METHODS OF CONTRACEPTION

CONTRACEPTION : All measures, temporary

or permanent, designed to prevent
pregnancy due to coital act.
IDEAL CONTRACEPTIVE:
 Highly effective
 Easily Accepted
 Safe
 Reversible
 Cheap
 With non contraceptive benefits
 Require minimal motivation , maintainance
and supervision
CONTRACEPTIVE EFFECTIVENESS :
 PEARL INDEX = No. of accidental
pregnancies X 1200
No. of patients X
months of use

This is the failure rate of any contraceptive

calculated in terms of pregnancy rate per
hundred women years of use.
Pregnancy rate < 10 means that the
effectiveness of a particular contraceptive
method is high as the failure rate is less.
Pregancy rate >20 means the effectiveness
is low.
 Methods of Contraception

Temporary Permanent
1.Barri
3.IUCD
er
s 1.Male:
Metho
4.Stero Vasectomy
ds
idal 2.Female:
2.Natu
contra
ral
ceptio Tubectomy
Metho
n
ds
 NATURAL METHODS
 RHYTHM METHOD : Abstinence from
sexual intercourse during fertility period of
cycle.
 Calender rhythm : Recording of previous
menstrual cycles
 Temperature rhythm : Basal body
temperature rise : avoid intercourse until 3
rd day of rise
ADVANTAGES DISADVANTAGES
 Mucus rhythm : By avoiding intercourse in
No side effects Difficult to calculate
presence of noticeable vaginal discharge +
No cost Not applicable in LA / irregular
3 days menses

Failure Rate : 20-30 HMY
 COITUS INTERRUPTUS : Withdrawal of penis
before ejaculation
ADVANTAGES DISADVANTAGES
No appliance required Requires Self control
No cost May lead to
anxiety/vaginismus
Failure Rate : 20 HMY
 LACTATIONAL AMENORRHEA :
 EBF for 6 months + amenorrhea : Risk of
pregnancy <2% in first 6 months , otherwise HIGH
failure rate
 EBF : alternate contraceptive advised in 3rd Post
Partum month
 Partial/ No Breastfeeding : Alternate contraception
in 3rd PP week.
 BARRIER METHODS
MOA: Prevent sperm deposition/sperm
penetration
MECHANI •MALE: Condom
•FEMALE: Condom/ Diaphragm/
CAL Cervical cap

CHEMICA •CREAMS: Delfen (Nonoxynol -9 )

•Jelly: Koromex , Volpar paste
L •Foam Tablets: Sponge (TODAY)

COMBINA •Mechanical +
TION Chemical
 CONDOM
Material : Polyurethrane / latex
Marketed ad NIRODH in India.
ADVANTAGES DISADVANTAGES
Cheap Accidental slippage /
breakage
No contra indications /side Inadequate sexual
effects experience
Simple / Disposable Allergic reaction to
latex
Protects against STDs and FAILURE RATE : 15 HMY
PID
Reduced incidence of
Ectopic
Protects against cervical cell
USES :
1. Elective contraceptive
2. Interim contraceptive after Vasectomy
3. During treatment of trichomonas vaginitis in
wife
4. Immunological infertility
 FEMALE CONDOM (FEMIDOM)
MATERIAL: Polyurethrane
Lines the vagina and the external genitalia
Length = 17 cm
Has 2 flexible rings
Inner ring : fitted at Apex of the vagina
Outer ring : remains outside
• ADVANTAGE: Protection against STI s :
CMV/HIV/HBV and PID
DISADVANTAGE: Expensive
Reusable
Failure rate : 5-21/ HMY
 CHEMICAL METHODS
 SPERMICIDES:
 Contain Nonoxynol-9/Octoxynol/Benzalkonium chloride
 Available as vaginal foam/cream/gel/suppository –
introduced high in vagina with an applicator before
coitus
 Duration of action : 1 hour
 FAILURE RATE : 18-29 HMY

• VAGINAL SPONGE (TODAY) :

 Polyurethrane sponge impregnated with Nonoxynol – 9
 MOA: Releases spermicide during coitus, absorbs
ejaculate and blcoks entrance to cervical canal. Remove
after 6 hours post coitus.
 FAILURE RATE : Parous : 32-20
Nulliparous : 16-9
ORAL CONTRACEPTIVES
COMBINED PREPERATIONS

MONOPHASIC

BIPHASIC

TRIPHASIC

EMERGENCY (POST COITAL)

