Definition of contraception o A method or a system which allows intercourse and yet prevents conception is called a contraceptive method.

Failure rate of any contraceptive method is described in terms of pregnancy rate per 100 woman years (Pearl index). o The calender method or the rhythm method o avoidance of sexual intercourse around ovulation o In a 28-day cycle ovulation normally occurs on the 14th day of the cycle ovulation may occur anytime between the 12th and 16th day (MCQ) Spermatozoa deposited in the female genital tract may survive for 24 hours ovum itself may live for 12 to 24 hours intercourse between the 11 th and 17th day may result in a pregnancy. (MCQ) o Safe period first day of the menstrual period until the 10th day of the cycle from the 18th to the 28th day(MCQ) o Risk period, from 3 days before ovulation to 3 days after ovulation. In a 35-day menstrual cycle ovulation will occur on the 21st day (that is 14 days before the next period) risk period is from day 18 to day 24. (MCQ) o Calendar method. Ogino-Knaus method fertile peiod is determined by subtracting 18 days from the shorest cycle and 10 days from the longest cycle which gives the first and the last day of fertile period, respectively. (MCQ) Failure rate : 25 pregnancies per 100 woman years. o Mucus method (billings or ovulation method). Under oestrogen influence the mucus increases in quantity becomes progressively more slippery and elastic until a peak is reached under the influence of progesterone after peak under estrogen influence ,mucus becomes thicker, scanty and dry until the onset of menses Intercourse is considered safe during the 'dry days' immediately after the menses until mucus is detected. T thereafter the couple must abstain until the fourth day after the 'peak (MCQ) o Temperature method. Progesterone is known to exert a thermogenic effect on the body. BBT chart will be biphasic in an ovulatory cycle day of temperature shift indicates the time of ovulation.

Abstinence during the fertile phase

o Symptothermal method. This combination method is more effective. The first day of abstinence is predicted either from the calender, by subtracting 21 from the length of the shortest menstrual cycle in the preceding 6 months, or first day mucus is detected, whichever comes first. (MCQ) The end of the fertile period is predicted by use of the 'basal body temperature' chart. The woman resumes intercourse 3 days after the thermal shift. o Withdrawal method (coitus interruptus) Failure rate : 25 per 100 woman years. (MCQ) The main cause of the failure is not that ejaculation occurs inside the vagina but that prostatic fluid secreted prior to ejaculation, frequently contains active spermatzoa. Breastfeeding o Regular breastfeeding with at least one feed at night is shown to prevent pregnancy for 6 months o failure rate of only 0.5 to 1.5%. (MCQ) Barrier methods o Condoms water-based spermicides should be used with latex condoms Because of irritation by latex in some women, non-latex polyurethane condoms are avail-able. (MCQ) They however slip and break easily and are more costly than the latex condoms. Latex condoms prevent STDs such as HIV less protective against STD transmitted from skin-to-skin contact such as human papilloma vims and herpes virus. Nirodh brand is distributed free of cost in the government hospitals in India. pregnancy rate of 10 to 14 per 100 woman years. (MCQ) Other uses of condom following vasecomy for 12 ejaculates(MCQ) in immunological infertility to prevent transmission of gonococcal, chlamydia, syphilis, trichomonad and fungal infection, HIV. (MCQ) o Spermicidal agents contain surfactants, such as nonoxynol-9, octoxynol and menfegol (MCQ) failure rate - 30 per 100 woman years. (MCQ) remain effective for 1 to 2 hours after the application. (MCQ) By causing irritation and abrasions in chronic use, they can cause vaginal ulceration and perhaps increase the risk of HIV spread rather than prevent it. Therefore, the sper-micidal agents should not be recommended to HIV couples. (MCQ) A new spermicidal cream, Tenofovir, prevents viral attachment to the vaginal mucosa and is non-irritant and is under development. (MCQ) o Ocdusive diaphragms

diaphragm liberally covered with spermicide can be inserted at any convenient time left in position for a minimum of 8 hours after coitus. (MCQ) It causes no discomfort no douching is required A refitting of the diaphragm is always required after childbirth, and this can be done about 6 to 8 weeks after confinement. (MCQ) The Dutch cap or diaphragm. ones in common use range between 65 and 80 mm fit obliquely in the vagina, stretcing from just behind the pubic ramus into the posterior fornix, thus covering the cervix. It is held in position by the tension of the spring rim Contraindications to use of diaphragm (MCQ) o prolapse, cystocele, rectocele because accurate fitting is not possible o recurrent urinary tract infection o allergy to rubber or spermicidal agent. Toxic shock syndrome (TSS) o occur if the diaphragm is left in the vagina for a long period o caused by staphylococcal pyogenic infection. failure rate of the Dutch cap is about 4 to 6 per 100 woman years Cervical cap. It fits closely to the cervix suitable where the cervix is long and firm. When a woman has a prolapse of uterus and vagina, a cervical cap is preferred to the vaginal diaphragm. Chronic cervicitis, erosion and cervical laceration contraindicate its use. available in four sizes, varying from 22 to 31 mm Dumas cap It is a cup-shaped rubber with a thickened rim fits well into the vault of the vagina so that it encloses the cervix(MCQ) size varies from 55 to 75 mm diameter. Femshield (female condom). known as 'FEM' or Femidom It is a loose-fitting 15 to 17 cm long sheath made of polyurethane prelubricated(MCQ) It has the combined features of a diaphragm and a condom It covers the entire vagina, cervix as well as the external genitalia. It is highly protective against spread of STDs, and AIDS in particular(MCQ) It can be removed immediately after intercourse.

