Contraception

CONTRACEPTION
Prof. Rupali Mahadik
PAMCHRC, Lucknow

Background
• What we call Birth control today has existed in every society from the earliest times - “People were
constantly trying to control or limit births.”
• Early methods of birth control, which ranged from inserted sea sponges to act as diaphragms to the
use of lemon juice as spermicide, weren’t always safe.
• The reason for this is simple: Having children has always been both expensive and dangerous.
“Not everyone can afford it, and its most people to not just let pregnancies happen one after another.
And that’s why the data shows that it’s only contraception that makes the difference.”

Basic Facts
• 2nd most populous & 7th in land area
• 17.5 % of world’s population & 2.4% land area.
• Every SIXTH MAN in the world is an Indian.
• A citizen is born at every 1.2 sec in this land.
• Our POPULATION is equivalent to USA,USSR,& INDONESIA put together and one AUSTRALIA is
added every year.
• India’s population as per 2011 census is 121 Crore (1.21 billion)
2021 its 1,391.99 BILLION

• Family planning is important not only for population
stabilization, but it has been increasingly realized that family
planning is central to improve maternal and newborn
survival and health.
• Family planning can avert more than 30% of maternal
deaths and 10% of child mortality if couples spaced their
pregnancies more than 2 years apart (Cleland J et al, 2006.
Lancet).
• In 1952, India was the world’s first nation when
Government of India (GoI) launched a Family Planning
Programme.
(first ever Family Planning programme in the world).

Many women find it difficult to practice contraception consistently or correctly over the course
of their entire reproductive lives and lack the information and services that would assist them
in doing so.
 As a result, roughly one in three reproductive age women will have had an abortion.
CONTRACEPTION

The term contraception includes all measures, temporary or permanent, designed to prevent
pregnancy due to the coital act.
Methods of Contraception
Temporary
Female
-Tubal Occlusion
-Steroidal Contraception
-IUCD
-Natural Contraception
-Barrier method
Permanent
Male
-vasectomy
Ideal contraceptive should fulfill the following criteria-
Widely acceptable, Inexpensive, Simple to use, Safe, Highly effective, Requiring minimum motivation,
maintenance and supervision.

Temporary Methods
• Mechanical ...... Condoms, Diaphragm, Cap, IUDs
• Chemical ......... Foam tablets, Jellies & Pastes.
• Combined ........Mechanical & Chemical.
• Behavioural .... Abstinence, Coitus-interruptus, Safe period, Natural
methods
• Hormonal .........Oral pill, Injectables & Implants, patch, spray, vaginal
ring
• Post-coital ........Hormonal pills & IUDs.
• Post-conceptual.- MR, Medical Abortion, M.T.P.

Barrier Methods

Barrier Methods
• Mechanical –
Male-Condoms
Female- Condoms, Diaphragm, Cap, IUDs
• Chemical –
Foam tablets-Sponge (Today)
Jellies-Volpar paste
Cream-Delfen
• Combined ........Mechanical & Chemical
 Barrier methods offer the added advantage of protection against sexually transmitted infections including
HIV/AIDS.

• Sheaths, or coverings, that fit over a man's erect penis.
• Most are made of thin latex rubber.
• Male condoms also are made from other materials, including
polyurethane, polyisoprene, lambskin, and nitrile.
• Work by forming a barrier that keeps sperm out of the vagina,
preventing pregnancy.
• Also keep infections in semen, on the penis, or in the vagina from
infecting the other partner.
• Effectiveness depends on the user: Risk of pregnancy or sexually
transmitted infection (STI) is greatest when condoms are not used with
every act of sex. Very few pregnancies or infections occur due to
incorrect use, slips, or break
Male Condoms

• Sheaths, or linings, that fit loosely inside a woman's vagina, made of thin,
transparent, soft plastic film.
• Have flexible rings at both ends
• One ring at the closed end helps to insert the condom
• The ring at the open end holds part of the condom outside the vagina
• Female condoms are made of various materials, such as latex, polyurethane, and
nitrile.
• Work by forming a barrier that keeps sperm out of the vagina, preventing
pregnancy.
• Also helps to keep infections in semen, on the penis, or in the vagina from
infecting the other partner.
• The male and female condoms should not be used at the same time because they
can get stuck together and cause one or the other to slip during intercourse,
making them ineffective.
Female Condoms

Basic Steps
(Insertion)
Before any physical contact,
insert the condom into the
vagina
• For the most protection, insert the condom before the penis
comes in contact with the vagina. Can be inserted up to 8 hours
before sex.
• Choose a position that is comfortable for insertion—squat,
raise one leg, sit, or lie down.
• Rub the sides of the female condom together to spread the
lubricant evenly.
• Grasp the ring at the closed end, and squeeze it so it becomes
long and narrow.
• With the other hand, separate the outer lips (labia) and locate
the opening of the vagina.
• Gently push the inner ring into the vagina as far up as it will
go. Insert a finger into the condom to push it into place. About
2 to 3 centimeters of the condom and the outer ring remain
outside the vagina.
(Removal)
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
• The female condom does not need to be removed immediately
after sex.
• Remove the condom before standing up, to avoid spilling
semen.
• If the couple has sex again, they should use a new condom.
• Reuse of female condoms is not recommended

