1. CONTRACEPTIVE UPDATES
Dr Abhay Dhanorkar
1

2. Scope
• Introduction
– Definition
– History
– Reproductive rights
– Contraceptive scenario in India & Maharashtra
• Classification of contraceptives
• Barrier methods
• Oral Contraceptive Pills and Emergency Contraceptive Pills
• Injectable contraceptives
• Intrauterine device (IUDs)
• Sterilization
• Miscellaneous
• Advanced contraceptive methods in pipeline
2

3. contraceptive methods
• Preventive methods to help women avoid unwanted
pregancies.
• Include all temporary and permanent measures to
prevent pregnancy.
3

4. Aim of contraception
• Family planning to check the population growth,
• To prevent STDs like AIDS.
• To reduce the stress of pregnancy, labour & lactation
in women suffering from heart disease etc.
4

5. HISTORY
3000BC Condoms - fish bladders, linen sheaths, and animal intestines.
1500
Spermicides condoms - linen cloth sheaths soaked in a chemical
solution and dried before using.
1838 Condoms and diaphragms- vulcanized rubber.
1916 Margaret Sanger - first birth control clinic in the US.
1960 1st oral contraceptive - Enovid, was marketed in US (Frank Colton)
1960s IUDs first manufactured and marketed in the US.
5

6. History contd…
1972 Legalition of birth control for all in US, irrespective of marital status.
1980s - Hormonal birth control methods expanded to include
1990s implants and injectables. Low-dose pills were introduced.
Emergency contraception became more widely available as a
1992 result of public awareness campaign
Rapid expansion in method availability and improvements in safety and
Today effectiveness, including introduction of the hormonal patch, vaginal ring,
new injectables, single rod implants, and transcervical female sterilization
Today Barriers to access contraception remain for women world-wide.
6

7. India – Some important landmarks
• 1951 - The National family planning program
• 1965 - Lippies loop introduced
• 1971 - MTP act
• 1977 - Family welfare programme
• 1978 - Child Marriage act
• 1992 - CSSM
• 1997 - RCH- I
• 2005 - RCH II
• 2007 - Nuvaring /NRHM
 Contraceptive usage has been rising gradually in India.
– In 1970 - 13%
– In 1997 - 35%
– In 2009 - 48% .
7

8. • The fertility rate in India has been in long-
term decline from 5.7 in 1966 to 2.62 in
2011.
• 14 Indian states have dipped below the 2.1
According to the latest health While achieved targeted TFR,
ministry data Worst TFR in Tamil Nadu (1.7)
Bihar (3.9) Kerala (1.7)
Uttar Pradesh (3.7) Maharashtra (1.9)
MP (3.3) Delhi (1.9)
Jharkhand (3.2) West Bengal (1.9)
Chhattisgarh (3) Karnataka (2)
Uttaranchal (2.6)
Assam (2.6)
Gujarat (2.5)
8

9. Reproductive Rights
To enable control over individual‘s reproductive lives
following rights are given.
1. Reproductive health as a component of overall health.
2. Reproductive decision-making for
a. Voluntary choice of marriage, family formation
b. Determination of the number, timing and spacing
of one‘s children
3. Enable individuals to make free and informed choices
free from discrimination based on gender
4. Reproductive security, including freedom from sexual
violence and coercion, and the right to privacy.
9

10. Contraceptive Scenario in India
The current trends in family planning in
India shows
– High level of knowledge among eligible
couples
– Low acceptance remains for spacing
methods.
– Female sterilization remains the most
widely used family planning method in spite
of efforts to popularise male sterilization.
10

11. INDIA FACT SHEET, NFHS-3, 2005-06
• Family Planning Use - &
• Fertility –
• Smaller families -becoming the norm.
• Fertility has continued to decline
– NFHS-2 – 2.9 Children
– NFHS-3 – 2.7 Children.
• 14 states have reached replacement level or
below replacement level fertility.
• Percentage of women with two daughters
and no sons say they want no more children,
– NFHS-2 – 47%
– NFHS-3 – 64%.
11

12. Declining fertility is due to
• Increased use of contraception - 43% to 49%
between NFHS-2 and NFHS-3.
• Women ages 20-24 were married before the
legal age of marriage of 18 years
– NFHS-2 - 50%
– NFHS-3 - 47.4%
• Increase in median age at first birth from
19.8 to 19.2.
12

13. Key Indicators for India from NFHS-3
Marriage and Fertility NFHS -1 NFHS-2 NFHS 3
Urban Rural
(1992-93) (1998-99) (2005-06)
Women age 20-24 married
54.2 50.0 47.4 29.3 56.2
by age 18 (%)
Men age 25-29 married by
NA NA 32.2 18.1 40.3
age 21 (%)
Total fertility rate (children
3.4 2.9 2.7 2.1 3.0
per woman)
Women age 15-19 who
were already mothers or
NA NA 16.0 8.7 19.1
pregnant at the time of the
survey
Median age at first birth for
19.4 19.3 19.8 20.9 19.3
women age 25-49
Married women with 2
living children wanting no 59.7 72.4 84.6 89.7 81.6
more children
Two sons 71.5 82.7 89.9 92.1 88.6
One son, one daughter 66.0 76.4 87.0 92.8 85.3
Two daughters 36.9 47.0 64.1 74.7 54.4
13

14. Key Indicators for India from NFHS-3 contd…
Family Planning
(currently married NFHS -1 NFHS-2 NFHS 3
Urban Rural
women, age 15–49) (1992-93) (1998-99) (2005-06)
Current use
Any method (%) 40.7 48.2 56.3 64.0 53.0
Any modern method (%) 36.5 42.8 48.5 55.8 45.3
Female sterilization (%) 27.4 34.1 37.3 37.8 37.1
Male sterilization (%) 3.5 1.9 1.0 1.1 1.0
IUD (%) 1.9 1.6 1.7 3.2 1.1
Pill (%) 1.2 2.1 3.1 3.8 2.8
Condom (%) 2.4 3.1 5.2 9.8 3.2
Total unmet need (%) 19.5 15.8 12.8 9.7 14.1
For spacing (%)
11.0 8.3 6.2 4.5 6.9
For limiting (%) 8.5 7.5 6.6 5.2 7.2
14

