Control of Conception (Family Planning)

Age long practice, different people across generations have devised different means of controlling conception

1850 BCE-kahum papyrus- pessary from crocodile dung and fermented dough- this created a hostile environment for sperm.

The Kahun papyrus also refers to vaginal plugs of gum, honey, and acacia.

Early second century in Rome, Soranus of Ephesus-acidic concoction of fruits, nuts, and wool, placed at the cervical os to create a spermicidal barrier.

Voluntary control of conception is of paramount importance to modern society.

Globally- rapid population growth threatens human survival.

In another 40 years the world will double its population while in less than 20 years in the poorer countries.

Effective control of reproduction can be essential to a woman's ability to achieve her individual goals and to contribute to her sense of well-being

A patient's choice of contraceptive method involves factors such as efficacy, safety, non-contraceptive benefits, cost, and personal considerations.

Decision making concerning fertility, for many is a deeply personal and sensitive issue, often involving religious or philosophical convictions.

Despite the introduction of modern contraceptive methods, unintended and unplanned pregnancies continue to be a major problem worldwide.

Current contraceptive use: modern contraceptive use is higher among the sexually active unmarried women (28%) than among currently married women (12%).

Contraceptive prevalence rate for any method is 17% among the currently married women

Contraceptive discontinuation: 2 of every 5x (41%) that women began using contraceptive method in 5 years preceding the survey. They discontinue within 12 months. The most common reason was desire to become pregnant (35%)

Demand for family planning: among currently married women is 36%.

Unmet need for family planning: higher among sexually active unmarried women (48%) than among the currently married women (19%)

Future use of contraception: 35% of currently married women who are not using contraception intend to use family planning in the future

Unmet need for contraception refers to the percentage of fecund (do not meet the criteria for infecundity) and sexually active women (married or in a union) of reproductive age who wish to postpone the next birth for at least 2 years or halt child bearing completely but are not using any form of contraception.

This concept points to the gap between women’s reproductive intentions and their contraceptive behavior.

214 million women of reproductive age in developing regions have unmet need for contraception. Reasons include—

• Limited access to contraception
• A limited choice of methods
• A fear or experience of side effects
• Cultural or religious opposition
• Poor quality of available resources
• Gender

For all Indications, providers of Family Planning must provide accurate information about benefits and risks of:

• Pregnancy
• Contraception

To be noted specifically are:

• Medical conditions that may substantially increase risk of some form of birth control usually increase the risk associated with pregnancy to an even greater extent.
• Policy in some less developed countries promote contraception in an effort to curb undesired population growth.

Coitus interruptus involves withdrawal of the entire penis from the vagina before ejaculation. Fertilization is prevented by lack of contact between spermatozoa and the ovum.

Efficacy: Effectiveness depends largely on the man's capability to withdraw prior to ejaculation. The failure rate is estimated to be approximately 4% in the first year of perfect use. In typical use, the rate is approximately 19% during the first year of use.

Advantages:

• Immediate availability
• No devices
• No cost
• No chemical involvement
• Theoretical reduced risk of transmission of sexually transmitted diseases (STDs).

Disadvantage

• The probability of pregnancy is high with incorrect or inconsistent use.

Elevated prolactin levels and a reduction of gonadotropin-releasing hormone from the hypothalamus during lactation suppress ovulation.

This leads to a reduction in luteinizing hormone (LH) release and inhibition of follicular maturation. The duration of this suppression varies and is influenced by the frequency and duration of breastfeeding and the length of time since birth.

Mothers only need to use breastfeeding to be successful; however, as soon as the first menses occurs, she must begin to use another method of birth control to avoid pregnancy.

Efficacy: The perfect-use failure rate within the first 6 months is 0.5%. The typical-use failure rate within the first 6 months is 2%.

Advantages:

• Rapid uterine involution.
• Menses are suppressed.
• Immediate use after childbirth.
• Facilitates postpartum weight loss.

Disadvantages:

• Return to fertility is uncertain.
• Frequent breastfeeding may be inconvenient.

Natural family planning: is one of the most widely used methods of fertility regulation, particularly for those whose religious or cultural beliefs do not permit devices or drugs for contraception.

This method involves periodic abstinence, with couples attempting to avoid intercourse during a woman's fertile period—around the time of ovulation. Techniques to determine the fertile period include

Cycle Beads Method

Also called a Standard Days Method

This is a Natural Family Planning Method

It is based on the knowledge that the menstrual cycle is made up of a fertile phase preceded and followed by infertile days

Cycle beads has 32 beads, each bead represents a day of the menstrual cycle

The red bead represents first day of menstruation and of the cycle

White beads represent days when a woman can get pregnant

95% effective with perfect use!

