Methods of contraception OBG GYN 2nd year.pptx

Methods of contraception. Family planning. Including surgical and non surgical methods

1. Methods of Contraception

2. Classification of contraceptive methods Temporary methods Permanent methods Natural family planning methods Females
Tubectomy Barrier methods Males
Vasectomy Estrogen and progesterone containing
OCP,vaginal rings ,transdermal patches Progesterone containing contraceptives
Mini pills,Implants,MIRENA IUCD

3. Efficacy of contraceptive Pearl index that is expressed in 100 women years

4. Natural Methods of contraception

5. Natural methods of contraception Abstinence during the fertile period Rhythm method Mucus method (Billings or ovulation) Temperature method Symptothermal method Withdrawal method (coitus interruptus) Breast feeding ( Lactational amenorrhoea method )

6. Rhythm method Also known as calendar method According to this method regular 28 day cycle Irregular cycles Safe period First and last 7 days of cycle Unsafe period Day 8 to day 19 1st day of unsafe period
Shortest cycle -18
Last day of unsafe period
Longest cycle -11

7. Cervical mucus method Effect of estrogen Effect of progesterone Thin Thick Watery and elastic Viscus Abundant Scanty Can be stretched between fingers
Spinbarkeit Cannot stretched between fiingers Intercourse is considered safe during the 'dry days' immediately after the menses until mucus is detected. Thereafter, the couple must abstain until the 4th day after the 'peak day’

8. Basal body temperature Progesterone increases BBT by 0.4 to 0.8 degree Celsius Procedure : Record BBT every morning If the woman records her basal body temperature (BBT) daily after waking up in the morning and plots the readings graphi-cally, the BBT chart will be biphasic in an ovulatory cycle . The day of temperature shift indicates the time of ovulation Unsafe period From day 5 to increase in bbt upto 3 days after it

9. Symptothermal method Combination of cervical mucus method + BBT

10. Lactational amenorrhea Increased prolactin results in Negative feedback on GnRH inturn leads to Decrease in LH and FSH hence No Ovulation Prerequisites Breast feeding should begin soon after delivery Exclusive breast feeding Atleast one feed at night Ovulation resumes 6 months if female is breast feeding exclusively 6 weeks if female is non breast feeding or partially breast feeding

11. Conclusion of natural methods of contraception Natural family planning method with least failure rate : Lactational amenorrhea Disadvantages of natural family planning methods Needs motivation Timed intercourse Associated with high failure rate

12. Barrier methods

13. Barrier methods Male and female condoms Diaphragm Today sponge

14. Barrier methods Protects against STD PID Cannot be used as an emergency contraceptive

15. Male condom Cheaper Nirodh brand is distributed free of cost in government hospitals Can only be used once Has to be put on an erect penis and removed once intercourse is over Made of polyurethane Failure rate 2-12 HWY

16. Female condoms Can be used upto two times Absolute contraindication rectocele and cystocele Made of polyurethane prelubricated. It has a polyurethane ring at the closed end of the sheath, serving as an insertion and anchoring device, and the second end is open and lies outside the vagina after insertion. It has the combined features of a diaphragm and a condom . It covers the entire vagina, cervix as well as the external genitalia. It is highly protective against spread of STDs, and AIDS in particular. It can be removed immediately after intercourse. The advantages are as follows (i) it is coital-independent and can be worn well in advance of the sexual act (ii) it does not slip off easily, and the failure rate is expected to be low (ii) it is stronger than the condom and does not burst easily; (iv) Failure rate is 5-15 per 100 woman-vears.

17. Diaphragm Dome shaped cups Made of rubber , latex or silicone Can be reused till 1 year Drawbacks are Spermicidal agents to be used additionally Needs to be removed 6 hours after intercourse Does not protect against HIV Contraindications for use Prolapse Fistula Eroded cervix Recurrent UTI

18. Today sponge Mushroom shaped device having 1gram nonyxnol 9( spermicidal agent) Once inserted can be used upto 24 hrs

19. ESTROGEN AND PROGESTERONE CONTRACEPTIVES

20. Oral combined pills(E+P) Most frequently used method of CONTRACEPTION CLASSIFICATION BASED ON Dose of pills Generation of the pills Estrogen component ( ethinyl estradiol) High dose pills- EE > 50mcg Low dose-EE<50mcg Very low dose- EE<20 mcg Progesterone component 1 st generation 2 nd generation 3 rd generation ( least androgenic) 4th generation ( anti androgenic)

