Contraception

1. Contraception
Making the Choice
Dr BuvanesChelliah
MD (UKM) MOG (UKM)
Obstetrician & Gynaecologist
Sarawak General Hospital

2. Contraception is a stepping stone for
effective Pre pregnancy care
especially for high risk women

3. Millennium Development Goals
(MDGs)

4. MMR 1950-2008
Further reduction of
maternal mortality will be a
challenge and will need the
support of other disciplines
for specialized skills,
multidisciplinary case
management, and
prevention of pregnancies
of known high-risk factors.

5. TYPES OF CONTRACEPTION

7. TYPES OF CONTRACEPTION
Natural FP/Fertility
awareness method
Calender
Ovulation method
Symptothermal
Hormone monitoring
Barrier methods
Male condom
Female condom
Diaphragm
Cervical cap
Sponges & spermicides
Combined Hormonal
contraception
COCPs
Extended-period:
Seasonale*
Combined Hormonal Patch:
EVRA*
Combined Hormonal Ring:
NuvaRing*
Progestogen-only pills
Long Acting Reversible
Contraception (LARC)
Non hormonal LARC
Hormonal LARC

8. TYPES OF CONTRACEPTION
Non-Hormonal LARC
Copper IUD
Frameless IUD*
Hormonal LARC
Injectablecontraception
Progestogen only
injectables
○DMPA
○NET-EN
Combined injectable
contraceptive
○Cyclofem/ Lunelle*
○Mesigna*
Implant
Implanon (etonogestrel
implant)
Norplant/ Jadelle*
(levonorgestrelimplant)
Intrauterine system (IUS)
LNG IUS : MIRENA
Sterilisation
Female : BTL, Hysteroscopic
sterilization: ESSURE*
Male : Vasectomy (scapel&
no-scapel), IVD implant *,
IVD clips*.

9. Failure rates of various contraceptive
methods
Method Typical Use Perfect Use
COCP 8 0.3
POP 8 0.3
IM Depo Provera 3 0.3
IUCD
-Copper
-Mirena
0.8
0.2
0.6
0.2
Implanon 0.05 0.05
Tubal Ligation (♀) 0.5 0.5
Vasectomy (♂) 0.15 0.1
Condom 15 2
Coitus Interruptus 18 4

10. So…which one to choose?

11. Natural family planning
Calender
WHO define “the voluntary avoidance of intercourse by a couple during the
fertile phase of the menstrual cycle in order to avoid a pregnancy”
Lactationalamenorrhoeamethod (LAM)

12. CALENDAR METHOD
General rule
Cycle length is recorded for
the min of 6 cycles
Likely fertile days are then
calculated allowing for the
survival of sperm and ova
First fertile day: shortest
cycle –20
Last fertile day: longest
cycle –10
Example :
If cycles of 26-32 days,
periodic abstinence should
be practice from day 6 to
day 22
Pregnancy rate of 40
per 100 women years

13. CALENDAR METHOD
Require long periods
of sexual abstinence
Provide low & varying
levels of efficacy
Do not provide any
protections against
STIs
Not suitablesfor:
Cycle length <23 days
or > 35 days
PCOS
Breastfeeding
Menopausal
symptoms
Women taking
hormonal medication

14. LACTATIONAL AMENORRHOEA
METHOD (LAM)
Exclusive BF during the
first 6 months after last
childbirth
Induced amenorrhea
FAILURE RATE 2 IN 100
WOMEN

15. Male condom
Failure rate
2-15/100 WY

16. ONLY WORKS IF APPLIED IN
THE RIGHT TRACK!!!!!!

17. Combined Oral Contraceptives
Pills (COCP)
Failure rate of 0.2-0.3 per 100 woman-years.
Examples of COCP
available in Malaysia:
•Regulon
•Rigevidon
•Microgynon
•Mercilon
•Marvelon

18. Mode of Action COCP
Suppression of ovulation
By prevention of ovarian follicular maturation
By interrupting the oestrogen-mediated positive
feedback on the hypothalamic-pituitary axis
thus preventing LH surge
Thicken the cervical mucus
Reduce sperm penetrability
Alteration of the endometrium
Thin endometriumpreventing implantation

