MOD ERN C ON TRAC EPT IV E

TECHNI QUES

By

E. Ejiro Emuveyan
Associate Professor of Obstetrics &
gynaecology
Department of Obstetrics & Gynaecology
College of Medicine, University of Lagos
P.M.B. 12003
Lagos
MALTHUS IAN C ONCE RNS

●TOO MANY PEOPLE REPRODUCING TOO

RAPIDLY

RETARDS ECONOMIC GROWTH

●

● DESTROYS THE ENVIRONMENT

● OVERSTRETCHES SOCIAL SERVICES

●
Worl d Po pu lat ion Pro file 1
Beginning of last century 2b
1970 4b
2000 6b
Rate of increase 1.2%
Estimated doubling time 42 yrs
10 Largest Countries in Population
China 1304
India 1104
USA 296
Indonesia 222
Brazil 184
Worl d Po pu lat ion Pro file 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
In di cat ions fo r f am ily
pl ann ing
● 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 a ll I ndi cati ons , p ro viders
of Fam ily Pl ann ing
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
Fe rt ility Co nt ro l

Most sensitive and intimate decision

Religious or philosophical convictions

Clinician approach it with sensitivity

Empathy, maturity and non-judgmental

behaviour
How So cio-Eco nom ic Ch ang es Af fect
Cont race pt ive Pr act ice
● Adolescents experiencing higher
pregnancy rates

● Women in later stages of reproductive

lifespan now tending to delay
childbearing until in their 30s and 40s.

● Demographic Shift
more women aged 30-44 years than
those aged 15-29 years.
needs of women with divergent social
or economic circumstances.
NIG ERI AN POP UL AT ION PR OF IL E
❁ 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 Profile
Women in reproductive age (15-44 yrs. -22.8%
Children Under 15 years 43.0%
CONT RACE PTIVE P REV ALE NCE
Worldwide (2005)-38.1m (53%) use effective
methods

Nigeria (1998) 6%
Ghana 19%
Benin 7%
Guinea-Conakry 4%
Kenya 32%
Tanzania 20%
HIST ORY OF FA MI LY P LA NNING
❑ 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.
BACK GROU ND H IST ORY CO NTINUES
❁ STONES IN THE WOMB OF CAMELS

❁ 1880 - CHEMICAL AGENTS AND

MECHANICAL DEVICES (INTRAVAGINAL
AND INTRAUTERINE)

❁ 1977 - IPPF - OVER 100 COUNTRIES

LE GAL ASP ECT S O F CONTRA CEP TION
❥ 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 PRO VIDE S T HAT ALL P ERSONS
MU ST

❆ Detailed Information about the use of the

❆ METHOD(S),

❆ BENEFITS

❆ RISKS,

❆ SIDE EFFECTS
CONSE NT AN D SER VIC E
● 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
ME THODS

CLASSIFICATION
TRADITIONAL 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
ME THODS

HORMONAL
- Oral
- Injectable
- Implantable Long-Acting Progestins

OTHER CONTRACEPTIVES
- IUCD
- Sterilisation
- Tubal Ligation
- Vasectomy
NA TU RAL C ONTRA CEP TION
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 INTERR UPTUS

● Oldest Method of Reversible Contraception

● Withdrawal before Ejaculation. Demands

Sufficient Self Control

● Statistics not reliable

● Failure rate - 10 Preg/100 Women Years

C. LAC TA TI ONA L A MENOR RHEA METH OD

● 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.

HI ST ORY O F OR AL CO NTA CEPTI ON

HISTORY
19th 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.
TYPE S
(A) Combined Oral Contraceptives (COCS).
Sequential - E Pill 15-16 days followed
E/P for 5 days
Problem: Than normal incidence of endometrial
cancer
Phasic - Monophasic, Biphasic, Triphasic
28 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
USAGE & FAI LURE 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
HORM ONAL CONT RACEP TION
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
HORM ONAL CONT RACEP TION
HISTORY: 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.
FAC TOR S CO NSIDER ED T O F IN D TH E R IGHT
ORAL C ON TRACEP TION

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).
Pos t-coit al co ntracept ion
Four hormonal methods

1. The combined oral contraceptive pill

2. Oestrogen only

3. Progestogen only

4. Danazol

Only the combined pill is recommended

COMPOSI TION AN D SI DE EFFEC T

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
Va gina l C ontra cep tive P ill (VCP )

