Birth control measures are an essential aspect of day to day life. From the prevention of unwanted pregnancy to avoidance of sexually transmitted diseases, birth control measures have multiple purposes.
Types of Temporary Birth Control Measures:
Fertility awareness methods:
Calendar method Recording of basal body temperature Cervical mucus technique Coitus interruptus Barrier Methods Calendar method
- Male condoms
- Female condoms
- Vaginal sponge
- Spermicidal agents
- Cervical cap
- Hormonal Contraceptives
- Oral Pills
- combined pills
- triphasic pills, monophasic pills
- progesterone only pills
- Injectable Preparations
- depot hydroxy progesterone acetate
- depot norethisterone
Intra Uterine Contraceptives
Permanent Birth control:
Tubectomy in women
Vasectomy in males
Fertility Awareness Method:
Fertility Awareness Method requires partner’s cooperation. The woman should know the fertile time of her menstrual cycle.
This is the only method approved by the Roman Catholic Church. The method is based on the identification of the fertile period of a cycle and to abstain from sexual intercourse during that period. This requires partner’s cooperation. The methods to determine the approximate time of ovulation and the fertile period include — (a) recording of previous menstrual cycles (calendar rhythm) (b) noting the basal body temperature chart (temperature rhythm) and (c) noting excessive mucoid vaginal discharge (mucus rhythm). The users of the calendar method obtain the period of abstinence from calculations based on the previous twelve menstrual cycle records. The first unsafe day is obtained by subtracting 20 days from the length of the shortest cycle and last unsafe day by deducting 10 days from the longest cycle. Users of temperature rhythm require abstinence until the third day of the rise of temperature. Users of mucus rhythm require abstinence on all days of noticeable mucus and for 3 days thereafter.
Coitus Interruptus (withdrawal) :
It is the oldest and probably the most widely accepted contraceptive method used by men. It necessitates withdrawal of penis shortly before ejaculation. It requires sufficient self-control by the man so that withdrawal of penis precedes ejaculation.
Breastfeeding, Lactational Amenorrhea (LAM):
Prolonged and sustained breastfeeding offers natural protection from pregnancy. This is more effective in women who are amenorrheic than those who are menstruating. The risk of pregnancy to a woman who is fully breastfeeding and amenorrheic is less than 2 percent in the first 6 months. Otherwise, the failure rate is high (1–10 percent). Thus during breastfeeding, additional contraceptive support should be given by condom, IUCD or injectable steroids where available to provide complete contraception. When the women are full breastfeeding, a contraceptive method should be used in the 3rd postpartum month and with partial or no breastfeeding, she should use it in the 3rd postpartum week. Fertility awareness based methods are: (1) Natural contraception (Rhythm method, Coitus interruptus and Lactational amenorrhea method) (2) Barrier method (Condoms, diaphragm and spermicides).
This is a very safe method because it does not have any adverse reactions or any discomfort. The disadvantage is that it is mostly a failure and requires lots of self-determination. It includes identifying fertile periods during the month and avoiding sex during that period. Fourteen days before the next period is the time of ovulation, two days before and three days after this date is considered as a fertile period. The failure rates are high in this method.
Recording of Basal Body Temperature:
The temperature of the body increases to up to 1-degree celsius during ovulation. Hence, regularly recording the woman's body temperature may help pick up the time of ovulation and avoid sexual intercourse during that period. There are too many confounding factors associated with this method and the failure rate is high. Similarly, the cervical mucus test can also be used to identify the time of ovulation. But these are obsolete and cannot be followed regularly.
These methods prevent sperm deposition in the vagina or prevent sperm penetration through the cervical canal. The objective is achieved by mechanical devices or by chemical means which produce sperm immobilization, or by combined means. The following are used.
Condoms are made of polyurethane or latex. Polyurethane condoms are thinner and suitable to those who are sensitive to latex rubber. It is the most widely practiced method used by the male. In India, one particular brand (latex) is widely marketed as ‘Nirodh’. The efficacy of condoms can be augmented by improving the quality of the products and by adding spermicidal agents during its use. Protection against sexually transmitted disease is an additional advantage. Occasionally, the partner may be allergic to latex. The method is suitable for couples who want to space their families and who have contraindications to the use of oral contraceptive or IUD. These are also suitable to those who have infrequent sexual intercourse.
The Female Condom (Femidom) :
It is a pouch made of polyurethane which lines the vagina and also the external genitalia. It is 17 cm in length with one flexible polyurethane ring at each end. The inner ring at the closed end is smaller compared to the outer ring. The inner ring is inserted at the apex of the vagina and the outer ring remains outside. It gives protection against sexually transmitted disease and pelvic inflammatory disease. It is expensive. Multiple uses can be made with washing, drying and with lubrication. The failure rate is about 5–21/HWY.