19. Non-contraceptive benefits

20. ENSURING SUCCESS ……
ISSUES AROUND SUCCESS
OF OCP
ADMINISTRATIVE ISSUE
SIDE EFFECTS
BATTLING MYTHS
RIGHT SELECTION
OF PATIENT

21. Administration Issue : When to
start COCP?
Timing of initiation is a commonly encountered
confusion
2 different packaging : 28days (1week of placebo or sugar pills) or
21days (7d pill free period)
7d of pill free period/placebo -women will have a ‘withdrawal bleed’
Best to be taken at same time every day
Contraception is immediate if starts the pills on D1 menses
If 1
st
pill after D2 , other contraception needed for 7 days
If vomiting or diarrhoea: extra contraception
If taking antibiotics : extra contraception
Post partum (not BF) : start day 21 after delivery
Post termination/ERPOC : within 7 days of termination

22. Administration Issue : When to
start COCP?
For COCP containing 20 mcg/30mcg
EE
•If 1 or 2 pills are missed at anytime,
take the pill ASAP (NO NEED EXTRA
COVER, DO NOT STOP)
•If 2 or more pills are missed in the:
1
st
week, needs emergency
contraception if unprotected sex
and use condoms for 7 days
2
nd
week, use condom for 7
days
3
rd
week, use condom for 7 days
and continue with next packet
without a break
Missed pills in first week :
EM + Condom for 1/52
Missed pills in second /
third week : Condom for
1/52

23. RIGHT PATIENT SELECTION….
•GRANDMULTIPARA
•DESIRE LONG TERM
CONTRACEPTION
•PREVIOUS HISTORY OF FAILED
COCP
•UNTOLERABLE SIDE EFFECTS
•POOR EDUCATION/SOCIAL
BACKGROUND
•COMPLIANCE IS AN ISSUE
•RISK OUT WEIGHS BENEFIT

24. Absolute Contraindication
WHO Category 4
•Pregnancy
•Cerebrovascularaccident
•Thromboembolism
•Liver diseases
•Estrogen-dependent tumours (breast cancer)
•Undiagnosed genital tract bleeding
•Recent trophoblastic disease
•Ischaemicheart disease

25. BATTLING MYTH !!!
WEIGHT GAIN
HORMONAL DISTURBANCES
INFERILITY

26. PROGESTOGEN-ONLY PILLS (POP)
Suitable for women with
Lactation ,VTE, migraine, older women who smoke
Hpt, valvularheart disease and DM–avoids oestrogenicS/E of
COCP, Sickle cell disease,SLEand other autoimmune disease
femulen Ethynodiol dA 500ug
noriday norethisterone 350ug
micronor noresthisterone 350ug
neogest Levonogestrel* 37.5ug
microval Levonogestrel* 30ug
norgestone Levonogestrel* 30ug

27. MODE OF ACTION : POP
Main effect : Thicken cervical mucus thus
decreased sperm penetrability of cervix
Reduce receptivity of endometriumto
implantation
Reduction in ovulation
Suppress ovulation in ~40%, this is unpredictable and
varies between cycles resulting in irregular menstruation
50% have regular ovulatorycycles with normal luteal
phase and a normal menstrual cycle
10-15% of women have complete inhibition of ovarian
activity and are amenorrhoeic
New : Cerazette97% inhibit ovulation
Reduce fallopian tube motility
Failure rate 0.3-5/100
women years

28. POP : ADMINISTRATIVE ISSUE
One pill daily taken continuously without a break
Best to be taken at same hour every day (within 3 hrs at the
most)
Contraception is immediate if starts the pills on D1 menses, no
eXtra
If 1
st
pill after D5 , eXtracontraception needed for 2 days
If taking antibiotics : do not effect the efficacy of POP
If taking Rifampicin/EID : reduction of efficacy dtincreased
metabolism of POP
Post partum (not BF) : start day 21 after delivery (regardless
BF)
Post termination/ERPOC : on the day of abortion or TOP

29. POP : ADMINISTRATIVE ISSUE
MISSED PILLS
If ˃ 3hours late or 27hours since last dose
Take missed pill ASAP
Take subsequent pill at the usual time
Use extra contraception for the next 2days
If vomit within 3 hours of ingestion
Take another pill immediately
Use extra contraception for the next 2 days
An estimated 48hrs of POP use was deemed necessary to achieve the
contraceptive effects on cervical mucus

30. Disadvantages of POP
Strict adherence to the rules of pill taking
is essential
Pattern of bleeding is unpredictable
Associated with increased incidence of
ovarian follicular cysts and increased risk
of ectopic pregnancy compared to COCP
but decreased compared to sexually active
non-contraceptive user

31. new
*Cerrazette
®
Released in 2003
Contain 3
rd
generation of
progestogen –desogestrel
97% -inhibits ovulation
Window period of 12 hours
instead of 3 hours
Taken every day with no break
Useful for younger women who
cannot or do not wish to take
oestrogencontaining products
or women who cannot tolerate
other POPs.