Mechanism of Action of Hormonal Contraceptives:

• Suppress ovulation (90 to 95% of time)
• Causes thickening of cervical mucus, which impedes sperm penetration and entry into the upper reproductive tract
• Causes endometrial atrophy
• May slow down tubal peristalsis

Injectables

More and more women are using injectable

• Effectiveness
• Long acting
• Privacy guaranteed

Types: Progestin-Only

• Depo Medroxy Progesterone Acetate (DMPA) 150 mg
• Microcrystalline suspension
• 3 monthly
• Norethisterone Enanthate (Net-En) 200 mg
• In oil
• 2 monthly

Newly approved Depo-provera:

Depo-subQ Provera (DMPA-SC)

• Contains 104 mg Depo-medroxy progesterone acetate
• In micro-crystalline suspension form
• Now Subcutaneous CF Intramuscular DMPA
• Also every 12 weeks
• Should not be used continuously for ˃2 years

Types:

• MPA combined with estradiol cypionate (E2C)
• Cyclofem, Lunelle (25mg MPA and 5 mg E2C)
• Net-En combined with estradiol valerate (E2V)
• Mesigyna, Norigynon 50mg Net-En; 5mg E2V

NORIGYNON:

Norigynon is a combined injectable contraceptive that contains 5 mg Estradiol valerate + 50 mg norethisterone enantate.

Mechanisms of Action:

• Suppresses ovulation
• Changes endometrium making implantation less likely
• Thickens cervical mucus preventing sperm penetration
• Reduces sperm transport in upper genital tract (fallopian tubes)

Norigynon Injection Schedule

• Monthly Administration
• Can be up to 3 days early or late
• Client can keep appointment card for next injection

Effectiveness of Norigynon

• In clinical trials, Norigynon has proved to be a highly effective contraceptive
• 12-month failure rates are less than 0.4% (1/250)

Advantages

• Highly effective
• Better cycle control
• Optimal compliance
• Reversible
• Ensures privacy
• Excellent tolerance (natural Estradiol)
• Reassuring to women
• Regular contact with health services
• Rapid return to fertility

Disadvantages

• Irregular bleeding, amenorrhea, heavy bleeding, prolonged bleeding, headaches, dizziness, body weight & mood changes.
• Require more frequent injections than POIs.
• Does not protect against STIs, including HIV.

Non-contraceptive Benefits

• Decreases menstrual flow (lighter, shorter periods)
• Decreases menstrual cramps (dysmenorrhoea)
• May improve anemia
• Favorable metabolic profile (lipid, carbohydrate, liver)
• Protects against ovarian and endometrial cancer
• Decreases benign breast disease and ovarian cysts
• Prevents ectopic pregnancy
• Protects against some causes of PID

Combined Injectables: Safety

• Safety of progestins is well established.
• Daily dose of estrogen is small.
• Long-term safety information not yet available.
• Contraindications based on those for COCs.

Norigynon: user profile

• Women demanding a “normal menstrual” bleeding pattern (less bleeding irregularities, less amenorrhea) and high contraceptive efficacy.

Eligibility Criteria: who can use:

Until sufficient clinical data become available, the eligibility criteria for the use of combined injectable contraceptives are based on data from combined oral contraceptives.

• Women who want a highly effective easy to use method
• Women wanting a reversible method
• Women of any age and any parity including adolescents
• Women who want discretion
• Women with sickle cell disease
• Women who can’t tolerate other methods
• Women who:
• Are of any reproductive age or parity who want highly effective protection against pregnancy
• Are breast feeding (6 months or more postpartum) or when supplementation of infants’ diet begins (if before 6 months)
• Are postpartum and not breast feeding (may begin after third week postpartum)
• Are post abortion clients (may begin immediately)
• Cannot remember to take a pill everyday
• Women with:
• Anemia
• Severe menstrual cramping (dysmenorrhoea)
• Irregular menstrual cycles
• Histories of ectopic pregnancy

Who Should Not Use Norigynon (WHO Class 4):

Norigynon should not be used if a woman:

• Is pregnant (known or suspected)
• Is breast feeding (< 6 months postpartum)
• Has ischemic heart disease or stroke (current or history of)
• Has blood clotting disorders (deep vein thrombophlebitis or pulmonary embolism
• Is a smoker and age 35 years or older
• Has diabetes (> 20 years duration)
• Has headaches (migraine)
• Has high blood pressure (> 180/110)
• Has breast cancer
• Has liver tumors
• Has to undergo major surgery with prolonged bed rest

When to begin Combined Injectables

• Any time during menstrual cycle
• Backup recommended if given after day 7
• Postpartum:
• Not breastfeeding: delay 3 weeks
• Breastfeeding: delay of 6 months recommended
• Post-abortion: immediately

Counseling

Clients considering the use of injectable contraception should be clearly informed about the advantages and disadvantages of the agents, their side-effects, their cost, and the alternative contraceptive options.

