Contraception types and methods

2. SUPERVISED BY;
PROF. MADYA DR. NANI DRAMAN

3. INTRODUCTION
Contraception defined as the intentional prevention of conception through the use of
various devices, sexual practices, chemicals, drugs, or surgical procedures.
Jain R, Muralidhar S. Contraceptive methods: needs, options and utilization. J Obstet Gynaecol India. 2011;61(6):626–634. doi:10.1007/s13224-011-0107-7

4. CONTRACEPTIVE METHODS & ITS EFFECTIVENESSS
*Sterilisation method – 99%

5. EFFECTIVENESS OF CONTRACEPTIVES

7. MEDICAL ELIGIBILITY

10. WHEN TO USE CONTRACEPTIVES?

12. Hormonal (Tablet)
• Non pregnant women-
Anytime, preferably
within the first 7 days
• After abortion- start
immediately
• After delivery-
• If non lactating- start
three weeks after
delivery
• If lactating- start 6
weeks after delivery
or earlier if stopped
lactating or if milk
substitute is given.
Injection Hormonal
• Start within 7 days of
menses
• Start immediately after
abortion
• After delivery
• If non lactating-
immediately after
delivery
• If lactating- 6 weeks
after delivery
Intrauterine device
• During menses
• Immediately after
abortion
• 6-8 weeks after
delivery before starting
on sexual activity
Sterilisation
• Female sterilization
(Tubal ligation)
• Immediately after
delivery or
• 6 weeks after delivery
or
• During caesarean
section or
• Anytime
• Male sterilization
(Vasectomy)
• Anytime
When to start contraception (normal women) ?
*COC , POP start Day 5 of menses
IUD start Day 2 of menses – os is open
http://www.myhealth.gov.my/en/family-planning

14. IMPORTANCE OF CONTRACEPTION
Benefits of family planning / contraception
Promotion of family planning and ensuring access to preferred contraceptive methods for
women and couples is essential to securing the well-being and autonomy of women, while
supporting the health and development of communities. Importance of contraception as
follows;
1. Prevent pregnancy-related health risks in women
2. Reduce infant mortality
3. Prevent HIV/AIDS & STD
4. Empower people and enhancing education
5. Reduce adolescent pregnancies
6. Slowing population growth

15. WHAT TO
ADVICE?
How well it prevent pregnancy
How often you have to use it
How easy it is to use
It’s side effect
It’s cost
Protect from infection
Plan for future pregnancy

16. Prevalence of women on contraception in
Malaysia (any methods)

17. Prevalence of women on contraception in
Malaysia (modern methods)

18. Contraception methods in KK Ketereh
Jan-Dec 2019
Types Pills Depo-
provera
injection
IUD Implant Others Total
Number of
user
24 35 0 0 9 68

19. References
• Garis Panduan Perkhidmatan Prakehamilan di Penjagaan Kesihatan Primer BPKK 2019
• MOH Perinatal Care Manual 3rd Edition
• WHO Reproductive Health Indicators-Guidelines for their generation, interpretation and analysis
for global monitoring
• Medical Eligibility Criteria for Contraceptive Use (2015, 5th ed)
• Selected Practice Recommendations for Contraceptive Use (2016, 3rd ed)
• https://www.indexmundi.com/facts/malaysia/contraceptive-prevalence

20. EMERGENCY
CONTRACEPTION
S E L E C T E D P R A C T I C E R E C O M M E N D A T I O N S F O R C O N T R A C E P T I V E U S E
( 2 0 1 6 , 3 R D E D ) , W H O

21. INTRODUCTION
Emergency contraception (EC), or postcoital contraception, refers to methods of
contraception that can be used to prevent pregnancy in the first few days after
intercourse. It is also intended for emergency use following unprotected intercourse,
contraceptive failure or misuse (such as forgotten pills or torn condoms), rape or coerced
sex.
This section provides recommendations on four methods of EC:
• copper-bearing intrauterine device (Cu-IUD)
• 3 different types of emergency contraceptive pills (ECPs):
 ulipristal acetate ECPs (UPAECPs)
 levonorgestrel-only ECPs (LNG-ECPs)
 combined estrogen–progestogen ECPs (combined ECPs).