32. LONG TERM REVERSIBLE
CONTRACEPTION
Non-Hormonal
Copper IUD
Hormonal
Injectablecontraception
Progestogen only injectables
Implant
Implanon
Norplant/ Jadelle*
Intrauterine system (IUS)
LNG IUS : MIRENA

33. INTRAUTERINE DEVICES (IUD)
NON-HORMONAL
HORMONAL

34. COPPER IUD
1
st
generation
Copper seven
Copper T 200
2
nd
generation
Multiload250
Nova T
3
rd
generation
Copper T380A
Multiload375*

35. Cu T 380 or T Safe 380A
Licensed for 8 years in
the UK
First choiceof IUCD
Low expulsion rate
8/100 women over 5
years
Low failure rate
1.4-2.2/100 women years

36. MultiloadCu 375
Licensed for 5 years
Twice as likely to result
in pregnancy compared
to Cu T 380
similar expulsion rate

37. Copper IUD
Efficacy is dependent
on the surface area of
copper
MOA :
Inhibiting fertilization by direct
toxicity
Inflammatory reaction w/in
endometrium induce anti-
implantation effect
Copper is toxic to ovum and
sperm
Copper in cervical mucus
inhibits sperm penetration.

38. Complications of Copper IUD use
Expulsion
Most common 1
st
3
months after insertion and
often during menses
Perforation
Risk 2/1000 insertions
Pelvic infection
Although 6 fold increase in
risk of developing PID in
the first 20 days, the
overall risk is low unless
there’s exposure to STIs
Bleeding pattern and
pain
Spotting,lightbleeding,heavier
or longer periods common 3-6
months
Pregnancy
Exclude ectopic pregnancy
( risk 1:25 with IUCD)
If threads are visible,IUCD
should be removed up to
12weeks
With IUCD left in situ : 2
nd
TS
abortion, PTL, infxn
Removal aw small risk of
abortion

39. Progestogen-only injection
InjectableContraception

40. INJECTABLE CONTRACEPTION
Preparations
MDPA : Depo-provera(depot
medroxyprogesteroneacetate)
NET-EN : norethisterone
enantate
MOA:Mainly; inhibition of
ovulation
Thickening of cervical mucus
prevents sperm penetration
Changes in endometriummaking
environment unfavourablefor
implantation
DMPA 150mg
Deep IM injection
Every 3 months +/-2 weeks
Failure rate 0.25-0.5/100
woman years

41. Benefits
Suitable for women
who forget to take pills, particularly travellers,
due to frequent changes in time zones, missed
pills are likely or where suboptimal
compliance is expected
Who wish for a secret or ‘private’ method
In whom oestrogenis contraindicated:
○mild to moderate hypertension
○diabetes mellitus in the absence of vascular disease
○age >35yo & smoking

42. Side effects & Risks
**Menstrual disturbances
(amenorrhea, spotting,
infrequent bleeding or prolonged
bleeding)
Amenorrhoeabecomes more
likely with ↑ duration of use
○30% after 3rd dose
○70% after 12
th
dose
**Weight gain(probably due to
progestogen ↑ appetite)
headaches, dizziness, breast
tenderness and mood changes
** reasons for discontinuation
Delay in return to normal
fertility
Following a final injection of
DMPA, ovulation returns after
6-12 months, may be as long
as 24 months
Following discontinuation:
78% conceive by 12 months
92% conceive by 24 months
Thought to be due to slow
metabolism of the drug from
the microcrystalline deposits
in muscle tissue
Osteoporosis

43. IMPLANTS

44. Implant
Trade nameProgesterone
Implanon etonogestrel1 rod
Norplantlevonorgestrel6 rods
Jadellelevonorgestrel2 rods

45. IMPLANON
®
68mg etonogestrel
Biodegradable single rod
implant
Initial release rate of
60-70µg/day and ↓ to
25-30µg at the end of 3
years

