FERTILITY CONTROL AND CONTRACEPTION

Asmaa al sanjary 2015

Family planning plays a critical role in promoting personal health of the women ,optimizing both maternal and fetal well being Every year 600000 women die world wide from pregnancy and pregnancy related causes.In developing countries the estimated average annual risk of dying from causes related to pregnancy and childbirth may be about 1 85 per 100,000 women not using contraception

3 million women suffer significant perminant disabilities.

Many STD can be prevented by contraception. (HIV )infection.

There is no one method that will suit everyone, and individuals will use different types of contraception at different stages in their lives.

the ideal contraceptive method should: •highly effective

•no side effects •cheap

•rapidly reversible •widespread availability

•acceptable to all cultures and religions •easily distributed

• can be administrated by non- health care personel.

As effective as modern contraceptives have been , they have not yet achieved their full potential.

Many unintended pregnancies still occur in a women who are using contraception but are not using their chosen method correctly.

Virtually all methods of contraception occasionallyfail and some are much more effective than others.

Failure rates are traditionally expressed as thenumber of failures per 100 woman-years (HwY ),i.e. the number of pregnancies if 100 women wereto use the method for1 year. Failure rates for some methods vary considerably,largely because of the potential for failure causedBy imperfect use (user failure) rather than an Intrinsic.

Contraceptive failure rate comparing typical

use and perfect use: typical use perfect use method

85% 85% No method

0.15% 0.10% Male sterilization

0.5% 0.5% Female sterilization

0.8% 0.6% Copper T IUD

0.1% 0.1% Levonorgestrel IUD

6.7% 0.3% DMPA

8.7% 0.3% OC-combined

8.7% 0.5% OC-progesterone only

16% 6% Diaphragm +spermic

17% 2% condom

32% 26% Cervical cap parous

16% 9% Cervical cap nullip

29% 15% spermicides

18.4% - Withdrawal

Classification:Combined oral contraceptive methods are grouped into tiers depending on their efficacy with typical use.

Method of contraception tier

Progesterone implant ,IUD Longer term

Depot medroxy prog acetate inj.Vaginal rings,transdermal patches,oral contraceptice pills.

Malecondom,diaphragm,caps,female condom,sheild ,spermicide,withdrawal,fertility awarwness method,natural family planning.

Combined hormonal

Barrier and behavioral methods

Classification:Methods not requiring medical consultation:1-coitus interruptus2-safe period[Natural family planning]3-vaginal spermicides4-barrier methods include :Male condomFemale barriers

Methods requiring medical supervision:1-Hormonal contraception:Combined oral contraceptive methodsProgesterone-only preparations :include A-progesterone only pills B-injectables C-Subdermal implants D-Hormone-releasing intauterine system

2-Intauterine device3-Post-coital emergency contraception4-occlusive diaphragms&caps

Perminant methods[sterilization]Female tubal occlusionMale vasectomy

Combined oral contraceptive pills(the pill)first licensed in the UK in 1961. It contains a combination

of two hormones: a synthetic oestrogen and progestogenavailable as once daily pill.Since COC was first introduced, the doses of bothoestrogen and progestogen have been reduced dramatically,which has considerably improved its safetyprofile..

Combined oral contraception is easy to use andoffers a very high degree of protection against pregnancy,with many other beneficial effects. It is mainlyused by young, healthy

Formulation:

Combined oral contraceptive pills contains both:

1-Synthetic Estrogen (Ethinyl estradiol mostly):The dose of oestrogen varies from 50 to 15 μg.2-Synthetic progestogens Either one of these : *First generation(e.g. norethindrone). *Second generation progestins (e.g.

levonorgestrel) . *Third generation series including gestodene,

desogestrel and norgestimate

Monophasic pills contain standard daily dosages

of oestrogen and progestogen . Biphasic or triphasic preparations have two

or three incremental variations in hormone dose.

Current thinking is that biphasic and triphasic preparations are more complicated for

women to use and have few real advantages. .

For maximum effectiveness, COC Most brands contain 21 pills; one pill to be taken daily, followed by a 7-day pill-free interval. There arealso some every-day (ED) preparations that Include seven placebo pills that are taken instead of having a pill-free interval shouldalways be taken regularly at roughly the sametime each day. Other are for extended cycleuse to eliminate or minimize the number of scheduled bleeding episode induced byplacebo pills.this scheduled bleeding is notmedically indicated but desired by some women for personal reason.

preparation1.low-dose pills containing 30μg of ethinyl estradiol

2.high-dose pills contain contain 50 μg estrogen. Higher dosages of oestrogen are strongly linked to

increased risks of both arterial and venous thrombosis3.Yasmin contains ethinyl estradiol and drospirenone. Drospirenone has antimineralocorticoid activity. It can

help prevent bloating, weight gain, and hypertension, but it can increase serum potassium.

