Contraception

Dr/Ahmed AbdelBaky
Assistant Lecturer
OB.Gyn.
2021
 Fertility
• Definitions:
– Fecundability: ability of a couple to achieve
pregnancy during one menstrual cycle. About 25%
– Fecundity: ability of a couple to have a live birth
during one menstrual cycle.
 Types of Contraceptive methods

1. Natural ( physiological)
2. Mechanical
3. Chemical
4. Hormonal
5. Surgical
 Efficacy
• Failure rate:
– Method effectiveness: data from clinical trials (Perfect
user)
– Use effectiveness : data from general population
(Typical user)
• Pearl index
× 100

• Example COCs:
– Method failure: 0.3 /HWY
– Use failure: 8/HWY
 Efficacy
Causes of failure:
• Pills, injections:
– Method failure: metabolism
– Use failure: missed pill, non-compliance, incorrect
use, discontinue
• IUD & Implants:
– Method failure: IUD perforation, already pregnant
– Use failure: discontinue
 Contraindications
Medical eligibility criteria:
• Category 1: there is no restriction for use of the Method.
• Category 2: the method may be used but that more
careful follow - up is required.
• Category 3: the risks of the method outweigh the benefits
(relatively contraindicated). Use is not recommended
unless there is no acceptable alternative.
• Category 4: an unacceptable health risk if the method is
used (absolutely contraindicated).
 Natural methods

1. Abstinence.
2. Coitus interruptus (withdrawal).
3. Periodic abstinence ( fertility awareness
based methods, safe period).
4. Lactational amenorrhea ( LAM ).
 Safe period
1. The calendar method:(for 28-day cycle→ 10-17)
– 1st day: Shortest-18
– Last day: Longest-11
2. BBT chart: 2 days after rise (at least 0.5 ⁰C)
3. Cervical mucous method: profuse, thin, stretchy
4. Symptothermal method: 2+3+other symptoms
and signs of ov. (breast pain, abdominal pain)
Fertile period
 LAM
• Definition of lactational amenorrhea:
1. woman who is fully or nearly fully breast -feeding
and
2. who remains amenorrhoeic
3. during the first 6 months after childbirth
• Failure rate: 2% chance of pregnancy
Advantages of natural methods
• User controlled
• Readily available
• Free from side effects and complications

Disadvantages of natural methods

• Require skills and motivation
• High failure rate: 20 / HWY
• No protection against STI
COCs
Generation Estrogen Progestogen Trade name
1st EE ≥ 50 norethindrone Not available
µg
2nd LNG 150 µg Microcept
3rd EE Norgestimate Cilest
30- 35 250 µg
µg Desogestrel1 Marvelon
(low dose 150 µg
COCs) Gestodene2 Gynera
75µg
4th Drosperinone3 Yasmin