23. I t i s i m p o r t a n t t o n o t e t h a t t h e
e f f e c t i v e n e s s o f e a c h m e t h o d
v a r i e s a c c o r d i n g t o i n d i v i d u a l
c i r c u m s t a n c e s i n c l u d i n g ;
• the type of ECP chosen
• the day of the menstrual cycle
• length of time between
unprotected intercourse and
initiation of ECPs
• effectiveness of ECPs may be
reduced with additional acts of
unprotected intercourse in the
same cycle, use of other
medications (e.g. cytochrome P450
3A4 [CYP 3A4] enzyme inducers),
and higher body weight or body

24. (a) Levonorgestrel (LNG)
• Levonorgestrel can be taken as a single dose of
1.5 mg or two 0.75-mg doses taken at the same
time or 12 hours apart within 72 hours of
unprotected.
• The expected pregnancy rate of 4% decreases
to less than 2% after use of levonorgestrel.
• Levonorgestrel works by interfering with the
luteinizing hormone peak during the cycle.

25. (b) Ulipristal (UPA)
• Ulipristal is a progesterone receptor modulator
and the newest FDA-approved medication for
emergency contraception.
• The dosing is a single 30-mg tablet taken
within 120 hours of unprotected intercourse.
• Ulipristal works by binding to progesterone
receptors, and subsequently inhibiting or
delaying ovulation.

26. (c) Combined ECPs:
• Split dose – one dose of 100 μg of
ethinyl estradiol plus 0.50 mg of LNG,
followed by a second dose of 100 μg of
ethinyl estradiol plus 0.50 mg of LNG
12 hours later.

28. (c) Copper IUD
• A copper IUD may be placed up to seven
days after unprotected intercourse.
• Reduces the risk of pregnancy by more
than 99% if inserted within 120 hours after
intercourse (2–5).
• The copper IUD is non-hormonal and
continuously releases copper into the
uterine cavity. It prevents pregnancy by
interfering with fertilization and
preventing implantation.

30. OTHER METHODS
OF EMERGENCY
CONTRACEPTION
TO CONSIDER:
Progestogen-only injectable (POI)
contraceptive
• Progestogen-only pill (POP)
Combined oral contraceptive (COC)
• Combined injectable contraceptive (CIC)
• Standard Days Method (SDM)

31. PREVENTION & MANAGEMENT OF NAUSEA
AND VOMITING WHEN TAKING ECPS
• LNG-ECPs or UPA-ECPs are preferable to combined ECPs because they cause less nausea and
vomiting. Routine use of anti-emetics before taking ECPs is not recommended.
• Vomiting within 2 hours after taking a dose of pills (LNG-ECPs or combined ECPs), another ECP
dose should be taken as soon as possible. If taking combined ECPs, may want to use an anti-
emetic before taking the 2nd dose. If vomiting continues, a repeat ECP dose can be given
vaginally.
• If the woman vomits within 3 hours after taking a dose of UPA-ECP, take another dose as soon
as possible

32. RESUMPTION OR INITIATION OF REGULAR
CONTRACEPTION AFTER USING EC
• After using a copper-bearing IUD (Cu-IUD) for EC, no additional contraceptive protection is
needed if she has a Cu-IUD inserted.
• Following administration of LNG-ECPs or combined ECPs, she may resume her contraceptive
method, or start any contraceptive method immediately, including a Cu-IUD.
• Following administration of UPA-ECPs, the woman may resume or start any progestogen-
containing method (either combined hormonal contraceptives or progestogen-only
contraceptives) on the 6th day after taking UPA. LNG-IUD can be inserted immediately if it can
be determined that she is not pregnant. Cu-IUD can be inserted immediately.

33. By : Muhammad Danial Fitri bin Ronzi ( 132825 )

35. Mechanism of action
• Prevent ovulation
- By prevention of ovarian follicular maturation
- By interrupt the oestrogen-mediated positive feedback on hypothalamic-pituitary
axis thus preventing LH surge
• Prevent sperm transport to the fallopian tube
- By thickening of mucus in the cervix
• Prevent implantation of embryo to the uterine wall
- By introducing intrauterine contraception

36. The WHO Medical eligibility
criteria for contraceptive use
(MEC) is a guidance document
that contains recommendations
for whether or not women with
given medical conditions are
eligible to use a particular
contraceptive method

37. Combined hormonal contraceptions
• CHC methods contain two hormones: an oestrogen and a progestogen. They are
available as oral pills, a transdermal patch and as a vaginal ring

38. Role of hormones in COC
Role of estrogen
• Enhances cycle control through
stabilizing the endometrium
• Inhibits FSH secretion : inhibition
of follicular development
• Enhances the ovulation
suppressing effect of progestins
Role of progestogen
• Inhibits midcycle LH surge :
prevents ovulation
• Thickens cervical mucus : impedes
sperm
COCs work by inhibiting ovulation !!

