CONTRACEPTIONPREVENTION OF FERTILIZATION

ARVIN RAJ GOONASEGARAN

061303507

GROUP B2

BATCH 20

OVERVIEW Tier 1 * Progestin implants * IUCD Tier 2 * DMPA * OCP * Vaginal rings * Transdermal patches Tier 3 * Male and female condoms, diaphragms, caps * Spermicides * Withdrawal, Fertility awareness method * Natural family planning

TIER 1

Most effective Reversible method Failure rate lesser than 1% on average Long term Convenient Not compliance dependent

CONTRACEPTIVE IMPLANTS

Implanon ( widely used the USA ) Specification : * 4cm long, 2mm diameter * Progestin used : 68mg Etonogestrel * Active metabolite of Desogestrel * 0.09 ng/ml vs Levonorgestrel 0.4 –

0.5ng/ml to inhibit ovulation * Mixed into matrix of plastic rod (ethylene vinyl acetate copolymer ) * 3 years coverage. Failure rate : 0.38%

SC IMPLANT – UPPER NONDOMINANT ARM

Absolute contraindication

- Breast cancer in last 5 years

- Current DVT

- Benign or malignant liver disease

- Anticonvulsants – phenobarbital , increase

Cyt P-450 activity which increases failure rate

Relative contraindication

- History of ectopic pregnancy

- Heavy smoker

- DM, HTN

- Within 6 weeks postpartum

CANDIDATES

Poor compliance

Medical conditions where pregnancy is

contraindicated

Estrogen contraindication

MOA

Suppression of the LH surge

Suppression of ovulation

Development of viscous and scant cervical

mucus to deter sperm penetration

Prevention of endometrial growth and

development.

Advantages - long term effectiveness - no exogenous Estrogen - prompt return of fertility after removal(3

weeks) - no adverse effect on breast milk production

Disadvantage - minor surgical procedure - spotting, irregular menses - weight gain, acne, and headaches lesser

than Norplant - decrease prevalence of frequent and

prolonged bleeding compare to Norplant

IUCD

Copper T380, Progestasert LNG-IUS ( Mirena ) Protection as good as sterilization

Copper T- 380 - 1988 Specification: - polyethylene with fine copper wrapped

around the vertical system - clear or white string - 308 mg of copper - First year failure rate : 0.7% - 10 – 12 years cumulative rate : 1.4 -1.9% Candidates : - Most women including, - Morbid obesity - HTN,DM - Stroke, MI, Cancer

Absolute Contraindication - PID - Uterine cavity distortion - Active cancer in cervix and uterus

Relative Contraindication - 4 – 6 weeks postpartum

MOA - immobilizing and killing sperms

Advice - menses may be heavier or longer ( better to use LNS – IUS )

Advantages - no systemic side effect - prolonged protection Disadvantages - uterine perforation at the time of insertion - increased dysmenorrhea - increased menstrual blood loss the first few

cycles - risk of ectopic pregnancy - no protection against STI

Mirena - 2000 Specification : - T - shaped polyethylene frame - reservoir that contains LNS - IUS has 20 mcg/day lasting 5 years - Cylinder has a membrane that regulates the

release - Visible on Xray - used to treat menorrhagia as well - First year failure rate : 0.14%

Advantages

- same as copper T

- added hormonal support

- lesser risk of ectopic pregnancy

- 20% experience amenorrhea

Disadvantages

- spotting, resolves by 12 mths in 20%

- episodes on unscheduled bleeding

- others similar to copper T

MOA

- Cervical mucus thicker in consistency,

altering sperm migration

- Uterotubal fluid and motility changes inhibit

sperm migration

- Endometrial suppression

TIER 2

Works primarily by thickening cervical mucus Blocks LH surge Failure rate in typical use : 8% FR in correct & consistent usage: 0.3 -2% Requires compliance Can be started on any day of a woman’s

cycle as long as she is not pregnant

COMBINED OCP

Beyaz – 4th generation

Specification :

