MODERN CONTRACEPTIVE TECHNIQUESMODERN CONTRACEPTIVE TECHNIQUES

By

E. Ejiro Emuveyan

Associate Professor of Obstetrics & gynaecologyDepartment of Obstetrics & GynaecologyCollege of Medicine, University of Lagos

P.M.B. 12003 Lagos

1950s AND 1960s

MALTHUSIAN CONCERNS

1950s AND 1960s

MALTHUSIAN CONCERNS

TOO MANY PEOPLE REPRODUCING TOO RAPIDLY

RETARDS ECONOMIC GROWTH

DESTROYS THE ENVIRONMENT

OVERSTRETCHES SOCIAL SERVICES

EXACERBATES POVERTY

FUELS CONFLICT

World Population Profile 1World Population Profile 1

Beginning of last century 2b1970 4b2000 6bRate of increase 1.2%Estimated doubling time 42 yrs10 Largest Countries in Population

China 1304

India 1104

USA 296

Indonesia 222

Brazil 184

Pakistan 162

Bangladesh 144

Russia 143

Nigeria 132

World Population Profile 2World Population Profile 2

1/3 under 15 years of age

25% live in developed or industrialised countries with low fertility rates

75% live in less developed countries that are characterized by high fertility rates, high maternal and infant mortality and low life expectancy

Number of women in reproductive age increased between 1990 and 2000 by about 200m posing great challenge to scientific community

Need therefore for increased methods of infertility regulation

Indications for family planningIndications for family planning Individual

Spacers

Limiters

Avoid childbearing because of severe disease in pregnancy

Pregnancy is life threatening to the mother as in case of severe aortic stenosis

For all Indications, providers of Family Planning

For all Indications, providers of Family Planning

Must provide accurate information about benefits and risks of:(i) Pregnancy

(ii) Contraception

To be noted specifically are:

Medical conditions that may substantially increase risk of some form of birth control usually increase the risk associated with pregnancy to an even greater extent.

Policy some less developed countries promote contraception in an effort to curb undesired population growth.

Fertility ControlFertility Control

Most sensitive and intimate decision

Religious or philosophical convictions

Clinician approach it with sensitivity

Empathy, maturity and non-judgmental behaviour

How Socio-Economic Changes Affect Contraceptive PracticeHow Socio-Economic Changes Affect Contraceptive Practice

Adolescents experiencing higher pregnancy rates

Women in later stages of reproductive lifespan now tending to delay childbearing until in their 30s and 40s.

Demographic Shiftmore women aged 30-44 years than those aged 15-29 years.needs of women with divergent social or economic circumstances.

NIGERIAN POPULATION PROFILENIGERIAN POPULATION PROFILE

Mid 2005 131.5 PRB Fertility rate: 5.9 per woman Pop. Growth rate 2.4 Living below USS2 per day 91% women using all methods 12 %

modern methods 8% Age ProfileWomen in reproductive age (15-44 yrs. -22.8%Children Under 15 years 43.0%

CONTRACEPTIVE PREVALENCECONTRACEPTIVE PREVALENCE

Worldwide (2005)-38.1m (53%) use effective methods

Nigeria (1998) 6%

Ghana 19%

Benin 7%

Guinea-Conakry 4%

Kenya 32%

Tanzania 20%

HISTORY OF FAMILY PLANNINGHISTORY OF FAMILY PLANNING

Religious and Moral Issues Natural Family-Planning

Coitus interruptus - Oldest method (17th century) Abstinence - Total/Periodic

Rev. Thomas Malthus - One of the founding fathers.

1864 - Gabriel Fallopio - Linen Sheath for Coitus.

BACKGROUND HISTORY CONTINUESBACKGROUND HISTORY CONTINUES

STONES IN THE WOMB OF CAMELS

1880 - CHEMICAL AGENTS AND MECHANICAL DEVICES (INTRAVAGINAL AND INTRAUTERINE)

1977 - IPPF - OVER 100 COUNTRIES

LEGAL ASPECTS OF CONTRACEPTIONLEGAL ASPECTS OF CONTRACEPTION

Without Restrictions

Information to Teenagers debatable

US Supreme Court ruling in 1977 minors have constitutional right of access.

