Contraception where have we been and where are we going is a presentation made by Dr.Laxmi Shrikhande who is a Fertility Specialist, Laparoscopic Surgeon & no scar Hysterectomy Specialist and a leading Gynaecologist from Nagpur

1. • Chairperson Elect ICOG –Indian College of OB/GY
• National Corresponding Editor-Journal of OB/GY of India JOGI
• National Corresponding Secretary Association of Medical Women, India
• Founder Patron & President –ISOPARB Vidarbha Chapter
• Chairperson-IMS Education Committee 2021-23
• President-Association of Medical Women, Nagpur AMWN 2021-24
• Nagpur Ratan Award @ hands of Union Minister Shri Nitinji Gadkari
• Received Bharat excellence Award for women’s health
• Received Mehroo Dara Hansotia Best Committee Award for her work as
Chairperson HIV/AIDS Committee, FOGSI 2007-2009
• Received appreciation letter from Maharashtra Government for her work in the
field of SAVE THE GIRL CHILD
• Senior Vice President FOGSI 2012
• President Menopause Society, Nagpur 2016-18
• President Nagpur OB/GY Society 2005-06
• Delivered 11 orations and 450 guest lectures
• Publications-Thirty National & Eleven International
• Sensitized 2 lakh boys and girls on adolescent health issues
Dr. Laxmi Shrikhande
MBBS; MD(OB/GY);
FICOG; FICMU; FICMCH
Medical Director-
Shrikhande Fertility Clinic
Nagpur, Maharashtra

2. Contraception- Where have
we been and
where are we going?
Dr Laxmi Shrikhande
Consultant –Shrikhande Hospital & Research Centre
Pvt Ltd
Nagpur

3. Population Projection – India & Global
India accounts for 17% of world’s population
By 2050 : expected population :
India : 1.63 Billion
World’s population 9.3 billion
(16% in 2050 will be over 65 – more would be over 85 yrs)
• Population increase due to
 lack of contraception
 Decline in infant mortality
 Increase in life expectancy.

4. The policy for the world population to survive, thrive and prosper was defined by the world
leaders in 2015 as the 17 sustainable development goals.
Heads of Governments undertook the responsibility of helping to achieve these goals in
their own countries, the region and the world by 2030.

5. SDGs and the World Population
• The goals are laudable but cannot be achieved with an ever increasing
population.
• To survive and thrive; the denominator i.e. the population need to be stable.
Contraception is the need of the hour
Global : Unmet need
225 million women in the reproductive age group who want contraception.
80 million unwanted pregnancies

6. 15.6 Million Abortions Occur
Annually in India
The Lancet Global Health—was conducted jointly by researchers at the International Institute for Population Sciences (IIPS), Mumbai; the
Population Council, New Delhi; and the New York–based Guttmacher Institute. 2017

7. Maternal deaths could be prevented by 3 Baskets of Care-
Contraception, Safe abortion care & Emergency Obstetrics
2 Medical interventions have been prioritised and chosen on the basis of their link with key causes of death and high impact potential to
save lives, and have been validated through literature review and expert opinion.
3 HIV data is estimated. Various sources state the total burden to be 3-17%. The 7% estimate is based on Spectrum modelling data.
4 Examples of treatment include uterotonics, uterine massage, balloon tamponade, uterine compression sutures, hysterectomy.
Text

8. Importance of FP and MCH Linkages
Unmet need for FP
Unintended
pregnancy
Childbirth
Maternal mortality
and morbidity
Abortion Unsafe abortion
Family planning plays a critical role in reducing maternal and infant mortality rates.

10. Current use of family planning methods (among
married women of reproductive age)
India (%)
Total unmet need 9.4
Any modern method use 56.5
Female sterilization 37.9
Male sterilisation 0.3
IUD/PPIUCD 2.1
Pill 5.1
Condom 9.5
Injectables 0.6
Source: National Family Health Survey (NFHS-5) 2019-20. Ministry of Health & Family Welfare, Government of India
• Unmet need : 9.4 %, indicating that 1 in 10 women want to space or limit births, are not able to do so
• Undue burden of family planning on women, the focus continues to be on female sterilization.
• Adoption of spacing methods and male participation remain low.