21. 3 rd generation Gestodene Norgestimate Desogestral 4 th generation Drospirenone(aldosterone antagonist-antagonizes water and salt retention caused by estrogen,Has antiandrogenic effect as well) Dienogest

22. Mechanism of action LH OCP Estrogen Decreased GnRH Anovulation Decreased FSH and LH Progesterone Thickens cervical mucosa Decreased tubal motility Unsuitable for implantation Decidualization of endometrium Thinning of endometrium

23. PREPARATIONS Monophasic Biphasic Triphasic Composition of important pills:- PILL COMPOSITION MALA D 30mcg EE + 0.15mg LNG Sold by government of India at subsided rates MALA N 30 mcg EE + 0.15mg LNG Distributed free of cost YASMIN 30mcg EE+ 3mg Drospirenone 4th generation OCP

24. CLINICAL USES OF OCP Contraception -regular and emergency Non contraceptive uses Action of OCP Used in Makes cycles regular Patients with irregular menstruation (DOC)
PCOS ( DOC) Reduce menstrual blood loss AUB Fibroid Endometriosis Makes cycles anovulatory Pelvic pain disorders- primary dysmenorrhea(DOC) and endometriosis Ovarian cyst ( functional) Menstrual migraine Mittelschmerz syndrome To manage PMS Oestrogen component HRT
Management of turner syndrome Progesterone component Decreases the chance of PID STD Ectopic pregnancy Decreases GnRH,LH,androgen Hirsutism (DOC) Acne hyperandrogensmi

25. Effects of OCPs on other diseases Increases Relieves/ decreases Hepatic adenomas Breast cancer in premenopausal females Ca cervix Endometrial cancer Ovarian cancer Ovariancysts Benignbreast disease Colorectal disease

26. Side effects Minor side effects Nausea,vomiting Candidal vaginitis Hyperpigmentation of face Weight gain Increase In cervical discharge Cardiovascular and metabolic adverse effects Venous thrombosis IHD Stroke Protein metabolism- increase in SHBG thereby increasing the level of total hormones by reducing thebioavailability of free hormones such as testosterone, thyroxine and Cortisol

27. Contraindications Uncontrolled hypertension (>160/110 mg of hg) Known/ suscaseof breast case Undiagnosed vaginal bleeding Smoker> 35yrs of age History of venous thrombosis, embolism,thrombophilia Known IHD Severe hypercholestremia,hypertriglyceridemia( 750mg/dl) Presently impaired liver function/liver cancer/Acute or chronic cholestatic liver disease Diabetes with vasculopathy Breast feeding and post Parfums females( <21 days)

28. Administration Start the pill on day1 of cycle(pills can be started on day 1- 5 days too) Pill started after day 5 -additional method of CONTRACEPTION should be used for 1week One pill should be taken daily at the same time Most common side effects- breaththrough bleeding ( 24 pill pack to avoid breakthrough bleeding) In case of missed pills One pill – take asap resume schedule Two pills- week 1 or 2 – take 2 pills daily for 2 days and finish the pack.backup for 7 days Week 3- start a new pack. Use backup immediately for 7 days( same for If 3 pills missed anytime) Fertility returns within 3 months of stopping the pills

29. Other forms of oestrogen- progesterone combinations Transvaginal rings Kept in Place for 3 weeks with1 week break before next period Less breakthrough bleeding and spotting NUVA RING ANNOVERA RING Ethinyl estradiol 15mcg/ day 13mcg/ day Progesterone component Etonorgestrel 120mcg/ day Segesterol 150mcg/ day

30. Transdermal patch EE ( 20mcg/ day) and progesterone: norelgestromin(150mcg/ day) Used for 3 weeks with 1 week before next cycle Site: lower abdomen,upper outer arm,upper torso

31. PROGESTERONE ONLY CONTRACEPTIVES

32. Types Mechanism of action Pop –thicken cervical mucus Implant,injections,cerazette( pop available in india) main mechanism- anovulation other mechanism- thick cervical mucus Inhibit tubal peristalsis thicken cervical mucus so sperms cannot penetratethe thickened mucus and therefore decrease chance of PID, STD Implants Progesterone only pills Injection IUCD

33. They don’t have any effect on :- Carbohydrate metabolism Lipid metabolism Clotting Factors Therefore, used by Breastfeeding ffemales Females with history of thromboembolism Smokers Age >35 yrw Obese females Hypertension and hypercholestremia Diabetes with vasculopathy

34. Side effects Irregular bleeding and may ultimately lead to secondary dysmenorrhea ( endometrial atrophy) Contraindications Undiagnosed vaginal bleeding Known or suspected breast cancer Benign or Malignant liver tumours

35. Progesterone only pills Eg : mini pills, cerazette Contains low dose progesterone Cerazette- mini pill available in India 75Mcg of Desogestral Acts by causing anovulation window period -12hrs They must be taken at the same time each day Or within the window period .