39. 1) Pills
• The recommendations on COCs in the guidlines refer to low-dose COCs
containing ≤ 35 µg ethinyl estradiol, combined with a progestogen.
• The progestogen available and most commonly used are second-
generation (levonorgestrel, norethisterone)
• Preparations :
- 21 pills followed by a 7-day pill-free interval (or 7 placebo tablets in place
of a 7-day pill-free interval)
- Some preparations contain 24 days of pills with a shorter pill-free interval
• Although traditional 21 days on and 7 days off usually results in a
withdrawal bleed during the pill-free interval, there is no reason why
women cannot take the pill continuously.

42. How effective?
• Effectiveness depends on the user:
- Risk of pregnancy is greatest when a woman starts a new pill pack
3 or more days late
- or misses 3 or more pills near the beginning or end of a pill pack.
• When no pill-taking mistakes are made, less than 1 pregnancy per
100 women using COCs over the first year (3 per 1,000 women).
• Return of fertility after COCs are stopped: No delay
• Protection against sexually transmitted infections (STIs): None

43. Explain how to use
?

44. Initiation of CHC

45. Initiation of COC,patch and ring
Having menstrual
cycles
- Within 5 days after the start of menstrual bleeding: COCs, the patch and
the CVR can be initiated
- More than 5 days since the start of menstrual bleeding: COCs, the patch
and the CVR can be initiated , abstain from sex or use additional
contraceptive protection for the next 7 days
Amenorrhoeic - COCs, the patch and the CVR can be initiated at any time, abstain from sex
or use additional contraceptive protection for the next 7 days
Postpartum
(breastfeeding )
- < 6 weeks postpartum, should not use COCs, the patch or the CVR
- > 6 weeks to < 6 months, use of COCs, the patch or the CVR is
generally not recommended
- > 6 months postpartum and amenorrhoic, COCs, the patch and the
CVR can be initiated as advised for other amenorrhoeic women.
- > 6 months postpartum and menstrual cyles returned, COCs, the
patch and the CVR can be initiated as advised for other women having
menstrual cycles.
Postpartum (non-
breastfeeding )
- < 21 days Use of COCs, the patch or the CVR is generally not
recommended
- > 21 days h no other risk factors for venous thromboembolism,
COCs, the patch and the CVR can generally be initiated

46. Managing missed pills
Key Message - Take a missed hormonal pill as soon as possible. Keep taking pills as
usual, one each day. (She may take 2 pills at the same time or on the
same day.)
Missed 1 or 2 pills? Started new pack
1 or 2 days late?
- Take a hormonal pill as soon as possible.
- Little or no risk of pregnancy.
Missed pills 3 or more days in a row
in the first or second week? Started
new pack 3 or more days late ?
- Take a hormonal pill as soon as possible.
- Use a backup method for the next 7 days.
- Also, if she had sex in the past 5 days, she can consider ECPs
Missed 3 or more pills in the third
week?
- Take a hormonal pill as soon as possible.
- Finish all hormonal pills in the pack. Throw away the 7 nonhormonal
pills in a 28-pill pack.
- Start a new pack the next day.
- Use a backup method for the next 7 days.
- Also, if she had sex in the past 5 days, she can consider ECPs

49. Combined hormonal patch
• The combined hormonal transdermal patch releases 33.9 μg
ethinyloestradiol/day and norelgestromin 203 μg/day. Also called Ortho Evra and
Evra
• Mechanism of action : same as COCP
• The woman puts on a new patch every week for 3 weeks, then no patch for the
fourth week. During this fourth week the woman will have monthly bleeding.
• It is applied to the skin of the lower abdomen, buttock or arm for 7 days, although
it can be applied to any skin covered area, except the breast
• The regimen usually involves application of patches for a total of 21 days
followed by a 7-day hormone-free interval

50. Combined vaginal ring
• The combined hormonal ring is a flexible ring of 54 mm diameter that releases 15 μg
ethinyloestradiol and 120 μg etonorgestrel daily also known as NuvaRing
• Mechanism of action : same as COCP
• She leaves the ring in place for 3 weeks, then removes it for the fourth week. During this fourth
week the woman will have monthly bleeding.
• The ring is self inserted and worn in the vagina for 21 days, followed by a 7-day hormone-free
interval
• Women should not feel discomfort from the ring and it can be removed for a short time (less
than 3 hours) and can be cleaned and replaced.

