Contraception - Different Birth Controls

In short: Contraception is of three kinds: mechanical, such as the IUD (about 99% effective), the condom and counting the fertile days; hormonal, such as the combined pill, the progesterone-only pill, injections and implants; and surgical, such as tying the fallopian tubes in the woman or vasectomy in the man. Ask your doctor which method best suits your health and lifestyle.

There are many types of contraception widely used now a days for the purposes of family planning. Every method has its advantages and suits special cases and doesn’t necessarily suits others, and the choice of contraception depends on different needs of the patients like the period of contraception, and also your doctor should decide which method suits your needs more. No method of contraception is completely effective, and failure rates for most reversible methods are strongly influenced by compliance.

Types of contraception:-

• Mechanical contraception
• Hormonal contraception
• Surgical contraception

Mechanical method of contraception:-

• IUD: It is a device that is designed to be inserted into the uterine cavity. It is available in different shapes and sizes. It could be composed of copper, polyethylene, or sometimes with a hormone component that controls the heavy bleeding in addition to its contraceptive effects (MIRENA IUD).

* Rhythm method for contraception:

This method can be used for patients with regular cycles only.

This is done depending on the exact knowledge of ovulation day and avoiding intercourse during the days before and after ovulation; for example, in a regular period that occurs every 28 days, ovulation usually happens around day 14 but can vary, so intercourse (or unprotected intercourse) should be avoided from day 8 to day 19 of the cycle. This method is less reliable than other methods: with typical use, about 1 in 4 women become pregnant within a year. Many methods were found to detect ovulation days;

• Increase in body temperature by about o.5 C.

(The temperature rises only after ovulation has happened, so it confirms that the fertile time has passed rather than predicting it.)

• Change in type of cervical mucous
• You can easily find ovulation kits these days for ovulation day detection by measuring LH surge.

Diaphragm and cup for contraception:-

These devices are made of plastic, and take different shapes and sizes and act as a barrier preventing the seminal fluid from entering the cervix. They are placed vaginally before intercourse and are sometimes coated with a spermicidal gel to increase their efficacy. The size should be adjusted by the doctor.

Suppositories for contraception:-

Spermicidal preparations applied vaginally before intercourse.

Used alone, spermicides are one of the least effective methods (about 1 in 4 to 5 women become pregnant each year), and frequent use can irritate the vagina and increase the risk of infections, so they are best combined with another method.

Male and female condoms:-

• Male condoms:

Thin sheaths made of latex (or polyurethane for people with latex allergy) designed to cover the erect penis and collect the semen. Condoms lubricated with spermicide are no longer recommended, because they do not work better and may irritate the vagina.

Usually incorporated into an inner base, which itself may impair sperm activity, e.g. nonoxynol-9,0. These are available as creams, jellies, foaming tablets, pessaries, and aerosols. Condoms are safe and effective, unless they are perforated during use.

Condoms are the only contraceptive method that also protects against sexually transmitted infections, including HIV. With typical use, about 13 in 100 women become pregnant each year, so they must be used correctly every time.

• Female condom:-

Polyurethane sheath with its open end attached to a flexible polyurethane ring. Spermicidal agents may be used with it. It is not a very popular method.

Hormonal contraception:-

1- Contraceptive pills

One of the most commonly used reversible contraceptive methods worldwide.

Ovulation arrest will be induced by the hormones in these pills, thus preventing pregnancy.

There are many types of oral contraceptive pills differing in the concentration and type of estrogen and progesterone used.

Combined oral contraceptive pills (COC):

This type contains estrogen, usually ethinyl estradiol and progesterone. The dose of estrogen in modern pills is 20-35 micrograms (mcg); these low-dose pills are much safer than the older higher-dose pills, since the cardiovascular risks of the pills are mainly due to estrogen. Combined pills are available as monophasic preparation in which every pill in the packet contains the same dose of steroid and biphasic and triphasic preparation in which the dose of both steroids changes once or twice during the cycle; studies have not shown that these give better cycle control than monophasic pills, which are usually the first choice.

Mode of action of oral contraceptive pills:-

The principal mode of action is inhibition of ovulation. Estrogens inhibit pituitary FSH, thus suppressing the development of ovarian follicle while progesterone inhibits the surge of the luteinizing hormone (LH).

