Contraception

Fall 2015Potpourri

Contraception• Variety of methods• Categorized by methodology

– Barriers– Hormonal methods– Fertility awareness methods– Sterilization

• Contraceptive issues vary across countries• Contraceptive methods in the U.S. (Guttmacher Institute, 2010)

• Contraceptive methods in the U.S., 1995 vs. 2006-10 (CDC)• Contraceptive prevalence (Excel, pdf map) across the world

(United Nations, 2012)• Contraceptive prevalence by method (United Nations, 2011)

Why Does Contraception Matter?

• We (taxpayers) pay for many unexpected pregnancies• Rates of unintended pr

egnancy (Guttmacher Institute)

– How much (Guttmacher Institute)

– How much, #2 (Guttmacher Institute, published 2/2015)

Sterilization

Sterilization

• Sterilization = permanent contraception– Women undergo tubal ligation or implant– Men undergo vasectomy

• The second most common contraceptive method used in the United States (men’s and women’s methods combined)– No formalized data collection system exists– Data retrieved from surveys, questionnaires

• Female sterilization: 700,000/year (emedicinehealth.com)

• Vasectomies: 500,000/year (WebMD)

Sterilization: Tubal Ligation

• Surgical technique• Animation (1:35+)• Close fallopian tubes,

preventing egg from traveling to uterus, preventing sperm from reaching egg

• Neither organs nor glands are removed

• Effectiveness: 99%+• Considered irreversible

Sterilization: Tubal Ligation

• Tubal sterilization:– Tubes can be tied and cut

(Pomeroy technique)– Tubes can be cauterized– Tubes can be clipped, clam

ped– These incision methods

often performed after childbirth/abortion

– Animation (SMART imagebase)

Sterilization: Tubal Ligation

• Cost: $0-3000• Side effects: thought by many to be rare;

hormonal imbalance may lead to increased menstrual bleeding, cramping; adhesions

• Complications: infection, internal bleeding, ectopic pregnancy

• Before/after photos (private Flickr account)

Sterilization: Implants

• Non-incision method– No general anesthesia– Under an hour

• Coils inserted into fallopian tubes

• In following months, coils and tissue grow together, forming barrier to prevent sperm from reaching egg

Sterilization: Implants

• Side effects: expulsion of coil inserts, risk for ectopic pregnancy, cramping, menstrual changes, nausea/vomiting

• Animation (YouTube)

• Thousands of complaints regarding implant complications reported to FDA (NY Times, 2015)

Sterilization: Vasectomy

• Vasectomy blocks sperm from traveling through the vas deferens, preventing sperm from mixing into semen

• No glands or organs are removed

• Effectiveness: 99%+• Considered irreversible

Sterilization: Vasectomy

• Vas deferens must be isolated

• Similar to tubal ligation, the vas deferens can be cut and tied, clamped, cauterized, no scalpel technique

• Another form of contraception must be used for a few months

Sterilization: Vasectomy• Cost: $350-1000 (plannedparenthood.com)

• Not currently covered via Affordable Care Act (arhp, 1/14)

• Side effects: bruising, sensitivity/pain, sperm leaking from tubes may lead to small lump (usually clears up on its own), antibodies to sperm may develop, reducing chances of fertility in a reversal

• Complications: rare, usually associated with infection (fever, pus/blood from incision site, swelling, pain); ends of tubes may grow back together (very rare); decreased sexual desire (4 out of 1000 cases per Planned Parenthood) - no apparent physical cause

Sterilization: Vasectomy

• Animation (BUPA Health via YouTube, 2:36)

• Open-ended (no scalpel) vasectomy (medicalvideos.us)

• Video (vasectomymedical.com)

Intrauterine Contraceptives (IUC’s)

• IUC’s are made of flexible plastic, available only through prescription

• Three types (U.S.)– ParaGard (copper)– Mirena (hormone)– Skyla (hormone)

IUC’s: ParaGard• ParaGard contains copper• Copper prevents sperm

from fertilizing an ovum• Copper also makes

implantation of fertilized ovum difficult

• Amount of copper released is less than needed in daily diet

• Copper intolerance or insensitivity would preclude use of ParaGard

IUC’s: Paragard

• Requires insertion into uterus by healthcare provider– Takes only a few minutes– Insertion may cause cramping, dizziness

• Once inserted, may remain in place for ten years– Patient should not feel IUD

• Since no hormones present, monthly cycle should remain unchanged

• Effectiveness: 99%+ against pregnancy• Requires monthly checking for IUD slippage

