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  1. 1. Contraception Dr. Saumya Prasad M.S (ObGyn)
  2. 2. India was the first country in the world to have launched a National programme for Family Planning in 1952. “The ideal family – two parents, two children” The red triangle is India’s family planning symbol.
  3. 3. Need for contraception 21 % of all pregnancies resulting live births are unintended Around 2/5th of all pregnancies are unintended If unmet needs of contraception is met then we can avoid: 55 million unwanted pregnancies 22 million fewer abortions 90,000 fewer maternal deaths
  4. 4. Reasons of unintended pregnancies: Unawareness Use of traditional methods Side effects High cost Difficult mode of delivery Fear of irreversibility of fertility
  5. 5. 1. Safe 2. 100% effective 3. Free of side effects 4. Easily obtainable 5. Affordable 6. Acceptable to the user 7. Free of effects on future pregnancies Characteristics Of Ideal Contraceptive
  6. 6. Various Types Of Contraceptives
  7. 7. Options for contraception LARC methods Non- LARC methods Barrier Methods
  8. 8. TYPES OF MALE CONDOMS DRY PRE- LUBRICATED SPERMICIDAL Latex Polyurethane NIRODH LUBRICATED Dry condoms Free of cost by GOI Nirodh Kohinoor Nirodh lubricated Kamasutra Rakshak 9
  9. 9. Latex Condoms • Latex condoms are the most common type of condoms • The main advantages of latex condoms are that they can be stretched a lot before it breaks • That means it is good at preventing the semen from going through the condom Failure rate Typical use 12% Perfect use 3% 10
  10. 10. Polyurethane Condoms • Polyurethane condoms are also very common • These are very similar to latex condoms in size • They have a longer shelf life than latex condoms • They have less allergic reactions to them • Can be used with oil based lubricant • These condoms also prevent STI’s • Slip more, break more • More expensive 11
  11. 11. Male Condoms Advantages Disadvantages Readily available Can cause hypersensitization Suitable for all age group Difficult to dispose in villages Harmless method Prevention against STI RR= 0.1% If used in later half of pregnancy, reduces risk of amniotic fluid infection If used >5years, reduces risk to cervical intraepithelial dysplasia MEC Category 4 None Category 3 Latex allergy High risk pregnancy in c/o failures 12
  12. 12. Female Condoms • This type of contraceptive is put into the vagina before having sex • It has two ends with rings on them • The end that goes into the vagina has a closed rim • The end that stays outside has an open rim Failure rate Typical use 21% Perfect use 5% 13
  13. 13. Occlusive caps Are not sperm proof mechanical barriers Retain spermicide with cervical os Spermicide must be used Usually manifacured by rubber Vaginal diaphragm Cervical cap Vault cap Vinule cap 14
  14. 14. Vaginal Diaphragms • This is a dome shaped object that is also made of rubber. • It fits around the cervix, preventing the sperm from being able to enter the uterus • This is used with spermicide • Available in diff sizes, 60,65,70,75mm • 3 types- flat type, coil type, arching type Failure rate Typical use 16% Perfect use 6% 15
  15. 15. Cervical Caps • Rubber caps that are inserted into the vagina and fits around the uterus • This blocks the passage way for sperm to enter the uterus • This is used with spermicides. • 3-4 sizes available- 21 to 31 mm. • Ex- ortho cervical cap, miller cervical cap Failure rate Typical use Nulliparous-16% Parous- 32% Perfect use Nulliparous- 9% Parous-26% 16
  16. 16. Vault cap Rubber or plastic cap 50-75mm in size Replaced by diaphragm Ex- dumas Vinule cap Type of cervical cap Used in women with prolpse When diaphragm cannot be retained Ex- vinule pessary Disadvantages of occlusive caps Spermicide can cause irritation in the vagina If the cap is not removed well in time, vaginal discharge may present Allergic reaction due to silicone cap TSS is a rare complication 17
  17. 17. 18 MEC for occlusive caps Category 4 None Category 3 History of TSS Uterine or vaginal abnormalities High risk of HIV Allergy to latexi Inability of the user to insert Category2 FTVD within6-12 weeks Parous women Complicated valvular disease
