MODERN CONTRACEPTIVE TECHNIQUES By E. Ejiro Emuveyan Associate Professor of Obstetrics & gynaecology Department of Obstetrics & Gynaecology College of Medicine, University of Lagos P.M.B. 12003 Lagos
MODERN CONTRACEPTIVE TECHNIQUESMODERN CONTRACEPTIVE TECHNIQUES
By
E. Ejiro Emuveyan
Associate Professor of Obstetrics & gynaecologyDepartment of Obstetrics & GynaecologyCollege of Medicine, University of Lagos
P.M.B. 12003 Lagos
1950s AND 1960s
MALTHUSIAN CONCERNS
1950s AND 1960s
MALTHUSIAN CONCERNS
TOO MANY PEOPLE REPRODUCING TOO RAPIDLY
RETARDS ECONOMIC GROWTH
DESTROYS THE ENVIRONMENT
OVERSTRETCHES SOCIAL SERVICES
EXACERBATES POVERTY
FUELS CONFLICT
World Population Profile 1World Population Profile 1
Beginning of last century 2b1970 4b2000 6bRate of increase 1.2%Estimated doubling time 42 yrs10 Largest Countries in Population
China 1304
India 1104
USA 296
Indonesia 222
Brazil 184
Pakistan 162
Bangladesh 144
Russia 143
Nigeria 132
World Population Profile 2World Population Profile 2
1/3 under 15 years of age
25% live in developed or industrialised countries with low fertility rates
75% live in less developed countries that are characterized by high fertility rates, high maternal and infant mortality and low life expectancy
Number of women in reproductive age increased between 1990 and 2000 by about 200m posing great challenge to scientific community
Need therefore for increased methods of infertility regulation
Indications for family planningIndications for family planning Individual
Spacers
Limiters
Avoid childbearing because of severe disease in pregnancy
Pregnancy is life threatening to the mother as in case of severe aortic stenosis
For all Indications, providers of Family Planning
For all Indications, providers of Family Planning
Must provide accurate information about benefits and risks of:(i) Pregnancy
(ii) Contraception
To be noted specifically are:
Medical conditions that may substantially increase risk of some form of birth control usually increase the risk associated with pregnancy to an even greater extent.
Policy some less developed countries promote contraception in an effort to curb undesired population growth.
Fertility ControlFertility Control
Most sensitive and intimate decision
Religious or philosophical convictions
Clinician approach it with sensitivity
Empathy, maturity and non-judgmental behaviour
How Socio-Economic Changes Affect Contraceptive PracticeHow Socio-Economic Changes Affect Contraceptive Practice
Adolescents experiencing higher pregnancy rates
Women in later stages of reproductive lifespan now tending to delay childbearing until in their 30s and 40s.
Demographic Shiftmore women aged 30-44 years than those aged 15-29 years.needs of women with divergent social or economic circumstances.
NIGERIAN POPULATION PROFILENIGERIAN POPULATION PROFILE
Mid 2005 131.5 PRB Fertility rate: 5.9 per woman Pop. Growth rate 2.4 Living below USS2 per day 91% women using all methods 12 %
modern methods 8% Age ProfileWomen in reproductive age (15-44 yrs. -22.8%Children Under 15 years 43.0%
CONTRACEPTIVE PREVALENCECONTRACEPTIVE PREVALENCE
Worldwide (2005)-38.1m (53%) use effective methods
Nigeria (1998) 6%
Ghana 19%
Benin 7%
Guinea-Conakry 4%
Kenya 32%
Tanzania 20%
HISTORY OF FAMILY PLANNINGHISTORY OF FAMILY PLANNING
Religious and Moral Issues Natural Family-Planning
Coitus interruptus - Oldest method (17th century) Abstinence - Total/Periodic
Rev. Thomas Malthus - One of the founding fathers.
1864 - Gabriel Fallopio - Linen Sheath for Coitus.
BACKGROUND HISTORY CONTINUESBACKGROUND HISTORY CONTINUES
STONES IN THE WOMB OF CAMELS
1880 - CHEMICAL AGENTS AND MECHANICAL DEVICES (INTRAVAGINAL AND INTRAUTERINE)
1977 - IPPF - OVER 100 COUNTRIES
LEGAL ASPECTS OF CONTRACEPTIONLEGAL ASPECTS OF CONTRACEPTION
Without Restrictions
Information to Teenagers debatable
US Supreme Court ruling in 1977 minors have constitutional right of access.
