PowerPoint presentation on Modern Contraceptives

An overview on current trends in contraceptive technology and use detailing the different types, indications, contraindications, advantages and disadvantages with examples.

1. MODERN CONTRACEPTIVES AND THE MEDICAL ELIGIBILITY CRITERIA DR G.TAJIBOLA DR B.A ESAN SUPERVISING CONSULTANT -PROF M.A OKUNLOLA 1

2. OUTLINE Introduction Definitions Epidemiology Ideal contraceptives Indications Classifications/Methods MEC Conclusion 2

3. INTRODUCTION …1/3 Africa has the fastest-growing population in the world and is expected to have over 1.8 billion people by 2035 (Bello- Schunemann et al., 2018 ) . Studies have identified rising population growth in many African countries as a militating factor to why setting developmental goals of eradicating poverty and hunger and reducing maternal and infant mortality are not yet achieved (UNFPA, 1993 ). 3

4. INTRODUCTION …2/3 Family planning (FP) is seen globally as a great public health intervention and its acceptance is rising; however, this is not the case in many African countries ( Ogboghodo et al. , 2017 ). Contraception is not just about limiting family size and spacing of birth, it is about promoting and maintaining the well-being of the mother, child, and that of the family 4

5. INTRODUCTION …3/3 Evidence around the world has shown that increased uptake of contraception directly leads to reductions in levels of hunger and poverty. Therefore, it is not surprising that only African countries with high contraceptive prevalence are the ones that have fared better in reducing infant and maternal mortality, and eliminating hunger and poverty (Stover , 2010). 5

6. DEFINITIONS Contraception: The voluntary prevention of pregnancy by interrupting the chain of events that lead to conception. Family planning: A way of thinking and living that is adopted voluntarily upon the basis of knowledge, attitude and responsible decisions by an individual or couple in order to promote health and welfare of the family group and contribute effectively to the social development of the country. 6

7. EPIDEMIOLOGY… 1/3 17 % of married women are currently using a contraceptive method (CPR ) ( NPC, 2018) Using countries in the family planning 2020 (FP2020) initiative, the average prevalence of modern contraceptive use was estimated to be 23.9% and 28.5% among married women and those engaged in relationships between 2012 and 2017 respectively 7

8. EPIDEMIOLOGY …2/3 This is one of the lowest in the continent despite Nigeria´s commitment to attaining a 36% prevalence rate by 2018 from the 15% reported by the FMOH in 2014 . 48% of sexually active unmarried women have an unmet need for family planning. 8

9. EPIDEMIOLOGY …3/3 19% of currently married women have an unmet need for family planning . Therefore, 36% of currently married women have a demand for FP. At present, 47% of the potential demand for family planning is being met. 9

10. MODERN CONTRACEPTIVES The term modern contraceptive is rarely defined, instead , organizations and individuals who use the term simply name contraceptives and approaches that fit into their perception of that label. This may be why organisations, researchers and individuals often differ in how they categorise methods. For example, the United Nations Population Fund (UNFPA) and the Guttmacher Institute name lactational amenorrhea as a traditional method ( Singh et al., 2014) , while the World Health Organization and researchers with the Demographic and Health Surveys label it as a modern method. 10

11. IDEAL CONTRACEPTIVE Highly effective (no failure rate) No side effects Cheap Independent of intercourse Rapidly reversible Widespread availability Acceptable to all cultures and religions Easily distributed Can be administered by non-healthcare personnel THERE IS NO IDEAL CONTRACEPTIVE METHOD 11

12. INDICATIONS To space child birth To limit family size Pre-existing systemic illnesses such as DM & heart diseases Temporary ill health in either partner Previous obstetric complications Diseases transmissible to fetus Previous abnormalities in offspring Early marriage Singles (adolescent/youth) To curb undesired population growth 12

13. MODERN CONTRACEPTIVES Modern Contraceptives include: Barrier methods Hormonal methods Intrauterine devices Permanent methods Emergency contraception 13

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15. BARRIER METHOD This includes Male condom Female condom Vaginal diaphragm Cervical cap Spermicidal preparations 15

16. MALE CONDOM …1/3 The condom is a contraceptive sheath which serves as a cover for the penis during coitus and prevents the deposition of semen in the vagina It is probably the most widely used mechanical contraceptive in the world The most common material used for male condom is latex, although there are also condoms made from polyurethane material and lamb ceca 16

17. MALE CONDOM …2/3 May contain a spermicide, which may offer further protection against failure Advantages include Highly effective Cheap and readily available Protection against sexually transmitted infections (STI ) Failure may result from Imperfections from manufacture (~3 in 1000) 17

18. MALE CONDOM …3/3 Applying the condom after some semen has escaped into the vagina Escape of semen from the condom as a result of failure of withdrawal before DE tumescence (slippage) Breakage Failure rates ranges from 2-15 pregnancies per 100 woman-years. 18

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21. FEMALE CONDOM …1/2 Made of thin polyurethane material with 2 flexible rings at each end One ring (closed end) fits into the depth of the vagina, and the other ring sits outside the vagina near the introitus Advantages include Under the control of the female partner Offering some protection against STDs 21