Provision for teenagers should be done within the the confines of appropriate restraints.

THE LAW PROVIDES THAT ALL PERSONS MUSTTHE LAW PROVIDES THAT ALL PERSONS MUST

Detailed Information about the use of the

METHOD(S),

BENEFITS

RISKS,

SIDE EFFECTS

CONSENT AND SERVICECONSENT AND SERVICE Documentation Of Discussion with client and her understanding

of what has been said is of legal importance. When using methods that require instrumentation or some type of

surgical approach use of consent forms that outline information discussed and the patient’s understanding is important.

Consent form serves as evidence if needed that:

(I) Counselling about use of particular birth control method was given

(II) Patient appeared to be competent to understand what was said to her

(III) She consented to receive contraceptive management in the manner specified.

METHODSMETHODS

CLASSIFICATIONTRADITIONAL OR FOLK- Coitus Interruptus- Post coital Douche - Lactational Amenorrhoea- Periodic Abstinence (Rhythm, Natural Family Planning)

BARRIER- Condom(Male and Female)- Diaphragm- Cervical Cap- Vaginal Sponge- Spermicides

METHODSMETHODS

HORMONAL

- Oral

- Injectable

- Implantable Long-Acting Progestins

OTHER CONTRACEPTIVES

- IUCD

- Sterilisation

- Tubal Ligation

- Vasectomy

NATURAL CONTRACEPTIONNATURAL CONTRACEPTION

A. PERIODIC ABSTINENCE/RHYTHM METHOD LONG AND CHEQUERED HISTORY FERTIILE PERIOD 2-3 days after ovulation

2 days before no less than 2 days after PROMOTED BY CATHOLICS

Types of periodic abstinence

- Calendar method

- Combined temperature/calendar method

- Cervical mucus (Billings) method

- Symptothermal method

Data subject to bias

B. COITUS INTERRUPTUSB. COITUS INTERRUPTUS

Oldest Method of Reversible Contraception

Withdrawal before Ejaculation. Demands Sufficient Self Control

Statistics not reliable

Failure rate - 10 Preg/100 Women Years

C. LACTATIONAL AMENORRHEA METHODC. LACTATIONAL AMENORRHEA METHOD

Women Less Fertile When Nursing

Exclusive Breast Feeding for Six Months Supplemental Feedings Alters Patterns Of Lactation/Intensity Of Infant Suckling.

Amnenorhoea Must Be Maintained

2% Pregnancy Rate If Properly Used.

HISTORY OF ORAL CONTACEPTIONHISTORY OF ORAL CONTACEPTION

HISTORY19th Century- Lack of follicular development in pregnancy

1921 - Ludwig Haberlandt

1929 - Oestrogen Synthesized

1934 - Progesterone synthesized

1959 - First OC (Norethynodrel - Menstranol)

1960 - Progressive lower dose pills.

TYPESTYPES(A) Combined Oral Contraceptives (COCS).

Sequential - E Pill 15-16 days followed E/P for 5 daysProblem: Than normal incidence of endometrial cancerPhasic - Monophasic, Biphasic, Triphasic28 days regimen (last 7 days placebo)

(B) Progesterone only pill/Minpill (POP)Taken everyday (Microdose nonstop progestins)Efficacy less than that of COC and occasional causes

amenorrhoea (C) Post Coital Contraceptive pill/morning - After pill E only Yuzpe, Danazol, Mesopristone Follow up and initiate another contraceptive

method

USAGE & FAILURE RATESUSAGE & FAILURE RATES

60 m current users worldwide Affected by age, family size, Politics

FAILURE RATES COC 0.2 - 1 per 100 woman years POP 0.3 - 5 per 100 woman years

PCC varies with types

HORMONAL CONTRACEPTIONHORMONAL CONTRACEPTION

HISTORY: 19TH CENTURY TO 1934

Late 19th Century: Ovarian follicles do not develop during pregnancy

1921 - Ludwig Harberlandt First proposed Hormonal Sterilisation

1929 - Molecular structure of Oestrogen determined

1934 - Molecular structure of Progesterone determined

HORMONAL CONTRACEPTIONHORMONAL CONTRACEPTIONHISTORY: 1952 - 1960

1952 - Colton and Djerassi independently synthesized substances with progesterone - like activity (Progestogens or progestins)

1956 - Rock J, Pincus G and Garcia C.R demonstrated that norethynodrel suppressed ovulation (Science 124:128)

1959 - Rock, Garcia, Pincus and Rice-Wray conducted large clinical trials in Puerto Rico using a combined oral contraceptive containing 10mg norethynodrel and 0.15mg mestranol.