Advantages of using combined contraceptive pills as contraceptive method :-

• It regulates menstrual cycles.
• Bleeding amount gets less
• Duration of the cycle gets shorter
• Decreases premenstrual symptoms and dysmenorrhea
• chances of having benign breast lumps and functional ovarian cysts are reduced, and symptoms of endometriosis and acne vulgaris usually improve.
• There is substantial evidence that COC protects against ovarian and endometrial cancer.

Disadvantages and side effects of oral contraceptive pills:-

• • Weight gain is often feared, but large studies have not shown that modern combined pills cause significant weight gain
• • Fluid retention
• • Nausea and vomiting
• • Cloasma
• • Mood changes
• • Breast enlargement and mastalgia
• • Loss of libido
• • Tendency to hypercoagulability, risk of DVT (deep-vein thrombosis) and hypertension, and also the risk of myocardial infarction, especially if associated with smoking.
• Contraindications to using oral contraceptive pills

Absolute contraindication to oral contraceptive pills:-

• Ischemic heart disease
• Valvular heart disease
• Arterial thrombosis
• Venous thrombosis
• CVA (cerebrovascular accidents)
• Vascular malformation in the brain
• Pulmonary hypertension
• Severe hyperlipidemia with other cardiovascular risk factors (milder cases need individual assessment)
• Migraine with aura
• Active liver disease or tumor
• Porphyria
• Oestrogen dependent neoplasm
• Undiagnosed genital tract bleeding

Smoking 15 or more cigarettes a day at age 35 or over; blood pressure of 160/100 or higher; a known clotting disorder (thrombophilia); the first 3 weeks after childbirth; current breast cancer; major surgery with prolonged immobilisation.

Relative contraindication to oral contraceptive pills:-

• Current symptomatic gallbladder disease (treated or silent gallstones are not a contraindication)

• History of arterial and venous disease in the family. Smoking, advanced age, obesity, diabetes mellitus, and migraine are additional risk factors to taking COC.

• Hyperprolactinaemia, since oestrogen, stimulates the lactotrophes, increasing prolactin secretion.

Progestogen- only pills :-

This was introduced to avoid the side effects of estrogen. It prevents pregnancy by inhibiting ovulation, changes cervical mucus reducing sperm permeability and transport. It also has an effect on the endometrium that compromises implantation.

Indications to Progestogen- only pills:-

It is commonly prescribed for women in whom oestrogen is absolutely or relatively contraindicated.

• Contraindications to Progestogen- only pills:-

Absolute Contraindications:-

• Known pregnancy – the pill is not needed then; if it is taken accidentally in early pregnancy, it is not known to harm the baby.
• Undiagnosed irregular uterine bleeding
• Recent history of serious cardiovascular disease.

Relative Contraindications:-

• Breast cancer (current breast cancer is a reason not to use it; past breast cancer needs specialist advice)
• Severe hypertension
• Chronic liver conditions

Side effects to Progestogen- only pills:-

Irregular bleeding, headache, nausea, bloating, breast tenderness, and mood changes.

2. Injectable progestogen:-

The most widely used injection is medroxyprogesterone acetate (Depo-Provera), given as 150 mg intramuscularly every 12-13 weeks (or 104 mg under the skin every 13 weeks); norethisterone enanthate (NET-EN) is a different injection given as 200 mg every 8 weeks. It prevents ovulation.

Side effects to Injectable progestogen:-

• Inappropriate for women wishing short-term contraception because it may take one year to return to normal fertility after cessation of treatment.
• Weight gain and reduction in bone mineral density (BMD)
• Prolonged amenorrhea and irregular cycles.
• Spotting.

3-Progestogen only implants:-

The contraceptive implant (such as Nexplanon) is a long-acting hormonal method consisting of a single small flexible rod that slowly releases a low dose of the progestogen etonogestrel. First local anesthesia is given then. The rod is inserted just under the skin of the inner aspect of the upper arm. Insertion and removal are minor surgical procedures, which require specialized training. It is licensed for three years, it is one of the most effective methods available (fewer than 1 in 1,000 women become pregnant each year), and fertility returns rapidly after removal. Side effects to such a regimen are menstrual disturbances with a very low failure rate.