• Female condoms help protect against sexually transmitted
infections, including HIV. Condoms are the only
contraceptive method that can protect against both
pregnancy and sexually transmitted infections.
• Require correct use with every act of sex for greatest
effectiveness.
• A woman can initiate female condom use, but the method
requires her partner's cooperation.
• May require some practice. Inserting and removing the
female condom from the vagina becomes easier with
experience.
A new female condom which is thin and soft and can easily be inserted like a tampon has been developed by the Program
for Appropriate Technology in Health (PATH) and is presently undergoing Phase III clinical trials

Diaphragm
 It is an intravaginal device made of a soft, rubber dome with flexible metal or
spring at the margin. forms a barrier to prevent sperm from reaching the cervix.
A spermicidal gel, which is ALWAYS used with it, kills or immobilizes sperm.
 A pelvic examination is needed before starting use. The provider must select a
diaphragm that fits properly.
 Require correct use with every act of sex for greatest effectiveness.
 The device is introduced 3 hrs before intercourse and is kept for atleast 6 hrs
after the last coital act.
 EFFECTIVENESS: 85%
 HOW TO USE IT:
Apply spermicide inside and around the rim of the diaphragm, then place it
deep into the vagina, covering the cervix.

Cervical Cap
 Cervical cap is a latex, thimble-shaped device that is inserted into the vagina and
fits snugly over the cervix.
 The effectiveness of a cervical cap depends on its fit.
Cervical caps come in different sizes to fit different women.
A fitting is done in a clinic.
 A cervical cap can stay in place for 48 hours. After intercourse, it should be left in
place for 8 hours.
 A cervical cap is used with spermicidal jellies or creams that kill sperm. As birth
control, cervical caps are 84-91% effective for women who have never given
birth.
 They are 68-74% effective for women who have given birth.

 Inserting
 Fill one-third of the cap with spermicidal cream, jelly, or foam.
 Press the rim of the cap around the cervix until it is completely covered, pressing gently on the
dome to apply suction and seal the cap.
 Insert the cervical cap any time up to 42 hours before having sex.
 Removing
 Leave the cervical cap in for at least 6 hours after her partner’s last ejaculation, but not more than
48 hours from the time it was put in.
 Leaving the cap in place for more than 48 hours may increase the risk of toxic shock syndrome
and can cause a bad odor and vaginal discharge.
 Tip the cap rim sideways to break the seal against the cervix, and then gently pull the cap down
and out of the vagina.

Chemical barrier method
Spermicide?
• A spermicide kills or disables sperm so that it cannot cause pregnancy.
• Spermicides come in many different forms: foam, jelly, cream, film, and suppositories.
• Most use the chemical nonoxynol-9 against sperm.

• Spermicides provide lubrication and can be used with other methods of birth control.
• They are most effective when used consistently and correctly with a barrier method of birth control,
like a condom.
• Spermicides are 71-82% effective as birth control.
• Used alone, spermicide does not protect against HIV/AIDS.
• Douching weakens spermicide.
• It is available in most drug stores and does not require a prescription

• The normal vaginal ecosystem is increasingly recognized as an important host defense mechanism
against acquisition of STIs.
• The interaction of hormonal contraceptives and the vaginal ecosystem is unknown; however, it is known from
animal model studies that hormonal contraceptives result in thinning of the vaginal epithelium.
• To assess the effects of contraceptives on the vaginal microflora, Gupta et al conducted a prospective
evaluation of women who were initiating use of birth control methods, including the diaphragm with
application of N-9 and oral contraceptives.
• The study showed that oral contraceptives had little effect on the vaginal microbial flora, whereas diaphragms
with added N-9 were associated with increased vaginal colonization by E.coli, Enterococcus species, and
anaerobic gram-negative rods.
• These data indicated that N-9 use may also alter the microbial constituents of the vaginal ecosystem. These
changes in flora could, in turn, affect the pro- and anti-inflammatory immune milieu in the reproductive tract.

Natural Contraception
Methods

Natural methods
 "Fertility awareness" means that a woman knows how to tell when the fertile time of her menstrual
cycle starts and ends.
 Sometimes called periodic abstinence or natural family planning.
 Couple must be committed to abstaining or using another method on fertile days.
 A woman can use several ways, alone or in combination, to tell when her fertile time begins and
ends.
 Must stay aware of body changes or keep track of days, according to rules of the specific method.
 The couple prevents pregnancy by avoiding unprotected vaginal sex during these fertile days—
usually by abstaining or by using condoms or a diaphragm.
Some couples use spermicides or withdrawal, but these are among the least effective methods.

• A woman can use several ways, alone or in combination, to tell when her fertile time begins and ends.
• Calendar-based methods involve
keeping track of days of the
menstrual cycle to identify the start
and end of the fertile time.
• Examples: Standard Days Method
which avoids unprotected vaginal
sex on days 8 through 19 of the
menstrual cycle, and calendar
rhythm method.