Yasmin is contraindicated in patients at risk for hyperkalemia and should not be combined with other drugs that can increase potassium

Mode of actionCombined oral contraception acts both centrally And peri pherally .

•centrally Inhibition of ovulation is by far the mostimportant effect. Both oestrogen and progestogensuppress the release of pituitary FSH and LH ,

which prevents follicular development within theovary and therefore ovulation .

•Peripheral effects include -Making endomtrium atrophic and hostile to an

implanting embryo -altering cervical mucus to prevent sperm

ascending into the uterine cavity.

Contraindication:absolute:

1 •Circulatory diseases: -iscihaemic heart disease- cerebrovascular accident

-significant hypertension -arterial or venous thrombosis

-any acquired or inherited pro-thrombotic tendency -any Significant risk factors for cardiovascularpisease

2 •Acute or severe liver disease3• Oestrogen-dependent neoplasms, particularly breastcancer4.Breastfeeding <6 weeks post-partum5.Smoking ≥15 cigarettes/day and age ≥35

6.Focal migraine

Relative contraindications •Generalized migraine

•Long-term immobilization• Irregular vaglinal bleeding (until a

diagnosis has been made)• Less severe risk factors for

cardiovascular disease,e.g. obesity, heavy smoking, diabetes

Side effect:

1-Venous thromboembolism: VTE is the major measurable risk other wise the

combined oral contraceptive pills are very safe. Oestrogens alter blood clotting and coagulation in away that induces a pro-thrombotic tendency, althoughthe exact mechanism of this is poorly understood.The higher the dose of oestrogen within COc, the

greater the risk of venous thromboembolism (VTE)...Type of progestogen also affects the risk of VTE, withusers of COC containing third-generation progestogensbeing twice as likely to sustain a VTE.

The risks of VTE are: •5 per 100 000 for normal population,

•15 per 100 000 for users of 2nd generation.•30 per 100 000 for users of 3rd generation.•60 per 100 000 for pregnant women.

2-Arterial disease*risk of hypertention:

1 per cent of COC users will become significantly hypertensive and they should be advised to stop taking COC *risk of myocardial infarction and

thrombotic stroke :in young, healthy women using low-dose COC is extremely small .

Cigarette smoking will, however, increase thearterial risk, and any woman who smokes mustbe advised to stop COC at the age of 30years .

3-MortalityThere is increased mortality in women using the pills over women not using it, related toage&smoking habits.Death is most often the result of pulmonary embolism,cerebral or coronary thrombosis.Women who are under 35 years, do notSmoke nor have hypertention or diabetes have no exess mortality otherwise women over 35 years ,women whoSmoke or have hypertention there is excess mortality .

4.Carcinogenic effect:

Breast cancer Most data do show a slight increase in the risk of developing breast cancer among current COC users (relative risk around l. 24).This is not of great significance to young women, as the background rate of breast cancer is very low at their age. However, for a woman in their forties, these are more relevant data, as the background rate of breast cancer is Higher, but beyond 10 years after stopping cocthere was no increase in breast cancer risk for formercoc users.

Cervical cancerMore than five years of pill use may be associated with small increase risk of cervical carcinoma. Liver cancerBenign hepatic adenoma is a rareconsequence of COC use

Minor side effects CNS

Gastrointestinal

Genitourinary system

Breast

miscellaneous

DepressionHeadachesLoss of libido

Nausea and vomitingWeight gainBloatednessGall-stonesCholestatic jaundice

CystitisIrregular bleedingVaginal dischargeGrowth of fibroids

Breast painIncreased risk ofbreast cancer

Chloasma (facial pigmentation)Leg cramps

Method of use The patient begins taking the pills on

the first day of menstrual cycle then in the next cycles they are administered in fifth day of the cycle and continue for 21 days, each day at the same time, then discontinued for 7 days to allow for withdrawal bleeding that mimics the normal menstrual cycle which occur after 3-5 days from stopping pills

If pills are missed ????

How lateare you???

Less than12 hours

late

Don't worry. Just takethe delayed pill atonce, and further

pills as usual

More than

12 hours late

•Take the most recentlydelayed pill now

•Use extra precautions

(condom, for instance)

for the next 7 days

Drug interaction*This can occur with enzyme-inducing agents Such as some anti-epileptic drugs increase activity of hepatic enzyme so reduce efficacy of COC.Higher dose oestrogen coccontaining 50 Mg ethinyl oestradiol may needto be prescribed *Some broad-spectrum antibiotics Ampicillin,

Amoxicillin, Tetracycline , Neomycin can alter intestinal absorption of COC and reduce its efficacy. Additional contraceptive measures should therefore be recommended during antibiotic therapy and for 1 week thereafter.

