Birth Control

Birth Control

Birth control measures are an essential aspect of day to day life. From the prevention of unwanted pregnancy to avoidance of sexually transmitted diseases, birth control measures have multiple purposes.

Types of Temporary Birth Control Measures:

Natural Methods

Fertility awareness methods:
Calendar method Recording of basal body temperature Cervical mucus technique Coitus interruptus Barrier Methods Calendar method

• Male condoms

• Female condoms

• Vaginal sponge

• Spermicidal agents

• Cervical cap

• Diaphragm

• Hormonal Contraceptives

• Oral Pills

• combined pills

• triphasic pills, monophasic pills

• progesterone only pills

• Injectable Preparations

• depot hydroxy progesterone acetate

• depot norethisterone

Intra Uterine Contraceptives

• Copper T

• Lippe’s Loop

• Progestasert

• Mirena

Permanent Birth control:

• Tubectomy in women

• Vasectomy in males

Fertility  Awareness  Method:

Fertility Awareness Method requires partner’s cooperation. The woman should know the fertile time of her menstrual cycle.

Rhythm Method:

This is  the only  method  approved by  the  Roman  Catholic  Church.  The method is based on the identification of the fertile period of a cycle and to abstain from sexual intercourse during that period.  This requires  partner’s  cooperation.  The methods  to determine  the approximate  time  of ovulation and  the fertile period  include  — (a) recording of previous  menstrual  cycles (calendar rhythm) (b) noting  the basal body temperature chart  (temperature rhythm) and (c) noting  excessive mucoid vaginal discharge (mucus  rhythm).  The users  of the calendar method obtain the period  of abstinence from calculations based on the previous twelve menstrual cycle records.  The first unsafe day is obtained by subtracting 20 days from the length of the shortest cycle and  last unsafe day  by deducting 10 days from the  longest cycle.  Users of temperature  rhythm  require  abstinence  until  the third  day of the rise  of temperature.  Users of  mucus rhythm  require abstinence on all days of noticeable mucus and for 3 days thereafter.

Coitus Interruptus (withdrawal) :  

It is the oldest and probably the most widely accepted contraceptive method used by men.  It necessitates withdrawal of penis shortly before ejaculation. It requires sufficient self-control by the man so that withdrawal of penis precedes ejaculation.

Breastfeeding,  Lactational Amenorrhea (LAM):

Prolonged  and  sustained  breastfeeding  offers natural protection from pregnancy. This is more effective in women who are  amenorrheic than those who are menstruating. The  risk of pregnancy to a woman who  is  fully breastfeeding and  amenorrheic  is  less  than  2 percent  in  the  first 6 months. Otherwise, the  failure rate  is  high (1–10 percent). Thus  during breastfeeding, additional contraceptive support should  be given by condom,  IUCD or injectable steroids  where available to provide complete contraception. When the women are  full breastfeeding, a contraceptive method should be used in the  3rd postpartum month and with partial or no breastfeeding,  she should use it in the 3rd postpartum week. Fertility awareness based methods are:  (1)  Natural contraception  (Rhythm  method,  Coitus  interruptus and Lactational amenorrhea method) (2)  Barrier method  (Condoms, diaphragm and spermicides).

Calendar Method:

This is a very safe method because it does not have any adverse reactions or any discomfort. The disadvantage is that it is mostly a failure and requires lots of self-determination. It includes identifying fertile periods during the month and avoiding sex during that period. Fourteen days before the next period is the time of ovulation, two days before and three days after this date is considered as a fertile period. The failure rates are high in this method.

Recording of Basal Body Temperature:

The temperature of the body increases to up to 1-degree celsius during ovulation. Hence, regularly recording the woman's body temperature may help pick up the time of ovulation and avoid sexual intercourse during that period. There are too many confounding factors associated with this method and the failure rate is high. Similarly, the cervical mucus test can also be used to identify the time of ovulation. But these are obsolete and cannot be followed regularly.

