Contraceptives - Methods
Contraceptives can be defined as prevention by mechanical
methods or chemical means of the possible natural and
procreative consequences of sexual intercourse, viz.
Contraception as the name suggests, means against conception,
creates an anti-conception mentality in its users, who
view children or even their conception as a danger or
interference to the relationship of the couple.
METHODS OF CONTRACEPTION
- Barrier methods
- Steroidal Contraception (Hormonal)
- Intra Uterine Devices
These methods prevent sperm deposition in the vagina or
prevent sperm penetration through the cervical canal.
The objective is achieved by mechanical devices or by
chemical means, which cause sperm immobilisation, or by
- Male : Condom
- Female : Diaphragm, Cervical Cap
- Creams (Delfen) Vaginal Contraceptives : Jelly,
Foam tablets, Sponge (Today)
- Combined use of mechanical and chemical.
Trade Name : Nirodh,
a Sanskrit word, meaning prevention. The condom is fitted
on the erect penis before intercourse. The air has to
be expelled from the teat end to make room for the ejaculate.
The effectiveness of a condom is increased by using
it in conjunction with a spermicidal jelly inserted
into the vagina before intercourse.
- It may slip off or tear during the act due to incorrect
use, and it interferes with sexual sensation.
- Couples find it messy, interruptive, unnatural and
- A new condom should be used for each sexual act.
- Could lead to latex allergies.
- Sperms have a diameter of .5 microns. Holes in the
wall of a latex condom have a diameter of 1.0 micron.
HIV retrovirus, which causes AIDS, has a diameter
of 0.1 microns. In effect, this would be like comparing,
perhaps an ant crawling on a basketball. Aids viruses
swim freely through the holes in the condom.
The diaphragm is a vaginal barrier. It is a hollow
cup made of synthetic rubber or plastic material, it
ranges in diameter from 5-10 cms. It has a flexible
rim made of spring metal. It is important that a woman
be fitted with a diaphragm of the proper size. In the
correct position, it lies within the vagina.
The diaphragm is inserted before sexual intercourse
and must be kept in place for not less than 6 hours
after sexual intercourse.
A spermicidal jelly is always used along with the diaphragm.
Initially a physician or other trained person will be
needed to demonstrate the technique of inserting the
diaphragm. Practice at insertion, privacy for this to
be carried out and facilities for washing and storing
the diaphragm preclude its use in most Indian families,
particularly in the rural areas. Therefore, the extent
of its use has never been great.
- If the diaphragm is left in the vagina for an extended
period, there is a possibility of infection.
- Increased risk of bladder infection.
- Allergies to latex or spermicide
VAGINAL CHEMICAL CONTRACEPTIVES (SPERMICIDES)
- Creams, jellies and pastes
- Soluble films
The spermicides contain a base into which a spermicide
is incorporated. These agents mostly produce sperm immobilisation
by inhibiting oxygen uptake and killing the sperms and
to some extent they prevent sperm penetration through
the cervical canal. The cream or jelly is introduced
high in the vagina with the help of an applicator just
before the act.
Foam tablets (1-2) are to be inserted into the vagina
at least 5 minutes before intercourse.
Sponge is made of synthetic polyurethane, impregnated
with spermicide and available in one size. It releases
spermicide during the act, absorbs ejaculate and blocks
the entrance to the cervical canal. It measures about
2 cm in diameter. The sponge is moistened with clear
water to activate the spermicide and inserted into the
vagina to cover the cervix.
- They have a high failure rate
- They must be used almost immediately before intercourse
and repeated for each sexual act
- They must be introduced into those regions of the
vagina where sperms are likely to be deposited
- They may cause mild burning, allergy or irritation,
INTRA UTERINE DEVICE (IUD)
There are two basic types of IUD, non-medicated and
medicated. They are usually made of polyethylene or
other polymers; in addition, the medicated or bio-active
IUD's release either metal ions (copper) or hormones
1st Generation IUD
Non-medicated e.g. Lippe's loop is a double S shaped
device made of polyethylene or plastic material that
is non-toxic, non-tissue reactive and extremely durable.
It contains a small amount of barium sulphate to allow
X Ray observation. The loop has attached threads of
fine nylon which projects into the vagina and helps
to check whether the loop is in place.
2nd Generation IUD
Medicated copper releasing device, CuT. Fine copper
wire is wound round the vertical stem of the device.
It is to be removed after 3 years. Multiload offers
the further advantage of having an effective life of
at least 5 years.
3rd Generation IUD
Hormone releasing Progestasert. It is a T-shaped device
filled with progesterone with a daily release of progesterone
(65 micro gram) into the uterine cavity. The release
from the depot continues only for one year, therefore
it should be replaced after one year.
Mode of action of IUD
- They produce a non-specific inflammatory foreign
body reaction in the endometrium thus preventing the
newly conceived human life from implanting in the
- There may be increased tubal motility which results
in quick migration of the fertilised ovum into the
uterine cavity before the endometrium is receptive.
Copper devices: The ionised
copper has got an additional anti-fertility effect by
affecting sperm survival.
Progestasert: It increases
the viscosity of the cervical mucus and thereby prevents
sperm from entering the cervix. They also maintain high
levels of progesterone in the endometrium and thus relatively
low levels of oestrogen thereby sustaining an endometrium
unfavourable for implantation.
Post-Coital Prevention: Today
the prevalent means of post-coital prevention is IUD.
IUD may be inserted within 5-7 days of unprotected intercourse
and its effectiveness is higher compared to other methods.
But prescribing IUD requires thorough assessment of
patient's individual characteristics, screening for
possible side-effects and patient's willingness to use
IUD for a reasonable period of time in future.
IUD is not suitable for post-coital contraception in
cases of teenagers or individuals frequently changing
partners because these populations are at a high risk
of infection and inflammatory diseases.
- Pelvic inflammation
- Dysfunctional uterine bleeding (Irregularities,
- Suspected pregnancy
- Prolapsed uterus (The uterus descends into the vagina)
- Fibroids, congenital malformation
- Severe dysmenorrhoea (Painful periods)
- Cervix with abnormal cytology
- Past history of ectopic pregnancy
- Nullipara (A woman who has not borne a child)
- Within 6 weeks following Caesarean section.
Side Effects and Complications
- Bleeding : Excessive menstrual
blood loss, irregularities in menstrual cycle
- Pain : Lower back pain, cramps
in lower abdomen and occasionally pain down the thighs
- Inflammation : Pelvic inflammation
due to infection
- Uterine perforation : 1:1000
- Spontaneous expulsion : 5%
- Pregnancy : 3-5% (Increased chances
of ectopic pregnancies 3-4% [Normal 0.8%]).
- Combined Pill
- Progesterone only Pill
- Post-coital Pill
- Once a month Pill
- NET - EN
- Combined pills
Commercial Names : Ovral, Mala N, Mala D, Primovlar.
The pill is given orally for 21 consecutive days beginning
on the 5th day of the menstrual cycle following a break
of 7 days during which period menstruation occurs, known
as withdrawal bleeding from an incompletely formed endometrium.
The pill should be taken daily, preferably at the same
Progesterone only (Mini Pill)
Not very effective. Has to be taken daily from
the first day of the cycle.
Once a month pill
Not very effective.
Mode of action
- Inhibition of ovulation
- Producing static endometrial hypoplasia i.e. endometrium
not favourable for implantation
- Alteration of the character of the cervical mucus
which is thick, viscid and scanty, so as to prevent
- Probably interferes with mobility and secretion
of fallopian tubes.
- Previous history of (h/o) thrombo-embolic manifestations
such as deep venous thrombosis, pulmonary embolism.
- Previous h/o jaundice, especially idiopathic jaundice
- Oestrogen dependent tumors such as breast adenoma
(Tumor) or fibroid uterus.
- Severe hypertension (High blood pressure).
- Organic heart disease.
- Cervix with abnormal cytology (Suspected cancer
- Varicosity (Varicose veins).
- Bronchial Asthma.
- Depression & fluctuation of mood.
- Age over 35.
- Nursing mothers during the first 6 months.
- Nausea, vomiting, headache (OGN), leg cramps (PGN).
- Mastalgia (OGN + PGN) (Pain in the breast).
- Weight gain.
- Chloasma (Patchy brown discoloration on the cheeks)
and acne (Pimples).
- Menstrual abnormalities i.e. Hypomenorrhoea (Decreased
menstrual flow) Menorrhagia (Excessive menstrual flow),
Amenorrhea (No menstrual flow).
- Less of libido due to dryness of vagina (PGN) (Decreased
desire for sex).
- Leucorrhoea, increased cervical mucus secretion
- Depression, change of mood, sleep disturbances.
- Hypertension (High blood pressure).
- Thrombo-embolic phenomenon (Thrombus/Clot is formed
in a blood vessel which detaches itself and is carried
to another part of the body).
- Neoplasia (Breast Tumor).
- Cholestatic jaundice (Obstructive Jaundice).
Centchroman is a non-steroidal chemical that is marketed
in India where it is manufactured, as a 'once-a-week
contraceptive pill.' It is free of side effects but
is an abortifacient.
