Contraception

05/25/24
Contraception
2

05/25/24
 Contraception
3

Hormonal Contraception
 1. OCP
 2. Transdermal – Patch- Evra

 3. Vaginal ring- Nuva Ring

 4. IM progestin- Depo Provera

 5. Emergency contraception

 6. IUD-Mirena

05/25/24
 Contraception
4

Non Hormonal Contraception

IUD- Copper
Essure
Tubal ligation
Condoms
Diaphragm

05/25/24
Background
 The Pearl Index
6

Created by Raymond Pearl 1933

Definition- the number of failures per 100 women-
years of exposure.
In the denominator- total months or cycles of
exposure from onset of method until completion of
the study/treatment .
The PI is usually based on a lengthy exposure (1 yr),
and therefore fails to accurately compare methods at
various durations of exposure.

05/25/24
 Life table analysis
7

Calculates a failure rate for each month of use.

A cumulative failure rate can compare methods for

any specific length of exposure.

05/25/24
 Hormonal CCs

Synthetic female sex steroids

E+P P only
 Hormonal CCs
Administration

Oral

Patch Implant

Injection Vaginal ring

 History
10

 The first hormonal contraceptive- Enovid , PO (150 ug of

mestranol and 9.85 mg of norethynodrel) was approved by
the FDA in 1960 (Pincus G. and Rock J.)

OCP – most widely used reversible form of hormonal

contraceptive

05/25/24
 Hormonal CCs

Steroid Hormones
 Rapidly absorbed in the gut

 Portal circulation  liver metabolism  inactivation

 High doses of steroids are required when orally

administered
 Hormonal CCs
Progestin (c-21)
 Hormonal CCs
13

The original progestin used in hormonal

contraception are all derived from ethisterone, an
orally active testosterone derivative.

Removal of the carbon at C-19 position gives the

progestational activity with some residual
androgenic activity ( 19-nortestosterone progestins)

05/25/24
 Hormonal CCs
14

The newer progestins – the levonorgestrel family

desogestrel ,gestodene and norgestimate were
designed to minimize androgenic side effects such
acne, hirsutism, nausea and lipid changes while
increasing progestational effects.

Drospirenone, Cyproterone acet. (Diane) and

Dienogest (Qlair) exhibit a progestational and
antiandrogenic activity.

05/25/24
 Hormonal CCs
Progestins
Differ from each other in their
Affinity for ER, AR and PR

Ability to inhibit ovulation

Ability to substitute for progesterone and

antagonize estrogen
 Hormonal CCs
Estrogen
Ethinyl estradiol – the main E in use

High dose OCP- 30 to 35 ug of EE (50ug)

Low dose OCP - 15-20 ug EE

Effective contraceptive agents in women at

reproductive age (0.07-2.1 preg per 100 woman

yrs of treatment)
 Hormonal CCs
Contraceptive effect- Combined OC
 E or P alone can inhibit ovulation

 They inhibit GT synthesis by acting on the pituitary

gland.
 Hormonal CCs
18

 Progestin mainly inhibits LH secretion (prevent ovulation)

 Estrogen- suppresses FSH secretion( the development of a

leading follicle)

 In combination – inhibition of ovulation at lower doses, (the

effect is dose related!)

 The progestin also acts on the endometrium, cervical mucus

and on the fallopian tubes

05/25/24
 Hormonal CCs
19

Oral contraceptive pill:

 EE+P vs. P only

 High dose EE vs. Low dose EE(30-50 ug vs. 15-25 ug EE)
 Monophasic- EE and P concentration are the same
throughout the treatment cycle
 Biphasic – same EE conc. With increase in the P
concentration at the middle of the cycle
 Triphasic- same EE but 3 different P conc. Along the cycle

05/25/24
 Hormonal CCs
20

 First generation OCP- products containing more than 50 ug

EE
 Second generation OCP- products containing EE 20-35 ug
and levonorgestrel or norgestimate.
 Third generation OCP- EE 20-35 ug with desogestrel or
gestodene
 Fourth generation- products containing drospirenone,
dienogest or nomegestrol acetate.

 Extended /continuous regimen OCP

05/25/24
 Hormonal CCs
21

Extended OC therapy:
 In 2003 the FDA approved Seasonale, a 91- day OCP(84
days of 30ug EE +0.15 mg levonogestrel +7 days of inactive
pills).
 Seasonique-(2006) the same dose of EE + levonogestrel
during the first 84 days but with 0.01 mg estrogen instead
of the placebo pills
 In 2007- Lybrel- 1 yr continuous extended active pills (20
ug EE with 0.09 mg of levonorgestrel)

05/25/24
 Hormonal CCs
22

Resulted in fewer bleeding days, decrease pain

associated with menstruation
Safety and S/E profiles similar to the 21 days cyclic
pills
99% of women resume ovulation within 3 months of
discontinuing the medication

05/25/24
 Hormonal CCs
Side effects- OCP
Nausea, breast tenderness, weight gain,

headaches

Less common with current LD OCs

Usually resolve after the first few cycles

 Hormonal CCs
Teratogenicity
No increase in overall risk for

 Malformation

 Congenital heart defects

 Limb reduction defects

HD-E taken in pregnancy can induce vaginal

Ca in exposed female offspring in utero

 Hormonal CCs
Transdermal - OrthoEvra
The patch- a combination of 20g of EE and 150g of

noregestromin daily, one patch weekly for 3 weeks

Provide sustained release of the steroids

Peak steroid levels < OCs but sufficient to prevent

ovulation
Greater convenience  improves compliance
 Hormonal CCs
Transdermal –
 However- the mean serum EE levels are higher

compare with the combined OCP (30ug of EE)

 More breakthrough

bleeding/spotting in
1st cycles

 Obese - ↑ pregnancy

rate
 Hormonal CCs
NuvaRing
 A combined estrogen/progesterone contraceptive

vaginal ring with low mean serum EE levels.

 Release of 15 g of EE and 120 g of etonogestrel daily

 outer diameter - 54mm

 Cross section - 4mm

 Use for 3 weeks+ 1 week free

 Hormonal CCs
NuvaRing
S/E- headaches, leukorrhea and vaginitis

Failure rate- 0.65 per 100 woman years

Fewer days of irregular bleeding/spotting

than women taking OCs
Can be removed during
coitus. Reinsertion within
3 hours
 Hormonal CCs
Depo Provera
(medroxyprogesterone acetate)
A single 150mg IM dose  ovulation
suppression for 14 wks
2004- FDA approved depo-subQ-provera,
104 mg for s/c use
Injected every 3 months

Highly effective
 Hormonal CCs
Depo Provera, S/E:
Breakthrough bleeding in new users

Return to fertility may be delayed

Median time to ovulation after last

injection – 10 months.
 70% conceive within 1 yr

 90% conceive within 2 yrs

 Hormonal CCs
Depo Provera
Safety (long use)
DMPA  E production↓  bone loss

Adolescents are of especial concern

FDA “black box warning”:

DMPA treatment be limited to 2 years at a time
unless the patient has no other good options for
contraception
 Hormonal CCs
Emergency CC
 Hormonal CCs
Emergency CC
1. High dose E
Taken within 72 hours of coitus
5 mg of EE daily for 5 days
Possible mechanisms
 Altered tubal motility
 Interference with CL function
 Alteration of the endometrium
Pregnancy rate - 0.15%
 Hormonal CCs
Emergency CC
2. E+P - Yuzpe
EE 100 ug and levonorgestrel 0.5 mg in 2
doses 12 hr apart ,up to 72 hr after
intercourse. (Preven)
Effective in inhibition or delay of ovulation
Pregnancy rate - 1.8%, but it is 1.2% if
treatment is started within 12 hours of
intercourse
Nausea and vomiting are common with both
regimens
 Hormonal CCs
Emergency CC
3. Plan B , Ella - Levonorgestrel Alone
0.75 mg initially followed by another 0.75
mg 12 hours later- up to 72 hr after
intercourse
1.5 mg levonorgestrel in one dose up to 72
after intercourse.
The emergency CC method
of choice at present
Less nausea and vomiting
 Hormonal CCs
Emergency CC
4. Copper IUD
Most effective emergency contraceptive
method
Insertion of a copper IUD within 7 days
 Hormonal CCs
Neoplasia- Endometrial Cancer
OCP use is associated with lower risk of
endometrial CA
2yrs  ↓ risk by 40%

> 4yrs  ↓ risk by 60%

Benefit continues for at least 15 years

from last use !!!
 Hormonal CCs
Neoplasia- Ovarian Cancer
 OCP decrease the risk for ovarian CA
 Most probably via the protective effect of the
progesterone
 3-4yrs  ↓ risk by 50%

 > 10yrs  ↓ risk by 80%

 Benefit continues for at least 15 years from last

use !!!
 Hormonal CCs
Neoplasia- Cervical Cancer
There may be a weak association ???

Risk factors for Cx Ca ….

Sexual Exposure to
intercourse HPV

OCs use   ↓ Barrier methods

 Hormonal CCs
Neoplasia- Breast Cancer
 Large volume of conflicting literature

 Generally, very small increase risk in current OC users under

35 yo, RR-1.24(Practice Committee of American Society for

Reproductive Medicine 2008)

 Current use
(Lancet-1996) Discontinuation

RR 1.24 1-4 yrs  RR 1.16

5-9 yrs  RR 1.07
> 10 yrs  RR 1.0
 Hormonal CCs
Neoplasia
Breast Cancer
 Breast CA diagnosed in OCP user was less advanced

 No increased risk in the 35-64 yo who were past users

(Kahlenborn et al 2006, Floger et al 2007)

For the present, the best

information available is
reassuring that there is little
or no direct association
 Hormonal CCs
Neoplasia
Liver Tumors
Association to liver adenomas

 Risk is related to prolonged use

 Usually regress when OC use is

discontinued
Newer low-dose OCs pose less risk

M/P no association to liver cancer

 Hormonal CCs
Neoplasia- Colon Cancer
Growing evidence of protective effect

 37% reduction in colon cancer

 34% reduction in rectal cancer

IUD
 IUD
2 Types :
Copper IUD
approved for up to 10 (7) years of
continuous use
 IUD
2 Types
Levonorgestrel-releasing IUD (Mirena)
approved for 5 years of use (52 mg)
Both provide safe, long-term CC with
effectiveness ~ to
tubal sterilization
 IUD
47

Jaydess- Levonorgestral- releasing IUD (13.5

mg), for up to 3 yr. (new release)

05/25/24
 IUD
Mechanism of action
Biologic Foam
Sterile inflammatory response to the
foreign body (cytotoxic cytokines, PGs)
Failure of sperm to reach the ovum

Inflammatory response to prevent

implantation
 Sterilization - Female
Methods
Tubal sterilization at the time of
laparotomy for a CS or other abdominal
operation
Laparoscopy
Hysteroscopy
Laparotomy
Laparotomy
Laparoscopy - bipolar
electrocoagulation
Laparoscopy
Falope ring

Producing ischemic
necrosis
Laparoscopy
Hulka clip
Laparoscopy
Filshie clip
 Sterilization - Female
Hysteroscopy
In 2002, the FDA approved a new
hysteroscopic method of permanent
birth control: the Essure system
 Hormonal CCs
Metabolic Effects- Venous Thrombosis
 OCP is associated with increase risk for VTE

The absolute risk of thrombosis (Danish data)

Low dose EE Low dose EE

Population with with
Levo/Noret desog/gesto

3:10000 3 fold 6-7 fold

women yrs increase increase
 Hormonal CCs
Metabolic Effects
Venous Thrombosis
 Both estrogen and progestin are risk factors

 OCP with the new P (desogestrel/gestodene) show

higher risk for VTE d/t increase estogenicity (high
SHBG)

 Other factors to consider- age, weight, smoking,

family history of VTE
 Hormonal CCs
Metabolic Effects
Venous Thrombosis
Risk is apparent by 4 months of use

Risk is highest during 1st year of use

Doesn't ↑ further with continued use

First choice OCP- A lowdose pill with

norethisterone/levonorgestrel
 Hormonal CCs
Metabolic Effects
Thrombophilia
Factor V Leiden (APCR)

 3-5% of the white population

 X 10 risk for a 1ST TE episode among OCs

users (~ 30:10000)- most common
associated with OCP
Hormonal CCs
 Hormonal CCs
Metabolic Effects
Thrombophilia
Any venous event while using OCs should

be evaluated and OCP stopped.

ATIII
Fac V leiden
Protein C
MTHFR
Protein S
APLA
Prothrombin
Contraception
63

05/25/24
 Contraception
64

Hormonal Contraception
 1. OCP
 2. Tran dermal – Patch

 3. Vaginal ring

 4. IM progestin

 5. Emergency contraception

 6. IUD

Non Hormonal Contraception

05/25/24
Background
 The Pearl Index
66

Created by Raymond Pearl 1933

Definition- the number of failures per 100 woman-
years of exposure.
In the denominator- total months or cycles of
exposure from onset of method until completion of
the study/treatment .
The PI is usually based on a lengthy exposure (1 yr),
and therefore fails to accurately compare methods at
various durations of exposure.

05/25/24
 Life table analysis
67

Calculates a failure rate for each month of use.

A cumulative failure rate can then compare methods

for any specific length of exposure.

05/25/24
Failure Rates During the 1st Year of Use
Failure Rates During the 1st Year of Use
 Hormonal CCs
Metabolic Effects
Ischemic Heart Disease

Past studies - IHD and stroke were the

major causes of death attributed to OCs

(with the high dose Ocs)

It’s now known that age and smoking

are the principal determinants of risk

 Hormonal CCs
Metabolic Effects
Ischemic Heart Disease
Recent studies

 After adjusting for age, illness, smoking, BMI, and

socio-demographic factors, risk for MI was not
increased by OC use

 Past use of OCs does not increase risk for subsequent MI

(Practice Committee of American Society for Reproductive Medicine 2008)

 Hormonal CCs
Ischemic Heart
Disease
 Hormonal CCs
Metabolic Effects- Ischemic Stroke –
 WHO (1996)- Low-dose OCs - no increase
risk for either type of stroke
 Higher-dose OCs did have measurable risk

 In 2002 (STROKE)– RATIO study- showed a

2.2 fold higher risk for ischemic stroke with

OCP containing less than 50 ug EE
 Hormonal CCs
Metabolic Effects
Stroke - recent studies
Conclusion - risk is primarily determined

by predisposing conditions but can be

magnified by OC use
 Hormonal CCs
Neoplasia- Endometrial Cancer
OCP use is associated with lower risk of
endometrial CA
2yrs  ↓ risk by 40%

> 4yrs  ↓ risk by 60%

Benefit continues for at least 15 years

from last use !!!
 Hormonal CCs
Neoplasia- Ovarian Cancer
 OCP decrease the risk for ovarian CA
 Most probably via the protective effect of the
progesteron
 3-4yrs  ↓ risk by 50%

 > 10yrs  ↓ risk by 80%

 Benefit continues for at least 15 years from last

use !!!
 Hormonal CCs
Neoplasia- Cervical Cancer
There may be a weak association ???

Risk factors for Cx Ca ….

Sexual Exposure to
intercourse HPV

OCs use   ↓ Barrier methodes

 Hormonal CCs
Neoplasia- Breast Cancer
 Large volume of conflicting literature

 Generally, very small increase risk in current OC users under

35 yo, RR-1.24(Practice Committee of American Society for

Reproductive Medicine 2008)

 Current use
(Lancet-1996) Discontinuation

RR 1.24 1-4 yrs  RR 1.16

5-9 yrs  RR 1.07
> 10 yrs  RR 1.0
 Hormonal CCs
Neoplasia
Breast Cancer
 Breast CA diagnosed in OCP user was less advanced

 No increased risk in the 35-64 yo who were past users

(Kahlenborn et al 2006, Floger et al 2007)

For the present, the best

information available is
reassuring that there is little
or no direct association
 Hormonal CCs
Neoplasia
Liver Tumors
Association to liver adenomas

 Risk is related to prolonged use

 Usually regress when OC use is

discontinued
Newer low-dose OCs pose less risk

M/P no association to liver cancer

 Hormonal CCs
Neoplasia- Colon Cancer
Growing evidence of protective effect

 37% reduction in colon cancer

 34% reduction in rectal cancer

IUD
 IUD
2 Types :
Copper IUD
approved for up to 10 (7) years of
continuous use
 IUD
2 Types
Levonorgestrel-releasing IUD (Mirena)
approved for 5 years of use (52 mg)
Both provide safe, long-term CC with
effectiveness ~ to
tubal sterilization
 IUD
85

Jaydess- Levonorgestral- releasing IUD (13.5

mg), for up to 3 yr. (new release)

05/25/24
 IUD
Mechanism of action
Biologic Foam
Sterile inflammatory response to the
foreign body (cytotoxic cytokines, PGs)
Failure of sperm to reach the ovum

Inflammatory response to prevent

implantation
Non Contraceptive Benefits
Background
 Non-hormonal Methods
Fertility Awareness
Eficacy
Sperm may survive 5 to 7 days in the
female genital tract
Even a week's abstinence around the
time of actual ovulation offers no
guarantee against pregnancy !!!
PI – perfect use 2-9%, typical use up to
25% !!!
 Non-hormonal Methods
Coitus Interruptus
Withdrawal of penis before ejaculation

A very important means of fertility

control in many countries
Pregnancy has occurred from
ejaculation on the female
external genitalia !!
 Non-hormonal Methods
Breastfeeding
Lactation Amenorrhea
PRL ↑  GnRH ↓  GT ↓  Ovulation is
suppressed
Duration of suppression is variable:

 Frequency of nursing

 Length of time since birth

 The mother's nutritional status

 Non-hormonal Methods
Breastfeeding
Time - ovulation eventually returns but is

unlikely before 6 months, especially if

 The woman is fully breastfeeding

 No supplemental foods given to

the infant
 Non-hormonal Methods
Breastfeeding
Frequency

 Intervals ≤ 4h during the day and 6h at night

 Supplemental feeding ≤ 5-10% of the total amount of

feeding
 Non-hormonal Methods
Fertility Awareness
Mucous Method
The woman attempts to feel the cervical
mucus with her fingers
 E influence  quantity and elasticity ↑ progressively
until [peak]
 P influence  scant and dry
until onset of the next menses
 Non-hormonal Methods
Fertility Awareness
Symptothermal Method
The 1st day of abstinence is predicted
either from the
 Calendar, by subtracting 21 from
cycle length or…
 1st day mucus is detected
 Non-hormonal Methods
Fertility Awareness
Symptothermal Method
The end of the fertile period is predicted
by use of basal body temperature
Temp’ - every morning

Intercourse may be resumed

3 days after the thermal shift
(the rise in body t’ that signals that the
CL is producing P)
 Non-hormonal Methods
Vaginal Spermicides
Nonoxynol-9
Less effective than condoms /
diaphragms
Higher rates of genital lesions  may ↑
the risk for STDs and HIV
Toxic to the lactobacilli.
Regular use  ↑ vaginal
colonization with the E. coli
may predispose to bacteriuria after
intercourse
 Non-hormonal Methods
Barrier Methods
Condom - male
In the 1700s, condoms made of animal
intestine were used by the aristocracy of
Europe
Condoms were not widely
available until the discovery
of rubber in the 1840
 Non-hormonal Methods
Barrier Methods
Condom - male
Condoms lubricated with the spermicide
nonoxynol-9 are more effective
Risk breakage is about 3%
 Related to friction
 Use of lubricants may reduce
the risk
 Non-hormonal Methods
Barrier Methods
Condom - male
Barrier methods reduce the risk of STDs
Chlamydia, HSV-2, HIV and HBV do not
penetrate latex condoms !!
Nonoxynol-9 should not be
used with condoms for HIV
protection because it has been
associated with genital lesions
 Non-hormonal Methods
Barrier Methods
Condom - male
60-80% reduction in cervical neoplasia

Presumed mechanism  reduced

transmission of human HPV
 Non-hormonal Methods
Barrier Methods
Diaphragm
A circular spring covered with fine latex
rubber
 Non-hormonal Methods
Barrier Methods
Diaphragm
The practitioner must
 Fit the diaphragm for the patient
 Instruct her in its insertion and
 Verify by examination that she can insert it correctly to
cover the cervix and upper vagina

Spermicide is always prescribed

 Non-hormonal Methods
Barrier Methods
Diaphragm
The diaphragm should open easily in
the vagina and fill the fornices
without pressure
The largest diaphragm that fits
comfortably should be selected
A size 65, 70, or 75mm diaphragm
will fit most women
 Non-hormonal Methods
Barrier Methods
Diaphragm
Insertion - several hours before
intercourse
If intercourse is repeated, additional
spermicidal jelly should be inserted
into the vagina without removing the
diaphragm
Removal - at least 6 hours after
intercourse
 Non-hormonal Methods
Barrier Methods
Diaphragm
Prolonged use  ↑ risk of bladder
infections
Risk increases with no. of days the
diaphragm is used in a week
IUD
 IUD
2 Types :
Copper IUD
approved for up to 10 (7) years of
continuous use
 IUD
2 Types
Levonorgestrel-releasing IUD (Mirena)
approved for 5 years of use (52 mg)
Both provide safe, long-term CC with
effectiveness ~ to
tubal sterilization
 IUD
110

Jaydess- Levonorgestral- releasing IUD (13.5

mg), for up to 3 yr. (new release)

05/25/24
 IUD
Mechanism of action
Biologic Foam
Sterile inflammatory response to the
foreign body (cytotoxic cytokines, PGs)
Failure of sperm to reach the ovum

Inflammatory response to prevent

implantation
 IUD
Mechanism of action
Levonogestrel Copper
• Potent progesterone • Release a small
• Endometrial atrophy amount of the metal
• Thicken cervical mucus • Greater inflammatory
• Inflammatory response response
• Blood levels sufficient
to block ovulation in
15%
• Bleeding can be
reduced
by 90%
 IUD
Effectiveness

