CONTRACEPTIO

N
MODERATOR :DR.GOVERDHAN
PRESENTED BY:DR.TEJASWINI
◦ Definition:

preventive methods to help the women to avoid

unwanted pregnancies ,they include all temporary
and permanent measure to prevent pregnancy
resulting from coitus .
◦DESIRED CHARACTERISTICS OF ideal contraceptive ?
◦Contraceptive which is safe
◦Effective
◦Acceptable
◦Inexpensive
◦Reversible
◦Simple to administer
◦Independent of coitus
◦Easy to dispose
◦But there is never be an ideal contraceptive
CLASSIFICATION
OF
CONTRACEPTIVE
S
PEARL’S INDEX
◦ Efficacy of a contraceptive method is calculated by pearl index
 NATURAL METHODS

◦Lactational amenorrhea method

◦Rhythm method/Calendar method
◦Basal body temperature method
◦Cervical mucus method
◦Symptothermal method
◦Standard days method
◦Withdrawl method (coitus interuptus )
LACTATIONAL AMENORRHEA
METHOD
◦ CRITERIA OF LAM
◦ Exclusive or nearly exclusive breast feeding
◦ Menstruation has not returned
◦ Less than 6 months postpartum

If any of these factors change,futher protection

needed to prevent pregnancy
◦ The suckling of the infant elevates prolactin levels and reduces
gonadotropin-releasing hormone (GnRH) from the
hypothalamus, reducing luteinizing hormone (LH) release and
thus inhibiting follicular maturation

◦ For maximum contraceptive reliability, feeding intervals should

not exceed 4 hours during the day and 6 hours at night

◦ Six-month pregnancy rates of 0.45% to 2.45% are reported for

couples relying solely on this method
◦ To prevent pregnancy, another method of contraception should
be used from 6 months after birth or sooner if menstruation
resumes
LAM
◦ ADVANTAGES ◦ DISADVANTAGES
 breast feeding practices  No protection against STI’s
required by LMA have health
benefits to both mother and baby  effectiveness after 6
 universally available months is uncertain
Can be used immediately after  chance of MTCT if mother
child birth is HIV positive
 no supplies or procedure needed Failure rate 0.5 -1.5%
Bridge to other contraceptive
method
No hormonal side effects
◦ Rhythm method : also called as calender method.
DISADVANTAGES
1)Can only be practiced by educated females.
2)Couple has to be motivated.
3)In irregular cycles this is nt applicable.
4)During breast feeding or immediately after
delivery nt applicable.
 BASAL BODY TEMPERATURE
METHOD
◦ This is method based on fact after ovulation progesterone level in
blood rises increase in BMR and causing rise of temperature by 0.5
-0.8 F in luteal phase
◦ Expected time of ovulation occurs 2- 3 days of BBT change it is
due to early lutinization of un ruptured follicle
◦ Couples are advised to meet 3 days after temperature rise in post
ovulatory period .
◦ Women should record her temp every day before getting up bed .
◦ Sometimes cold ,fever ,temperature recording at different time give
false information
CERVICAL MUCUS METHOD
◦Also called billings ovulation method
◦This method is based on recognizing the changes that occur in
cervical mucus due to the effect of estrogen and progesterone
at different times of menstrual cycle
◦Due to the effect of estrogen at the time of ovulation
pre ovulatory cervical discharge changes in character to
profuse watery transparent slippery discharge which can be
drawn into thread (spinbraket test)
◦Post ovulatory discharge thick and scanty due effect of
progesterone
◦Couple should abstain as soon as 1st sign mucus appearing in
the pre ovulatory phase during the wet days of ovulatory phase
and 3 days after peak mucus .
SYMPTOTHERMAL METHOD
◦ Sympto thermal method pinpoints fertile period
with greater precision under reliability
◦ It is based on observation basal body thermal
change ,cervical mucus change(by billing’s ),other
manifestation of fertile period such as midcycle
light spotting or bleeding and breast tenderness
these observation are noted in symptothermal
method
STANDARD DAYS METHOD
◦ Couple can use SDM to identify their fertile days and
limit unprotected sex to days on which women is not
likely to be fertile.
◦ To keep track of there fertile days the developers of the
method have created string of colour coded beads called
cycle beads ,that represent women menstrual cycle
◦ SDM method appropriate for women with regular
menstrual cycle 26 – 32 days ,
◦ It identifies day 8 to19 of menstrual cycle as fertile days
STANDARD DAY METHOD
DISADVANTAGES

It is used only if the cycles is between 26-32 days .

