Contraception and sterilization dr.feda thekr allahDone by shaden haddad

Every woman ovulates only once in each cycle. If in the rare occasion two or more ovulation occur, they will occur within 24

hours. After ovulation, the egg can be fertilized for a maximum of 18 hours. After intercourse, male sperm will remain active and fertile in the female body for

a maximum of 3-5 days. This means that there are six days in every cycle when a woman can get

pregnant: five days before ovulation and on the day she ovulates

Methods of contraception:

Natural methods: periodic abstinence coitus interruptus lactational amenorrhea

Barrier method and spermicides: male condoms female condoms diaphragm cervical cap spermicides Intrauterine devices

Hormonal contraceptive methods

Natural methods“periodic abstinence” Rhythm or calendar method

It emphasizes fertility awareness and abstinence shortly before and after ovulation period

Ovulation assessment method: use ovulation prediction kits basal body temperature menstrual cycle tracking cervical mucous evaluation Effectiveness: 55-80% Advantages: uses neither chemical nor

mechanical barriers (some religious reasons).

They can be used to collect a sample right in the urine stream, making them a great for couples trying to become pregnant.

With a high sensitivity of 25 mIU/mL (lower is better), ovulation test strips can be used to detect ovulation surge, which occurs just before the best time to conceive.

The test strips work by detecting LH, a hormone released released in greater quantities as ovulation surge approaches

Ovulation prediction kits

Natural methods “coitus interruptus” Withdrawal of penis from vagina before

ejaculation Majority of semen is deposited outside

the female reproductive tract. Effectiveness : rate of failure is high

27% Failure due to deposition of semen into

vagina before orgasm or deposition of semen near introitus after intercourse.

Natural methods“lactational amenorrhea”

Lactational amenorrhea is the natural postnatal infertility that occurs when a woman is amenorrheic and fully breastfeeding. If not combined with chemicals or devices, Lactational amenorrhea method (LAM) may be considered natural family planning

Method of action: after delivery, restoration of ovulation is delayed because of nursing induced hypothalamic suppression of ovulation

“prolactin induced inhibition of GnRH from hypothalamus resulting in suppression of ovulation” .

Effectiveness : - duration of ovulatory suppression is variable - 50% of lactating mothers will begin to ovulate before 6-12 months of delivery even while breast feeding -(the return of ovulation occurs before the return of menstruation .)

Natural methods “lactational amenorrhea”

Effectiveness enhancement by : - breast feeding only form of nutrition for infant The infant must breastfeed at least every four hours during the day and at least every six hours at night. The infant must be less than six months old - this method used only as long as woman is experiencing amenorrhea - should only be used for max 6 months after delivery.

Barrier methods “male condoms”

Barrier methods prevents sperms from entering endometrial cavity ,fallopian tube and peritoneal cavity

Male condoms: - made of latex rubber sheaths - placed over the erect penis before ejaculation -it is important to leave a space at the tip to collect the ejaculate and to prevent the leak Effectiveness: -98% effective in preventing contraception -efficacy increased by using spermicides Side effects: hypersensitivity to latex, lubricant or spermicide in

the condom Advantages: widely available, moderate cost prevent transmission of many STD protect against HIV

Male condoms:

Barrier methods“female condoms” Vaginal pouch made of polyurethane Has flexible ring at each end (one ring fits

into depth of vagina ,other stays outside vagina near introitus)

Effectiveness:-failure rate higher by 25% than male condoms Advantages: protects against STD Disadvantages: cost and overall bulkiness

Female condoms

Barrier methods“diaphragm” Dom-shaped latex rubber sheet stretched over a thin coiled rim Spermicidal jelly placed on rim and sides of diaphragm then

placed into vagina to cover the cervix Placed into the vagina before intercourse and left in place 6-8

hours after intercourse If after 6-8 hours further intercourse is going to happen

additional spermicide should be placed without removing diaphragm.

Upon removal, a diaphragm should be cleansed with warm mild soapy water before storage. The diaphragm must be removed for cleaning at least once every 24 hours and can be re-inserted immediately.