15. Key Indicators for Maharashtra from NFHS-3
Marriage and Fertility NFHS -1 NFHS-2 NFHS 3
Urban Rural
(1992-93) (1998-99) (2005-06)
Women age 20-24 married
53.9 47.7 39.4 29.2 49.9
by age 18 (%)
Men age 25-29 married by
NA NA 15.0 12.6 18.9
age 21 (%)
Total fertility rate (children
2.9 2.5 2.1 1.9 2.3
per woman)
Women age 15-19 who
were already mothers or
NA NA 13.8 9.3 18.2
pregnant at the time of the
survey
Median age at first birth for
19.0 19.0 19.9 20.9 19.0
women age 25-49
Married women with 2
living children wanting no 73.1 81.2 89.0 89.0 89.1
more children
Two sons 81.7 93.5 95.5 93.1 97.5
One son, one daughter 79.2 85.3 92.8 91.5 94.2
Two daughters 37.6 41.4 55.1 69.2 36.5
15

16. Key Indicators for Maharashtra from NFHS-3 contd…
Family Planning
(currently married NFHS -1 NFHS-2 NFHS 3
Urban Rural
women, age 15–49) (1992-93) (1998-99) (2005-06)
Current use
Any method (%) 54.1 60.9 66.9 66.7 67.1
Any modern method (%)
52.9 59.9 64.9 64.0 65.8
Female sterilization (%)
40.3 48.5 51.1 44.2 57.5
Male sterilization (%) 6.2 3.7 2.1 1.0 3.2
IUD (%) 2.5 1.9 3.0 5.3 0.8
Pill (%) 1.4 1.7 2.4 3.6 1.3
Condom (%) 2.5 4.0 6.2 9.8 2.9
Total unmet need (%)
14.1 13.0 9.4 9.8 9.0
For spacing (%)
7.3 8.1 5.4 5.3 5.6
For limiting (%) 6.8 4.9 3.9 4.5 3.3 16

17. Need for Updates
The current unmet need for family
planning is -12.8 % of which
– For spacing - 6.2 % and
– For Limiting births - 6.6 %
Two important issues in catering to the
unmet demand are
– Poor access to family planning services.
– Poor Quality of family planning services.
17

18. Classification of contraceptive methods
Barrier Methods
Intrauterine Devices
Spacing Methods Hormonal Method
Post Conceptive
Methods
Contraceptive Methods
Miscellaneous
Male Sterilisation
(Vasectomy)
Terminal methods
Female Sterilisation
(Tubectomy)
18

19. Evaluation of contraceptive methods
Contraceptive efficiency:
It is the measurement of unplanned pregnancies even after
the use of contraceptive measures.
1) Pearl Index: no. Of failures/100 woman-yr of exposure
Failure rate/HWY= Total accidental pregnancies × 1200
total months of exposure
2) Life table analysis: calculates a failure rate for each
month of use
19

20. I) Barrier methods
Physical methods
Chemical methods
Combined methods
20

21. Physical methods
1) condoms:
•Made up of fine latex sheath
•Most widely used barrier in males
•Highly effective if used correctly
ADVANTAGE:
•Simple spacing method
•No side effects
•Easily available, safe & inexpensive
•Protects against STDs
DISADVANTAGE:
•Chances of slip off and tear off
Failure rate: 2-3/HWY
21

22. Types of condoms
1. Flavoured condoms
2. Dotted condoms
3. Super thin condoms
It is transparent with a thin layer made of sheerlon material
that acts like a second skin. It is highly effective against
pregnancy and STDs.
4. Pleasure-shaped condoms
It heightens sensitivity for both the partners. It has loose and
enlarged tip.
5. Glow in the dark condoms
When exposed to light for 30 seconds, it glows in the dark. It
is non-toxic and has three layers. The inner and the outermost
layers are made up of latex and the middle one contains a safe
pigment that makes it glow.
22

23. Other Advances in Male Condoms
• Desensitizing condoms with ―climax control
lubricant featuring benzocaine that helps prolong
sexual pleasure and aids in prevention of
premature ejaculation‖ (Durex Performax, Trojan
Extended Pleasure)
• Spermicidally lubricated condoms
• Distrubution of condoms: Health worker, Asha,
Condom vending machine
23

24. Condom Applicator
• A South African designer invented : a condom that can be
applied in less than four seconds. Dubbed Pronto, the
condom aims to be quicker and easier to apply than
conventional brands with the hopes of encouraging more
people to use them.
• The condom is contained within a foil pack -- which also
acts as the applicator.
• Crack the pack in half and slip the plastic applicator apart,
then roll the condom down and snap the applicator off the
condom -- all in one swift movement.
• Cost -Rs.33.95 per condom.
• British biotech company Futura Medical has created a new
condom, -CSD500 -coated with a vasodilator gel.
24

25.  Strong, soft, transparent polyurethane sheath
inserted in the vagina before sexual intercourse
 15 cm long X 7 cm diameter
 There is silicone-based lubricant on the
condom, but additional lubrication can be used.
Has two flexible rings
 The outer ring , The larger, open ring stays outside
the vagina, covering part of the perineum and labia
during intercourse.
 The inner ring at the closed end of the condom
eases insertion into the vagina, covering the cervix
and holding the condom in place
25

26. The female condom has been available since
1992
brand names,
FC Female Condom, Aastha,
Velvete,Reality, Femidom,
Dominique, Femy, Myfemy,
Protectiv' and Care.
26

27. Female condom instructions
A new condom every time
Make sure the condom is in place
NO male condom with a female condom
Inserted for up to 8 hours
Wash your hands carefully with soap and water before
inserting, or removing the female condom.
27

28. Female Condoms
How to insert the female condom ?
28

29. How to remove the female condom?
To remove the Wrap the condom in the
condom, twist the package or in tissue, and
outer ring and gently throw it in the garbage. Do
pull the condom out. not put it into the toilet.
29

30. Advantages of Female Condom
• Female-controlled
• No medical condition limits use.
• More comfortable to men, less decrease in sensation
than male latex condoms.
• Ease of use by men with erectile dysfunction.
• Offers greater protection as it covers both internal and
external genitalia.
• Stronger (polyurethane is 40% more stronger than
latex), and therefore there is less frequent breakage
(1% compared to 4% for male condoms)
• Longer shelf-life under unfavourable storage conditions.
• CSWs found that the it allowed them to continue their
job without interruption during menstruation.
30

31. Disadvantages of Female condom
• Difficulties in insertion and removal.
• Casues discomfort and inconvenience
associated with use and movement of device
during use.
• More expensive than male condoms.
• Failure rate – 21/HWY
31

32. Some Evidences of FC use
• In a study in Alabama,
• 25% - Unable to correctly insert in first use
• 3% - Never able to do so despite additional
instructions and multiple efforts.
• A study focused mainly on acceptability in 58
respondents from urban slums in Chennai and CSWs
showed good acceptability in this group.
• Study conducted in the Andhra Pradesh, Kerala and
Maharashtra, amongst 2 target groups, FSWs and
eligible couples. For study period of 2 months, Usage
levels were above 90% in both categories.
32

33. Physical methods contd...
2)diaphragm:
• Dutch cap / Fem caps
• Vaginal barrier
• Consists of a flexible ring
made up of spring material
to which a cup shaped
synthetic rubber is
attached
• Inserted into vagina over
cervix
• A spermicidal jelly is
always used
Failure Rate: 6-12/HWY
33

34. Physical methods (c0ntd...)
3) Cervical cap:
smaller as compared to diaphragm
Applied over cervix
ADVANTAGE:
•Inexpensive,
•No medical consultation
•Total absence of risks and medical CIs
DISADVANTAGE:
•Failures are quite common
•Chances of displacement high
•Cervicitis and local irritation
Failure rate: 11/HWY
34

35. physical Methods (contd...)
4) VAGINAL SPONGE
•Trade name ‗TODAY‘
•Polyurethane foam sponge
saturated with spermicide
nonoxynol 9 (1gm)
•Less effective than diaphragm
Failure Rate:
•20-40/HWY in multiparous
•9-20/HWY in nulliparous
35

36. Chemical barriers
Spermicidal agents which can
destroy sperms when applied in
female genital tract
They are available as
1) Foams
2) Creams. Jellies, Paste
3) Suppositories
4) Soluble films
Common spermicidal agents
1) Nanoynol-9
2) Octoxynol-3
Failure rate: 6/HWY
36

37. Chemical barriers (contd...)
ADVANTAGES:
• Inexpensive
• Well tolerated
• Good protection
DISADVANTAGES:
• High failure rate
• Must be used immediately before intercourse
• Mild burning and irritation
• If used alone, not most effective in preventing
pregnancy
37

38. Intrauterine devices
classification
First Generation
Eg. Lippe’s loop
Nonmedicated
IUD Second Genration
Eg. Copper IUD
Medicated
Third Generation
Eg. Hormonal IUD
38

39. First generation iud
•They are inert or Nonmedicated devices
made up of polyethylene
•Different shapes and sizes
LIPPE‘S LOOP:
• Double ‗S‘ shaped device
• Made up polyethylene material
• Non toxic, non tissue reactive &
extremely durable
• Small amount of Barium Sulphate is
also added for radiological examination
• Available in 4 sizes A,B,C &D
Failure rate: 3-5 / HWY
39

40. Second generation Iud
•Made up of metal - copper.
EARLIER DEVICES
•Copper-7
•Copper-T 200
NEWER DEVICES
•Variants of T device
T copper 220C
T copper 380A
•Nova T
•Multiload devices
ML-Cu250
ML-Cu375
Failure rate: 0.8/HWY 40

41. Intra-uterine Contraception
GyneFix -
“frameless and flexible”=
less pain and bleeding
Non-biodegradable suture thread 6
Cu tubes (5mmx2.2mm) surface
area 330mm2
Special inserting device to anchor
knot into fundal myometrium
Suitable for nulliparous
Expulsion less than other IUDs
41

42. Third generation iud
•Hormone releasing IUD
Progestastert
Most commonly used
•T shaped device
•filled with 38mg of progesterone
•Releasing rate 65µg/day.
•Effective for 1 yr
LNG-20 (Minera)
•Releases 20µg of levonorgesterol.
•Effective for 5 yrs
•Effective rate 99%
Failure rate: 0.2 / HWY
42

43. Mechanism of action of Iud
IUD
IUD
Cellular and Hormone
biochemical changes Copper ions
in Endometrium releasing IUD
Affect uterine Viscosity of
Viability of gamete is
impaired enzymes cervical mucous
is increased
Chances of Composition of Sperm entry is
fertilization are cervical mucosa
reduced impaired
is altered 43

44. IUD EFFECTIVENESS
Progestasert 12-18 months
CuT 200 4 yrs
Nova T 5yrs
CuT 380 A 10yrs
Levonoregestrel 5 yrs
44

45. ADVANTAGES OF IUDs:
• Safe, Effective, Reversible
• Inexpensive
• High continuation rate
DISADVANTAGES OF IUDs:
• Heavy bleeding and pain
• Pelvic Inflammatory diseases
• Ectopic pregnancy
• May come out accidently if not properly inserted
45

46. TIMING OF INSERTION:
• Inserted with a plunger
• Any time during women‘s reproductive period Except
in pregnancy
• Most ideal time is during or within 10 days of the
beginning of menstruation the diameter of cervical
cavity is greatest at this time.
46

47. IDEAL IUD CANDIDATE:
• Who has borne at least 1 child
• Has no history of PID
• Has normal menstrual periods
• Is willing to check IUD tail
• Has an access to follow up and treatment of potential
problems
• Is in monogamous relationship
47

48. Hormonal methods
48

49. Classification of hormonal
contraceptives
Combined pills
Progesterone only
pills (POP)
Oral Pills
Once – a – month
(long acting) pills
Hormonal Male pill
contraceptives
Injectables
Depot Preparations Subdermal Implants
Vaginal Rings
49

50. Hormonal control of menstrual cycle
50

51. Oral Contraceptive and
Emergency Contraceptive Pills
Combined oral contraceptive pills
A. Monophasic pills
1. Standard dose pills
2. Low dose pills
3. Very low dose pills
B. Multiphasic pills
1. Triphasic pills
2. Biphasic pills
C. Progesterone only pills/minipills
51

52. Multiphasic pills
• These were developed with the aim of
reducing the total monthly hormone intake
while maintaining the efficacy.
• Biphasic pills: EE- 0.035 mg constant
• Low dose progesterone first 7 days
• High dose progesterone next 14 days. These
have higher failure rates and are not available
in India.
52

53. Triphasic pills:
• EE- 0.03mg + LNG 0.05mg for 5 days
• EE- 0.03mg + LNG 0.075mg for 10 days
• EE- 0.03mg + LNG 0.125mg for 7 day
• These pills have fewer side effects like
amenorrhoea, breakthrough bleeding and
decreased incidence of acne.
• The drawbacks include errors in pill taking,
increased failure and difficulty in postponing
menstruation if required.
53

54. Absorption of oral preparations
• Hormones are absorbed from the upper small intestine.
• Peak plasma levels reached within 2 hours
• Vomiting within 2 hours of ingestion reduces the amount
of hormones absorbed, & missed pill instructions should
be followed during the attack and for the next 7 days.
• In combined oral contraception, the pill free interval
should be omitted if less than 7 pills remain in the
packet.
• Diarrhoea (unless severe) is unlikely to affect drug
levels; there are no studies showing any pharmacological
basis for failure.
54

55. Combined pills
Composition:
•In early 1960s –
•Oestrogen - 100-200µg and
•Progesterone - 10mg
•Greater side effects
•Nowadays
•Oestrogen - 30-35µg and
•Progesterone - 0.05-0.15mg.
Taken from 5th to 25th day of menstrual cycle, followed
by a break of 7 days (withdrawal bleeding).
•Failure rate: 0.1/HWY
55

56. Main type
A) MALA-D: (Levonorgestrol 0.15mg + EE
0.03mg) Packet of 28 tabs. 21 are white and
7 are brown coloured containing Ferrous
Fumarate.
B) MALA-N : (Levonorgestrol 0.15mg + EE
0.03mg)Packet of 28 tabs.
Govt Supply.
Mechanism of action:
A) Prevents ovulation
B) Prevents implantation
C) Makes cervical secretions thick
Effectiveness
100% effective if taken correctly. 56

57. Beneficial Effects with Combination Oral
Contraceptives
• 100% effective in correct users.
• Beneficial effects on menorrhagia (anemia),
dysmenorrhea, ovulatory pain, acne and hirsutism
• Preventive effects on salpingitis, endometriosis,
adenomyosis and myomas
• Lower the risk of endometrial, ovarian- (30-50%) and
possibly colon cancer
• Preserves bone mineral density (3.3% > BMD in
premenopausal females with OCP use
• May reduce the risk of ovarian cysts, rheumatoid
arthritis, benign breast disease & Ectopic preg.
• May have protective effect against atherosclerosis.
57

58. Untoward Effects with Combination Oral Contraceptives
 Cardiovascular effects
hypertension in 5% users
myocardial infarction
 Stroke ; ischemic or haemorrhagic
 DVT‘s especially smokers >35, overweight and sedentary
 Cancers (increase risk of)
breast
hepatocellular
cervical
 Endocrine and metabolic effect, impaires glucose tolerance
and responses to glucose challenge
 Breast tenderness, Weight gain, Headache and migraine
 Special infections,
HIV, HPV
58

59. Contraindications to OCP Use
Absolute Contraindications Relative Contraindications
 Cancer of breast and  Age above 40 yrs.
Genitals  Smoking and age above
 H/O venous 35 yrs
thromboembolism  HTN with SBP>160,
 Vascular disease- CAD or DBP>99
CVD  Chronic renal diseases
 Liver disease ( i.e. Viral  Epilepsy , Migraine
hepatitis, cirrhosis)  Hyperlipidemia LDL>160
 Pregnancy  DM with secondary
 Congenital complications
hyperlipidaemia  Infrequent bleeding,
Amenorrhoea. 59

60. • Postpartum women - not breastfeeding can start combined
hormonal methods at 3 weeks (MEC category 2).
• Women who have additional risk factors for venous
thromboembolism (VTE) generally should not start
combined hormonal methods until 6 weeks after childbirth,
depending on the number, severity, and combination of the
risk factors (MEC category 2/3).
These additional risk
factors include
•Previous VTE •Postpartum hemorrhage
•Thrombophilia •Pre-eclampsia
•Caesarean delivery •Obesity
•Blood transfusion at •Smoking
delivery
60

61. • Women with deep vein thrombosis who are
established on anticoagulant therapy
generally can use progestin-only
contraceptives (MEC category 2) but not
combined hormonal methods (MEC category
4).
61

62. • Women with systemic lupus erythematosus generally
can use any contraceptive except that:
(a) A woman with positive (or unknown)
antiphospholipid antibodies should not use
combined hormonal methods (MEC category 4) and
generally should not use progestin-only methods
(MEC category 3).
(b) A woman with severe thrombocytopenia
generally should not start a progestin-only
injectable (MEC category 3).
62

63. Progesterone only pills
Minipill or Micropill.
Composition:
•Low dosage of progesterone,
mainly Norgestrel 0.075mg
Dosage:
•One tab daily throughout the
menstrual cycle
•It is mainly given in older
women in whom combined pills
are C/I as in CVDs
Efficacy 96-98%
Failure rate:0.5/HWY 63

64. Pop (contd...)
Mechanism of action:
 Makes cervical mucosa thick – action starts in 2-4 hrs last for
24hrs.
 Decreases the motility of Fallopian tubes.
 Prevent pregnancy without preventing ovulation, as ovulation
occurs in 20-30% women.
• Suitable for
 Lactating women
 Smokers above 35 yrs old
 Estrogen sensitive women
Disadvantages:
Higher risk of neoplasia in women taking POP than in women on
Combined Pills
• Poor control of cycle.
64

65. Progesterone only contraceptives
Types
 Norethindrone 350 mcg (Micronor/Noriday)
 Levonorgestrel 75 mcg (Neogest)
 Norgestrel 30 mcg (Microval/Norgestone)
 Ethynodiol diacetate 500 mcg (Femulen)
 Desogestrel 75 mcg (Cerazette).

