2. • Fertility control is the use of any method or device to
prevent pregnancy.
• It is also called Birth control, Family planning or
Contraception.
• Fertility control techniques can be divided into..
Temporary contraceptive methods
Permanent contraceptive methods
2
5. • Total abstinence
• Coitus interruptus
• Lactational amenorrhea method
- Exclusive breast feeding
- Menstruation has not started
- Up to 6 months postpartum
• Methods based on fertility awareness
- Calendar method or rhythm method
- Basal body temperature method (BBT)
- Cervical mucous (Billing’s method)
- Symptothermal method
- High tech hormonal monitoring 5
6. They are especially suitable for the following people..
- Those who have contraindications to OCs & IUCDs
- Those who can not tolerate OCs & IUCDs
- Those who take a break, for a period of time from OCs & IUCDs
- Those who are sexually active with a number of partners
- Those who for personal reasons prefer not to use OCs & IUCDs
6
8. • It is made up of fine latex material and is disposable one.
• Thick rubber washable (reusable) condoms used in past
are now, outdated.
• Latex condoms are available in different sizes from 160 –
180 mm length, 49 – 52 mm in flat width and thickness
varying from 0.04 to 0.07 mm.
• It may be plain or there is teat at the tip for collection of
semen during ejaculation.
8
9. • It should be applied on erect penis & prelubricated one is preferred.
• If there is no teat, some space pressed empty of air is left at the end.
• During sexual act, after ejaculation is over one should be sure that condom does
not get dislodged from the penis. i.e. penis should be withdrawn while still erect
and condom should be held firmly at the root of penis.
• Chemical contraceptive (Spermicidal jelly) used along with it gives extra
protection and lubrication.
• Don’t use lubricants made with oil. Most of them damages condom.
• Heat, light, humidity, fingernails & rings or unrolling of condom can also
damage it. Thus, handle it carefully before use.
• Checking the condom before throwing it away is also advisable. If it is torn, use
one of the emergency contraceptive methods. 9
10. • New polyurethane condoms are non latex condoms.
• Polyurethane is resistant to deterioration and stronger than
latex. It is useful for those who are sensitive or allergic to latex.
• Tactylon is a new condom made up of synthetic material styrene
ethylene butylene styrene (SEBS).
• The newer condoms are claimed to have less odour, fit more
comfortably and are less constricting. However, they break or slip
more often during intercourse than latex condoms. Yet the failure
rate is almost same.
10
11. • Easy to use
• Relatively cheap
• Easily available without prescription and does not require medical
supervision
•Protects against common vaginal infections i.e. trichomoniasis and
moniliasis as well as STDs like syphillis, gonorrhea, chlamydia,
herpes virus & HIV.
• Protects against Ca. Cervix as it is caused by highly oncogenic
strains (16 & 18) of HPV, which is sexually transmitted.
• Safe. (No hormonal side effects)
• Can be used at any age
• Often helps prevent premature ejaculation
• Can be used where pills and IUCD are contraindicated. i.e. follow
up of vesicular mole, diabetes and valvular heart disease.
11
12. • Failure rate is high as compared to IUCD and pills.
• Because it prevents full genital contact, many are
complaining about decreased sensation and thus making
intercourse less enjoyable.
• In male partner, rarely it causes psychological
disturbance and even impotence is reported.
• Disposal is a social problem. It may embarrass some to
buy condoms.
• Hypersensitivity reaction to either partner.
12
13. Failure rate : 3 – 18/ 100 women year observation.
Causes of failure :-
• Incorrect use
• Inconsistent use
• Defective condoms
• Tearing or bursting of condom while intercourse
Other uses :-
• In TVS, applied over probe
• For preparation of mould in vaginoplasty
• Immunological cervical factor in infertility
Husband should use it for 3-6 months so the antibody level against the sperms in
cervical mucous decreases. Then chances of pregnancy increases.
• Threatened abortion – After 4 to 6 weeks if couple resumes sexual relations, male should
use condom because semen contains prostaglandins which may cause abortion.
13
14. • A female barrier contraceptive
• Consists of two flexible polyurethane rings located at either end of
a 15 cm soft loose fitting polyurethane sheath.