◦ Failure rates =2/HWY

COITUS INTERRUPTUS
◦ Discharge of semen outside the female genitilia at
the end of sexual intercourse by withdrawing penis
shortly before ejaculation
◦ Advantages :
◦ It needs no appliance or medical supervision
◦ It is free of cost
◦ It causes no harm
DISADVANTAGES :
◦ It needs great motivation and self control by male partner
◦ The either of spouse may develop sexual neurosis,pelvic
congestion syndrome with dysmenorrhea or
hypothalamic amenorrhea due to fear of pregnancy
◦ High failure rate (upto 18 per HWY) as precoital
secretion may contain sperms
◦ Accidental deposition of sperms into vagina
BARRIER METHODS
◦ Barrier methods of contraception are the oldest and
the most widely used contraceptive techniques
throughout recorded history.
◦ These are also the only contraceptive methods that
protect against sexually transmitted infections
(STIs).
BARRIER METHODS
◦ Occlusive methods suitable for both men and women are available
◦ They have both contraceptive and non contraceptive advantages
◦ Contraceptive advantage is absence of side effects associated with
pill and IUD
◦ Non contraceptive advantages :Protection from STD,PID ,cervical
cancer.
◦ Barrier methods require high degree of motivation
◦ Effective only when used consistently and carefully
MALE Condom
◦ Most widely known and used barrier device by
males around world
◦ In India known by trade name “NIRODH”
◦ It prevent the semen from being deposited in
vagina
◦ Effectiveness of condom increased used in
conjuction with spermicidal jelly
 Male Condom

Efficacy
• The failure rate : ~ 3%.
• Advantages
• Readily available and inexpensive
• Effective against both pregnancy and STDs

Disadvantages
• Decrease pleasure of sex
• Latex allergy
• Condom breakage and slippage decrease effectiveness
◦ Most are made of latex; polyurethane and silicone,
rubber condoms are also now manufactured.
◦ “Natural skin”(lamb’s intestine) condoms are still
obtainable (about 1% of sales).
◦ Latex condoms are0.3–0.8 mm thick. Sperm that are
0.003 mm in diameter cannot penetrate condoms.
◦ organisms that cause STIs and AIDS also do not
penetrate latex condoms, but they can penetrate
condoms made from the intestine.
 ADVANTAGES DISADVANTAGES

◦ Easily available ◦ May slip off or tear during

◦ Safe and inexpensive due to incorrect use
◦ Easy to use ;do not use ◦ Interfere with sex
medical supervision sensation locally
◦ Protect against STD ◦ Disposal is difficult.
Female condom
◦ It is a pouch made up of
polyurethene which lines the
vagina
◦ The internal ring in the close
end of pouch covers the cervix
and external ring lies outside
vagina
◦ It is effective barrier to STD
◦ Failure rates during first year
use vary from 5/1oo women
years .
Female Diaphragm
Diaphragm is a vaginal
barrier
◦ It is a shallow cup made of
synthetic rubber or plastic
material ranges in diameter
from 5-10cm.
◦ It has a flexible ring made up
of spring or metal . It is held
in position partly by spring
tension and partly by vaginal
muscle tone.
 Diaphragm
• Spermicidal cream or jelly is applied to the inside of the dome
• Once in position, the diaphragm provides effective contraception
for 6 hours.
• Efficacy
• The typical-use failure rate within the first year is estimated
to be 20%.
• Advantages
• The diaphragm does not entail hormonal usage.
• Disadvantages
• Prolonged use during multiple acts of intercourse may
increase the risk of urinary tract infections.
• May cause vaginal erosions.
Choice and use of diaphragm

◦ 3 major types of latex diaphragm

◦ Most manufactures produce size ranging from 50-
105mm diameter , in implement of 2.5-5mm
◦ Most women uses sizes between 65-80mm
◦ Metal spring are three types : flat type and coil
type and arcing spring type with allows the rim to
assume an arcing rather than flat, folded shape
◦ For women or partner with who are latex allergies
SILCS diaphragm used with contraceptive gel.
Fitting
Timing
◦ Diaphragm should be inserted 6hrs prior to
intercourse.
◦ Spermicidal jelly is applied at dome of diaphragm
prior to insertion. Some of the spermicide should
be spread around the rim with finger.
◦ Additional spermicide should be place in the
vagina before each additional sexual intercourse
while diaphragm is in place.
CERVICAL CAP
◦ Cervical cap are small thimble or dome shaped rubber appliances
designed to cover the cervix they remain in place by suction.
◦ The degree of suction depends upon tightness of the fit hence the
cap must be tailored to fit each cervix
◦ Currently, the only cervical cap available is the Fem Cap.
◦ The Fem Cap is made of non allergenic silicone rubber and is
shaped like a sailor’s hat,a design that allows a snug fit over the
cervix and in the vaginal fornices and provides a“brim” for easy
removal.
◦ Cervical caps have several advantages over the
diaphragm. They can be left in place for a longer
time (up to 48 hours), and they need not be used
with a spermicide.
◦ The most common cause of failure :
Dislodgment of the cap from the cervix during
sexual intercourse.
◦ There is no evidence that cervical caps cause toxic
shock syndrome or dysplastic changes in the
cervical mucosa.
Contraceptive sponge
◦ The vaginal contraceptive sponge is a sustained-release
system for a spermicide.
◦ The sponge also absorbs semen and blocks the entrance to
the cervical canal.
◦ The “Today” sponge is a dimpled polyurethane disc
impregnated with 1 g of nonoxynol-9.
◦ Approximately 20% of the nonoxynol-9 is released over
the 24 hours that the sponge is left in the vagina. “
◦ The spermicidal agents are sodium cholate,
nonoxynol-9, and benzalkonium chloride. This
combination exerts anti viral actions in vitro

◦ The dispersing agent, poly dimethylsiloxane,

forms a protective coating over the entirevagina,
providing sustained protection
*To insert, the Today sponge is moistened with water (squeezing out
the excess) and placed firmly against the cervix.

