CONTRACEPTION & FAMIY PLANNING

DR. LAMA ALMUHAISEN 2009

IDEAL CONTRACEPTIVE
Inexpensive Easy and simple to use with minimum side

effects Rapidly reversible Readily available Highly effective.? Can be administered by non-healthcare personnel.

Contraceptive effectiveness
Difficult to determine : 1. Perfect VS typical use (method failure and patient failure) 2. Correct VS incorrect use 3. long term VS short term

Pearl index
Method used for determination of pregnancy failure rate:

Pregnancy rate = no. of pregnancies x100women/12 months of use

classifications
A. Natural Methods

Periodic abstinence Withdrawal Lactational Amenorrhea Method

B. Barrier Methods C. Hormonal D Intrauterine Devices E.. Sterilization

HORMONAL CONTRACEPTION
BY: AHMAD HUSSEIN YAAKUB 2009

Objectives
Combined pills

Progestin pills (minipills)

Subdermal patches

Injections
Vaginal ring

Oral contraceptive pills

World wide used very convenient method Reversible methods

Combined
Composition Combination of Estrogen & Progesterone Ethinyl Estradiol (most commonly used nowadays) Levonorgestrel, Norethindrone, Intake 21 days: 1 pill/day Last 7 days: free

Minipills

Used for 28 days, no breaks Same time of the day

Mechanism of action
Combined : most effective method because they inhibit midcycle gonadotropin surge and prevent ovulation Progestin only pills: dont mainly not inhibit ovulation Both types act by -altering cervical mucus making it thick viscid and scanty -alter endometrium so not fit for implantation - alter ovarian responsiveness to gonadotropin stimulation

How to prevent ovulation?

Interfere with the release of GnRH from hypothalamus so it will suppress LH & FSH In high concentration they will inhibit pituitary gland directly Progestin only pills don't inhibit ovulation mainly because a lower dose of progestin is used in preparations less than combine forms it is important to be taken at the same time of the day to ensure that blood level do not fall below the effective levels

Side effects
Mostly caused by progestin Nausea Breast tenderness Fluid retention Depression Headache acne

Estrogen cause pigmentation and high level of estrogen may accelerate the development of gallbladder disease in young female but not increase the risk of acute cholelithiasis Progestin : because they are structural related to testosterone they produce androgenic effects like increase weight and acnes

Metabolic effects
combined HDL LDL TG chemical increase decrease increase clinical cardiovascular disease ?

Progestin only
HDL decrease

LDL
TG

increase
decrease

NONCONTRACEPTIVE BENEFITS
BENEFITS FROM ANTIESTROGENIC EFFECTS OP PROGESTERON: 1-decrease menses blood loss & improve anemia 2- risk of adeno CA of uterus 3- estrogen receptors in breast so risk begnin breast disease ? BENEFITS FROM INHIBITION OF OVULATION (dysmenorrhea ) use as therapy of severe dysmenorrhea OTHER BENEFITS: risk (PID,Rhumatoid a, bone loss)

complications
CVS: DVT Myocardial infarction Stroke

Neoplastic effects
Breast CA Endometrial CA : protection related to duration of use Ovarian CA : decrease risk duration related Liver adenoma and CA? Pituitary adenoma : mask symptoms produced by prolactinoma amenorrhea and galactoria colorectal CA: protection Liver cyst and adenoma

Contraindications
Absolutes Histoy of vascular disease (thromboembolism) Systemic diseases (affect vascular system) SLE , DM with retinopathy or nephropathy Undiagnosed uterine bleeding Increase serum TGs Heart failure rare because incidence of heart diseases are mostly after menopause Smoking in female more than 35y

Contraindications
Relatives: Migraine headache Undiagnosed amenorrhea and depression Smoking in female less than 35 y

LONG ACTING CONTRACEPTIONS

VAGINAL RING
Steroids absorbed though vaginal epithelium directly into circulation Contain ethniyl estradiol and etonogestreland Place in vagina for 21 days and remove 7 days to allow withdrawal bleedings