PI < than 0.2 per 100

woman-years
 IUD
Effectiveness
All IUDs together in first year:
Failure rate < 1:100 WY
Expulsion rate - 5%
cramping, vag’ discharge, uterine bleeding,
nothing
Removal rate – 15%
mainly for bleeding and pain
With increasing duration of use and age,
failure and removal rates decrease
 IUD
Benefits
Protect against EP
Levonogestrel - reduces menstrual
bleeding and cramping
 Tx of menorrhagia
 ↓ Risk of endometrial cancer
 Improvement in symptoms of endometriosis
 IUD
Risks - PID
WHO study
PID increased only during the first 3 wks
after insertion (x6)
Thereafter, rate of diagnosis was the
same as in the general population
(about 1.6 / 1,000 / Yr)
 IUD
Risks - PID
WHO study
Exposure to STD pathogens is a more
important determinant than is wearing
an IUD
Married women or woman who
had only 1 sexual partner in the
past 6 m had no increase in PID
 IUD
Risks – PID
Actinomycosis
PID with actinomycosis has been
reported only in women wearing an IUD
Risk ↑ with duration of use
(plastic devices >> copper IUDs)
Tx - removal of IUD + oral
penicillin
 IUD
Risks – PID
Management
Antibiotic therapy
IUD Removal is not necessary unless
symptoms do not improve within 72
hours of tx
Pelvic abscess should be ruled
out by US
 IUD
Risks – EP
IUD have an 80-90% reduction in the
risk of EP (compared to no CC)
If pregnancy occurs  EP in ~ 5%
Women using OCs have a
similar reduction (90%)
No ↑ in risk with ↑
duration of use
 IUD
Intra uterine Pregnancy
Visible strings
IUD should be removed ASAP to prevent
Septic abortion
Premature rupture of the
membranes
Premature birth
 IUD
Intra uterine Pregnancy
No visible strings
US  if IUD present, 3 options:
1. Therapeutic abortion
2. US-guided removal of
IUD
1. Continuation of the
pregnancy
 IUD
Intra uterine Pregnancy
Pregnancy + IUD
Patient must be warned of the symptoms
of intrauterine infection
Fever, Abdominal cramping,
Bleeding
Signs of infection
 High-dose IV Abx and
 Prompt pregnancy evacuation
 IUD
CI
Pregnancy
Puerperal sepsis
PID or STD current / within past 3m
Endometrial / cervical cancer
Undiagnosed genital bleeding
Uterine anomalies
Fibroid that distorts endometrial cavity
Copper allergy, Wilson's dis’ – copper IUD
STERILIZATION

“The most popular type of

contraception world wide!”
 Sterilization - Female
Methods
Tubal sterilization at the time of
laparotomy for a CS or other abdominal
operation
Laparoscopy
Hysteroscopy
Laparotomy
Laparotomy
Laparoscop y - bipolar
electrocoagulation
Laparoscopy
Falope ring

Producing ischemic
necrosis
Laparoscopy
Hulka clip
Laparoscopy
Filshie clip
 Sterilization - Female
Lap techniques – disadvantages
Ring and clips cannot be applied if the
tube is thickened (previous salpingitis)
Pain during the first several hours after
Falope ring application
Misapplication of ring / clips
 Sterilization - Female
Lap techniques – disadvantages
Elctro’ failure
 Tuboperitoneal fistula  EP > 50%
 Inadequate electrical energy - a thin band of
fallopian tube with intact lumen remains 
allows intrauterine pregnancy to occur
 Sterilization - Female
Hysteroscopy
In 2002, the FDA approved a new
hysteroscopic method of permanent
birth control: the Essure system
 Sterilization - Female
Eficacy
 Sterilization - Female
Eficacy
Safe procedures
Tubal ligation is associated with reduced
risk for ovarian cancer that persists for
as long as 20 years after surgery !!!
 Sterilization - Female
Failure
Usually during the 1st m after procedure
(Pregnancy+ at the time of sterilization)
CC should be continued until surgery
Pegnancy test should be performed on
the day of surgery
 Sterilization - Female
Late Sequelae
“Post–tubal ligation syndrome”
Increased menstrual irregularity and pain
CREST study found no evidence to
support the syndrome (90s)
 140

Thank you!!

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141

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142

05/25/24
 Background
Most of reproductive years are spent

trying to avoid pregnancy

Effective control of reproduction is

essential to a woman's ability to

accomplish her individual goals
 Background
At its present rate, the population of the

world will double in ~ 50 years, and that

of many of the poorer countries of the

world will double in about 20 years !!!

 Background
For the individual and for the planet,

reproductive health requires careful use

of effective means to prevent both

pregnancy and sexually transmitted

diseases (STDs)
 Background
7.4% of sexually active couples do not use

contraception

Each year, 2 of every 100 women aged 15

to 44 years have an induced abortion !

 Background
 Young women are much

more likely to experience

unplanned pregnancy
 They are more fertile

 They are more likely to have

intercourse without CC
Background
Failure Rates During the 1st Year of Use
Failure Rates During the 1st Year of Use
 Background
Safety
• All of the methods are safer than the
alternative (pregnancy with birth)
• Possible exception - oral contraceptive
(OC) use by women older than 35 years of

age who smoke

 Background
Safety
Most methods provide noncontraceptive
health benefits in addition to contraception
• Oral contraceptives reduce the risk of ovarian and
endometrial cancer and ectopic pregnancy
• Barrier methods provide some protection against
STDs, cervical cancer, and tubal infertility
 Background
Safety
% of women experiencing

an accidental pregnancy,

in the first 2 years of use,

according to method
Background
 Non-hormonal Methods
Coitus Interruptus
Withdrawal of penis before ejaculation

A very important means of fertility

control in many countries
Pregnancy has occurred from
ejaculation on the female
external genitalia !!
 Non-hormonal Methods
Coitus Interruptus
Reduce transmission of HIV in couples
who are mutually monogamous
Eficacy (PI)

 4 with perfect use

 27 with typical use

 Non-hormonal Methods
Breastfeeding
Lactation Amenorrhea
PRL ↑  GnRH ↓  GT ↓  Ovulation is
suppressed
Duration of suppression is variable:

 Frequency of nursing

 Length of time since birth

 The mother's nutritional status

 Non-hormonal Methods
Breastfeeding
Time - ovulation eventually returns but is

unlikely before 6 months, especially if

 The woman is fully breastfeeding

 No supplemental foods given to

the infant
 Non-hormonal Methods
Breastfeeding
Frequency

 Intervals ≤ 4h during the day and 6h at night

 Supplemental feeding ≤ 5-10% of the total amount of

feeding
 Non-hormonal Methods
Fertility Awareness
Mucous Method
The woman attempts to feel the cervical
mucus with her fingers
 E influence  quantity and elasticity ↑ progressively
until [peak]
 P influence  scant and dry
until onset of the next menses
 Non-hormonal Methods
Fertility Awareness
Symptothermal Method
The 1st day of abstinence is predicted
either from the
 Calendar, by subtracting 21 from
cycle length or…
 1st day mucus is detected
 Non-hormonal Methods
Fertility Awareness
Symptothermal Method
The end of the fertile period is predicted
by use of basal body temperature
Temp’ - every morning

Intercourse may be resumed

3 days after the thermal shift
(the rise in body t’ that signals that the
CL is producing P)
 Non-hormonal Methods
Fertility Awareness
Eficacy
Sperm may survive 5 to 7 days in the
female genital tract
Even a week's abstinence around the
time of actual ovulation offers no
guarantee against pregnancy !!!
PI – perfect use 2-9%, typical use up to
25% !!!
 Non-hormonal Methods
Vaginal Spermicides
Nonoxynol-9
Less effective than condoms /
diaphragms
Higher rates of genital lesions  may ↑
the risk for STDs and HIV
Toxic to the lactobacilli.
Regular use  ↑ vaginal
colonization with the E. coli
may predispose to bacteriuria after
intercourse
 Non-hormonal Methods
Barrier Methods
Condom - male
In the 1700s, condoms made of animal
intestine were used by the aristocracy of
Europe
Condoms were not widely
available until the discovery
of rubber in the 1840
 Non-hormonal Methods
Barrier Methods
Condom - male
Condoms lubricated with the spermicide
nonoxynol-9 are more effective
Risk breakage is about 3%
 Related to friction
 Use of lubricants may reduce
the risk
 Non-hormonal Methods
Barrier Methods
Condom - male
Barrier methods reduce the risk of STDs
Chlamydia, HSV-2, HIV and HBV do not
penetrate latex condoms !!
Nonoxynol-9 should not be
used with condoms for HIV
protection because it has been
associated with genital lesions
 Non-hormonal Methods
Barrier Methods
Condom - male
60-80% reduction in cervical neoplasia

Presumed mechanism  reduced

transmission of human HPV
 Non-hormonal Methods
Barrier Methods
Diaphragm
A circular spring covered with fine latex
rubber
 Non-hormonal Methods
Barrier Methods
Diaphragm
The practitioner must
 Fit the diaphragm for the patient
 Instruct her in its insertion and
 Verify by examination that she can insert it correctly to
cover the cervix and upper vagina