Hormonal methods for men that suppress sperm production are still being studied in research trials and are not yet approved for routine use. The technique consists of implanting rods that contain the hormones testosterone and progestin into the arm of the man under local anesthesia. Early results are promising, but these methods are not yet available outside clinical trials. Testosterone acts by turning off the signal from the pituitary gland that stimulates the testis to produce sperms, and progestin acts directly on the testis to decrease sperm production.

Surgical contraception

1. Female sterilization

Surgical female sterilization is done by blocking both fallopian tubes by three ways:

Laparotomy minilaparatomy laparoscopy

Laparotomy: Bilateral salpingectomy or hysterectomy may be preferable when there is a coexistent pathology while the other two ways are preferred because they are more effective and safe.

Methods of tubal occlusions:-

• *Tubal ligation by sutures, whether absorbable or non-absorbable, the ends left free or buried in the broad ligament or uterine cornue.
• *Using bipolar diathermy for electrocauterisation allows only the tissue held between the jaws of the forceps to be cauterized.
• *Falope ring: a specially designed applicator is used to place a ring of silicone or rubber over a loop of the tube. This destroys two to three cm of the tube.
• *Clips: A variety of clips are available: Hulka-clemens clip (stainless steel and polycarbonal and filshie clip) (titanium lined with silicon rubber). In this method, a smaller length of the tube is destroyed as compared to the ring.
• *Laser: using CO2 laser divides the tube very cleanly but may allow a high incidence of recanalization.
• *A number of chemical agents have been tested for their ability to occlude the Fallopian tube when installed into the tube either directly or transcervically via the uterus, e.g. 252 mg quinacrine pellet inserted through IUD inserter passed through the cervix. Inflammation and fibrosis will result and can occlude the tubes. However, the World Health Organization recommends against quinacrine sterilization because its safety is not established, so it should not be used; the surgical method is the accepted method.

Today many surgeons offer complete removal of both tubes (bilateral salpingectomy) by laparoscopy, as it is very effective and also reduces the future risk of ovarian cancer. Female sterilization should be regarded as permanent; about 1 in 200 women may still become pregnant after tubal clips or ligation.

2-Male sterilization:-

Vasectomy:-surgical occlusion of the vas deferens to prevent the passage of sperm.

Methods:-

• Clips
• Diathermy
• injection of sclerosing agents percutaneously or occlusive substances (such as silicone used in China).

The success of the procedure is confirmed by a semen test done about 12 weeks after the vasectomy (and after at least 20 ejaculations) showing no sperm, or only very few non-moving sperm. Other contraception must be continued until the semen test confirms that the vasectomy has worked, usually about 3 months after the procedure.

Points discussed before using any contraceptive method:

• *Use of COC for curing menstrual symptoms.
• *Size of the family and possible desire for future pregnancy.
• *Maternal disease threatening her life.
• *Sexual life pattern.
• *Maternal age and risk of side effects.
• *Reversibility of the method used.
• *Educational state of couples.
• *Cost.
• *Choosing which partner to sterilize.

Reversal of sterilization

This is required if the sterilization was done at a young age or immediately postpartum or after a therapeutic abortion. A change of partner is the commonest reason for requesting reversal.

Reversal of female sterilization involves laparotomy, but may fail. Microsurgical techniques are associated with around 70% success and carry a high risk of ectopic pregnancy. Ovulation should be confirmed and semen analysis done before reversal is undertaken. Reversal of vasectomy is technically feasible in many cases with patency rate 90%, but pregnancy rate reaches only 70%, and may be due to antisperm antibodies.

Emergency contraception

If you have had unprotected sex or think your method might have failed, there are three emergency options: two emergency pills (levonorgestrel within 72 hours, or ulipristal acetate up to 120 hours, which is more effective) and the copper IUD. The copper IUD is the most effective emergency method (it prevents more than 99% of pregnancies) and can then be kept as regular contraception; it must be inserted up to five days after sex, or up to five days after the earliest time you could have released an egg (ovulation).

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist