Physiology of Contraception

CONTRACEPTIVE METHODS IN FEMALES

Contraception refers to prevention of pregnancy.
Methods of contraceptions :
 Spacing methods
Terminal methods.
SPACING METHODS
The spacing methods increase the gap between two pregnancies.
Rhythm method,
Barrier methods,
Chemical methods and
Intrauterine contraceptive devices.
Rhythm method
Its also known as calender method or safe period method or natural method.
This method of contraception depends on the time of ovulation (dangerous
period).
Rest of the cycle, i.e. 5–6 days after bleeding phase of menstrual cycle and 5–6
days before the next cycle is the safe period (period of least fertility).
Disadvantage:
Unreliable when the menstrual cycles are irregular and time of ovulation is variable.
BARRIER METHODS
• This prevent the meeting of ovum and sperms after coitus.
• Mechanical barriers
• Diaphragm( fig A) and cervical caps ( fig B)
Advantages.
• These devices are inexpensive and usually do not require any medical consultation.
Disadvantages :
• Failures are quite common because chances of displacement of the device are very
high.
• Some women get cervicitis (inflammation of cervix) and local irritation.
2. Chemical barriers
•Its refer to spermicidal agents, destroy the sperms when applied in the female
genital tract before coitus.
•The common spermicidal agents used are:
Ricinoleic acid (oldest)
 Nonoxynol-9
 Octoxynol-3.
•These spermicidal agents are available in various forms : foam tablets, pastes,
creams, jellies and vaginal sponges.
•Vaginal sponge is a polyurethane sponge impregnated with nonoxynol-9. It is
available by the trade name ‘TODAY’.
3. Combined methods
•Mechanical barriers (diaphragm and cervical caps) along with the spermicidal
agents give good protection.
CHEMICAL METHODS
•Used in various forms in the form of cream, jellies and as drugs (either orally or in
injectable form or as implants).
(a) Oral contraceptives
Oral contraceptives/steroidal drugs are most widely used.
Recommended in women of younger age group (up to 35 years).
Mechanism of action
Its contain synthetic estrogen and progesterone and raised levels, by their negative
feedback, inhibit the release of gonadotropins (FSH and LH) and thus inhibit
ovulation.
Types of pills :
 Combined pill (classical pill)
 Sequential pill
 Minipill
 Post-coital (morning after) pill.
1. Combined pill or classical pill
 It contains both oestrogen and progesterone
 Available under twobrand names;
 MALA-N (packet of 21 tablets) and
 MALA-D (packet of 28 pills, out of which 21 are white coloured of hormones and
7 are brown coloured containing ferrous fumarate).
Dosage.
 The combined pills are taken orally every day at fixed time (preferably at night
before going to bed) for 21 days, starting from fifth day of menstrual cycle to
25th day followed by a gap of 7 days in case of MALA-N.
 During this gap period bleeding occurs.
 This bleeding is not a menstrual bleeding as it occurs due to withdrawal of the
hormones; withdrawal bleeding.
2. Sequential pill
These pills contain high dose of oestrogen along with a moderate dose of
progesterone.
Dosage-
Only oestrogen is given starting from fifth day of menstrual cycle to 15th day and
then followed by both (oestrogen + progesterone) for next 5 days.
Note. Its not preferred because of high incidence of endometrial carcinoma.
3. Minipill
Minipill (progesterone only) or micropill.
Dosage-
Pill should be taken daily through whole of the menstrual cycle.
•Its prevents fertility without inhibiting ovulation.
•It acts on the cervical mucosa (makes it thick), and also decreases motility of
fallopian tubes.
4. Post-coital pill (morning after pill)
it is recommended within 72 h of the unprotected intercourse.
This method of contraception should be used only in emergency cases, like rape,
contraceptive failure and unprotected sex.
Dosage-
Double dose of combined pill (2 pills) should be taken immediately followed by
another double dose (two pills) after 12 h.
Possible mechanisms involved are:
 It causes hypermotility of the fallopian tubes and of uterus and thus prevents
fertilization and implantation.
 If ovulation and fertilization has occurred, then it prevents implantation of the
blastocyst.
Disadvantages
•Routinely, this method of contraception is not practiced because of various side
effects like nausea and vomiting.
Advantages and disadvantages of oral contraceptives
Advantages- Oral contraceptives have 100% effectively
Disadvantage-
its prolong use leads to certain adverse effects as:
carcinoma of breast or of uterus,
 Liver diseases and
 Hyperlipidaemia.
