Contraceptive Devices

1. NAMITA BATRA GUIN
Associate Professor

2.  Preventive methods to help women avoid
unwanted pregnancies.They include all
temporary and permanent measures to prevent
pregnancy resulting from coitus.

3.  Safe
 Effective
 Acceptable
 Inexpensive
 Reversible
 Simple to administer
 Independent of coitus
 Long lasting requiring less frequent administration
 Requiring little or no medical supervision.

4.  Cafeteria Approach: to offer all the methods
from which an individual can choose
according to his needs and wishes and to
promote family planning as a way of life.

5.  Spacing methods
 Barrier methods
 Physical methods
 Chemical methods
 Combined methods
 Intra-uterine devices
 Hormonal methods
 Post-conceptional methods
 Miscellaneous
 Terminal methods
 Male sterilization – vasectomy
 Female sterilization- tubectomy

6.  Barrier methods
 Aim is to prevent the live sperm from meeting the ovum.
 Advantage is the absence of side effects associated with
pills and IUD.
 Protection from Sexually transmitted diseases.
 Reduction in incidence of PID and cervical cancer to some
extent.
 It requires high degree of motivation from user.
 Effective only when used consistently and carefully.

7.  Physical methods
 Condom
 Widely used as barrier method by males
 Better known as ‘Nirodh’
 Prevents semen from being deposited in the vagina
 Effectiveness increases if used in conjunction with the spermicidal
jelly.
 Highly effective method of contraception if used correctly at every
coitus.
 Most of the failures are due to incorrect use of the device.

9.  Advantages
 Easily available
 Safe and inexpensive
 Easy to use, no medical supervision
 No side effects
 Light, compact and disposable
 Protection against pregnancy as well as STDs.

10.  Disadvantages
 Slip off or tear during coitus due to incorrect use.
 Interferes with sex sensation.

12.  A pouch made of polyurethane, lines the vagina
 Internal ring in the close end of pouch covers the
cervix.
 External ring remains outside the vagina.
 Prelubricated with silicon (spermicide)
 Effective against STDs
 High cost and acceptability are disadvantages.

14.  Vaginal barrier
 Also known as ‘Dutch cap’
 Shallow cup made up of synthetic rubber or
plastic material
 Diameter ranges 5-10cms
 Inserted before the sexual intercourse and
must remain in place for not less than 6
hours. After the intercourse.

16.  A spermicidal is used along.
 Side effects are nil.
 Advantages:
 Total absence of risks and medical contraindications.
 Disadvantages:
 Initially needs demonstration from trained personnel.
 After delivery, used only after involution of the uterus is
complete.

19.  Were in practice for hundreds of years.
 In practice now with the trade name of TODAY
 Small polyurethane foam sponge measuring
5cmX2.5cm, saturated with a spermicide.
 Less effective than diaphragm.

22.  Comprises of four categories:
 Foams: foam tablets, aerosols.
 Creams, jellies and pastes
 Suppositories
 Soluble films.
They attach themselves to the spermatozoa and inhibit
oxygen uptake and kill the sperms.

23.  Drawbacks:
 High failure rate
 Used immediately before the intercourse and repeated
before each act of intercourse.
 Should be introduced to the regions where sperms are
likely to get deposited in vagina.
 May cause mild irritation, burning or irritation.

25.  Types:
 Medicated and
 Non-medicated
 Medicated IUDs release either metal ions or hormones.
 Non-medicated are referred to as First Generation IUDs.
 Copper IUDs – Second Generation IUDs
 Hormone- releasing IUDs- Third Generation IUDs.

26.  Non-medicated devices.
 Made up of Polyethylene or other polymers.
 Appeared in spirals, loops, coils, rings etc.
 Lippe’s loop is the commonly used device under
the First generation IUDs.

28.  Double S- shaped device made up of polyethylene.
 Contains small amount of barium sulphate.
 Has attached threads or tail made of fine nylon.
 Tail can be easily felt.

30.  Copper has strong anti-fertility effect.
 Devices available are:
 Cu T – 220
 Cu T- 380A
 Nova T
 Multiload devices

31.  Advantages:
 Low expulsion rate
 Low incidence of side effects.
 Easy to fit
 Better tolerated
 Effective as post coital contraceptive, if inserted within 3-
5days after unprotected –intercourse.
 Increased effectiveness.

34.  Hormone releasing IUD
 Progestasert – T-shaped device filled with 38mg
of progesterone.
 It is released at the rate 65mcg daily.
 Has direct local effect on uterine lining, cervical
mucous and on sperms.
 It is gradually depleted, regular replacement
required.
 More expensive

35.  Foreign body reactions caused uterine
biochemical and cellular changes in
endometrium and endocrine fluids, which
impairs the viability of the gametes, thus
reducing the chance of fertilization, rather than
its implantation.
 Medicated IUDs causes other local effects.
Copper enhances the reaction. It also affects
the sperm motility and survival.
 Hormone – releasing – increases the viscosity
of the cervical mucous thus preventing sperm
from entering the cervix.

36.  Simplicity
 Insertion takes few minutes
 Stays in place as long as required
 Inexpensive
 Contraceptive effect is reversible by removal of IUD
 Free from systemic metabolic side-effects associated
with oral pills.
 No need for continual motivation.

37.  Absolute :
 Suspected pregnancy
 PID
 Vaginal bleeding
 Ca cervix
 Previous ectopic pregnancy
 Relative:
 Anemia
 Menorrhagia
 History of PID
 Purulent cervical discharge
 Distortion of uterine cavity due to congenital malformations
 Unmotivated person

38.  Who has borne at least one child
 Has no history of PID
 Has normal menstrual period
 Is willing to check the IUD tail
 Has access to follow-up and treatment of potential
problems
 Is in a monogamous relationship.

39.  Prepared through need based education and motivation.
 Interaction with women who have been using the device for
sometime for better motivation.

40.  Inserted anytime during the reproductive years of
woman (except during pregnancy)
 During menstruation or within 10days of beginning of a
menstrual period.
 While last 2 days of menstruation are considered as
most appropriate period for insertion.
 During this period, insertion is easy because diameter
of cervical canal is greater at this time than during the
secretory phase.
 And also the uterus is relaxed and myometrial
contractions are at minimum.

41.  Check her pads during the menstruation and feel for the
tail intra-vaginally after every period.
 If she misses the tail, must report to the health center
 Must switch on barrier contraceptive if she fails to
report in time.
 Must take technical help whenever she faces any
discomfort.
 Must do the required follow ups after the insertion of
IUD.
 If she misses a period she must consult to the doctor.

42.  Objective of follow-up are:
 To provide motivation and emotional support
 To confirm the presence of IUD
 To diagnose and treat any side-effects or complications.
 When to follow up:
 At the first menstrual period – to evaluate the problems of pain
and bleeding.
 At six months.
 At one year.

43.  Bleeding:
 Commonest complaint.
 10-20% acceptor encounter this and get IUD removed.
 Forms of bleeding: greater volume blood loss, longer menstrual
periods or mid-cycle bleeding.
 Usually bleeding or spotting between the periods settles within
1-2months
 Management: ferrous sulphate 200mg T.D.S.
 If bleeding is heavy and patient develops anemia despite of the
supplements – IUD should be removed.

44.  Pain:
 Second major side-effect leading to IUD removal.
 It may be experienced during insertion and for a few days
thereafter as well as during menstruation.
 Symptoms include: low back ache, cramps in lower abdomen
and pain down the thighs.
 It usually disappear by the 3rd month.
 If it is severe, it may be because of incorrect size, or placement,
infection, or perforation.
 Slight pain is controlled by aspirin and codein, while in case of
incontrollable pain, IUD should be removed.

45.  Pelvic Infections:
 It may be due to introduction of bacteria during the IUD
insertion.
 Symptoms are: vaginal discharge, pelvic pain and tenderness,
banormal bleeding, chills and fever.
 One or two episodes of PID can cause infertility.
 Treatment with broad spectrum antibiotics.
 Removal of IUD.

46.  Perforation:
 May be incomplete or complete
 Device penetrates the wall and migrates into peritoneal cavity
causing serious complication like intestinal obstruction.
 Copper also causes intense tissue reactions leading to
adhesions.
 More common during post partum (48hrs and 6 weeks)
 Symptoms: h/o sharp pain at the time of insertion, bleeding
following insertion, disappearance of the tail or dyspareunia.
 It may not cause any symptom and pass unnoticed.
 Diagnosis is made by ultrasonography.
 Surgical removal is done. Perforation usually heals without
treatment.

47.  Pregnancy:
 Pregnancy with IUD is regarded as potential medical
complication with the danger of infection and spontaneous
abortion.
 Chances of ectopic pregnancy are lesser in women using
levonorgestrel IUD.
 Women should be taught to recognize the symptoms of ectopic
pregnancy- dark and scanty vaginal bleeding, amenorrhea,
lower abdominal pain.
 Women reporting with pregnancy (not ectopic) should be
offered the option of abortion.
 If pregnancy has to be continued, then IUD should be removed.

48.  Expulsion:
 Can be partial or complete.
 It is influenced by the skill of insertion, timing of insertion, age
and parity of the user.
 Can be diagnosed on speculum examination.
 Usually occurs during the first few weeks following the
insertion or during menstruation.
 If expulsion is unnoticed pregnancy may occur.
 If it is incomplete- device should be removed and replaced by
new one.
 If no trace found- women may be fitted with new device.

49.  If properly used, are most effective
 Combined type of Oral pill provides 100% prevention
against pregnancy.
 It includes:
 Oral pills
 Combined pills
 Progestogen only pill (POP)
 Post –coital pill
 Once a month pill
 Male pill
 Depot formulations
 Injectables
 Subcutaeneous implants
 Vaginal rings.

50.  Oral pills

51.  Combined Pills:
 Given orally for 21 consecutive days, beginning on 5th day of
menstrual cycle.
 It is followed by break period of 7days during which
menstruation occurs.
 When bleeding occurs it is considered as the first day of next
cycle.
 It is called withdrawal bleeding.
 It should be taken everyday at a fixed time, preferably before
going to bed at night.
 If user misses the dose/pill, she should take as soon a she
remembers and next pill should be taken at the usual time.
 Types: MALA-D and MALA-N
 Mala-D : contains D-norgestrel (0.5mg) and ethinyl estradiol
(0.04mg)
 Mala- N: Contains norethindrone (1mg) and ethinyl estradiol
(0.03mg)

52.  Progestogen – only Pills:
 Known as minipill or micropill
 Given in small doses throughout the cycle.
 Commonly used progestogens are norethisterone and
levonorgestrel.
 Can be prescribed to older women for whom combined pills
may be contraindicated because of Cardiovascular risks.
 Post coital contraception:
 Recommended within 72 hrs of unprotected intercourse.
 An emergency method.
 Should not be used as main contraception method, as it
contains high doses.
 Types:
 IUD- specially he copper device within 7 days.
 Hormonal: Levonorgestrel 0.75mg tab within 72hrs and 2nd tab after
12hrs of first dose.
 Mifepristone – 10mg once within 72hrs.

53.  Once a month pill:
 Long acting estrogen is given in combination of short acting
progestogen.
 High failure rate.
 Male pill:
 Made of Gossypol – derivative of cotton seed oil.
 Effective in causing azoospermia or severe oligospermia.
 It could be toxic, as studies showed narrow margin between
effective and toxic doses.
 Till now not in use.

54.  Prevent the release of ovum from the ovary, by blocking the
secretion of gonadotropins which is necessary for the
ovulation.
 Progestogen- only preparations makes the cervical mucus
thick and scanty and thereby inhibit sperm penetration.
 Progestogens also inhibit tubal motility and delay transport of
sperms and ovum to the uterine cavity.

55.  Cardio-vascular effects:
 Use of combined pill is associated with excess of mortality.
 The estrogen component is responsible for the cardiovascular
diseases.
 Carcinogenesis:
 Increased risk of cervical cancers with increasing duration of use of
oral contraceptives.
 Metabolic effects:
 High B.P, altered serum lipids, decreased HDL, blood clotting and
inability to modify CHO metabolism resulting in high Glucose
 It is associated with progestogen component.
 Other effects:
 Liver disorders: leads to cholestatic jaundice, gall bladder disease.
 Lactation: affect the constituents and quantity of milk.
 Subsequent fertility: use beyond 5-10years may affect fertility
 Ectopic Pregnancies: more likely in POP users but not in combined
users.
 Foetal development: increases the incidence of birth defects, if taken

56.  Almost 100% effective in preventing pregnancy.
 According to studies it prevents various diseases: ovarian cysts, benign
breast disorders, iron-deficiency anemia and ovarian cancer etc.

57.  Absolute:
 Ca breast and genitals
 Liver disease
 H/o thromboembolism
 Cardiac abnormalities
 Congenital hyperlipidemia
 Undiagnosed abnormal uterine bleeding.
 Special problems requiring medical surveillance:
 Age over 40years
 Smoking and age over 35years
 Mild HTN.
 Chronic renal disease
 Epilepsy
 Migraine
 Lactating mothers in first 6mnths
 DM
 Gall bladder disease
 H/o infrequent bleeding
 Amenorrhea

58.  Highly effective
 Reversible
 Long acting
 Oestrogen-free for spacing pregnancies
 Single administration is sufficient for months to years
 Types: injectables, subdermal implants and vaginal rings.

59.  Injectable contraceptives:
 Two types: progestogen only and once a month combined injectables
 Progestogen only injectables:
 DMPA: depot medroxyprogesterone acetate
 NET- EN – norethisterone enantate
 DMPA- SC

60.  DMPA:
 150 mg every 3months I.M.
 Gives 99% protection against pregnancy
 Supresses the ovulation
 Also affects endometrium, cerrvical mucus and
fallopian tubes.
 Side effects include weight increase, irregular
menstrual bleeding and prolonged infertility.

61.  NET –EN
 200mg every 2 months I.M.
 Inhibits the ovulation and progestogenic effects on
cervical mucous.
 Initial injections are given during the first 5days of
the menstrual period.
 Never massage the site
 DMPA- SC
 Lower dose formulation
 104mg of DMPA given S/C
 Given in upper thigh or abdomen.

62.  Combined Injectables:
 Progestogen and oestrogen
 Given at monthly intervals plus minus 3days
 Supresses the ovulation
 Cervical mucus also gets affected
 Less effective than the other types.
 Not suitable for lactating mothers for 6months post
partum
 Cyclofem and mesigyna are the examples

63.  Norplant
 Consists 6 silastic capsules containing 35mg of
levonorgestrel.
 Thee are implanted beneath the skin of the forearm
or upper arm.
 Effective for 5years
 Contraceptive effect is reversible on removal of
capsules
 Main disadvantage- irregular menstrual bleeding and
surgical procedure is necessary for its insertion.

66.  Rings containing levonorgestrel is worn in
vagina for 3weeks of the cycle and is removed
for the 4th.
 Hormone is slowly absorbed through vaginal
mucosa, bypassing the liver and digestive
system.

67.  Menstrual regulation:
 Simple method of birth control
 Aspiration of uterine contents 6-14 days of a missed
period.
 Cervical dilatation is indicated in nulliparous.
 Immediate complication: uterine perforation and
trauma.
 Late complications: infertility, menstrual disorders
etc.
 Different from abortion: lack of certainty regarding
termination of pregnancy, lack of legal restrictions
and increased safety.

68.  Menstrual Induction:
 Intra-uterine application of 1-5mg solution of
prosaglandin impact under sedation.
 Uterus responds with the sustained contractions
lasting fpr about 7minutes, followed by the cyclic
contractions continuing for 3-4hrs.
 Bleeding starts and continues for 7-8days.
 Product of conception is removed with the bleeding

69.  Oral Abortifacients:
 Mifepristone (RU486) in combination with
misoprostol.
 95% successful in terminating pregnancy.
 Regimen: mifepristone 200mg orally on day 1,
followed by misoprostol 800mcg vaginally either
immediately or within 6-8hrs.
 Also available in combipack of mifepristone (1 tab of
200mg) and misoprostol (4tabs of 200mcg).
 Patient should come for follow up after 14 days for
confirmation of complete termination,
ultrasonographically.
 Contraindications: H/o allergy to these drugs,
confirmed ectopic pregnancy, hemorrhagic

70.  Abortion:
 Termination of pregnancy before the fetus become
viable. (28weeks and wt. approximately 1000g)
 Hazards due to abortion: hemorrhage, uterine
perforation, cervical injury, thromboembolism,
infertility, risk of spontaneous abortion.
 MTP act allows the abortion only upto 20weeks of
pregnancy.

71.  Abstinence:
 Complete cessation of sexual intercourse.
 Leads to repression and results in various disorders like
nervous breakdown.
 Is not considered as a method of contraception.
 Coitus interruptus:
 Oldest method of voluntary fertility control.
 Male withdraws before ejaculation, thereby preventing
deposition of semen into vagina.
 Drawback: pre-coital secretion may contain sperms.
 Failure rate is as high as 25%.