22. FEMALE CONDOM …2/2 Disadvantages include Cost Overall bulkiness Failure rates with perfect use for 6 months is 2.6% & about 20% with typical use 22

23. MALE & FEMALE CONDOMS 23

24. FEMALE CONDOM – REALITY SHIELD/ POUCH 24

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26. THE PANTY CONDOM …1/3 The Panty Condom consists of a sensual, sexy cotton or nylon panty (thong) with an aperture in the front lower section of the panty where an interior membrane (much like a feminine day pad) contains a self adhesive condom that develops during sexual intercourse. 26

27. THE PANTY CONDOM …2/3 Female Condom is manufactured from a polyethylene resin; a material that is thinner and stronger than latex. Polyethylene is anti- allergic, ultra sensitive, transparent and odorless unlike latex. 27

28. THE PANTY CONDOM …3/3 The Panty Condom is lubricated. The Panty Condom is discreet, sexy, sensual, safe, easy to use and you can wear it all day. The condom itself is protected inside a membrane until used. The panty is re-usable and the condom is replaceable. Manufactured from polyethylene. 28

29. VAGINAL DIAPHRAGM …1/3 Circular rings of different sizes ranging from 50-105mm in diameter Mechanical barrier btw the vagina and the cervical canal Designed to fit in the vaginal cul-de-sac and cover the cervix I nsertion of the device 29

30. VAGINAL DIAPHRAGM …2/3 A contraceptive jelly or cream should be placed on the cervical side of the diaphragm before insertion because the device is ineffective without it. This medication also serves as a lubricant Additional jelly should be introduced into the vagina on and around the diaphragm after it is securely in place Advantages include Protection against STDs 30

31. VAGINAL DIAPHRAGM …3/4 Disadvantages include Requires fitting by a physician or a trained paramedic Difficulty in choosing the proper size as weight alterations & deliveries change the vaginal diameter Failure rates is 6 pregnancies per 100 woman-years with perfect use and 15-20 pregnancies per 100 woman-years with typical use 31

32. VAGINAL DIAPHRAGM …4/4 Failure may result from Improper fitting or placement Dislodgement of the diaphragm during intercourse Side effects include Vaginal wall irritation Increase risk of UTI 32

33. CERVICAL CAP Smaller cup-like diaphragms placed tightly over the cervix and held in place by suction Left in place 8-48 hours after intercourse, and its proper placement over the cervix should be confirmed by digital self-examination after each sexual act Mechanism of action, advantages, disadvantages and efficacy are similar to those diaphragms Commonest cause of failure is dislodgement 33

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36. CERVICAL BARRIER: LEAS SHIELD It is a reusable cervical barrier made up of medical grade silicone rubber. Has the same shape as cervical cap; Contains a valve in the center and a loop at the anterior end to facilitate removal. It acts by preventing sperm from entering the cervix. For maximum effectiveness Leas Shield should be inserted in vagina anytime before intercourse and should be left in for 8 hours after intercourse. 36

37. SPERMICIDAL PREPARATIONS Spermicidal vaginal jellies, creams, gels, suppositories, vaginal sponge and foams could also act as mechanical barriers to entry of sperm into the cervical canal, in addition to their toxic effect on sperm Can be used alone or in conjunction with a diaphragm, cervical cap or condom Failure rates of ~15% per year with perfect use and ~30% with typical use Do not protect against STIs Side effects include chemical irritation of the vaginal mucosa and external genitalia 37

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39. VAGINAL SPONGE Prevents pregnancy by releasing spermicides, absorbing semen and creating barrier. No fitting needed - can be used without visit to provider. Effective for 24 hours; for multiple act of intercourse Less effective in parous women. Limited availability 39

40. HORMONAL METHODS 40

41. COMBINED ORAL CONTRACEPTIVE PILLS (COCP ) Pills contain an estrogen (ethinyl estradiol) and a progestin Pills are taken each day for 21 days, followed by 7 days of placebo pills during which time most women experience withdrawal bleeding The regimen is started either with the onset of the menstrual cycle or on the Sunday closest to the start of menses Failure rates ranges between 0.1-1 per 100 woman-year 41

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43. MECHANISM OF ACTION OF COMBINED ORAL CONTRACEPTIVES (COCS) They w ork primarily by: preventing ovulation. Thickening the cervical mucus. Making the endometrial lining less receptive to implantation, Alter tubal transport of both sperm and oocyte 43

44. PHARMACOLOGY OF COCP Ethinyl estradiol: orally active estrogen compound found in most OCPs Recent new preparation: estradiol valerate Progesterone: bind to androgen receptor 1st generation: norethindrone acetate, ethynodiol diacetate 2nd generation: levonorgestrel, di- norgestrel 3rd generation: desogestrel, norgestimate Unclassified : drospirenone ( Yaz , Yasmin) . 44

45. DOSING OF COCP Low dose estrogen 20 – 25 mcg, contraceptive efficacy , more likely to have bleeding disturbances but uncertain if related to progestin as well Standard dosage estrogen 30 – 35 mcg Efficacy the same with 1 st , 2nd and 3rd generation progestins 45