1& 2→ less androgenic effects. 3→ anti-androgenic effects

 2nd
Generation
 3rd
Generation
 4th
Generation
 COCs formulations
• Monophasic: described above
• Multiphasic: bi-, Tri-, tertraphasic
 Prescription
• COCs are taken for 21 days followed by a 7 –
days pill - free interval when withdrawal
bleeding usually occurs.
• Start day1-5 of the cycle (or abortion).
• If after day 5→ use codom or avoid sex for 7
days.
• After delivery: after 6 months if full BF. After 6
weeks if no or partial BF.
 Mechanism of action
• Mainly: Inhibition of ovulation
• Others: effect on CX, Endometrium, Tube
 Contraindications
1. Breast cancer, Breast feeding in first 6 months (3) 6
weeks (4)
2. Brain: ischemic Stroke, Migraine
3. Heart: ischemic heart
4. Hepatic: active viral hepatitis, decompensated liver
cirrhosis, Tumours, liver enz. Inducing drugs (e.g.
rifampicin, Lanzoprazol, antiepileptics),
5. DVT (current, past, family history, risk: major surgery,
immobilization, Thrombophilias)
6. D.M: > 20y or with vascular complications.
 Contraindications
7. age > 35 y + Smoking
8. BMI > 30
9. BP > 140/90 (3)…. >160/110 (4)
10.Current gallbladder dse.
 Side effects
Minor:
Fluid retention, nausea and vomiting, chloasma,
mastalgia and breast enlargement. Most
improve with time
 Side effects
Major:
1. DVT
2. MI
3. Ischemic stroke
4. Breast cancer
5. Cancer cervix
 Advantages of COCs
1. Highly effective if used correctly.
2. Immediate return of fertility after stoppage.
3. Suitable for nulligravida women and newly
married couples.
4. Completely controlled by the woman and can
be stopped at any time unlike other methods
(IUD & Implants).
5. No need to do any thing at the time of
intercourse.
6. Non-contraceptive benifits
 Non-contraceptive benefits
• ↓ risk of ovarian cancer, endometrial, colon
cancer.
• ↓ risk of benign breast diseases
• ↓ risk of ectopic preg.
• ↓ risk of menstrual irregulaity
• ↓ risk of dysmenorrhea, endometriosis
• Improve acne
 Non-contraceptive uses of COCs
1. DUB
2. 1ry dysmenorrhea
3. hirsutism
4. Functional ovarian cyst
5. Endometriosis
Missed 1 pill Missed ≥ 2 pills

• Take a pill as soon as possible

• Continue taking pills daily.

No additional method Additional method for 7 d

If 1st W….. EC.

If 3rd W…… omit the
pill-free interval.
 Transdermal
Evra patch
• EE + norelgestromin
• Each patch lasts 7 days, three patches being
used consecutively with a patch - free interval
in week 4 when withdrawal bleeding occurs.
• Bleeding pattern, side effects, efficacy, and CI
= COCs
 Vaginal ring
Nuva ring
• EE + etonogestrel
• Each ring lasts 3 weeks, with a ring- free
interval in week 4 when withdrawal bleeding
occurs.
• Bleeding pattern, side effects, efficacy, and CI
= COCs
 Combined injectable

Cyclofem estradiol DMPA

cypionate (Depo-medroxy-progesterone acetate)

Mesigyna estradiol NET-EN

Mesocept valerate (Norethindrone-enanthate)
 Combined injectable
• Use: monthly injection. Grace period: 3 days
• Bleeding pattern: monthly
• Side effects, efficacy, & CI= COCs
 Progestogen - only contraception
1. Oral
2. Injectable
3. implants
4. IUS
 Progestogen only pills
Composition Trade name
Traditional POPs
• LNG 30 µg Microlut
• Lynestrenol 500 µg Exluton
New POPs
• Desogestrel 75 µg Cerazette
 Contraindications
• Breast cancer (4)
• Brain: Stroke, Migraine with aura
• Heart: ischemic heart
• Hepatic: active viral hepatitis, decompensated
liver cirrhosis, Tumours, liver enz. Inducing
drugs (e.g. rifampicin, Lanzoprazol,
antiepileptics).
 Prescription
• POPs Ideally should be taken at or around the
same time every day and there should be no
pill-free interval.
– Delay > 3h (12 for Cerazette)→ additional methods
for 2 days
• Start day1-5 of the cycle (or abortion).
• If after day 5→ use condom or avoid sex for 2
days.
• After delivery: up to day 21 .
Mechanism of action

• Traditional POPs: cervical mucous

• Desogestrel-only pills: Inhibition of ovulation (70 %)
Efficacy

• Traditional POPs: less than COCs

• Desogestrel-only pills: similar to COCs
 Side effects
• Bleeding pattern:
– 20% →amenorrhoeic
– 40% → will bleed regularly
– 40% → will have irregular bleeding
• Nausia, mood changes, follicular cyst.
 Progesterone only injectables

DMPA 150 mg Depoprovera IM inj./3 m

(Grace: 2w)
NET-EN 200mg Noristerate IM inj./2 m
(Grace: 1w)
 Side effects
1. Menstrual irregularities. 70% amenorrhea at
1y.
2. Delay in return of fertility 1y.
3. Weight gain
4. Reduced bone density.
5. Headache, mood changes, and dizziness
6. increased C.V.S. diseases
7. increase of cancer
Mechanism of action

• Mainly: Inhibition of ovulation

• Others: effect on CX, Endometrium, Tube

Efficacy
– Method failure: 0.3 /HWY
– Use failure: 3/HWY
 Contraindications
• Breast cancer (4)
• Brain: ischemic Stroke, Migraine with aura
• Heart: ischemic heart
• Hepatic: active viral hepatitis, decompensated
liver cirrhosis, Tumours, liver enz. Inducing drugs
(e.g. rifampicin, Lanzoprazol, antiepileptics).
• Age < 18y.
• Unexplained vaginal bleeding
• DVT (current)
• D.M. (>20y or vascular complications)
 Prescription
• IM inj. / 2m (norestrate) or /3 m (Depo-Provera).
• Start day1-5 of the cycle (or abortion). If after
day 5→ use additional method for 7 days.
• After delivery: day 1- 21 .
 Progestagen only
implants
1. Norplant: 6 rod (LNG)
2. Implanon: 1 rod
(etonogestrel 68mg
→release 30µg/day)
Mechanism of action

• Mainly: Inhibition of
ovulation
• Others: effect on CX,
Endometrium, Tube

Efficacy
• Use failure = method failure= 0.05 HWY
 Side effects
• Bleeding pattern:
– 20% →amenorrhoeic
– 60% → will have light and infrequent bleeding
– 20% → will have heavy or frequent bleeding
• Nausia, mood changes, follicular cyst.
 Contraindications
• Breast cancer (4)
• Brain: Stroke, Migraine with aura (C)
• Heart: ischemic heart(C)
• Hepatic: active viral hepatitis, decompensated
liver cirrhosis, Tumours, liver enz. Inducing drugs
(e.g. rifampicin, Lanzoprazol, antiepileptics).

• Unexplained vaginal bleeding

• DVT (current)
 Insertion & removal
• Inner left arm. Licensed for 3 ys (Implanon)
• Inserted & removed: aseptic condition using LA.
Intrauterine contraceptive device (IUD)
 Types of IUDs
I. Copper IUDs
1. CUT380A
2. Multiload 375
3. Nova T
II. Hormone releasing IUDs:
Mirena = LNG-IUS
(52 mg LNG→ release 20µg/day)
 CUT380A
Multiload 375

Nova-T 380 Mirena

 Mechanism of action
• Cu-IUD works primarily by inhibiting
fertilisation (copper is toxic to ovum & sperm)
• In addition, the endometrial inflammatory
reaction has an anti-implantation effect and
alterations in the copper content of cervical
mucus inhibit sperm penetration.
• LNG-IUS → effect on the endometrium which
prevents implantation.
Efficacy
• CuT380A…….0.2/HWY
• LNG-IUS………. 0.1/HWY

Duration of use
 CuT380A…….10 y
 LNG-IUS………. 5 y
 Disadvantages
• Need health care provider for insertion &
removal
• Side effects & complications
• No protection against STD
• Mirena costy
 Side effects & complications
• Pregnancy. (Leave lone unless threads are visible before 12w)
• Ectopic pregnancy (overall risk is not increased)
• PID: Infection. TTT by Ab→ remove if no improvement after
72h.
• Bleeding: 3-6m. TTT by NSAIDs, tranexamic acid
• Pain: 2ry dysmenorrhea
• Protrusion (Expulsion)
• Perforation
• Passed (missed threads )
• Discharge
• Difficult removal
 Contraindications for IUD
• Pregnancy
• Delivery: 48h-4w
• Malignancy: ovarian, endometrial, cervix, GTD
• Genital infection: cervicitis, PID, puerperal
sepsis, septic abortion (I).
• Unexplained vaginal bleeding (I)
• Distortion of uterine cavity: fibroid, anomaly
• Drugs: anticoagulant
 Contraindications specific for merina
• Breast cancer (4)
• Brain: Stroke, Migraine with aura (C)
• Heart: ischemic heart(C)
• Hepatic: active viral hepatitis, decompensated
liver cirrhosis, Tumours.
 Insertion
• Timing:
• Postmenstrual day 1-7. (at any time of
menstrual cycle if sure that the woman is not
pregnant. IUD effective immediately).
• Post partum: in the first 48h or after 6w.
• Postabortion: immediately or after 1w
• Post coital as emergency contraception up
to72h
• Post extraction
 Insertion
• Insert Cusco's speculum
• Cervical cleaning
• Grasp cervix with volsellum
• Sounding
• Sterile gloves
• Load the IUD
• Adjust the insertion set
• Insertion: withdrawal technique
• Routine follow up: after next cycle
 Non-contraceptive uses of IUS
1. DUB
2. As part of HRT
3. In conjunction with GnRH for PMS
4. TTT Endometrial hyperplasia
5. adenomyosis
 Missed threads
Management of missed IUD
History: failure to feel threads of IUD
IUD Localization
Examination: PV + Cusco’s speculum…….threads
may be adherent to cervical mucous
Exclude pregnancy : U/S & pregnancy test
Plain X-ray: radio-opaque shadow of IUD
hystroscopy
Missed IUD
 Missed threads