Cervical secretions:
When a woman sees or feels cervical
secretions, she may be fertile. She
may feel just a little vaginal wetness.
The couple avoids vaginal sex or
uses condoms or a diaphragm on
each day with secretions and on each
day following a day with secretions.
Resume unprotected sex after 2 dry
days
Symptoms-based methods depend on observing signs of fertility.

Symptoms-based methods depend on observing signs of fertility.
 Basal body temperature (BBT):
• A woman’s resting body temperature BBT falls
at 0.5⁰F before the day of ovulation and during
ovulation, it rises to a full degree .
• The woman must take her temperature early
every morning before any activity, and if she
notices that there is a slight decrease and then an
increase in her temperature, this is a sign that she
has ovulated.
• The woman must abstain from coitus for the next
3 days.

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.
 Also known as coitus interruptus and “pulling out.”
 Works by keeping sperm out of the woman’s body.
 It requires sufficient self control by the man so that withdrawal of penis precedes
ejaculation

Lactational amenorrhea method (LAM)
 A temporary family planning method based on the natural effect of breastfeeding on fertility.
(“Lactational” means related to breastfeeding. “Amenorrhea” means not having monthly bleeding.)
 Works primarily by preventing the release of eggs from the ovaries (ovulation). Frequent
breastfeeding temporarily prevents the release of the natural hormones that cause ovulation.
 The lactational amenorrhea method (LAM) requires 3 conditions. All 3 must be met:
• The mother's monthly bleeding has not returned
• The baby is fully or nearly fully breastfed and is fed often, day and night
• The baby is less than 6 months old

Intrauterine device (IUD)
• The released copper ions interfere with sperm mobility and incite a
foreign-body reaction that results in a spermicidal environment.
• Barium sulfate has been added to the polyethylene substrate to
make the device radiopaque.
• A 3-mm plastic ball is located at the base of the IUD, through
which the monofilament thread passes.
• Once inserted, the IUD can remain in place for up to 10 years.
• IUDs are 99.2-99.9% effective as birth control.
• They do not protect against sexually transmitted infections,
including HIV/AIDS
• The copper-bearing intrauterine device (IUD) is a T-shaped polyethylene device with 380 mm2
of exposed surface area of copper on its arms and stem - One of the most effective and long-
lasting methods.

A pelvic examination and STI risk assessment should be done before IUD insertion.
An ideal candidate for an IUD is a parous woman in a stable, mutually monogamous relationship, with no
history of pelvic inflammatory disease.
 Timing –
• Menstrual cycle – first eight days
• After Abortion – after next MP
• Post delivery - six weeks – 3 mnths.
• Post coital – within five days
 Follow Up –
• after MP
• Six months
• One year

Proper insertion technique can help prevent many problems, such as infection, expulsion, and
perforation
 Follow proper infection-prevention procedures.
 Use high-level disinfected or sterile instruments. High-level disinfect by boiling, steaming, or
soaking them in disinfectant chemicals.
 Use a new, presterilized IUD that is packaged with its inserter.
 The “no-touch” insertion technique is safest. This includes not letting the loaded IUD or
uterine sound touch any unsterile surfaces (for example, hands, speculum, vagina, table top).
The no-touch technique involves:
• Loading the IUD into the inserter while the IUD is still in the sterile package, to avoid
touching the IUD directly
• Cleaning the cervix thoroughly with antiseptic before IUD insertion
• Being careful not to touch the vaginal wall or speculum blades with the uterine sound or
loaded IUD inserter.
• Passing both the uterine sound and the loaded IUD inserter only once each through the
cervical canal.
 Giving antibiotics routinely is generally not recommended for women at low risk of STIs.

Insertion procedure
• Under proper infection-prevention procedures conducts a pelvic examination to determine
the position of the uterus and assess eligibility
• first do the bimanual examination and then inserts a speculum into the vagina to inspect the
cervix.
• clean the cervix and vagina with appropriate antiseptic.
• slowly insert the tenaculum through the speculum and close the tenaculum just enough to
gently hold the cervix and uterus steady.
• Then slowly and gently pass the uterine sound through the cervix to measure the depth and
position of the uterus.
• Load the IUD into the inserter while both are still in the unopened sterile package.
• Slowly and gently inserts the IUD into the uterus and removes the inserter.
• cut the strings on the IUD, leaving about 3 centimeters hanging out of the cervix.
• After the insertion, make the woman rest.

 Side Effects
 Changes in bleeding patterns (especially in the first 3 to 6 months) including:
• Prolonged and heavy monthly bleeding
• Irregular bleeding
• More cramps and pain during monthly bleeding
 Complications
 Rare:
• Puncturing (perforation) of the wall of the uterus by the IUD or an instrument used for
insertion. Usually heals without treatment.
• Miscarriage, preterm birth, or infection in the rare case that the woman becomes pregnant with
the IUD in place.