46. CONTINUOUS PILL Seasonale : levonorgestrel 0.15 mg, ethinyl estradiol 30 mcg, 7 days placebo Seasonique : same except placebos contain 10 mcg of ethinyl estradiol Lybrel : levonorgestrel 0.09 mg, ethinyl estradiol 20 mcg , no placebo Used often with endometriosis, PMS, hyperandrogenism 46

47. CHEWABLE ORAL CONTRACEPTIVES First chewable OCP, Ovcon 35 (Bristol Myers Squibb Company, Princeton, NJ) Spearmint-flavored 28-day regimen pill that contains the same hormones used in standard OCPs Women should drink about 200ml of liquid afterward to ensure that the full dose reaches the stomach. 47

48. ADVANTAGES OF COCP …1/2 Reduced risk of ovarian cancer Reduced risk of endometrial cancer Reduced risk of ectopic pregnancy Reduced risk of PID (but not against lower tract infections) Reduced risk of menstrual disorders (menstrual blood loss & dysmenorrhea) 48

49. ADVANTAGES OF COCP …2/2 Reduced risk of benign breast disease Reduced risk of acne Possible protection against bone mineral density loss Possible protection against colorectal cancer Possible protection against progression of rheumatoid arthritis 49

50. DISADVANTAGES & SIDE EFFECTS OF COCP Pulmonary embolism Venous thromboembolism (VTE) Myocardial infarction Stroke Cervical cancer Breast cancer Vaginal discharge Nausea & vomiting Headaches (migraine) Weight gain Loss of libido 50

51. CONTRAINDICATIONS TO COCP Absolute Pregnancy Circulatory dxs : IHD, CVA & significant HTN Active liver disease Current or prior breast cancer Relative Undiagnosed vaginal bleeding Women at increased risk for CVS sequelae , such as active systemic lupus erythematosus , uncontrolled diabetes, or hypertension Cigarette smokers over age 35 years 51

52. PROGESTIN- ONLY PILL (MINIPILL) The minipill contains a low concentration of progestin alone Minipills must be taken each day promptly. Even a delay of 2–3 hours diminishes the contraceptive effectiveness for the next 48 hours It has a safe biological profile. 52

53. IDEAL CANDIDATES FOR POP Ideal for women for whom estrogen is contraindicated Breastfeeding women Women older than 35yeaars Sickle cell anemia Hypertension DM women who smoke , mental retardation . migraine headache . SLE . 53

54. PROGESTIN-ONLY PILLS (POP) Mechanism of action Cervical mucus becomes less permeable to sperm Endometrial lining becomes less receptive for implantation Advantages include Side effects attributable to estrogen in COCP are eliminated because no estrogen is given No special sequence of pill-taking is necessary because minipill is taken every day Failure rates is ~2-7 pregnancies per 100 woman-years Side effects include irregular bleeding and acne 54

55. INJECTABLES Injectables are long-acting reversible contraceptives . 2 categories: Progestin-only Injectables Depot Medroxyprogesterone Acetate (DMPA) Norethisterone enanthate (NET-EN ) Combined Injectables MPA/ estradiol cypionate: Cyclofem , Cyclo- provera NET-EN/ estradiol valerate: Mesigyna , Norigynon 55

56. DEPOT MEDROXYPROGESTERONE ACETATE (DMPA) …1/5 56

57. DEPOT MEDROXYPROGESTERONE ACETATE (DMPA) …2/5 DMPA is an aqueous suspension of 17-acetoxy-6-methyl progesterone. Usual dose is 150mg administered into the gluteus maximus or deltoid every 3 months (12-13weeks). Dose of NET-EN: 200mg stat. Its a bsorption is immediate, following injection and achieves concentrations sufficient for contraceptive protection within 24 hours. 57

58. DEPOT MEDROXYPROGESTERONE ACETATE (DMPA) …3/5 Mechanisms of action: Suppression of ovulation by suppression the surge of gonadotropins. Thickening cervical mucus to impede ascent of sperm. Endometrial thinning. 58

59. DEPOT MEDROXYPROGESTERONE ACETATE (DMPA) …4/5 Although effective for up to 13 weeks, the contraceptive ability can persist for approximately 4 months after the injection. During 1 year of use, the perfect use failure rate is 0.3 pregnancies per 100 woman-years. Failure rate with typical use is however 3 pregnancies per 100 woman-years . On discontinuation of DMPA, the return to baseline fertility may take up to 10 months, about 9 months for NET-EN. 59

60. DEPOT MEDROXYPROGESTERONE ACETATE (DMPA) …5/5 Health benefits Drawbacks Reduces risk of ectopic pregnancy Reduction in bone mineral density Reduces risk of endometrial cancer (up to 80%) Some patients have reported weight gain, low sex drive, changes in menstrual pattern in first 6 months, headaches, dizziness. Reduces frequency of sickle cell crises (up to 70%) Improves endometriosis symptoms Protects against PID and uterine fibroids 60

61. NORETHISTERONE ENANTHATE Not as widely used as DMPA Usual dose is 200mg IM for 8 weeks 61

62. DMPA-SC( DEPO-SUBQ PROVERA 62

63. DMPA-SC( DEPO-SUBQ PROVERA) …1/2 DMPA-SC is a new lower dose formulation of DMPA that allows for subcutaneous delivery. Contains 104 mg Depo-medroxy progesterone acetate In micro-crystalline suspension form It is available in 2 injection systems- in the Uniject device and in prefilled, single-dose, conventional syringes. 63