Provision for teenagers should be done within the the confines of appropriate restraints.
THE LAW PROVIDES THAT ALL PERSONS MUSTTHE LAW PROVIDES THAT ALL PERSONS MUST
Detailed Information about the use of the
METHOD(S),
BENEFITS
RISKS,
SIDE EFFECTS
CONSENT AND SERVICECONSENT AND SERVICE Documentation Of Discussion with client and her understanding
of what has been said is of legal importance. When using methods that require instrumentation or some type of
surgical approach use of consent forms that outline information discussed and the patient’s understanding is important.
Consent form serves as evidence if needed that:
(I) Counselling about use of particular birth control method was given
(II) Patient appeared to be competent to understand what was said to her
(III) She consented to receive contraceptive management in the manner specified.
METHODSMETHODS
CLASSIFICATIONTRADITIONAL OR FOLK- Coitus Interruptus- Post coital Douche - Lactational Amenorrhoea- Periodic Abstinence (Rhythm, Natural Family Planning)
BARRIER- Condom(Male and Female)- Diaphragm- Cervical Cap- Vaginal Sponge- Spermicides
METHODSMETHODS
HORMONAL
- Oral
- Injectable
- Implantable Long-Acting Progestins
OTHER CONTRACEPTIVES
- IUCD
- Sterilisation
- Tubal Ligation
- Vasectomy
NATURAL CONTRACEPTIONNATURAL CONTRACEPTION
A. PERIODIC ABSTINENCE/RHYTHM METHOD LONG AND CHEQUERED HISTORY FERTIILE PERIOD 2-3 days after ovulation
2 days before no less than 2 days after PROMOTED BY CATHOLICS
Types of periodic abstinence
- Calendar method
- Combined temperature/calendar method
- Cervical mucus (Billings) method
- Symptothermal method
Data subject to bias
B. COITUS INTERRUPTUSB. COITUS INTERRUPTUS
Oldest Method of Reversible Contraception
Withdrawal before Ejaculation. Demands Sufficient Self Control
Statistics not reliable
Failure rate - 10 Preg/100 Women Years
C. LACTATIONAL AMENORRHEA METHODC. LACTATIONAL AMENORRHEA METHOD
Women Less Fertile When Nursing
Exclusive Breast Feeding for Six Months Supplemental Feedings Alters Patterns Of Lactation/Intensity Of Infant Suckling.
Amnenorhoea Must Be Maintained
2% Pregnancy Rate If Properly Used.
HISTORY OF ORAL CONTACEPTIONHISTORY OF ORAL CONTACEPTION
HISTORY19th Century- Lack of follicular development in pregnancy
1921 - Ludwig Haberlandt
1929 - Oestrogen Synthesized
1934 - Progesterone synthesized
1959 - First OC (Norethynodrel - Menstranol)
1960 - Progressive lower dose pills.
TYPESTYPES(A) Combined Oral Contraceptives (COCS).
Sequential - E Pill 15-16 days followed E/P for 5 daysProblem: Than normal incidence of endometrial cancerPhasic - Monophasic, Biphasic, Triphasic28 days regimen (last 7 days placebo)
(B) Progesterone only pill/Minpill (POP)Taken everyday (Microdose nonstop progestins)Efficacy less than that of COC and occasional causes
amenorrhoea (C) Post Coital Contraceptive pill/morning - After pill E only Yuzpe, Danazol, Mesopristone Follow up and initiate another contraceptive
method
USAGE & FAILURE RATESUSAGE & FAILURE RATES
60 m current users worldwide Affected by age, family size, Politics
FAILURE RATES COC 0.2 - 1 per 100 woman years POP 0.3 - 5 per 100 woman years
PCC varies with types
HORMONAL CONTRACEPTIONHORMONAL CONTRACEPTION
HISTORY: 19TH CENTURY TO 1934
Late 19th Century: Ovarian follicles do not develop during pregnancy
1921 - Ludwig Harberlandt First proposed Hormonal Sterilisation
1929 - Molecular structure of Oestrogen determined
1934 - Molecular structure of Progesterone determined
HORMONAL CONTRACEPTIONHORMONAL CONTRACEPTIONHISTORY: 1952 - 1960
1952 - Colton and Djerassi independently synthesized substances with progesterone - like activity (Progestogens or progestins)
1956 - Rock J, Pincus G and Garcia C.R demonstrated that norethynodrel suppressed ovulation (Science 124:128)
1959 - Rock, Garcia, Pincus and Rice-Wray conducted large clinical trials in Puerto Rico using a combined oral contraceptive containing 10mg norethynodrel and 0.15mg mestranol.