Effectiveness: 49% effective , if with spermicide 85%

Barrier methods“diaphragm”

Side effects: -bladder irritation….UTI -colonization of staph aureus …..toxic shock syndrome -hypersensitivity to rubber, spermicides Disadvantages: -cost effective -need to be replaced every 2 years or if patient loses or gains more than 20% of body weight -needs rechecking after each pregnancy -women not experienced well to fit it due to pelvic relaxation

diaphragm

Barrier methods “cervical cap” Fem cap ,small soft silicon cap that fits directly over cervix Held in place by suction Act as a barrier to sperms and must be used with spermicidal jell. Fitted by a doctor Effectiveness :

- 68%-80% -depends on woman’s parity (failure in parous women) -dislodgment common cause of failure Advantages:

-inserted up to 6 hours before intercourse and can be left up to 1-2 days Disadvantages:

-foul discharge after first day -needs refitting after pregnancy or weight gain

Cervical cap

Barrier methods “spermicides” Varying forms : cream ,gels ,suppositories Most used :nonoxynol-9

octoxynol-9 Mechanism of action:

- disrupt cell membrane of spermatozoa -act as a mechanical barrier to cervical canal -placed in vagina 30 min before intercourse -used alone or with previous contraception method Effectiveness:

-95% if with condom -75%if used alone Side effects:

-irritates vaginal mucosa and external genitalia Disadvantages:

-no protection against STD (most woman susceptible to STD due to vaginal mucosa irritation)

Intrauterine devices Most widely used method of reversible contraception in the world IUD indicated for :

-women with the following medical conditions: Diabetes Thromboembolism Menorrahagia Breast feeding (copper only till 4 to 6 wks postpartum Breast cancer ( copper only ) Liver disease (copper only) - multiparous and nulliparous women at low risk for STDs - women who desire long term reversible contraception

Method of action:-IUD introduced into the endometrial cavity using a cervical cannula-2 monofilament strings extend through cervix-IUDs act by killing sperms and preventing fertilization -produce a sterile inflammatory response therefore sperms engulfed and immobilized and destroyed by inflammatory cells-it decreases tubal motility therefore inhibiting sperm and blastocyst transport.- It doesn’t affect ovulation

Intrauterine devicesTcu-380A

Copper in paragard will stop sperms motility and capitation

Therefore sperms rarely reach fallopian tubes and no fertilization occurs.

Intrauterine devicesMirina

Progesterone in mirina thickens cervical mucous and atrophies endometrium to prevent implantation

Also labeled to treat menorrhagia and dysmenorrhea

Used in postmenopausal women receiving estrogen therapy

Used in young women who didn’t complete child bearing age,nullipara women

Used to treat endometriosis and endometrial hypertrophy and have decreased risk of PID due to protection of progesterone induced cervical mucous thickness

Intrauterine devices Effectiveness:

-failure 0.8% in paragard-failure 0.1% in mirena Side effects:

-Pain and bleeding -pregnancy-expulsion-perforation-infection-may lead to insertion related PID if inserted into woman with cervical infectionNote: pelvic infection rarely seen beyond 20 days after insertion most women need tube screened for gonorrhea and chlamydia prior to insertion of IUD-even though pregnancy rate is low but if happened spontaneous abortion increase to 50%Note : IUDs not associated with increased risk of congenital abnormalities

Intrauterine devices Advantages:-paragard IUD used for 10 years but maybe effective for 14 years-mirena used for 5 years ….7 years-IUDs can be immediately inserted after spontaneous abortion in 1st trim -less risk of ectopic pregnancy. It is an acceptable form of contraception for women with prior history of ectopic pregnancy.Disadvantages:-Paragard have increased rate of expulsion

Intrauterine devicesAbsolute contraindications

Known pregnancy Undiagnosed abnormal

vaginal bleeding Acute cervical ,

uterine ,infection Copper allergy or wilson

disease (paragard ) Current breast cancer

(mirena)

Relative contraindications

Prior ectopic pregnancy History of STI in the

past 3 months Uterine anomaly or

fibroid distorting the cavity

Current menorrhagia or dysmenorrhea (paragard only )

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