TRANSDERMAL PATCH
It releases norelgestromin & ethinyl estradiol Weekly applied, for 3 weeks, and the last week of the cycle is a patch-free week Normal activities can be done while using the patch

Subdermal implantation for continuous release Effective for up to 3 years Rapid return of fertility Problems Menstrual irregularity Weight gain Surgical implantation & removal

INJECTABLE SUSPENTIONS
Depomedroxyprogesteron(DMPA) IM,SC every 3 months doesn't increase risk of breast ca Other types: medroxyprogesteron acetate (AMP)

EMERGENCY CONTRACEPTION
After intercourse and before implantation Indication: failure of condoms Unprotected intercourse Within 72 hours after unprotected intercourse Levonorgestrel Combined Prescription Single dose, the earlier the better Prevented 75% of unplanned pregnancies

IUD Emergency Contraception Within 5 days after unprotected intercourse Copper IUD

NATURAL, PHYSICAL AND SURGICAL METHODS

by ABDUL MINER ALSANUSI

Periodic Abstinence
calendar method

Natural methods
Lactational amenorrhea
Definition Efficacy Advantages Disadvantages

Barrier methods of contraception

Two types : 1. Physical barrier methods, such as condoms, diaphragm, and cervical caps, that prevent pregnancy by blocking the entry of sperm into the upper genital tract; 2. Chemical barrier methods (spermicides) that kill or inactivate sperm on contact. ( less effective , used in combination , no STDs protection )

Barrier methods of contraception

easily available, reversible, and have fewer side effects than hormonal methods. effective and acceptable if used consistently and correctly.

Protect against STD

Male condoms

It is one of the most popular mechanical barriers. Among all of the barrier methods, the condom provides the most effective protection of the genital tract from STDs. Its usage has increass because of the concern regarding the acquisition of HIV and STDs.

Male condoms
Increasing the efficacy : reservoir tip The addition of spermicidal lubricant to the condom. (water-based not oilbased) the addition of an intravaginal spermicidal agent .

Female condoms

It contains 2 flexible rings. The ring at the closed end of the sheath serves as an insertion mechanism and internal anchor that is placed inside the vaginal canal. The other ring forms the external patent edge of the device and remains outside of the canal after insertion.

Female condoms
- Mechanism of action : Prevents passage of sperm and infections into the vagina ( protection against STDs ) Can be inserted up to 8 hours prior to intercourse; can remain in place up to 8 hours

Female condoms
- Efficacy Pregnancy rates for the female condom range between 5 and 21 per 100 women per year. (higher than male condoms) To increase efficacy Simultaneous use of both the female and male condom is not recommended Re-use is not recommended .

Diaphragm
The diaphragm is a shallow latex cup with a spring mechanism in its rim to hold it in place in the vagina It is inserted before intercourse so that the posterior rim fits into the posterior fornix and the anterior rim is placed behind the pubic bone.

Spermicidal cream is applied to the inside of the dome, which fits against the vaginal wall.

Diaphragm
It prevents pregnancy by acting as a barrier to the passage of semen into the cervix provides effective contraception for 6 hours. After intercourse, the diaphragm must be left in place for at least 6 hours.

Effectiveness depends on the age of the user, continuity of use, and the use of spermicide along with the diaphragm. Failure rate is estimated to be 20% .

Diaphragm
Relative Contraindications :
- Latex allergy - Uterine prolapse - Repeated UTIs

Diaphragm
Disadvantages :
- Prolonged use increase the risk of UTI

- More than 24 hours use is not recommended

due to the possible risk of TSS.

- Might cause vaginal erosions if not placed properly . - Requires a professional fitting (trained provider is needed) .

Cervical cap
a cup-shaped latex device that fits over the base of the cervix. The cap must be filled one third full with spermicide prior to insertion

Inserted 8 hours before coitus and can be left in place for as long as 48 hours.