1960 - Knowledge increased and principles of hormonal contraception have been reconsidered now and again.
FACTORS CONSIDERED TO FIND THE RIGHT ORAL CONTRACEPTIONFACTORS CONSIDERED TO FIND THE RIGHT ORAL CONTRACEPTION
1. The constitutional type of the woman on the woman of somatic and historical data.
2. Tolerance shown towards the hormonal contraceptives previously taken and the type of side effects occurred.
3. Contraindications because of health status disposition to thrombosis lactation or special conditions (only occasional sexual
intercourse).
Post-coital contraceptionPost-coital contraceptionFour hormonal methods
1. The combined oral contraceptive pill
2. Oestrogen only
3. Progestogen only
4. Danazol
Only the combined pill is recommended
COMPOSITION AND SIDE EFFECTCOMPOSITION AND SIDE EFFECT
Two pills (Eugynon 50 micrograms of ethinyl estradiol and 250 micrograms of Levonorgestrel taken immediately and same dose repeated 12 hours later.
Side-effects are nausea and vomiting and these can be alleviated by the concomitant administration of an anti-emetic.- method should not be substituted for conventional contraceptive practice.- use of hormonal methods of postcoital contraception are an emergency procedure and should not be used repeatedly.
Vaginal Contraceptive Pill (VCP)Vaginal Contraceptive Pill (VCP)
- Recent
- Undergoing multicentre trials
- Historical evolution from vaginal rings
INTRA-UTERINE CONTRACEPTIVESINTRA-UTERINE CONTRACEPTIVES
Plastic devices placed in the uterine cavity to prevent pregnancy
Different shapes, sizes and types
MAIN MECHANISM OF ACTIONInterference with implantation
Increase with sperm transport
Inhibit capacitation
TYPESTYPES1. Non medicated (inert) e.g Lippes loop2. Medicated - less bleeding and pain
(a) CU DEVICES1st Generation - Cu 7
- Cu T2nd Generation - Multiload 250
Nova T3rd Generation - Multiload 375
Cu T 380 A Flexigard 330 Cu Fix PP 330
Eficacy - 1.5 per 100 woman years
(b) Progesterone Releasing Devices- Progestasert - levonorgestrel- Levonova - levonorgestrel
MOST SUITABLE CLIENTS FOR IUCD AREMOST SUITABLE CLIENTS FOR IUCD ARE
- Parous women in mutually monogamous relationship
- No current or prior history of RTIs
INJECTABLE STEROIDS INJECTABLE STEROIDSTwo types are currently in use
DMPA Depot Medroxyprogesterone Acetate (up john) Supplied in aqueous
microcrystalline suspension 150mg/ml in 1ml and 3ml/vials
DNO Depot Norethisterone Onanthate - derivative of 19nortestosterone supplied as
200mg/ml in benzyl benzoate and castor oil in 1ml vials.Third may be in use in the near future.
CYDCLOPROVERA
MECHANISM OF ACTIONMECHANISM OF ACTION
1. Inhibit ovulation by inhibiting the mid- cycle LH surge and suppresses the cyclic variation of oestrogen secretion by the ovaries.
2. Inhibit proliferation of the endometrium making it to become thin and atrophic and therefore the
endometrium is unfavourable for implantation.
3. Makes the cervical mucus to become thick and scanty thereby inhibiting the progression of
sperm into the uterus.
ADMINISTRATIONADMINISTRATION I.M buttocks or upper arm
DMPA Must be well shaken before filling the syringe site of injection must not be rubbed because this disperses the
injection. Amorphous white deposit is left in the muscle which is slowly absorbed.
