Contraception and sterilization

1. Contraception and sterilization dr.fedathekrallah Done by shadenhaddad

2. 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

3. 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

4. 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).

6. 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

7. 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 introitusafter intercourse.

8. 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 .)

9. 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.

10. 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

11. Male condoms:

12. 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

13. Female condoms

14. 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%

15. 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

16. diaphragm

17. 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

18. Cervical cap

19. 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 mucosaand external genitalia • Disadvantages: -no protection against STD (most woman susceptible to STD due to vaginal mucosa irritation)

20. 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

21. Intrauterine devices Tcu-380A • Copper in paragard will stop sperms motility and capitation • Therefore sperms rarely reach fallopian tubes and no fertilization occurs.

22. Intrauterine devices Mirina • 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

23. 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 infection Note: 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

24. 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

25. Intrauterine devices Absolute contraindications 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 ) • Known pregnancy • Undiagnosed abnormal vaginal bleeding • Acute cervical , uterine ,infection • Copper allergy or wilson disease (paragard ) • Current breast cancer (mirena)

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