CONTRACEPTIONProf. Roshan Ara Qazi

Chairperson Obstetrics & Gynaecology

LUMHS, Jamshoro

The student will be able to: Describe contraception, importance of

family planning & concept of “healthy timing & spacing of pregnancy” (HTSP)

Describe major family planning methods including mechanism of action, benefits & limitations

LEARNING OBJECTIVES

Contraception: Intentional prevention of conception or

impregnation through use of various devices, agents, drugs, sexual practices or surgical procedures.

Family Planning: It allows people to attain their desired

number of children and determine the spacing of pregnancies. It is achieved through use of contraception

Definations

In June 2005, WHO brought together more than 30 technical experts to review the global scientific evidence regarding optional birth spacing & answer the following questions

1) Does pregnancy spacing affect the health of mothers and newborn?2) How long should a woman wait to get

pregnant after childbirth?

HEALTHY TIMING & SPACING OF PREGNANCY (HTSP)

3) How long should a woman wait to get pregnant after miscarriage or induced abortion?

The set of recommendation called healthy timing & spacing of pregnancy is based on the results of this technical consultation.

HEALTHY TIMING & SPACING OF PREGNANCY (HTSP) Cont..

Ref: WHO 2006; Report of a WHO technical consultation on birth spacing, Geneva, Switzerland, 13-15 June 2005, WHO Geneva

Short birth intervals are associated with multiple adverse outcomes for mothers & newborns

An infant born after short birth interval is at increased risk of ◦ Preterm birth◦ Low birth weight◦ Small for gestational age◦ Death

Key research finding

A women who becomes pregnant too quickly following previous birth/miscarriage or induced abortion faces higher risks of ◦ Anemia◦ Pre rupture of membranes◦ Abortion◦ Death

Key research finding (cont..)

AFTER LIVE BIRTHThe recommended interval before attempting the next pregnancy is at least 24 months in order to reduce the risk of advise maternal perinatal & infant outcomes

AFTER MISCARRIAGE OR INDUCED ABORTIONThe recommended minimum interval to next pregnancy should be at least 6months in order to reduce the risk of adverse maternal and perinatal outcomes

DELAY ADOLESCENCE PREGNANCYDelay timing of the first pregnancy until age 18 to reduce risks of adverse maternal, perinatal & infant outcomes

3 COMPONENTS OF HTSP

6th most populous country of Pakistan with high unmet need of family planning about 25%

Approximately 1 in 3 births occurs less than 24 months after a previous birth

The shortest birth intervals occurs in women ages 15 – 19 who are already at highest risk of pregnancy related complications

Country Profile Pakistan

The client will be given full information about optimal pregnancy spacing and the benefits of HTSP as a part of FP health education and counseling. The importance of timely initiation of an FP method after childbirth, miscarriage, or abortion will be emphasized

The client’s right to make a free and informed choice regarding eventual family size and fertility will be respected.

Country Policy

Combined hormonal contraception◦ The pill, patches, the vaginal ring

Progestogen – only preparations◦ Progestogen-only pills, injectables, subdermal implants

Hormonal emergency contraception Intrauterine contraception

◦ Copper intrauterine device (IUD), hormone-releasing intrauterine system (IUS)

Barrier Methods◦ Condoms, female barriers, coitus interruptus, natural family

planning Sterilization (Voluntary Surgical Contraception)

◦ Female sterilization, vasectomy

Classification of Contraception

Method of contraceptionFailure rate

per 100 woman years

Combined oral contraceptive pill 0.1 – 1

Progestogen – only pill 1 – 3

Depo – Provera ® 0.1 – 2

Implanon 0.1

Copper IUD 1 – 2

Mirena 0.5

Male condom 2 – 5

Diaphragm 1 – 15

Natural family planning 2 – 3

Vasectomy 0.02

Female sterilization 0.13

Effectiveness of contraceptive methods

A) Lactational Amenorrhea Method (LAM or Breastfeeding)B) Fertility awareness-based method

1) Calendar Based Method• Calendar based method• Standard days method (SDM)

2) Symptoms Based Methods• Ovulation method / cervical mucus method• Basal Body Temperature (BBT) method

3) Withdrawal Method

Natural family planning method

Helps a couple know which days they should not have unprotected intercourse

For women with menstrual cycles between 26 and 32 days long

Couples who can avoid unprotected intercourse from day 8-19

Standard Days Method

Keeping a record of at least 6 menstrual cycles.

Find the longest and shortest of the menstrual cycle

Subtract 18 from the number of days in the shortest cycle to find the first fertile day of a current cycle. (e.g. 28-18=10days)

Subtract 11 from the number of days in the longest cycle to find the last fertile day of a cycle. (e.g. 30-11=19days)

Calendar Rhythm Method

Preventing pregnancy by breast feeding Mechanism of action: ovulation prevention Very effective: 1-2 pregnancies / 100

women in firs 6 months No side effects or health risks Health benefits for the baby

Lactational Amenorrhea Method (LAM)

Women who:◦ Are fully or nearly fully breastfeeding◦ Have not had return of menses◦ Are less than 6 months postpartum

Who Can Use LAM?