66. Post coital pills (contd...)
Mechanism of action:
• Hypermotility of fallopian tube
• Hypermotility of uterus hence no implantation and
fertilization
Disadvantages:
Nausea and vomiting.
Next period may start earlier or later
Do not protect against STI & HIV
66

67. ECP OCP
After taking emergency contraceptive pills
(ECPs)
• She can start COCs the day after she finishes
taking the ECPs. There is no need to wait for
her next monthly bleeding to start her pills.
• A new COC user should begin a new pill pack.
• A continuing user who needed ECPs due to pill-
taking errors can continue where she left off
with her current pack.
• All women will need to use a backup method for
the first 7 days of taking pills.
67

68. Instructions for missed pill
68

69. Once a month (long acting) pill
In this method a long acting oestrogen
(Quinestrol) + short acting progesterone is
given
But the results are highly disappointing.
69

70. Male pills
The hormones which reduce sperm
count tend to reduce testosterone
levels hence they affect potency
and libido
Gossypol:
2,2′-bis-(Formyl-1,6,7-trihydroxy-5-
isopropyl-3-methylnaphthalene)
•Cotton seed derivative
•Causes azoospermia and severe
oligospermia
•Toxic
•Use for 6 months leads to
complete sterility
70

71. Oestrogenic and progestrogenic effect & side effects
• Estrogenic Effects
– Ovulation is inhibited in part by follicle
stimulating hormone (FSH) and lutenizing
hormone (LH) suppression. Therefore the
pituitary does not release hormones to
stimulate the ovary
– Secretions of the uterus are altered
– Ovum transport is accelerated
71

72. • Estrogen component of OCP’s
• Ethinyl estradiol (20-50 mcg)
• Estrogen Mediated Side Effects of OCP’s
• Nausea
• Bloating
• Breast tenderness
• Vascular Headaches
• HTN
• DVT/ Leg Pain
72

73. • Progestational effects
– Ovulation is inhibited in part by inhibition
of lutenizing hormone (LH)
– A thickened cervical mucus is created
inhibiting sperm transport
– Implantation is inhibited
– Ovum transport may be slowed
– Activation of enzymes that permit the
sperm to penetrate the ovum may be
inhibited
73

74. • Progestin component of OCP‘ s
• Pregnanes
• Estranes
• Gonanes
• Progestin Mediated Side Effects of
OCP‘s
• Poor control of cycle
• Increase chances of neoplasm.
• Lipid Abnormalities: lowers high density
lipoproteins (HDL)
74

75. Categorizations of Progestins
Progestins
Progesterone 19-nortestosterone 17α-spirolactone
Pregnanes Estranes Gonanes
Medroxy- Norethindrone Norgestrel Drospirenone
progesterone Norethindrone Levonorgestrel
acetate acetate Norgestimate
Cyproterone Ethynodiol Desogestrel
acetate diacetate Gestodene
Chlormadinone
acetate
75

76. The drugs known to have a clinically
significant impact on contraceptive efficacy
• Rifampicin
• Griseofulvin,
• Some anticonvulsants
– Topiramate,
– Barbiturates,
– Carbamazepine,
– Primidone
• Ritonovir.
76

77. • Women with AIDS who are treated with
ritonavir- protease inhibitors, generally
should not use combined hormonal methods or
progestin-only pills (MEC cat 3).
• These ARV drugs may make these
contraceptive methods less effective.
• These women can use progestin-only
injectables, implants, and other methods.
• Women taking only other classes of ARVs can
use any hormonal method.
77

78. • Women with chronic hepatitis or mild
cirrhosis of the liver can use any
contraceptive method (MEC cat 1).
• Women taking medicines for seizures or
rifampicin generally can use implants.
78

79. Quick Start (also for ring, patch, Depo)
• If negative pregnancy test: swallow first pill under
direct observation during visit (regardless of menstrual
day).
• Give Emergency Contraception if indicated (and usually
Quick Start the next day).
• Use back-up with condoms for 1 week.
• Repeat pregnancy test if no withdrawal bleed, or
follow-up pregnancy test in 2-4 weeks.
• Women prefer it. (81%- 97%)
• Higher initiation/continuance rates.
• No bleeding differences based on day of initiation.
79

80. Quick Start contd…
• Very low pregnancy rates in first cycle with quick
start even if recent unprotected intercourse (3%
or lower).
• Consider the impact on initiation rate:
– 100% with observed quick start.
– About 75% if pills dispensed (even lower if RX only)
• Hormonal contraceptives are not teratogenic (or
abortifacients) even if pregnancy does occur.
80

81. Oral Contraceptives: Extended Use
Counseling on Safety
• Standard/traditional pill is 21 days active
pills and 7 days placebo (21/7 regimen)
– Monthly withdrawal bleeding is designed to
make the pill cycle feel ―natural‖
• But, there is no ovulation on the pill
• And, no menstrual lining ―build up‖
81

82. Perceived Benefits of Menstruation
• Myths about monthly menstruation
– Necessary for ―cleansing the system‖
– A ―natural‖ state
– A symbol of femininity, fertility, and youth
– A sign a woman is not pregnant
• Address safety concerns of the patient
(her parents or partner) before
prescribing extended OCPs.
82

83. Who might benefit from reduced
frequency of menstruation?
Women with menstrual-related disorders
– dysmenorrhea, menorrhagia, menstrual migraines,
cyclic breast pain…
• Athletes
• Women in the military
• Developmentally delayed women
• Any woman who chooses to bleed less
frequently
83

84. Seasonale
• 30 mcg EE and 150 mcg Levonorgestrel
• 84 active pills then 7 days placebo
• 4 menses per year
• Generic version Nordette/Levlen also
available.
84

85. Seasonique
• Extended biphasic regimen
• 84 tablets
• Levonorgestrel - 0.15mg & ethinyl estradiol -
0.03 mg
• Then 7 tablets 0.01 mg ethinyl estradiol
• Method failure rate 0.64%
• Potentially decrease estrogen withdrawal side
effects and PMS symptoms.
85

86. Lybrel
• 1st Continuous Oral contraceptive
• 20 mcg ethinyl estradiol & 90 mcg levonorgestrel
• Given daily. No hormone free break
• 60% amenorrhea rate at 1 year
• Increased breakthrough bleeding/spotting
• Return to menses by 90 days
86

87. Femcon Fe
– (norethindrone0.4mg and
ethinyl estradiol 35mcg chewable and
ferrous fumarate tablets)
– Chewable birth control
– Spearmint flavored
LoEstrin 24 Fe
– (Norethindrone acetate 1mg
&Ethinyl Estradiol 20 mcg)
– 24 hormone days with
only 4 placebo days
87

88. Injectable
Depot
Subdermal
preparati implants
ons
Vaginal
rings
88

89. Injectable contraceptives
Classification
DMPA
(depot- medroxy
progesterone
Progesterone only acetate)
injectables
NET-EN
Injectable
contraceptives. ( Norethandrone
Combined Enanthate)
injectables
89