11. Female
Sterilisation ,
37.9%
Male
Sterilisation ,
0.3%
IUD/PPIUD,
2.1%
Pills , 5.1%
Condom,
9.5%
Injectables ,
0.6%
India
Source: National Family Health Survey (NFHS-5) 2019-20. Ministry of Health & Family Welfare, Government of India

18. Promoting quality sterilization services
1. Enhanced Compensation Scheme (for HFS)
2. National Family Planning Indemnity Scheme
3. Mobile teams dedicated for FP services in hard to reach areas
4. Scheme for ensuring pick up and drop back services to sterilization
clients
5. Technical Manual Update for ensuring quality in services

19. Snapshot- New Contraceptives

20. Injectable Contraceptive MPA (Antara Program)
Long-acting reversible contraceptive (LARC)
• 4th most prevalent contraceptive
• Currently 42 million women worldwide use MPA as a method of choice
• Developed in 1954 by the Upjohn Company for treatment of
endometriosis and habitual or threatened abortions
• Since 1960, licensed to be used as Contraceptive
• USFDA in Feb 1992 approved DMPA as a contraceptive
• Currently approved for use in more than 130 countries
(WHO: Family Planning: A Global Handbook for Providers)

21. Global Evidence (OCPs)
• Oral Contraceptive Use:
• Worldwide, 8% of all married women- 100 million women.
• Number one contraceptive method in Africa, Europe, America and
Oceania (Australia, New Zealand and the South Pacific islands).

22. During the last 50 years, improvement of the
oral pill has been concentrated on
continuously
lowering the Estrogen dosage,
and developing newer generations of
Progestogens
to make “safer” and “made to order” pills
Gregory Pincus
The first research on the
Oral Contraceptive pill
50 Years

23. Development of Hormonal Contraception
150 μg mestranol
50 μg EE
35 μg EE
30 μg EE
25 μg EE
20 μg EE
(10-15 μg EE)
lowering the Estrogen dosage Newer generations of Progestogens
Estrogen
component is
: Ethanyl
estradiol
Modifications to
neutralize the
androgenic
activity
Norethisterone
Levonorgestrel
Gestodene
Desogestrel
Drospirenone
Cyproterone acetate
Reducing
Androgenicity

24. Global Evidence : ECPs
Use of ECPs is increasing worldwide.
• Most women who had ever used emergency contraception had done
so once (59%) or twice (24%)*
• From 2009 to 2014-India’s market for emergency contraceptives
jumped by 88%, ranking the country third in the world after the US
and China.
• **One in four (23%) Young adult women aged 20–24 were most likely
to have ever used emergency contraception
*(Euro monitor International’s report)
** (Source: CDC, NCHS Data Brief No. 112, February 2013).

25. Is there a need for a newer contraceptive in India ?
Study shows that addition of one method
available to at least half the population
correlates with an increase of 4–8 percentage
points in total use of all modern methods

26. Two New Progestin-only contraceptives introduced in India
DMPA –SC (Sayana Press)
Subcutaneous injectables
Subdermal Progesterone Implants

27. Both are injectable Medroxy Progesterone Acetate for 3 monthly use

28. Action of DMPA
Prevents ovulation Endometrium thinner Cervical mucous thicker

29. Uniject
Gap

30. Activate the Uniject
9.5 mm needle length
•The injection site should NOT be massaged by the provider or the client as this may make the
body use the DMPA faster and act for a shorter time.

31. DMPA -SC
 Initiate within 7 days of menses
 Rule out pregnancy
 Reinjection in 3 months
 Safe during lactation , after 6 weeks postpartum
 Grace period : works for 3 months + 4 weeks
 Return of fertility delayed 7 to 10 months
 Contra-indications: migraine headaches, h/o heart attack,
stroke,serious liver condition,high blood pressure, CA breast

32. DMPA SC–Side effects
Temporary mild skin irritation
Irregular menses initial months
Amenorrhoea : 55% at one year
70% at 2 years
Bone Mineral Density (BMD)
Use is associated with loss of BMD
After stopping, recovery of BMD is seen , return to baseline in 1-4 years
No increase in fracture risk
Berenson et al. Obstet Gynecol 2004;103, Scholes et al. Arch Pediatr Adolesc Med 2005;159:139, Harel et al. Contraception 2010;81:281