* There should always be a lapse of at least 6 hours after sexual

intercourse before removal, even if the sponge has been in place for
24 hours before intercourse (maximal wear time, therefore, is 30
hours).
*It can be inserted immediately before sexual intercourse or up to 24
hours beforehand.
*It is removed by hooking a finger through the ribbon attached to
the back of the sponge.
*The Protectaid sponge can be inserted up to 12 hours before
intercourse, and it is easier to remove than the Today sponge.
*Obviously, the sponge is not a good choice for women with
anatomical changes that make proper insertion and placement
difficult.
◦ Side effects associated with the sponge include allergic
reactions in about 4% of users.
◦ Another 8% complain of vaginal dryness, soreness, or itching.
Some women find removal difficult. There is no risk of toxic
shock syndrome,
◦ The nonoxynol-9 retards staphylococcal replication and toxin
production.
◦ There has been some concern that the sponge may damage the
vaginal mucosa and enhance HIV transmission.
◦ Women using the sponge have lower rates of infection with
gonorrhea, trichomonas, and chlamydia.
Spermicides
◦ Jellies, creams, foams, melting suppositories, foaming
tablets, foaming suppositories ,and soluble films
◦ These spermicide used as vehicles for chemical
agents that inactivate sperm in the vagina before they
can move into the upper genital tract.
◦ Some are used together with diaphragms, caps, and
condoms, but even used alone, they can provide
protection against pregnancy
Mechanism of action
◦ Spermicides contain non ionic surfactant which
alters sperm surface membrane permeability
causing osmotic changes resulting in killing of
sperms
◦ Agents used are ;nonoxynol -9 ,octoxynol -
9,benzalkonium chloride ,menfegol
◦ spermicides do not provide additional protection
against STIs over that associated with condoms
◦ spermicides should not be used without condoms
if a primary objective is to prevent infection with
HIV, gonorrhea, or chlamydia.
 Advantages
◦ Use of spermicide needs
no instruction by doctor or
nurse
◦ Easily available and easy
to use ,no gross medical
side effects
Disadvantages
◦ Messy to use not liked by some
couples
◦ Allergic manifestation occur
rarely
◦ Failure rate is high when used
alone
◦ It will not protect against STD
INTRA UTERINE DEVICES
◦ IUD : They are effective safe contraceptive
method. They are particularly suitable method for:
1. women desiring to delay pregnancy for years.
2. Are breast feeding
3. Have difficuilty in using other reversible
methods
4. Prefer a method that does not require supervision
or action before sexual intercourse
Types of IUD
Two basic types of IUD:
1. non medicated
2. Medicated
both are usually made up of polyethylene or other
polymers.
in addition medicated or bioactive IUDs release either
metal ions {copper} or hormones {progesterones}
First generation IUDs : non medicated IUDs
Second generation IUDs : copper IUDs
Third generation IUDs : hormone releasing IUD

In India , under national family welfare programme,

CuT-200 B is used
In 2002, CuT-380 A has been introduced in
programme .
First generation IUD
It comprises of inert or non medicated devices

INERT DEVICES :
*Lippes loop
*Chinese single coil loop
*Mahaua ring
*Ota ring
Second generation IUD
Copper releasing IUDs :
Cu7
CuT200
Multiload copper 250
Multiload copper 375
Copper T 380 A
Copper T 380Ag
Copper T 380S
Nova T
Copper T 220C
Third generation IUDs
Hormone – releasing IUD :
◦ Progestasert IUD
◦ LNG – IUD { Mirena , LNG 20}
Mechanism of action
1.IUCDs cause nonspecific inflammatory and biochemical
changes in endometrium .Endometrial inflammatory
response prevents transport of sperms.
2. Copper is spermatotoxic&gametotoxic.
3. Ionized copper prevents implantation by enzymatic
interferrnce.
4.Lysosomal disintegration from macrophages releases
prostaglandins, which are toxic to sperms.
5. Sperm mobility , capacitation and survival are also
affected by biochemical changes in cervical mucus
produced by copper.
6. Copper devices act locally and do not interfere hormonal
levels , nor do they have any systemic toxic effect in
humans .
TIMING OF INSERTION
Interval insertion :

◦ At least 6 week after parturition ,MTP or abortion

◦ Insertion of IUD soon after menstruation as cervix
softer ,more dilated easier for insertion
INSERTION DURING LACTATIONAL PERIOD : after
ruling out pregnancy
Post abortal :can be inserted safely immediately at the end of
evacuation of uterus
◦ IUD can be inserted after 2wks of ensuring complete abortion
IMMEDIATE POST PARTUM/POST
PLACENTAL INSERTION ;IUD can be inserted
following delivery both after normal delivery or
cesarean section

POST COITAL INSERTION; copper T devices

can be used within 48hrs -5 days of unprotected
sexual intercourse
CU T 380
◦ CU T 380 is supplied free of cost by the govt of india.
◦ 380 refers to the total surface area of copper wire wound around the stem
(314mm2)plus the copper sleeve on the horizontal arms (33mm2)
◦ “A” refers to the cu sleeve on the arms .
◦ The frame contains barium sulfate ,which makes it radioopaque .
◦ It has to be replaced by every 10 years.
TECHNIQUE OF INSERTION OF
CU-T380A
◦ No sedation or anaesthesia required
◦ To reduce cramping pain,tab drotaverine alone or with mefenamic
acid or ibuprofen given 30 mins before insertion
◦ ‘NO TOUCH’ INSERTION method is preferred
i. To load cu T in the inserter both parts are still in sterile package.
ii. Cleaning the cervix with antiseptic before iud insertion
iii. Avoid touching vaginal wall or speculum blades with uterine
sound or loaded iud inserter.
iv. Passing both uterine sound and loaded iud inserter,only once
through the cervical canal.
Steps of insertion of cuT by
withdrawl method
INSERTION OF LNG IUS(MIRENA)

◦ Grasp the upper lip of cervix with tenaculum and apply

gentle traction to align cervical canal with the uterine cavity
◦ The uterus should sound to a depth of 6 to 9cms.
◦ Insertion of LNG IUS into a uterine cavity less than 6cms
by sounding may increase the incidence of
expulsion ,bleeding ,pain, perforation and possibly
pregnancy
◦ The Evo insertor has been devised to simplify the insertion
procedure for inserting LNG IUS
WHO ELIGIBILITY CRITERIA
FOR USE OF IUD(WHO 2015)
WHO CAT 1:NO RESTRICTION ON USE
◦ Age .+20yrs,parous women
◦ Smoking any age and amount of smoking
◦ Obesity
◦ Neurological condition like migraine with or with out aura,stroke and
epilepsy
◦ Cardiovascular conditions like thromboembolic disorders,uncomplicated
valvular heart disease,IHD.
◦ Endocrinological conditions like thyroid disorders and diabetes .
◦ Liver and gall bladder disease
◦ Medical conditions like malaria,non pelvic TB and schistosomiasis
WHO CAT 2;ADVANTAGES
OUTWEIGH THE RISK
1)Gynaec/obstetric conditions
i. Nulliparity
ii. Menstrual patterns with prolonged or heavy bleeding/severe
dysmenorrohea
iii. Endometriosis
iv. Past PID with out subsequent pregnancy
v. Uterine or cervical abnormalities(including fibroids)that do not distort
thhe uterine cavity or interfere with iud insertion
vi. postpartum <48hrs
vii. Vaginal bleeding
viii.Vaginitis with out cervical pus or discharge
2)Cardiovascular conditions: complicated valvular
heart disease(prophylactic antibiotic advised)
3)Chronic disease or other conditions that increase
blood loss like thalssemia,iron deficiency
anaemia,sickle cell disease
4)STD/HIV risk(avoid condom use)
5)Anti retro viraal therapy
7)Immunosuppressive treatment
WHO CAT 3:RISK OUTWEIGH THE ADVANTAGES
AVOID USING IUD UNLESS ABSOLUTELY
NECESSARY

◦ Postpartum 48hrs to 4weeks

◦ Benign GTD
◦ Increase risk of STD/HIV(advice condom use)
◦ HIV positive or AIDS(advice condom use)
◦ ovarian cancer
◦ Severe thrombocytopenia
WHO CAT 4: DO NOT USE
ABSOLUTE CONTRAINDICATION OF IUD

◦ PID,Current or within past 3 months

◦ Current STD or STD with in past 3 months
◦ Known pelvic TB
◦ Unexplained or suspicious vaginal bleeding
◦ Malignant GTD
◦ Cervical and endometrial cancer
◦ Uterine/cervicaL Abnormality incompatible with IUD insertion
◦ Pubertal or postabortal sepsis
◦ Suspected pregnancy
◦ Puerperal sepsis
COMPLICATIONS
◦ EARLY COMPLICATION
Vasovagal attack or fainting
Spasmodic pain
Uterine perforation
LATE COMPLICATIONS:

Excessive vaginal discharge or leucorrohea

Dysmenorrohea
Menstrual dysfunction
Anaemia
Pelvic inflammatory disease
Actinomycosis
Ectopic pregnancy
Infertility
Expulsion
Misplaced iud
Uterine perforation
Pregnancy with iud
INDICATION FOR REMOVAL
◦ Abnormal uterine bleeding not responding to
medical treatment
◦ Acute PID
◦ Missing thread
◦ Uterine perforation
◦ Partial expiulsion of device
◦ The woman wants to concieve
◦ After the life span of the device
◦ One year after onset of menopause
Hormonal contraception
◦ Hormonal contraceptives are steroidal hormones to
prevent pregnancy .

1)COC pill is combined synthetic estrogen (ethinyl

estradiol )& synthetic progesterone.
2)PROGESTOGEN ONLY PILLS
COMBINED ORAL
CONTRACEPTIVE PILLS
◦ MONOPHASIC PILLS : contains same amount of estrogen &
progesterone
◦ PHASIC PILLS :different amount of estrogen & progesterone over
◦ 2WEEKS =BIPHASIC
◦ 3 WEEKS = TRIPHASIC
◦ PILLS can be classified as standard& LOW DOSE pills based on
dosage of EE in the coc pills
◦ Standard dose:30-35mcg
◦ Low dose:20-25mcg ( less risk of side effects &
thromboembolism).
◦ Generation of pills ;based on type of progesterone
and estrogen content
◦ First generation :OC contain 50 mcg or more of
ethinyl estradiol .the progesterone is norethindrone
acetate ,ethynodiol and lynesterol used rarely
◦ Second generation :OC contain 30-35 mcg of ethinyl
estradiol with progestogens such as levonogesterol
and d –levonogesterol(e.g. Mala- N ,Mala - D)
MALA D& MALA N
◦ It is supplied by govt of india
◦ CONTENT :ETHINYLESTRADIOL(30mcg)&
LEVONORGESTREL (0.15mg).
◦ MALA D: 21 ocp and 7 iron tablets ( 60 mg
ferrous fumarate ) available to the consumer
through social marketing at a subsidized rate.
◦ MALA N :FREE OF COST .
◦ Third generation :OC contain progestogen
norgestimate ,desogestrol or gestodene with 20 -30
mcg ethinyl estradiol (e.g. femilon ,loette)
◦ Minesse contain only 15 mcg ethinyl estradiol
◦ New third generation pills or the fouth generation
pills ; the fouth generation pills available in india
conatin ethinyl estradiol and drosperenone with weak
antimineralocorticoid activity e.g. yasmin ,yaz ,dronis
30 & 20
Mechanism of action
◦ INHIBITS OVULATION
◦ THICKENS CERVICAL MUCUS TO PREVENT SPERM
PENETRATION .
◦ MAKES ENDOMETRIUM NONRECETIVE TO IMPLANTATION.

◦ FAILURE RATE 0.1 PER HWY.

Indication
◦ Couple desiring of postponing /spacing pregnancies
◦ Women with endometriosis
◦ Women in of short or long term reversible contraception
◦ Women suffering from menorhhagia ,polymenorrhea
and dysmenorrhea
◦ Post partum or postabortal contraception
◦ Women with pcod and anovulatory cycle
◦ Perimenopausal women
MEC CRITERIA
◦ WHO CATEGORY 1 ; no restriction of use
◦ Age ;menarche to 35 years
◦ Nulliparous or parous
◦ Postpartum : non breastfeeding for >21 days
◦ Post abortion : 1st or 2nd trimester or immediate post
abortion
◦ Past ectopic pregnancy
◦ Cardio vascular disorder :varicose veins ,minor surgery
◦ WHO CATEGORY 2: advantages outweigh risk can be used with caution
◦ Age > 35 years
◦ Obesity > 90kg
◦ Cardiovascular disorder
◦ History of HTN
◦ Family h/o DVT / PE
◦ Superficial thromboplebhitis
◦ Uncomplicated cardio vascular disease
◦ Major surgery witout prolonged immobilisation
◦ WHO CATEGORY 3 ; Risk outweigh the advantages
◦ Age >35 years having <35 cigarette/day
◦ Post partum : >6 weeks to < 6 months
◦ Non breast feeding <21 days
◦ Hypertension
a ) adequately controlled BP
b) systolic 140 -159 / diastolic -90 99
◦ Hyperlipidemia
◦ Diabetes , non focal migraine
◦ WHO CATEGORY 4 : absolute contra
indication
◦ Age >35 years smoking > 35 ciggarette / day
◦ Post partum breastfeeding women < 6 weeks
◦ Cardiovascular disorder :HTN systolic >160 or
diastolic > 100 mmhg
◦ DVT or pulmonary embolism
◦ IHD or pulmonary HTN
◦ Severe or multiple risk factor for venous or arterial
disease
◦ Atherogenic lipid disorder
◦ NEUROLOGICAL DISORDER :
◦ Focal migraine
◦ TIA
◦ Past cerebral hemorrhage
◦ Multiple disorder ; old age, smoking ,DM ,HTM
◦ PROTEIN C AND PROTEIN S deficiency
◦ Anti thrombin deficiency
ADMINISTRATION
◦ OC pills to be taken during 1 st cycle from first day or any of the next 4
days and should be continued daily for 21 days