36. Implants Single rod implant called implanon is used Nexplanon Implant containing etonorgestrel 60mcg/ day Lifespan of implanon- 3 Years Inserted on the medial side of non dominant arm Insertion and removal are simple opd procedures Fertility returns within a month of removal

37. Depot medroxyprogestrone acetate It is an injection Included by the Antara in national family planning program 150mg DMPA Administered IM in deltoid or gluten region Taken once in 3 months Window period 4 weeks Advantages – contraceptive of choice in epilepsy and sickle cell anemia Disadvantages- delayed return of fertility ( 12 – 24 months) and decreases bone mineral density

38. Intrauterine contraceptive device

39. Types of IUCD 1 st generation : Inert IUCDS ex: Lippes Loop 2 nd generation : Cu containing IUCD eg : CU T , Multiload devices 3 rd generation : Hormone containing IUCD ( progesterone) eg :MIRENA

40. Patient Selection . IUCDs are a good contraceptive choice for the following groups of women: Low risk of STD Multiparous woman Monogamous relationship Desirous of long-term reversible method of contraception, but not yet desirous of permanent sterilization Unhappy or unreliable users of oral contraception or barrier contraception Uses of IUCD As a contraceptive Postcoital contraception (emergency contraception) Following intrauterine procedure such as adhesiolysis and septal resection prevents development of Asherman syndrome (to be used after removing the copper) Hormonal IUCD (Mirena) in menorrhagia and dysmen-orrhoea, and hormonal replacement therapy in menopausal women In a woman on Tamoxifen for breast cancer, Mirena can be used to counteract endometrial hyperplasia

41. Contraindications Suspected pregnancy Pelvic inflammatory disease (PID), lower genital tract infection Presence of fibroids - because of misfit Menorrhagia and dysmenorrhoea, if Copper-T is used Severe anaemia Diabetic women who are not well controlled - because of slight increase in pelvic infection Previous ectopic pregnancy Scarred uterus Preferably avoid its use in unmarried and nulliparous patients because of the risk of PID and subsequent tubal infertility LNG IUCD in breast cancer Uterine anomalies such as bicornuate uterus, septate uterus

42. Complications Immediate Difficulty in insertion Vasovagal attack Uterine cramps Early Expulsion (2%-5%) Perforation (1%-2%) Spotting, menorrhagia (2%-10%) Dysmenorrhoea (2%-10%) Vaginal infection Actinomycosis Late PID - 2%-5%. IUCD does not prevent transmission of HIV Pregnancy - 1-3 per 100 woman-years (failure rate) Ectopic pregnancy Perforation Menorrhagia Dysmenorrhoea

43. Mechanism of Action Several mechanisms are responsible for the contraceptive effect of an IUCD. The presence of a foreign body in the uterine cavity renders the migration of spermatozoa difficult. A foreign body within the uterus provokes uterine contractility through prostaglandin release and increases the tubal peristalsis so that the fertilized egg is propelled down the fallopian tube more rapidly than in normal and it reaches the uterine cavity before the development of chorionic villi and thus is unable to implant. The device in situ causes leucocytic infiltration in the endometrium. The macrophages engulf the fertilized egg if it enters the endometrial tissue.  Copper-T elutes copper which brings about certain enzymatic and metabolic changes in the endometrial tissue which are inimical to the implantation of the fertilized ovum.  Progestogen-carrying device causes alteration in the cervical mucus which prevents penetration of sperm, in addition to its local action. It also causes endometrial atrophy. It prevents ovulation in about 40%.

44. Missing IUD Methods of identification X-ray USG Hysteroscopy

45. Permanent Methods

46. Types Vasectomy, Tubectomy

47. Vasectomy Segment of vas deferens of both the sides are resected and the cut ends are ligated. Method; no scalpel vasectomy(NSV)

48. Steps of NSV Procedure is done under local anesthetic. The vas is palpated with three fingers of the left hand; index and thumb in front and the middle behind. This is done at the level midway between the top of the testis and the base of the penis The vas is grasped with a ringed clamp applied perpendicularly on the skin overlying the vas. The skin is punctured with the sharp pointed end of the medial blade of dissecting forceps. The puncture point is enlarged by spreading the tissues (dartos muscle and spermatic fascia) inserting both the tips of the dissecting forceps.