1960 - Knowledge increased and principles of hormonal contraception have been reconsidered now and again.

FACTORS CONSIDERED TO FIND THE RIGHT ORAL CONTRACEPTIONFACTORS CONSIDERED TO FIND THE RIGHT ORAL CONTRACEPTION

1. The constitutional type of the woman on the woman of somatic and historical data.

2. Tolerance shown towards the hormonal contraceptives previously taken and the type of side effects occurred.

3. Contraindications because of health status disposition to thrombosis lactation or special conditions (only occasional sexual

intercourse).

Post-coital contraceptionPost-coital contraceptionFour hormonal methods

1. The combined oral contraceptive pill

2. Oestrogen only

3. Progestogen only

4. Danazol

Only the combined pill is recommended

COMPOSITION AND SIDE EFFECTCOMPOSITION AND SIDE EFFECT

Two pills (Eugynon 50 micrograms of ethinyl estradiol and 250 micrograms of Levonorgestrel taken immediately and same dose repeated 12 hours later.

Side-effects are nausea and vomiting and these can be alleviated by the concomitant administration of an anti-emetic.- method should not be substituted for conventional contraceptive practice.- use of hormonal methods of postcoital contraception are an emergency procedure and should not be used repeatedly.

Vaginal Contraceptive Pill (VCP)Vaginal Contraceptive Pill (VCP)

- Recent

- Undergoing multicentre trials

- Historical evolution from vaginal rings

INTRA-UTERINE CONTRACEPTIVESINTRA-UTERINE CONTRACEPTIVES

Plastic devices placed in the uterine cavity to prevent pregnancy

Different shapes, sizes and types

MAIN MECHANISM OF ACTIONInterference with implantation

Increase with sperm transport

Inhibit capacitation

TYPESTYPES1. Non medicated (inert) e.g Lippes loop2. Medicated - less bleeding and pain

(a) CU DEVICES1st Generation - Cu 7

- Cu T2nd Generation - Multiload 250

Nova T3rd Generation - Multiload 375

Cu T 380 A Flexigard 330 Cu Fix PP 330

Eficacy - 1.5 per 100 woman years

(b) Progesterone Releasing Devices- Progestasert - levonorgestrel- Levonova - levonorgestrel

MOST SUITABLE CLIENTS FOR IUCD AREMOST SUITABLE CLIENTS FOR IUCD ARE

- Parous women in mutually monogamous relationship

- No current or prior history of RTIs

INJECTABLE STEROIDS INJECTABLE STEROIDSTwo types are currently in use

DMPA Depot Medroxyprogesterone Acetate (up john) Supplied in aqueous

microcrystalline suspension 150mg/ml in 1ml and 3ml/vials

DNO Depot Norethisterone Onanthate - derivative of 19nortestosterone supplied as

200mg/ml in benzyl benzoate and castor oil in 1ml vials.Third may be in use in the near future.

CYDCLOPROVERA

MECHANISM OF ACTIONMECHANISM OF ACTION

1. Inhibit ovulation by inhibiting the mid- cycle LH surge and suppresses the cyclic variation of oestrogen secretion by the ovaries.

2. Inhibit proliferation of the endometrium making it to become thin and atrophic and therefore the

endometrium is unfavourable for implantation.

3. Makes the cervical mucus to become thick and scanty thereby inhibiting the progression of

sperm into the uterus.

ADMINISTRATIONADMINISTRATION I.M buttocks or upper arm

DMPA Must be well shaken before filling the syringe site of injection must not be rubbed because this disperses the

injection. Amorphous white deposit is left in the muscle which is slowly absorbed.

DNO Supplied on oily solution more difficult to inject and may cause some discomfort.