Spermicide is always prescribed

 Non-hormonal Methods
Barrier Methods
Diaphragm
The diaphragm should open easily in
the vagina and fill the fornices
without pressure
The largest diaphragm that fits
comfortably should be selected
A size 65, 70, or 75mm diaphragm
will fit most women
 Non-hormonal Methods
Barrier Methods
Diaphragm
Insertion - several hours before
intercourse
If intercourse is repeated, additional
spermicidal jelly should be inserted
into the vagina without removing the
diaphragm
Removal - at least 6 hours after
intercourse
 Non-hormonal Methods
Barrier Methods
Diaphragm
Prolonged use  ↑ risk of bladder
infections
Risk increases with no. of days the
diaphragm is used in a week
IUD
 IUD
2 Types
Copper IUD
approved for up to 10 years of continuous
use
 IUD
2 Types
levonorgestrel-releasing IUD (Mirena)
approved for 5 years of use
Both provide safe, long-term CC with
effectiveness ~ to
tubal sterilization
 IUD
Mechanism of action
Biologic Foam
Sterile inflammatory response to the
foreign body (cytotoxic cytokines, PGs)
Failure of sperm to reach the ovum

Inflammatory response also prevent

implantation
 IUD
Mechanism of action

Levonogestrel Copper
• Potent progesterone • Release a small
• Endometrial atrophy amount of the
• Thicken cervical metal
mucus • Greater
• Inflammatory inflammatory
response response
• Blood levels
sufficient
to block ovulation in
15%
 IUD
Effectiveness

PI < than 0.2 per 100

woman-years
 IUD
Effectiveness
All IUDs together in first year:
Failure rate < 1:100 WY
Expulsion rate - 5%
cramping, vag’ discharge, uterine bleeding,
nothing
Removal rate – 15%
mainly for bleeding and pain
With increasing duration of use and age,
failure and removal rates decrease
 IUD
Benefits
Protect against EP
Levonogestrel - reduces menstrual
bleeding and cramping
 Tx of menorrhagia
 ↓ Risk of endometrial cancer
 Improvement in symptoms of endometriosis
 IUD
Risks - PID
WHO study
PID increased only during the first 3 wks
after insertion (x6)
Thereafter, rate of diagnosis was the
same as in the general population
(about 1.6 / 1,000 / Yr)
 IUD
Risks - PID
WHO study
Exposure to STD pathogens is a more
important determinant than is wearing
an IUD
Married women or woman who
had only 1 sexual partner in the
past 6 m had no increase in PID
 IUD
Risks – PID
Actinomycosis
PID with actinomycosis has been
reported only in women wearing an IUD
Risk ↑ with duration of use
(plastic devices >> copper IUDs)
Tx - removal of IUD + oral
penicillin
 IUD
Risks – PID
Management
Antibiotic therapy
IUD Removal is not necessary unless
symptoms do not improve within 72
hours of tx
Pelvic abscess should be ruled
out by US
 IUD
Risks – EP
IUD have an 80-90% reduction in the
risk of EP (compared to no CC)
If pregnancy occurs  EP in ~ 5%
Women using OCs have a
similar reduction (90%)
No ↑ in risk with ↑
duration of use
 IUD
Intra uterine Pregnancy
Visible strings
IUD should be removed ASAP to prevent
Septic abortion
Premature rupture of the
membranes
Premature birth
 IUD
Intra uterine Pregnancy
No visible strings
US  if IUD present, 3 options:
1. Therapeutic abortion
2. US-guided removal of IUD
3. Continuation of the
pregnancy
 IUD
Intra uterine Pregnancy
Pregnancy + IUD
Patient must be warned of the symptoms
of intrauterine infection
Fever, Abdominal cramping,
Bleeding
Signs of infection
 High-dose IV Abx and
 Prompt pregnancy evacuation
 IUD
CI
Pregnancy
Puerperal sepsis
PID or STD current / within past 3m
Endometrial / cervical cancer
Undiagnosed genital bleeding
Uterine anomalies
Fibroid that distorts endometrial cavity
Copper allergy, Wilson's dis’ – copper IUD
STERILIZATION

“The most popular type of

contraception world wide!”
 Sterilization - Female
Methods
Tubal sterilization at the time of
laparotomy for a CS or other abdominal
operation
Laparoscopy
Hysteroscopy
Laparotomy
Laparotomy
Laparoscopy
bipolar electrocoagulation
Laparoscopy
Falope ring

Producing ischemic
necrosis
Laparoscopy
Hulka clip
Laparoscopy
Filshie clip
 Sterilization - Female
Lap techniques – disadvantages
Ring and clips cannot be applied if the
tube is thickened (previous salpingitis)
Pain during the first several hours after
Falope ring application
Misapplication of ring / clips
 Sterilization - Female
Lap techniques – disadvantages
Elctro’ failure
 Tuboperitoneal fistula  EP > 50%
 Inadequate electrical energy - a thin band of
fallopian tube with intact lumen remains 
allows intrauterine pregnancy to occur
 Sterilization - Female
Hysteroscopy
In 2002, the FDA approved a new
hysteroscopic method of permanent
birth control: the Essure system
 Sterilization - Female
Eficacy
 Sterilization - Female
Eficacy
Safe procedures
Tubal ligation is associated with reduced
risk for ovarian cancer that persists for
as long as 20 years after surgery !!!
 Sterilization - Female
Failure
Usually during the 1st m after procedure
(Pregnancy+ at the time of sterilization)
CC should be continued until surgery
Pegnancy test should be performed on
the day of surgery
 Sterilization - Female
Late Sequelae
“Post–tubal ligation syndrome”
Increased menstrual irregularity and pain
CREST study found no evidence to
support the syndrome (90s)
207

05/25/24
 208

Thank you

05/25/24
 Hormonal CCs
Sexuality
Normally - ↑ in sexual activity at the time
of ovulation
Not present in women on OCs
 Hormonal CCs
Teratogenicity
No increase in overall risk for

 Malformation

 Congenital heart defects

 Limb reduction defects

HD-E taken in pregnancy can induce vaginal

Ca in exposed female offspring in utero

 Hormonal CCs
Side effects
Common side effects – nausea, breast

tenderness, weight gain

Less common with current LD OCs

Usually resolve after the first few cycles

 Hormonal CCs
Side effects
Breakthrough bleeding and spotting
Common at 1st months of use

Generally improve with time

LD OCs > HD OCs

 Hormonal CCs
Side effects
Breast tenderness
Related to E

OCs that contain high potency progestin

(A activity)  fewer breast symptoms
 Hormonal CCs
Side effects
Nausea
Related to E
 Hormonal CCs
Side effects
Weight gain
Related to P

Water retention

May benefit from a change to the

drospirenone / EE pill
 Hormonal CCs
Transdermal
Combinations of potent P with EE

Provides constant levels of steroids to the

body
The patch- 20g of EE, 150g of

norelgestromin daily, one patch weekly for 3

weeks
Greater convenience  improves compliance
 Hormonal CCs
Transdermal - Patch
OrthoEvra
 However- the mean serum EE levels are higher

compare with the combined OCP (30ug of EE)

 Greater convenience 

 improves compliance

 More breakthrough

bleeding/spotting in
1st cycles
 Hormonal CCs
Transdermal Patch
OrthoEvra
Similar side effects as OCs

Obese - ↑ pregnancy
rate
 Hormonal CCs
NuvaRing

 A combined estrogen/progesteron contraceptive

vaginal ring with low mean serum EE levels.