- Recent

- Undergoing multicentre trials

- Historical evolution from vaginal rings

IN TR A-UT ER IN E CO NTRACEPT IV ES

Plastic devices placed in the uterine cavity

to prevent pregnancy
Different shapes, sizes and types

MAIN MECHANISM OF ACTION

Interference with implantation
Increase with sperm transport
Inhibit capacitation
TYPE S
1. Non medicated (inert) e.g Lippes loop
2. Medicated - less bleeding and pain

(a) CU DEVICES
1st Generation - Cu 7
- Cu T
2nd Generation - Multiload 250
Nova T
3rd Generation - Multiload 375
Cu T 380 A
Flexigard 330
Cu Fix PP 330
Eficacy - 1.5 per 100 woman years

(b) Progesterone Releasing Devices

MO ST SUITABLE CLIENTS FO R IUCD AR E

- Parous women in mutually

monogamous relationship

- No current or prior history of RTIs

INJEC TAB LE ST EROI DS
Two 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
ME CH ANISM OF ACT IO N

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

ADM INIST RAT IO N

❊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.
EFFE CT IV ENESS

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 EF FE CTS
Menstrual Disturbances
1. Frequent and irregular bleeding
71% women of 1st injection
2. 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 EF FE CTS

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
CO NTRAINDICAT IO NS
ABSOLUTE
❊ 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
CARCINO GEN IC 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 M ONTH I NJEC TA BL ES I N U SE

1. Dihydroxyprogesterone
acetophenide (acetophenide 150mg and
estradiol enanthate 10mg).
DHPA/E2-EN “Deladroxate” or
Perlutal
2. 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. 1
REFERENCES
Impl ants

❊ Synthetic polymers developed to

provide sustained release of
contraceptive steroids for
prolonged use.

❊ Silastic capsules pf progestagens

implanted subcutaneously or
subdermally.
Impl ants

❊ 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 protection

Multicentre 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`
CO NTRACEP TIVE I MPLAN TS

1987 Dr. Sheldon Segal discovered

subdermal implants.

Advantages
As for injectables

Disadvantages
As for injectibles
Requires surgical procedure
CO NTRACEP TIVE I MPLAN TS

(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)
BIO DEG RADAB LE C ON TRACEP TIVE IMP LA NTS

- 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
IMP LAN ON

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.
Norplan t 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
Norplan t 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.
VAG INA L CONTRA CE PT IVE RING S

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.
DESIG N OF VAGI NA L CONT RACE PT IV E RING S

Vaginal fornix around cervix

- homogenous ring

- shell ring

- core ring
TYP ES OF VAGINAL CONTRAC EP TIVE RIN GS

(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
BARR IE R DEV ICE S AND CH EM ICAL
AG ENT S

40 million couples worldwide

Over three centuries
Initially limited acceptability
Renewed interest - Aids
pandemic
FE MA LE
(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 condom
Design
- 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
FE MA LE

(c) Sponge
(i) Today sponge - polyurethane and
Nonoxynol-9
Toxic to Spermatozoa
(ii) Protected

(d) Chemical agents

Foams, jellies, tablets, suppositories,
aerosols
Nonoxynol-9, Octoxynol-9, Menfegol
Male Co ndom
1864 - Gabriel Fallopio
Linen Sheath

20% of contraceptives use; renewed interest - Aids

pandemic.

(i) Latex
Teat ended
Plain

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

less rupture

Failure rate: 3 per 100 woman years

High risk women - “Double Dutch” method

Vo lu nt ary Surg ical Cont race pt ion

FEMALE STERILISATION

Occlusion of the uterine tubes to prevent

pregnancy commonest form of permanent
contraception in Europe/N-America.

SURGICAL
Commonest Approaches
(a) Minilap
(b) Laparoscopy
(c) Laparotomy
(d) Vaginal
 TUBA L LIG AT ION T ECH NIQUES

(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-SURGICA L

- via hysteroscopy

- by use of chemicals

- phenols

- quinacrine

- methyl cyano Accrylate

MA LE S TE RILISA TION

(I) SURGICAL
16% of contraceptive use
(i) Vasectomy
(a) Scalpel
(b) Non-scalpel - 1974: China,
Ligation
Excision (segmental)
Coagulation

(ii) Clips
(iii) Silicone rods
MA LE S TE RILISA TION

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
OT HER MA LE CO NTRA CEP TION
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
ME THODS B EING DE VE LOP ED
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
ME THODS B EING DE VE LOP ED
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
CONCLUS ION

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