• The inner ring is placed high in vagina while outer ring covers labia
& base of penis.
• Prelubricated with silicone based lubricants.
14
15. Advantages :-
• Controlled by woman
• Prevents STD more effectively than condom as it covers some
perineal area also.
• Less allergic reaction as it is made up of Polyurethane.
• More convenient than male condom as there is no need to remove
it immediately after ejaculation.
• less chances of tearing.
Disadvantages :-
• Expensive (at least at present)
• Some women also feel difficulties in insertion
15
17. • A female barrier contraceptives
• It is saucer shaped synthetic rubber diaphragm with flexible metal ring in
its rim.
Method of Use :-
• Patient should be able to feel her cervix by self examination.
• Spermicidal jelly is smeared on both sides of diaphragm and some jelly is
taken in hollow.
• It is inserted before the sexual act in squatting position.
•It should be kept for minimum 6 hours after sexual act. It remains in
position by tension of the ring and elasticity of vaginal wall.
Contraindication :-
• Uterine or vaginal wall prolapse
• Local infection and allergy to rubber. 17
18. Failure Rate :- 4 – 12/ 100 women years
Can be due to..
-Wrong size or improper insertion
- Lack of spermicidal jelly
- Defect in diaphragm or displacement during coitus
Advantages :-
• Relatively cheap
• Used by female. So, co-operation by male partner is not required
• Doesn’t interfere with natural coitus or orgasm of either partner
• Gives some protection against PID
Disadvantages :-
• Failure rate is high as compared to IUCDs and pills
• Allergic reaction to rubber can occur
• Vaginitis, UTI and rarely TSS are reported
• In sensitive patients, it may cause embarrassment and thus high degree of motivation is
required for its use. 18
20. • First generation devices (Innert or Unmedicated devices)
e.g. Lippes loop
• Second generation devices (Bioactive or Medicated devices)
They contain metals like copper, zinc, silver or containing
hormones
e.g. TCu-380, Mirena, Progestasert
• Hormone containing IUCDs are often called the Third generation
devices
20
21. • It is a T shaped IUCD made from low density polyethylene with barium
sulphate added for x-ray opacity.
• Copper wire is wound tightly around the vertical stem (surface area 310
mm2). There are two solid copper sleeves on transverse arms (each has
surface area of 35mm2).
• Its applicator, made up of synthetic plastic consists of cannula with
guard and a plunger rod.
• The CuT 380 S (slimline) has the copper wire on vertical stem as usual
but copper sleeves are at the ends of horizontal arms (as against middle
of each arm in 380A) embedded into the arms.
• In T Cu-380 Ag, copper wire on the vertical stem has a silver core which
prevents fragmentation of copper & prolongs the effective life of the
device. 21
23. Time of Insertion :-
-During menstrual period from 2nd day onwards or within 10 days of
menstruation
- Immediately after first trimester MTP or spontaneous abortion
- Postpartum period
- At the time of LSCS
Lifespan :-
CuT 380A is for 6 – 10 years. There is no time limit for non
medicated device. They can remain for several years without causing
any harm.
23
24. Contraindications :-
Absolute :-
• Abnormal menstruation – irregular, heavy or prolonged
• Suspected pregnancy
• Recent or past pelvic infection
• Suspected malignancy of genital tract
• Uterine anomalies or uterine pathologies like Bicornuate uterus,
fibroid
• Bleeding disorders
Relative :-
• Nulliparous patient
• Previous LSCS or other scar on uterus
• Local infections like cervicitis or vaginitis
• Moderate or severe anemia 24
25. Method of insertion :-
-Patient is explained about the type, principle, side effects and failure rate,
etc. of the device.
- Informed consent
- Detailed history and pelvic examination for contraindications
- Full aseptic precautions
- Uterine sounding to know the direction and length of utero cervical canal.
Loaded applicator is introduced with guard previously adjusted at the total
utero cervical length of that patient. So when the guard is at external os,
tip of the applicator with Cu T is at fundus
Now plunger is fixed by one hand and cannula is withdrawn over it, so CuT
is released high up at fundus without being pushed.