 Release of 15 g of EE and 120 g of etonogestrel daily

 outer diameter - 54mm

 Cross section - 4mm

 Use for 3 weeks+ 1 week free

 Hormonal CCs
NuvaRing
S/E- headaches, leukorrhea and vaginitis

Failure rate- 0.65 per 100 woman years

Fewer days of irregular bleeding/spotting

than women taking OCs
Can be removed during
coitus. Reinsertion within
3 hours
 Hormonal CCs
Depo Provera
A single 150mg IM dose  ovulation
suppression for 14 wks
2004- FDA approved depo-subQ-provera,
104 mg for s/c use
Injected every 3 months

Highly effective
 Hormonal CCs
Depo
Provera
 Hormonal CCs
Depo Provera, S/E:
Breakthrough bleeding in new users

Return to fertility may be delayed

Median time to ovulation after last

injection – 10 months.
 70% conceive within 1 yr

 90% conceive within 2 yrs

 Hormonal CCs
Depo Provera
Safety (long use)
DMPA  E production↓  bone loss

Adolescents are of especial concern

FDA “black box warning”:

DMPA treatment be limited to 2 years at a time
unless the patient has no other good options for
contraception
 Hormonal CCs
Emergency CC
 Hormonal CCs
Emergency CC
1. High dose E
Taken within 72 hours of coitus
5 mg of EE daily for 5 days
Possible mechanisms
 Altered tubal motility
 Interference with CL function
 Alteration of the endometrium
Pregnancy rate - 0.15%
 Hormonal CCs
Emergency CC
2. E+P - Yuzpe
EE 100 ug and levonorgestrel 0.5 mg in 2
doses 12 hr apart ,up to 72 hr after
intercourse. (Preven)
Effective in inhibition or delay of ovulation
Pregnancy rate - 1.8%, but it is 1.2% if
treatment is started within 12 hours of
intercourse
Nausea and vomiting are common with both
regimens
 Hormonal CCs
Emergency CC
3. Plan B - Levonorgestrel Alone
0.75 mg initially followed by another 0.75
mg 12 hours later- up to 72 hr after
intercourse
1.5 mg levonorgestrel in one dose up to 72
after intercourse.
The emergency CC method
of choice at present
Less nausea and vomiting
 Hormonal CCs
Emergency CC
Plan B - Levonorgestrel Alone
 Hormonal CCs
Emergency CC
4. Copper IUD
Insertion of a copper IUD within 7 days
Appears to be even more effective than
steroids
Thank You
 Background
Most of reproductive years are spent

trying to avoid pregnancy

Effective control of reproduction is

essential to a woman's ability to

accomplish her individual goals
 Background
At its present rate, the population of the

world will double in ~ 50 years, and that

of many of the poorer countries of the

world will double in about 20 years !!!

 Background
For the individual and for the planet,

reproductive health requires careful use

of effective means to prevent both

pregnancy and sexually transmitted

diseases (STDs)
 Background
7.4% of sexually active couples do not use

contraception

Each year, 2 of every 100 women aged 15

to 44 years have an induced abortion !

 Background
 Young women are much

more likely to experience

unplanned pregnancy
 They are more fertile

 They are more likely to have

intercourse without CC
Background
 Background
Eficacy
 Background
Eficacy
 Background
Safety
• All of the methods are safer than the
alternative (pregnancy with birth)
• Possible exception - oral contraceptive
(OC) use by women older than 35 years of

age who smoke

 Background
Safety
Most methods provide noncontraceptive
health benefits in addition to contraception
• Oral contraceptives reduce the risk of ovarian and
endometrial cancer and ectopic pregnancy
• Barrier methods provide some protection against
STDs, cervical cancer, and tubal infertility
 Background
Safety
% of women experiencing

an accidental pregnancy,

in the first 2 years of use,

according to method
Background
 Non-hormonal Methods
Coitus Interruptus
Withdrawal of penis before ejaculation

A very important means of fertility

control in many countries
Pregnancy has occurred from
ejaculation on the female
external genitalia !!
 Non-hormonal Methods
Coitus Interruptus
Reduce transmission of HIV in couples
who are mutually monogamous
Eficacy (PI)

 4 with perfect use

 27 with typical use

 Non-hormonal Methods
Breastfeeding
Lactation Amenorrhea
PRL ↑  GnRH ↓  GT ↓  Ovulation is
suppressed
Duration of suppression is variable:

 Frequency of nursing

 Length of time since birth

 The mother's nutritional status

 Non-hormonal Methods
Breastfeeding
Time - ovulation eventually returns but is

unlikely before 6 months, especially if

 The woman is fully breastfeeding

 No supplemental foods given to

the infant
 Non-hormonal Methods
Breastfeeding
Frequency

 Intervals ≤ 4h during the day and 6h at night

 Supplemental feeding ≤ 5-10% of the total amount of

feeding
 Non-hormonal Methods
Fertility Awareness
Mucous Method
The woman attempts to feel the cervical
mucus with her fingers
 E influence  quantity and elasticity ↑ progressively
until [peak]
 P influence  scant and dry
until onset of the next menses
 Non-hormonal Methods
Fertility Awareness
Symptothermal Method
The 1st day of abstinence is predicted
either from the
 Calendar, by subtracting 21 from
cycle length or…
 1st day mucus is detected
 Non-hormonal Methods
Fertility Awareness
Symptothermal Method
The end of the fertile period is predicted
by use of basal body temperature
Temp’ - every morning

Intercourse may be resumed

3 days after the thermal shift
(the rise in body t’ that signals that the
CL is producing P)
 Non-hormonal Methods
Fertility Awareness
Eficacy
Sperm may survive 5 to 7 days in the
female genital tract
Even a week's abstinence around the
time of actual ovulation offers no
guarantee against pregnancy !!!
PI – perfect use 2-9%, typical use up to
25% !!!
 Non-hormonal Methods
Vaginal Spermicides
Nonoxynol-9
Less effective than condoms /
diaphragms
Higher rates of genital lesions  may ↑
the risk for STDs and HIV
Toxic to the lactobacilli.
Regular use  ↑ vaginal
colonization with the E. coli
may predispose to bacteriuria after
intercourse
 Non-hormonal Methods
Barrier Methods
Condom - male
In the 1700s, condoms made of animal
intestine were used by the aristocracy of
Europe
Condoms were not widely
available until the discovery
of rubber in the 1840
 Non-hormonal Methods
Barrier Methods
Condom - male
Condoms lubricated with the spermicide
nonoxynol-9 are more effective
Risk breakage is about 3%
 Related to friction
 Use of lubricants may reduce
the risk
 Non-hormonal Methods
Barrier Methods
Condom - male
Barrier methods reduce the risk of STDs
Chlamydia, HSV-2, HIV and HBV do not
penetrate latex condoms !!
Nonoxynol-9 should not be
used with condoms for HIV
protection because it has been
associated with genital lesions
 Non-hormonal Methods
Barrier Methods
Condom - male
60-80% reduction in cervical neoplasia

Presumed mechanism  reduced

transmission of human HPV
 Non-hormonal Methods
Barrier Methods
Diaphragm
A circular spring covered with fine latex
rubber
 Non-hormonal Methods
Barrier Methods
Diaphragm
The practitioner must
 Fit the diaphragm for the patient
 Instruct her in its insertion and
 Verify by examination that she can insert it correctly to
cover the cervix and upper vagina

Spermicide is always prescribed

 Non-hormonal Methods
Barrier Methods
Diaphragm
The diaphragm should open easily in
the vagina and fill the fornices
without pressure
The largest diaphragm that fits
comfortably should be selected
A size 65, 70, or 75mm diaphragm
will fit most women
 Non-hormonal Methods
Barrier Methods
Diaphragm
Insertion - several hours before
intercourse
If intercourse is repeated, additional
spermicidal jelly should be inserted
into the vagina without removing the
diaphragm
Removal - at least 6 hours after
intercourse
 Non-hormonal Methods
Barrier Methods
Diaphragm
Prolonged use  ↑ risk of bladder
infections
Risk increases with no. of days the
diaphragm is used in a week
IUD
 IUD
2 Types
Copper IUD
approved for up to 10 years of continuous
use
 IUD
2 Types
levonorgestrel-releasing IUD (Mirena)
approved for 5 years of use
Both provide safe, long-term CC with
effectiveness ~ to
tubal sterilization
 IUD
Mechanism of action
Biologic Foam
Sterile inflammatory response to the
foreign body (cytotoxic cytokines, PGs)
Failure of sperm to reach the ovum