64. DMPA-SC (DEPO-SUBQ PROVERA) …2/2 With the Uniject system, the user squeezes a flexible reservoir that pushes the fluid through the neddle . DMPA-SC in the Uniject system is marketed under the brand name Sayana Press. Routes of administration include the abdomen and anterior thigh and upper arm . Also every 12 weeks 64

65. IMPLANTS …1/5 65

66. IMPLANTS …2/5 Non-biodegradable implants Norplant ( now discarded , 6 silastic rods) JADELLE - (2 silicon rods , levonorgestrel 75mg ) – 5 years UNIPLANT - (1 rod , levonorgestrel 75mg ) – 5 years IMPLANON - (1 rod etonogestrel 68mg ) – 3 years ) Implanon NXT ( etonogestrel 68mg ) – 3 years Biodegradable Implants Capronor II and III (which contains Levonorgestrel ) Annuelle 66

67. IMPLANTS …3/5 Norplant Implanon Thickening of cervical mucus. Inhibition of ovulation Suppressing the LH surge and causing either anovulatory cycles or luteal insufficiency. Others same as Norplant. Causes endometrial atrophy 67 MECHANISM OF ACTION OF IMPLANTS

68. IMPLANTS …4/5 Site of Insertion Inserted subcutaneously on the inner surface of the upper arm under local anaesthesia 68

69. IMPLANTS …5/5 Advantages Can be used in females with contraindication for the use of oestrogen containing contraceptives Can be used immediately postpartum Can be used by lactating mothers Not associated with changes in carbohydrate or lipid metabolism No adverse effect on bone density Side effects Menorrhagia Headaches 69

70. IMPLANON NXT Implanon NXT is essentially identical to Implanon except it has 15 mg of Barium sulphate added to the core, so it is detectable by x-ray / USS Has a pre-loaded applicator for easier insertion (improved insertion device) Implanon NXT Applicator 70

71. CONTRACEPTIVE MICROCHIP …1/2 Developed by MicroCHIP Contraceptive Implant with remote control Ability to turn the device on / off for those planning their families (may soon be available) Chip has levonorgestrel protected by titanium and platinum seals Will last 16 years then removed Dispenses 30mcg daily 71

72. 72 CONTRACEPTIVE MICROCHIP …2/2

73. INTRAUTERINE DEVICES Basically of two types: inert & medicated. Frame made of polyethylene and impregnated with barium. Mode of action: 1. Induce chemical endometritis. 2. Copper ions are toxic to gametes & negatively affect tubal fluid/ gamete transport. 3. Progestin devices inhibit ovulation and induce endometrial atrophy. Pearl index: ˂ 1 per hundred women year 73

74. INTRAUTERINE CONTRACEPTIVE DEVICE (IUCDS) IUDs are classified as: First generation : Inert or non-medicated devices. e.g., Lippe’s loop. Second generation : Consists of copper or silver-containing IUDs. e.g., CuT 380A, Nova T, Multiload Cu 250/375. Third generation : This consists of hormone releasing IUDs. E.g., Progestasert , Mirena (registered in the UK and Canada ) and Levo -Nova (registered in Finland / Generic . 74

75. SIDE - EFFECTS Menorrhagia Pelvic cramps. Ectopic gestation. Expulsion. Uterine perforation. Risk of PID. Missing string. Pregnancy with IUD in – situ. 75

76. CONTRAINDICATIONS Pregnancy. Active PID. Undiagnosed uterine bleeding Puerperal sepsis in the past year. Significant uterine congenital anomaly. Cancer of the uterus. Past ectopic pregnancy. Multiple sex partners. History of STIs in past 3 months. Menorrhagia. Wilson’s disease/ copper allergy. Risk of bacteraemia from valvular heart disease, renal dialysis, & immunosuppressive drug use. 76

77. LEVONORGESTREL INTRAUTERINE SYSTEM (MIRENA TM ) …1/3 A T-shaped polyethylene device. The frame is 32 millimeter in both the horizontal and the vertical directions. The cylindrical reservoir around the vertical stem contains a mixture of silicone and 52 mg of levonorgestrel, a progestin widely used in implants, oral contraceptives, and vaginal rings. 77

78. LEVONORGESTREL INTRAUTERINE SYSTEM (MIRENA TM ) …2/3 25 microgram of levonorgestrel is released every day. A monofilament removal thread is attached to a loop at the end of the vertical stem. Mirena is packaged within a newly designed inserter, which is discarded after use. Mirena has an effective life of 5 years. 78

79. LEVONORGESTREL INTRAUTERINE SYSTEM (MIRENA TM ) …3/3 It is highly effective with the first year failure rate of 0.1 percent and five year cumulative failure rate of 0.7 percent. There is a marked reduction in menstrual blood loss and the systemic level of hormone is very low as compared to the other progestin-only methods. Unlike copper IUDs, Mirena provides dramatic relief in dysmenorrhea .  79

