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. conception.

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

• Sterilisation

BARRIER METHODS

Mechanical

• Male : Condom
• Female : Diaphragm, Cervical Cap

Chemical

• Creams (Delfen) Vaginal Contraceptives : Jelly, Foam tablets, Sponge (Today)

Combination

• Combined use of mechanical and chemical.

CONDOM

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.

Disadvantage

• 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 unreliable.
• 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.

DIAPHRAGM

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.

Disadvantage

• 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)

• Foams
• Creams, jellies and pastes
• Suppositories
• 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.

Disadvantage

• 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, besides messiness.

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 (progesterone).

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 endometrium
• There may be increased tubal motility which results in quick migration of the fertilised ovum into the uterine cavity before the endometrium is receptive.

IN ADDITION

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.

Disadvantage
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.

Contra-indication

• Pelvic inflammation
• Dysfunctional uterine bleeding (Irregularities, Menstrual disturbances)
• 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%]).

HORMONAL CONTRACEPTION

Oral

• Combined Pill
• Progesterone only Pill
• Post-coital Pill
• Once a month Pill

Injectable

• NET - EN
• DMPA
• Depo-Provera

Subdermal implants

• Norplant
• Jadelle
• 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 time.

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

1. Inhibition of ovulation
2. Producing static endometrial hypoplasia i.e. endometrium not favourable for implantation
3. Alteration of the character of the cervical mucus which is thick, viscid and scanty, so as to prevent sperm penetration
4. Probably interferes with mobility and secretion of fallopian tubes.

CONTRA-INDICATIONS

Absolute

• Previous history of (h/o) thrombo-embolic manifestations such as deep venous thrombosis, pulmonary embolism.
• Previous h/o jaundice, especially idiopathic jaundice in pregnancy.
• Diabetes.
• 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 of cervix).

Relative

• Migraine
• Obesit.
• Varicosity (Varicose veins).
• Epilepsy.
• Bronchial Asthma.
• Depression & fluctuation of mood.
• Age over 35.
• Nursing mothers during the first 6 months.

SIDE EFFECTS

Minor

1. Nausea, vomiting, headache (OGN), leg cramps (PGN).
2. Mastalgia (OGN + PGN) (Pain in the breast).
3. Weight gain.
4. Chloasma (Patchy brown discoloration on the cheeks) and acne (Pimples).
5. Menstrual abnormalities i.e. Hypomenorrhoea (Decreased menstrual flow) Menorrhagia (Excessive menstrual flow), Amenorrhea (No menstrual flow).
6. Less of libido due to dryness of vagina (PGN) (Decreased desire for sex).
7. Leucorrhoea, increased cervical mucus secretion (OGN).

Major

1. Depression, change of mood, sleep disturbances.
2. Hypertension (High blood pressure).
3. Thrombo-embolic phenomenon (Thrombus/Clot is formed in a blood vessel which detaches itself and is carried to another part of the body).
4. Neoplasia (Breast Tumor).
5. 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 justified.

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 egg.

INJECTABLES

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.

Advantage

• Reduces menstrual cramps.
• Can be used while breast feeding, starting 6 weeks after delivery.

Disadvantage

1. Side effects include loss of monthly period or discomforts including irregular bleeding, headaches, depression, abdominal pain and increased or decreased se
2. Side effects cannot be reversed until medication wears off (up to 12 weeks).
3. May cause delay in getting pregnant after shots are stopped.
4. Chances of ectopic pregnancy.
5. 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.

PERMANENT METHODS

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.

Complications

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 on pressure.

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.

Reversals

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.

Complications

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.

Reversals

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.