EFFECTIVENESSEFFECTIVENESS

100% Effective

Pregnancy rates of 0.0 - 1.2 per 100 women years reported for 150mg.

DMPA given every 12 weeks and 0.01 - 1.3 per 100 woman years for 200mg DNO given every 8 weeks.

SIDE EFFECTSSIDE EFFECTSMenstrual Disturbances1. Frequent and irregular bleeding

71% women of 1st injection2. Amenorrhoea

54% of woman after 1 year of treatment.35% have complete

Amenorrhoea during at least 1 injection cycle.Amenorrhoea cycles becomes less frequent with

Noristerat

Management of Irregular bleeding With combined oral contraceptive Premarin 1.25 - 2.5mg daily x 21 days.

SIDE EFFECTSSIDE EFFECTS

3. Weight gain

Result of an increase appetite rather than fluid retention

4. Delayed return of fertility

6 - 12 months

2 years in extreme cases

Quicker return of ovulation with DNO reported

Women who have been treated for depression or have been depressed while taking oral contraceptive should not use depot contraceptive.

CONTRAINDICATIONSCONTRAINDICATIONSABSOLUTE Abnormal uterine bleeding Secondary amenorrhoea Arterial disease Cancer of the breast (except where used to treat endometrial cancer and breast cancer when much larger doses are required) Liver disease Trophoblastic disease until HCG levels are normal.RELATIVE Abnormal uterine bleeding - a definite established and possibility of

genital malignancy eliminated. Depression may be aggravated malignancy eliminated. Investigations of carbohydrate metabolism may be distorted. Women with history of thromboembolism B.P before treatment once controlled, DMPA can be used.

CARCINOGENIC EFFECTSCARCINOGENIC EFFECTS

Animal studies caused concern about

Mammary tomours in female beagle dogs and discovery of endometrial cancer in two rhesus monkeys that received 50 times the human dose.

WHO studies after 5 years of use, users have twice risk of carcinoma in situ

ONCE - A MONTH INJECTABLES IN USEONCE - A MONTH INJECTABLES IN USE

1. Dihydroxyprogesterone acetophenide (acetophenide 150mg and estradiol enanthate 10mg).

DHPA/E2-EN “Deladroxate” or Perlutal2. Deposit-Medroxyprogesterone acetate 25mg and estraldiol cypionate 5mg DMPA/E2C; HRP11Z “Cyclofem” or “Cycloprovera.3. Norethisterone enanthate 50mg and estraldiol valerate 5mg NET-EN/E2V; HRP102 “Mesigyna”4. 17 & Hydroxyprogesterone caproate 250mg andestraldiol valerate 5mg Chinese injectible No. 1REFERENCESMetabolic effects of once-a-month combined injectible contraceptives.Contraception 1994; 49: 421-433

ImplantsImplants

Synthetic polymers developed to provide sustained release of contraceptive steroids for prolonged use.

Silastic capsules pf progestagens implanted subcutaneously or subdermally.

ImplantsImplants

Can be placed in vaginal rings

In rings problems of erosion/vaginal/cervix/vaginal infection and inconvenience during S.I

Norplant 6 (six capsules) - 5 years protectionMulticentre trials in progress all over the world including Nigeria Now approved for use in several countries.

Normogestrol Acetate Uniplant - 1 year protection multicentre trials in progress all over the world including

Lagos/Ibadan`

CONTRACEPTIVE IMPLANTSCONTRACEPTIVE IMPLANTS

1987 Dr. Sheldon Segal discovered subdermal implants.

Advantages

As for injectables

Disadvantages

As for injectibles

Requires surgical procedure

CONTRACEPTIVE IMPLANTSCONTRACEPTIVE IMPLANTS

(i) Norplant -6 capsules (levonorgestrel)

- inserted inside inner aspect of the upper arm above the elbow.

- provides 5 years protection

- efficacy 1st year rates 0.2% and cumulative 5-year pregnancy rate 3.9%

- side effects are time dependent with the rate declining by about 50% after 1 year.

- no delay in restoration of fertility

(ii) Norplant 2 capsules

(iii) ST 1435 (Nestrone)-Lactation, less lipoprotein effects.