Steroidal Contraception
Methods

Hormonal
Observations
• Ovarian follicles do not develop during pregnancy
• 1897 - ? Corpus Luteum
• 1930 – yes
• Neuro endocrine control of reproduction was established

• 15–20:CL secretes prog. and small
amount of estrogen, inhibit Fsh LH
• No Fertilization and Nidation
• 20 – 28 :
• CL starts regressing on 20th day, full
regression by 28th day, P & E fall down
• Endometrium- ischemia stasis necrosis
• Allows FSH surge and follicle takes
quantum leap towards ovulation
• 15-20:CL secrets prog. and small
amount of estrogen, inhibits FSH LH
• Fertilization and Implantation
• 20 – 28 :
• Chorion – CL does not regress, goes on
secreting progesteron,
• Endometrim– no necrosis
• No FSH surge no development of follicle
– no ovulation
*Progesterone is the hormone which prevents Ovulation

2
3
1 • Stops ovulation
• Prevents uterus lining from build up
(endometrial atrophy)
• Making the cervical mucous thick to prevent
penetration of sperm
All hormonal birth
control measures act
via same mechanism
Hormonal contraception has been increasingly accessible and widely used for both spacing and limiting
births

Oral Hormonal Contraceptives
The first steroidal OC pill was approved in the 1960s.
Because of its ease of use and the sense of empowerment and
freedom that it gave to its users, the popularity and use of the pill
steadily increased throughout the 1960s.
“It gave women a kind of privacy about what they were trying to
do,”
Following the birth control pill’s success, a variety of hormonal birth
control methods flooded the market: implants, intrauterine devices,
injectables, rings.

2
3
4
5
1 Oral : Combined Pills, P O Pills
Injectable : Intramuscular, Subcutaneous
Implants : Rods
Transdermal : Patch, Spray
Vaginal : Ring
Hormonal
Delivery routes
6 Uterus : IUS

 The policy is to use minimum effective dose. And to rule out
contraindications.
 OC – contraindications - past or present circulatory disease, Hypertension,
Diabetes, Migraine, valvular heart disease, h/o Jaundice
 POP – Indications – older age group, DM, HT, During Lactation ( most
important)
 Non contraceptive benefits
Reduced risk –
PID
Ectopic pregnancy
Reduced incidence –
Sickle cell crises
Epileptic seizures
Protection against –
End. Ca.,
Ovarian Ca.
Endometriosis,
Ovarian cysts.
Anaemia
Benign breast lumps

Oral Contraceptive pills
• Pills in the early trial had extremely high doses of the hormone progesterone, which led
to extreme side effects like nausea, dizziness, headaches, stomach pain, blood clots
and vomiting.
• Concerns over the adverse effects of hormonal contraceptives have led to research and
development of new combinations with improved metabolic profile

Formulations
 Monophasic -
(each tablet contains a fixed amount of estrogen and progestin);
 Biphasic-
(each tablet contains a fixed amount of estrogen, while the amount of
progestin increases in the second half of the cycle)
 Triphasic-
(the amount of estrogen may be fixed or variable, while the amount of
progestin increases in 3 equal phases).
 Pop-
(It only contains progestin)

Recent advances
 Estrogen
• The first generation OCs contained mestranol which was then replaced by the type of estrogen used wherein
natural compounds such as estradiol (E2) and estradiol valerate (E2V) are being used with the objective of
overcoming metabolic effects and decrease the thrombotic risk of formulations with EE.
• Ethinyl estradiol (EE) initially in doses as high as 150 mcg per pill, which decreased to 100, 80, and 50 µg was then
further decreased to 30 and 20 µg.
 Progesterone
• Most progestins used in OCs of the first and second generation were chemically related to testosterone (19-
nortestosterone derivatives; estrane and gonane groups).
• However, these progestins were responsible for undesirable androgenic side effects such as acne, oily skin, and
hair growth, as well as negative effect on high-density lipoproteins (HDL).
• New progestins derived from the progesterone structure or from spironolactone have been developed to avoid the
androgenic effects and to improve the safety profile.

Yasmin EE 30 ug Drospirenone 3mg
Yaz EE 20 ug Drospirenone 3mg

A recently approved 4 phasic pills
• Estrogen-estradiol valarate along with newer progestin -dienogest DNG is used.
• Step down doses of estrogen and step up doses of progestin preparation is used
this has shown favorable results in hemostasis and metabolism studies . However, large safety surveillance
studies are ongoing and will confirm whether the improved metabolic profile will correlate with a decreased
incidence of Venous thromboembolism
Days E₂ V DNG
E₂ V-DNG 1-2 3mg
3-7 2 mg 2 mg
8-24 2 mg 3 mg
25-26 1 mg
27-28 Placebo

Extended and Continuous Use of Combined Oral Contraceptives
Some COC users do not follow the usual cycle of 3 weeks taking hormonal pills followed by
one week without hormones.
Some women take hormonal pills for 12 weeks without a break, followed by one week of
nonhormonal pills (or no pills). This is extended use.
Other women take hormonal pills without any breaks at all. This is continuous use.
Monophasic pills are recommended for such use