49. Steps of NSV The vas is elevated with the dissecting forceps and in hold with the ringed clamp. At least 1 cm of length of vas is made free and mobilized. The vas is ligated at two places 1 cm apart by chromic catgut and the segment of the vas in between the ligatures is resected out. Wound dressing is done and a small pressure bandage is applied. The same procedure is repeated on the other side. A scrotal suspensory bandage is worn. The patient is allowed to go home after half an hour. Histological examination of the excised segment of the vas should be done for confirmation if the surgeon is in any doubt.

50. Advice Antibiotic (Injection Penidure LA6 IM) is administered as a routine and an analgesic is prescribed. Heavy work or cycling is restricted for about 2 weeks, For checkup, the patient should report back after 1 week, or earlier, if complication arises. Additional contraceptive should be used for 3–4 months.

51. Precaution Semen should be examined either by one test after 16 weeks or by two test at 12 weeks and 16 weeks after vasectomy and if the two consecutive semen analyses show absence of spermatozoa, the man is declared as sterile. Till then, additional contraceptive (condom or DMPA to wife) should be advised.

52. Complication Immediate Wound sepsis which may lead to scrotal cellulitis or abscess; Scrotal hematoma. Remote Spermgranuloma is due to inflammatory reaction to sperm leakage. (prevented by cauterization), Chronic intrascrotal pain and discomfort (scar tissue formation, or tubular distension of the epididymis), Spontaneous recanalization (1 in 2,000) is rare.

53. Tubectomy Resection of a segment of both the Fallopian tubes is done to achieve permanent sterilization. The approach may be: Abdominal Vaginal

54. Abdominal approach Conventional Minilaporotomy

55. Conventional (Laparotomy)—Steps: Anesthesia: General or spinal or local anesthesia. Incision: In puerperal cases, where the uterus is felt per abdomen, the incision is made two fingers breadth below the fundal height and in interval cases, the incision is made two fingers breadth above the symphysis pubis. midline or paramedian or transverse. Delivery of the tube: The index finger is introduced through the incision. The finger is passed across the posterior surface of the uterus and then to the posterior leaf of the broad ligament from where the tube is hooked out. The tube is identified by the fimbrial end and mesosalpinx containing utero-ovarian anastomotic vessels.

56. Techniques Pomeroy’s:

57. Uchida technique—A saline solution is injected subserosally in the mid portion of the tube to create a bleb. The serous coat is incised along the antimesenteric border to expose the muscular tube. The tube is ligated with chromic catgut on either side and about 3–5 cm of the tube is resected off. The ligated proximal stump is allowed to retract beneath the serous coat. The serous coat is closed with a fine suture in such a way that the proximal stump is buried but the distal stump is open to the peritoneal cavity. No failure in this method has been observed so far.

58. Irving method — The tube is ligated on either side and mid portion of the tube (between the ties) is excised. The free medial end of the tube is then turned back and buried into the posterior uterine wall creating a myometrial tunnel and distal cut end is buried in the mesosalpinx;

59. Madlener technique- It is the easiest method. The loop of the tube is crushed with an artery forceps. The crushed area is tied with black silk. The loop is not excised. The failure rate is very high to the extent of 7% and hence, it is abandoned in preference to the Pomeroy’s technique.

60. Kroener method the ampullary end of the tube is ligated and resected not a common procedure.

61. Minilaporotmy MINILAPAROTOMY (MINI-LAP): When the tubectomy is done through a small abdominal incision along with some device, the procedure is called mini-lap. Steps: (1) Anesthesia —local, 2) Plan of incision — smaller incision compared to conventional method, 3) Specially designed retractor may be introduced after the abdomen is opened; 4) Uterus is elevated or pushed to one side or the other by the elevator that has already been introduced transvaginally into the uterine cavity. This helps manipulation of the tube in bringing it close to the incisional area, when it is seized by artery forceps; 5) The appropriate technique of tubectomy is performed on one side and then repeated on the other side; 6) The peritoneum is closed by purse string suture.

62. Vaginal ligation The approach to the tube is through posterior colpotomy. Surgeon needs additional skill of vaginal surgery. Interval cases (uterus < 12 weeks) are most suited. It is done under general or spinal anesthesia. It takes longer time. Laparotomy may sometimes be needed due to difficulties. Complications are: hemorrhage, broad ligament hematoma and rarely rectal injury. Dyspareunia may be a late complication. Advantage: Short hospital stay, convenient in obese women.