◦ Stopped And restarted after gap of 7 days irrespective of onset or

stoppage of menstruation during pill free days
◦ For amennorhea ,oc pills can be started at any time if she is not
pregnant and she should take additional contraceptive for seven days
◦ in non lactating women COC should be started 3- 6 weeks after child
or if menstruation starts whichever earlier
◦ COC should be started during first 7 days of after 1 st or 2nd trimester
abortion
Management of missed pill
◦ If one pill is missed in any part of cycle to be taken as soon
as remembered or
◦ Two pills taken at usual time
◦ If 2 or more pills missed during first 2 weeks and women
has unprotected coitus within previous 7 days then
emergency contraception added
◦ if 2 or more pills have been missed during 3rd week,back
up method of contraception must be used for 7 days .start
new pack without a break.
Advantages
◦ Prevention of pregnancy
◦ Cycle stabilization
◦ Cure of menstrual disorder
◦ Protection against cancer :endometrial cancer,
ovarian cancer ,choriocarcinoma
◦ Protection against benign breast disease :fibrocystic
and fibroadenoma
◦ Ovarian functional cyst
◦ Ectopic pregnancy
◦ endometriosis
◦ Menorrhagia ,dysmenorrhea , DUB
◦ Pre menstrual syndrome
◦ No affect on future fertility
SIDE EFFECTS
◦ Minor side effects ;nausea ,vomiting ,lack of apetite ,
breakthrough bleeding , menorrhagia& irregular bleeding
◦ Oligomenorrhea and amenorrhea
◦ Breast changes
◦ Vaginal discharges
◦ Headche and migraine
◦ Weight gain and chloasma
◦ Pyschosexual troubles
DISADVANTAGES
◦ Relative expensivenes
◦ Interfernce with biochemical and biopsy finding
MAJOR SIDE EFFECTS AND
RISK
◦ CARDIOVASCULAR DISORDERS
◦ MI
◦ Ischemic stroke
◦ Hemorrhagic stroke
◦ Venous thromboembolism
◦ Hypertension
◦ Coagulation and lipids
◦ POSSIBILTY CARCINOGENICITY
◦ Breast cancer ,cervical cancer, liver cancer
◦ Affection of liver and gallbladder ;
◦ increased risk of gallstones and primary
hepatocvellular adenoma
◦ Effect on lactation : reduces milk secretion
Interaction with drugs
◦ Barbiturates , sulphonamides ,rifampicin ,anti
convulsants interfere with OCs and increase failure
rates
◦ In case of patient using rifampicin non hormonal
methods are preffered
Indication for stopping pill
◦ Severe and throbbing unilateral headache with or without
scotoma
◦ Chest pain with or without dyspnea
◦ Visual problems like double vision,blurring of
vision,blindness
◦ Acute and severe pain in one leg
◦ Jaundice,severe depression,excessive obesity
◦ Missing 2 conjugative menstrual periods
◦ persistent AUB after 3 months of pills use
◦ 6weeks before major operation
FOLLOW UP AND DURATION
OF USE
◦ After 3 months of use ,then after every 1 to 2 yrs .
◦ The pill can be used until upto menopause
◦ In indian conditions for postponement of 1st
pregnancy and spacing upto 5 yrs
PROGESTOGEN
(PROGESTIN )ONLY PILLS
◦ TYPES
◦ Levonorgesterel -0.075mg
◦ Norgesterel -0.030 mg
◦ Desogestrerol -0.075 mg
◦ Norethindrone -0.035 mg
◦ Ethynodiol diacetate -0.500 mg
Indication
◦ Nursing mother 6 weeks after delivery
◦ Women in whom estrogen contraindicated
◦ In patients whom OC pills contraindicated
MECHANISM OF ACTION
◦ Rendering the cervical mucous thick and non receptive to
spermatozoa
◦ Rendering endometrium atrophic and hostile to
implanatation
◦ Premature leuteolysis
◦ Inhibition ovulation in 60 % of cases
Contraindication
◦ Absolute C/I
◦ Breast cancer
◦ Relative contraindication (WHO category 3: risk outweigh advantages )
1)breastfeeding < 6 weeks postpartum
2)cardiovascular disorders :DVT/IHD
◦ Migraine with aura
◦ Liver disoreder
a)Active viral hepatitis
b)Severe cirrhosis
c)Benign /malignant liver tumors
d)Drugs effects liver enzymes
Prescription of mini pill
◦ Started 6 weeks of delivery in lactating women / within
first 5 days of the period