Oral contraceptive should not be given to woman of age group above 35 years.
(b) Depot preparations
 These are long-acting drugs and highly effective.
These are available in three forms:
 Injectable preparations
 Subdermal implants
 Vaginal rings.
Advantages and disadvantages
Advantages
As these are long-acting drugs, therefore to avoid daily intake of oral pill,
contraceptive effectively lasts for longer period.
Disadvantages
Sometimes lead to sterility and alterations in menstrual bleeding pattern.
INTRAUTERINE CONTRACEPTIVE DEVICES
Intrauterine contraceptive devices (IUCDs) are inserted into the uterine cavity for
long-term contraception.
These are made up of inert materials like plastic, polythene and metal.
Lippes loop –
It is a serpentine or S-shaped device made up of plastic to which is attached a fine
nylon tail.
A small amount of barium sulphate is also present in the plastic material to allow
its radiographic observation.
Copper-T
This the most commonly used IUCD in India.
Its shape resembles the letter T.
Like Lippes loop it is also attached with a nylon thread (tail)
Insertion
Ideal time for its insertion is during menstruation or within 10 days of the beginning of
menstruation
Because the diameter of cervical cavity at this time is greater.
It can also be inserted during first week after the delivery.
Mechanism of action
Prevents implantation and growth of fertilized ovum by evoking aseptic inflammation.
Advantages of IUCDs
Provides long-term contraception without adverse effects
Disadvantages of IUCDs
In some cases may cause heavy bleeding
Risks of ectopic pregnancy
TERMINAL METHODS
•Its permanent sterilization, can be achieved either surgically or laparoscopically.
Surgical methods
Tubectomy in female
Fallopian tubes are cut and then cut ends are ligated and buried
Laparoscopic occlusion
Fallopian tubes are occluded using silicon rubber bands, Falope rings or Hulka-
Clemens clips.
MEDICAL TERMINATION OF PREGNANCY
•Medical termination of pregnancy (MTP or abortion) is allowed under
MTP Act 1971.
Conditions in which pregnancy can be terminated are:
 Medical- When continuation of pregnancy is hazardous to the mother.
 Eugenic- When there is substantial risk to the child if born from that pregnancy.
 Humanitarian grounds- When pregnancy is the result of rape.
 Failure of contraceptive measure.
Methods
Dilatation and curettage- Cervix is dilated with dilators and implanted ovum is removed
by doing curettage of the endometrium
Vacuum aspiration-cervix is dilated and then implanted ovum is removed (aspirated) by
applying suction. This method is employed only up to 12 weeks of gestation.
Administration of prostaglandins- into the vagina (intravaginally) causes uterine
contractions resulting in expulsion of the products of conception.
 CONTRACEPTIVE METHODS IN MALES
The spacing methods of contraception used in males are:
 Natural method
 Barrier methods
 Chemical methods
Natural method or coitus interruptus
•Its a voluntary fertility control, male withdraws the penis before
ejaculation into the vagina and tries to prevent deposition of semen into
the vagina.
Barrier methods
Condom-Nirodh –It consists of a fine latex sheath
•Its prevents deposition of semen into the vagina.
Chemical methods
Antispermatogenic drugs
•Few drugs which inhibit spermatogenesis
1.Male pill (Gossypol)
2. Hormonal preparations
3.Testosterone. Testosterone (400 mg) when given orally produces azoospermia.
4.Testosterone with danazol (17α-ethyl testosterone). This preparation is better tolerated
and is more effective.
5.Cyproterone acetate- It acts as a potent antiandrogenic agent. It produces oligospermia
but also causes loss of libido.
3. Tripterygium wilfordii
•Special type of wine (prepared from a plant) used in Chinese medicine which reduces the sperm
count
4. Calcium channel blockers
•Calcium channel blockers (e.g. nifedipine) block the Ca2+ channels on the cell membrane of the
sperms
Terminal methods
Permanent methods
•Vasectomy
• Vas occlusion using no scalpel technique
Vasectomy
1 cm piece of vas deferens is removed after clamping. Then both the ends are ligated
and sutured so that they face away from each other.
No scalpel vas occlusion
A newer technique
•An elastomer is injected into the vas deferens,
•it get hardened in situ within 20 min and plug the
vas(occlude it).
Advantages. It is an easy procedure and reversal is possible
with 100% efficacy.