*Steroids ,Ascorbic acid (Vitamin C) and acetaminophen may elevate plasma ethinyl estradiol so increase its efficacy.

Positive health benefits*COC users generally have light, pain -free, regular

bleed and therefore COC can be used to treat heavy or painful periods

(menorrhagia & dysmenorrhea) *It will also improve premenstrual syndrome(PMS) *reduce the risk of pelvic inflammatory disease(PID).*decreased incidence of benign breast lump. *decrease number of functional ovarian cyst.*less endometriosis.*COC offers long-term protection.against both ovarian and endometrial cancers .

*It can also be used as a treatment for acne.

Combined oestrogen and progesterone vaginal ring

It is soft ring that a woman can insert into

vagina; and the Women who use Ring leave the ring in place for 3 weeks during

amonth. During the 4th week, the ring isremoved for 7 days. A new ring is used for each cycle.

Combined hormonal patchesA contraceptive transdermal patch containing Oestrogen and progestogen has been Developed and releases norelgestromin 150 Mg and ethinylestradiol 20 Mg per 24 hours. Patches are applied weekly for 3 weeks, afterwhich there is a patch-free week .

Contraceptive patches have the same risks and benefits as COC and, although they are relatively more expensive, may have bettercompliance.

Progesterone only contraception:

All other types of hormonal contraception in current use in the world are progestogen -only and share many similar features in terms of mode of action and side effects .

Because they do not contain oestrogen, they

are extremely safe & can be used if woman has cardiovascular risk factors.

The dose of progestogen within them varies from very low to high

The current methods of progestogen-only contraception are

•progestogen-only pill, or 'mini-pill' •subdermal implant Implanon®

• injectables. •hormone-releasing intrauterine system

Mechanism of action1-peripheral effects: *local effect on cervical mucus making it

hostile to ascending sperm.*Local effect on the endometrium making

it thin & atrophic thereby preventing implantation

*Progestin use also causes decreased tubal and endometrial motility.

2-central effectsHigher dose progestogen-only methods

can act centrally & inhibit ovulation .

Side effects

Menstrual disturbances either irregular vaginal bleeding or amenorrhea.

Functional ovarian cyst Increase risk of ectopic pregnancy :this has

not been confirmed,although it is probably that POP protect much more effectively against intrauterine than ectopic pregnancy.

Progestogen-only pills

The progestogen-only pill (POP) is ideal for Women who like the convenience of pill taking but cannot take COC. Although thefailure rate of the POP is greater than that Of COC , it is ideal for women at times of lower fertility. If the POP fails, there is a slightly higher risk of ectopic pregnancy

they contain *the second-generation progestogen

norethisterone or norgestrel (or their derivatives)

* or the third-generation progestogen desogestrel .

The POP is taken every day without a break

Particular indications for the POP include: •breastfeeding

•older age •cardiovascular risk factors

•diabetes.

Injectable progestogens

Two injectable progestogens are marketed.

•Depot medroxyprogesterone acetate 150 mg

(Depo-Provera or DMPA ) which lasts 12-13 around weeks.

•Norethisterone enanthate 200 mg (Noristerat) which only lasts for 8 weeks and is not nearly so widely used.

Depo-Provera is a highly effective methodOf contraception and it is given by deep intramuscular injection Most women who use it develop very light or absent menstruation. Depo-Provera will improve PMS and can be used to treat menstrual problems such as painful or heavy periods. It is particularly useful for women who have difficulty remembering to take a pill

Particular side effects of Depo-Provera

•weight gain of around 3 kg in the first year, •delay in return of fertility - it may take

Around 6 months longer to conceive comparedto a woman who stops COC,

•persistent menstrual irregularity ,irregular vaginal bleeding may occur or amenorrhea in prolonged use of this injection

•very long-term use may slightly increase the Risk of osteoporosis (because of low oestrogenlevels)

This injection can be given Within five days after the onset of menses.within 6 weeks after delivery if breast-feeding infant. Also it can be used after having an abortion

Particular indications for depo provera-contraindication to estrogen -Following rubella vaccination in peurperium.-Husband waiting for effect of vasectomy. -Mental retarded women. . -Breast-feeding. -population control in developing countries.