 Benefits of Extended and Continuous Use
• Women have vaginal bleeding only 4 times a year or not at all.
• Reduces how often some women suffer headaches, premenstrual syndrome, mood changes,
and heavy or painful bleeding during the week without hormonal pills.
 Disadvantages of Extended and Continuous Use
• Irregular bleeding may last as long as the first 6 months of use— especially among women
who have never before used COCs.
• More supplies needed—15 to 17 packs every year instead of 13

 Extended Use Instructions
• Take 84 hormonal pills in a row, one each day. (These are the hormonal pills in 4 monthly
packs.)
• Users of 28-pill packs do not take the nonhormonal pills.
• After 84 hormonal pills, wait 7 days and start the next pack of pills on the 8th day. (Users of
28-pill packs can take the nonhormonal pills in the 4th pack if they wish and start the hormonal
pills the day after the last nonhormonal pill.)
• Expect some bleeding during this week of not taking the hormonal pills.
 Continuous Use Instructions
• A woman should take one hormonal pill every day for as long as she wishes to use COCs.
• If bothersome irregular bleeding occurs, she can stop taking pills for 3 or 4 days and then start
taking hormonal pills continuously again.

Progestin-only pill (POP)
 The progestin-only pill (POP), also called the “Mini-pill,” is a type of birth control pill (oral contraceptive)
that comes in a pack of 28 pills -it doesn’t contain estrogen.
 It may be prescribed for young and adult women who can’t take estrogen due to an underlying medical
condition, sensitivity or because of an unwanted side effect.
 Take one pill every day. No breaks between packs.
 Safe for breastfeeding women and their babies. Progestin-only pills do not affect milk production.
 Add to the contraceptive effect of breastfeeding. Together, they provide effective pregnancy protection.
 Bleeding changes are common but not harmful.
POP -focuses on breastfeeding women

Injectable Contraceptives:
 DMPA (depot-medroxyprogesterone acetate) –
Every 3 months 150 mg – intramuscular (Deltoid or Gluteal )
 NetEn (Norethisterone Enanthate )–
Every 2 months 200 mg- intramuscular (Deltoid or Gluteal )
 DMPA sc – subcutaneous 104-mg DMPA-is injected subcutaneously into the anterior thigh
or abdomen. Depo-subQ Provera 104 is used to treat pain associated with endometriosis.

Injectable Depot-Medroxyprogesterone Acetate
Timing – 1st Injection
MP – any time, within 7 days – 5 days
MTP or Abortion – immediately – next MP
Post delivery – 6 wks to 2 months
Mode – intramuscular
Deltoid or Gluteal - gluteal (No rubbing, no fomentation)
Further appointment – 84 – 90 days
Injectable contraceptive is a good choice and most suitable in lactation period especially after
first child.
Oral pills are not preferred in first six- eight months of delivery. If there is PIH or Gest.
Hyperglycaemia, injectable is preferred.
Effective, Safe and Convenient

Injectable Contraceptive-MPA
(Under Antara Programme)
Injectable contraceptive (MPA-medroxyprogesteron) is a hormonal contraceptive method for
women that prevents pregnancy for three months
How does it work?
•It prevents monthly ovulation, thickens cervical mucus
thus blocking sperms from meeting eggs.
•Makes implantation of fertilized egg difficult
How is it used?
•Get an injection every 3 months
•It can easily be administered in the arms, thighs or
buttocks
•The date of subsequent dose may be remembered from
MPA card provided.

Combined monthly injections – once-a-month
 Cyclofem – 25 dmpa + 5mg. E C (estradiol cypionate )
 Mesigyna – 50 neten + 5 mg. E V (estradiol valerate )
The main reason for the development of once-a-month injectable contraceptives is the need for a
long-acting method which produces a regular vaginal bleeding pattern
Combined estrogen-progestogen once-a-month injectables produce much more regular bleeding
patterns than long-acting injectables like depot-medroxyprogesterone acetate, the patterns are
not entirely normal.

IMPLANTS
 Small plastic rods or capsules, each about the size of a
matchstick, that release a progestin like the natural
hormone progesterone in a woman's body.
 A specifically trained provider performs a minor surgical
procedure to place one or 2 rods under the skin on the
inside of a woman’s upper arm.
 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 Levonorgestre
l
75 mg x 2
effective for 5
years
Implanon NXT
(Nexplanon)
1 rod Etonogestrel
68 mg
labeled for up to
3 years
Replaces Implanon;
Implanon NXT can be
seen on X-ray and has
an improved insertion
device
Levoplant
(Sino-Implant (II)
2 rods Levonorgestre
l
75 mg x 2
Labeled for up to
4 years
Norplant 6 capsules levonorgestrel
36 mg x 6
effective for 5−7
years
was discontinued in
2008 and is no longer
available for
insertion.
**Norplant was taken out from market because of issues with insertion, removal and inexperience of
some health care providers in administering the implants.

Transdermal Patch
• Also called Ortho Evra and Evra.
• Continuously releases 2 hormones—a progestin and an
estrogen, like the natural hormones progesterone and estrogen
in a woman’s body—directly through the skin into the
bloodstream.
• Patch contains –
6 mg norelgestromin as a active progestin & 0.75 mg ethinyl
estradiol
• A woman wears a small adhesive patch on her body at all times, day and night. A new patch is
put on each week for 3 weeks, and then no patch for the fourth week . During this fourth week
the woman will have monthly bleeding.

Transdermal Patch: Disadvantages
• Application site reactions
• Not as effective in women weighing >198 pounds
• Side effects are similar to oral contraceptives. May be
difficult to conceal except- higher rate of dysmenorrhea
and of breast pain during the first two cycles.
• privacy may be compromised due to the patch’s visibility
• No protection against HIV or other sexually transmitted
infections
Zieman M, et al. Fertil Steril. 2002;77(Suppl 2):S13-S18.

Patch: Patient Counseling
• 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
• Unused patches -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

Patch: Instructions for Late Replacement or Removal, or if the Patch Comes
Forgot to apply a new patch after the 7-day
patch-free interval?
•Apply a new patch as soon as possible.
•Keep the same patch-change day.
•If late by only 1 or 2 days (48 hours or less), there is no need for a backup method.
•If more than 2 days late (more than 48 hours) (that is, no patch was worn for 10 days or more in a row), use a backup method* for the
first 7 days of patch use.
•Also, if more than 2 days late and unprotected sex occurred in the past 5 days, consider taking emergency contraceptive pills
Late changing the patch at the end of week
1 or 2?
•If late by only 1 or 2 days (48 hours or less), apply a new patch as soon as possible. Keep the same patch-change day. No need for
a backup method.
•If more than 2 days late (more than 48 hours), apply a new patch as soon as possible. This patch will begin a new 4-week patch
cycle, and this day of the week will become the new patch-change day. Also use a backup method for the next 7 days.
•Also, if more than 2 days late and unprotected sex occurred in the past 5 days, consider taking emergency contraceptive pills
Late taking off the patch at the end of week
3?
•Remove the patch.
•Start the next cycle on the usual patch-change day.
•No need for a backup method.
The patch came off and was off for less than
2 days (48 hours or less)?
•Apply a new patch as soon as possible. (The same patch can be re-used if it was off less than 24 hours.)
•No need for a backup method.
•Keep the same patch change day.
The patch came off and was off for more
than 2 days (more than 48 hours)?
•Apply a new patch as soon as possible.
•Use a backup method* for the next 7 days.
•Keep the same patch-change day.
•If during week 3, skip the patch-free week and start a new patch immediately after week 3. If a new patch cannot be started
immediately, use a backup method* and keep using it through the first 7 days of patch use.
•If during week one and unprotected sex occurred in the past 5 days, consider taking emergency contraceptive pills
*
Backup methods include abstinence, male and female condoms, spermicides, and withdrawal. Tell her that spermicides and withdrawal are the least effective contraceptive
methods. If possible, give her condoms.

• (CVR) is a relatively new hormonal contraceptive method, considered a semi long-acting or mid-
acting method.
• Flexible ring inserted into the vagina and releases estrogen -EE (15 mcg/day) and progesterone -
etonogestrel ENG (120 mcg/day)
• Hormones released from the CVR are rapidly absorbed by vaginal the vaginal epithelium, pass into
the general circulation, achieve rapidly a steady state, and prevent follicular development and
ovulation .
Contraceptive vaginal ring (CVR)
Nuva Ring-
Very popular in European
countries

The advantages of the ring, a user-controlled method, include its easy insertion and removal by the
woman herself on a 3-weeks in, 1-week out schedule.
The ring does not need to be placed in a specific site and one size is suitable for all women.
Therefore the method is easy to distribute as it does not need trained health providers for insertion
and removal, and also it may increase compliance as daily attention is not required.
To insert the ring:
 with clean hands, squeeze the ring between the thumb
and finger, and gently insert the tip into vagina
 gently push the ring up into vagina until it feels
comfortable
 Unlike a diaphragm or cap, the ring doesn’t need to
cover the entrance to your womb (the cervix) to work.

Progesterone vaginal ring (PVR) as a new contraceptive option for lactating
mothers
• Another 3-month ring which contains only natural progesterone (P) is marketed under the brand name
Progering, in Chile and Peru.
• PVR is designed to release about 10 mg of P daily in order to prolong lactational amenorrhea (LAM) and
can be used up to one year ( 4 rings of 3 months duration).
• Use of the ring starts 4 to 9 weeks after giving birth.
• Each ring is kept in place for 90 days. The woman can then replace it with a new ring immediately. Up to
4 rings can be used, one after another, with no breaks.
• Works by preventing release of an egg from the ovaries (ovulation). Progesterone extends the postpartum
amenorrhea of the breastfeeding woman. That is, it delays the return of monthly bleeding.
• Safe and effective option for a woman:
• Who has a baby at least 4 weeks old
• Who is breastfeeding her baby at least 4 times per day and plans to continue breastfeeding
• Whose monthly bleeding has not returned

IUS- Levonorgestrel-releasing intrauterine system
•Bioactive IUD - Mirena – POP
•T shaped frame with a reservoir ( LNG )
•Releases low daily dose for 5 years
•Return of fertility is rapid
Mirena — birth control that also helps with heavy periods