Where once-a-month injectables are available, clients should be told about the differences between these injectables and POIs.

Women who desire a rapid return to fertility on discontinuation of their contraceptive should be advised to use CICs where available or another method.

Addition of small quantities of testosterone to injectable to:

• Correct risk of osteoporosis from long term use!
• Improve or correct risk of reduced libido

Contraceptive Implants

All can be considered as new (1985)

Implanted into medial aspect of less dominant arm

Initially Six Rods, Norplant (now discarded)

• Inserted last ones in 2005 in Jos

Two rod Jadelle (levonorgestrel) – 5 years

One rod Implanon (etonogestrel) – 3 years

Bio-degradable (Capronor) that does not require removal (2 years) – Developed by Research Triangle Institute.

NEXPLANON:

Nexplanon is essentially identical to Implanon except Nexplanon has 15 mg of Barium sulphate added to the core, so it is detectable by x-ray.

Nexplanon also has a pre-loaded applicator for easier insertion

Nexplanon is off-white, non-biodegradable and 4 cm long, diameter of 2 mm

• 2 mm wide
• 4 cm long

Vaginal contraceptive rings

Method of long-term contraception which is entirely patient’s control.

Steroids absorbed efficiently through vaginal epithelium.

Advantages

• Under patient’s control
• Not coitus related
• No daily administration
• Greater contraceptive effect
• Milder adverse effects.

Design of vaginal contraceptive rings

• Vaginal fornix around cervix
• Homogenous ring
• Shell ring
• Core ring

One of the newest developments in hormonal contraceptives is the vaginal contraceptive ring.

Also known as the Ring and sold under the brand name NuvaRing.

Each ring provides continuous protection against pregnancy for up to one month.

How the Ring is used

A new vaginal ring needs to be inserted every month.

Once inserted, the Ring is worn for 3 consecutive weeks before it is removed for 1 week.

During the week that the Ring is not worn, menstruation occurs.

Each ring provides a month’s contraception

Progesterone Vaginal Ring

Progesterone diffuses at a continuous flow of 10mg per day through the silicone

• Prolongs lactation amenorrhea
• Used for Postpartum contraception
• After 6 weeks of delivery and for 3 months

A vaginal ring is inserted at postnatal visit (6 weeks)

Once inserted, the Ring is worn 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

Contraceptive Patch

Trans-dermal contraceptive system

Square, flexible, extended-release matrix patch system

Contains norelgestromin (NGMN) and ethinyl estradiol (EE) for use in a weekly dosing schedule

Product launched: April 2002

Benefits of the Patch

• Female-controlled
• Prompt contraceptive reversibility
• Allows for spontaneity
• Highly efficacious contraceptive
• High rates of compliance across age groups

Method of use

A woman applies her first patch onto her

• Upper outer arm
• Abdomen
• Buttocks
• Thigh

Applied weekly

The day of application is known from that point as patch change day.

On the 4th patch change day, the patch is removed and not replaced.

The woman waits 7 days without a patch in place, and on the next patch change day she applies a new patch (a new cycle)

Lippes Loop as a contraceptive now obsolete

• May be found in Gynecology theatres for treatment of Ashermans

CuT380A: Commonest IUD in use today

New IUD designs may reduce side effects

• Cramping
• Excessive menstrual loss

1970s: The second generation of plastic- copper IUDs came around. These IUDs increased the surface area of the devices and increased their effectiveness to above 99%.

Hormone Containing IUDs

Progestasert: Contains pure Progesterone

• Meant for 1 year
• Not easily available

Levonova: levonorgestrel IUD (Mirena/Eliora)

• May actually reduce menstrual loss
• Lasts for 5 and up to 7 years

Cap

• Vaginal diaphragms most widely used spermicide types coil springs, flat spring, arcing? Failure rate 2-20 pregnancies per 100 women users per year of exposure.
• Cervical Cap
• Fem-cap
• Lea’s shield
• Long acting spermicides releasing diaphragms
• PH sensitive releasing

Female condom, panty condom

• Pouch thin polyurethane with 2 flexible rings at each end- one deep and the other at the intriotus)
• Failure rate - 26% for the first year
• Overall acceptability 65-79% for women users and 75-80% for their partners.