Inflammatory response also prevent

implantation
 IUD
Mechanism of action
Levonogestrel Copper
• Potent progesterone • Release a small
• Endometrial atrophy amount of the metal
• Thicken cervical mucus • Greater inflammatory
• Inflammatory response response
• Blood levels sufficient
to block ovulation in
15%
• Bleeding can be
reduced
by 90%
 IUD
Effectiveness

PI < than 0.2 per 100

woman-years
 IUD
Effectiveness
All IUDs together in first year:
Failure rate < 1:100 WY
Expulsion rate - 5%
cramping, vag’ discharge, uterine bleeding,
nothing
Removal rate – 15%
mainly for bleeding and pain
With increasing duration of use and age,
failure and removal rates decrease
 IUD
Benefits
Protect against EP
Levonogestrel - reduces menstrual
bleeding and cramping
 Tx of menorrhagia
 ↓ Risk of endometrial cancer
 Improvement in symptoms of endometriosis
 IUD
Risks - PID
WHO study
PID increased only during the first 3 wks
after insertion (x6)
Thereafter, rate of diagnosis was the
same as in the general population
(about 1.6 / 1,000 / Yr)
 IUD
Risks - PID
WHO study
Exposure to STD pathogens is a more
important determinant than is wearing
an IUD
Married women or woman who
had only 1 sexual partner in the
past 6 m had no increase in PID
 IUD
Risks – PID
Actinomycosis
PID with actinomycosis has been
reported only in women wearing an IUD
Risk ↑ with duration of use
(plastic devices >> copper IUDs)
Tx - removal of IUD + oral
penicillin
 IUD
Risks – PID
Management
Antibiotic therapy
IUD Removal is not necessary unless
symptoms do not improve within 72
hours of tx
Pelvic abscess should be ruled
out by US
 IUD
Risks – EP
IUD have an 80-90% reduction in the
risk of EP (compared to no CC)
If pregnancy occurs  EP in ~ 5%
Women using OCs have a
similar reduction (90%)
No ↑ in risk with ↑
duration of use
 IUD
Intra uterine Pregnancy
Visible strings
IUD should be removed ASAP to prevent
Septic abortion
Premature rupture of the
membranes
Premature birth
 IUD
Intra uterine Pregnancy
No visible strings
US  if IUD present, 3 options:
1. Therapeutic abortion
2. US-guided removal of IUD
3. Continuation of the
pregnancy
 IUD
Intra uterine Pregnancy
Pregnancy + IUD
Patient must be warned of the symptoms
of intrauterine infection
Fever, Abdominal cramping,
Bleeding
Signs of infection
 High-dose IV Abx and
 Prompt pregnancy evacuation
 IUD
CI
Pregnancy
Puerperal sepsis
PID or STD current / within past 3m
Endometrial / cervical cancer
Undiagnosed genital bleeding
Uterine anomalies
Fibroid that distorts endometrial cavity
Copper allergy, Wilson's dis’ – copper IUD
STERILIZATION

“The most popular type of

contraception world wide!”
 Sterilization - Female
Methods
Tubal sterilization at the time of
laparotomy for a CS or other abdominal
operation
Laparoscopy
Hysteroscopy
Laparotomy
Laparotomy
Laparoscopy
bipolar electrocoagulation
Laparoscopy
Falope ring

Producing ischemic
necrosis
Laparoscopy
Hulka clip
Laparoscopy
Filshie clip
 Sterilization - Female
Lap techniques – disadvantages
Ring and clips cannot be applied if the
tube is thickened (previous salpingitis)
Pain during the first several hours after
Falope ring application
Misapplication of ring / clips
 Sterilization - Female
Lap techniques – disadvantages
Elctro’ failure
 Tuboperitoneal fistula  EP > 50%
 Inadequate electrical energy - a thin band of
fallopian tube with intact lumen remains 
allows intrauterine pregnancy to occur
 Sterilization - Female
Hysteroscopy
In 2002, the FDA approved a new
hysteroscopic method of permanent
birth control: the Essure system
 Sterilization - Female
Eficacy
 Sterilization - Female
Eficacy
Safe procedures
Tubal ligation is associated with reduced
risk for ovarian cancer that persists for
as long as 20 years after surgery !!!
 Sterilization - Female
Failure
Usually during the 1st m after procedure
(Pregnancy+ at the time of sterilization)
CC should be continued until surgery
Pegnancy test should be performed on
the day of surgery
 Sterilization - Female
Late Sequelae
“Post–tubal ligation syndrome”
Increased menstrual irregularity and pain
CREST study found no evidence to
support the syndrome (90s)
 Background
Most of reproductive years are spent

trying to avoid pregnancy

Effective control of reproduction is

essential to a woman's ability to

accomplish her individual goals
 Background
At its present rate, the population of the

world will double in ~ 50 years, and that

of many of the poorer countries of the

world will double in about 20 years !!!

 Background
For the individual and for the planet,

reproductive health requires careful use

of effective means to prevent both

pregnancy and sexually transmitted

diseases (STDs)
 Background
7.4% of sexually active couples do not use

contraception

Each year, 2 of every 100 women aged 15

to 44 years have an induced abortion !

 Background
 Young women are much

more likely to experience

unplanned pregnancy
 They are more fertile

 They are more likely to have

intercourse without CC
Background
 Background
Eficacy
 Background
Eficacy
 Background
Safety
• All of the methods are safer than the
alternative (pregnancy with birth)
• Possible exception - oral contraceptive
(OC) use by women older than 35 years of

age who smoke

 Background
Safety
Most methods provide noncontraceptive
health benefits in addition to contraception
• Oral contraceptives reduce the risk of ovarian and
endometrial cancer and ectopic pregnancy
• Barrier methods provide some protection against
STDs, cervical cancer, and tubal infertility
 Background
Safety
% of women experiencing

an accidental pregnancy,

in the first 2 years of use,

according to method
Background
 Non-hormonal Methods
Coitus Interruptus
Withdrawal of penis before ejaculation

A very important means of fertility

control in many countries
Pregnancy has occurred from
ejaculation on the female
external genitalia !!
 Non-hormonal Methods
Coitus Interruptus
Reduce transmission of HIV in couples
who are mutually monogamous
Eficacy (PI)

 4 with perfect use

 27 with typical use

 Non-hormonal Methods
Breastfeeding
Lactation Amenorrhea
PRL ↑  GnRH ↓  GT ↓  Ovulation is
suppressed
Duration of suppression is variable:

 Frequency of nursing

 Length of time since birth

 The mother's nutritional status

 Non-hormonal Methods
Breastfeeding
Time - ovulation eventually returns but is

unlikely before 6 months, especially if

 The woman is fully breastfeeding

 No supplemental foods given to

the infant
 Non-hormonal Methods
Breastfeeding
Frequency

 Intervals ≤ 4h during the day and 6h at night

 Supplemental feeding ≤ 5-10% of the total amount of

feeding
 Non-hormonal Methods
Fertility Awareness
Mucous Method
The woman attempts to feel the cervical
mucus with her fingers
 E influence  quantity and elasticity ↑ progressively
until [peak]
 P influence  scant and dry
until onset of the next menses
 Non-hormonal Methods
Fertility Awareness
Symptothermal Method
The 1st day of abstinence is predicted
either from the
 Calendar, by subtracting 21 from
cycle length or…
 1st day mucus is detected
 Non-hormonal Methods
Fertility Awareness
Symptothermal Method
The end of the fertile period is predicted
by use of basal body temperature
Temp’ - every morning