  18. 18. Sponges • “Today” is most common • It is saturated with nonoxynol-9 • Nonoxynol- spermicide action • Blocks the cervix and absorption of semen • Acts for 24hrs • Can be removed after 8-24hrs but not before 6 hours • Major s/e – TSSS Failure rate Typical use 16% Perfect use 9% 19
  19. 19. Spermicide 20 Alter sperm surface membrane permeability Osmotic changes Killing of sperms Category 4 Clients with high risk of HIV Who are HIV positive Category 2 Who have high risk of pregnancy Sensitivity to a spermicide Cervical cancer MEC criteria for spermicide
  20. 20. Non- LARC Hormonal contraception Combined oral contraceptive COC Patch Ring Progesterone only pill
  21. 21. Type of progesterone Monophasic pills Triphasic pills Levonorgestrel Microgynon 30/ED Ovranette (30 EE) Eugynon (30 EE) Trinodial Logynon/ ED Norethisterone Ovysmen / Brevinor (35 EE) Norimin( 35) Loestrin 20/30 Trinovum Binovum Synphase Norgestimate Cilest (35 EE) Desogestrol Mercilon 20 Ee Marvelon 30 EE Gestogene Femodene (ED/ 30EE) Minulet (30 EE) Femodette(20 EE) Tri-Minulet Drospirenone Yasmin (30 EE) Types of combined oral contraceptive pills
  22. 22. Formulations Monophasic Biphasic Triphasic Each tablet contains a fixed amount of estrogen and progestin Each tablet contains a fixed amount of estrogen, while the amount of progestin increases in the second half of the cycle The amount of estrogen may be fixed or variable, while the amount of progestin increases in 3 equal phases
  23. 23. First generation Second generation 3rd generation 4th new generation 50mcg of ethinyl estradiol 30-35 mcg ethinyl estradiol with progestin such as levonorgestrel, norgestimate Mala N, Mala D 20-30 ethinyl estradiol with desogestrel or gestone Femilon, Loette 20-30 ethinyl esradiol with drospirenone dienogest or nomegestrol India: Yasmin Ethinul estradiol and drospirenone with weak anti minerocorticoid activity; helpful in PCOD Different generations of oral contraceptives
  24. 24. Progestin only Pill Each tablet contains one •0.075mg Levonorgestrel •0.030 Norgestrel •0.075 Desogestrel •0.035 Norethindrone •0.50 Ethynodiol diacetate Started after 6 weeks of delivery in lactating wome within first 5 days of the periods Safety margin 12 hours Failure rate 0.5-2/HWY
  25. 25. New Formulations Of Oral Contraceptive Continuous use of OCs Seasonale 0.15mg levonorgestrel + 30mcg EE Women take a pill every day for 84 days and 7 days hormone free pill week Seasonique LNG 0.15mg + EE 0.30mg 84/7 day tablet Femcon Fes EE 35mcg + Norethindrne 0.4mg Chewable spear mint flavoured tablet Centchroman 30mg centchroman Once a week OC One tablet twice weekly from the 1st day of menses for the first 3 months and then once a week
  26. 26. Contraceptive Patch 150 mcg of progestogen + 20 mcg EE Ortho Evra Each patch lasts for 1 week, hence 3 patch for each cycle followed by a week patch free interval Failure rate: 1/HWY • 5cm x 5cm • EE 20mcg/norelgestromin 150mcg • Cilest via the skin • Compliance • Avoids all absorption problems from GI disorders • Bulimia/purging/travellers/air crew • Constant hormone levels Not yet available in India
  27. 27. Long Acting Reversible Contraceptive Sub- dermal Implant Intra-uterine system Injectable contraception
  28. 28. HORMONAL IMPLANTS Norplant Consists of 6 capsules with 216mg of levonorgestrel with each capsule havig 36mg of LNG Rate of release of LNG is 85mcg per day during first 6 months, 50mcg per day for next 9 months and then 30 mcg there after Effective for 5 years Norplant-2 (Jadelle) 2 rods Each rod consists of 75 mg of the drug Rate of release is same Effective for 5 years Implanon/ Nexplanon 68mg of etonogestrel Initially the release is 60-70mcg per day which reduces to 25-30 mcg per day Effective for 3 years Capronor Biodegradable LNG for faster release of LNG For 1 year
  29. 29. Implant failures Over 50% linked with non-insertion 25% with liver enzyme inducers (mostly carbamazepine and none with lamotrigine) Overall 0.049 per 100 implants fitted  Method failure rate 0.01 per 100 implants  11.6% of all in-treatment pregnancies were ectopic