• Removal if IUD intrauterine and the patient

wishes to remove it:
1. Novak curette
2. UGA:
a) dialatation+ ring forceps
b) Hysteroscopic removal
Missed IUD
Management of missed IUD
• Removal if not pregnant+ use another
contraceptive method
a) Laparoscopy
b) Laparotomy
• Leave lone if pregnant (exception→ threads are
visible <12 w)
 Emergency contraception (EC)
1. LNG-EC: single dose 1500 µg within 72h of
intercourse. Prevent 85 % of pregnancies.
2. Yuzpe regimen (4 tab of low dose COCs 2
doses 12h apart) within 72h of intercourse.
– Has a lower efficacy and a higher incidence of
adverse effects than LNG - EC.
3. IUD: inserted up to 5 days after the
estimated day of ovulation. Prevent 99 % of
pregnancies.
 Sterilization
A permanent method of contraception
 Tubal Sterilization
Disadvantages:
1. Failure rate: 1/200 HWY
2. Associated with morbidity:
a. Operative
b. Post-operative
c. Irreversible …………Regret
 Tubal Sterilization
Advantages:
1. No hormones
2. Can be done at time of CS
Obtaining consent concurrent with
labor or an
abortion procedure should be
avoided.
 Time of tubal sterilization
• At the same time of CS (planned before onset
of labour)
• Post-partum: within 48 h→
mini laparotomy
• Interval sterilization: after puerperium →
mini laparotomy
Laparoscopy
 Technique of tubal sterilization

1.Laparotomy
2.Laparoscopy
3.Hysteroscopy
 Laparotomy: Pomeroy

Step 1 Step 2
Laparotomy: Parkland
Laparotomy: Irving
Laparoscopy: coagulation
Laparoscopy: clips
Laparoscopy: fallope ring
Hysteroscopy
Barrier methods
Female condom Male condom
 Vaginal
Cervical cap
diaphragm
 Barrier methods
1. Male condom: failure rate 15 %. The most
popular method. Protect against HIV
– Latex: allergy
– Polyurethane
2. Female condom: failure rate > male condom.
Polyurethane. Protect against HIV
3. Vaginal diaphragm: need spermicide. No
protection against HIV. UTI. Difficult use
4. Cervical cap: need spermicide. No protection
against HIV. Difficult use. No risk of UTI.
 Chemical methode

Spermicide
Nanoxnol -9 &octoxynol-9
Supplied as :foam,jell,cream,supp.,
Inserted 1h before IC
High faliure rate
 Postpartum contraception
1. Breast feeding
2. Barrier methodes
3. IUCD
4. POP or COCs if not lactating
5. Postpartum sterlization
 Emergency contraception
Hormomal
POP: LNG 1.5 mg single dose
High dose COC ;ovral 2 tab repeated after 12h
SPRM; ULIPRSITAL 30 MG
Mechanical
IUD