Barrier Methods:

These methods prevent sperm deposition in the vagina or prevent sperm penetration through the cervical canal. The objective is achieved by mechanical devices or by chemical means which produce sperm immobilization, or by combined means. The following are used.

CONDOM (MALE):

Condoms are made of polyurethane or latex. Polyurethane condoms are thinner and suitable to those who are sensitive to latex rubber. It is the most widely practiced method used by the male. In India, one particular brand (latex) is widely marketed as ‘Nirodh’. The efficacy of condoms can be augmented by improving the quality of the products and by adding spermicidal agents during its use. Protection against sexually transmitted disease is an additional advantage. Occasionally, the partner may be allergic to latex. The method is suitable for couples who want to space their families and who have contraindications to the use of oral contraceptive or IUD. These are also suitable to those who have infrequent sexual intercourse.

The Female Condom (Femidom) :

It is a pouch made of polyurethane which lines the vagina and also the external genitalia. It is 17 cm in length with one flexible polyurethane ring at each end. The inner ring at the closed end is smaller compared to the outer ring. The inner ring is inserted at the apex of the vagina and the outer ring remains outside. It gives protection against sexually transmitted disease and pelvic inflammatory disease. It is expensive. Multiple uses can be made with washing, drying and with lubrication. The failure rate is about 5–21/HWY.

Diaphragm:

It is an intravaginal device made of latex with flexible metal or spring ring at the margin. Its diameter varies from 5–10 cm. It requires a medical or paramedical personnel to measure the size of the device. The distance between the tip of the middle finger placed in the posterior fornix and the point over the finger below the symphysis pubis gives the approximate diameter of the diaphragm. The diaphragm should completely cover the cervix. As it cannot effectively prevent the ascent of the sperms alongside the margin of the device, the additional chemical spermicidal agent should be placed on the superior surface of the device during insertion, so that it remains in contact with the cervix. The device is introduced up to 3 hours before intercourse and is to be kept for at least 6 hours after the last coital act. Ill fitting and accidental displacement during intercourse increase the failure rate.

Vaginal Contraceptives

Not suitable for women with uterine prolapse. Failure rate—16 (HWY)

Spermicides:

Spermicides are available as vaginal foams, gels, creams, tablets and suppositories. Usually, they contain  surfactants like nonoxynol–9,  octoxynol or  benzalkonium  chloride. These agents mostly cause sperm immobilization.  The cream or jelly  is introduced high in the vagina with the help of the applicator soon before  coitus.  Foam tablets  (1–2) are to be introduced  high in the vagina at least 5 minutes prior to intercourse. In isolation, it is not effective (18–29 HWY), but enhances  the efficacy of condom  or diaphragm  when used  along with it. There may be occasional local allergic manifestations either in the vagina or vulva.  

Vaginal Contraceptive Sponge (Today):

It is  made  of  polyurethane impregnated with 1 g of  nonoxynol-9 as  a spermicide. Nonoxynol-9 acts as a surfactant which either  immobilizes or kills sperm.  It  releases spermicide during coitus, absorbs ejaculate and blocks the entrance to the cervical canal. The sponge  should not be removed  for 6  hours  after intercourse.  Its  failure rate (HWY)  is  about  —  Parous women: 32-20,  Nulliparous 16-9. Currently  it is observed that  nonoxynol–9 is not effective in preventing  cervical gonorrhea, chlamydia or HIV infection. Moreover, it  produces lesions in the  genital tract when used frequently. Those lesions are associated with increased risk of HIV transmission.