90. Progesterone only
injectables
Dmpa:
• Dose: 150mg IM every 3 months.
• MOA: suppresses ovulation
• Advantage: doesn‘t affect lactation, useful in postpartum
period. Can be used in the multiparae of age >35yr
NET-en:
• Dose: 200mg IM every 2 months
• Both DMPA & NET-EN are given in 1st 5 days
of menstrual cycle. They are given deep IM
in gluteus maximus
90

91. New formulation of DMPA (Uniject)
 Prefilled, singleuse syringe
could be particularly
 They contain a special
formulation of DMPA,
called DMPA-SC (104 mg).
 Short needle meant for
subcutaneous injection
 Useful to provide DMPA in
the community.
 Injections by appropriately
trained community health
workers is safe, effective,
and acceptable.
91

92. • A woman may have a repeat injection of
DMPA up to 4 weeks late. (Previous guidance
said that she could have her DMPA
reinjection up to 2 weeks late.)
• The guidance for reinjection of NET-EN
remains at up to 2 weeks late.
92

93. Side effects:
• Disruption of normal menses
• Amenorrhoea
Contraindications:
• Breast cancer
• Genital cancer
• Undiagnosed uterine bleeding
• Suspected malignancy
• Lactating women
Failure rate: 0.3/HWY
93

94. Combined injectables
• Containing long-acting progesterone with short action
estrogen
 25 mg DMPA + 15 mg estradiol cypionate (Cyclofem) and
 50 mg NET-EN + 5 mg estrdiol valerate (Mesigyna)
• Given once a month and produce a menstruation like
pattern. The trials are currently taking place in India.
MOA:
• Suppression of ovulation
• Alteration of cervical and endometrial secretions.
C/I:
• Pregnancy, ° Thromboembolytic disorders
• Cerebrovascular disease ° Coronory artery disease
• Migraine ° Breast cancer
• DM
94

95. Subdermal implant
•Norplant
For long term contraception.
Has 6 capsules containing
35mg each of norgestrel.
•Norplant R2 – contains rods
of norgestrel. Contraception
is achieved in 24hrs & lasts
for 5-6 yrs
Disadvantage:
Surgical procedure
Failure Rate: 0.1/HWY
95

96. IMPLANON/ Jadellen
A flexible plastic single flexible
rod 4cm long x 2mm diameter
Contains 68mg ETONOGESTREL,
an active metabolite of
desogestrel
Effective for 3 years
Release of etonogestrel
60-70ug/day in first 5-6 weeks
35-45ug/day end of year 1
30-40ug/day end of year 2
25-30ug/day end of year 3
96

97. Implanon
Benefits Adverse side effects
• reliable long term • Bleeding pattern altered:
contraception Amenorrhoea 20%
• Improvement in Infrequent - 26%
menorrhagia and
dysmenorrhoea Frequent - 6%
• Beneficial effect on Prolonged - 12%
acne in 59% • Weight gain of >10% in 21%
• No adverse effects on - no change from reference
bone mass group
• No significant effect • Hormonal ‗nuisance‘ effects
on lipids, haemostasis eg breast pain, headache,
or liver function libido decrease, dizziness,
nausea
• Other (<2.5%) alopecia,
depression,change in libido
97

98. The Patch (OrthoEvra)
• The ORTHO EVRA patch
is a thin & plastic patch
that sticks to the skin.
• The sticky part of the patch contains
the hormones: norelgestromin (progestin) and ethinyl
estradiol (estrogen).
• Weekly for 3wks then patch free 1 week.
• These hormones are absorbed continuously through
the skin and into the bloodstream.
98

99. 99
Vaginal ring (Nuvaring)
• Etonorgestrel 120mcg +Ethinylestradiol 15mcg daily
 Use for three weeks with a withdrawal week
 Inhibits ovulation
 Cycle control good
 Effective – Pearl index 1.8
 Non-latex
• Implanted intravaginally
• The progesterone is absorbed slowly through the vaginal
mucosa.
• Store 2-8 degrees; if room temperature, up to 4-12
• NuvaRing is 98% effective when used correctly.
• Effectiveness: Overall perfect use failure rate 0.3%,
typical use failure rate 8%
99

100. Nonsteroidal contraceptive drugs
Centchroman:
•Non steroidal OCD developed by CDRI
Lucknow contains Ormeloxifene 30mg
•Trade name ‗Saheli‘
Dose:
30mg twice a week for 12 weeks followed
by once in a week
MOA:
•Suppression of Corpus Leuteum functions
•Interferes with motility of fallopian
tube hence no implantation.
Advantages:
•Normal Menstruation
•Complete reversibility on withdrawal 100

101. Post conceptional methods Classification
Menstrual Regulation
Menstrual Induction
Post conceptional
methods
Oral Abortifacient
Abortion
101

102. Menstrual regulation
• No legal restriction
• Aspiration of uterine content
• within 6-14 days of missed period
• Cervical dilatation needed in nullipara
• Early complications : Bleeding, Uterine perforation
and trauma.
• Late complications : Tendency to abortion or
premature births, infertility, menstrual disorders,
ectopic pregnancy & Rh isoimmunisation
102

103. Menstrual induction
• Based on disturbing the normal progesteron-
prostaglandin balance by IU application of 1.5mg
solution or 2.5-5mg pellet of prostaglandin F 2.
• Causes sustained uterine contraction for 7 min.
followed by cyclical contraction for 3- 4 hrs.
• Bleeding starts and continues for 7-8 days.
103

104. Oral abortifacient
• Mifepristone + Misoprostol – 95% successful in
terminating pregnancies upto 9 weeks.
• Commonly used regimen
• Mifepristone 200mg oral on day 1 followed by
Misoprostol 800mcg vaginally immediately or 6 -
8 hrs later.
• Other regimen is
• Mifepristone 600mg oral on day 1 followed by
Misoprostol 400mcg orally on day 3
• Follow up visit is must within 14 days for clinical
and/or USG examination
104

105. abortion
Definition:
Termination of pregnancy before the foetus becomes
viable
LEGALISATION
Medical termination of pregnancy act 1971
1) Conditions under which abortion is done
• Medical
• Eugenic
• Humanitarian
• Socio-economic
• In failure of contraceptive device
105

106. 2) Who can perform abortion?
If < 12 weeks 1 RMP having experience in OB-GYN
If > 12 weeks -20 weeks then 2 RMP opinion
3) Where can abortion be done?
Place approved by civil surgeon.
106