Who should not use Mirena?
Mirena is not right for everyone. Do not use Mirena if you:
 are or might be pregnant; Mirena cannot be used as an emergency contraceptive
 have a serious pelvic infection called pelvic inflammatory disease (PID) or have had PID in the past
 have an untreated genital infection
 Can get infections easily. For example, if ;
 have multiple sexual partners or your partner has multiple sexual partners
 have problems with your immune system
 have or suspect you might have cancer of the uterus or cervix
 have bleeding from the vagina that has not been explained
 have liver disease or a liver tumor
 have breast cancer or any other cancer that is sensitive to progestin , now or in the past
 have a condition of the uterus that changes the shape of the uterine cavity, such as large fibroid tumors
 are allergic to levonorgestrel, silicone, polyethylene, silica, barium sulfate or iron oxide

Male Hormonal Contraception
• Hormones inhibit fertility in men by suppressing sperm production.
• Hormonally induced azoospermia by weekly im injections of testosterone enanthate provides effective and
reversible male contraception,
• Combined administration of levonorgestrel and testosterone induces more rapid and effective suppression of
spermatogenesis than testosterone alone.
• Thus, these regimens may represent viable options for male contraception.

“Reversible Inhibition of Sperm Under Guidance”-RIUSG
• RISUG consists of a polymer—SMA, which is dissolved in dimethyl
sulfoxide (DMSO) it works by an injection into the vas deferens.
• RISUG is similar to vasectomy in that a local anesthetic is administered,
an incision- 120 microlitres of RISUG is injected into each vas deferensis
made in the scrotum, and the vasa deferentia are injected with a polymer
gel (rather than being cut and cauterized).
• In a matter of minutes, the injection coats the walls of the vasa with a
clear.
• By November 2019, the ICMR had successfully completed clinical trials
of the world's first injectable male contraceptive, for which 303
candidates were recruited with 97.3% success rate and no reported side
effects.

• Unprofitable business model for drug companies who work on the principle of continuous
demand and long term profit-Pharmaceutical companies have expressed little interest in
RISUG.
• One obstacle facing marketing of the product is that men generally perceive contraception as
a woman's issue.
• Men may also not choose alternative methods of contraception because there are fewer
options for birth control for them than there are for women, they fear the side effects, or
because of their cultural or religious beliefs.

Emergency
Contraception

Emergency contraception postcoital
• After unplanned or unprotected sex act - As soon as possible not later than 72 hrs

Methods of Emergency Contraception
All the hormonal oral contraceptive pills (combined as well as single) in varying doses and IUCDs
can be used for EC.
The following methods are in use:
• High doses of progestogen only pill containing levonorgestrel (LNG)
• High doses of combined oral contraceptive containing ethylestradiol and levonorgestrol
• Copper releasing intrauterine devices (IUCD) such as CuT 380A
* Under the National Reproductive and Child Health Program , the Drug Controller of India has only approved Levonorgestrel
(LNG) 0.75mg tablets for use as ECP. LNG is the ‘dedicated product’ for emergency contraception and is specially packaged at
the correct dosage for use as ECP.

Emergency Contraceptive Pills (ECP)
• Emergency contraception refers to back-up methods for contraceptive emergencies which
women can use within 72 hours ( the earlier the better) of an unprotected act of intercourse
to prevent an unwanted pregnancy.
• The Government of India introduced Emergency Contraceptive Pills (ECP) in the National
Family Welfare Programs in 2003 as one of the strategies to prevent unwanted pregnancies.
Note: The emergency contraceptive pill (ECP)
is not recommended as a regular method of
birth control

Emergency Contraception Can be Used
• After voluntary sexual act without contraceptive protection.
• Incorrect or inconsistent use of regular contraceptive methods: failure to take oral contraceptives for more than 3
days, being late for contraceptive injection
• In case of contraceptive failure or mishaps: miscalculation of infertile period, failed coitus interruptus, expulsion
of an intrauterine device and, or in case of slippage/leakage/breakage of condom
• In the event of sexual assault
 Recent advances-
Oral Ulipristal acetate (UPA)- has recently been approved for emergency contraception as a single oral dose of 30
mg and appears to be effective for a longer duration, up to 5 days postcoital, than LNG emergency contraception
active up to 3 days following a single act of unprotected intercourse

Non-hormonal pill

Non-hormonal pill
Chhaya or Centchroman is a non-hormonal pill that prevents implantation of
fertilized egg in the uterus.

 How is it used?
• Take one pill twice a week for the first 3 months
• From 4th month take pill once a week on the first pill day
• The first pill can be taken on the first day of the menstrual cycle or any other day provided pregnancy has
been ruled out
• After finishing one pack, take the first pill from next pack on scheduled day
 Why Chhaya is the right choice?
• Chhaya is an effective reversible method of contraception
• It is safe for women of all age groups.
• It is safe for breastfeeding women, even immediately after childbirth
• Return to fertility on stopping the pills is prompt
*During the first three months of taking Chhaya, women may notice lighter or irregular periods. This should
be no cause of worry, as menstrual cycle gets normal once the body gets used to the pill.

