Chapter 133

Physiology of
Contraception
 LEARNING OBJECTIVES
On completion of study of this chapter: The student will be able to: (MUST KNOW)
1. Classify contraceptives used for males and for females.
2. Name the temporary and permanent methods of contraception in males and females.
3. Explain the mechanism of action of oral contraceptive pills (OCP) and intrauterine contraceptive devices
(IUCD).
4. List the merits and demerits of each IUCD.
5. Remember the merits and demerits of other types of contraceptives.
6. Give the mechanism of action of other contraceptives.
7. Say which contraceptive will be better for which category of couple.
8. Mention the effectiveness of each category of contraceptive as per WHO notification, 2007.
9. Mention the failure rate of each contraceptive method. The student may also be able to: (DESIRABLE TO
KNOW) 1. Describe the mechanisms, merits, and demerits of different types of contraceptives
 INTRODUCTION
India is a highly populous nation. One of the major problems India is facing in recent years is birth control.
In April, 1976, India formulated its first “National Population Policy”, and “National Population Policy–
2000” is the latest in the series. All these policies primarily aim at reducing the birth rate. When birth
control procedures work prior to implantation of the fertilized egg, they are called contraceptives, and
when work after implantation (cause death of the embryo), they are termed as abortifacients. .
 CLASSIFICATION
Contraceptive methods are classified into following categories:
1. Barrier methods:
• Physical methods
• Chemical methods.
2. Intrauterine devices (IUDs)
3. Hormonal methods
4. Postconceptional methods
5. Permanent methods. They may
also be classified as temporary
and permanent methods.
Physical Methods
In Males
Condom is the most widely used barrier device in male. It prevents sperm to be deposited in the vagina.
The biggest advantage is that it provides protection against sexually transmitted diseases.
In Females
Diaphragm is the most commonly used vaginal barrier. A spermicidal jelly is usually used along with the
diaphragm. Another female barrier device is vaginal sponge.
Chemical Methods
Various spermicidal agents like foams, creams, and suppositories are inserted manually into vagina before
intercourse. These act as “surface active agents” that attach themselves to sperms and decrease their
oxygen uptake and kill them. They are not usually used due to their high failure rate.
 INTRAUTERINE DEVICES
Types
The IUD are of three generations (Figs. 133.1A to D):
1. First generation IUD: Lippes loop
2. Second generation IUD: Earlier devices:
Copper–7; Copper T–200 Newer devices:
Copper T variants (T–Cu 220C; T–Cu 380A;
T–Cu 380Ag)
3. Third generation IUD (with hormonal
preparation): Progestasert:
a T-shaped device filled with 38 mg of
progesterone. Levonorgestrel–20 (LNG-20):
a T-shaped IUD releasing 20 mcg of
levonorgestrel, a synthetic steroid.
Mechanism of Action
Intrauterine device works by several mechanisms.
1. Usually, they work after fertilization has occurred, but before implantation is completed. The presence of
these small objects in the uterus brings about uterine changes that interfere with the endometrial
preparation for acceptance of the blastocyst. Thus, implantation is prevented.
2. They also act as foreign body in the uterine cavity (Fig. 133.2) causing cellular and biochemical changes
in the endometrium and the uterine fluid that impair the viability of the gamete. Therefore, the chance
of fertilization is reduced.
3. Copper facilitates cellular reaction in endometrium, composition of cervical mucus, impairs sperm
motility, and impairs capacitation of sperm.
4. Hormone-releasing devices increase the viscosity of cervical mucus by releasing progesterone. They
make mucus thick, so that sperm cannot enter the uterus. They also make the endometrium unfavorable
for implantation.
 HORMONAL CONTRACEPTIVES
1. Oral contraceptive pills:
• Combined pill
• Progestogen-only pill
• Postcoital pill
• Once-a-month pill
• Male pill.
2. Depots (slow releasing formulations):
• Injectable preparations
• Subcutaneous implants
• Vaginal rings.
 ORAL CONTRACEPTIVE PILLS (OCPs)
 Presently, OCPs contain 30–35 mcg of estrogen and 0.5–1 mg of progesterone.
 The pill is given for 21 days from 5th day of the cycle.
 Oral contraceptives are based on the principle that estrogen and progesterone inhibit pituitary gonadotropin
release, thereby preventing ovulation.