Cervical cap
Acts as both mechanical barrier to sperm and as a chemical agent with the use of spermicide . Pregnancy rates range between 4 and 36 per 100 women per year. Effectiveness depends on the parity of women due to the shape of the cervical os. Disadvantages : cervical erosions and vaginal spotting , risk for TSS , requires professional fitting and training for use , high failure rate , and candidates must have a history of normal results of pap smears.

Spermicides
consist of a base combined with either nonoxynol-9 or octoxynol Surfactant that destroys the sperm cell membrane

Forms available : vaginal foams, suppositories, jellies, films, foaming tablets, and creams.

Spermicides
Failure rate is about 26% within the 1st year of use. Advantages : ease of application , available over the counter , inexpensive and it augments the contraceptive efficacy of the cervical cap and diaphragm .

Disadvantages : minimal protection against STDs , risk of vaginal irritation and allergic reaction.

IUD
-IUD is the world's most widely used

method of reversible birth control. 3 TYPES: 1- Inert ( no longer recommended because of painful and heavy periods). 2-Copper Releasing (paragard). 3-Progesterone Releasing (IUS): A-Progestasert (progesterone T) 1976 2001.

Clinical uses
Long-term contraception
Women with contraindications to COC Emergency contraceptive (1:1000 ) menorrhagia , endometriosis, chronic pelvic pain, dysmenorrhea , anemia.

Mechanism of Action
These mechanisms have not been defined precisely and are the subject of ongoing controversy . It has several effects on the reproductive system : - The Mirena is intended to initially release a daily dose of 20 micrograms levonorgestral (a progestin). - Inhibition of ovulation.
-Cervical mucus is changed to obstruct passage of sperm

through the cervix.

- endometrial thinning which inhibits implantation of embryos

Absolute Contraindications
-Pregnancy. -Post partum puerperal sepsis -Immediately post-septic abortion

-Undiagnosed abnormal vaginal bleeding. -Suspected gynecological malignancy. (Cervical cancer, Endometrial cancer) -Current STDs. -Current PID. -anatomical abnormalities

Sterilization
Sterilization :female sterilization and male vasectomy are permenant metod of contaception and highly effective They are generally chosen by relatively older couple who are sure that they copleted their family. Also individual who carry a genetic disorder may choose to be strlizer. 28% of reproductive age women undergo tubal ligation and 10% of men undergo vasectomy. Sterilization methods include: 1- Vasectomy in males.

2- Tubal Ligation in females .

Tubal Ligation
This involve mechanically blockage of both fallopian tube to prevent the sperm reaching and fertilizing the oocyte

sterilization performed by laparoscopically(under GA) or through a suprapubic mini-laparotomy

Failure rate: 0.5%

Tubal Ligation
Advantages: intended to be permanent highly effective safe quick recovery lack of significant long-term side effects cost effective

Tubal Ligation
Disadvantage: possibility of patient regret

difficult to reverse
future pregnancy could require assisted reproductive technology (such as IVF) more expensive than vasectomy

Cont.
Complication:
A women may experienced anasthetic problem or may be damage to intra-abdominal during the procedure.

NOTE:
ectopic pregnancy can be a late complications and any sterilized women who misses her period and has symptom of pregnancy should seek medical advice.

Vasectomy
Mechanism of action:
Vasectomy involve division of the vas deferens on each side to prevent the release of sperm during ejaculation. Easier than tubal ligation. Usually done under local anesthesia. Failure rate: 0.1%.

Vasectomy
Advantages: permanent highly effective safe quick recovery lack of significant long-term side effects cost effective; less expensive than tubal ligation

Vasectomy
Disadvantages:

reversal is difficult, expensive, often unsuccessful not effective until all sperm cleared from the reproductive tract (may take up to 12 w) no protection from STDs

Cont.
Complication of vasectomy:
Immediately bleeding, wound infection and hematoma may occur. At the cut of vas deferns small lump will apear as a result of a local inflammation response this is called sperm granuloma it needs surgica excision.

Cont.
some men develop anti-sperm antibody following vasectomy

THANK YOU