Intrauterine Contraceptives:

The intrauterine device has been used throughout the world. During the last couple of decades, however, there has been a significant improvement in its design and content. The idea is to obtain maximum efficacy without increasing the adverse effects.  The device  is classified  as open, when it has got no circumscribed  aperture of more  than  5 mm  so  that  a  loop  of  intestine  or omentum  cannot  enter  and become  strangulated  if, accidentally, the device perforates through  the uterus into the peritoneal cavity. Lippes loop, Cu T, Cu 7, Multiload and Progestasert  are examples  of  open  devices.  If closed devices, like Grafenberg ring and  Birnberg bow, accidentally enter  the  abdominal cavity, they  have the  potential  of causing strangulation  of the  gut; and hence are obsolete. The  device  may  be  non-medicated  as Lippes  loop  or  medicated  (bioactive)  by incorporating a  metal copper, in devices like Cu T-200, Cu T-380A, Multiload-250, Multiload-375.

Intrauterine contraceptive device  is  a widely acceptable reversible method  of  contraception for  spacing  of  births.  Amongst many, either a copper impregnated  device like Cu T, multiload  or a hormone releasing device like LNG-IUS  is  commonly used. Its mode of  action  is  not  clear.  Probably,  it  produces  nonspecific  biochemical  and  histological  changes  in  the  endometrium and  ionized  copper has got spasmolytic  and genotoxic effects. LNG-IUS induces  uniform  suppression  of  endometrium and produces very scanty cervical mucus.  It should not be used in newly married  women or  when any pelvic pathology is present.  The device can be introduced in the interval period or following abortion or childbirth. The introduction is  an  outdoor  procedure and  can  be  done  even  by a  trained  paramedical personnel  without anesthesia.  The  technique employed is either “push-out” in Lippes loop or “withdrawal” in Cu T.  The immediate complications  include cramp-like pains  or  even syncopal  attacks.  The delayed  complications  include  pelvic  pain, menstrual  irregularities, expulsion of  the IUD  or even perforation of the uterus. Complications  are much  less  with third generation of IUDs.  The indications  of its removal are,  missing  threads,  persistent pelvic  pain, menorrhagia, pregnancy, displacement  of  the device  and  flaring up of pelvic infection. While Cu T 200 should be  removed after  3–4 years, multiload 375 is replaced after 5 years, Cu T 380A  after 10 years  and  LNG-IUS  after 5 years. The  failure rate is  about 0.5–2 per HWY. Copper device  can  also  be used  as  postcoital contraception and following synaecolysis.

Steroidal Contraceptives:

Enovid  (norethynodrel  10  mg  and  menstranol  0.15  mg)  was  used  in  the  first  contraceptive  field  trial  in  Puerto Rico  in  1956  by  Pincus  and his colleagues.  Intensive  pharmacological research  and clinical  trials  were  conducted during the following years to minimize the adverse effects of estrogen without reducing the contraceptive efficacy, resulted in lowering the dose of estrogen to a minimum of 20  µg or even 15  µg in the tablet.

Oral Contraceptives:

Combined Pillls:

The  combined  oral  steroidal  contraceptives  is  the  most effective  reversible  method  of  contraception.  In the combination pill,  the commonly used progestins are either levonorgestrel or norethisterone or desogestreland the estrogens are principally confined to either ethinyl-estradiol or menstranol  (3 methylether of ethinylestradiol). Currently ‘lipid friendly’,  third generation progestins,  namely desogestrel, gestodene, norgestimate are available. Some of the preparations available in the market are mentioned in the Table 35.8. Only Mala-N is distributed through government channel free of cost (Fig. 35.8). 4th generation:  Drospirenone  which is an analogue of spironolactone is used as progestin. It  has antiandrogenic and antimineralocorticoid action. It causes retention of K+.

Instruction:

New users  should normally start their pill packet  on day one of their  cycle.  One tablet is  to be taken daily  preferably at bed time  for  consecutive  21  days.  It is  continued  for  21 days  and then have a 7 days  break, with this routine there is  contraceptive protection from  the first pill. Next pack should be started on the eighth day, irrespective of bleeding (same  day of the week, the pill finished). Thus,  a  simple regime  of  “3  weeks  on  and  1  week  off”  is  to be  followed.  Packing  of  28  tablets,  there  should be no break between packs. Seven of the pills are dummies and contain either iron or vitamin preparations. However, a woman can  start the pill up to day 5 of  the bleeding. In that case  she  is  advised  to use  a condom for the next  7 days. The pill should be  started on the  day after  abortion. Following  childbirth  in non-lactating woman, it is  started  after 3 weeks  and  in a lactating woman, it is  to be withheld  for 6 months .