33. Contraceptive efficacy : 99%
Highly effective contraception with a similar
tolerability profile to DMPA-IM
 DMPA-SC is an effective and well-tolerated contraceptive option,
providing comparable efficacy and BMD safety to DMPA-IM.
-Subcutaneous DMPA vs. intramuscular DMPA: a 2-year randomized study of contraceptive
efficacy and bone mineral density
Andrew M Kaunitz 1, Philip D Darney, Douglas Ross, Kevin D Wolter, Leon Speroff
ORIGINAL RESEARCH ARTICLE| VOLUME 80, ISSUE 1, P7-17, JULY 01, 2009

34. Acceptability studies for User
 Less invasive/ painful - prefer the smaller needle and SC
route
 Uganda and Sengal :
 > 80 % preferred DMPA SC over DMPA IM

35. Providers and community health workers :
98 % preferred DMPA SC over DMPA IM

36. DMPA-SC Self injection Way forward …
Client self-
injection under
supervision at
PHC (two visits)
Self-injection
independently at home
for two doses
Client returns to healthcare
facility after six months for
check up and DMPA-SC re-
supply
DMPA-SC can be self –Administered- Improve autonomy
Cost effectiveness : travel, service provision
Improved continuation rates
DMPA SC
injection
admistered by
Healthcare
provider

37. Why DMPA-SC ?
 The dose is lower (one-third)
 Equally effective and safe
 Prefilled with the correct dose, sterile
 More acceptable : Users Less invasive/ painful
 Health workers & frontline workers
 Can be self –Administered- Improve autonomy
 Cost effectiveness : travel, service provision
 Improved continuation rates
 Reduced plastic waste :Uniject generates 70 percent less

38. Progesterone Implants

39. Implants - LARC
 Implanon NXT (Nexplanon): 1-rod
 effective for 3 years
 68 mg of Etonorgestrel
 bio-equivalent to Implanon but has an
addition of barium sulphate that makes it
radio-opaque.
Jadelle: 2-rod
effective for 5 years
Levonogestrel 75 mg
Progestin-filled small flexible rod
Inserted under the skin of the Inner upper arm

40. Who Can Start Implants
blood pressure ≥160/100, postpartum and breast
feeding < 6 weeks, cervical cancer, history of
DVT/PE, diabetes with vascular complications, heavy
or prolonged vaginal bleeding patterns, multiple risk
factors for CVD, heart disease, hypertension >160-
>100, migraine with aura
Category 2
adolescents, nulliparity, heavy smokers, breastfeeding
6 weeks to < 6 months, endometriosis, endometrial or
ovarian cancer, thyroid disorders, uterine fibroids,
hepatitis, hypertension 140-150/90-99,HIV, PID
Category 1
Conditions
WHO
Category
Source: WHO, 2015.
Implants are safe for nearly all women.
Many women who cannot use methods that contain estrogen can safely use
• Based on WHO Medical eligibility criteria (MEC)

41. Clinical effectiveness: Highly effective. Best among long acting reversible
More effective than permanent sterilization
0.05% typical (and perfect-use) failure
Croxatto HB. Eur J Contracept Reprod Health Care. 2000;5(suppl 2):21
Funk et al. Contraception 2005;71:319
Trussell. Contraception 2011;83:397

42. Implant Insertion
 Outpatient procedure
 Pre-loaded device
 rule out pregnancy
 Back up method if not within the 1st 5
days of menses
Funk et al. Contraception 2005;71:319.
IMPLANON / Nexplanon should be inserted at
the inner side of the non-dominant arm about
8 to 10 cm (3–4 inches) above the medial
epicondyle of the humerus
special applicator

43. Implant removal
 Minor surgical procedure
 Local anaesthesia
 Trained provider
 Average removal time 3.5 minutes
 Difficult removal- due to local fibrosis

44. Complications from Implants Are
Uncommon or Rare
 Infection at insertion site
 If occurs, most likely within the first 2 months
 Difficult removal
 Rare if inserted properly and removed by a trained
provider
 Expulsions
 Rare; most occur within the first 4 months
Source: CCP and WHO, 2011.

45. Etonogestrel implant bleeding patterns
Funk et al. Contraception 2005;71:319.
~20% amenorrhea in 1st year
Mansour et al. Eur J Contr Reprod Health Care 2008;13S1:13

46. Management of bleeding
Mansour et al. Contraception 2011;83:202
1st Choice
Daily COC for 21 days, followed by 7-day break.
Use for up to 3 months.
2nd Choice
High-dose progestin for 21 days with 7-day break
(e.g. medroxyprogesterone acetate 10mg twice daily).
Use for up to 3 months.

