Contraception
Presenting by Abdullahi Mohamud Jama
OUTLINE
Overview of contraceptives
Intrauterine devices
Barrier Contraceptives
Definition
Is any method used to prevent
pregnancy.
History of contraception
Birth Control are well documented in
Ancient Egypt.
The Ebers Papyrus from 1550 BC and
the Kahun Papyrus from 1850 BC have
within them some of the earliest
documented descriptions of birth
control:
The use of honey
Acacia leaves
Lint to be placed in the vagina to block
sperm.
Things to know……….
Over 50% of all pregnancies in
the United States are unplanned,
the highest rate in the developed
world. Yet every year new
contraceptive options are
introduced touting various
“improvements.”
Although no method is effective
if it is not used correctly, many
methods are very reliable.
Although there are many kinds of
contraceptives, all work either by
inhibiting the development or
release of ova or blocking the
meeting of ova and sperm.
Before helping any woman or couple
choose among the many contraceptive
options the physician must understand
and be able to explain (in language the
woman and partner can understand) the
physiologic or pharmacologic
mechanism of action of all of the
available contraceptive methods, along
with their effectiveness rates,
indications, contraindications,
complications, advantages, and
disadvantages.
Efficacy Of Contraceptives
It depends:
The method used
Is it used correctly.
The expected pregnancy rate in
women using no method of
contraception is 85%.
FACTORS AFFECTING THE
CHOICE OF CONTRACEPTIVE
METHOD
Although efficacy is important in
the choice of contraceptive
methods, other factors to be
considered include safety,
availability, cost, acceptability,
and, in some cases, the patient’s
physical ability to appropriately
use the method.
Intrauterine Contraception
Intrauterine contraceptives, also
known as IUDs or intrauterine
contraception devices, are
recommended for adolescent,
nulliparous, and parous women
and are among the most
commonly used and safe
methods of interval contraception
worldwide.
continued disinterest in IUDs stems from
early kinds of IUDs that were associated
with an increased incidence of pelvic
inflammatory disease (PID) and infertility.
These devices were removed from use
and the current IUDs are not associated
with PID. Nonetheless, the fear continues
to dissuade some women, and
practitioners, from IUD use despite the
proven safety profile of the current
models.
There are four IUDs available in
the United States—three hormonal
and one nonhormonal.
All are T shaped. The hormonal
IUDs release a small amount of
levonorgestrel (LNG-IUD) into the
uterus (0.2/0.2%), and the
nonhormonal IUD releases a small
amount of copper (Cu-IUD) into
the uterus (0.8/0.6%).
Insertion
IUD insertion is best accomplished when
the patient is menstruating. This timing is
beneficial because it confirms the patient
is not pregnant and her cervix is usually
slightly open. If that timing cannot be
achieved, it can be done at other times in
the cycle as the patient is switching from
another reliable method of contraception.
The devices may also be inserted in
breastfeeding women, who, in fact,
demonstrate a lower incidence of
postinsertional discomfort and bleeding.
AllIUD insertion techniques share the same
basic rules:
careful bimanual examination before
insertion to determine the likely direction of
insertion into the endometrial cavity, proper
loading of the device into the inserter,
careful placement to the fundal margin of
the endometrial cavity, and proper inserter
removal while leaving the IUD in place .
Sterile technique and a vaginal prep with
povidone-iodine should be used prior to
insertion of an IUD.
The overall expulsion rate for IUDs is 1%
to 5%, with the greatest likelihood in the
first few months of use. Expulsion is
often preceded by cramping, vaginal
discharge, or bleeding, although it may
be asymptomatic, with the only
evidence being the observed
lengthening of the IUD string or the
partner feeling the device during
intercourse. Patients should be
counseled to see their clinician if
expulsion is suspected.
Insertion may be performed
immediately postpartum (within
10 minutes of placental delivery)
or intraoperatively during a
cesarean before closure of the
hysterotomy incision.
Mechanism of Action
There are three hormonal IUDs
(LNG-IUD’s) that work by
preventing the sperm and egg
from meeting by thickening the
cervical mucus, thus decreasing
the number of sperms that enter
the uterine cavity and creating an
unfavorable uterine environment
by thinning the uterine lining.
The copper ions from the copper IUD
(Cu-IUD) act as a spermicide, inhibiting
sperm motility and the acrosomal
reaction necessary for fertilization.
It rarely works by inhibiting
implantation and does not function as
an abortifacient in normal use.
The Cu-IUD may also be used
postcoitally as an EC. When used in this
way, it may interfere with implantation.
Side Effects
A clinically important side effect
of LNG-IUDs is a decrease in
menstrual blood loss (up to 50%)
and severity of dysmenorrhea.
Although the LGN-IUDs are
associated with menstrual
irregularities, typically lighter
periods, or amenorrhea, serum
progesterone levels are not
affected.
The Cu-IUD is associated with heavier
periods and dysmenorrhea that often
result in discontinuation. The LGN-
IUDs have a lesser incidence of this
problem because of the progestin
effect on the endometrium.
Thus, increased menstrual flow and
pain may be encountered in women
choosing Cu-IUDs compared with
LGN-IUDs.
Risks
There is a slight increased risk of
infection the first 20 days after
IUD insertion.
