Contraceptive methods II

contraceptive methods part two for MBBS UG students including information on Oral contraceptives, injectable contraceptives, Natural methods and terminal methods-tubectomy/vasectomy

1. Contraceptive methods-II Dr Mamta Gehlawat MBBS MD PGDHHM PGDG Asst Prof Comm Med GMC SDPT

2. Hormonal Contraceptives Very effective spacing method Almost 100% effective

3. Gonadal steroids Synthetic estrogen = Ethinyl- estradiol Synthetic progesterone Pregnanes = MPA (? Breast tumors ) Oestrones= Norethisterone Gonanes = Levonorgesterol

4. Combined pill

5. Progestogen only pill (POP) = mini pill Only progestogen- small doses Useful in women where combined pills are C/I

6. MOA of the oral pills Prevent release of ovum from ovary By blocking gonadotropin from pituitary gland Drug interactions with-Rifampicin, phenobarbital, ampicillin POP pills- Thickens cervical mucus- inhibit sperm motility Also inhibit tubal motility- delay sperm and ovum transport

7. Adverse effects Others: Liver Disorders Affect lactation Delayed fertility Birth defects S/E affecting daily life: Breast tenderness Weight gain Headache/Migraine Bleeding disturbances Cardiovascular effects: MI, CVA, DVT CA Cervix Metabolic effects: Hypertension, Hyperlipidemia , Hyperglycemia

8. Benefits Protection against: Benign breast disorders Ovarian cysts Iron deficiency anemia Pelvic Inflammatory disease Ectopic pregnancy Ovarian Cancer

9. Absolute CA breast/genitals Liver disease H/o thromboembolism Cardiac abnormalities Congenital hyperlipidemia Abnormal uterine bleeding Relative Age>40 Age>35 and smoker Hypertension CKD Epilepsy Migraine Lactation DM Gall bladder disease Amennorhea /irregular bleeding

10. Use Younger women For spacing >35 years not recommended >40 years---- high risk of cardiovascular complications Annual checkup advised- to identify contraindications

11. Post-coital contraception/Morning after pill Within 72 hours of unprotected intercourse An emergency method

12. Once-a-month (long-acting) pill Quinestrol Long acting estrogen with short acting progestogen Unsuccessful

13. Chhaya

14. Male pill Research on- Preventing spermatogenesis Interfering with sperm storage and maturation Preventing sperm transport in vas differens Affecting constituents of seminal fluid Ideal male pill Decrease sperm count Not affect testosterone Not affect libido/potency

15. Gossypol Produces azoospermia/severe oligospermia 10% men permanently azoospermic in 6 months Possible toxic s/e Animal studies not convincing

16. Depot preparations 1.Injectable contraceptives a.Progesterone only DMPA NET-EN DMPA-SC b.Combined injectable contraceptives 2.Subdermal implants 3.Vaginal rings

17. DMPA=Depo Provera 150mg im 3 mthly Suppresses ovulation, tubal motility, increase cervical mucus 200mg im 2mthly Inhibits ovulation, increase cervical mucus NET-EN 104mg sc 3mthly In upper thigh/abdomen DMPA-SC = depo subQ provera 104

18. Progestin only injectables S/E- wt increase, irregular menstruation, delayed fertility Use- multipara >35 yrs with completed family Contra-indications- Same as OC pills Combined Injectable contraceptives- Cyclofem / Cycloprovera / Mesigyna Given monthly Mainly suppresses ovulation S/E and use same as OC combined pills

19. Antara

20. Sub-dermal implants Norplant------------ 6 silicone rubber capsules with LNG Norplant R 2 -----------------------------2 small rods of LNG Implanted beneath skin of forearm/arm 5 years contraception duration Disadvantage- irregular bleeding; surgical procedure needed Vaginal rings Levonorgesterol ring Worn in vagina for 3 weeks every cycle

21. Other/Misc. methods of Family Planning

22. A.Abstinence Repression of natural desire----possible mental health issues

23. B.Coitus interruptus Male withdraws his penis before ejaculation Drawback- 25% failure rate Precoital secretion may contain sperm Mistake in withdrawal timing may lead to insemination Depends on couple’s preference

24. C. Safe Period/ Rhythm method/ Calender method Based on fact that ovulation occurs from day 12 to 16 before menstruation Shortest cycle minus 18 days = first day of fertile period Longest cycle minus 10 days = last day of fertile period

25. Simple advice -To avoid intercourse between day 8 to 22 of cycle. Drawbacks- No ideal cycle High motivation Programmed sex n/a in postnatal period High failure rate S/effects- Ectopic pregnancy/ fetal anomaly

26. D. Natural methods= discipline + understanding

27. 1.Basal body temperature method (BBT) Increase in BBT of 0.5 degree at ovulation- early morning check Need for abstinence in entire pre-ovulatory period

28. 2. Cervical Mucus / Billings /Ovulation method Keeping track of cervical mucus consistency throughout the cycle Needs high motivation – inside vagina by tissue wipe

29. 3. Symptothermic method Combination of calender + cervical mucus + temperature methods Gives chance to double check the interpretation

30. E. Breastfeeding Lactational Amenorrhea Not very reliable F. Birth control vaccine In research phase One concept- vaccine from beta unit of hCG Effective for 6mth-1 year

31. Terminal methods/ Sterilization

32. Who can get sterilized? 2 living children Husband age between 25-50 yrs Wife age between 20-45 yrs Age limits may be relaxed if > 3 living children Voluntarily and with consent of spouse Understanding of the irreversible procedure

33. Male sterilization/Vasectomy

34. Important points Not immediate sterility To use another methods upto 30 ejaculations Sperm production/testosterone/libido/potency not affected Simpler, faster, cheaper than tubectomy

35. Complications Post-operative- pain, hematoma, local infection, sperm granules Spontaneous recanalization- to check in yearly follow up Auto-immune response- may reduce sperm count Psychological- if not voluntary decision Failure- Due to mis-identification of vas deferens/ anatomical variation

36. Post operative advice Minimum 30 ejaculations to achieve sterility- use contraceptive Avoid bathing 1 day Wear T bandage/support for 15 days, maintain hygiene Avoid cycling/lifting heavy weights for 15 days Stitches removal-5 th day

37. NSV= No scalpel vasectomy

38. Female sterilization/Tubectomy

39. Laparoscopy Falope rings/clips to occlude the tubes Only under supervision of OG specialist Quick procedure, short p.o.stay , small scar

40. Patient selection Follow-up Complications Not for 6 week postpartum Can be done with MTP Hb > 8 g/dl No h/o medical disorders 48 hours post op stay Home visit by health worker b/w 7-10 days post op b/w 12-18 mths post op Uncommon but may be serious requiring surgery Eg. Puncture of large blood vessels

41. Minilap /Pomeroy

42. Minilap operation/ Pomeroy technique Modification of abdominal laparoscopy Simpler process Smaller abdominal incision 2.5-3cm under local anesthesia Suitable at PHC level/ mass campaigns Safe/efficient/easy Suitable for postpartum sterilization

43. Thank you for planning 