It is an intravaginal device made of latex with flexible metal or spring ring at the margin. Its diameter varies from 5–10 cm. It requires a medical or paramedical personnel to measure the size of the device. The distance between the tip of the middle finger placed in the posterior fornix and the point over the finger below the symphysis pubis gives the approximate diameter of the diaphragm. The diaphragm should completely cover the cervix. As it cannot effectively prevent the ascent of the sperms alongside the margin of the device, the additional chemical spermicidal agent should be placed on the superior surface of the device during insertion, so that it remains in contact with the cervix. The device is introduced up to 3 hours before intercourse and is to be kept for at least 6 hours after the last coital act. Ill fitting and accidental displacement during intercourse increase the failure rate.
Not suitable for women with uterine prolapse. Failure rate—16 (HWY)
Spermicides are available as vaginal foams, gels, creams, tablets and suppositories. Usually, they contain surfactants like nonoxynol–9, octoxynol or benzalkonium chloride. These agents mostly cause sperm immobilization. The cream or jelly is introduced high in the vagina with the help of the applicator soon before coitus. Foam tablets (1–2) are to be introduced high in the vagina at least 5 minutes prior to intercourse. In isolation, it is not effective (18–29 HWY), but enhances the efficacy of condom or diaphragm when used along with it. There may be occasional local allergic manifestations either in the vagina or vulva.
Vaginal Contraceptive Sponge (Today):
It is made of polyurethane impregnated with 1 g of nonoxynol-9 as a spermicide. Nonoxynol-9 acts as a surfactant which either immobilizes or kills sperm. It releases spermicide during coitus, absorbs ejaculate and blocks the entrance to the cervical canal. The sponge should not be removed for 6 hours after intercourse. Its failure rate (HWY) is about — Parous women: 32-20, Nulliparous 16-9. Currently it is observed that nonoxynol–9 is not effective in preventing cervical gonorrhea, chlamydia or HIV infection. Moreover, it produces lesions in the genital tract when used frequently. Those lesions are associated with increased risk of HIV transmission.
The intrauterine device has been used throughout the world. During the last couple of decades, however, there has been a significant improvement in its design and content. The idea is to obtain maximum efficacy without increasing the adverse effects. The device is classified as open, when it has got no circumscribed aperture of more than 5 mm so that a loop of intestine or omentum cannot enter and become strangulated if, accidentally, the device perforates through the uterus into the peritoneal cavity. Lippes loop, Cu T, Cu 7, Multiload and Progestasert are examples of open devices. If closed devices, like Grafenberg ring and Birnberg bow, accidentally enter the abdominal cavity, they have the potential of causing strangulation of the gut; and hence are obsolete. The device may be non-medicated as Lippes loop or medicated (bioactive) by incorporating a metal copper, in devices like Cu T-200, Cu T-380A, Multiload-250, Multiload-375.
Intrauterine contraceptive device is a widely acceptable reversible method of contraception for spacing of births. Amongst many, either a copper impregnated device like Cu T, multiload or a hormone releasing device like LNG-IUS is commonly used. Its mode of action is not clear. Probably, it produces nonspecific biochemical and histological changes in the endometrium and ionized copper has got spasmolytic and genotoxic effects. LNG-IUS induces uniform suppression of endometrium and produces very scanty cervical mucus. It should not be used in newly married women or when any pelvic pathology is present. The device can be introduced in the interval period or following abortion or childbirth. The introduction is an outdoor procedure and can be done even by a trained paramedical personnel without anesthesia. The technique employed is either “push-out” in Lippes loop or “withdrawal” in Cu T. The immediate complications include cramp-like pains or even syncopal attacks. The delayed complications include pelvic pain, menstrual irregularities, expulsion of the IUD or even perforation of the uterus. Complications are much less with third generation of IUDs. The indications of its removal are, missing threads, persistent pelvic pain, menorrhagia, pregnancy, displacement of the device and flaring up of pelvic infection. While Cu T 200 should be removed after 3–4 years, multiload 375 is replaced after 5 years, Cu T 380A after 10 years and LNG-IUS after 5 years. The failure rate is about 0.5–2 per HWY. Copper device can also be used as postcoital contraception and following synaecolysis.
Enovid (norethynodrel 10 mg and menstranol 0.15 mg) was used in the first contraceptive field trial in Puerto Rico in 1956 by Pincus and his colleagues. Intensive pharmacological research and clinical trials were conducted during the following years to minimize the adverse effects of estrogen without reducing the contraceptive efficacy, resulted in lowering the dose of estrogen to a minimum of 20 µg or even 15 µg in the tablet.