DNO Supplied on oily solution more difficult to inject and may cause some discomfort.
EFFECTIVENESSEFFECTIVENESS
100% Effective
Pregnancy rates of 0.0 - 1.2 per 100 women years reported for 150mg.
DMPA given every 12 weeks and 0.01 - 1.3 per 100 woman years for 200mg DNO given every 8 weeks.
SIDE EFFECTSSIDE EFFECTSMenstrual Disturbances1. Frequent and irregular bleeding
71% women of 1st injection2. Amenorrhoea
54% of woman after 1 year of treatment.35% have complete
Amenorrhoea during at least 1 injection cycle.Amenorrhoea cycles becomes less frequent with
Noristerat
Management of Irregular bleeding With combined oral contraceptive Premarin 1.25 - 2.5mg daily x 21 days.
SIDE EFFECTSSIDE EFFECTS
3. Weight gain
Result of an increase appetite rather than fluid retention
4. Delayed return of fertility
6 - 12 months
2 years in extreme cases
Quicker return of ovulation with DNO reported
Women who have been treated for depression or have been depressed while taking oral contraceptive should not use depot contraceptive.
CONTRAINDICATIONSCONTRAINDICATIONSABSOLUTE Abnormal uterine bleeding Secondary amenorrhoea Arterial disease Cancer of the breast (except where used to treat endometrial cancer and breast cancer when much larger doses are required) Liver disease Trophoblastic disease until HCG levels are normal.RELATIVE Abnormal uterine bleeding - a definite established and possibility of
genital malignancy eliminated. Depression may be aggravated malignancy eliminated. Investigations of carbohydrate metabolism may be distorted. Women with history of thromboembolism B.P before treatment once controlled, DMPA can be used.
CARCINOGENIC EFFECTSCARCINOGENIC EFFECTS
Animal studies caused concern about
Mammary tomours in female beagle dogs and discovery of endometrial cancer in two rhesus monkeys that received 50 times the human dose.
WHO studies after 5 years of use, users have twice risk of carcinoma in situ
ONCE - A MONTH INJECTABLES IN USEONCE - A MONTH INJECTABLES IN USE
1. Dihydroxyprogesterone acetophenide (acetophenide 150mg and estradiol enanthate 10mg).
DHPA/E2-EN “Deladroxate” or Perlutal2. Deposit-Medroxyprogesterone acetate 25mg and estraldiol cypionate 5mg DMPA/E2C; HRP11Z “Cyclofem” or “Cycloprovera.3. Norethisterone enanthate 50mg and estraldiol valerate 5mg NET-EN/E2V; HRP102 “Mesigyna”4. 17 & Hydroxyprogesterone caproate 250mg andestraldiol valerate 5mg Chinese injectible No. 1REFERENCESMetabolic effects of once-a-month combined injectible contraceptives.Contraception 1994; 49: 421-433
ImplantsImplants
Synthetic polymers developed to provide sustained release of contraceptive steroids for prolonged use.
Silastic capsules pf progestagens implanted subcutaneously or subdermally.
ImplantsImplants
Can be placed in vaginal rings
In rings problems of erosion/vaginal/cervix/vaginal infection and inconvenience during S.I
Norplant 6 (six capsules) - 5 years protectionMulticentre trials in progress all over the world including Nigeria Now approved for use in several countries.
Normogestrol Acetate Uniplant - 1 year protection multicentre trials in progress all over the world including
Lagos/Ibadan`
CONTRACEPTIVE IMPLANTSCONTRACEPTIVE IMPLANTS
1987 Dr. Sheldon Segal discovered subdermal implants.
Advantages
As for injectables
Disadvantages
As for injectibles
Requires surgical procedure
CONTRACEPTIVE IMPLANTSCONTRACEPTIVE IMPLANTS
(i) Norplant -6 capsules (levonorgestrel)
- inserted inside inner aspect of the upper arm above the elbow.
- provides 5 years protection
- efficacy 1st year rates 0.2% and cumulative 5-year pregnancy rate 3.9%
- side effects are time dependent with the rate declining by about 50% after 1 year.
