There are many types of contraception widely used now days for family
planning purposes. Each method has its advantages and suits special cases
and not necessarily suits others and the choice of contraception depends on
different needs of the patients like the period of contraception and also
your doctor should decide which method suits your needs more. No method of
contraception is completely effective and failure rates for most reversible
methods are strongly influenced by compliance.
* IUCD: It is a device that is designed to be inserted into the uterine
cavity. It is available in different shapes and sizes. It could be composed
of polyethylene, copper, or sometimes containing a hormone that controls the
heavy bleeding in addition to its contraceptive effects (MIRENA IUCD).
* Rhythm method:
· This method can be used for patients with regular cycles only.
This is done depending on the exact knowledge of ovulation day and avoiding
intercourse during the days before and after ovulation; for example in a
regular period that occurs every 28 days the exact day of ovulation should
be the day 14 so intercourse should be avoided 4-5 days before and after
this days. There are many methods to detect ovulation days;
1- Increase in body temperature by about o.5 C.
2- Change in type cervical mucous
3- Ovulation kits nowadays are available for ovulation day detection by
measuring LH surge.
* Diaphragm and cup:-
These devices are made of plastic, and take different shapes and sizes and
act as a barrier preventing the seminal fluid from entering the cervix. They
are placed vaginally before intercourse and are sometimes coated with a
spermicidal gel to increase their efficacy. The size should be adjusted by
the doctor.
* Suppositories:-
* Spermicidal preparations applied vaginally before intercourse.
* Male and female condoms:-
-Male condoms: Devices made of latex lubricated with spermicidal agents
designed to cover the erect penis and capable of destroying sperms.
Usually incorporated into an inner base, which itself may impair sperm
activity e.g. nonoxynol-9,0 these are available as creams, jellies, foaming
tablets, pesaries and aerosols. Condoms are safe and effective unless they
are perforated during use. -Female condom:-
Polyurethane sheath with its open end attached to a flexible polyurethane
ring. Spermicidal agents may be used with it. It is not a very popular
method.
Hormonal contraception:-
1- Contraceptive pills
The most widely used contraceptive method worldwide especially India, China
and South Africa.
These pills contain hormones that arrest the ovulation process thus
preventing pregnancy.
There are many types of oral contraceptive pills differing in the
concentration and type of estrogen and progesterone used.
* Combined oral contraceptive pills (COC):
This type contains estrogen usually ethinyl oestradiol and progesterone. The
dose of estrogen varies from 20-50 mg; the low dose pills 30-35 mg are much
safer since the cardiovascular risks of the pills are mainly due to
estrogen. Combined pills are available as monophasic preparation in which
every pill in the packet contains the same dose of steroid and biphasic and
triphasic preparation in which the dose of both steroids change, once or
twice during the cycle because this regimen mimics the normal cycle and
produces better cycle control.
Mode of action:-
The principle mode of action is inhibition of ovulation. Estrogens inhibit
pituitary FSH thus suppressing the development of ovarian follicle while
progesterone inhibits the surge of the luteinizing hormone (LH).
Advantages of combined contraceptive pills:-
-Regulates menstrual cycles.
-Bleeding amount gets less
-Duration of cycle gets shorter
-Decreases premenstrual symptoms and dysmenorrhea
-Incidence of benign breast lumps, functional ovarian cyst, endometriosis,
acne vulgaris and possibly pelvic inflammatory disease.
-There is substantial evidence that COC protects against ovarian and
endometrial cancer.
Disadvantages and side effects of COC:-
* Weight gain
* Fluid retention.
* Nausea and vomiting
* Cloasma.
* Mood changes.
* Breast enlargement and mastalgia.
* Loss of libido
* Tendency to hypercoagulability, risk of DVT (deep vein thrombosis) and
hypertension and also the risk of myocardial infraction especially if
associated with smoking.
- History of arterial and venous disease in the family. Smoking, advanced
age, obesity, Diabetes Mellitus, and migraine are additional risk factors to
taking COC.
- Hyperprolactinaemia, since oestrogen, stimulates the lactotrophes,
increasing prolactin secretion.
* Progestogen only pills :-
This was introduced to avoid the side effects of estrogen. It prevents
pregnancy by inhibiting ovulation, changes cervical mucus reducing sperm
permeability and transport. Also has an effect on the endometrium that
compromises implantation.
* Indications:-
It is commonly prescribed for women in whom oestrogen is absolutely or
relatively contraindicated.
*
Contraindications:-
Absolute:-
-Known or suspected pregnancy because it leads to musculinization of the
genitalia of the female fetus.
-Undiagnosed irregular uterine bleeding.
-Current history of serious cardiovascular disease.
Relative:-
- Severe obesity.