80. Cu-T 380 A Mirena Content It is T-shaped. Has 314mm 2 Cu wire on vertical stem and 2 33mm 2 Cu sleeves on the 2 arms, releasing 50mcg of copper daily. 52mg Levonorgestrel, releasing 20mcg daily Life span Effective for 10 years. Approved for 5 years but has been used for 7-10years . Time of insertion Within first 10 days of menstruation. Immediately after 1 st trimester TOP Immediately post delivery (both SVD or CS) or 6 weeks after delivery. Within first 7 days of menstruation. Immediately after 1 st or 2 nd trimester TOP Immediately post delivery (both SVD or CS) Others Can be used as an emergency contraceptive. 80

81. NEW COPPER IUDS Researchers have been working to design Cu IUDs that: Are highly effective; Have minimal pain and bleeding associated with their use; Can be provided to nulliparous women; Easy to insert and remove and have lower accidental expulsion rates. Have higher continuation rates. 81

82. RECENTLY INTRODUCED IUDS Gyne -fix A frameless IUD CuSafe A T-shaped Cu IUD with flexible and uniquely-shaped arms 82

83. FINCOID 350 IUD Developed in Finland Has a movable joint that easily constricts and expands with uterine contractions. 83

84. INTRACERVICAL FIXING DEVICE Consists of a rod-shaped, copper-coated polyethylene frame that is about 4cm long with a 5 mm projection at the distal end. Through the projection, the IUD is anchored (fixed) to the inner cervical wall using a modified tenaculum . 84

85. SOFT-T IUD Manufactured and approved only for use in Switzerland. A Cu IUD with a unique shape to enhance effectiveness. 85

86. MULTILOAD MARK II Updated version of the original Multiload 375 (ML 375) ML 375 has been associated with problematic insertions. The new design allows easy insertions. 86

87. NON-CONTRACEPTIVE USES OF LNG-CONTAINING IUCD Management of menorrhagia. Reduction in dysmenorrhea. Decrease pelvic infection rates E ndometrial hyperplasia. Adenomyosis . Uterine leiomyomas . Endometriosis . Hormone replacement therapy when used over the period of transition into menopause. 87

88. VAGINAL RING (COMBINED ESTROGEN AND PROGESTIN ) One of the newest developments in Hormonal Contraception Also known as ‘The Ring’ and sold under the brand name NuvaRing Each ring provides continuous protection against pregnancy for up to one month Releases 0.012mg of ethinyl estradiol and 0.015mg of etonogestrel daily. Failure rate over 1 year of use is 0.65 pregnancies per 100 woman-years Use is unrelated to intercourse Fertility returns rapidly on removal 88

89. HOW THE RING IS USED New ring inserted every month Once inserted, the Ring is worn for 3 consecutive weeks and removed for 1 week. During the week that the Ring is not worn, menstruation occurs. Each ring provides a month’s contraception Side effects include : Sensation of a foreign body , Leucorrhea Vaginitis, Coital problems 89

90. PROGESTERONE VAGINAL RING (PVR) (PROGESTERONE-ONLY) Progesterone diffuses at a continuous flow of 10mg per day through the silicone Prolongs lactation amenorrhoea Used for Postpartum contraception Inserted after 6 weeks of delivery and for 3 months 90

91. HOW THE RING IS USED Inserted at postnatal visit (6 weeks) Worn continuously for 3 months At end of 3 months, it is removed and another replaced For now, use is stopped when menstruation returns, or for a maximum of 1 year Meant for breastfeeding women only 91

92. THE TRANSDERMAL PATCH ...1/2 The patch contains 150 µg norelgestromin and 35 µg ethinylestradiol (EE). The patch is removed after 7 days and a new patch is applied to another skin site The patch, which comes in a 20 cm 2  size, is applied once weekly for 3 weeks, followed by a patch-free week, for a 21–7 cycle Failure rates is 0.70 pregnancies per 100 woman-years for perfect use & 0.88 for typical use 92

93. THE TRANSDERMAL PATCH …2/2 Areas of application of the patch include: the lower abdomen, upper arm, upper torso ,back, buttocks. Do not apply on the breasts . The most common adverse events are estrogen related VTE Nausea Headache Application site reactions Dysmenorrhea Increase weight Breast tenderness 93

94. EMERGENCY CONTRACEPTION (EC) Is used after unprotected coitus or sex emergency to avoid pregnancy by preventing ovulation, fertilization or implantation Sex emergency can occur in any relationship (stable/unstable; consensual/nonconsensual ). Sex emergency is defined as unprotected coitus that exposes the female consort to the risk of unwanted pregnancy, and is accompanied with a sense of agitation There are no absolute medical contraindications to the use of emergency contraception. There are no age limits for the use of emergency contraception .  94

95. INDICATIONS Sexual assault/ nonconsensual sex. Ruptured condom. Missing condom Forgotten pills. Delay in receiving scheduled dose of Injectable contraceptive. Displaced diaphragm, cervical cap and vaginal ring during coitus. 95

96. EMERGENCY CONTRACEPTION Mechanism of action The hormonal method delay/inhibit ovulation or disrupt the function of the corpus luteum depending on when in the cycle the hormonal EC is taken The IUD prevents implantation and possibly interfere with sperm function Side effects include nausea and vomiting with hormonal EC 96