Then plunger is withdrawn, cannulas withdrawn and threads are cut for 2-
3 cm from external os so that patient can easily feel it by self examination.
25
26. Mechanism of Action :-
-Presence of device with its nylon thread occupies some space in the uterus and causes
mechanical obstruction to ascent of sperms.
- Transcervical threads cause changes in the cervical mucous and make it hostile to sperms.
- IgM levels in serum is increased so antifertility action is in part to their ability to produce
antibodies.
Action of copper :-
- Directly damages sperms and fertilized ovum
- Causes biochemical changes in cervical mucous and renders it hostile. Sperm motility and
capacitation are affected.
- Changes in Endometrium :- Enzymatic inhibition i.e. Carbonic anhydrase (Copper replaces
zinc), Decrease in glycogen contents of cell, Increase in fibrinolytic activity of endometrium,
Endometrial vasoconstriction and ischemic damage
- Increase in tubal motility to fertilized ovum before it is mature for implantation, reaches
uterus which is also unprepared.
- Increases uterine contraction which result in expulsion of newly implanted ovum. 26
27. Failure Rate :-
0.3 to 0.8/ hundred women years for CuT 380A.
Side effects & Complications :-
• Heavy or prolonged periods, especially in first 2-3 months
• Cramps like pain in lower abdomen
• Dysmenorrhea
• Pelvic infection
• Displacement of the device
• Spontaneous expulsion : the rate is 5-15/1000 insertion
• Ectopic pregnancy
27
28. Advantages :-
-Simple to use
- Immediate return of fertility on removal of device
- Cheap
- No systemic side effects
- Effective in long term
Disadvantages :-
-Side effects and complications
- Does not prevent HIV/ STDs
- Can’t use on her own or stop on her own. Some medical help required for insertion &
removal
- may come out without woman’s knowledge
Other uses :-
-After breaking of adhesion in a case of uterine synechia to prevent refusion of walls
- After Straussman operation – to prevent fusion of anterior and posterior wall.
28
29. (1)LNG 20 (Mirena, LNG intrauterine system) :-
• T shaped device with flexible arms
• Nova T shape with capsule on the stem
• The core of the capsule contains mixture of silicone rubber & 52 mg levonorgestrel,
which is released at 20 µg/ day.
• It is effective for 5 years.
Dual mechanism of action :- IUCD as well as hormonal contraceptive
Other uses :- Helps in treatment of DUB, fibroids, adenomyosis & Endometriosis
Failure rate :- 0.1 to 0.2 per 100 women in the first year of use
Side effects (Due to hormones) :- Nausea, vomiting, headache, acne, dizziness, breast
tenderness, weight gain, ovarian cyst 29
31. (2) Progestasert :-
• It was the first hormone containing IUCD developed in 1976.
• It contains 38 mg progesterone in vertical arm, dispensed in silicon oil &
daily releases 65 µg progesterone.
• Progesterone has added contraceptive effect. It causes decidual changes
in the endometrium and glandular atrophy which interfere with normal
reproductive process.
• It is useful where use of another device has caused excessive bleeding
or cramping which may be relieved by progestasert.
• But, on the other hand, spotting and chances of ectopic pregnancy are
increased with it.
• Unlike Cu T, it is to be replaced every year.
31
33. • They contain synthetic female hormones (estrogen and progesterone)
which are steroid in nature.
Types :-
Oral : Commonly known as pills or OC pills
- Combined
- Phasic
- Minipill
- Newer pills
Injectable – Intramuscular
Newer sustained release systems
33
34. • Combination of estrogen and progesterone
• 21 tablets with 7 placebo tablets containing iron and vitamins to complete the
menstrual cycle
• Commonly used estrogen : Ethinyl estradiol (EE) 30µg
• Commonly used progesterone : Norethisterone 1 mg
• It is started from any of the first 5 days of the cycle. It is taken daily one, preferably at
bed time for 21 days. Second pack is started after 7 days irrespective of onset or stoppage
of menstruation.
• In a family planning programme it is supplied free of charge by government: Mala – D &
Mala – N.
