This document discusses various methods of contraception, including their mechanisms of action, advantages, and disadvantages. It describes temporary contraceptive methods like barrier methods (condoms), hormonal methods (oral contraceptive pill, injectables, implants), intrauterine devices, and emergency contraception. It also discusses permanent sterilization methods like vasectomy and tubal ligation. The ideal contraceptive is described as widely acceptable, inexpensive, simple to use, safe, highly effective, and requiring minimal effort. Failure rates for different contraceptive methods during the first year of use are also provided for comparison.

1. Contraception

2. Competency
• PY 9.6
• Enumerate the contraceptive methods for male and female.
• Discuss their advantages & disadvantages.

3. Learning objectives
• Classify contraceptives in male and female
• Name the temporary & permanent methods of contraception
• Explain the mechanism of action of contraceptives
• Comment on which contraceptive is better for which type of couple

4. What is Contraception?
• all measures, temporary or permanent, designed to prevent
pregnancy due to the coital act
• Ideal contraceptive method:
✓widely acceptable
✓inexpensive
✓simple to use
✓safe
✓highly effective
✓Requiring minimal motivation, maintenance and supervision

5. Methods
of
Contraception Temporary
Barrier Methods
Natural contraception
Intrauterine
contraceptive devices
Steroidal
contraception
Permanent
Male – Vasectomy
Female – Tubal
occlusion, ligation

6. Methods of contraception
• Spacing methods – increases gap between two pregnancy
• Terminal methods – permanent sterilization, which can be achieved either
surgically or laparoscopically

7. Contraceptive methods
in females
• Spacing
methods
1. Rhythm
method
2. Barrier
methods
3. Chemical
methods
4. Intrauterine
contraceptive
devices
• Terminal
methods
1. Surgical
methods
A. Tubectomy
B. Laparoscopic
occlusion
2. Medical
termination of
pregnancy
Contraceptive methods
in male
Spacing methods
1. Natural methods
2. Barrier methods
3. Chemical methods
Terminal method
• Vasectomy

8. Barrier Methods: prevent
sperm deposition or prevent
sperm penetration through
the cervical canal
Mechanical: polyurethane or
latex, prevent STD, spacing of
births
Male condom
Female condom, cervical cap,
diaphragm
Chemical: spermicides -
contain surfactants like
nonoxynol–9, octoxynol or
benzalkonium chloride -
sperm immobilization
Creams — Delfen
(nonoxynol-9, 12.5 %)
Jelly — Koromex, Volpar paste
Foam tablets—
Aerosol foams, Chlorimin T or
Contab, Sponge (Today – use
causes lesions associated with
STD)
Mixed: Combined use of
mechanical and chemical –
chemical methods not so

11. Rhythm Method: abstinence during
fertile period – calendar, temperature,
mucus
Withdrawal method/ Coitus Interruptus
Lactational Amenorrhoea
Fertility awareness based methods are:
(1) Natural and (2) Barrier
Based on knowledge of
Safe and Unsafe days for intercourse
Natural Contraceptive
methods –
Fertility Awareness

12. Fertility Awareness
• Depends on awareness of time
of ovulation
• In a women having regular
menstrual cycle ovulation
occur at 14th day of the cycle.
• Safe period 5 – 6 days after
bleeding phase of menstrual
cycle and 5 – 6 days before the
next cycle.
• Disadvantages – most
unreliable method when the
menstrual cycles are irregular
and time of ovulation is
variable.

14. Non-medicated:
Lippes loop (discontinued)
1st gen
Medicated (bioactive): metal copper in
devices, 2nd gen, 3rd gen
CuT-200 B (4 yrs),
CuT-200 (3 yrs),
CuT-380A (10 yrs),
Multiload-250,
Multiload-375
Hormone containing IUD: 3rd gen
progesterone (progestasert) or
levonorgestrel (LNG IUS) (7 yrs)
Intrauterine
Contraceptive
Devices
Intrauterine
Contraceptive
Devices

15. Ist Generation
III rd Generation
II nd Generation

17. 1. Biochemical and histological changes in the endometrium- Non-specific
inflammatory reaction along with biochemical changes in the endometrium:
gametotoxic and spermicidal property
• Lysosomal disintegration from macrophages attached to the device liberates
prostaglandins
• Macrophages cause phagocytosis of spermatozoa
2. Increased tubal motility-
prevents fertilization of ovum
3. Endometrial inflammatory
response – Decreased sperm
transport to fertilize the ovum
4. Copper devices- Ionized copper -
local antifertility effect prevents
blastocyst implantation through
enzymatic interference.
• Copper initiates the release of
cytokines which are cytotoxic
5. Levonorgestrel-IUS (Mirena)—
Insufficient luteal phase activity
• Strong and uniform suppression of
endometrium
• Cervical mucus becomes very
scantly
• Anovulation