107. METHODS
• Dilatation and Curettage: cervix is dilated
with dilators and implanted ovum is removed
by doing curettage of endometrium
• Vaccum Aspiration: Implanted ovum is
removed by applying suction
• PG Administration : PGE1 (misoprostol) PGF2
(carboprost),PGE2 (Dinoprost)
• Intrauterine instillation :
– Intraamniotic – Hypertonic urea (40%) , saline
(20%)
– Extraamniotic – Ethacrydine lactate
107

108. Miscellaneous methods
1. Abstinence
2. Coitus Interruptus: failure rate 25/HWY
3. Safe period/rhythm period/ calendar method
Basis: ouvulation from 12th-16th day before onset of menses
Calculation: 1st day of fertile period = shortest cycle-18days
Last day of fertile period = longest cycle-10days
108

109. Drawbacks:
• Irregular cycle so difficult to predict
• Only for educated and responsible couples
• Programmed Sex
High Failure rate 9/HWY
Complication:
Embryonic Abnormalities, Ectopic Pregnancy
109

110. 4) Natural family planning method:
Basis: same as calendar method but here the women
employs self recognition of certain signs and
symptoms associated with ovulation.
a) Basal Body temperature method
b) Cervical mucous method
c) Symptothermic : It is based on the observation of
changes in different body signs: cervical
secretions, basal body temperature and the
position of the opening of the cervix.
5) Lactation
110

111. Lactational Amenorrhea Method Algorithm
111

112. Standard Days Method
 Identifies days 8-19 of the cycle as fertile
 Is appropriate with menstrual cycles between 26 and
32 days long
 Helps a couple plan or prevent pregnancy by knowing
which days they should or should not have unprotected
sex.
 It is used with CycleBeads, a color-coded string of
beads to help a woman:
 Track her cycle days
 Know when she is fertile
 Monitor her cycle length
112

113. Terminal methods
Vasectomy
Male
sterlisation
No scalpel
vas occlusion
Terminal
methods Tubectomy
Female Laparoscopic
sterlisation occlusion
Tubal inserts
(no incision)
113

114. vasectomy
NSV
114

115. Failure Rate: 0.15/HWY (due to mistaken identification
of vas)
COMPLICATIONS:
• Operative
• Sperm granules
• Spontaneous recanalisation
• Autoimmune response
• Psychological response
115

116. No scalpel vas occlusion
METHODS
• Elastomer plugs: Gets hardened and plugs the vas
• SHUG: preformed silicon rubber plug is inserted.
• RISUG: Reversible Inhibition of Sperm Under
Guidance
116

117. Tubectomy
Failure rate: 0.5/HWY 117

118. Approaches to the fallopian tubes, surgical procedures, timing of
procedure,and related occlusion techniques
118

119. Tubal inserts (no incision)
119

120. 1.New Male Pill
• The pill contains desogestrel as well as testosterone.
Blocks the production of sperm while maintaining male
characteristics and sex drive.
• It must be taken daily.
• 100% effective and completely reversible in
preliminary clinical trials .
• In clinical trials, all of the participants‘ sperm counts
dropped to zero, which means that the male pill would
be more effective than the condom and even the
female pill.
120

121. 2. CatSper Blocker
• Sperm rely on calcium ions in sperm-
tail for mobility and fertilization.
• Humans -ion-channel gene -CatSper.
• Blocking CatSper action - effective form of birth control.
• Men or women could take this potential CatSper ―blocker‖
because it could be made to act ‖wherever sperm are
present.‖
• Active only in fully developed sperm, which means blocking
or boosting its action could have few or no side effects.
121

122. 3. Spray On -Contraceptive
• Australian biotech company Acrux has come up
with a world first — a contraceptive spray for women.
• Metered Dose Transdermal System (MDTS) to administer a pre-
set dose of the Nestorone to the skin (forearm) every 14 days.
• The fast-drying spray gradually absorbed into the bloodstream.
• Suitable for
• Breastfeeding mothers
• Who cannot tolerate contraceptive pills with oestrogens.
• Leaves no visible residue & less irritation than patches.
• Because it does not have to be taken at the same time every
day, it will suit women who often forget to take the Pill.
122

123. 4. Adjudin “the male patch”
Adjudin (2,4-dichlorobenzyl-
1H-indazole-3-carbohydrazide)
is non-hormonal male contraceptive
drug, which acts by blocking the
maturation of sperm in the testes,
but without affecting testosterone
production.
• Normal spermatogenesis returned in 95% within 210
days after the drug had been discontinued.
• The oral dose effective for contraception is so high
that there have been side effects in the muscles and
liver, therefore the drug is being manufactured as
implant or patch for males.
123

124. 5. contraction inhibitor pill “dry orgasm”
• 2 different types of smooth muscle in vasa deferentia
• longitudinal muscle fibers and
• circular muscle fibers.
• When segments of vasa deferentia were exposed to
phenoxybenzamine or thioridazine , the longitudinal
smooth muscle fibers did not contract. The circular
smooth muscles did, causes, clamping the vas shut.
• Thioridizine‘s side effects were so extreme(hives,
difficult breathing;,swelling of face) that the
manufacturer discontinued it in 2005, the common
side effects of phenoxybenzamine are dizziness ,
fast heartbeat & stuffy nose.
124

125. 6. Anti-Fertility Vaccines
• Contraceptive vaccine either target
 Gamete production (GRH, FSH and LH)
 Gamete function (ZP)
 Gamete outcome (hCG).
• CVs targeting gamete function are better choices but
induce oophoritis affecting sex steroids.
• Antisperm antibody-mediated immunoinfertility
provides a naturally occurring model to indicate how
an antisperm vaccine will work in humans.
• The hCG vaccine is the first vaccine to undergo
clinical trials in humans. Both the efficacy and the
lack of immunotoxicity have been reasonably well
demonstrated for this vaccine.
125

126. 7. R.I.S.U.G
• Reversible Inhibition of Sperm Under Guidance (RISUG),
developed at IIT Kharagpur in India by Dr. Sujoy K Guha.
• It is currently undergoing clinical trials in India.
• RISUG is a non-hormonal injectable contraceptive composed
of SMA (styrene maleic anhydride) mixed with DMSO
(solvent dimethylsulfoxide).
• Partially blocks the vasa deferentia and destructs the sperm
• The differential charge from the gel ruptures the sperm‘s
cell membrane, stopping the sperm before they can even
start their journey to the egg.
• Reversals by multiple injection of dimethyl sulfoxide or
sodium bicarbonate – and several months to reverse.
126