51. Progestogen-only contraceptives
• Progestogen-only contraceptives (POCs) include progestogen-only implants, progestogen-
only injectable contraceptives (POIs) and progestogen-only pills (POPs)
• POCs do not protect against sexually transmitted infections (STIs), including HIV. If there
is a risk of STI/HIV, the correct and consistent use of condoms is recommended

52. CONTRAINDICATION
MEC 4 :
-Active breast cancer within the past 5 years
MEC 3 :
-SLE
-Unexplained vaginal bleeding
-IHD or stroke
-Severe cirrhosis or hepatocellular carcinoma.
- On liver enzyme-inducing drugs

53. Progestogen-only pills
• Medium-dose pills (e.g. containing desogestrel) inhibit ovulation in 99% of
cycles, lower-dose pills inhibit ovulation in less than onehalf of cycles,
relying on the cervical mucus effect for contraception
Peripheral effect:
● make the endometrium atrophic
↓
Prevent implantation
● alter cervical mucus to prevent sperm ascending into the uterine cavity

55. Initiation of POI
Having menstrual cycles - Within 5 days after the start of menstrual bleeding: POPs can be
initiated
- More than 5 days since the start of menstrual bleeding: POPs can
be initiated , will need to abstain from sex or use additional
contraceptive protection for the next 2 days.
Amenorrhoeic - POPs can be initiated at any time , she will need to abstain from sex
or use additional contraceptive protection for the next 2 days.
Postpartum (breastfeeding) - < 6 weeks , POPs can generally be initiated
- > 6 weeks and < 6 months, : POPs can be initiated
- > 6 months postpartum and having menses, POPs can be
initiated as advised for other women having menstrual cycles
Postpartum - < 21 days, POPs can be initiated.
- 21 days or more and menstrual cycles have not returned,
POPs can be initiated, will need to abstain from sex or use
additional contraceptive protection for the next 2 days
- Menstrual cycles have returned: POPs can be initiated as
advised for other women having menstrual cycles

56. Explain how to use

57. Managing missed pills
Key message - Take a missed pill as soon as possible.
- Keep taking pills as usual, one each day. (She may take 2 pills at the same
time or on the same day.)
Do you have monthly bleeding
regularly?
- If yes, she also should use a backup method for the next 2 days.
- Also, if she had sex in the past 5 days, she can consider taking ECPs
Severe vomiting or diarrhea - If she vomits within 2 hours after taking a pill, she should take another pill
from her pack as soon as possible, and keep taking pills as usual.

59. Progestin-Only Injectables
• The most commonly used injectable worldwide is a depot injection of medroxyprogesterone acetate (
DMPA )
• Work primarily by preventing the release of eggs from the ovaries (ovulation).
• Can be administered intramuscularly (buttock, upper arm, lower abdomen) as the formulation
Depoprovera® (150 mg), subcutaneously as the micronized lower-dose formulation of Sayana
press®(104 mg )
• The injectable is the only hormonal method that may delay return of fertility after discontinuation, in
some cases it may take up to 1 year after the last injection for ovulation to return.

60. How effective ?
• Effectiveness depends on getting injections regularly: Risk of pregnancy is
greatest when a woman misses an injection
• When women have injections on time, less than 1 pregnancy per 100
women using progestin-only injectables over the first year (2 per 1,000
women).
• Return of fertility after injections are stopped : Delayed
- An average of about 4 months longer for DMPA
- 1 month longer for NET-EN than with most other methods
• Protection against sexually transmitted infections (STIs): None

62. Progestogen-only Implants
• Small plastic rods, each about the size of a matchstick, that release a
progestin like the natural hormone progesterone in a woman’s body
• Do not contain estrogen, and so can be used throughout breastfeeding
and by women who cannot use methods with estrogen.
• Types of implants:
− Jadelle: 2 rods containing levonorgestrel, highly effective for 5 years
− Implanon NXT (Nexplanon): 1 rod containing etonogestrel, labeled for up
to 3 years of use
− Levoplant (Sino-Implant (II)), 2 rods containing levonorgestrel. Labeled for
up to 4 years of use.
• Work primarily by:
– Preventing the release of eggs from the ovaries (ovulation)
– Thickening cervical mucus (this blocks sperm from reaching an egg)