PROGESTERONE
GENERATIONS
 COMBINED ORAL CONTRACEPTIVE
PILLS
PROGESTERONE + ESTROGEN
PROGESTINS:
Levonogestrel/Norethisterone/Desogestrel
ESTROGENS: Ethinylestradiol/ Mestranol
MOA :
 INHIBITION OF OVULATION : By supressing HP
axis .
 Endometrial hypoplasia
 Alteration in cervical mucus
 Interferes with tubal motility
 ESTROGEN : Inhibits FSH surge and prevents
follicular growth.
 AVAILABLE PREPERATIONS
COMMERCIAL PROGESTIN ESTROGEN NO. OF
NAME (MG) (MCG) TABLETS

MALA N (Govt Levonorgestrel Ethinyl 21+7 iron

of India) 0.15 estradiol -30 tablets

MALA D Levonorgestrel Ethinyl 21+7 iron

0.15 estradiol -30 tablets

LOETTE Desogestrel Ethinyl 21

0.15 estradiol -20

YASMIN Drospirenone Ethinyl 21

3 mg estradiol -30
INDICATIONS AND CONTRAINDICATIONS
 USAGE :
 NEW USERS: Started on Day 1 of cycle and continued for
21 days  7 days break  New pack from Day 8 of next
cycle.
 POST-ABORTION: Start immediately
 NON LACTATING MOTHER : After 3 weeks
 LACTATING WOMAN : After 6 months of child birth

 MISSED PILLS :
 1 pill (late upto 24hrs): Take the missed pill immediately

 2 pills (day 1-7): Take 2 pills on each of the next 2 day

and then continue the rest as schedule

 2 pills (day 15-21) or if more than 2 pills are missed at

any time, another form of contraception to be used as
backup for next 7 days.
 NON CONTRACEPTIVE BENEFITS OF
COMBINED PILLS
1. Regulation of menstrual cycle
2. Reduction in dysmenorrhea
3. Reduction in PMS
4. Reduction of Mittelschmerz syndrome
5. Protection against Iron deficiency anemia (7 day
blister pack)
6. Protection against : PID (by making cervical
mucus thick), Ectopic Pregnancy, Endometriosis,
Fibroid, Hirsuitism and acne, ovarian cysts, Benign
Breast disease, Osteopenia/Osteoporosis, RA
7. Increases bone mineral density
8. Prevents: Endometrial/colorectal/epithelial
Ovarian malignancy
 ADVERSE EFFECTS
MINOR MAJOR

Nausea/vomiting/headache (E) Depression

Mastalgia (E+P) Hypertension (E )

Weight gain (P) VASCULAR (E) : Venous

Thromboembolism/Arterial
thrombosis
Chloasma (E) / Acne (P) Cholestatic jaundice

Menstrual Abnormalities : Neoplasia (E) : ? Cervical

Hypomenorrhea (P) / cancer
Menorrhagia (O) / Amenorrhea
(E+P)
Reduced Libido (P)

Leukorrhea (O)
 PROGESTERONE ONLY PREPERATIONS
ORAL : PROGESTERONE ONLY PILLS
 Low dose progesterone : 75mcg Levonorgestrel /
350 mcg Norethisterone / 75mcg Desogestrel/ 30
mcg Norgestrel
 Taken from Day 1 of cycle
 MOA: Thick cervical mucus prevents sperm
penetration + prevents implantation
 DOSAGE: From Day 1 of cycle without break
 ADVANTAGE :
1. Estrogenic side effects are eliminated
2. Suitable for lactation
3. Compliance is more
4. Safe in HTN/Fibroid/DM/epilepsy/
Thromboembolism
 DISADVANTAGES :
1. Acne/mastalgia
2. Simple ovarian cysts
3. Failure Rate : 0.3-2/ HWY

 CONTRAINDICATIONS :
1. Pregnancy
2. Unexplained vaginal bleeding
3. Thromboembolic/ Arterial disease
4. Recent breast cancer
 INJECTABLE PROGESTINS
DEPOT MEDROXY PROGESTERONE ACETATE (DMPA)
1. 150mg every 3 months , IM within 5 days of cycle
2. 300 mg every 6 months
 NORETHISTERONE ENANTHATE (NET-EN)
1. 200mg every 2 months , IM , within 5 days of
cycle

 MOA : Inhibition of ovulation/ Thick cervical

mucus/ Endometrial atrophy
 ADVANTAGES :
• More compliance than oral pills
• Safe in lactation
• No estrogenic side effects
• Reduced menstrual symptoms
• Protects against Endometrial cancer
• Reduces : PID/Endometriosis/Ectopic