Subdermal implantsImplanon consists of a single silastic rod that isinserted subdermally under local anaesthetic into the upper arm. It releases the progestogen etonogestrel 25-70 Mg daily (the dose releaseddecreases with time), which is metabolized to theThird-generation progestogen desogestrel. Implanon was introduced into the UK in the late 1990s.Other type of implant is the six-rod implant, Norplant, which is withdrawn from the market

It lasts for 3 years and thereafter can be easily

removed or a further implant inserted.Implanon is particularly useful for women whohave difficulty remembering to take a pill

andWho want highly effective long-termcontraception. There is a rapid return of fertility when it is removed.

Intrauterine device

IUDs can be classified as either:

Medicated, copper-bearing T380A(copper T IUD)levonorgestrel hormone-releasing (LNG-

IUD)

Unmedicated, or inert The majority of the IUDs now widely usedare copper-bearing.

This IUD provides excellent pregnancy protection that is convenient and rapidly reversible.

1st year failure rates are 0.7% and cumulative 10- to 12-year pregnancy rate are 1.4% to 1.9%.

most women are candidate for IUD use includingthose with serious medical problems as Hypertension, morbid obesity, diabetes, stroke ,MI , and even cancer.

Mechanism of action of copper T IUD

Induce inflammatory reaction within the endometrium make the cavity and tube fluid that is toxic to the sperm ,oocyte and the embryo, Copper ions released from copper IUD reach a level in the uterine

cavity fluid that is toxic to the sperm oocyte and embryo. It appear that IUD mainly interfere with the fertilization, that’s

only few sperms reaching the fallopian tube by cervical mucos hostility and by interfering with sperm motility,and affecting tubal motility,

and if reaching are incapable of fertilization, even the oocyte is incapabale to be fertilized. IUD interfere with sperm motility , oocyte capability of

fertilization and implantation.

Complication of IUD:Bleeding and pain

q Increased menstrual bleeding, often with pain, is the most common problem of IUD use and the most common medical reason for removing lUDs

q Older women and women with children generally have lower rates of removal due to bleeding and pain.

n Unlike other IUDs, hormone-releasing devices decrease menstrual blood flow or, may even stop menstruation altogether

n With all IUDs, abnormal bleeding and pain may be due not to the IUD itself but to pelvic inflammatory disease (PID), ectopic pregnancy, malignancy, or other conditions

IUD use has not been proved to induce clinical anemia

In a study of the TCu-380Ag carried out in several developing countries and the US, the proportion of women with anemia rose only from 24% to 25.4% during four years of use

Infection(PID): Many studies have confirmed that the risk of

infection and infertility among IUD users is very low (2004). However, studies also indicate that the insertion process and not the IUD or its strings, pose the temporary risk of infection.

Good infection prevention procedures should be practiced.

Antibiotic prophylaxis should not be used routinely prior to insertion.

The risk of infection following IUD insertion returns to a very low or normal level after 20 days (1992).

perforation

Perforation of the uterus occurs when the IUD, the inserter tube, the sound, or another gynecological instrument used during insertion pierces the uterine muscle wall, most often at the fundus, or top of the uterus

Careful insertion technique can prevent most perforations

Perforations may go unnoticed at the time of insertion

Over time lUDs may become embedded in the uterine wall without perforating it

Expulsion

After IUD insertion, uterine contractions can push the device downward, causing partial or complete expulsion

Most expulsions occur in the first year and especially the first three months after insertion

Younger women and women who have never been pregnant or have never had children are more likely to expel their lUDs

Women who had painful menstruation or abnormally large menstrual flows were more likely to expel copper-T IUDs

Correct insertion, with the IUD placed up to

the fundus, is thought to reduce the chances of expulsion

Intrauterine pregnancy

If pregnancy does occur, potentially severe complications can result. Medical attention is always needed

Spontaneous abortion is the most frequent complication of pregnancy with an IUD in place

the IUD should be removed as soon as pregnancy is confirmed

An IUD left in place during pregnancy also increases the risk of premature delivery. It does not increase the risk of other complications-birth defects, genetic abnormalities, or molar pregnancy

Ectopic pregnancy

y Mounting evidence indicates that most lUDs help to protect against ectopic pregnancy while they are in use

y IUD users were half as likely to experience ectopic pregnancies as women using no contraception

A recent analysis of randomized trials found that second-generation copper lUDs and the LNG-20 reduce ectopic pregnancy rates to 10% of the level among women using no contraception

lUDs provide less protection against

ectopic pregnancy than consistently used oral contraceptives or barrier methods

Any pregnancy in an IUD user is uncommon, however. The ectopic pregnancy in an IUD user is rare

TCu-380A and MLCu-375, have the lowest ectopic pregnancy rates – 0.25 and close to 0 per 1,000 woman years

Clinical implications:

k Women using lUDs should be told about the signs of ectopic pregnancy

k If an IUD user conceives or shows signs of pregnancy, health care providers should always look for ectopic pregnancy

A woman who has had an ectopic pregnancy can use an IUD

There is no evidence that IUDs cause any type of cancer

among IUD users. WHO and US researchers have/estimated about one to two deaths per 100,000 IUD users per year from infection, ectopic pregnancy, or second-trimester septic abortion.