97. EMERGENCY CONTRACEPTION Method Timing Dosage COCP- 5 days 100 µg ethinyl estradiol Albert Yuzpe (1974) +0.5 mg LNG stat. repeat after 12 hrs POP ( Levonorgestrel tablets) 120 hours 0.75 mg LNG stat Repeat after 12 hours LNG taken as a single dose of 1.5 mg, or alternatively, LNG taken in 2 doses of 0.75 mg each, 12 hours apart. Ulipristal acetate 30mg (Ella) 4. Estrogen 72 hours 5mg ethinyl estradiol stat. Repeat q day 4/7 5. Danazol (Androgen ) 72 hours 600 mg stat Repeat after 12 hours 6. Antiprogesten (mifepristone ) 72 hours 600 mg stat 7. IUCD (cu-T) inserted within 5 days 97

98. FEMALE STERILIZATION Definition: Is a group of surgical procedures which involve ligation of both fallopian tubes through an incision in the anterior abdominal wall or posterior fornix of the vagina; removal of the uterus; or extirpation of the ovaries The basic principle of female sterilization is breaking the continuity of both fallopian tubes thus preventing the egg from moving down the fallopian tubes and keeps the sperm from the egg . Fewer than 1 in 100 women get pregnant within 1 year of having the surgery . 98

99. TIMING Immediate postpartum (within 48 hrs ) At caesarean section Interval sterilization ( 6 weeks pp ) After an abortion/ TOP Failure rate 3x higher for Post Partum Sterilisation than Interval Sterilisation because of increased vascularity and wider lumen Post Partum. 99

100. TECHNIQUE Ligation: Pomeroy Parkland Madlenar Fimbiectomy Separation of divided ends: Irvin Cooke Uchida Oxford Occlusive: Electrocoagulation Filshe clips & Falope’s rings Thermocoagulation Laser 100

101. OTHER FEMALE STERILIZATION Essure – The coil is placed inside the uterine end of the fallopian tubes using a hysteroscope via trans-cervical approach Quinacrine : A chemical compound in form of pellets inserted into the uterus, results in sterilization by producing scarring to block fallopian tubes The Adiana procedure: Trancervical sterilization procedure in which a catheter is delivered through a hysteroscope into the fallopian tube and superficial lesion is created by low level radiofrequency energy 101

102. MALE CONTRACEPTION Male sterilization: Vasectomy: Surgical technique Non surgical / No-Scalpel Vasectomy (New) Vas deferens plugs - Chemical injection of styrene maleic anhydride (SMA) into the the vas to kill the sperm as they pass through 102

103. VASECTOMY Vasectomy is a simple, safe and effective surgical procedure that permanently ends a man’s fertility Involves division of the vas deferens on each side Performed under local anaesthesia Failure rate is 0.02 per 100 woman-years Available techniques include Ligation Clips Diathermy Excision Silicon plugs/ Sclerosing agents 103

104. THE MALE PILL Gossypol , a derivative of cotton seed oil demonstrated to depress spermatogenesis effectiveness rate of 99% Potassium depletion has been reported in some users and this may lead to cardiac arrhythmias Testosterone Derivative e.g. Testosterone enanthate ( may interfere with erection ) TE + LHRH Agonist: - Effectively depresses spermatogenesis, may preserve libido Testosterone + Progestin: being tried as male contraceptive 104

105. THE ‘MALE INJECTABLE’ Male systemic method using testosterone , suppresses / inhibits pituitary Gonadotrophin, Testosterone levels are still adequate for male behaviour Levels in testis fall so low that sperm production stops High doses of testosterone in the man can cause aggressive male behaviour 105

106. OTHER PROSPECTIVE MALE CONTRACEPTIVES …1/3 JQ1 – A Thieno-triazolo-diazepine Developed by Harvard University Shuts off sperm production Eppin – An epididymal protease inhibitor Developed at UNC Chapel Hill, now researched at Eppin Pharma Inhibits sperm motility / swimming Gendarussa – Developed at Airlangga University in Surabaya, Indonesia Hypothesized to prohibit fertilization 106

107. OTHER PROSPECTIVE MALE CONTRACEPTIVES …2/3 Vasalgel — a polymer gel injected into the vas deferens, reversible birth control injection for men — may be available to all men soon Developed by Parsemus Foundation in San Francisco, CA. Blocks sperm passage Bromodomain - has testis-specific effect; Prevents spermatogenesis, requires daily injection 107

108. OTHER PROSPECTIVE MALE CONTRACEPTIVES… 3/3 ' Clean Sheets ' pill . As the name suggests, this early-stage compound, based on a known side effect of an older drug, phenoxybenzamine inhibits ejaculation (without affecting orgasm) by temporarily preventing contraction of the longitudinal muscle fibres of vas deferens Developed by King’s College, London Stops semen from being ejaculated 108

109. MEDICAL ELIGIBILITY CRITERIA MEC helps a provider to decide whether a particular contraceptive method can be used, in the presence of a given individual characteristic or medical condition. The safety of the method should be weighed along with the benefits of preventing unintended pregnancy. 109

