until the night of 3If practice alone, it requires abstinence until the night of 3rdrd day ofday of a shift in temperaturea shift in temperature  Combining the basal body temperature with the mucusCombining the basal body temperature with the mucus methodmethod  abstinence begins when the mucus becomes sticky and moist.abstinence begins when the mucus becomes sticky and moist.  Intercourse resumes the night of either the 3Intercourse resumes the night of either the 3rdrd day of a temp shiftday of a temp shift or the 4or the 4thth day after the last day of sticky, wet mucus which ever isday after the last day of sticky, wet mucus which ever is laterlater
  • CONTRACEPTIVECONTRACEPTIVE VACCINESVACCINES  Research on vaccines has focused on threeResearch on vaccines has focused on three targets:targets: 1.1. human chorionic gonadotropin (hCG),human chorionic gonadotropin (hCG), 2.2. the sperm-binding glycoprotein in the zonathe sperm-binding glycoprotein in the zona pellucida of the egg, andpellucida of the egg, and 3.3. sperm.sperm.  Research on vaccines has been ongoing forResearch on vaccines has been ongoing for decades; many problems must be overcome,decades; many problems must be overcome, including inducing autoantibodies.including inducing autoantibodies.
  • Current status of FRV (fertilityCurrent status of FRV (fertility regulating vaccinesregulating vaccines )) developmentdevelopment  Anti-sperm vaccinesAnti-sperm vaccines Sperm enzymes.Sperm enzymes. Sperm membrane antigens.Sperm membrane antigens.  Anti-ovum vaccinesAnti-ovum vaccines  Anti-conceptus vaccinesAnti-conceptus vaccines Structural placental antigens.Structural placental antigens. Hormonal placental antigens.Hormonal placental antigens.
  • Mechanism of action,Mechanism of action, reversibility and choicereversibility and choice  FRVs could act by preventing spermFRVs could act by preventing sperm production, by interfering with ovulation,production, by interfering with ovulation, by inhibiting fertilization, or by preventingby inhibiting fertilization, or by preventing implantation of the blastocyst. It isimplantation of the blastocyst. It is important that studies are carried out toimportant that studies are carried out to clearly determine how each FRV works.clearly determine how each FRV works. By understanding their mechanisms ofBy understanding their mechanisms of action, more efficient and predictableaction, more efficient and predictable FRVs can be prepared and rationalFRVs can be prepared and rational intervention strategies can be developedintervention strategies can be developed to reverse the effects of the FRVs onto reverse the effects of the FRVs on demand.demand.
  • Mechanism of action,Mechanism of action, reversibility and choicereversibility and choice  In addition, the user would be able to beIn addition, the user would be able to be fully informed of the known or suspectedfully informed of the known or suspected mechanisms of action of FRVs so that hemechanisms of action of FRVs so that he or she can choose a FRV that isor she can choose a FRV that is compatible with their personal beliefs andcompatible with their personal beliefs and needs.needs.
  • Future prospects and needsFuture prospects and needs  Vaccine optimizationVaccine optimization  Long-term safetyLong-term safety
  • Contraceptive Methods and Cancer RiskContraceptive Methods and Cancer Risk Method Breast Cancer Cervical Cancer Endometrial Cancer Ovarian Cancer Oral contraceptive ?    Vaginal ring NA NA NA NA Contraceptive patch NA NA NA NA Condom —  — — Diaphragm —  — — Injectable contraceptive — —  — Intrauterine device —   — Abstinence —  — — Fertility awareness — — — — Sterilization —    NA= research has not been conducted on the cancer–related risk of this method
  • Failures of contraceptionFailures of contraception METHOD OF CONTRACEPTION FAILURE RATE PER 100 WOMAN YEARS Combined oral contraceptive pills 0.1-1 Progestogen-only pills 1-3 Depo-Provera® 0.1-2 Implanon® 0.1 Copper IUD 1-2 Mirena® 0.5 Male condom 2-5 Diaphragm 1-15 Natural family planning 2-3 Vasectomy 0.02 Female sterilization 0.13
  • ConclusionConclusion • Any method of family planning is better than no method, though some methods are better than others.
  • Thank you for yourThank you for your attentionattention