127. 8. Hydrothermal Male Control
• Methods used include
1. Hot water applied to the scrotum
2. Heat generated by ultrasound
3. Artificial cryptorchidism (holding the testicles inside the
abdomen) using specialized briefs.
• Raising the body temperature above 42 degrees Celsius
initiates certain processes, resulting in cells disability. It is
called Heat Shock Factor (HSF).It disable sperm cells.
• Hot water bath (about 46.7 degrees Celsius)for 45 minutes
daily for 3 weeks - simple wet heating - ensure up to 6
months of male infertility.
• ultrasound method - the testicles are heated with the help
of ultrasound - only two procedures 48 hours - temporary
infertility for up to 10 months.
127

128. 9. Biodegradable Time Releasing
Contraceptive Implant
• In pipeline is a biodegradable
contraceptive Implant that does not
require surgical removal, consists of
long-acting contraceptive capsule-type
implant-CaproF.
128

129. 10. SILCS Diaphragm
• The SILCS diaphragm is a silicone barrier
contraceptive device .
• Its dome is filled with BufferGel that acts both as
a spermicide and microbicide that not only
immobilizes the sperms but also kills them and
fights infections.
• It avoids the need for many sizes and a pelvic exam
for a correct fit; it is designed as a ―one size fits
most‖ device.
• The new device is being evaluated for comfort and
ease-of-use in studies, underway in the Dominican
Republic, South Africa, Thailand, and the United
States.
129

130. 11. Injectable silicone plugs
• Often used by men in China as a potential
alternative to vasectomy.
• There are two tested types of injected plugs:
– Medical-grade polyurethane (MPU)
– Medical-grade silicone rubber (MSR).
• The polymer (special ingredient) is injected
directly into the vasa deferentia, Once
injected, the polymer solidifies in place,
forming a flexible plug.
• The procedure takes less than 30 minutes
under local anesthesia.
• It is easier to reverse. It takes 2 to 4 years
after the reversal procedure.
130

131. 12.Essure
• The Essure procedure involves placing a small
& flexible device called a Micro- insert into
each fallopian tubes.
• The Micro- inserts are made from materials that
have been well studied and used successfully in the
heart and other parts of the human body for many
years.
• Once the Micro-inserts are in place, body tissue
grows into the Micro- inserts, blocking the fallopian
tubes.
131

132. References
• Contraceptive Updates, Reference Manual for Doctors 2009,
by MOHFW & UNFPA,India.
• WHO - Medical eligibility criteria for contraceptive use –
4th ed 2009.
• WHO, Family Planning A GLOBAL HANDBOOK FOR
PROVIDERS Update 2011
• “Guidelines for administration of emergency contraceptive
pills by medical officers,” Research Studies and Standard
Division, Department of Family Welfare, Government of
India, June 2009.
• The essentials of Contraceptive Technology, a handbook for
clinic staff, John Hopkins Population Information Program,
2010
• Projestin Only Injectables: Fact Sheet. UNFPA India, 2004
• Guidelines for IUDs for medical officers, research studies and
standard division, Department of Family Welfare,
Government of India - June 2007
132

133. References contd…
• Westhoff C, Heartwell S, Edwards S. Initiation of Oral Contraceptives
Using a Quick Start Compared With a Conventional Start: A
Randomized Controlled TrialObstet Gynecol. 2007 Jun;109(6):1270-
1276.
• Jick SS et al. Risk of non fatal VTE in women using a contraceptive
transdermal patch and oral contraceptives containing 35 mcg EE
and norgestimate. Contraception 2006;73(3):223-8.
• Sheng J et al. The LNG-IUS study on adenomyosis: a 3–year follow-
up study on the efficacy and side effects of the use of
levonorgestrel intrauterine system for the treatment of
dysmenorrhea associated with adenomyosis. Contraception. 2009
Mar;79(3):189-93.
• Grimes DA et al. Cochrane systematic reviews of IUD trials: lessons
learned. Contraception. 2007 Jun;75(6 Suppl):S55-9.
• Lethaby AE et al. Progesterone or progestogen-releasing
intrauterine systems for heavy menstrual bleeding. Cochrane
Database Syst Rev. 2005 Oct 19;(4)
• K.Park, Text book of preventive and social medicine,contraceptive
methods pp.457-474,21st edition,Bhanot publication,Jabalpur,
India.
133

134. References contd…
• Trussell J. Contraceptive efficacy. In Hatcher RA,
Trussell J. Stewart F, et al Contraceptive Technology:
17th Revised Edition. New York. NY: Ardent Media,
1998.
• Jick SS, Jick H. The contraceptive patch in relation to
ischaemic stroke and acute myocardial infarction.
Pharmacotherapy, 2007, 27:218-220.
• Elkind-Hirsch KE, Darensbourg C, Ogden B et al.
Contraceptive vaginal ring use for women has less
adverse metabolic effects than an oral contraceptive.
Contraception, 2007, 76:348-356.
• World Health Organization. Emergency Contraception.
Fact Sheet No. 244, October 2005. Available at:
http://who.int/mediacent/factsheets/fs244/en/print.ht
ml
134

135. References contd…
• Allen RH, Goldberg AB, Grimes DA. Expanding access to intrauterine
contraception. American Journal of Obstetrics and Gynecology
2009;201(5):456-61.
• Grimes DA, Lopez LM, Schulz KF, Immediate post-partum insertion of
intrauterine devices Review, published in The Cochrane Library2010, Issue
5.
• Rajesh K.Naz, Satish K.Gupta, Jagdish C.Gupta, Recent advances in
contraceptive vaccine development: a mini-review Human Reproduction
2005;vol.20,(12): 3271–3283.
• Amobi, NI, J Guillebaud, AV Kaisary, E Turner and IC Smith (2002)
“Discrimination by SZL49 between contractions evoked by noradrenaline
in longitudinal and circular muscle of human vas deferens.” British Journal
of Pharmacology 136(1):127-35.
• http://www.who.int/reproductionhealth/publications/family_planning/
• http://www.pillwatch.com/info/male-contraception-what-to-choose.html
• http://www.smashinglists.com/10-advanced-methods-of-birth-control-in-
pipeline/
• http://www.fsrh.org/admin/uploads/630_NuvaringProductReview240309.
pdf
135