110. PURPOSE OF THE MEDICAL ELIGIBILITY CRITERIA 110

111. WHO MEDICAL ELIGIBILITY CRITERIA CLASSIFICATION CATEGORIES 111

112. PRINCIPLES GOVERNING THE USE OF CONTRACEPTIVES Choices are usually based on safety, effectiveness, availability, acceptability and affordability. Dual protection from the simultaneous risk of HIV and other STDs must be addressed by consistent and correct use of male latex condoms . Long Acting Reversible Contraception (LARCs) -IUDs and implants are appropriate for most women including adolescents and nulliparous women. All women should receive appropriate counselling on the full range and effectiveness of all methods that they are medically eligible to use. 112

113. CONTRACEPTIVE OPTIONS FOR WOMEN WITH CHRONIC MEDICAL DISORDERS Women who have chronic medical conditions that make pregnancy an unacceptable health risk need long acting highly effective contraceptives. Barrier and behaviour based methods may not be appropriate due to their high failure rate even among typical-users. 113

114. WHO MEC CONTRACEPTIVE WHEEL RECOMMENDED CONTRACEPTVE METHODS Combined pills, COC (low dose combined oral contraceptives, with ≤ 35 μ g ethinyl estradiol) Combined contraceptive patch, P Combined contraceptive vaginal ring, CVR Combined injectable contraceptives, CIC Progestogen -only pills, POP Progestogen -only injectables , DMPA (IM,SC)/ NET-EN (depot medroxyprogesterone acetate intramuscular or subcutaneous or norethisterone enantate intramuscular ) Progestogen -only implants, LNG/ETG ( levonorgestrel or etonogestrel ) Levonorgestrel -releasing intrauterine device, LNG-IUD Copper-bearing intrauterine device, Cu-IUD 114

115. CONTRACEPTIVE OPTIONS FOR WOMEN WITH CHRONIC MEDICAL DISORDERS Medical Condition Cu-IUD LNG-IUD Implants DMPA POP Combined Hormonal Contraceptives 1. Multiple Risk factors for atherosclerotic cardiovascular disease like Older age, HTN, DM, Smoking and high/low HDL 1 2 2 3 2 3/4 2.Diabetes Mellitus History of GDM NIDDM IDDM 1 1 1 1 2 2 1 2 2 1 2 2 1 2 2 1 2 2 115

116. Medical Condition Cu-IUD LNG-IUD Implants DMPA POP Combined Hormonal Contraceptives Hypertension Adequately controlled Systolic 140-159mmHg or diastolic 90-99mmHg Systolic >160mmHg or diastolic >100mmHg 1 1 1 1 1 2 1 1 2 2 2 3 1 1 2 3 3 4 4. Sickle Cell Disease 2 1 1 1 1 2 5. Viral Hepatitis a. Carrier b. Chronic 1 1 1 1 1 1 1 1 1 1 1 1 116

117. Medical Condition Cu-IUD LNG-IUD Implants DMPA POP Combined Hormonal contraceptives 6. High Risk For HIV Initiation 2 Continuation 2 Initiation 2 Continuation 2 1 1 1 1 a. HIV positive Women; Clinically Well on ARVs Initiation 1 Continuation 1 Initiation 1 Continuation 1 1 1 1 Reduces effectiveness of Ritonavir 1 b. HIV positive Women, Not clinically well, not on ARVs Initiation 2 Continuation 1 Initiation 2 Continuation 1 - - - Reduces effectiveness of Ritonavir - 117

118. Medical Condition Cu-IUD LNG-IUD Implants DMPA POP Combined Hormonal Contraceptives 7. Uterine Fibroids 2 2 1 1 1 1 8. Tuberculosis Non Pelvic Pelvic Initiation 1 Continuation 1 Initiation 4 Continuation 3 Initiation 1 Continuation 1 Initiation 4 Continuation 3 1 1 1 1 1 1 1 1 9. Endometriosis 2 1 1 1 1 1 10. Unexplained vaginal bleeding Initiation 4 Continuation 2 Initiation 4 Continuation 2 3 3 2 2 118

119. Medical Condition Cu-IUD LNG-IUD Implants DMPA POP Combined Hormonal Contraceptives 11. Past PID With subsequent pregnancy Without subsequent pregnancy Initiation 1 Continuation 1 Initiation 2 Continuation 2 Initiation 1 Continuation 1 Initiation 2 Continuation 2 1 1 1 1 1 1 1 1 12. Rheumatoid Arthritis On Immunosuppressive Tx Not on immunosuppressive Tx Initiation 2 Continuation 1 1 Initiation 2 Continuation 1 1 1 1 2/3 2 1 1 2 2 13. Undiagnosed breast disease 1 2 1 1 1 1 14. Benign ovarian tumours including cysts 1 1 1 1 1 1 15. Obesity BMI >30kg/m2 1 1 1 1 1 2 119

120. SUMMARY OF MEC RECOMMENDATIONS FOR AGE 120

121. ADOLESCENTS AND IUD Cu-IUD LNG-IUD Menarche to < 20 years > 20 years 2 1 2 1 Evidence: Risks of pregnancy, infection and perforation are low among IUD users of any age. Heavy bleeding or removals for bleeding do not seem to be associated with age. Young women using Cu-IUDs may have an increased risk of expulsion compared with older Cu-IUD users. 121