Sponge

• Contains polyurethane and Nonoxynol-9
• Toxic to Spermatozoa

Chemical agents

• Foams, jellies, tablets, suppositories, aerosols
• Nonoxynol-9, Octoxynol-9, Menfegol

Panty Condom

• A condom for women, used in the traditional sense as a barrier birth control method
• Protects against STIs and HIV; Prevents unwanted pregnancy (Dual Protection)
• Created to empower women with a contraceptive under their control
• Discreet, Sexy, sensual, safe, easy to use
• Can be worn all day
• The condom itself is protected inside a membrane until used
• The panty is re-usable the condom is replaceable
• Manufactured from polyethylene
• Not Available here yet!

Abstinence

Withdrawal Method or ‘Coitus Interruptus’

Condoms

Vasectomy

• Traditional or scalpel method
• No scalpel method

Male Pill

Vas deferens plugs

Immunization?

Male Condom

1864 - Gabriel Fallopio, Linen Sheath

20% of contraceptives use; renewed interest - Aids pandemic.

• Latex
• Teat ended
• Plain
• Non-latex - polyurethane, plastics stronger, less rupture
• Failure rate: 3 per 100 woman years
• High risk women - “Double Dutch” method

The Male Pill!

Gossypol, a derivative of cotton seed oil

• Demonstrated to depress spermatogenesis
• Effecttiveness 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: - which effectively depresses spermatogenesis, may preserve libido

Testosterone + Progestin: being tried as male contraceptive

The ‘Male Injectable’

Male systemic method using testosterone

• Suppresses/inhibits pituitary gonadotropins.
• Testosterone levels are still adequate for male behavior.

Levels in testis fall so low that sperm production stops.

High doses of testosterone in the man can cause aggressive male behavior.

Sperm production takes 120 days, so male systemic methods may take long time to act and to reverse.

No natural period of inhibition of fertility to imitate in the man as in the female (during pregnancy and lactation).

Considered irreversible

Male:

• Easier
• Cheaper
• Complications less

Female:

• More costly
• More technical
• More complications

Male Permanent Methods

Vasectomy

No-Scalpel Vasectomy

Vas deferens plugs

Female Permanent Methods

Bilateral Tubal Ligation

• Laparotomy
• Laparoscopy
• Clips, Yoon Rings
• Minilaparotomy under local anesthesia
• Quinacrine
• Essure

Tubal ligation techniques

1. Pomeroy
2. Madlener
3. Fimbriectomy
4. Salpingectomy
5. Uchinda
6. Irvine

E and F more effective

Others?

• Occlusive bands or rings: Falope
• Occlusive clips - Filshie or Hulka - Clemems
• Tubal diathermy (Thermocoagulation)
• Hysterectomy

• Immediate
• Delayed
• Long term

Quinacrine

A chemical compound in form of pellets

Results in permanent sterilization when inserted into the uterus - tubes

Causes scaring which blocks the fallopian tubes.

The Adiana Procedure: Quinacrine

• Catheter is inserted through a hysteroscope into the fallopian tube
• A superficial lesion is created by low level radiofrequency energy
• A porous plastic implant called matrix is placed into the lesion
• The surrounding tissues grows into the matrix over the next 12 weeks
• The grown tissues result in total closure of the fallopian tubes.

Essure

Non-surgical sterilization that uses the trans-cervical route.

Consist of a micro-coil made up of a spring-like device

The coil is placed in the uterine end of the fallopian tube using a hysteroscope

Scar tissues grow into the coil to plug it within 3 months

There is need for a temporary contraceptive method in the first three months.

Tubal blockage is confirmed after 3 months with ultrasound or Fluoroscopy or HSG.

Yuzpe Regimen

• High Dose Combined Pills
• Low Dose Combined Pills

Progestin Only (High Dose)

• Postinor
• Provera

IUD: Inserted within 5 days of Coitus

Mifepristone (RU 486)

Mechanism of Action of OCPs in Emergency Contraception

• If taken before ovulation, ECPs disrupt normal follicular development and maturation,
• Block LH surge, and inhibit ovulation,
• May also create deficient luteal phase,
• May affect tubal transport of sperm or ova

Mechanism of Action of IUD in Emergency Contraception

• IUD in EC
• Largely unknown
• Causes endometrial changes that inhibit ovulation
• Copper ions released appear to be directly embryotoxic
• Rarely, may act as contraceptive, if inserted days before ovulation

Emergency Contraception with Mifepristone (RU-486)

• An anti-progestogen
• Single dose of 10mg to 25mg (China) mifepristone (RU-486)
• Taken within 5 days of unprotected intercourse.
• Effectiveness: Prevents over 98% of pregnancies

Mechanism of Action of Mifepristone

• Blocks action of progesterone by binding to its receptors
• Stops ovulation if given in follicular phase (contraceptive)
• Slows endometrial maturation in luteal phase (interceptive)

New Developments in Contraception

• Contraceptive vaccine
• Theoretically possible
• Complexity of the topic and lack of funds have stalled research