64. How Effective?
• One of the most effective and long-lasting methods
• A small risk of pregnancy remains beyond the first year of use and continues as long as
the woman is using implants.
• For heavier women, the effectiveness of Jadelle and Levoplant may decrease near the
end of the duration of use stated on the label. These users may want to replace their
implants sooner
• Return of fertility after implants are removed: No delay
• Protection against sexually transmitted infections (STIs): None

66. “Come Back Any Time”
• Reasons to Return
- Assure every client that she is welcome to come back any time
- for example, if she has problems, questions, or wants another method;
she has a major change in health status; or she thinks she might be
pregnant.
- Also if she has pain, heat, pus, or redness at the insertion site that
becomes worse or does not go away, or she sees a rod coming out.
- She wants the implants taken out, for whatever reason. It is time for the
implants to be removed and, if she wishes, for new implants to be put in.

67. Levonorgestrel Intrauterine Device
- The 52 mg LNG-IUS (Mirena®) is licensed for 5 years for contraceptive use (but if
inserted in women 45 years or older, may be used for contraception until the
menopause ), the 13.5 mg LNG IUS (known as Jaydess® in the USA) is licensed for 3
years for contraceptive use
• MOA :
- releases a progestin hormone (levonorgestrel) into uterus
- thickening of the cervical mucus
- inhibits sperm from reaching or fertilizing the egg
- thins the uterine lining
- prevent the ovaries from releasing eggs

69. How Effective?
- One of the most effective and long-lasting methods
- A small risk of pregnancy remains beyond the first year of use and continues as
long as the woman is using the LNG-IUD.
- Mirena and Kyleena are approved for up to 5 years of use. Research suggests that
Mirena may remain highly effective for up to 7 years.
- Return of fertility after LNG-IUD is removed: No delay
- Protection against sexually transmitted infections (STIs): None
Absolute contraindications :
- active PID
- undiagnosed abnormal genital tract bleeding
- current or past history of breast cancer

70. Before starting an IUD
• Healthcare provider should do pelvic examination prior insertion of IUD
• When performing the pelvic examination (both bimanual and speculum), asking yourself the
questions below helps you check for signs of conditions that would rule out IUD insertion.

71. STI assessment
• A woman who has gonorrhea or chlamydia now should not have an IUD inserted.
• Having these sexually transmitted infections (STIs) at the time of insertion may
increase the risk of pelvic inflammatory disease
• . Without clinical signs or symptoms and without laboratory testing, the only
indication that a woman might already have an STI is whether her behavior or her
situation places her at very high individual risk of infection.
• If this risk for the individual client is very high, she generally should not have an
IUD inserted

72. Benefits
• Hormonal contraceptives may be used for their beneficial side-effects
Method Benefits against
LNG-IUS (52 mg) - Heavy menstrual bleeding
- Endometriosis
- Adenomyosis
- Dysmenorrhoea
- Endometrial protection
- Simple hyperplasia
Combined hormonal
contraception
- Heavy menstrual bleeding
- Irregular menses
- Hirsutism
- Acne
- Premenstrual syndrome
- Reduces risk of ovarian cancer
- Reduces risk of endometrial
cancer
Progestogen-only injectable
(depot medroxyprogesterone
acetate)
- Heavy menstrual bleeding
- Endometriosis
- Dysmenorrhoea

74. References
• Family Planning-A Global Handbook for Providers ( 2018 )
• WHO Medical Eligibility for Contraceptive Use ( 2015, 5th ed )

75. By: Low Yi Huey

76. BARRIER METHOD

77. Condom
• If used correctly, male condoms are very effective contraceptives with an
efficacy of 98 %.
• Condom-Sheath-shaped barrier device.
• Used during sexual intercourse to reduce the probability of pregnancy and
sexually transmitted infection, including HIV.
• 15-20% of failure rate.
Reason for failure
• Condom put on after genitals contact
• Incomplete unrolled into penis
• Condom slippage
• Condom leakage
Side effect:
-None