- Drospirenone : 3 mg

- Ethinyl estradiol : 20 mcg ( Yasmin : 30 mcg )

- Levomefolate calcium : 451 mcg

Yaz : doesn’t have folate

Reduction of estrogen dose to 20 mcg

Failure rate : 0.1 to 5%

USAGE

Monophasic - hormonal dose constant

Phasic - either or both hormonal dose may vary

Used on first day of menses or the first Sunday

after menses has begun

21 hormonal pills, 7 placebo pills

Usage of 24-day OCP having long half-life

progestogen has higher effectiveness1

1. Dinger J, Minh TD, Buttmann N, Bardenheuer K. Effectiveness of oral contraceptive pills in a large U.S. cohort

comparing progestogen and regimen. Obstet Gynecol. Jan 2011;117(1):33-40.

When 1 or 2 pills is missed,

Take 1 tablet the moment she remembers

Then take 1 pill twice a day until coverage of

missed pills is achieved.

If more than 2 pills missed, continue pills

with back up barrier contraception till next

menses

MOA

Prevention of ovulation – dominant MOA

By inhibiting both FSH and LH

Alter consistency of cervical mucus

Affect endometrial lining

Alter tubal transport

Advantages

- good success rate

- decrease incidence such as weight gain,

breast tenderness and nausea – lower dose Est

- treats menstrual irregularities

- reduce or eliminate mittelschmerz

- allows women to avoid menses during certain

events

- prevents benign breast disease, PID,

functional cysts and ectopic

- prevent ovarian and endometrial ca

- 40% reduced risk of malignant and

borderline epithelial ca

- 50% reduced risk of adenoCa of

endometrium

- protection for 15 years after discontinuation

Disadvantages

- “ Concerns about the safety of drospirenone with respect to VTE

risk were raised in 2 recent articles published online April 21 in the

BMJ. These studies showed a 2- to 3-fold greater risk for VTEs in

women using oral contraceptives containing drospirenone compared

with those using contraceptives containing levonorgestrel.”

- Breakthrough bleeding

- Amenorrhea

- Headaches

- No STI protection

- Increase failure rate with inconsistent use

- Delay in restart of menstrual cycle aft discontinuation

Metabolic effects and safety

- DVT

- HTN : not so in newer generation OCPs

- Atherogenesis and stroke : inadequate data

to suggest risk of CVS disease.

- sedentary, overweight, heavy smoking,

hypertensive, diabetic and high cholesterol

are definite risk factors

- Hepatocellular adenoma – benign but risk of

rupture. But lower risk in new OCPs.

Cancer

- relation to Breast ca still remains

controversial

- but the risk is small

- relation to cervical Ca is also controversial.

- weak assc btw OCP and SCC of cervix

- early sexual debut and HPV still remain

more important

- do annual Pap smear to monitor

CONTRAINDICATIONS

CVA, CAD

Hx of DVT, PE or CCF

Untreated HTN, DM with vascular

complications

Existing Breast Ca

Undiagnosed vaginal bleeding

Known or suspected pregnancy

Active liver disease

> 35 yrs old

Smoking

Kidney and adrenal gland insufficiency

K+ levels has to be monitored especially

when ACE inhibitors and NSAIDS used

concurrently

SEASONIQUE

91-day combined OCP 12 weeks active tablets 30mcg EE, 150 mcg LNG 7 extra active pills of 10 mcg EE Diminished amount of unplanned bleeding

and spotting Fewer or no symptoms (eg, cramping,

bloating, headaches)

POP ( MINIPILL )

Less than 1% use it

Breastfeeding and contrainidication to Est

2 formulations : 75mcg norgestrel OR 350mcg

norethindrone

Suppression of ovulation

Variable dampening effect on LH and FSH

Increase cervical mucus viscosity

Reduce number and size of endometrial glands

Alter tubal motility

Failure rate : 7% in the 1st year of typical use

Advantage :

