contraceptive methods part two for MBBS UG students including information on Oral contraceptives, injectable contraceptives, Natural methods and terminal methods-tubectomy/vasectomy

1. Contraceptive
methods-II
Dr Mamta Gehlawat
MBBS MD PGDHHM PGDG
Asst Prof Comm Med
GMC SDPT

2. Hormonal Contraceptives
• Very effective spacing method
• Almost 100% effective

3. Gonadal steroids
1. Synthetic estrogen = Ethinyl-estradiol
2. Synthetic progesterone
i. Pregnanes= MPA (? Breast tumors)
ii. Oestrones= Norethisterone
iii. Gonanes = Levonorgesterol

4. Hormonal contraceptives
Oral pills
Combined
pill
Progestogen
only pill
Post
coital pill
Once a
month
pill
Male
pill
Depot/slow release
formulations
Injectables
Subcut.
implants
Vaginal
rings

5. Combined pill

8. Progestogen only pill (POP) = mini pill
• Only progestogen- small doses
• Useful in women where
combined pills are C/I

9. MOA of the oral pills
• Prevent release of ovum from ovary
• By blocking gonadotropin from pituitary gland
Drug interactions with-Rifampicin, phenobarbital, ampicillin
POP pills-
• Thickens cervical mucus- inhibit sperm motility
• Also inhibit tubal motility- delay sperm and ovum transport

10. Adverse effects
Others:
Liver Disorders
Affect lactation
Delayed fertility
Birth defects
S/E affecting daily life:
Breast tenderness
Weight gain
Headache/Migraine
Bleeding disturbances
Cardiovascular effects:
MI, CVA, DVT
CA Cervix
Metabolic effects:
Hypertension,
Hyperlipidemia,
Hyperglycemia

11. Benefits
• Protection against:
1. Benign breast disorders
2. Ovarian cysts
3. Iron deficiency anemia
4. Pelvic Inflammatory disease
5. Ectopic pregnancy
6. Ovarian Cancer

12. • Absolute
1. CA breast/genitals
2. Liver disease
3. H/o thromboembolism
4. Cardiac abnormalities
5. Congenital hyperlipidemia
6. Abnormal uterine bleeding
• Relative
1. Age>40
2. Age>35 and smoker
3. Hypertension
4. CKD
5. Epilepsy
6. Migraine
7. Lactation
8. DM
9. Gall bladder disease
10. Amennorhea/irregular bleeding

13. Use
• Younger women
• For spacing
• >35 years not recommended
• >40 years---- high risk of cardiovascular complications
• Annual checkup advised- to identify contraindications

14. Post-coital contraception/Morning after pill
• Within 72 hours of unprotected intercourse
• An emergency method
IUD- Cu-T within
5 days
Levonorgesterol
1*0.75mg-
1*0.75mg
Ethinyl estradiol
2*50mcg-
2*50mcg
Ethiny estradiol
4*30mcg-
4*30mcg
Mifepristone
1*10mg

16. Once-a-month (long-acting) pill
• Quinestrol
• Long acting estrogen with short acting
progestogen
• Unsuccessful

17. Chhaya

18. Male pill
Research on-
• Preventing spermatogenesis
• Interfering with sperm
storage and maturation
• Preventing sperm transport in
vas differens
• Affecting constituents of
seminal fluid
Ideal male pill
• Decrease sperm count
• Not affect testosterone
• Not affect libido/potency

20. Gossypol
• Produces azoospermia/severe oligospermia
• 10% men permanently azoospermic in 6 months
• Possible toxic s/e
• Animal studies not convincing

21. Depot preparations
1.Injectable contraceptives
a.Progesterone only
• DMPA
• NET-EN
• DMPA-SC
b.Combined injectable contraceptives
2.Subdermal implants
3.Vaginal rings

22. DMPA=Depo Provera
• 150mg im 3 mthly
• Suppresses ovulation,
tubal motility, increase
cervical mucus
• 200mg im 2mthly
• Inhibits ovulation, increase
cervical mucus
NET-EN
• 104mg sc 3mthly
• In upper thigh/abdomen
DMPA-SC = depo subQ provera 104