• Mala – D : Estrogen 30 µg + Norgestrel 0.3 mg
• Mala – N : Estrogen 30 µg + Norethisterone 1 mg
34
36. • Biphasic or Triphasic
• Biphasic : All 21 tablets contain E + P but dose of progesterone
doubled after first 10 days, dose of estrogen remain constant.
• Triphasic : All 21 tablets contain E + P but dose vary in 3 phases.
Triquillar :
EE Levonorgestrel Days
30 µg 50 µg 1 – 6
40 µg 75 µg 7 – 11
30 µg 125 µg 12 - 21
36
37. • Contains only progesterone. i.e. Norgestrel 75 µg or Norethisterone 350 µg or
Levonorgestrel 30 µg
• Newer estrogen free pill available in India is Cerazette containing 75 µg
Desogestrel, to be taken daily one throughout the cycle & at the same time each
day.
• It inhibits ovulation & also acts locally by making endometrium unreceptable
for implantation and renders cervical mucous hostile to sperms.
• It avoids undesirable side effects of estrogen found with combined pills and
sickle cell patients or lactating mothers can take it.
• Menstrual irregularities and amenorrhea are common with its use.
• Side effects contributed to progesterone content can occur. i.e. alopecia, loss of
libido, weight gain, nervous irritability.
37
38. Intimacy plus 2, Femilon : They contain only 20 µg ethinyl estradiol &
150 µg Desogestrel. (Desogestrel is a new progesterone which has
minimal androgenic side effects – reduces the risk of cardiovascular
diseases)
Once a month pill : Each pill contains 3 mg of Quinesterol (long
acting estrogen) & 12 mg megesterol acetate (progesterone)
Pill with antiandrogenic effects :- It contains ethinyl estradiol (35 µg)
+ cyproterone acetate (2 mg)
Rasmin & Yasmin : EE (30 µg) + Drospirenone (3 mg) (Aldosterone
derivative)
- Due to antiandrogenic effects they are useful in patients with PCOS,
acne, hirsutism & androgenic alopecia. 38
39. Mechanism of Actions :-
Pills containing estrogen & progesterone work in following ways..
• Their main action is inhibition of ovulation. They act at
hypothalamic level inhibiting release of GnRH. Secretion of FSH &
LH from pituitary are thus suppressed, so there is no follicular
growth. As there is no LH surge, ovulation is suppressed.
• They alter the maturation of endometrium, making it unsuitable
for implantation. Under the effect of progesterone there is stromal
edema with glandular atrophy.
• Progesterone makes cervical mucous thick, viscid and
impermeable to sperms.
39
40. Contraindications :-
According to revised criteria of WHO in 2009, there are four categories..
(for any method)
Category I : No restriction for use of the contraceptive method
Category II : Advantages generally outweigh the risks. The method is
used with precautions
Category III : Theoretical or proven risks usually outweigh the
advantages. The method generally should not be used. An alternative
method is preferred. However, health personnel may make an exception
in an individual case with her informed consent.
Category IV : A method that represents an unacceptable health risk. It
should not be used.
40
41. For OC pills :-
Absolute :-
-Thrombo embolic disease
- Acute or chronic diseases of liver
- Cancer of breasts or genitals
- Known or suspected pregnancy
Relative :-
-Hypertension & Diabetes
- Valvular heart disease
- Epilepsy
- Smokers over 35 years
- Sickle cell anemia & Thalassemia
- Asthma & allergic disorders
- Varicose veins
- Obesity
- Elective surgeries 41
42. Side effects and Complications :-
• Nausea & Vomiting
• Breakthrough bleeding
• Absence of withdrawal bleeding (Pill amenorrhea)
• Hypertension
• Cardiovascular diseases
Venous thromboembolism
Myocardial infarction
Cerebrovascular stroke
• Weight gain & fluid retention
• Pain, tenderness and engorgement of breasts
• Glucose tolerance is impaired
• Higher risk of breast and cervical carcinoma
• Teratogenicity
42
43. Failure Rate :- 0.11 to 0.58/ HWY due to..
• Irregular taking
• In very first cycle, if it is not started from the 1st day
• Malabsorption disorders
• Taken along with the drugs like Rifampicin, Penicillin, Tetracycline, Ampicillin, Phenytoin,
Sulfonamides, etc.