- no delay in restoration of fertility
(ii) Norplant 2 capsules
(iii) ST 1435 (Nestrone)-Lactation, less lipoprotein effects.
(iv) Uniplant (Nomegestrel Acetate)
(v) Implanon - 3 Keto-Dessogestrel
BIODEGRADABLE CONTRACEPTIVE IMPLANTSBIODEGRADABLE CONTRACEPTIVE IMPLANTS
- Does not require removal;
(i) Capronor - single; levonorgestrel
(ii) Capronr II
(iii) Capronor III
(iv) Annuelle - 90% Norethindrone + 10% Cholesterol.
Problems of Nonbiodegradable are those of removal
IMPLANONIMPLANON
Organon International Simple 30 mm silastic rod Release the progestin 3 keto -desogestrel at a rate of 30 ug
per day Effective for two to three years Removal is quick and relatively simple 3 keto-Desogestrel may inhibit ovulation more than levonogestrel.
Norplant 6Norplant 6
Norplant subdermal contraceptive the first represents the efforts of scientists of the Population Council who licensed Leiras of Finland in 1983 to manufacture and distribute Norplant. Norplant is a safe, effective method of reversible fertility regulation. Despite this, the apparent major shortcoming is menstrual disorders which cause about half of all discontinuations. The observed menstrual changes though not associated with a adverse alteration of haematological indices encouraged further
research at the local mechanism underlying contraceptive induced endometrial bleeding.
In view of observed undesirable side effects, appropriate counselling of potential acceptors is recommended as well as efforts to focus scientific research aimed at resolving some of the implants to improve continuation rates.
Norplant IINorplant II
Also from Population Council
Two rods slightly longer than Norplant 6 capsules
Two rods contain levonogestrel embedded
homogeneously within the silastic rod which is covered by a thin sheath of plain silastic.
Side-effect similar to Norplant
Easier to implant and to remove because there are fewer rods.
VAGINAL CONTRACEPTIVE RINGSVAGINAL CONTRACEPTIVE RINGS
Method of long-term contraception which is entirely patient’s control.
Steroids absorbed efficiently through vaginal epithelium.
Advantages
- Under patient’s control
- not coitus related
- no daily administration
- greater contraceptive effect
- milder adverse effects.
DESIGN OF VAGINAL CONTRACEPTIVE RINGSDESIGN OF VAGINAL CONTRACEPTIVE RINGS
Vaginal fornix around cervix
- homogenous ring
- shell ring
- core ring
TYPES OF VAGINAL CONTRACEPTIVE RINGSTYPES OF VAGINAL CONTRACEPTIVE RINGS
(a) Progestogen only(i) Levonogestrel - continuos low dose(ii) Progesterone - 90 days use
- Natural- Prolongs lactational amenorrhoea- Ineffective during weaning
(iii) ST 1435 (Nestrone) - 3 weeks in 1 weeks out.
- less metabolic effects.
(b) Combination rings(i) Levonogestrel/Ethinyl Estradiol(ii) 3 Keto-Desogestrel/EE(iii) Norethindrone Acetate/EE(iv) ST 1435/EE
BARRIER DEVICES AND CHEMICAL AGENTSBARRIER DEVICES AND CHEMICAL AGENTS
40 million couples worldwide
Over three centuries
Initially limited acceptability
Renewed interest - Aids pandemic
FEMALEFEMALE
(a) Cap(i) Vaginal diaphragms most widely used
spermicide types coil springs, flat spring, arcing failure rate 2-20
pregnancies per 100 women users per year of exposure.
(ii) Cervical Cap(iii) Fem-cap(iv) Lea’s shield(v) Long Acting Spermicides releasing diaphragms(vi) PH sensitive releasing devices
(b) Female condomDesign - Pouch thin polyurethane with 2 flexible rings at
each end/9one deep and the other at the intriotus)- Failure rate - 26% for the first year- Overall acceptability 65-79% for women users and 75-80% for their partners.
FEMALEFEMALE
(c) Sponge(i) Today sponge - polyurethane and
Nonoxynol-9Toxic to Spermatozoa
(ii) Protected
(d) Chemical agentsFoams, jellies, tablets, suppositories, aerosolsNonoxynol-9, Octoxynol-9, Menfegol
Male CondomMale Condom
1864 - Gabriel Fallopio Linen Sheath
20% of contraceptives use; renewed interest - Aids pandemic.