IUC’s: ParaGard

• Side effects: heavier and longer periods, cramping, spotting in between periods– May lessen after a few months on ParaGard

• Complication risks: pelvic inflammatory disease shortly after insertion, perforation of uterus, expulsion

• Copper may provide protective benefit against endometrial cancer

• Cost: $0-1000 (Planned Parenthood)

IUC’s: Mirena

• Hormonal method (pregestogen)

• Intrauterine device• Lasts for five years• Mirena:

– Prevents sperm from fertilizing ovum

– Prevents release of egg– Changes uterine lining

IUC’s: Mirena• Insertion: Similar to ParaGard• Effectiveness: 99%+ against pregnancy• Cost: $0-1000 (Planned Parenthood, Bedsider.org)• Side effects: Abdominal cramping (10% of users

during first few months), acne, breast tenderness, headache, mood changes, back pain– May lessen after a few months– As use continues, less menstrual bleeding

• Complication effects: ovarian cysts, pelvic inflammatory disease shortly after insertion, perforation of uterus, expulsion

IUC’s

• Internal Birth Control- IUD’s (via Youtube)• Insertion of IUC (Medialvideos.us)

Barrier Contraceptive Methods

• Physical barriers– Prevent sperm from

entering cervix– Block sperm from

fertilizing ovum

Barrier Contraceptive Methods

• Historically, pessaries used– Objects or substances

inserted into vagina– Pregnancy prevention

effectiveness– Infection effectiveness

• Current barrier methods: spermicide, male condom, female condom, diaphragm, cervical cap, sponge

Barriers: Spermicide Nonoxynol-9• Ingredient in spermicides, may be included in condom

packaging• Originally thought nonoxynol-9 protected against HIV• In late 1990’s, early 2000’s, nonoxynol-9 was no longer

thought to provide that protection– Among commercial sex workers in Africa, Thailand– Frequent use– Nonoxynol-9 may increase risk for disease transmission

• Increases vaginal irritation, which can lead to lesions/sores• Lesions typically result in disease transmission vulnerability

• 2007: FDA required manufacturers to provide warning• Effect of Coke on Sperm Motility

• Mythbusters (1:04-4:00)

Contraception: News, Interesting Info, Future, Past

• Silk Parasol (product website)

• Caya – new diaphragm, 2015 (0:30-2:35, product website)

• RAPE-AXE female condom (YouTube)

Contraception in the Future• Nestorone

– Estrogen and progestin– Gel or spray– Population Council

Announcement, 2010– Phase III trials (Antares Pharma)

– Eventual availability?

• New vaginal ring– 90 days– Progestin + microbicide

• Microbicide = drug to reduce HIV, herpes, HPV

– Human trials 2014

Contraception: The Future

• Vasalgel (human trials in 2016-2017, per Parsemus Foundation)– Similar to India’s RISUG:Reversible Inhibition of Sperm Under

Guidance– Contraceptive method for men, not available in U.S.– Injection into vas deferens of male (video, wired.com, :34)– Vasalgel disrupts membranes of sperm so they cannot fertilize– One injection to last 10 years– Marketing challenges

Contraception: The Future

• Male pills (5-10 years)– Gendarussa – plant-based, interferes with sperm’s ability

to fertilize egg– Anti-Eppin – interferes with sperm motility– “Clean sheets” pill - Inhibit ejaculation but allow orgasm

• Short-term (<24 hours) method via pill, or longer-term via implant• If no ejaculate, STI risk may decrease

Contraception: The Past

• Male Contraceptive: Heat– Prolonged heat exposure

can impair sperm production in testes

– Ancient method– Effectiveness?

• 116 degree bath• 45 minutes• Every day• Three weeks

Contraception: Impact of Heat on Sperm

Contraception: Impact of Heat on Sperm

Dada, R, Gupta, NP, & K. Kucheria. Deterioration of Sperm Morphology in Men Exposed to High Temperature. Journal of the Anatomical Society of India.Vol. 50, No. 2 (2001-07-2001-12)

Contraception: Impact of Heat on Sperm

• Upper left: coiled tail• Upper right: bent tail• Lower left: double

head• Lower right: triple

head

Dada, R, Gupta, NP, & K. Kucheria. Deterioration of Sperm Morphology in Men Exposed to High Temperature. Journal of the Anatomical Society of India. Vol. 50, No. 2 (2001-07-2001-12)