 DISADVANTAGES :
• Failure Rate : 0-0.3/HMY
• Delayed return of fertility after
discontinuation : 4-6 months
• Loss of bone mineral density
 IMPLANTS
1. IMPLANON : NEXPLANON
 Single closed capsule with 68 mg Etonogestrel
 Releases 60 mcg hormone/day
 Does not decrease bone mineral density.
 MOA : Inhibits ovulation , causes atrophy of
endometrium and thickens cervical mucus.
 INSERTION : Subdermal insertion in inner aspect
of arm, between biceps and triceps.
 TIMING: ay 5 of menstruation/Post-abortion/ 3
weeks Post Partum.
 REMOVAL: within 3 years
 Fertility recovery: Immediate
 PEARL INDEX: 0.01
ADVANTAGES:
 Effective for long term use
 Rapidly reversible
 Useful in women with non compliance to OCPs
DRAWBACKS:
 Irregular menstrual
bleeding/spotting/amenorrhea
CONTRAINDICATIONS :
 Pregnancy
 Unexplained bleeding p/v
 Breast cancer
 Thromboembolic /Arterial disease
 On Anti-epileptics
2. NORPLANT- II (JADELLE) :
Two rods with 75 mg levonorgestrel each.
Releases 5o mcg per day
Failure Rate: 0.06 /HMY
Life span: 3 years
 EMERGENCY
CONTRACEPTION
1. HORMONAL PILLS :
 LEVONORGESTREL : 0.75 mg, 2 doses 12 hours
apart/ 1.5mg single dose.
First dose should be taken within 72 hours max
upto 120 hours.
 MOA:
1. Ovulation is prevented/delayed
2. Fertilization is interefered.
3. Implantation is prevented  endometrium
rendered infavourable
4. Interfered with corpus luteum / luteolysis.
 DRAWBACK: Nausea/vomiting
 Pregnancy Rate: 0-1%
 COMBINED HORMONAL (YUZPE) METHOD : Two
tablets OVRAL (0.25 mg Levonorgestrel + 50 mcg
Ethinyl Estradiol) taken within 72 hours followed by
2 tablets 12 hours later.
2. COPPER IUD :
 Insertion within 5 days provides emergency
contraception.
 MOA: Prevents implantation ‘
 Failure Rate: 0-1 %
 ADVANTAGE: Can be kept in-situ for 10 years

3. ANTIPROGESTERONE : RU-486 Mifepristone blocks

progesterone receptors and prevents implantation.
Dose: 100 mg within 5 days of intercourse.
Pregnancy Rate: 0-0.6%
4. ULIPRISTAL ACETATE : Progesterone receptor
modulator.
Dose: 30 mg single dose within 120 hours of
coitus.
MOA:
Supresses follicular and endometrial growth.
Delays ovulation and inhibits implantation.
C/I : Hepatic dysfunction and severe asthma
 INTRA-UTERINE CONTRACEPTIVE
DEVICES
NON MEDICATED : Lippes loop
MEDICATED: Copper containing
 CuT – 200 , CuT-380 , Multiload – 250,
Multiload- 375
HORMONE CONTAINING :
 Progestasert
 LNG-IUD
MOA:
1. Biochemical changes in the endometrium
making it gametotoxic and spermicidal.
2. Increased tubal motility
3. Endometrial inflammatory response
4. Copper prevents blastocyst implantation
through enzymatic degradation
5. LNG-IUD :
• Suppresses the endometrium
• Cervical mucus plug becomes thick
• Reduces tubal motility
• Reduces luteal phase activity
TIMING OF INSERTION :
 Preferably inserted 2-3 days after menstruation is
over.
 Interval Insertion : >6 weeks following child birth
 Post- abortal : Immediately following termination of
pregnancy.
 Immediate Post-Partum:
o After expulsion of placenta in vaginal delivery
o Intracesarean insertion
o Within 48 hours after delivery