- Breast cancer
- Molar pregnancy.
- Severe hypertension.
- History of recurrent ovarian cyst.
- Chronic liver conditions.
Side effects:-
Irregular bleeding, headache, nausea, bloating, breast tenderness and mood
changes.
2. Injectable progestogen:-
Long acting injections of Norethisterone-enanthate (NET-EN) and medroxy
progesterone acetate (MPA) is given as intramuscular injection of 150 mg/ 12
weeks. It prevents ovulation.
Side effects:-
-Inappropriate for women wishing short-term contraception because it may
take 1 year to return to normal fertility after cessation of treatment.
-Weight gain and reduction in bone mineral density (BMD)
-Prolonged amenorrhea and irregular cycles.
-spotting.
3-Progestogen only implants:-
Norplant is a long acting hormonal method of contraception consisting of six
flexible capsules releasing a low dose of levenorgestrel 30-35 mg/ 24 hours
for 18 months .The capsules are inserted subdermally in the inner aspect of
the upper arm under local anesthesia. Insertion and removal are minor
surgical procedures which require specialized training. It lasts for 5 years
and fertility returns rapidly after removal. Side effects to such regimen
are menstrual disturbances with very low failure rate.
Recently a new hormonal therapy has been used for males to suppress sperm
production. The technique consists of implanting rods that contain the
hormones testosterone and progestin into the arm of man under local
anesthesia. They last long and are very effective and easily removed after
12 weeks after insertion. Testosterone acts by turning off the signal from
the pituitary gland that stimulates the testis to produce sperms and
progestin acts directly on the testis to decrease sperm production.
Surgical contraception.
1. Female sterilization
Female sterilization is done surgically by blocking both fallopian tubes by
three ways:
Laparotomy minilaparatomy laparoscopy
Laparotomy:
Bilateral salpingectomy or hysterectomy may be preferable when there is a
coexistent pathology while the other two ways are more preferable, safe and
effective
Methods of tubal occlusions:-
*Ligation by absorbable or non-absorbable sutures the ends left free or
buried in the broad ligament or uterine cornue.
*Electrocautery:-Bipolar diathermy allows only the tissue held between the
jaws of the forceps to be cauterized.
*Falope ring:-ring of silicone or rubber is placed over a loop of the tube
with a specially designed applicator. This destroys 2-3 cm of tube.
*Clips: - a variety of clips are available tlulka-clemens clip (stainless
steel and polycarbonal and filshie clip) (titanium lined with silicon
rubber). Smaller length of the tube is destroyed via this method.
*Laser; CO2 laser divides tube very cleanly but may allow a high incidence
of recanalization.
*A number of chemical agents have been tested for their ability to occlude
the fallopian tube when installed into the tube either directly or
transcervically via the uterus e.g. 252 mg quinacrine pellet inserted
through IUCD inserter passed through the cervix. Inflammation and fibrosis
result and occlude the tubes. However, safety of quinacrine sterilization
has not yet been determined so surgical method is safer
2-Male sterilization:-
Vasectomy:-division or occlusion of the vas deference prevents the passage
of sperms.
Methods:-
1-Clips
2-Diathermy
3-Percutaneous injection of sclerosing agents or occlusive substances (such
as silicone used in china).
The success of the procedure is verified by the absence of sperms from two
consecutive samples of ejaculate collected at least 4 weeks apart.
Contraception must be continued until confirmation of two negative semen
results has been achieved and this is achieved after 16-18 weeks of
performing the vasectomy.
Points discussed before using any contraceptive method:
*Use of COC for curing menstrual symptoms.
*Size of the family and possible desire for future pregnancy.
*Maternal disease threatening her life.
*Sexual life pattern.
*Maternal age and risk of side effects.
*Reversibility of the method used.
*Educational state of couples.
*Cost.
*Choosing which partner to sterilize.
Reversal of sterilization
This is required if the sterilization was done at a young age or immediately
postpartum or after a therapeutic abortion. A change of partner is the
commonest reason for requesting reversal.
Reversal of female sterilization involves Laparotomy but may fail.
Microsurgical techniques are associated with around 70% success and carry a
high risk of ectopic pregnancy. Ovulation should be confirmed, semen
analysis done before reversal is undertaken. Reversal of vasectomy is
technically feasible in many cases with patency rate 90% but pregnancy rate
reaches only 70% and may be due to antisperm antibodies.
Emergency contraception
If you have had sex without using contraception or think your method might
have failed there are two emergency methods you can use.
The emergency hormonal pill – must be taken up to 3 days (72 hours) after
sex. It is more effective, the earlier it is taken after sex.
An IUD – must be fitted up to 5 days after sex, or up to 5 days after the
earliest time you could have released an egg (ovulation).