The IUD is one of the safest family planning

methods, according to estimates of annual

death rates among US women using various

family planning methods or no method.

Containdication: Nulliparity and infertility: higher rate of

expulsion and discomfort,,,infertility ??? Active infection,,if IUD Increased risk of

actinomyces which is recovered after removal and re insertion.

Uterine anomalies increase risk of expulsion and perforation.

gynecologic malignancy. genital bleeding of unknown cause. gestational trophoblastic disease.

Levonorgestrel releasing IUD

• The LNG IUS is made of flexible plastic

• The LNG IUS contains a progestin hormone called levonorgestrel which has been used in birth control pills since the 1970s

• The safety of levonorgestrel has been proven by clinical use also in sub-dermal implants and intrauterine systems since decades

in every country LNG-IUD is approved for contracepttion with an effect comparable to sterilization with an ability for regret, and is approved for treatment of heavy prolonged menstrual bleeding ,and is effective as endometrial ablation.

LNG IUS MECHANISMS OF ACTION• Thickens cervical mucus

• Inhibits sperm function in uterus

• Reduces monthly growth of the lining of the uterus making periods lighter and shorter; there is no evidence that LNG IUS has any impact on implantation

• LNG IUS can also lessen menstrual blood loss in women who have heavy menstrual flow

Treatment of heavy menstrual bleeding

Use of LNG IUS makes periods lighter, shorter and less painful

Over 12 months, blood loss reduced by 80-96% in women with menorrhagia

Clinical improvement in associated anemia:

Hemoglobin levels rise 1.8g/L in one year of use with LNG IUS, compared to a decrease of 1.2g/L with Copper-T.

Irregular bleeding or spotting common in first 3-6 months; 20% with amenorrhea at 12 months. Sometimes the amenorrhea rate can be higher than 20% e.g. up to 50% at 12 and 24 months of use.

What are the most common side-effects of the LNG IUS?

10+ in every 100 women are likely to experience the following:

• Headache

• Abdominal/ pelvic pain

• Bleeding changes

• Vulvovaginitis (inflammation of the external genital organs or vagina)

• Genital discharge

1 to 10 in every 100 women are likely to

experience the following:

• Depression

• Migraine

• Nausea

• Acne

• Hirsutism (excessive body hair)

• Back pain

These side effects are common among OC Pill users as well.

Source: Luukkainen 1995

LNG-and risk of ectopic pregnancy

• It is very rare to become pregnant while using LNG IUS

• However, if you become pregnant while using LNG IUS, the risk having an ectopic (extra-uterine) pregnancy is relatively increased

• About 1 in a 1000 women correctly using LNG IUS have an ectopic pregnancy per year. This rate is lower than that among women not using any contraception (about 3 to 5 in a 1000 women per year)

• Woman who have already had an extra-uterine pregnancy, pelvic surgery or pelvic infection carry a higher risk of experiencing an ectopic pregnancy

Emergency contraception

Post-coital contraception is any drug or device used prevent pregnancy after unprotected intercourseThere are two types of emergency contraception[EC]

A-hormonal emergency contraception1-Combined oestrogen&progesterone[CEP]:Combination of 100 microgram ethinyl estradiol

&0.5 mg levonorgestrel is taken twice the two doses being 12 hours apart & started within 72 hours of unprotected intercourse

Nausea & vomiting are common side effects .The precise mechanism of action is not known but probably involves disruption of ovulation or corpus luteal function depending on the time in the cycle when hormonal EC is taken so it inhibit ovulation or interfere with implantation.

2-Levonorgestrel alone:Levonorgestrel 0.75 mg taken twice with two doses separated by 12 hours ,it may be more effective & better tolerated It has to be taken within 72 hours of an episodeof unprotected intercourse and is more effective the earlier it is taken

B -intrauterine device

A copper-bearing IUD is highly effective post-coital contraceptive with failure rate less than 1%,used up to five days after the estimated day of ovulation.It prevent implantation &the copper exerts an embryotoxic effectThe hormone-releasing IUS has not been shown to be effective for EC and should not be used in this situation

Ultrasound imagingCopper IUD LNG IUD

X ray with LNG IUD