Symptom Based Method

Based Body Temperature

Cervico Mucus

Shift in BBT to identify post ovulatory infertile (safe) days

Take temperature every morning before any activity

Recorded daily on a graph paper

Within twelve hours of ovulation , the BBT will rise (0.4 to 1 F) until start of next cycle

Presence or absence of cervical mucus◦ Dry (safe) days◦ Wet (fertile) days

Note mucus for:◦ Color (yellow, white,

clear, cloudy)◦ Consistency (thick,

sticky, stretchy) ◦ Feel (dry, wet, slippery,

stretchy)

Condoms are commonly made of thin sheaths of rubber (latex) or vinyl. They differ in, color, lubrication, thickness, texture and addition of spermicide.

Prevent sperm from gaining access to female reproductive tract.

Prevent microorganisms (STIs) passing from one partner to other.

Barrier Methods: Male condoms

BENEFITS No systemic side effects Widely available No prescription or medical assessment necessary Only FP method that provides protection against

STIs

LIMITATIONS Effectiveness depends on willingness to follow

instructions User-dependent (require continued motivation and

use with each act of intercourse)

Male Condoms: Contraceptive & Health Benefits and limitations

Containing both estrogen and progestin (COCs)

Prevents the release of the ovum or egg from ovaries

Brief Introduction of COCs

Highly effective when taken daily (0.1 to 1) pregnancies per 100 women during the first year of use)

Client can stop use Fertility returns soon after stopping Decrease menstrual flow (lighter, shorter

periods) Decrease menstrual cramps Protect against ovarian and endometrial

cancer

COCs: Contraceptive & Health Benifits

Some nausea, dizziness, mild breast tenderness, headaches or spotting may occur

Effectiveness may be lowered when certain drugs are taken barbiturates, carbamazetine, phenytoin and rifampicin

Rare serious side effects possible Resupply must be readily and easily available Do not protect against STIs (e.g., HBV,

HIV/AIDS)

COCs: Limitations

Women:◦ Of any reproductive age or parity who want highly

effective protection against pregnancy (within first 5 days of the menstrual cycle or any time if the client is not pregnant)

◦ Who are breastfeeding (6 months or more postpartum)◦ Who are postpartum and are not breastfeeding (begin

after third week)◦ Who are post abortion (start immediately or within 7

days)◦ With severe menstrual cramping or with irregular

menses ◦ In need of emergency contraception

Who Can Use COCs

Contains only progestin (single hormone) Mechanism of action

◦ Inhabits ovulation◦ Thickness cervical mucous

Used less often in Pakistan than COCs

Progestin only Pills (POPs) – Minipills – General Information

Injectable Contraceptives

Combined injectable contraceptive

Progestin injectable contraceptive

Contains both estrogen and progesterone

Mechanism of action: preventing ovulation

Given every 1 month Very effective at < 1

pregnancy / 100 women

Health benefits and risk similar to COC

Only progestin:◦ DMPA◦ NET-EN

Mechanism of action: preventing ovulation / thickness cervical mucous

Given ◦ DMPA – every 3 months◦ mNet-EN - every 2 months

Very effective at < 1 pregnancy/100 women

Very effective Reversible Do not affect breastfeeding Few side effects Protect against endometrial cancer and

fibroids

PICs: Advantages

Return to health clinic for an injection every 3 months (DMPA) or every 2 months (NET-EN)

Changes in menstrual bleeding patterns are common

If using DMPA, return of fertility is temporarily delayed, but does not decrease fertility in the long term

If using DMPA, 50% of women will stop having any bleeding by end of first year of use

PICs do not provide protection against STIs, (e.g., HBV, HIV/AIDS).

PICs: Limitations

EC should be considered if unprotected intercourse has occurred, if there has been failure of a barrier method for example a burst condom or if hormonal contraception has been forgotten.

1) Hormonal emergency contraception: single dose levonorgestrel 1.5mg within 72hours of unprotected intercourse

2) IUD for emergency contraception: upto 5days of unprotected intercourse.

Emergency Contraception

Intra Uterine Contraceptive Device

Intrauterine Contraceptive Devices (IUCDs) Types of IUCDs

Copper containing IUCD

Hormone releasing intra uterine system (Levonorgestrel)

Copper T 380 A

Mirena

Multiload Cu 375

LNG - IUCD

Prevents Fertilization by:

Changing endometrial lining

Interfering with ability of sperm to pass through uterine cavity

Mode of Action (IUCD)

Highly effective and economical Does not interfere with intercourse Long lasting (Multiload up to 5 years and

CuT up to 12 years) Quick return of fertility after removal no

systemic effects

Characteristics of Copper IUCD

Minor voluntary surgical procedure for permanently terminating fertility in men (vasectomy) and women (mini-laparotomy and laparoscopy)

Voluntary Surgical Contraception (VSC): Definition

Vasectomy (no-scalpel or incisional):◦ By blocking the vas deferens, sperm are no longer

present in the ejaculate Minilaparotomy or laparoscopy:

◦ By blocking the fallopian tube (tying the cutting, rings, clips or electrocautery) ovum is prevented from meeting with sperm

VSC: Mechanism of Action

BENEFITS◦ Highly effective, Permanent ◦ Simple surgery usually performed under local

anesthesia◦ No change in sexual functin

LIMITATIONS◦ Must be considered permanent (not reversible)◦ Client may regret later◦ Short-term discomfort/pain following procedure

VSC

Thank You