FERTILITY

CONTROL
(CONTRACEPTION)

People will use different types of contraception at

different stages in their lives and there is no one
method that will suit everyone.
There is no perfect method of contraception
and each method will have a balance of advantages
and disadvantages.

CHARATERISTICS OF THE IDEAL

CONTRACEPTIVE METHOD

Highly effective.
No side effects.
Cheap.
Independent of intercourse.
Rapidly reversible.
Wide spread availability.
Acceptable to all cultures and religions.
Easily distributed.
Can be administered by non-healthcare personal.
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Failure rates
Failure rates for some methods vary considerably, largely
because of the potential for failure caused by poor use
(user failure) rather than an intrinsic failure of the method
itself. Methods which prevent ovulation are usually highly
effective because if there is no egg then fertilization simply
cannot occur. However, if, for example, pills are forgotten,
then breakthrough ovulation can occur and failure rates are
higher. Methods which require no regular need for the user
to remember to do anything, for example an intrauterine
device or Implanon, are generally much more effective
than methods which rely on the user to do something
regularly

EFICACY OF METHODS OF
CONTRACEPTION
CONTRACEPTIVE METHOD
FAILURE RATE
Combined oral contraceptive pills
Progesterone-only pills
Depo-provera

0.1 1
13
0.1 2

Implanon

Copper-bearing IUD
Levonorgestrel-releasing system
Male condom
Female diaphragm
Natural family planning
Vasectomy
Female sterilization

12
0.5
23
1 15
23
0.02
0.13
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Non-contraceptive health benefits

Condoms : prevent sexually transmitted infections .
Condoms and diaphragms : both protect against cervical
cancer.

Mirena: help heavy or painful periods.

The combined pill :
protects against both ovarian and endometrial cancer
Increased bone density
Reduce menstrual blood loss & anemia
Decrease the risk of ectopic pregnancy
Inhibition of hirsutism progression & improvement of acne
Prevention of atherogenesis
Decrease activity of rheumatoid arthritis
Decrease incidence and severity of acute salpingitis & PID

A. Combined hormonal
contraception

1- Combined oral contraceptive pills

(COCP)
Composition:
It contains various amounts of oestrogen (ethinyl
oestradiol) and one of a variety of progestins.
The progestogens used commonly are norethindrone or
levonorgestrel (second generation) or one of the third
generation such as gestodene, desogestrel, or
norgestimate, or use the anti-mineralocorticoid and antiandrogenic progestogen (drospirenone).

Mode of action
COCPs acts both centrally and peripherally:
Central effect
Inhibition of ovulation is the most important effect. Both
oestrogen and progestogen suppress the release of pituitary
FSH and LH, which prevents follicular development within the
ovary and therefore ovulation .
Peripheral effects:
Making the endometrium atrophic and hostile to an
implanting embryo.
Altering the cervical mucus to prevent sperm ascending into
the uterine cavity.
Alteration of tubal motility.

Way to use:
Most brands contain 21 pills; one pill to be taken daily at the
same time, followed by a seven day free interval (during interval
withdrawal menstrual bleeding happens).or there is every day
preparation that contain 7 placebo pills to be taken in the pillsfree interval

Contraindications
Absolute:
Breast feeding <6 weeks postpartum
Smoking 15 cigarettes/day and age 35
Current or history of ischaemic heart disease
Current or history of stroke
Hypertension: systolic 160 or diastolic 100 mmHg
Hypertension with vascular disease
Current history of DVT /pulmonary embolism
Any acquired or inherited pro-thrombotic tendency
Diabetes for 20 years or with severe vascular disease or
with severe nephropathy, retinopathy or neuropathy
Major surgery with prolonged immobilization
Complicated valvular heart disease
Migraine with aura

 Liver disease (active viral hepatitis, severe cirrhosis)

Oestrogen-dependent neoplasm, particularly breast cancer
Benign or malignant liver tumours

Relative
Multiple risk factors for arterial disease
Hypertension: systolic blood pressure 140159 or diastolic
pressure 9099 mmHg, or adequately
treated to below 140/90 mmHg
Some known hyperlipidaemias
Diabetes mellitus with vascular disease
Smoking (<15 cigarettes/day) and age 35 years
Obesity

Migraine, even without aura, and age 35 years

Breast cancer with >5 years without recurrence
Breast feeding until six months postpartum
Postpartum and not breastfeeding until 21 days after
childbirth
Current or medically treated gallbladder disease
History of cholestasis related to combined oral
contraceptives
Mild cirrhosis

Complications:
1- Venous thromboembolism : COC increases risk of
venous thromboembolism (VTE) three- to five-fold. Oestrogens alter
blood clotting and coagulation in a way that induces a pro-thrombotic
tendency
The type of progestogen also affects the risk of VTE, with users of
COC containing third-generation progestogens being twice as likely to
sustain a VTE than those using older second generation preparations.