21. Contraindications-
Insertion of IUCD:
(1)Pelvic infection, STI
(2)Undiagnosed genital
tract bleeding
(3) Suspected pregnancy
(4) Distortion of shape of
uterine cavity - fibroid or
congenital
(5) Severe dysmenorrhea
(6) Past history of ectopic
pregnancy
(7) Within 6 weeks
following cesarean section
(8) Trophoblastic disease
(9) Significant
immunosuppression
CuT
(10) Wilson disease
(11) Copper allergy
LNG-IUS
(12) Hepatic tumor or
hepatocellular disease
(active)
(13) Current breast cancer
(14) Severe arterial disease

22. Advantages of third generation of IUDs
(Cu T 380A, Multiload 375 and Levonorgestrel IUS)
(1) Higher efficacy with lowest pregnancy rate
(less than one per 100 women years)
(2) Longer duration of action (5–10 years)
(3) Low expulsion rate and fewer indications for
medical removal
(4) Risk of ectopic pregnancy is significantly
reduced (Cu T 380A and LNG-IUS: 0.02 HWY)
(5) Risk of PID is reduced, anemia is improved
(6) Non-contraceptive benefits LNG-IUS:
(i) Significant reduction in menstrual blood loss,
Menorrhagia, Dysmenorrhea and
Premenstrual Tension Syndrome (PMS)
(ii) May be used in the treatment of Endometrial
hyperplasia, adenomyosis, endometriosis,
uterine leiomyomas and endometrial cancer
(iii)May be used as an alternative to hysterectomy
for menorrhagia, DUB
(iv)It provides benefits of Hormone Replacement
Therapy (HRT) when used over the transition
years of reproduction to perimenopause

23. Disadvantages of third Generation of IUDs
1. Expensive
2. not available through government channel in India
currently
3. Amenorrhea (5%) - cause of its discontinuation
4. Malpositioning with long duration of use may cause
pregnancy (failure) or expulsion

24. Steroidal
Contraceptives
Oral
Combined preparations: monophasic,
biphasic, triphasic, emergency/post coital
Single preparations: progestin only mini pills,
estrogen only emergency pill
Parenteral
Injectables: DMPA, NET-EN, Combined
Implants: Implanon, Norplant II, LNG rod
Device
IUD: LNG-IUS
Vaginal: LNG ring, combined ring
Transdermal patch: nestorone

25. Combined oral
contraceptive pill
Most effective reversible
method of contraception
from 5th day of cycle to
25th day
Progestins:
levonorgestrel or
norethisterone
or
‘lipid friendly’, 3rd gen
progestins - desogestrel,
gestodene, norgestimate
4th gen: Drospirenone, an
analogue of spironolactone
used as progestin
Estrogens:
ethinyl-estradiol or
menstranol

27. Mechanism of action of combined OCPs
Inhibition of ovulation: hormones act synergistically on the hypothalamopituitary axis
to prevent release of gonadotropin releasing hormones - no peak release of FSH and LH -
follicular growth is either not initiated or if initiated, recruitment does not occur.
Producing static endometrial hypoplasia: stromal edema, decidual reaction, regression
of glands making endometrium nonreceptive to the embryo
Alteration of the character of the cervical mucus (thick, viscid and scanty) so as to
prevent sperm penetration
Probably interferes with tubal motility and alters tubal transport

29. PROGESTIN ONLY CONTRACEPTION (POP/MINI PILL) POP:
Devoid of any estrogen compound - contains very low dose of a progestin—
Levonorgestrel 75 µg, norethisterone 350 µg,
desogestrel 75 µg, lynestrenol 500 µg or norgestrel 30 µg
taken daily from the first day of the cycle
Mechanism of action:
▪ Makes cervical mucus thick and viscous, thereby prevents sperm penetration
▪ Endometrium becomes atrophic, so blastocyst implantation is also hindered
▪ In about 2 percent of cases ovulation is inhibited

30. Advantages:
▪ Side effects attributed to estrogen in the
combined pill are totally eliminated
▪ No adverse effect on lactation - can be
suitably prescribed in lactating women,
“Lactation Pill”
▪ Easy to take as there is no “On and Off”
regime
▪ It may be prescribed in patient having
(medical disorders) hypertension, fibroid,
diabetes, epilepsy, smoking and history of
thromboembolism
▪ Reduces the risk of PID and endometrial
cancer
Disadvantages:
▪ acne, mastalgia, headache, breakthrough
bleeding, or at times amenorrhea in
about 20–30 percent cases
▪ Simple cysts of the ovary - they do not
require surgery
Contraindications:
▪ Pregnancy
▪ Unexplained vaginal bleeding
▪ Recent breast cancer
▪ Arterial disease
▪ Thromboembolic disease

31. INJECTABLE PROGESTINS
▪ depomedroxy progesterone acetate (DMPA - 150 mg, every three months)
▪ norethisterone enanthate (NET-EN - 200 mg, two-monthly intervals)
▪ intramuscular (deltoid or gluteus muscle) within 5 days of the cycle
▪ subcutaneously over the anterior thigh or abdomen
▪ Mechanism of action:
▪ Inhibition of ovulation — by suppressing the mid cycle LH peak
▪ Cervical mucus becomes thick and viscid thereby prevents sperm penetration
▪ Endometrium is atrophic preventing blastocyst implantation.