(i) LatexTeat endedPlain
(ii) Non-latex - polyurethane, plastics stronger, less rupture
Failure rate: 3 per 100 woman years
High risk women - “Double Dutch” method
Voluntary Surgical ContraceptionVoluntary Surgical Contraception
FEMALE STERILISATION
Occlusion of the uterine tubes to prevent pregnancy commonest form of permanent contraception in Europe/N-America.
SURGICALCommonest Approaches(a) Minilap(b) Laparoscopy (c) Laparotomy(d) Vaginal
TUBAL LIGATION TECHNIQUESTUBAL LIGATION TECHNIQUES
(a) Pomeroy(b) Madlener
(c) Fimbriectomy(d) Salpingectomy(e) Uchinda(f) Irvine
E and F more effective(i) Occlusive bands or rings: Falope(ii) Occlusive clips - Filshie or Hulka - Clemems(iii) Tubal diathermy (Thermocoagulation)(iv) Hysterectomy
COMPLICATIONS- immediate- delayed- long term
NON-SURGICALNON-SURGICAL
- via hysteroscopy
- by use of chemicals
- phenols
- quinacrine
- methyl cyano Accrylate
MALE STERILISATIONMALE STERILISATION
(I) SURGICAL
16% of contraceptive use
(i) Vasectomy
(a) Scalpel
(b) Non-scalpel - 1974: China,
Ligation
Excision (segmental)
Coagulation
(ii) Clips
(iii) Silicone rods
MALE STERILISATIONMALE STERILISATION
NON SURGICAL
Percutaneous Intravasal Injection of Sclerosants viz
(a) Carbolic Acid
(b) N Butyl-cyno-acrylate
OTHER MORE REVERSIBLE AGENTS INCLUDE:
(c) Polyurethane Elastomers - form plugs
(d) Styrene Malate Anhydride
OTHER MALE CONTRACEPTIONOTHER MALE CONTRACEPTION
Research over 50 years
TYPES(a) Androgens(b) Progestogens + Androgens(c) Danazol + Androgens(d) Gonadotrophin Releasing Hormone (GnRH).(e) Anti Progestogens
Problems- continued sperm production- histamine like effects - GnRH
Antagonists- Testosterone use viz lipoprotein
changes, acne
METHODS BEING DEVELOPEDMETHODS BEING DEVELOPED
CONTRACEPTIVE VACCINES
Research has been on for a few decades
PRINCIPLES OF ACTION
TYPES
A: ANTI-PERIMPLANTATION VACCINE - B-hCG= TT
B: HETEROSPECIES DIMER VACCINE - HSD
C: CTP VACCINE - 37 AA Carboxyl terminal peptide of B-hCG
Linked to Diphtheria Toxoid as Carrier
METHODS BEING DEVELOPEDMETHODS BEING DEVELOPED
D: LH-RH VACCINES
E: OTHERS: - Anti-Sperm
- Anti-Ovum
- Anti-Zona Pellucida
- Recombinant Zona Pellucida Antigens
F: MALE VACCINES - Passive/Active
Immunisation against FSH - Gn-RH Vaccine
CONCLUSIONCONCLUSION
PROGRESS MADE IN THE FIELD OF CONTRACEPTIVE DEVELOPMENT CAN BE SUMMED UP IN THE DECLARATION OF THE INTERNATIONAL SYMPOSIUM ON CONTRACEPTIVE RESEARCH AND DEVELOPMENT (YEAR 2000 AND BEYOND)
“IF ALL THE PEOPLE OF THE WORLD ARE TO ENJOY THE HIGHEST POSSIBLE LEVEL OF HEALTH AND BASIC HUMAN RIGHTS, ITS IS IMPERERATIVE THAT CONTRACEPTIVE DEVELOPMENT CONTINUES UNHINDERED. MOREOVER, WITHOUT SUCH RESEARCH, IT WOULD BE DIFFICULT FOR THE WORLD TO BRING ITS POPULATION AND NATURAL RESOURCES INTO A SUSTAINABLE BALANCE”.