2- Arterial disease
3- Breast cancer
Beyond 10 years after stopping COCP there is no increase in breast
cancer risk for former COCP users

4- Central nervous system:

Depression, headaches, loss of libido
5- breast :
Breast pain , enlarged breast
6- Gastrointestinal:
Nausea and vomiting, weight gain,
bloatedness,
7- Miscellaneous:
Chloasma (facial pigmentation) and leg
cramps.

Drug interactions:
This can occur with enzyme-inducing agents
such as some anti-epileptic drugs. Higher dose
oestrogen pills containing 50 mcg ethinyl
oestradiol may need to be prescribed here.
Some broad spectrum antibiotics can alter
intestinal absorption of COCP and reduce its
efficacy, so additional contraceptive measures
should be recommended during antibiotic
therapy and for one week thereafter.

Patient management;
Before prescribing COCP a detailed past
medical and family history should be taken
to search for contraindications and risk
factors.
Blood pressure should be checked, Routine
weighing, breast and pelvic examinations
are not mandatory and should be offered
when indicated.
Women needs clear advise about what to do
if they miss any pills

2.Combined hormonal patches

Transdermal patches that contain estrogen &
progesteron .Patches are applied weekly for 3 weeks,
after which there is a patch-free week.
Have the same risks and benefits as COCP and although
they are relatively more expensive, may have better
compliance

3.Combined hormonal vaginal rings

It is made of latex-free plastic and has a diameter of
54The ring is worn for 21 days and removed for 7 days,
during which time a withdrawal bleed occurs. Mode of
action and efficacy are similar to COCP mm.

4.Injection combined hormonal methods

monthly injectable is administered during
the first 5 days of a womans cycle and
reinjected every 28 days.

B. Progesteron only
contraception
They are extremely safe because they do not
contain oestrogen and can be used if a woman
has cardiovascular risk factors. The dose of
progestogen within them varies from very low to
high.
All progestogen-only methods work by a local
effect on cervical mucus and on the endometrium
(making it thin and atrophic), thereby preventing
implantation and sperm transport. Higher dose
progestogen-only methods will also act centrally
and inhibit ovulation.

the common side effects of

progestogen-only methods
include:
1- erratic or absent menstrual bleeding
2- functional ovarian cysts
3- breast tenderness
4- acne

1- Progesterone-only pill, or (mini-pill)

The progestogen-only pills is ideal for women who like pill
taking but cannot take COCP. Although the failure rate of
the POP is greater than that of COCP, it is ideal for
women at times of lower fertility. If the POP fails there is a
slightly higher risk of Ectopic pregnancy. They contain the
second-generation progestogen (norethisterone or
norgestrel or their derivitives) and the third-generation
progestogen desogestrel.
The POP is taken every day without a break.

Particular indications for the POP

include:
1- breast feeding
2- older age
3- cardiovascular risk factors
4- diabetes

Advantages:
1- No alteration of milk production and nearly 100%
effectiveness in breast feeding women.
2- Tolerance in women who are unable to take oestrogen.
3- Independent of sexual intercourse.
Disadvantages:
1- Irregular vaginal bleeding.
2- No protection against sexually transmitted
infections (STIs).
3- Need for daily administration at approximately the
same time each day for 28 days without a pill-free
interval.

2-Injectable progestogens
1- Depo-provera (medroxy progesterone acetate) 150 mg
injection given every 12 weeks. It is highly effective
method of contraception and is given by deep I.M
injection.
2- Norethisterone enanthate last for 8 weeks and is not
nearly so widely used. Most women choose Depoprovera.

Advantages of Depo-provera:
1- Most women who use it develop very light or absent
menstruation, so can be used to treat heavy periods in women
requiring contraception as well.
2- It will improve premenstrual syndrome such as painful periods.
3- It is particularly useful for women who have difficulty
remembering to take a pill.
Side effects of Depo-provera:
1- Weight gain of around 3 kg in the first year.
2- Delay in return of fertility.
It may take around 6 months longer to conceive compared to a
woman who stops COCP.
3- Very long-term use may slightly increase the risk of
osteoporosis.

3. Subdermal implant (Implanon )

is a subdrmal implant that consists of a single silastic rod
that is inserted subdermally under local anesthetic into
the upper arm.
It is highly effective and there have been no genuine
failures reported with it to date. It lasts for 3 years and
thereafter can be easily removed or a further implant
inserted It releases the progestogen etonogestrel 2570
mg daily (the dose released decreases with time)

It is particularly useful for women who have difficulty

in remembering to take a pill and who want highly
effective long-term contraception. There is a rapid
return of fertility when it is removed.