- lack of est side effects

- decreased dysmenorrhea

- decreased mestrual blood loss

- decrease PMS symptoms

- immediate reestablishment of fertility on

cessation – rapid return to baseline : 24 hrs

Disadvantage:

- requires compliance

- require backup contraception if pills missed or

taken late

- late if take more than 3 hours of designated time

- when pill missed : take it immediately when

remembered and take next pill on scheduled time

- use backup for the next 48 hrs

- nausea, breast tenderness

- headache and amenorrhea

INJECTABLE DMPA

Suspension of microcrystals of synthetic progestin – IM

Serum concentration of 1ng/ml maintained for 3 months

5th month – 0.2ng/ml 7th – 9th month : undetectable Inhibit ovulation and eliminates LH surge 150 mg single dose – works for 14 weeks Failure rate : 0.3%

Advantages: same as POP, but better

compliance

Disadvantages :

- eventual amenorrhea in 50%

- irregular bleeding treated by starting next

dose earlier or use low dose Est temporarily

- delay of return to fertility

70% in 12months

90% in 24 months

- weight gain2

- depression - decreases bone mineral density Newer SC version : depo-subQ provera 104

2 Bonny AE, Secic M, Cromer B. Early weight gain related to later weight gain in adolescents on depot medroxyprogesterone acetate. Obstet Gynecol. Apr 2011;117(4):793-7.

TRANSDERMAL PATCH Each patch contains 1 wk supply of: - norelgestromin and EE Failure rate : 1% Good compliance Lesser N&V due to avoidance of 1st pass

effect Disadvantage : - skin irritation - other S/E similar to OCP

VAGINAL RING

First developed in1970s NuvaRing – nonbiodegradable, flexible,

colourless ring 11.7 mg etonogestrel , 2.7 mg EE Releases 120 mcg etonogestrel and 15mcg

EE per day Used for 3 weeks, and removed for 1 week to

allow menses Inserted any day of the first 5 days of

menses Use backup for the first 7 days

If it comes out within 3 weeks

Wash with lukewarm water and replace

If ring free interval > 3hrs, use back up for 7

days

Never leave it in for > 4 weeks

Reported better compliance than OCP in 3-

month trial period

Advantage : - higher efficacy of complete suppression of

ovulation - effective reversibility - failure rate : 1% in perfect use - hepatic first-pass metabolism of progestin

prevented - N & V is also much lesser Disadvantage - headaches and vaginal irritation or

discharge - ring slips out during intercourse Other contraindications : similar to OCP

TIER 3

Only to be used at the time of intercourse

Used as back up contraceptive

Can prevent STIs

Most commonly used male condoms

Usage of condoms in Malaysia is 9.72%3

3. World Contraceptive Use. (2007). Retrieved July 18, 2010, from United Nations Department of Economic and Social Affairs Population Division Web site: http://www.un.org/esa/population/publications/contraceptive2007/contraceptive_2007_table.pdf

MALE CONDOMS

Latex

Various brands, designs, colours, flavours

Cheap

Easily available

Mechanical barrier

Protects against STIs

Failure rate : 2% perfect use

14-17% typical use

Reason for failure

- failure to use throughout intercourse

- improper lubricant : oil based

- incorrect placement

- poor withdrawal technique

FEMALE CONDOM

7.8cm in diameter , 17 cm long

Prevents passage of semen

Don’t use with male condom together, the may

adhere and lead to slippage or displacement

Failure rate : 15% in 6 months

Less than 1% of females use it

Can be used 8 hrs before intercourse

Oil based lubricant doesn’t affect its intergrity

Disadvantage

- lubricant doesn’t contain spermicide

- inner ring may cause discomfort

- may cause UTI if left for a prolonged period

OTHER BARRIERS

Spermicide - base + nonoxynol-9 / octoxynol - has surfactant that destroys the sperm cell

membrane - bases : vaginal foams, creams, jellies - reduces risk of infection by both viral and

bacteria - but it’s toxic to lactobacilli - MOA: attacks sperms’s flagella and body - reduces its motility - disrupting their fructolytic activity

Diaphragm

Cervical cap

PERIODIC ABSTINENCE

Coitus Interruptus - withdrawal of penis before ejaculation - failure rate 4% - typical use : 19% - no cost, no chemical, readily available - probability of pregnancy is used incorrectly

LACTATIONAL AMENORRHEA

Elevated prolactin levels

Reduction in GnRH

Leading to reduction in LH and inhibition of

follicular maturation

Depends on frequency and duration of

breastfeeding

Length of time since birth

As soon as menses begin, use other

contraceptive

Failure rate in perfect use within 6 months :

0.5%

Failure rate in typical use within 6 months :

2%

Should not be used in HIV mothers

NATURAL FAMILY PLANNING

Widely used

Involves period abstinence

Techniques to determine the fertile period

- calendar method

- cervical mucus method

- symptothermal method

Typical use failure rate : 25%

Calendar method

- 3 assumptions:

a) ovum is capable of fertilizing up to 24 hrs after

ovulation

b) sperms survives for 48 -72 hrs

c) ovulation occurs 12-16 days before onset of

next

menses

- record menses for 6 cycles

- earliest day of fertile period : shortest cycle - 18

- latest day : longest cycle - 11

Cervical mucus method

- quantifying the cervical mucus with her fingers

- intercourse is allowed 4 days after the maximal

cervical mucus until menstruation

Symptothermal method

- end of the fertile period is predicted based on

BBT

- BBT relatively low during the follicular phase

- rises in the luteal phase due to progesterone

- rise begins 1-2 days after ovulation

- intercourse can resume after 3 days

EMERGENCY CONTRACEPTION

Drug or device to prevent pregnancy after

unprotected coitus or contraceptive failure

EM pills, copper T380 IUCD, Minipill EM

method

Candidates:

- use within 72 hrs of unprotected coitus

- no absolute CI as the high dose is short lived

ECP 2 pills

0.5mg LNG and 100 mcg EE each

Taken 12 hrs apart

Total of 4 pills

Yuzpe method

MOA:

- taken before ovulation inhibits follicular dev and

maturation

- taken after ovulation affects endometrium and FT

PROGESTERONE ONLY PILL

0.75mg LNG, two dose in 12 hours interval.

First dose as soon as possible within 72

hours

Replaced yuzpe

More effective

Lesser N&V

IUCD

Used as late as 7 days after

99% effective

STERILIZATION

Permanent method of contraception

Can be reversed but it’s more difficult than

the original procedure

Tubal reanastomosis has greater success as

compared to reanastomosis of the vas

FEMALE STERILIZATION

Done in postpartum period or during interval period

Small transverse infraumbilical incision in PP period

Laparoscopy, laparotomy, or colpotomy in interval period

Methods : -Falope rings, clips or bands -Segmental destruction with electrocoagulation -Suture ligation with partial salphingectomy

Essure System

Interrupts the FT

No surgical incision

Done under LA

Performed using hysteroscope

Microinsert placed directly in FT

Acts as a barrier

99.8% effective

After 3 months – hysterosalphingogram to

ensure placement

MALE STERILIZATION

Vasectomy

Transection of vas deferens

Occlusion of both severed ends by suture

ligation or fulguration

- Destruction of tissue, by means of a high-

frequency electric current applied with a

- needle-like electrode

OPD procedure under LA

Complications :hematoma formation and

sperm granulomas.

Spontaneous resolution : rare

Not considered sterile till ejaculate is sperm

free.

Requires 15-20 ejaculations

MOA: Prevents passage of sperms via vas to

seminal fluid

Failure rate : 0.1%

Short term discomfort

FUTURE ?

Vaccine against hCG

REFERENCE

http://emedicine.medscape.com/article/258507-overview

Hacker and Moore’s 5th edition Essentials of O&G

MUCHAS GRACIAS!!