32. Advantages:
▪ Eliminates regular medication as imposed by oral pill
▪ Safe during lactation
▪ Increases the milk secretion without altering its composition
▪ No estrogen related side effects, Protective against endometrial cancer
▪ Menstrual symptoms, e.g. menorrhagia, dysmenorrhea are reduced
▪ Can be used as an interim contraception before vasectomy becomes effective
▪ Reduction in PID, endometriosis, ectopic pregnancy and ovarian cancer
▪ The non-contraceptive benefits: reduced risk of—salpingitis, endometrial
cancer, iron deficiency anemia, sickle cell problems and endometriosis

33. Disadvantages:
▪ Failure rate for DMPA – (0–0.3) (HWY)
▪ There is chance of irregular bleeding and occasional phase of amenorrhea.
▪ Return of fertility after their discontinuation is usually delayed for several
months (4–8 months)
▪ However, with NET-EN the return of fertility is quicker
▪ Loss of bone mineral density (reversible) has been observed with long-term use
of depot provera
▪ Overweight, insulin resistant women may develop diabetes.
▪ Other side effects are: weight gain and headache
▪ Contraindications:
▪ Women with high risk factors for osteoporosis and the others are same as in
POP

34. IMPLANT
Implanon
progestin - 3 Ketodesogestrel (etonorgestrel), long-term (up to 3 years)
reversible contraception
inhibits ovulation in 90 percent of the cycles for the first year
supplementary effect on endometrium (atrophy) and cervical mucus (thick)
Highly effective for long-term use
Frequent irregular menstrual bleeding, spotting and amenorrhea
NORPLANT–II (Jadelle)
levonorgesterel, 3 years

35. EMERGENCY CONTRACEPTION (EC) POSTCOITAL CONTRACEPTION
• Hormones • IUD
• Anti-progesterone • Others
Indications: Unprotected intercourse, condom rupture, missed pill, delay in taking POP
for more than 3 hours, sexual assault
Hormones
Morning-after Pill- not true contraception, ’interception’
Levonorgestrel - 0.75 mg stat and after 12 hours
Ethinyl-estradiol 2.5 mg - taken orally twice daily for 5 days, beginning soon after the
exposure but not later than 72 hours
Mode of action:
▪ Ovulation is either prevented/ delayed
▪ Fertilization is interfered
▪ Implantation is prevented (except E. Pills) as the endometrium is rendered
unfavorable
▪ Interferes with the function of corpus luteum or may cause luteolysis.
Drawbacks: Nausea and vomiting

36. Copper IUD:
Introduction of a copper IUD within a maximum period of 5 days can prevent
conception & implantation
Combined hormonal regimen (Yuzpe method):
Two tablets of Ovral (0.25 mg levonorgestrel and 50 µg ethinyl estradiol) should
be taken as early as possible after coitus (< 72 hours) and two more tablets are
to be taken 12 hours later
Oral antiemetic (10 mg metoclopramide) may be taken 1 hour before each dose
to reduce the problem of nausea and vomiting

37. Anti-progesterone
Anti-progesterone (RU 486- Mifepristone) binds competitively to progesterone
receptors and nullifies the effect of endogenous progesterone
Dose: A single dose of 100 mg is to be taken within 17 days of intercourse
Implantation is prevented due to its anti-progesterone effect
Pregnancy rate is 0–0.6 percent
Ulipristal acetate as an EC is as effective as levonorgestrel
A single dose 30 mg, taken orally as soon as possible or within 120 hours of coitus
suppresses follicular, endometrial growth, delays ovulation, inhibits implantation

39. Chemical methods in Males
• Drugs – which inhibits spermatogenesis
A. Male pill (Gossypol)
B. Hormonal preparations –Testosterone, testosterone with danazol,
cyproterone acetate
C. Tripterygium wilfordii – special type of wine used in Chinese medicine
D. Calcium channel blocker - nifedipine

42. Tubectomy
• Tubectomy – fallopian tubes
are cut and ends ligated and
buried.
• Laparoscopic occlusion –
fallopian tube occluded using
silicon rubber bands, fallope
ring & Hulka-Clemens clips.

44. Vasectomy
• Vasectomy – bilateral ligation of the
vas deferens
• Advantages – safe and convenient
method
• Disadvantages – 50% of vasectomised
patients develop antibodies against
sperm.
• Vas occlusion using no scalp
technique

45. Miscellaneous methods
• Hot baths
• Suspensory
• Insulated scrotal sack

47. Failure Rate of Contraceptives in 1st 1 yr of Use
(Pregnancy Rate per 100 women years)
Method Failure Method Failure
No method 85 Combined Oral Pill 0.1
Natural 25 Progestin Only Pill 1
Withdrawal 27 DMPA and NET injectables 0.3
Lactational
Amenorrhoea
2 Norplant 0.05
Male condom 15 Implanon 0.01
Female condom 21 Vasectomy 0.15
Diaphragm 16 Tubectomy 0.15
IUCD Cu T 380 A 0.8
LNG 20 0.1

49. References
• DC DUTTA’s Textbook of GYNECOLOGY
• Indu Khurana’s Textbook of Medical Physiology