78. MALE CONDOM FEMALE CONDOM
Made up Latex or rubber sheath that covers the penis and
collects semen
Plastic (polyurethane) sheath with flexible rings at
each end, inserted into the vagina
How it works Prevents sperm from entering the vagina as it
cover the penis
Functions as a cover in the vaginal canal
Pros • Cheap, easy to use, and can prevent unplanned
pregnancy
• Protect against STD
• Easily to obtain
• does not require medical personnel to prescribe
• Protect against STD, helps to keep infections in
semen, on the penis, or in the vagina from
infecting the other partner.
• Easy to use
Cons • To be effective, it must be applied on erected
penis before penetration happens
• Condom may slip during withdrawal
• Can tear and broke
• May cause discomfort and irritation
• Needs practice to insert it correctly
• The outside ring may slip into the vagina during
intercourse
• May cause discomfort and vaginal irritation
• Not easily available and expensive

79. How to use male condom ?
Use a new condom
for each time
Check the condom
package. (torn or
damage)
Avoid use condom
past the expiration
date.
Place condom on
tip of penis with
rolled rim facing
away from body.
For the most
protection, put
the condom on
before any
genital, oral or
anal contact.
Unroll
condom all
the way to
base of the
penis
Immediately
after
ejaculation,
hold the rim of
the condom in
place and
withdraw the
penis while it is
still erect.
Throw
away
used
condom
properly.

80. How to use female condom ?
1. Use a new female condom for each act of sex.
2. Before any physical contact, insert the condom into the
vagina.
3. Ensure that the penis enters the condom and stays inside
the condom.
4. After the man withdraws his penis, hold the outer ring of
the condom, twist to seal in fluids, and gently pull it out of
the vagina.
5. Dispose of the used condom safely.
About 2-3cm of the
condom and the outer
ring remain outside
the vagina.

81. Spermicide
• Sperm-killing substances inserted deep in the vagina, near the cervix,
before sex. (Nonoxynol-9 is most widely used.)
• Available in:- foaming tablets, cans of pressurized foam, melting film,
jelly, and cream.
MOA: Kill sperm or make sperm unable to move towards the egg.
*Foam or cream: Any time less than one hour before sex.
*Tablets, jellies, film: Btw 10 mins and 1 hr before sex.
• Simple to use but not as effective in preventing pregnancy
• Act as adjunct and provides protection against some STD (except HIV)
• 28% failure rate
Side effect: Irritation in or around the vagina or penis
• Do not wash the vagina
(douche) after sex
• Douching
• will wash away the
spermicide.
• increase the risk of sexually
transmitted infections.
• wait for at least 6 hrs after sex.
Insert the applicator deep into the vagina, near
the cervix, and push the plunger.

82. Diaphragm & Cervical Cap
Diaphragm
- A soft latex cup with a flexible ring that fit over the
cervix.
(Plastic and silicone diaphragms may also be available.)
* used with spermicide cream, jelly or foam to
improve effectiveness
* failure rate- 16%
Function : blocking sperm from entering the cervix.
- May help protect certain STI- exp: chlamydia, gonorrhea
, but high risk in HIV.
Side effect: irritation in or around the vagina or penis.
1. Squeeze a
spoonful of
spermicidal
cream, jelly, or
foam into the
diaphragm and
around the rim
2. Press the rim
together; push
into the vagina
as far as it goes
-Insert the
diaphragm less
than 6 hours
before having
sex.
3. To remove, slide a
finger under the rim of the
diaphragm and pull it
down and out

83. Cervical Cap
- A soft, deep, latex or plastic rubber cup that snugly covers the cervix.
- non allergic silicone cap
- designed to conform the natural shape of cervix
* failure rate- 8-20%
Side effect: same as diaphragm.

84. INTRAUTERINE
DEVICE (IUD)

85. • IUDs are placed by a health care provider through the vagina and cervix into uterus.
There are 2 types of devices :-
Copper-containing IUD
(Copper T-380)
Levonorgestrel-releasing
IUD
(Mirena)

86. 1) Copper IUD
• Chemical change- damage sperm and eggs
before they meet.
• Long term pregnancy protection- Duration of
use is between 3-10 years, depends on the
device used and age
*40 yrs and above- can be left in-situ till menopause
Side Effect
• heavier menstrual period or more cramps
during their period, irregular menses.
(common)
• Lower failure rates ( One of the most effective and
long-lasting methods)
MODE OF ACTION

87. Complications
Rare:
• Perforation of the wall of
uterus; rare but happens -
inexperienced clinician,
breastfeeding, being less than
6 months of post-partum.
• Miscarriage, preterm birth in
the rare case that the woman
becomes pregnant with the
IUD in place.
• Infection - 3 weeks of insertion;
removed and oral penicillin will
be given.
Who should not have an IUD inserted?
Condition:
• Between 48 hours and 4 weeks since giving birth
• Noncancerous (benign) gestational trophoblast
disease
• Current ovarian cancer
• Is at very high individual risk for STIs at the time of
insertion
• Has severe or advanced HIV clinical disease
• Has systemic lupus erythematosus with severe
thrombocytopenia

88. How to insert ?
• Done by specifically trained provider.
• Pelvic examination will be conducted
before insertion. (to determine the
position of uterus and assess
eligibility)
• Can be inserted :
• During menses - immediately
effective
• Immediately after abortion
• 6-8 weeks after delivery before
starting on sexual activity
• For emergency contraception
(within 5 days after unprotected
sex)
https://www.youtube.com/watch?v=X3Ge3FCEfww

89. Contraception
Natural / Behavioural Method
Sterilization
Leow Tan Chun Khai (132811)

90. Fertility Awareness Method
• Mode of action: Avoid intercourse during calculated fertile period
• Life span of
• Sperm: up to 5 days in fertile mucus
• Ovum: less than 24 hours
• Calendar-based method
• Symptom-based method
• Basal body temperature method
• Billings ovulation method
Ref: N Engl J Med 1995; 333:1517-1521

91. Calendar-based Method
• Involves keeping track of days of the menstrual cycle to identify the
start and end of the fertile time.
• Steps:
• Records the number of days in each menstrual cycle for at least 6 months.
• Fertile time = (shortest recorded cycle – 18) until (longest recorded cycle – 11)
• Avoid unprotected sex during fertile time
• Update calculations monthly using the 6 most recent cycles

92. Symptom-based Method
• Basal body temperature method
• Monitor temperature daily at the same time
• Temperature rises about 0.2-0.5℃ just after ovulation.
• Avoid sex or use another method from 1st day of menstrual cycle until 3 days
after the temperature rise
Avoid unprotected sex

93. Symptom-based Method (Cont.)
• Ovulation method
• Check cervical secretions daily
• Avoid unprotected sex on days of heavy monthly bleeding
• Resume unprotected sex until secretion begin
• Avoid unprotected sex when secretions begin and until 4 days after “peak
day”

95. • Effectiveness: Depends on the user. As commonly used, in the first year
about 15 pregnancies per 100 women using periodic abstinence.
• Advantages:
• Free
• No side effect
• Can be used to identify fertile days by both women who want to become pregnant
and women who want to avoid pregnancy
• Disadvantages:
• Not very effective
• Requires willingness to abstain during fertile period
• Needs motivation & record keeping
• Affected by other factors: menses irregularities, fever, vaginal infection, drugs

96. Withdrawal
• Just before ejaculation, the man withdraws his penis from his
partner’s vagina and ejaculates outside the vagina, keeping his semen
away from her external genitalia.
• Least effective. As commonly used, about 20 pregnancies per 100
women whose partners use withdrawal over the first year.

97. Lactational Amenorrhea Method
• Provides contraception for the mother and best feeding for the baby.
• Mode of action: Inhibition of ovulation
• Can be effective for up to 6 months after childbirth
• Effectiveness: As commonly used, about 2 pregnancies per 100
women using LAM in the first 6 months after childbirth

98. Female Sterilization
• Permanent surgical contraception (tubal ligation)
• Via mini-laparotomy or laparoscopy / hysteroscopic approach
• Effectiveness: Less than 1 pregnancy per 100 women over the first
year after having the sterilization procedure (5 per 1,000).

99. • Advantages:
• No side-effects
• Does not interfere with coital act or breast-feeding
• Permanent contraception
• Disadvantages:
• Irreversible (success of reversal of sterilization varies)
• Surgical procedure (pain, bleeding, anaesthesia risk)
• Small risk of failure (0.1-0.4%)
• May regret later in life

100. Male Sterilization
• Permanent contraception (vasectomy)
• Sperms are absent in the ejaculated semen.
• 3-month delay in taking effect
• Effectiveness: 1 in every 100 will become pregnant in the first year of
use of the method. (2 in 1,000).
No-scalpel vasectomy