◦ Mini pills must be taken daily at the same time of the day
◦ Best time is afternoon or bedtime according to their
convinience
◦ Desogestrel POP containing 75 mcg used daily .safety
margin is 12 hrs
◦ For missed pill backup method (e,g; condom) should be
used for 48 hours
ADVANTAGES
◦ No effect on quantity and quality of milk
◦ Absence of estrogen side effects
◦ Useful in >40 years
◦ Can be given to women with medical
disorders :diabetes ,epilepsy,smoking , and history of
thromboembolism
◦ Also used in obese ,hypertensives and women with
varicose veins
◦ Decrese chances of PID and endometrial cancer
Disadavntages
◦ Irregular vaginal bleeding is common in 20 -30 %
◦ Minor side effects like headache and mastalgia
◦ Amenorrhea can occur such cases intrauterine and ectopic
pregnancy to be ruled out
◦ Higher failure rate (0.5 -2 /HWY )
◦ Must be taken at same time daily
◦ For delay of >3 hours ,backup method should be use for
48 hours
PROGESTERONE (PROGESTIN )
INJECTABLES
DEPOT MEDROXY PROGESTERONE
ACETATE (DMPA)
◦Depo – provera comes as
microcrystal suspended in an
aqueous solution
◦Dosage : 150 mg
◦Route: IM z track technique
(Deltoid or gluteal ) without local
massage for every 3 months
◦Efficacy equal to that of
sterilization
◦New formulation avavilable as
Depo – sub provera 104 mg
◦Antara program govt of india
made available FREE of cost
◦ Norethindrone enanthate (NET –EN)
◦ Dosage :200 mg every 2 months
SIDE EFFECTS
◦ Irregular bleeding
◦ Weight gain
◦ Delayed return of fertility
◦ Psychological side effects like loss of
libido,depression,fatigue,nervousness
◦ Acne ,hirsutism
Counselling
◦ Important counselling about succesful use of NET
–EN
◦ Potential for weight gain
◦ Patients should be warned about amenorrhea and
irregular bleeding
◦ Returning for timely injection
◦ Lack of protection from STDs
◦ Delay in nfertilty after stopping medication
HORMONAL IMPLANTS
◦Hormonal implants are progestogen
implants
◦Norplant :consist of 6 capsules with
216 mg of LNG
◦Each capsule having 36 mg of LNG
◦Each capsule is 34 mm long and
2.4 mm wide
◦Rate of release :85 mcg per day
during 6 months, <50 mcg per day
by 9 months and 30 mcg per day
later
◦It last for 5 years
MECHANISM OF ACTION
◦ Norplant makes cervical mucus scanty ,thick and
hostile sperm penetration
◦ It supresses ovulation in 50 % cases by inhibiting
hypo thalamo –pituitary axis
◦ It depresses endometrial growth inhibiting
implantation
INSERTION
◦ Six sialistic capsules of norplant are inserted under
the skin in the inside of upper arm ( 6cm above the
cubital fossa )
◦ They are inserted in fan shaped manner under local
anesthesia
◦ Inserted within day 1-7 of cycle
◦ Immediately after abortion or 6 weeks after
delivery
NORPLANT – 2( JADELLE)
◦ Norplant is composed of
two levonogesterel rods
◦ Each rod measures 43 mm
in length and 2.5 mm in
diameter
◦ Contain 75 mg of the drug
◦ Effective for 5 years
IMPLANON
◦ Implanon is a long acting single rod
subdermal implant
◦ Rod measure 4 cm in length and
2mm in diameter
◦ Core of the implant contain 68 mg of
crystalline etonogestrel, dispersed in
ethylene vinyl acetate copolymer
◦ Initial release rate is 60 -70 mcg per
day and declines to 25-30 mcg at the
end of the 3rd year
◦ Use recommonded for 3 years
ADVANTAGES
◦ Implants are highly effective
◦ Effective within 24 hours ,provides long term
contraception
◦ Fertility returns immediately on removal of caqpsules
◦ Contrtaception is free from act of sexual intercourse
◦ No estrogen side effects
◦ Implants are considered as reversible sterilization
Disadvantages and side effects
◦ Requires minor surgical procedure for insertion
and removal of implants
◦ Women suffer from mastalgia ,weight
gain ,irregular menses ,hirsutism
◦ No protection against STDs
◦ Diminished efficacy in epileptics on treatment
◦ High cost
EMEREGENCY CONTRACEPTION