Pelvic infection occurring 3
months or more after IUD
insertion may be presumed to be
an acquired STD and treated
accordingly.
Women at high risk for STDs may
benefit from screening prior to
The IUD may remain in place
unless there is evidence of
spread of the infection to the
endometrium or fallopian tubes
and/or failure of treatment with
appropriate antibiotics.
IUDs do not increase the overall risk of ectopic
pregnancy. However, because the IUD offers
greater protection against intrauterine than
extrauterine pregnancy, the relative ratio of
extrauterine pregnancy is greater in a woman
who uses an IUD than in a woman not using
contraception.
Therefore, in the rare instance that a woman with
an IUD in place becomes pregnant, that
pregnancy would have a high risk of being
extrauterine.
About 40% to 50% of patients who become
pregnant with an IUD in place will spontaneously
abort in the first trimester.
There is no evidence of an
increased risk of congenital
anomalies with LNG-IUD or Cu-
IUD.
There is, however, an
approximate two- to four-fold
increase in the incidence of
preterm labor and delivery.
Patient counseling and skillful
insertion are crucial to the
successful use of the IUD as a
method of contraception.
BARRIER
CONTRACEPTIVES
Among the oldest and most widely used
contraceptive methods are those that provide
a barrier between the sperm and egg.
These barriers include condoms, diaphragms,
and cervical caps. Some methods, such as
fertility awareness, may be thought of as
providing a “time” barrier between coitus and
conception.
Each of these methods depends on the
proper use before or at the time of
intercourse and, as such, is subject to a
higher failure rate than noncoitus-dependent
methods.
This is the result of inconsistent
or incorrect use as well as actual
damage to the barrier material
itself. For example, the latex in
condoms, diaphragm, and
cervical cap can be damaged by
the application of oil-based
lubricants.
Despite this, these methods provide
relatively good contraception and
are inexpensive, and most require
little or no medical consultation.
In addition, condoms provide some
protection against the transmission
of STDs, including gonorrhea,
herpes, chlamydia, human
immunodeficiency virus (HIV), and
human papillomavirus infection.
Condoms:
Condoms are sheaths worn over
the erect penis (male condom) or
inside the vagina (female
condom) to prevent sperm from
reaching the cervix and upper
genital tract.
Although almost one half of all
condoms are sold to women, the
condom is the only reliable,
nonpermanent method of
contraception available to men.
Condoms are widely available and
inexpensive.
They may be made of latex; nonlatex;
or, less commonly, animal membrane
(usually sheep cecum), but only latex
condoms protect against HIV.
A reservoir tip reduces the
likelihood of breakage.
Recommending reservoir tip
condoms may decrease condom
breakage, a common cause of
contraceptive failure with the use
of this contraceptive method.
Condoms are well tolerated, with only rare
reports of skin irritation or allergic reaction.
Some men complain of reduced sensation
with the use of condoms, but this may
actually be an advantage for those with
rapid or premature ejaculation.
The slippage and breakage rate in normal
use is estimated at 5% to 8%. In these
cases, couples should be counseled to seek
medical care within 120 hours so that
emergency contraceptive methods may be
used.
Sponge:
The contraceptive sponge is a small,
pillow-shaped sponge containing
spermicide. The sponge has a dimple that
is designed to fit over the cervix and
remain in place during intercourse.
The opposite side has a loop to facilitate
removal.
All have slippage and breakage rates of
about 3%, and, as in the case of
diaphragms, it is recommended that they
be left in place 6 to 8 hours after coitus.
The sponge is available only in
one size, which may explain why
it is more effective in a
nulliparous woman than in one
who has had children.
The sponge is moistened prior to
insertion and can be used for
repeated acts of intercourse in a
24-hour period.
The sponge should be left in
place for at least 6 hours after
intercourse, but wearing it for
more than 30 hours is not
recommended because of the
risk of toxic shock syndrome.
Diaphragm:
The diaphragm is a small, latex-covered,
dome-shaped device.
Proper use of a diaphragm includes
applying a contraceptive jelly or cream
containing spermicide into the center
and along the rim of the device, which is
then inserted into the vagina, over the
cervix, and behind the pubic symphysis.
In this position, the diaphragm covers
the anterior vaginal wall and cervix.
The diaphragm can be inserted up to 6
hours before intercourse and must be left
in place for 6 to 8 hours afterward, but not
more than 24 hours. It may then be
removed, washed, and stored.
Users should be cautioned not to use talc
to dry the diaphragm.
If additional intercourse is desired during
the 6- to 8-hour waiting time, additional
spermicide should be applied without
removing the diaphragm, and the waiting
time should be restarted.
There are several sizes of
diaphragm available and one
must be fitted to the individual
patient. Fit may change with
significant weight change,
vaginal birth, or pelvic surgery.
Side Effects
Women who use diaphragms are
approximately twice as likely to have
urinary tract infections (UTIs) as
women using hormonal contraception.
The increased risk of UTI may be
caused by a combination of pressure
against the urethra, causing urinary
stasis, and an effect of spermicides on
the normal vaginal flora, increasing
the risk of Escherichia coli bacteriuria
and infection.
Reference
Beckmann and ling Obstetrics
and Gynecology