  30. 30. Classification based on the content of IUD Inert (non-medicated) Inserted by “push out technique” Lippe’s loop, saf T coil Bioactive (medicated ) Withdrawal technique Cu T 200, Multi Load 250, Cu T 380A, Cu T 300 A Hormone releasing IUDs Withdrawal technique Mirena, LNG IUS
  31. 31. Cu 380A Its has 380 Mm2 Release of Cu is abt 50mcg per day Multiload copper devices No plunger 250mm Release about 75mcg per day2 Levonorgestrel intrauterine system Contains 52mg LNG with a release of 20mch per day Low failure rate: 1- 3/1000 women Progestasert Contains 38mg progesterone that release 65mcg per day It is effective fro 1 year Other IUS are copper T 200C, Copper 7, Copper T 200 Intrauterine devices
  32. 32. Gynefix Frameless IUD Contain 6 bracelet of copper that are crimped on to a string and affixed to the fundal myometrium Contains 330mm2 of copper Higher expulsion rate
  33. 33. Injectable progestogen contraceptive Depot medroxy progesterone acetate (DMPA) Microcrystals suspended in an aq solution and given as 150mg intramuscular injection by the Z track technique every 3 months Given within the first 7 days of the current menstrual cycle Efficacy is equal to sterilization New formulation contain 30% less progestogen than DMPA and is given subcutaneously Norethindrone enanthate (NET- EN) Given in a dose of 200mg i.m every 2 months Same way
  34. 34. DMPA IN GOVT OF INDIA CONTRACEPTIVE BASKET Once every three months, women in the age group of 18-45 years will be given DMPA injections free of cost at all state-run primary health centres and hospitals. It will be administered by doctors and staff nurses at government hospitals nearly four times a year to women who want to delay or avoid pregnancies.
  35. 35. Nestragel Successful phase 2 trial Suppressed ovulation for 21 days Well tolerated No androgenic properties Applied in dose 2.3mg/day once for 21 days with 7 free days Transdermal contraceptive gel
  36. 36. Male contraceptive Gossypol It is an aldehyde derieved from seeds, stem and roots of cotton plant Inhibits spermatogenesis, decereases epididymal motility, decreases conversion of proacrosin to acrosin Administered 10-20mg daily for 3 months and then 20mg twice weekly
  37. 37. Quinacrine pellets Intratubal chemical methods Pellets have being inserted in the fallopian tubes transervically to result in permanent sterilization by producing scarring to block the fallopian tubesEssure system Transcervical method Cornual end of fallopian tube is occluded with a microinsert with fine stainless steel inner coil and an expandable outer coil of nickel and titanium Very expensive Success rate of 99%
  38. 38. Adiana Hysteroscopic sterilization 2 step process controlled thermal damage o endosalpinx followed by insertion of biocompatible matrix plus within the tubal lumen Ulipristil-IUD Failure rate 0.1-2.5 IUD impregnated with SPRM Act by suppression of ovulation, endometrial atrophy
  39. 39. 104mg/0.65ml suspension for injection of medroxyprogesterone acetate Licensed for self administration Given every 13 weeks +/-7 days SC pre-filled Uniject injector given into front upper thigh or abdomen Use if i.m is C/I or unsafe In thin women Less invassive
  40. 40. IUB and SPHERA The IUB is a revolutionary new product in the intrauterine contraception field. The IUB is a three-dimensional, ball- shaped device that is inserted into the uterine cavity to prevent pregnancy. Its efficacy is similar to current copper intrauterine devices (IUD), however its insertion is simpler, its improved safety profile has been demonstrated in a clinical trial and it is expected to offer a better quality of life over current devices
  41. 41. Fertility regulating vaccine Anti Hcg vaccine Uses tetanus toxoid diphtheria as carriers The antibodies produced by the anti hcg vaccine neutralize hcg from fertilized egg leading to endometrial shedding with loss of fertilized ovum However the initial results are not very promising
  43. 43. Conclusion India's public sector programme claims to provide a “cafeteria approach” with a “basket of choices”. The method-mix in this programme includes five official methods : 1. Female sterilisation, 2. Male sterilisation 3. Intrauterine contraceptive device (IUCD) 4. Oral contraceptives 5. Condoms