◦ Definition :
Method of contraception used as an emergency
procedure before menstruation is missed ,to
prevent pregnancy following unprotected
intercourse or expected failure of contraceptive
Indications
◦ Risk of pregnancy due to rupture or slippage of
condoms
◦ For aged couples having infrequent coitus
◦ Missing pills with coitus
◦ Ejaculation on external genitilia
◦ Following a single act of unprotected coitus in
young girls
◦ Case of rape and incest
Mechanism of action
◦ Emergency contraceptive act either by stopping or
postponing ovulation or by interfering with
postovulatory events necessary for implantation

◦ Cause alteration in tubal motility ,interfere with

corpus luteum function and induce cervical mucus
changes
METHODS AND DOSE
◦ LEVONOGESTREL :
◦ DOSE : 0.75 mg two doses at 12 hours apart at earliest after
unprotected coitus but within 72 hours
◦ Single dose of 1.5 mg (2 tablets ) is equally effective
◦ Method of choice for emergency contraception
◦ Very effective and economical
◦ US FDA approved use of progestin only as EC called plan B
◦ It is taken without prescription
◦ COMBINED ESTROGEN AND PROGESTOGEN
PILLS (YUZPE method )
◦ Dose : Ethinyl estradiol 100mcg + 1 mg d – norgestrel
◦ Route – oral
◦ How to use : two divided dose 12 hours apart starting
within 72 hours of unprotected intercourse
◦ Total 4 tab ovral each containing 50 mcg of ethinyl
estradiol and 0.25 mg d – norgestrel
◦ Conjugated equine estrogen 15 mg
◦ Route :oral
◦ Duration :twice daily for 5 days soon after intercourse
not later than 72 hours
◦ MIFEPRISTONE (RU 486 ):
◦ Anti progesterone blocks the action of progestreone
◦ Cause endometrium sloughing and implantation
◦ Dose – 25 -50 mg with succes rate 99.1%
◦ ULLIPRISTAL ACETATE :
◦ DOSE : single tablet 30 mg within 5 days of
intercourse
◦ MOA :inhibits or delays ovulation and suppresses
endometrium preventing implantation
◦ Failure rate upto 2%
◦ Side effects :mood changes and headache
◦ Avoided in severe liver disorder and severe asthama
◦ CENTCHROMAN :
(ORMELOXIFEN )
◦ DOSE : 60 mg (two tablets ) twice
(repeated after 12 hours ) in first
24 hours of coitus to prevent
implantation
◦ Failure rate: 1 -2 %
◦ Cu T 380 -A :
◦ To be used within 5 days of
intercourse
◦ Useful in married women needing
continued contraception
◦ Failure rate 0- 1 %
FEMALE STERILIZATION
◦ It is surgical procedure used to end a women’s ability to
become pregnant.
◦ The procedure involves ligation, with or without resection or
blocking of the fallopian tube ,so that eggs and sperms cannot
meet
◦ Female sterilization is the most widely used contraceptive
method in the world
◦ In the develpoping countries surveyed female sterilization
found to be the most popular method of contraception
overall .
Eligibility of Providers for
Performing Female Sterilization
◦ Service -Basic Qualification Requirement of Provider
◦ Minilap services -Trained MBBS doctor
◦ Laparoscopic sterilization -DGO, MD (Obst. & Gynae.),
MS (Surgery) (trained in laparoscopic sterilization)
◦ The state should constitute a district-wise panel of
doctors for performing sterilization
◦ operations in government institutions and accredited
private/NGO centres based on the above criteria.
◦ Only those doctors whose names appear on the panel
should be entitled to carry out sterilization
operations in the government and/or government-
accredited institutions.
CASE SELECTION CRITERIA
◦ Clients should be married
◦ Female clients should be below the age of 49 years and
above the age of 22 years.
◦ The couple should have at least one child whose age is
above one year
◦ the sterilization is medically indicated.
◦ Clients or their spouses/partners must not have
undergone sterilization in the past (not applicable in cases
of failure of previous sterilization).
◦ Clients must be in a sound state of mind so as to
understand the full implications of sterilization.
◦ Mentally ill clients must be certified by a
psychiatrist, and a statement should be given by
the legal guardian/spouse regarding the soundness
of the client’s state of mind.
COUNSELLING
◦ The following steps must be taken before clients sign the
consent form:
◦ Clients must be informed of all the available methods of family
planning and should be made aware that for all practical purposes this
operation is a permanent one.
◦ Clients must make an informed decision for sterilization voluntarily.
◦ Clients must be counselled whenever required in the language that
they understand.
◦ Clients should be made to understand what will happen before, during,
and after the surgery, its side effects, and potential complications.
The following features of the sterilization
procedure must be explained to the client:

◦It is a permanent procedure for preventing future pregnancies.

◦It is a surgical procedure that has a possibility of complications,
including failure, requiring further management
◦It does not affect sexual pleasure, ability, or performance.
◦It will not affect the client’s strength or her ability to perform
normal day-to-day functions.
◦Sterilization does not protect against RTIs, STIs, or HIV/AIDS.
◦Clients must be told that a reversal of this surgery is possible, but
that the
◦reversal involves major surgery and that its success cannot be
guaranteed.
 TIMING OF SURGICAL
PROCEDURE
◦ Interval sterilization; should be performed within 7 days of the menstrual
period (in the follicular phase of the menstrual cycle).
◦ Post-partum sterilization ;should be done after 24 hours up to 7 days of
delivery.
◦ Sterilization with medical termination of pregnancy (MTP) can be
performed concurrently.
◦ Sterilization following spontaneous abortion can be performed provided the
client fulfils the medical eligibility criteria.
◦ Laparoscopic tubal ligation should not be done concurrently with second-
trimester
◦ Tubal ligation are performed by ;
◦ Trans abdominally (Conventional laprotomy)
◦ Minilaprotomy
◦ Transvaginally
CONVENTIONAL
LAPAROTOMY
◦ Operation performed under general anesthesia or local
anesthesia
◦ Incision made subumbilically on the abdominal wall.
◦ The size and situation of the incision depends on the size of the
uterus
◦ In peurperal sterilization ,an incision of 3-4 cm length is made
2cm below the level of fundus,while interval ligation the
incision is made 2.5 cm above the pubic symphysis,
◦ The transverse incision preferred over longitudinal incision as
incidence of ventral hernia more in peurperal sterilization
TECQNIQUES OF TUBAL
LIGATION
◦ Pomeroy technique
◦ Irving method
◦ Uchida technique
◦ Fimbriectomy (kroener’s method)
◦ Madlener technique
◦ Parkland technique
◦ Minilaprotomy
◦ Laproscopic sterilization
POMEROY TEQNIQUE
IRVING’S METHOD

1)Tube cut at isthmo ampullary junction

2)a tunnel is made in the myometrium into which the proximal part of ft is burreied .distal
part is attached to broad ligament
UCHIDA TECHNIQUE
PARKLAND’S TECNIQUE
MINI LAPROTOMY
STEPS
LAPROSCOPIC STERILIZATION
THANK YOU
REFFERENCES
◦ 1. DC DUTTA OF OBSTETRICS
◦ 2.CLINICAL OBS ANG GNY BY SHARMILA
◦ 3.MARROW EDITION 4