Missing a pill :-
• If patient forgets to take one white tablet (hormonal), she should take it as soon as she
remembers and 2nd pill is taken as usual.
• If she misses for two consecutive days, then for 7 days she should avoid sex or use other
protective measures like condoms.
• If seven or more white tablets are left in the pack, she should take all the rest of the
pills as usual.
• If less than seven tablets are left in the pack, take rest of the white pills as usual. Don’t
take brown tablets & start a new pack after the last white tablet of previous pack. She
may miss a period, but that is alright.
• Missing one or more brown tablet is of no significance. 43
44. Other uses of pills :-
-Regularization of cycles
- In cases of DUB
- Endometriosis (taken continuously for 6-9 months and not in cyclic manner as in
other indications)
- Postponement of menstrual period
- Suppression of functional ovarian cysts
Beneficial Side Effects :-
-Menstrual comfort : regularization of cycle & blood loss is controlled
- Prevents PID : Cervical mucous is thickened, menstrual blood loss is reduced,
uterine contractions are inhibited. Thus spread of infection to tubes is prevented
- Prevents ectopic pregnancy
- Lowers risk of endometrial cancer : Because of progesterone component
- Lowers risk of ovarian cancer : Because of suppression of pituitary secretion of
Gonadotropins and ovulation
- Protection against benign breast diseases and functional ovarian cysts
44
45. Injectable
Contraceptives
Long acting
Progestins
Combined
Injectables
(E + P)
1. Depot Medroxy progesterone acetate
(DMPA) – 150 mg every 3 months
2. Norehisterone Enanthate (NET – EN) –
200 mg every 2 months
1. DMPA 25 mg + Estradiol cypionate 5 mg –
monthly
2. NET – EN 50 mg + Estradiol Valerate 5 mg
- monthly
Failure Rate : <1/ 100 women years
45
46. • An emergency measure to prevent pregnancy following an unprotected but possibly
fertile intercourse.
• Indications are…
- Failure of barrier method
- Unsuccessful coitus interuptus
- Missed Oral contraceptive pills
- Sexual assault
Progesterone only pill :-
Levonorgestrel 0.75 mg 2 doses 12 hours apart.
First dose should be started as early as possible but within 72 hours.
Recent evidences show that instead of 2 doses 12 hours apart, single dose of 1.5 mg is
equally effective.
If taken in first 12 hours, failure rate is only 1% and if taken later, but within 72 hours,
failure rate is 2% 46
47. Yuzpe Method :-
- Combined OC pills containing ethinyl estradiol 50 µg and norgestrel 500 µg (or
levonorgestrel 250 µg) are taken
-2 pills as early as possible & 2 after 12 hours of first dose.
- Most effective if first dose is taken within 12-24 hours of intercourse but it should be
taken within 72 hours.
- OC pills containing lower dose of estrogen (30 µg) should be taken as 2 doses of 4 pills,
12 hours apart.
- Failure rate ranges from 0.2 to 2%.
IUCD :-
Insertion of copper IUCD within 5 days of intercourse. (later than hormonal method)
Reported failure rate is 0.1%
Antiprogesterone :-
Mefipristone 600 mg oral single dose within 72 hours of unprotected intercourse.
Recently, doses as low as 50 & even 10 mg are found effective
47
48. Tubectomy :-
In tubectomy, the fallopian tubes are cut and both the cut ends are
ligated.
It prevents entry of ovum into uterus.
The operation is done through vaginal orifice in the postpartum
period. During other periods, it is done by abdominal incision.
Recently, Tubectomy is done quickly (in few minutes) by using a
laproscope.
Though tubectomy causes permanent sterility, if necessary
recanalization of fallopian tube can be done using plastic tube by
another surgical procedure. 48
49. Vasectomy :-
In vasectomy, the vas deferens is cut and the cut ends are
ligated. So the sperms cannot enter the ejaculatory duct and
the semen is devoid of sperms.
It is done by surgical procedure with local anesthesia. If
necessary, the recanalization of vas deferens can be done
with plastic tube.
49