ADVANTAGES :
 Safe and highly effective
 Immediate action
 Long term protection
 Immediate return of fertility post removal
 CONTRAINDICATIONS :
1. Pregnancy/ suspected pregnancy
2. Undiagnosed genital tract bleeding
3. Current pelvic infection or within last 3 months
4. Distorted uterine cavity
5. Severe dysmenorrhea
6. Suspected uterine/cervical neoplasia
7. Endometritis in last 3 months
8. STDs : current/last 3 months
9. Trophoblastic disease
10. Immunosuppression
 Additionally CuT : Wilson disease
Copper Allergy
 LNG-IUD: Hepatocellular cancer
Breast cancer
Arterial disease
1. CuT 380 A :
 Total copper= 380 sq mm
 Vertical stem : 314 sq mm . Made of polyethylene
 Horizontal arms : 33 sq mm each
 Threads for detection and removal of device
 Barium sulphate added to make device
radiopaque.
 Life span : 10 years
 Uses :
 Contraception
 To prevent recurrent adhesion formaion
2. MULTILOAD Cu 375 :
 Copper content : 375 sq mm
 No requirement of plunger and applicator
 Life span: 5 years

3. LNG – IUS :
 Contains POLYDIMETHYL SILOXANE
membrane
which acts as a steroid reservoir.
 Contains LEVONOGESTREL 52mg
 Rate of release: 20mcg/day
 Life span : 7 years
4. Other devices :
 Cu-T 200
 Multiload 250
 Progestasert : contains 38 mg
Progesterone. No longer used
 Lippes Loop : First generation.
Non medicated IUCD. No
longer used.
WITHDRAWAL TECHNIQUE OF INSERTION
OF Cu-T
COMPLICATIONS :
 IMMEDIATE –
 Pain
 Syncopal attack: due to distension of uterine cavity
 Perforation of uterus
 REMOTE –
 Prolonged pain
 Abnormal menstrual bleeding :
Menorrhagia/Metrorrhagia .
(Less with 3rd generation IUDs)
 Pelvic Inflammatory Disease : 2-10 times higher
risk.
Infection with Chlamydia/Actinomyces.
Maximum risk in first 3 weeks of insertion.
 Spontaneous Expulsion :
 About 5 % cases.
 Failure to palpate thread which was previously
palpable.
 More with postabortal/puerperal insertions.
 Less with newer IUDs.

 Perforation of the uterus :

 Incidence : 1/1000
Diagnosis :
 Non visibility of thread through external os
 Pelvic symptoms
 Non visualization on exploration
 USG
 X- RAY : After introducing sound in the uterine cavity.
Management : Removal by Laproscopy/ Laprotomy.
PREGNANCY RATE WITH IUCD :
2 per HMY
Lowest with Cu-T 380 A (0.8 HMY) and LNG-IUS (0.2
HMY)
Risk of ectopic : 0.02 %

INDICATIONS FOR REMOVAL :

Persistent excessive regular/ irregular uterine bleeding
Salphingitis
Perforation
Partial expulsion
Pregnancy with device in-situ
Wanted conception
Missing thread
1 year after menopause
ADVANTAGES OF THIRD GENERATION IUDs :
(Cu-T 380 A , Multiload 375 ,LNG-IUS )
 Higher efficacy with lower pregnancy rate
 Longer duration of action (5-10 years)
 Low expulsion rate
 Risk of ectopic is less
 Risk of PID is less
NON CONTRACEPTIVE BENEFITS :
 Reduction in menstrual blood loss, menorrhagia,
dysmenorrhea and PMS
 Treatment of endometrial hyperplasia, Adenomyosis,
endometriosis, fibroids and endometrial cancer
 Alternative for hysterectomy for menorrhagia and
DUB
 Benefits of HRT (Fibroplant)
 ADVANTAGES DISADVANTAGES

Inexpensive Requires motivation

Simple to insert Limitations in use
Prolonged contraceptive Risk of ectopic
protection (5-10 years)
Systemic side effects are Local Reactions :
less. Suitable for Menstrual abnormality ,
hypertensives, PID , pelvic pain, heavy
breastfeeding women and menstrual bleeding.
epileptics.
Prompt reversal of fertility
after removal
 STERILIZATION

FEMALE :
MALE: VASECTOMY
TUBECTOMY
 TUBECTOMY
TIMING :
 PUERPERAL : 24- 48 hours following delivery
 INTERVAL : >3 months following
delivery/abortion. Ideally following menstrual
period in the proliferative phase
 CONCURRENT : With LSCS/MTP