23. Progestin only injectables
• S/E- wt increase, irregular menstruation, delayed fertility
• Use- multipara >35 yrs with completed family
• Contra-indications-
Same as OC pills
Combined Injectable contraceptives- Cyclofem/Cycloprovera/Mesigyna
• Given monthly
• Mainly suppresses ovulation
• S/E and use same as OC combined pills

24. Antara

25. Sub-dermal implants
• Norplant------------ 6 silicone rubber capsules with LNG
• Norplant R 2 -----------------------------2 small rods of LNG
• Implanted beneath skin of forearm/arm
• 5 years contraception duration
• Disadvantage- irregular bleeding; surgical procedure needed
Vaginal rings
• Levonorgesterol ring
• Worn in vagina for 3 weeks every cycle

26. Other/Misc.
methods of
Family Planning

27. A.Abstinence
• Repression of natural desire----possible mental health issues

28. B.Coitus interruptus
• Male withdraws his penis before ejaculation
Drawback- 25% failure rate
• Precoital secretion may contain sperm
• Mistake in withdrawal timing may lead to
insemination
• Depends on couple’s preference

29. C. Safe Period/ Rhythm method/ Calender
method
• Based on fact that ovulation occurs
from day 12 to 16 before
menstruation
• Shortest cycle minus 18 days = first
day of fertile period
• Longest cycle minus 10 days = last
day of fertile period

30. • Simple advice
-To avoid intercourse
between day 8 to 22
of cycle.
Drawbacks-
• No ideal cycle
• High motivation
• Programmed sex
• n/a in postnatal
period
• High failure rate
S/effects-
• Ectopic
pregnancy/fetal
anomaly

31. D. Natural methods= discipline + understanding

32. 1.Basal body temperature method (BBT)
• Increase in BBT of 0.5 degree at ovulation- early morning check
• Need for abstinence in entire pre-ovulatory period

33. 2. Cervical Mucus / Billings/Ovulation method
• Keeping track of cervical mucus consistency throughout the cycle
• Needs high motivation – inside vagina by tissue wipe

34. 3. Symptothermic method
• Combination of calender +
cervical mucus + temperature
methods
• Gives chance to double check
the interpretation

35. E. Breastfeeding
• Lactational Amenorrhea
• Not very reliable
F. Birth control vaccine
• In research phase
• One concept- vaccine from beta unit of hCG
• Effective for 6mth-1 year

36. Terminal methods/ Sterilization

37. Who can get sterilized?
• 2 living children
• Husband age between 25-50 yrs
• Wife age between 20-45 yrs
• Age limits may be relaxed if >3 living children
• Voluntarily and with consent of spouse
• Understanding of the irreversible procedure

38. Male sterilization/Vasectomy

39. Important points
• Not immediate sterility
• To use another methods upto 30 ejaculations
• Sperm production/testosterone/libido/potency not affected
• Simpler, faster, cheaper than tubectomy

40. Complications
• Post-operative- pain, hematoma, local infection, sperm granules
• Spontaneous recanalization- to check in yearly follow up
• Auto-immune response- may reduce sperm count
• Psychological- if not voluntary decision
• Failure-
Due to mis-identification of vas deferens/ anatomical variation

41. Post operative advice
• Minimum 30 ejaculations to achieve sterility- use contraceptive
• Avoid bathing 1 day
• Wear T bandage/support for 15 days, maintain hygiene
• Avoid cycling/lifting heavy weights for 15 days
• Stitches removal-5th day

42. NSV= No scalpel vasectomy

43. Female sterilization/Tubectomy

44. Laparoscopy
• Falope
rings/clips to
occlude the
tubes
• Only under
supervision of
OG specialist
• Quick
procedure,
short p.o.stay,
small scar

45. Patient selection Follow-up Complications
• Not for 6 week
postpartum
• Can be done with MTP
• Hb > 8 g/dl
• No h/o medical
disorders
• 48 hours post op stay
Home visit by health
worker
• b/w 7-10 days post op
• b/w 12-18 mths post
op
Uncommon but may be
serious requiring surgery
Eg. Puncture of large
blood vessels

46. Minilap/Pomeroy

47. Minilap operation/Pomeroy technique
• Modification of abdominal laparoscopy
• Simpler process
• Smaller abdominal incision 2.5-3cm under local anesthesia
• Suitable at PHC level/ mass campaigns
• Safe/efficient/easy
• Suitable for postpartum sterilization

48. Thank you for planning 