46. IMPLANON
®
Inserted subdermallyin the groove between biceps and
triceps in the non-dominant hand about 8-10cm from the
medial epicondyle
Can be administered up to day 5 of menses without the need
for additional contraception
License for 3 years –efficacy may be lower during the 3
rd
year in overweight women
Inhibit ovulation by prevention of LH surge, also affect
cervical mucus thickening and endometrium

47. BENEFIT OF IMPLANON
Independence of user
compliance
Rapid return to
fertility
90% of women ovulate
within 30 days
Efficacy not being
affected by broad-
spectrum antibiotics
Failure rate <0.1/100
woman years

48. SIDE EFFECTS of IMPLANON
Menstrual disturbances
Improve over 3-5 months
NSAIDs and low dose COCs are generally effective
treatment strategies for implanon related bleeding
2.5-5% of women suffer from alopecia,
emotional lability, depressive symptoms and
dysmenorrhea
>5% of women suffer from headache, acne and
breast pain
Little or no increase risks of VTE
No evidence to suggest clinically significant effect on
BMD
Prophylactic abs to prevent endocarditisare not
needed for insertion and removal of implants

49. LNG –IUS (MIRENA)

50. LNG-IUS : MIRENA
®
Long-acting, rapidly
reversible
52mg levonorgestrel
released at the rate of
20mcg/ day
Frame is rendered radio-
opaque by impregnation
with barium sulphate
Licensed for contraception
for 5 years

51. LNG-IUS Mechanism
The contraceptive effect
is achieved by
Works primarily by its
effect on endometrium
preventing implantation
endometrial glandular and
stromalatrophy and
endometrium
unresponsive to oestrogen
Changes in the cervical
mucus which prevent
ascent of spermatozoa
Failure rate of 0.09/100
women years

52. May be fitted up to 7 day of
menstrual cycle without
need of additional
contraception
Or at any time in the
menstrual cycle with
barrier contraceptives for
the next 7 days (exclude
pregnancy first)

53. Side effects/ complications
of LNG-IUS
Difficult insertion
especially in nulliparous
woman
Bleeding pattern
Irregular bleeding & spotting
common during 1
st
6-8mths
By 1 year amenorrhoeaor
light bleeding ensues
Amenorrhoea
Some women may regard this
as abnormal –counseling
important
Increased incidence of
functional ovarian cysts
compared to copper IUD
users
Progestogenic SE –
oedema/ headache/ breast
tenderness/ acne –subside
after a few months
Expulsion –commonly
occurs during first month
following insertion

54. STERILIZATION
Female
Mini Laparotomy
○The Pomeroy method
○The Parkland technique
○The Ushidamethod
○The Irving method
○fimbriectomy
Laparoscopic
○Filshie clip
○Hulkaclip
○Falopering
Hysteroscopic
○Chemical method:
quinacrine
○Mechanical method
Ovabloc®
Essure® device

55. STERILISATION
A permanent and usually an irreversible
Counselling, written information, its risks,
benefits & failure rates should be
provided
Discussion & information should be given
re: other methods of contraception.
Both men and women should be informed
that reversal are rarely provided.

56. PRO & CONS OF BTL
ADVANTAGES
99% effective in the first
year following the
procedure
DISADVANTAGES
Difficult to reverse (meant to
be PERMANENT)
If pregnancy does occur it
carries a 33% chance of being
an ectopic pregnancy
Expose to risk of anaesthetic/
surgical complication
More difficult than vasectomy
(complication: 1-4% with
BTL)

57. EMERGENCY CONTRACEPTION

58. EC regimes
Yuzperegime:
100µg EE & 500 µg LNG
(2Doses, 12h apart)
LNG only
Single dose of 1.5mg
LNG or 0.75mg x2 in
12h apart
Will prevent 85% of
expected pregnancies
(If taken w/in 72h of
unprotected coitus)
SE : N,V (if vomit w/in
2h,take further dose ASAP)
Erratic PV bleed first 7
days
Oral EC
IUCD EC should be inserted
w/in 72h following UPSI.
Failure rate < 1%
It can be removed after the next
menstruation or retained for
ongoing contraception.
Copper IUCD

59. THANK YOU