The combined oral steroidal contraceptives is the most effective reversible method of contraception. In the combination pill, the commonly used progestins are either levonorgestrel or norethisterone or desogestreland the estrogens are principally confined to either ethinyl-estradiol or menstranol (3 methylether of ethinylestradiol). Currently ‘lipid friendly’, third generation progestins, namely desogestrel, gestodene, norgestimate are available. Some of the preparations available in the market are mentioned in the Table 35.8. Only Mala-N is distributed through government channel free of cost (Fig. 35.8). 4th generation: Drospirenone which is an analogue of spironolactone is used as progestin. It has antiandrogenic and antimineralocorticoid action. It causes retention of K+.
New users should normally start their pill packet on day one of their cycle. One tablet is to be taken daily preferably at bed time for consecutive 21 days. It is continued for 21 days and then have a 7 days break, with this routine there is contraceptive protection from the first pill. Next pack should be started on the eighth day, irrespective of bleeding (same day of the week, the pill finished). Thus, a simple regime of “3 weeks on and 1 week off” is to be followed. Packing of 28 tablets, there should be no break between packs. Seven of the pills are dummies and contain either iron or vitamin preparations. However, a woman can start the pill up to day 5 of the bleeding. In that case she is advised to use a condom for the next 7 days. The pill should be started on the day after abortion. Following childbirth in non-lactating woman, it is started after 3 weeks and in a lactating woman, it is to be withheld for 6 months .
The patient should be examined after 3 months, then after 6 months and then yearly. The patients above the age of 35 should be checked more frequently. At each visit, any adverse symptoms are to be noted. Examination of the breasts, weight and blood pressure recording and pelvic examination including cervical cytology, are to be done and compared with the previous records. MISSED PILLS: Normally there is return of pituitary and ovarian follicular activity during the pillfree interval (PFI) of 7 days. Breakthrough ovulation may occur in about 20 percent cases during the time. Lengthening of PFI due to omissions, malabsorption, or vomiting either at the start or at the end of a packet, increases the risk of breakthrough ovulation and therefore pregnancy.
POP is devoid of any estrogen compound. It contains very low dose of a progestin in any one of the following form — Levonorgestrel 75 µg, norethisterone 350 µg, desogestrel 75 µg, lynestrenol 500 µg or norgestrel 30 µg. It has to be taken daily from the first day of the cycle.
Unprotected intercourse, condom rupture, missed pill, delay in taking POP for more than 3 hours, sexual assault or rape and first time intercourse, is known to be always unplanned. Risk of pregnancy following a single act of unprotected coitus around the time of ovulation is 8 percent.
This is not true contraception but has rightly been called interception, preventing conception in the case of accidental unprotected exposure around the time of ovulation. Drugs commonly used, levonorgestrel, ethinyl-estradiol 2.5 mg. The drug is taken orally twice daily for 5 days, beginning soon after the exposure but not later than 72 hours. Levonorgestrel (E. Pills) 0.75 mg, two doses given at 12 hours interval, is very successful and without any side effects. The two tablets (1.50 mg) can be taken as a single dose also. The first dose should be taken within 72 hours . No fetal adverse effects has been observed when there is failure of emergency contraception. However, induced abortion should be offered to the patient, if the method fails.
Combined hormonal regimen (Yuzpe method) is equally effective. Two tablets of Ovral (0.25 mg levonorgestrel and 50 µg ethinylestradiol) should be taken as early as possible after coitus (< 72 hours) and two more tablets are to be taken 12 hours later. Oral antiemetic (10 mg metoclopramide) may be taken 1 hour before each dose to reduce the problem of nausea and vomiting. Anti-progesterone: Anti-progesterone (RU 486- Mifepristone) binds competitively to progesterone receptors and nullifies the effect of endogenous progesterone. Dose: A single dose of 100 mg is to be taken within 17 days of intercourse. Implantation is prevented due to its antiprogesterone effect. Pregnancy rate is 0–0.6 percent. Ulipristal acetate as an EC is as effective as levonorgestrel. A single dose 30 mg, to be taken orally as soon as possible or within 120 hours of coitus. It acts by suppressing follicular and endometrial growth. It delays ovulation and inhibits implantation. It should not be prescribed to women with severe hepatic dysfunction or severe asthma.
Permanent surgical contraception, also called voluntary sterilization, is a surgical method whereby the reproductive function of an individual male or female is purposefully and permanently destroyed. The operation done on male is vasectomy and that on the female is tubal occlusion, or tubectomy. Couple must be counseled adequately before any permanent procedure is undertaken. Individual procedure must be discussed in terms of benefits, risks, side effects, failure rate and reversibility.