Permanent
Contraception Methods

Female Sterilization
• Permanent surgical contraception for women who will not want
more children. Also called tubal sterilization, tubal ligation,
voluntary surgical contraception, tubectomy, bi-tubal ligation,
tying the tubes, minilap, and “the operation.”
• Works because the fallopian tubes are blocked or cut. Eggs
released from the ovaries cannot move down the tubes, and so
they do not meet sperm.
• Tubectomy during caesarean operation and minilaparotomy are popular methods in developing
countries whereas laparoscopic sterilization and hysteroscopic tubal occlusion are the preferred
methods in developed countries.

Timing
Female sterilization can be carried out, at any of the following time-
Postpartum sterilization – done within seven days of delivery,
Caesarean tubal ligation – the 2 procedures are combined,
Interval ligation -done six weeks after delivery,
Postabortal ligation -immediately after evacuation of uterus after induced or incomplete abortion,
Gynaecological ligation-combined with gynaecological surgeries such as myomectomy, cystectomy or fothergill’s operation.
Female sterilization may be performed in several ways such as minilaparotomy, laparoscopic sterilization and hysteroscopic methods.

 The 2 surgical approaches most often used:
• Minilaparotomy involves making a small
incision in the abdomen. The fallopian tubes
are brought to the incision to be cut or
blocked.
• Laparoscopy involves inserting a long, thin
tube containing lenses into the abdomen
through a small incision. This laparoscope
enables the doctor to reach and block or cut
the fallopian tubes in the abdomen. Each tube
is closed with a clip or a ring, or by electric
current applied to block the tube
(electrocoagulation).

Vasectomy
 Permanent contraception- also called male sterilization and male surgical contraception.
 Through a puncture or small incision in the scrotum, the provider locates each of the
2 tubes that carries sperm to the penis (vas deferens) and cuts or blocks them by cutting
and tying them closed or by applying heat or electricity (cautery).
 Works by closing off each vas deferens, keeping sperm out of semen. Semen is ejaculated,
but it cannot cause pregnancy.
 Vasectomy is not fully effective for 3 months after the procedure.
 One of the most effective methods but carries a small risk of failure.
If the partner of a man who has had a vasectomy becomes pregnant, it may be because:
• The couple did not always use another method during the first 3 months after the
procedure
• The provider made a mistake
• The cut ends of the vas deferens grew back together

Performing the Vasectomy Procedure
 The provider uses proper infection-prevention procedures at all times.
 The man receives an injection of local anesthetic in his scrotum to prevent
pain. He stays awake throughout the procedure.
 The provider feels the skin of the scrotum to find each vas deferens— the 2
tubes in the scrotum that carry sperm.
 The provider makes a puncture or incision in the skin
• Using the no-scalpel vasectomy technique, the provider grasps the tube with
specially designed forceps and makes a tiny puncture in the skin at the midline
of the scrotum with a special sharp surgical instrument.
• Using the conventional procedure, the provider makes 1 or 2 small incisions in
the skin with a scalpel.
 The provider lifts out a small loop of each vas from the puncture or incision.

No-Scalpel Vasectomy
 No-scalpel vasectomy is the recommended technique for reaching
each of the 2 tubes in the scrotum (vas deferens) that carries sperm
to the penis. It is becoming the standard around the world.
 Differences from conventional procedure using incisions:
• Uses one small puncture instead of 1 or 2 incisions in the scrotum.
• No stitches required to close the skin.
• Special anesthesia technique needs only one needle puncture
instead of 2 or more.
 Advantages:
• Less pain and bruising and quicker recovery.
• Fewer infections and less collection of blood in the tissue
(hematoma).
• Total time for the vasectomy has been shorter when skilled
providers use the no-scalpel approach.
 Both no-scalpel and conventional incision procedures are quick,
safe, and effective.

Is it better for the man to have a vasectomy or for the woman to have female
sterilization?
 Each couple must decide for themselves which method is best for them. Both are very effective,
safe, permanent methods for couples who know that they will not want more children.
 Ideally, a couple should consider both methods. If both are acceptable to the couple, vasectomy
would be preferable because it is simpler, safer, easier, and less expensive than female
sterilization.
 The man takes responsibility for contraception—takes burden off the woman

 Before choosing a birth control method, think about how well each method works
 Birth control methods are measured for effectiveness by -
typical users
(% of couples who use the method and have an accidental pregnancy during the 1st year)
and by
perfect use
(per cent of couples who use it all the time and use it perfectly and still have an accidental
pregnancy during the 1st year)
 The chart on next slide shows the effectiveness or how well each method works.
For example:- if 100 women use the birth control pill, it prevents pregnancy for 92 to 99 %
of the women

Conclusion
• Steady progress in contraception research has been
achieved over the past 50 years.
• Hormonal and non-hormonal contraceptives have
improved women’s lives by reducing different health
conditions that contributed to considerable
morbidity.
• Most women will use many methods on basis of-
✔ Provider Education
✔ Reducing mythology
✔ Increasing knowledge of non-contraceptive
benefits

Every couple should have children by choice,
not by chance
- Every child a wanted child

THANK YOU

Contraception

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