(intrauterine device
IUD)
Advantages:
IUD is ideal for women who want a long-term
method of contraception independent of
intercourse and where regular compliance is not
required.
IUD protects against both intrauterine and
ectopic pregnancy, but if pregnancy occurs,
there is a higher rate than it will be ectopic.
Types of :
1- Copper-bearing IUDs.
2- Hormone-releasing IUDs.
3- plastic inert IUDs.

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32

It is inserted inside the uterus by a well

trained personnel and a fine thread is left
protruding from the cervix into the vagina
and the IUD can be removed by traction on
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the thread.

Copper-bearing IUDs:
Are available in various shapes and sizes. Most
licensed for 3-5 years of use but many may last
for up to 10 years. The more copper wire a
device has, the more effective it is.
Mode of action:
It causes a local sterile inflammatory reaction in
the uterus and the intrauterine environment
becomes spermicidal.
The copper has a toxic effect on both sperm and
eggs which prevents fertilization.
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Side effects:
1- Increased menstrual
blood loss
2- Increased
dysmenorrhoea
3- Increased risk of
pelvic infection in
the first few weeks
following insertion
4- No protection
against STIs
5- Risk of uterine
perforation during
insertion and

1- Recent history of PID or

STD.
2- Previous history of
ectopic pregnancy
3- Known malformations
of the uterus
4- Known or suspected
pregnancy
5- Copper allergy (for
copper type)
6- Malignant trophoblastic
disease
7- Unexplained vaginal
bleeding
8- Endometrial & cervical
cancer until assessed
and treatedn
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Intrauterine-releasing system IUS

(Mirena):
It has a capsule containing
levonorgestrel around its stem
which release a daily 20 microgram of hormone inside the
uterus.

Mode of action:
Induces a sterile inflammatory reaction in the endometrium
and prevents implantation. The progestogen
levonorgestrel exerts a local effect on the endometrium
and cervix making cervical mucous unreceptive for sperm
and endometrium unfavorable for implantation.
36

Advantages:
1-Highly effective & It provides 5 years of contraception from
one intrauterine device (IUD).
2- Useful in treatment of menorrhagia and dysmenorrhoea.
3- Resumption of fertility on removal of the IUS.
4- protection against PID.

Disadvantage :
1. Persistent spotting and irregular bleeding in first few
months of use .
2. Progesterone side effect e.g acne ,breast tenderness
,mood swing .
3. Expensive .

Contraindications:
Same for copper IUD with the exception of copper allergy.
37

3- inert devices
Which often maid from plastic or
stainless steel caused significantly
heavier and more painful menstrual
period these are no longer available,
although some women still have
them in situ .once fitted , they could
left until the menopause .

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Emergency contraception (EC):

It is a method that is used after intercourse has taken place
and before implantation has occurred.
EC should be considered if :
1. Unprotected intercourse has occurred
2. Failure of barrier method ex: burst condome
3. If hormonal contraception has been forgotten
Methods:
1- Combined oestrogen and progestogens (CEP):
This involves using a combination of 100 mcg of
ethinyloestradiol and 0.5 mg levonorgestrel taken twice
with the two doses seperated by 12 hours, taken within 72
hrs of unprotected intercourse.
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2- Progestogen only: A single dose of 1.5 mg of

levonorgestrel (levonelle) or used in two doses of 0.75
mg separated by 12 hours, taken within 72 hours of
unprotected intercourse. It is more effective than the CEP
and is better tolerated.
The mechanism of action is not known but probably involves
disruption of ovulation or corpus luteal function depending
on the time in the cycle when hormonal EC is taken.
3- Copper-bearing IUD:
is a highly effective postcoital contraceptive with failure rate
of less than 1%. It should be placed for up to 5 days after
the estimated day of ovulation.
It is appropriate method for women who wish to continue the
IUD as a long-term method of contraception.
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The IUD prevents implantation and the

copper ions exert an embryo-toxic effect.
The normal contraindications to an IUD
apply and if there is a risk of STIs, antibiotic
cover should be given.
The hormone releasing
IUS has not been shown
to be effective for EC and
should not be used in
this situation.