METHODS :
 Conventional : Laprotomy
 Minilaprotomy
 Laproscopic
 TECHNIQUES OF TUBAL
LIGATION
 POMEROY’S METHOD :
1. Tube is held with Babcock’s forceps in the
form of a loop.
2. Loop contains mainly isthmus and ampulla
3. Needle with chromic catgut is passed
through the mesosalpinx.
4. Both limbs of the loop are firmly tied.
5. 1-1.5 cm of segment of the loop is excised.
6. 1.5 cm of tube adjacent to uterus remains.
7. Process repeated on opposite side.
8. The cut ends are independently sealed off
and separated after absorption of ligature.
9. ADVANTAGE: Easy, safe and effective
10. FAILURE RATE : 0.1-0.5 %
 UCHIDA TECHNIQUE :
1. Inject saline subserosally to create a bleb.
2. Serous coat is incised along the anti-
mesenteric border to expose the muscular
coat of tube.
3. Tube is ligated with chromic catgut.
4. 3-5 cm of the tube is resected.
5. Ligated proximal stump is allowed to retract
beneath serous coat.
6. Proximal stump is buried and serous coat is
closed.
7. Distal stump is left open in peritoneal cavity.
8. FAILURE RATE: Nil
 IRVING METHOD :
1. Tube is ligated on either side.
2. Mid portion of tube is excised.
3. Free medial end of the tube is turned
towards the uterus and buried into posterior
uterine wall by creating a myometrial
tunnel.
4. Lateral end is buried in the mesosalpinx.
 MADLENER TECHNIQUE :
1. Loop of tube is crushed with artery forceps.
2. Crushed area is tied with black silk.
3. Loop is NOT EXCISED.
4. FAILURE RATE : 7%
 KROENER METHOD :
1. Fimbriectomy done bilaterally.
MINILAPROTOMY (MINI-LAP)
LAPROSCOPIC STERILIZATION
Done as an interval procedure
Single/Double puncture techniques
Tubes can be occluded by :
 Fallope Ring
 Filshie clip : 4mm tube destroyed.
Failure Rate : 0.1%
 Hulka-Clemens clip
 Electro-cauterization : Bipolar> Unipolar
Failure Rate :
2.1 %
1. ANAESTHESIA : Local/ Spinal
2. POSITION : Lithotomy
3. CREATING PNEUMOPERITONEUM : Veress
needle is introduced through a 1.25 cm sub-
umblical incision and abdomen is inflated
with 2L of CO2/N2O/O2/room air.
4. INTRODUCTION OF TROCAR AND
LAPROSCOPE : Laproscope loaded with
silastic rings is introduced.
5. A loop (2.5cm) is created at junction of
proximal and middle third of the tube and
the ring is slipped into the base .
6. Repeated on the other side.
 MINI-LAP LAPROSCOPIC

COST Cheaper Expensive

TIMING Puerperium, Should not be
Interval, with done <6 weeks
MTP of delivery or
with enlarged
uterus
CONTRAINDICATION None Lung/Heart
diseases , Intra-
abdominal
adhesions ,
morbid obesity
HOSPITAL STAY 3-5 days 3-4 hours
FAILURE RATE 0.1 – 0.3 % 0.2-0.6 %
REVERSIBILITY Difficult due to Easier. Longer
 VASECTOMY
 Permanent sterilization in males.
 Segment of vas deferens of both sides are resected
and cut ends ligated.
 ADVANTAGES :
1. Simple operative technique
2. Can be done as an outdoor procedure
3. Minimal complications
4. Minimal failure rate : 1 in 2000
5. Successful reversal (70-80%)
6. Minimal expenditure
 DRAWBACKS:
1. Additional contraceptive for 2-3 months post
vasectomy
2. Psychological impotency
 N0-SCALPEL VASECTOMY
 TECHNIQUE :
1. Palpate vas midway between top of testis and base of
penis.
2. Vas is grasped with a ringed clamp applied
perpendicularly
3. Skin is punctured with dissecting forceps
4. Dissect dartos muscle and spermatic fascia
5. Vas is elevated with dissecting forceps and held with
ringed clamp.
6. 1 cm of vas is mobilized and ligated at 2 ends with
chromic catgut . Segment between ligatures is resected.
7. Fascia is interpositioned.
8. Skin sutures not required.
9. Repeat on other side.
 PRECAUTIONS :
1. It takes 3 months/20 ejaculations to empty out
stored semen and sterility. Hence, additional
contraceptive is required.
2. Semen analysis for spermatozoa should be done at
16 weeks.

 COMPLICATIONS :
1. Immediate : Scrotal cellulitis /Scrotal haematoma
2. Remote :
• Impotency – psychological
• Sperm granuloma
• Post-vasectomy Syndrome: chronic intrascrotal pain
• Spontaneous recanalization