122. CONTRACEPTIVE OPTIONS FOR WOMEN NEAR MENOPAUSE Older women can use any method until it is clear that they are no longer fertile Hormonal Methods (COCs, Injectables, patch, ring): should not be used by women >35 years of age who smoke or have migraine. Progestin only method be used in women who cannot use estrogen. ECPs can be used in women who cannot use hormonal methods on a continuous basis. Male and female condoms may be used Fertility awareness Methods should be avoided. 122

123. WHO MEC CONTRACEPTIVE WHEEL Updated in 2015 It is a convenient tool to help family planning providers. Contains the MEC for starting use of contraceptive methods This is a guide on the choice of contraceptives for women with some medical disorders. It includes choices for emergency contraception 123

124. HOW TO USE WHO CONTRACEPTIVE WHEEL It has 2 moving parts: an inner wheel with the contraceptive methods and an outer wheel with reproductive and medical conditions plus other factors that may put a woman at risk . The wheel matches up the contraceptive methods, shown on the inner disk, with specific medical conditions or characteristics shown around the outer rim. The numbers shown in the viewing slot tell you whether the woman who has this known condition or characteristic is able to start /use the contraceptive method. 124

125. Breastfeeding and postpartum Part I Explanation of development Question 1: Among breastfeeding women, does initiation of combined hormonal contraceptives (CHCs) at < 6 weeks postpartum have negative effects on breastfeeding outcomes or infant outcomes, compared with no contraception or non-hormonal contraception? (Direct evidence) PICO and databases searched Recommendations Remarks Summary of the evidence Quality of the evidence Tables and references 125

126. MEC WHEEL Selected methods Medical or health conditions MEC category Comments 126

127. THE WHO MEC APP This tool is the digital version of the MEC wheel. It is a free mobile app launched on 12 November 2018. It is available on both android playstore and Apple iOS for use by family planning practitioners. 127

128. CONCLUSION Decision-making concerning fertility control is, for many people, a deeply personal and sensitive issue, often involving religious or philosophical convictions. Thus, it is important for the clinician to approach the subject with particular sensitivity, empathy, maturity, and nonjudgmental behavior All hands must be on deck on information and provision of modern contraceptives to women who need them, empowerment of health workers and the provision and mass circulation of a national policy, tailored after the eligibility criteria on family planning/ contraceptive methods. 128

129. REFERENCES …1/2 Adefalu AA, Ladipo OA, Akinyemi OO, Popoola OA, Latunji OO, Iyanda OF. Awareness and opinions regarding contraception by women of reproductive age in North-West Nigeria. Pan African Medical Journal. 2018 May 28;30:65 Adeyemi AS, Olugbenga-Bello AI, Adeoye OA, Salawu MO, Aderinoye AA, Agbaje MA. Contraceptive prevalence and detrminants among women of reproductive age group in Ogbomoso Oyo state Nigeria. Open Access J Contracept. 2016 Mar 29 Ashimi AO, Amole T, Ugwa EA, Ohonsi AO. Awareness, practice, and predictors of family planning by pregnant women attending a tertiary hospital in a semi-rural communityof North- westNigeria . Journal of Basic and Clinical Reproductive Sciences. 2016;5(1):6-11. Bello- Schunemann J, Cilliers J, Donnenfeld Z, Aucoin C, Porter A. African future 2035: key trends. Futures Stud. 2018 Sep 1;23:127-40 . Medical eligibility criteria for contraceptive use, 5 th edition, WHO (accessed online via https://www.who.int/publications/i/item/9789241549158 19/11/2022) Ogboghodo EO, Adam VY, Wagbatsoma VA. Prevalence and determinants of contraceptive use among women of child-bearing age in a rural community in Southern Nigeria. Journal of Community Medicine and Primary Health Care. 2017 Nov 2;29(2):97-107 129

130. REFERENCES …2/2 Otovwe A, R A O-BO, Okandeji -Barry O. RA. Knowledge and perception of vasectomy among male staffs of Novena University Ogume Delta State Nigeria. IOSR J Nurs Heal Sci 2018; 7: 2320–1940. 18. Onasoga OA, Edoni EER, Ekanem J, Ekiokenigha ER. Knowledge and attitude of men towards vasectomy as a family planning method in Edo State, Nigeria. J Res Nurs Midwifery (JRNM 2013; 2: 13–21. Sihlabela - Shongwe PV. The perceptions and acceptability of vasectomy as a family planning option by adult Swazi men in Swaziland. 2019 https://repository.smu.ac.za/handle/20.500.12308/616 (accessed Oct 7, 2020). Singh S, Darroch J, Ashford L. Adding it up: the costs and benefits of investing in sexual and reproductive health. New York: Guttmacher Institute and United Nations Population Fund; 2014. Stover J, Ross J. How increased contraceptive use has reduced maternal mortality. Matern Child Health J. 2010 Sep;14(5):687-695 Tamunomie N, Vademene O, Journal OW-SM, 2016 U. Knowledge and attitude toward vasectomy among antenatal clinic attendees in a tertiary health facility in Nigeria. Sahel Med J Online 2016; 19: 201–5. 20. 130

131. THANK YOU FOR LISTENING 131