(iv) Uniplant (Nomegestrel Acetate)

(v) Implanon - 3 Keto-Dessogestrel

BIODEGRADABLE CONTRACEPTIVE IMPLANTSBIODEGRADABLE CONTRACEPTIVE IMPLANTS

- Does not require removal;

(i) Capronor - single; levonorgestrel

(ii) Capronr II

(iii) Capronor III

(iv) Annuelle - 90% Norethindrone + 10% Cholesterol.

Problems of Nonbiodegradable are those of removal

IMPLANONIMPLANON

Organon International Simple 30 mm silastic rod Release the progestin 3 keto -desogestrel at a rate of 30 ug

per day Effective for two to three years Removal is quick and relatively simple 3 keto-Desogestrel may inhibit ovulation more than levonogestrel.

Norplant 6Norplant 6

Norplant subdermal contraceptive the first represents the efforts of scientists of the Population Council who licensed Leiras of Finland in 1983 to manufacture and distribute Norplant. Norplant is a safe, effective method of reversible fertility regulation. Despite this, the apparent major shortcoming is menstrual disorders which cause about half of all discontinuations. The observed menstrual changes though not associated with a adverse alteration of haematological indices encouraged further

research at the local mechanism underlying contraceptive induced endometrial bleeding.

In view of observed undesirable side effects, appropriate counselling of potential acceptors is recommended as well as efforts to focus scientific research aimed at resolving some of the implants to improve continuation rates.

Norplant IINorplant II

Also from Population Council

Two rods slightly longer than Norplant 6 capsules

Two rods contain levonogestrel embedded

homogeneously within the silastic rod which is covered by a thin sheath of plain silastic.

Side-effect similar to Norplant

Easier to implant and to remove because there are fewer rods.

VAGINAL CONTRACEPTIVE RINGSVAGINAL CONTRACEPTIVE RINGS

Method of long-term contraception which is entirely patient’s control.

Steroids absorbed efficiently through vaginal epithelium.

Advantages

- Under patient’s control

- not coitus related

- no daily administration

- greater contraceptive effect

- milder adverse effects.

DESIGN OF VAGINAL CONTRACEPTIVE RINGSDESIGN OF VAGINAL CONTRACEPTIVE RINGS

Vaginal fornix around cervix

- homogenous ring

- shell ring

- core ring

TYPES OF VAGINAL CONTRACEPTIVE RINGSTYPES OF VAGINAL CONTRACEPTIVE RINGS

(a) Progestogen only(i) Levonogestrel - continuos low dose(ii) Progesterone - 90 days use

- Natural- Prolongs lactational amenorrhoea- Ineffective during weaning

(iii) ST 1435 (Nestrone) - 3 weeks in 1 weeks out.

- less metabolic effects.

(b) Combination rings(i) Levonogestrel/Ethinyl Estradiol(ii) 3 Keto-Desogestrel/EE(iii) Norethindrone Acetate/EE(iv) ST 1435/EE

BARRIER DEVICES AND CHEMICAL AGENTSBARRIER DEVICES AND CHEMICAL AGENTS

40 million couples worldwide

Over three centuries

Initially limited acceptability

Renewed interest - Aids pandemic

FEMALEFEMALE

(a) Cap(i) Vaginal diaphragms most widely used

spermicide types coil springs, flat spring, arcing failure rate 2-20

pregnancies per 100 women users per year of exposure.

(ii) Cervical Cap(iii) Fem-cap(iv) Lea’s shield(v) Long Acting Spermicides releasing diaphragms(vi) PH sensitive releasing devices

(b) Female condomDesign - Pouch thin polyurethane with 2 flexible rings at

each end/9one deep and the other at the intriotus)- Failure rate - 26% for the first year- Overall acceptability 65-79% for women users and 75-80% for their partners.

FEMALEFEMALE

(c) Sponge(i) Today sponge - polyurethane and

Nonoxynol-9Toxic to Spermatozoa

(ii) Protected

(d) Chemical agentsFoams, jellies, tablets, suppositories, aerosolsNonoxynol-9, Octoxynol-9, Menfegol

Male CondomMale Condom

1864 - Gabriel Fallopio Linen Sheath

20% of contraceptives use; renewed interest - Aids pandemic.

(i) LatexTeat endedPlain

(ii) Non-latex - polyurethane, plastics stronger, less rupture

Failure rate: 3 per 100 woman years

High risk women - “Double Dutch” method

Voluntary Surgical ContraceptionVoluntary Surgical Contraception

FEMALE STERILISATION

Occlusion of the uterine tubes to prevent pregnancy commonest form of permanent contraception in Europe/N-America.

SURGICALCommonest Approaches(a) Minilap(b) Laparoscopy (c) Laparotomy(d) Vaginal

TUBAL LIGATION TECHNIQUESTUBAL LIGATION TECHNIQUES

(a) Pomeroy(b) Madlener

(c) Fimbriectomy(d) Salpingectomy(e) Uchinda(f) Irvine

E and F more effective(i) Occlusive bands or rings: Falope(ii) Occlusive clips - Filshie or Hulka - Clemems(iii) Tubal diathermy (Thermocoagulation)(iv) Hysterectomy

COMPLICATIONS- immediate- delayed- long term

NON-SURGICALNON-SURGICAL

- via hysteroscopy

- by use of chemicals

- phenols

- quinacrine

- methyl cyano Accrylate

MALE STERILISATIONMALE STERILISATION

(I) SURGICAL

16% of contraceptive use

(i) Vasectomy

(a) Scalpel

(b) Non-scalpel - 1974: China,

Ligation

Excision (segmental)

Coagulation

(ii) Clips

(iii) Silicone rods

MALE STERILISATIONMALE STERILISATION

NON SURGICAL

Percutaneous Intravasal Injection of Sclerosants viz

(a) Carbolic Acid

(b) N Butyl-cyno-acrylate

OTHER MORE REVERSIBLE AGENTS INCLUDE:

(c) Polyurethane Elastomers - form plugs

(d) Styrene Malate Anhydride

OTHER MALE CONTRACEPTIONOTHER MALE CONTRACEPTION

Research over 50 years

TYPES(a) Androgens(b) Progestogens + Androgens(c) Danazol + Androgens(d) Gonadotrophin Releasing Hormone (GnRH).(e) Anti Progestogens

Problems- continued sperm production- histamine like effects - GnRH

Antagonists- Testosterone use viz lipoprotein

changes, acne

METHODS BEING DEVELOPEDMETHODS BEING DEVELOPED

CONTRACEPTIVE VACCINES

Research has been on for a few decades

PRINCIPLES OF ACTION

TYPES

A: ANTI-PERIMPLANTATION VACCINE - B-hCG= TT

B: HETEROSPECIES DIMER VACCINE - HSD

C: CTP VACCINE - 37 AA Carboxyl terminal peptide of B-hCG

Linked to Diphtheria Toxoid as Carrier

METHODS BEING DEVELOPEDMETHODS BEING DEVELOPED

D: LH-RH VACCINES

E: OTHERS: - Anti-Sperm

- Anti-Ovum

- Anti-Zona Pellucida

- Recombinant Zona Pellucida Antigens

F: MALE VACCINES - Passive/Active

Immunisation against FSH - Gn-RH Vaccine

CONCLUSIONCONCLUSION

PROGRESS MADE IN THE FIELD OF CONTRACEPTIVE DEVELOPMENT CAN BE SUMMED UP IN THE DECLARATION OF THE INTERNATIONAL SYMPOSIUM ON CONTRACEPTIVE RESEARCH AND DEVELOPMENT (YEAR 2000 AND BEYOND)

“IF ALL THE PEOPLE OF THE WORLD ARE TO ENJOY THE HIGHEST POSSIBLE LEVEL OF HEALTH AND BASIC HUMAN RIGHTS, ITS IS IMPERERATIVE THAT CONTRACEPTIVE DEVELOPMENT CONTINUES UNHINDERED. MOREOVER, WITHOUT SUCH RESEARCH, IT WOULD BE DIFFICULT FOR THE WORLD TO BRING ITS POPULATION AND NATURAL RESOURCES INTO A SUSTAINABLE BALANCE”.