POST- COITAL PILL
This is not true contraception. In medical literature
it is also referred to as "fire alarm" and
"morning after" prevention. But the most conventional
term is Post-Coital or Emergency Contraception (EC).
It is accepted world wide and propagated that pregnancy
begins at implantation, therefore the action of EC is
Emergency Contraception Pills (ECPs) are ordinary oral
contraceptive pills containing oestrogen and progesterone
hormones. The first dose consisting 3-6 pills, as instructed
by the manufacturer, is taken within 72 hours of intercourse
followed by a second dose 12 hours later. Contra-indications
include serious liver disorders and breast cancer.
Postinor: It is a gestagenic drug
widely used in Russia. Mode of action, if taken 7 days
before ovulation, suppresses it and if after fertilization
prevents implantation (Abortifacient). Mini pills are
also taken likewise.
After intercourse, emergency contraception may prevent
pregnancy by delaying or suppressing ovulation, inhibiting
fertilization or inhibiting implantation of the fertilized
DMPA Depot Medroxyprogesterone Acetate
once in 3 months.
NET - EN Norethisterone Enanthate
once in 2 months.
DEPO-PROVERA Deep intra-muscular injections
are given in the arm or buttock every 12 weeks.
- Reduces menstrual cramps.
- Can be used while breast feeding, starting 6 weeks
- Side effects include loss of monthly period or discomforts
including irregular bleeding, headaches, depression,
abdominal pain and increased or decreased se
- Side effects cannot be reversed until medication
wears off (up to 12 weeks).
- May cause delay in getting pregnant after shots
- Chances of ectopic pregnancy.
- Prevent implantation if fertilization takes place.
SUB DERMAL IMPLANTS
Norplant The silastic capsules are
implanted beneath the skin of the forearm or upper arm
- Effective contraception for 5 years.
Jadelle Consists of only two small
rods rather than 6 capsules as in Norplant. Insertion
and removal are easier and takes less time.
FEMALE STERILISATION / TUBAL LIGATION
Female sterilisation is mainly done as an interval
procedure, post partum or at the time of abortion. The
commonly used procedures are Laparoscopy and Minilaprotomy.
Resection of a segment of both the fallopian tubes is
done. Failure rate is 0.1% due to surgical error, equipment
failure, natural process in which the body re-establishes
a connection from the uterus to the abdominal cavity.
Operative in 800 to 2000 per 100,000 women.
Long term : 22-37% cases.
Severe cramps, heavier and longer periods, dysfunctional
uterine bleeding, pain with intercourse, pelvic pains
40% increase in menstrual blood loss.
26% increase in menstrual pain.
Cervical cancer 3.5 times more than the normal rate.
Pre-menstrual syndrome due to decrease in progesterone
from ovaries, due to interruption of blood flow from
the uterine artery.
Cystic degeneration of the ovary may also result due
to the same.
3.4 times more likely to have subsequent hysterectomy
(Removal of Uterus) due to menstrual problems.
70% of women are not accepted for reversals due to
extensive damage done. In 4-64% of cases, tubal pregnancy
occurs. About 100,000 women are sterilized each year
in the U.S. In a 10 year study of 10,000 women, there
was a failure (i.e. a pregnancy) in one out of fifty.
One third of these pregnancies were in the tube.
MALE STERILISATION / VASECTOMY
A piece of the vas, at least 1 cm in length, is removed
after clamping. The ends are ligated and then folded
back on themselves and sutured into position so that
the cut ends face away from each other. This will reduce
the risk of re-canalisation later. Following vasectomy,
sperm production and hormone output are not affected.
Failure rate 0.1% due to re-canalisation.
The sperm production continues as before, 50,000 per
minute. Lacking a normal anatomical passage, these cells
are either consumed by destroyer cells (macrophages)
or degenerate and produce antigens that cause antibodies
to be produced. At least 8 sperm antigens have been
identified. These antigens frequently infiltrate into
the blood stream and induce other cells throughout the
body to manufacture antibodies against the sperms, anti-sperm
antibodies. An autoimmune condition develops i.e. allergic
to itself, body gears up its defenses to destroy cells
of its own making. 55-75% of cases of antisperm antibodies
appear after 2 years. Atherosclerosis, rheumatoid arthritis
are examples of auto-immune diseases caused. The risk
of developing cancer of prostate is 5.3 times more.
Personality disturbances are observed after vasectomy.
Infection or blood clot in or near the testicles is
possible. Temporary bruises, swelling or tenderness
of the scrotum. Sperm leakage may form small temporary
lumps near the testicles.
High cost microsurgery techniques reverse sterilisation.
The functional success rates vary widely. A published
paper reported rates around 50%. Still, men and women
must consider any sterilisation technique as permanent.