Follow-up:

The patient should  be examined after 3 months, then after 6 months and then yearly.  The patients above  the  age of 35  should  be  checked  more frequently.  At  each  visit,  any adverse symptoms  are  to be noted. Examination of the breasts, weight and blood pressure recording and pelvic examination including cervical cytology, are to be done and compared with the previous records. MISSED  PILLS:  Normally there is return of pituitary and ovarian follicular activity during the pillfree  interval  (PFI)  of  7  days.  Breakthrough  ovulation  may  occur  in  about  20 percent  cases  during  the  time. Lengthening  of  PFI due to  omissions,  malabsorption,  or  vomiting  either  at  the  start  or  at  the  end  of  a  packet, increases the risk of breakthrough ovulation and therefore pregnancy.

Minipills:

POP is  devoid  of any estrogen compound.  It contains very low dose  of a progestin in any one of the following form  — Levonorgestrel 75  µg, norethisterone 350  µg, desogestrel  75  µg, lynestrenol 500  µg or norgestrel 30  µg. It has to be taken daily from the first day of the cycle.

Emergency Contraception:

Unprotected  intercourse,  condom  rupture,  missed  pill,  delay  in  taking  POP  for more  than  3  hours,  sexual  assault  or  rape  and  first  time  intercourse,  is known  to  be  always unplanned.  Risk  of pregnancy following a single act of unprotected coitus around the time of ovulation is 8 percent.

Morning-After Pill:

This  is  not true  contraception  but has  rightly been called  interception, preventing conception in the case  of  accidental  unprotected exposure  around  the time of  ovulation.  Drugs commonly used, levonorgestrel, ethinyl-estradiol 2.5 mg. The drug is taken orally twice daily for 5 days, beginning  soon after the exposure but not later than 72 hours. Levonorgestrel  (E.  Pills) 0.75  mg, two  doses  given at 12 hours interval, is very successful and without any side effects. The two tablets (1.50 mg) can be taken as a single dose also. The first dose should be taken within 72 hours . No  fetal adverse effects has been observed when there is failure of emergency contraception.  However, induced abortion should be offered to the patient, if the method fails.

Combined hormonal regimen (Yuzpe method) is equally effective. Two tablets of Ovral (0.25 mg levonorgestrel and 50  µg ethinylestradiol) should be taken as early as possible after coitus (< 72 hours) and two more tablets are to be taken 12 hours later. Oral antiemetic (10 mg metoclopramide) may be taken 1 hour before each dose to reduce the problem of nausea and vomiting. Anti-progesterone:  Anti-progesterone (RU  486-  Mifepristone)  binds  competitively  to  progesterone  receptors  and  nullifies the effect of endogenous progesterone. Dose:  A  single dose  of  100 mg  is  to be taken within 17  days  of  intercourse. Implantation is  prevented  due  to its  antiprogesterone effect. Pregnancy rate is 0–0.6 percent. Ulipristal  acetate  as  an  EC  is  as  effective as  levonorgestrel.  A  single dose  30  mg,  to  be taken  orally as soon  as  possible or within 120 hours of coitus. It acts by suppressing follicular and endometrial growth. It delays ovulation and inhibits implantation. It should not be prescribed to women with severe hepatic dysfunction or severe asthma.

Permanent Methods:

Permanent  surgical  contraception,  also  called  voluntary  sterilization,  is  a  surgical  method  whereby  the reproductive function of an individual male or female is  purposefully and permanently destroyed.  The operation done on male is vasectomy and that on the female is tubal occlusion,  or tubectomy.  Couple must be counseled adequately before any permanent procedure is undertaken. Individual procedure must be discussed in terms of benefits, risks, side effects, failure rate and reversibility.