Used for family planning counselling- is popular from 1980’s
• G - Greet Build a rapport.
• A - Ask Ask questions • T - Tell Tell the relevant regarding method of contraception • H - Help Help the client to reach a decision • E - Explain Explain about the method • R - Return Return for ongoing contraceptive method is advised. A note about TRADITIONAL METHODS Also called fertility awareness methods (FAMS) • Rhythm method/ Calendar method • Basal Body temperature method • Cervical mucus method/ Billing’s method Requires motivated women with • Sympto-thermal method regular cycles and co – operation of • Standard days method using Cycle beads both partners
• Two day method
• Ovulation detection • Coitus interruptus • Lactational Amenorrhoea • Abstinence •Rhythm method /Calendar method: • Abstain between the duration most effective is symptothermal ▪ Shortest cycle - 18 : first day of fertile period method- ▪ Longest cycle - 11 : last day of fertile period failure rate: 2 /HWY • Basal Body Temperature Method:
• Based on rise in body temp(0.5- 0.8 degree F) due to thermogenic effect
of progesterone • Intercourse only 3 days after rise
• Cervical mucus/ Billing’s/ Ovulation method:
• Based on change in vaginal secretions from scant- to profuse and sticky- lasts for 3 days • To abstain 3 days after the last WET day • Symptothermal method: • Combines BBT and Billing’s method + manifestations of fertile period LACTATIONAL AMENORRHEA (LAM) • Based on the antifertility effects of prolactin ✔ Inhibits LH - decreases ovarian response to gonadotrophins
✔ Initiation must satisfy the Bellagio criteria:
✔ Menstrual cycles have not resumed ✔ Infant is fully or nearly fully breast fed, day and night ✔ Infant is under 6 months of age
In amenorrheic women who fully or partially breastfeed,
pregnancy rates are 1 HWY in the first 6 months Fertil Steril 2008 SHORT ACTING REVERSIBLE CONTRACEPTIVES Includes • Combined oral contraceptive pills
• Progesterone only pills
• Injectible progesterone
• Injectible combined hormonal contraceptives
• Vaginal rings
• Transdermal patches FOUR GENERATIONS OF OCP’S Evolution of OCP’s Characteristi First Second Third Fourth cs generation generatio generation generation n Estrogen Ethinyl estradiol(EE) EE EE EE/Estradiol valerate (EV)
Faculty of Sexual and Reproductive Healthcare, 2007.
NEWER CLASSIFICATION FOR OCPs
• Constant dose of both E2 & P4 in each of the hormonally active pills
Monophasic throughout the entire cycle (21 days of active pills) pills
• Change the level of P4 once (halfway)during the menstrual cycle.
Biphasic • Jenest ,Mircette ,Nelova ,Necon pills
• Contain three different doses of P4 in the active pills (changing every 7
days during the first 3 weeks of pills). Triphasic • Ex: Necon,Nortrel,Ortho Tricyclen ,Ortho Tricyclen Lo ,Ortho-Novum ,Tri- pills Levlen ,TriNessa DEPOT MEDROXY PROGESTERONE ACETATE
Injectable, progestin-only Grace period: 2 weeks
contraceptive. Do UPT after 15 weeks: next dose + back up contraception 150 mg/1 mL – i.m. Injection- every 3 x 7d months
104 mg/0.65 ml - s.c. injection. (Sayana
Press) • Subcutaneous: 30 % lower dose, slower, ↑ sustained absorption . No indication for BMD testing on • Same duration of action, equal prolonged use efficacy, less painful may be self ACOG Committee Opinion 415, 2008 administered.
Keith et al, Savana press
review,Contraception 2014 TRANSDERMAL HORMONAL CONTRACEPTIVES • Highly effective, long acting reversible contraceptive • ↑ Compliance, coitus independent • Ortho Evra: only brand available • 20 x 20 mm Increased risk • Daily release: 20 mcg EE +150 mcg norelgestromin (metabolite of VTE is aof concern with norgestimate) use of non • Duration: 1 patch/week x 3 wk. oral CHC Long acting reversible contraceptives (LARC)
⚫ Includes ⚫ Intrauterine devices (IUDs) ( Cu T, LNG – IUD) ⚫ Subdermal implants (Implanon/Nexplanon) ⚫ Not user-dependent ⚫ Very low failure rates – 0.27 /HWY Launched by ACOG in 2008 with aim to reduce unintended Winner et al, N Eng J Med , 2012 pregnancy and increase access to LARC methods Intrauterine contraceptive devices • 1 generation : Lippes Loop st
52 mg LNG 360) Contains 13.5 mg LNG Releases 20 mcg/ d 52 mg LNG Releases 14 mcg/ day effective for 5 yrs Releases 18.6 mcg/ d effective for 3 yrs 32 x 32 mm effective for 3 yrs smaller 28 x 30 mm Rate of amenorrhea after 32 x 32 mm Contains silver core 1 year- 20% Similar rates of Rate of amenorrhea after amenorrhea as mirena 1 yr of use- 6% IUD INSERTION • Timing : 1st 7 d of menses, post abortal- immediate – 1 wk, post partum- immediate - 48 hours or after 6 wks. • Back up contraception x 7 d : • >7d of menstrual cycle • Post abortal • PP- < 21d , not lactating
• Cervical inspection and bimanual examination is mandatory.
• Prophylactic antibiotics not recommended for IUD insertion. • Standard practice cleansing the cervix and sterilizing instruments. • Routine follow up not required. • NO TOUCH TECHNIQUE, WITHDRAWL METHOD. CuT 380A has ↑ efficacy than Multiload 375. No difference in side effect profile, ease of insertion. Cochrane systematic review 2007 • Older implants: IMPLANTS
• Norplant: 36mg/rod, 6 LNG rods
• Jadelle : 75mg two LNG rods
• Implanon: marketed as Nexplanon- bioequivalent- has I rod of 68 mg
etonorgestrel- releases 60 mcg/ day ⚫ Has 99% contraceptive efficacy over 3 years Graessel et al,Eur J Contracept Reprod Health Care. 2008
• Nexplanon: ⚫ radiopaque, ⚫ with easier insertion EMERGENCY CONTRACEPTION
INDICATIONS • When contraceptive method NOT used • Sexual assault • During contraceptive failure or incorrect use, including:
⚫ Condom breakage, slippage or incorrect use.
⚫ 3 or more consecutively missed COCs. ⚫ POP > 3 hours late, DMPA > 4 weeks late. ⚫ Dislodgment, delay in placing, or early removal of a contraceptive hormonal ring or skin patch; ⚫ Failed withdrawal, miscalculation of fertile periods.. ⚫ Expulsion of IUD or implant. • LNG- I PILL
✔ Single dose regimen LNG- 1.5 mg
• more convenient than split dose regimen
• as effective as a split dose, without increasing the frequency of side effects
✔ Interval between 2 doses of LNG can be lengthened to 24 hours apart
without changing efficacy Hansen et al,Pharmacotherapy. ,2007
• MIFEPRISTONE ✔ 25/50 mg stat dose- even 10 mg dose is accepted
✔ prevents 92–100% of pregnancies with an acceptable side-effect profile
✔ In a comparative study of 4136 healthy women,( single dose of 10 mg
mifepristone vs 1.5 mg levonorgestrel vs 2 doses of 0.75 mg levonorgestrel 12 h apart) pregnancy rates 1.5% :mifepristone & single dose of levonorgestrel ,1.8% :split dose LNG •Copper intrauterinecontraception (IUD) Most effective method of emergency contraception Advantages: ✔continuing contraception after initial IUD placement ✔more effective than oral regimens, especially in overweight/obese women
Sample :1963 women, 18–44 years for EC
Results :No pregnancies occurred prior to or at the first follow-up visit, making CuT380A 100% effective as emergency contraception. ✔The pregnancy rate over the 12-month period was 0.23 per 100 women. ✔The main side-effects were increased menstrual bleeding and menstrual disturbances ✔ The 12-month post insertion continuation rate was 94.0 per 100 woman-years. Ulipristal acetate : 30 mg UPA stat dose within 120 hrs is a SPRM- inhibits ovulation Contraindications : •Suspected pregnancy •Poorly controlled asthma •Hepatic dysfunction.
STD HOW TO USE? • Vomiting Within 3 Hours of Taking ECPs: Repeat dose ± antiemetic. U. S. S.P.R. for Contraceptive Use 2013.
• EC failure: No ↑ ectopic pregnancy, few cases
reported. Cleland K et al Am J Obstet Gynecol 2010.
• EC failure: No ↑ congenital malformations.
Zhang L et al, Hum Reprod 2009.
MALE CONTRACEPTION: RECENT ADVANCES
Includes: • Barrier methods:Condoms • Hormonal/non hormonal preparations • Immunocontraceptive • RISUG MALE CONDOMS NEWER CONDOMS Polyurethane: Avanti, Supra Styrene based plastic: Tactylon Polyisoprene: Skyne (thinnest)
Polyurethane condom vs. latex condom
Pregnancy rates : 5.4% with latex
9% with polyurethane Advantages: More resistant to heat & oxidation Thinner material; can be used with any lubricant Disadvantages: Higher risk of breakage, lesser STI protection, costlier. (Cochrane database systemic Rev 2006) HORMONAL PREPARATIONS • Inhibits release of LH and FSH thereby decreasing intratesticular testosterone levels • Single agent ⚫ Testosterone enanthate(TE)- 200 mg i.m./ week Testosterone is available in the form of injections/ ⚫ Testosterone undecanoate(TU)-depot i.m./1-2 month implants(6 monthly)/ • Dual agent transdermal patches(3 monthly)/gels ⚫ Testosterone +progestin(DMPA/levonorgestrol/etonogestrel/norethisterone enanthate/cyproterone acetate) ⚫ Synthetic agents 7a-Methyl-19-nortestosterone (MENT) is a selective androgen receptor modulator (SARM) and is effective orally, is usually combined with progestins Kogan et al. Male Contraception History and Development Urol Clin N Am 41 2014 IVD(Intra vas devices)
• Intra-vas implants like Intavas( a urethane device filled with
nylon threads) blocks sperm but allows the passage of fluid • Inserted through a small scrotal incision identical to that used for vasectomy
• Success rate : 94.3% at 12 months compared with 98.6% for
vasectomy . Song et al.Int J Androl 2006 RISUG is currently RISUG undergoing phase III trials . • Reversible Inhibition of Sperm Under Guidance. • Developed by Dr. Sujoy Guha. • Technique: injection of styrene maleic anhydride (SMA) dissolved in dimethyl sulfoxide (DMSO) into the vas under direct visualization through a small incision
100% reversibility achieved using:
❑ progressive percutaneous Another similar alternative is the squeezing of the vas VASAGEL( polymer gel)- which is currently awaiting FDA approval ❑electrical stimulation, for human trials ❑digital rectal massage of the ampullary vas Lohiya et al. contraception 1998 PERMANENT METHODS OF CONTRACEPTION • Female sterilisation ⚫ Minilaparotomy ⚫ Laparoscopic ⚫ Hysteroscopic • Male sterilisation ⚫ Traditional vasectomy ⚫ No scalpel vasectomy Indian guidelines for sterilisation MEC for sterilisation
WHO 2004 SPECIAL CASES: CATEGORY D In females In males
⚫ Acute DVT ⚫ Local infection
⚫ Puerpural / post abortion sepsis/ ⚫ Current systemic infection ⚫ Severe PPH ⚫ Ischemic Heart Disease ⚫ Unexplained vaginal bleeding ⚫ Genital malignancies ⚫ Acute PID ⚫ Acute respiratory/ GI illness ⚫ Severe anemia< 7 g/ dl
Standards for female and male sterilisation. MOHFW, 2006
WHAT’S NEW: HYSTEROSCOPIC STERILISATION • Involves placement of metal coil in the tubal ostia (Essure) through hysteroscope • Approved by the US (FDA) in 2002 • Requires interim contraception for 3 months followed by HSG to confirm bilateral occlusion. ACOG committee opinion 2012
• Benefits – faster recovery
• Drawbacks- ⚫ Not effective immediately, ⚫ Higher chance of ectopic pregnancy if fails ⚫ Can be associated with new onset pain or a worsening of a pre- existing painful gynecologic condition although both are very rare. Kamecic H et al J Minim Invasive Gynecol 2016 Thank you all !