47. Other Side Effects
 Weight gain : Not a significant increase
 Overall increase in BMI 0.7kg/m2 12.7% of women
reported weight gain
 Not contraindicated in obese women
 Acne : 17% reported acne
 No differences in BMD changes
 Return to fertility: Within one month of removal
Funk et al. Contraception 2005;71:319. Beerthuizen et al. Human Reproduction 2000;15:118

48. Emergency contraception
Method Dosing Formulation Efficacy Number of days
after intercourse
Side effects
LNG
0.75mg
2 doses 12
hours apart
LNG 750mcg 12
hours apart
75% 3 days Well
tolerated
LNG 1.5
mg
One dose LNG 75% 3 days Well
tolerated
Ulipristal One dose SPRM 30mg 75% 5 days Nausea &
vomiting
Cu IUD 99% 5 days
Combined
pills
2 doses 12
hours apart
EE 200mcg+LNG
1mg 12 hours apart
75% 3 days Frequent
nausea &
vomiting.

49. Emergency contraception
 Ulipristal acetate
( progesterone receptor modulator)
 Single dose 30mg within 120 hours
 The UPA EC regimen is slightly more
effective than LNG as shown by a
meta-analysis (n = 3242) of two
randomised controlled comparative
trials
 UPA may be more effective than
LNG for women who are obese.
 Cu-IUD
 Inserted within 120 hours
 Large systematic review of 42 studies
showed that Cu‐IUD is the most
effective EC with failure rates of
<0.1%.
Levonorgestrel 1.5 mg single dose ?
Although for use within 72 hours, there is evidence that efficacy may be maintained up to 96 hours post UPSI
Piaggio G, Kapp N, von Hertzen H. Effect on pregnancy rates of the delay in the administration of levonorgestrel for emergency contraception: a combined
analysis of four WHO trials. Contraception 2011;84:35–9
Cheng L, Che Y, Gulmezoglu AM. Interventions for emergency contraception. Cochrane Database Syst Rev 2012;8:CD001324

50. Other newer routes of administration of combined
hormonal contraception
Vaginal rings Contraceptive Patch
Monthly combined
Injectable

51. Nuvaring – vaginal ring
A flexible transparent ring of ethylene vinyl
acetate with an outer diameter of 54 mm
and cross-sectional diameter of 4 mm
One size for all!
Combined hormonal contraceptive vaginal
ring containing 2.7 mg ethinylestradiol and
11.7 mg etonorgestrel
It has the lowest oestrogen
content of any combined hormonal
contraceptive

52. Ingredients - Nuvaring
Every 24 hours the device releases:
15 mcg EE
120 mcg ENG
The hormones are absorbed into the
rich supply of blood vessels within the
vagina and enter the general
circulation, avoiding the first-pass
metabolism by the liver
Each Nuvaring is used for one monthly
cycle
It stay in the vagina for 3 weeks and is
then removed for a 1 week ring-free
interval
The 7 days without Nuvaring allows
for a withdrawal bleed
No daily pill taking; low dose; avoids 1st pass effect; low incidence of BTB or
adverse effects; latex free

53. Evra - contraceptive patch
Daily dose 20mcg EE + 150 mcg Norelgestromin
(similar to Cilest)
Levels sufficient to inhibit ovulation for at least 7
days
Efficacy similar to triphasic COC (overall PI 1.24)
BTB more common in 1st 2 cycles than COC
Suitable for women with absorption problems,
who are forgetful or have difficulty swallowing
pills

54. Combined injectable contraceptives (monthly
injectables)
54
Compared to progestin-only injectables DMPA monthly injectables:
Contain estrogen as well progestins, that is, combined methods.
Contain less progestin
More regular bleeding, fewer bleeding disturbances.
Require a monthly injection, whereas DMPA is injected every 3 months.

55. Women are Dying Every Day…
• Every 15 minute……., somewhere in India, a woman dies in
pregnancy or childbirth
-One – Third of these deaths could be avoided if women
who wanted effective contraception had access to it

56. Questions

57. My World of sharing happiness!
Shrikhande Fertility Clinic
Ph- 91 8805577600
shrikhandedrlaxmi@gmail.com

58. The more you give, the more you will get.
Then life will become a sheer dance of love.
H. H. Sri. Sri. Ravishankar
The Art of Living
Thank you