Intercourse may be resumed

3 days after the thermal shift
(the rise in body t’ that signals that the
CL is producing P)
 Non-hormonal Methods
Fertility Awareness
Eficacy
Sperm may survive 5 to 7 days in the
female genital tract
Even a week's abstinence around the
time of actual ovulation offers no
guarantee against pregnancy !!!
PI – perfect use 2-9%, typical use up to
25% !!!
 Non-hormonal Methods
Vaginal Spermicides
Nonoxynol-9
Less effective than condoms /
diaphragms
Higher rates of genital lesions  may ↑
the risk for STDs and HIV
Toxic to the lactobacilli.
Regular use  ↑ vaginal
colonization with the E. coli
may predispose to bacteriuria after
intercourse
 Non-hormonal Methods
Barrier Methods
Condom - male
In the 1700s, condoms made of animal
intestine were used by the aristocracy of
Europe
Condoms were not widely
available until the discovery
of rubber in the 1840
 Non-hormonal Methods
Barrier Methods
Condom - male
Condoms lubricated with the spermicide
nonoxynol-9 are more effective
Risk breakage is about 3%
 Related to friction
 Use of lubricants may reduce
the risk
 Non-hormonal Methods
Barrier Methods
Condom - male
Barrier methods reduce the risk of STDs
Chlamydia, HSV-2, HIV and HBV do not
penetrate latex condoms !!
Nonoxynol-9 should not be
used with condoms for HIV
protection because it has been
associated with genital lesions
 Non-hormonal Methods
Barrier Methods
Condom - male
60-80% reduction in cervical neoplasia

Presumed mechanism  reduced

transmission of human HPV
 Non-hormonal Methods
Barrier Methods
Diaphragm
A circular spring covered with fine latex
rubber
 Non-hormonal Methods
Barrier Methods
Diaphragm
The practitioner must
 Fit the diaphragm for the patient
 Instruct her in its insertion and
 Verify by examination that she can insert it correctly to
cover the cervix and upper vagina

Spermicide is always prescribed

 Non-hormonal Methods
Barrier Methods
Diaphragm
The diaphragm should open easily in
the vagina and fill the fornices
without pressure
The largest diaphragm that fits
comfortably should be selected
A size 65, 70, or 75mm diaphragm
will fit most women
 Non-hormonal Methods
Barrier Methods
Diaphragm
Insertion - several hours before
intercourse
If intercourse is repeated, additional
spermicidal jelly should be inserted
into the vagina without removing the
diaphragm
Removal - at least 6 hours after
intercourse
 Non-hormonal Methods
Barrier Methods
Diaphragm
Prolonged use  ↑ risk of bladder
infections
Risk increases with no. of days the
diaphragm is used in a week
IUD
 IUD
2 Types
Copper IUD
approved for up to 10 years of continuous
use
 IUD
2 Types
levonorgestrel-releasing IUD (Mirena)
approved for 5 years of use
Both provide safe, long-term CC with
effectiveness ~ to
tubal sterilization
 IUD
Mechanism of action
Biologic Foam
Sterile inflammatory response to the
foreign body (cytotoxic cytokines, PGs)
Failure of sperm to reach the ovum

Inflammatory response also prevent

implantation
 IUD
Mechanism of action

Levonogestrel Copper
• Potent progesterone • Release a small
• Endometrial atrophy amount of the
• Thicken cervical metal
mucus • Greater
• Inflammatory inflammatory
response response
• Blood levels
sufficient
to block ovulation in
15%
 IUD
Effectiveness

PI < than 0.2 per 100

woman-years
 IUD
Effectiveness
All IUDs together in first year:
Failure rate < 1:100 WY
Expulsion rate - 5%
cramping, vag’ discharge, uterine bleeding,
nothing
Removal rate – 15%
mainly for bleeding and pain
With increasing duration of use and age,
failure and removal rates decrease
 IUD
Benefits
Protect against EP
Levonogestrel - reduces menstrual
bleeding and cramping
 Tx of menorrhagia
 ↓ Risk of endometrial cancer
 Improvement in symptoms of endometriosis
 IUD
Risks - PID
WHO study
PID increased only during the first 3 wks
after insertion (x6)
Thereafter, rate of diagnosis was the
same as in the general population
(about 1.6 / 1,000 / Yr)
 IUD
Risks - PID
WHO study
Exposure to STD pathogens is a more
important determinant than is wearing
an IUD
Married women or woman who
had only 1 sexual partner in the
past 6 m had no increase in PID
 IUD
Risks – PID
Actinomycosis
PID with actinomycosis has been
reported only in women wearing an IUD
Risk ↑ with duration of use
(plastic devices >> copper IUDs)
Tx - removal of IUD + oral
penicillin
 IUD
Risks – PID
Management
Antibiotic therapy
IUD Removal is not necessary unless
symptoms do not improve within 72
hours of tx
Pelvic abscess should be ruled
out by US
 IUD
Risks – EP
IUD have an 80-90% reduction in the
risk of EP (compared to no CC)
If pregnancy occurs  EP in ~ 5%
Women using OCs have a
similar reduction (90%)
No ↑ in risk with ↑
duration of use
 IUD
Intra uterine Pregnancy
Visible strings
IUD should be removed ASAP to prevent
Septic abortion
Premature rupture of the
membranes
Premature birth
 IUD
Intra uterine Pregnancy
No visible strings
US  if IUD present, 3 options:
1. Therapeutic abortion
2. US-guided removal of IUD
3. Continuation of the
pregnancy
 IUD
Intra uterine Pregnancy
Pregnancy + IUD
Patient must be warned of the symptoms
of intrauterine infection
Fever, Abdominal cramping,
Bleeding
Signs of infection
 High-dose IV Abx and
 Prompt pregnancy evacuation
 IUD
CI
Pregnancy
Puerperal sepsis
PID or STD current / within past 3m
Endometrial / cervical cancer
Undiagnosed genital bleeding
Uterine anomalies
Fibroid that distorts endometrial cavity
Copper allergy, Wilson's dis’ – copper IUD
STERILIZATION

“The most popular type of

contraception world wide!”
 Sterilization - Female
Methods
Tubal sterilization at the time of
laparotomy for a CS or other abdominal
operation
Laparoscopy
Hysteroscopy
Laparotomy
Laparotomy
Laparoscopy
bipolar electrocoagulation
Laparoscopy
Falope ring

Producing ischemic
necrosis
Laparoscopy
Hulka clip
Laparoscopy
Filshie clip
 Sterilization - Female
Lap techniques – disadvantages
Ring and clips cannot be applied if the
tube is thickened (previous salpingitis)
Pain during the first several hours after
Falope ring application
Misapplication of ring / clips
 Sterilization - Female
Lap techniques – disadvantages
Elctro’ failure
 Tuboperitoneal fistula  EP > 50%
 Inadequate electrical energy - a thin band of
fallopian tube with intact lumen remains 
allows intrauterine pregnancy to occur
 Sterilization - Female
Hysteroscopy
In 2002, the FDA approved a new
hysteroscopic method of permanent
birth control: the Essure system
 Sterilization - Female
Eficacy
 Sterilization - Female
Eficacy
Safe procedures
Tubal ligation is associated with reduced
risk for ovarian cancer that persists for
as long as 20 years after surgery !!!
 Sterilization - Female
Failure
Usually during the 1st m after procedure
(Pregnancy+ at the time of sterilization)
CC should be continued until surgery
Pegnancy test should be performed on
the day of surgery
 Sterilization - Female
Late Sequelae
“Post–tubal ligation syndrome”
Increased menstrual irregularity and pain
CREST study found no evidence to
support the syndrome (90s)
360

05/25/24
 Hormonal CCs
Contraceptive effect
Progestin Only

Inhibits LH surge
Thick cervical mucus

Cerrazet
Microlut