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Barrier method of
contraception

Control block sperm from entering the uterus

using a spermicide with barrier method give you
the best possible barrier method protection.
The spermicide kills most of the sperm that enter
the vagina
Barrier method then blocks any remaining sperm
from entering the cervix to fertilize anegg
Unlike other methods of birth control barrier
methods are used only when you have sexual
intercourse

Barrier methods
diaphragm

cervicalcap

Male
condom

Cervical
shield

Female
condom+foam+sp
onges+film

male condom
Commonly used during sexual
intercourseto reduce the chance of
pregnancy and reduce the risk of
transmitted STDS as HIV
It is put before genital contact and
withdraw theerect penis from the vagina
immediately after ejaculation
It is made from latex rubber

Advantages

disadvantage
s

Used for
collection of
semen

Condom may slip

off the penis after
ejaculation or break
due to improper
application

Inexpensive
,easy to use
,having few side
effects

Physical damage or
slip ,break due to
past expiration date

Female condom
Most people use female condom with no
problems for themselves or their partners
Some women and men may not like the
female condom because it may cause
irritation of the vagina ,vulva ,penis, or
anus .

diaphragm
Is abarrier method round dome shaped
device made of rubber that has a firm
flexible rim .it fits inside a womens vagina
and covers the cervix immedatly prior to
the intercourse and should be removed
not earlier than 6 hr later. it should always
used with spermicidal cream or gels

Advantages :
Does not affect the future fertility ,it used
only at the time of sexual intercourse ,safe
to use during breast feeding, less
expensive ,can be used by woman with
health problems when use of estrogen is
danger or who is smoke
Disadvantages:
not used by woman that have hx of toxic
shock syndrome , increased risk of UTI,
may cause allergy to latex

Vaginal sponge
Contains spermicides called nonoxynol-9
that is released over 24hrs that the
sponge may left in the vagina ,it is also
block the cervix so sperm cannot pass.it
can be inserted before intercourse or up to
24hr,left in place for 6 hrsafter intercourse.
High failure rate ,temporary method can
be used in breast feeding

spermcides
Substances that kill the sperm ,it can be in
the form of jelly,foam ,cream,suppositories
and film ,the active ingredient nonoxynol-9
Cheap,can be used in a woman with
health problemor breast feeding
They cause extra discharge from the
vagina ,women who use it should not
dough for at least 8hrs to prevent
pregnancy

Some people allergic to nonoxynol-9

cause irritation to the itching,sores
,in the vagina or penis ,HIVcan be
transmitted
Cevical cap :
made of rubber ,shouldfits tightly to the uterus ,used with
spermcides
Advantages
temporary method,can be used with breastfeeding,
Disadvantages
may cause bad odor if left more than 24hrs,not used if
had ahx of TSST ,may difficult to place properly, irritate
the cervix,should not be used if the woman currently have
vaginal or cervical infection

Cervicalshield
made of silicone so no allergy to to the
latex similar to cervical cap ,sponge and
diaphragm
Cervical shield comes in one size
only simplifying the fitting process ,
requires prescription.

Condoms and diaphragms may

reduce the risk of cervical
cancer and STDs

Chemical method
Use chemical known as nonoxnol-9 the foam is
inserted into the vagina prior to the sexual
intercourse ,can be used with maleor female
condom., destroy the sperm and prevent it from
fertilizing the egg and also blockthe opening of
the cervix
Can cause irritation ,messy and may leak from
the vagina
Suppository :contain nonoxynol-9,place into the
vagina ,cause irritation

Withdrawal coitus
interruptus
This method does not require any medical
advice .the penis is removed from the
vagina immediately before ejaculation
It is not reliable since pre ejaculatory
secretion may contain millions of sperm
and young men found it is hard to judge
the timing of withdrawl.

Natural family planning

This mean abstaining from intercourse during
the fertile period of the month .
The fertile periodis calculated by
1-change in the basal body temperature
2-changes in the cervical mucus
3-tracking cycle days
4-combined approaches
5-commercial kits for reading urinary hormones
High failure rate

Lactational amenorrhea
Used by fully breastfeeding mother ,
during the first 6 months of infant life full
breast feeding give more than 98%
contraceptive protection.

Sterilization
permenant method of
contraception

Female sterilization
Mechanical blockage of both fallopian
tubes to prevent sperm from reaching and
fertilizing the oocyte . It can also achieved
by hysterectomy ,or total removal of
fallopian tube which is performed by
laproscope or mini laprotomy underGA by
clips,fallop ring,ligation
,electrocautery\diathermy ,essure or
chemical agents ex,quinacrine

Complication
Anaesthetic problems
Damage to the intraabdominal organs
Some woman presented with abnormal
uterine bleeding

Vasectomy
Easier ,cheaper,more effective than female
sterilization does not require GA
It is involve the division of the vasdeferens on
each side to prevent the release of sperm during
the ejaculation
If 2consecutive semen samples taken at
12&16wks are freeof sperm the vasectomy can
be considerd complete and another method of
contraception can be use

Thank you