72.  Safe period:
 Also known as calendar method or rhythm method.
 Drawbacks:
 Cycle is not always regular
 Can only be used by educated and responsible couple with high motivation.
 Compulsory abstinence during the fertility time.
 Not applicable in post partum period.
 High failure rate.
 Complications:
 Ectopic pregnancy
 Embryonic abnormalities.

73.  Natural family planning methods:
 BBT – basal body temperature
 Cervical mucus method
 Symptothermic method.
 Based on calendar method.

74.  Basal Body Temperature:
 BBT rises at the time of ovulation, because of
increased in production of pregesterone.
 Rise of temp. is very small.
 Temp. is measured early in morning.
 Post –ovulatory infertile period occurs 3days after
ovulatory temp. rise and continues till beginning of
menstruation.
 Abstinence is required for entire pre-ovulatory
period.

75.  Cervical mucus method
 Also known as Billing’s method or ovulation mahod.
 Based on changes in the characteristic of cervical
mucus.
 At the time of ovulation, cervical mucus become
watery clear and resemble raw egg white, smooth,
slippery and profuse.
 After the ovulation, under the effect of progesterone,
cervical mucus becomes thick and lessens in the
quantity.
 To practice this woman should know the difference
between types of mucus.
 Requires high motivation.

76.  Symptothermic method:
 Combination of BBT , cervical mucus and calendar
method.

77.  One time method
 Doesnot require sustained motivation.
 Most effective protection against pregnancy
 Cost – effective.
 Guideline:
 Age of husband not be less than 25yrs and over
50yrs.
 Age of wife not less than 20yrs and over 45yrs.
 Must have 2 living children at the time of operation.
 If 3 children, lower limit of both can be relaxed
 Consent needs to be taken who undergoes the
process.

78.  MALE STERILIZATION
 Performed even at PHC level.
 Under local anesthesia and strict asepsis.
 1cm piece of vas is removed after clamping. The
ends are ligated and folded back on themselves and
sutured far away from each other.
 This reduces the recanalization.
 Male doesnot get sterile immediately after the
procedure.
 After approx. 30 ejaculations, male may be
considered sterile.
 Sperm produced are destroyed intraluminally by
phagocytes.
 Simpler, faster and less expensive.

80.  MALE STERILIZATION
 Complications:
 Operative: scrotal hematoma, local infection.
Antibiotics reduces this risk.
 Sperm granules: caused by accumulation of sperms.
Aapear in 10-14 days after the procedure. Symptoms:
swelling & pain. They provide medium for
anastomosis. Metal clips may be used to close the
vas, to reduce the problems.
 Auto-immune response: blocking of vas causes
reabsorption of spermatozoa and antibodies against
sperm in the blood.
 Psychological: men complain of diminution of sexual
vigor, impotence, headache, fatigue etc. it is more in
those who have undergone vasectomy under
emotional pressure

81.  MALE STERILIZATION
 Post-op advices:
 He will become sterile only after 30 ejaculations
approx. so should undergo seminal examination.
 Use contraceptives until aspermia has been
established.
 Avoid taking bath for atleast 24hrs after the operation
 Wear a T-bandage or scrotal support for 15days and
keep site neat , clean and dry.
 Avoid cycling, heavy wt. lifting for 15days.
 Stitches are removed on 5th day after operation.

82.  FEMALE STERILIZATION
 Two procedures: laproscopy and minilap
 Laproscopy
 Tubes are visualised and Falope rings are applied to
occlude the tubes.
 Done where obstetrician or gynecologists are
available.
 Short operating time, shorter stay at hospital and a
small scar.
 Not for post partum women. Hb should be not less
than 8mg/dl.
 No associated medical disorders like: DM, HTN.
 Hospital stay is minimum 48hrs.
 Should be followed up once between 7-10days and
once again between 12-18months after operation.

84.  FEMALE STERILIZATION
 Minilap /Pomeroy technique
 Modification of abdominal tubectomy.
 Small abdominal incision- 2.5 to 3cm.
 Conducted under GA.
 Suitable procedure at PHC and in mass campaigns.
 Suitable for postpartum tubal ligation.