 Progesterone-only pill affects the composition of the cervical mucus, reducing the ability of the sperm to pass
through the cervix, and inhibit the estrogen-induced proliferation of the endometrium, making it inhospitable
for implantation.
Side Effects of OCP
Though OCPs are 100% effective in preventing pregnancy, there are risks of few side effects, especially when
consumed for many years.
Cardiovascular Side Effects
Myocardial infarction, cerebral thrombosis, venous thrombosis, and hypertension have been reported. These side
effects are more seen in aged (more than 35 years) women and in smokers.
• Hypertension occurs due to fluid retention and increased angiotensin level.
• Estrogen increases renin-angiotensin activity and thereby increases angiotensin II production which is a potent
vasoconstrictor
Carcinogenesis
Increased risks of cervical cancer and breast neoplasia have been reported. Hepatic tumors occur rarely.
Metabolic Side Effects
Oral contraceptive pills decrease HDL and alter blood coagulability. These two factors facilitate
atherosclerosis and proneness to myocardial infarction and stroke. They also cause glucose intolerance and
insulin resistance. Miscellaneous
Other side effects include cholestatic jaundice, breast tenderness, weight gain, and migraine.
Depots
Subcutaneous implants are contraceptive (progestogen) capsules (Norplant) implanted beneath the skin that
release hormone slowly and last for five years.
Injectable forms (intramuscular injection of progestogen substance like DepoProvera every 3 months) are
also available. Vaginal ring containing levonorgestrel has been found to be effective.
Postconceptional Pills
Contraceptives can be used within 72 hours after intercourse (postcoital contraception).
1. These pills interfere with ovulation, transport of the conceptus to the uterus, or implantation.
2. Usually, high dose of estrogen, or two large doses (12 hours apart) of a combined estrogen-progestin oral
preparations are prescribed.
3. Most effective with fewer side effects is the pill RU 486 (mifepristone), which antagonizes progesterone
activity by binding competitively with progesterone receptors in the uterus.
4. This causes the endometrium to erode and the contractions of the fallopian tubes and myometrium to
increase.
 OTHER METHODS
The Rhythm (Safe Period) Method
The rhythm method is the abstinence from sexual intercourse during the fertile period of the cycle (near the time
of ovulation).
1. In 28 days regular cycles, normally ovulation occurs between 12th and 16th day (usually on 14th day).
Functionally sperm can survive for 2 days and ovum for 3 days.
2. Therefore, unprotected intercourse should be avoided during the fertile period of the cycle, which will fall
between 2 days before and 3 days after ovulation, i.e. from 10th day to 19th day of the cycle (refer Figure
127.6; Chapter 127). Rest of the period in the cycle is considered to be safe period.
3. However, the day of ovulation is not always fixed even in regular cycles and cycle length is also not always
regular. Moreover, only the length of luteal phase is constant, which is 14 days from the day of ovulation, and
practically it is difficult and tedious to know the day of ovulation.
4. Therefore, in practice, shortest cycle minus 18 days gives the first day of fertile period and longest cycle minus
10 days gives the last day of fertile period. For example, if the duration of shortest cycle is 25 days (25 – 18 =
7th day) and duration of longest cycle is 32 days (32 – 10 = 22nd day), the unprotected intercourse should be
avoided between 7th and 22nd day of any cycle.
5. However, pregnancy has been documented due to intercourse on any day of the cycle. Therefore, it is believed
that no period in any cycle, even during the bleeding phase is absolutely safe
Coitus Interruptus
In this method, during fertile period, the male partner withdraws penis from vagina before ejaculation.
Thus, sperm is not deposited in the female genital tract in the fertile period.
Breastfeeding
Till the mother continues to nurse the baby with breastfeeding, ovulation does not occur. This is because
prolactin secreted during lactation produces lactational amenorrhea by inhibiting GnRH secretion.
 FAMILY PLANNING OPERATIONS
Male Sterilization
Male sterilization is performed by vasectomy. In vasectomy, bilateral ligation of vas deferens is performed
instead of sectioning the vas as recanalization can be taken up in future whenever needed. However,
antibodies developed against spermatozoa following vasectomy cause infertility following restoration of
patency of the vas.
Female Sterilization
Female sterilization is performed by bilateral tubal ligation. Tubal recanalization can also be performed later
whenever needed.