Today

(MCQ) Advantages of the Femshield (MCQ) o it is coital-independent and can be worn well in advance of the sexual act o it does not slip off easily, and the failure rate is expected to be low, o it is stronger than the condom and does not burst easily o it can be worn during the puerperal period unlike the diaphragm. Failure rate is 5 to 15 per 100 woman years. (MCQ) Femshield is expensive, costing 2 to 3 dollars per piece It is not re-usable
It is a mushroom-shaped polyurethane disposal sponge

contains 1 g of nonoxynol-9(MCQ) It can remain effective for 24 hours. (MCQ) Failure rate - 9 to 30 per 100 woman years(MCQ) expensive, coital-dependent may cause TSS if left over a long period. o Intrauterine contraceptive devices an effective, reversible and long-term method of contraception it does not require replacement for long periods it does not interfere with sexual activity. It is commonly made of polyethylene (MCQ) It is impregnated with barium sulphate to render it radiopaque so that the presence or absence of the device in the pelvis can be easily detected by radiograph. Biologically inert devices indude Lippes loop and Saf-T-Coil. They can be left in situ for several years, provided they cause no side effects Copper carrying devices copper wire of surface area 200 to 250 mm is wrapped round the vertical stem of a polypropylene frame. (MCQ) Copper T 200, Copper 7, Multiload Copper 250, CopperT380, CopperT220 and NovaT. have an effective life of about 3 to 5 years(MCQ) It is estimated that about 50 microgms of copper is eluted daily in the uterus. (MCQ) Paraguard o Copper T 380A (MCQ) o has a lifespan of 10 years. (MCQ) Nova T has silver added to the copper wire (MCQ) lifespan is 5 years. (MCQ) Progestasert and levonova. Progestasert

a T- shaped device carry 38 mg of progesterone in silicon oil reservoir in the vertical stem. (MCQ) It releases 65 micrograms of the hormone per day. (MCQ) Mechanism of contraceptive effect.

o Hormone released in the uterus forms a thick plug of mucus at the cervical os which prevents penetration by the sperms Menstrual problems like menorrhagia and dysmenorrhoea noticed with Copper T are less with this device (40% reduction). (MCQ) Requires yearly replacement Levonova o Contains 60 mg of levonorgestrel (LNG) o releases the hormone in very low doses (20 micrograms/day). (MCQ) o It is longer-acting (5 years) (MCQ) o It has a low pregnancy rate of 0 to 3 per 100 woman years(MCQ) o incidence of ectopic pregnancy is sixfold to nine-fold higher in women who do become pregnant as compared to failures amongst Copper T users. (MCQ) o It can be safely recommended for nursing mothers. (MCQ) Mirena o contains 52 mg LNG(MCQ) o elutes 20 microgram daily. (MCQ) o It can be retained for 5 years(MCQ) o It has a failure rate of 0.1 to 0.4 per 100 woman years Frameless IUCD IUCD under trial. contains several copper cylinders tied together on a string anchored 1 cm deep into fundus IUCDs are a good contraceptive choice for Low risk of STD Multiparous woman (MCQ) Monogamous relationship Desirous of long-term reversible method of contraception, but not yet desirous of permanent sterilization Unhappy or unreliable users of oral contraception or barrier contraception. Uses of IUCD As a contraceptive

Postcoital contraception (emergency contraception) Following excision of uterine septum, Asherman's syndrome(MCQ) Hormonal IUCD (Mirena) in o menorrhagia and dysmenorrhea(MCQ) o hormonal replacement therapy in menopausal women(MCQ) o In a woman on tamoxifen for breast cancer, it can be used to counteract endometrial hyperplasia. (MCQ) Contraindications of IUCD Suspected pregnancy Pelvic inflammatory disease (PID) lower genital tract infection Presence of fibroidsbecause of misfit(MCQ) Menorrhagia and dysmenorrhoea, if Copper T is used Severe anaemia Diabetic women who are not well controlledbecause of slight increase in pelvic infection(MCQ) Heart diseaserisk of infection(MCQ) Previous ectopic pregnancy(MCQ) Preferably avoid its use in unmarried and nulliparous patient because of the risk of PID and subsequent tubal infertility(MCQ) LNG IUCD in breast cancer (MCQ) Abnormally shaped uterus, septate uterus(MCQ) Mechanism of action The presence of a foreign body in the uterine cavity renders the migration of spermatozoa difficult. A foreign body within the uterus provokes uterine contractility through prostaglandin release It increases the tubal peristalsis (MCQ) the fertilized egg is propelled down the fallopian tube more rapidly than in normal it fertilized egg reaches the uterine cavity before the development of chorionic villi and thus is unable to implant. The device in situ causes leucocytic infiltration in the endometrium. (MCQ) Copper T o elutes copper which brings about certain enzymatic and metabolic changes in the endometrial tissue which are inimical to the implantation of the fertilized ovum. (MCQ) Progestogen-carrying device o causes alteration in the cervical mucus which prevents penetration of sperm, in addition to its local action. o It also causes endometrial atrophy(MCQ) o It prevents ovulation in about 40%.(MCQ)

Complications(MCQ) Immediate o Difficulty in insertion o Vasovagal attack o Uterine cramps Early o Expulsion (2 to 5%) o Perforation (1 to 2%) o Spotting, menorrhagia (2 to 10%) o Dysmenorrhoea (2 to 10%) o Vaginal infection o Actinomycosis Late o PID-2 to 5%. o IUCD does not prevent transmission of HIV. o Pregnancy 1 to 3 per 100 woman years (failure rate) o Ectopic pregnancy o Perforation o Menorrhagia o Dysmenorrhoea. IUCD can be inserted in HIV-positive woman on medication. (MCQ) Long-term follow-up of women wearing IUCD has shown no ill effects on systemic diseases. There is no evidence that the device predisposes to either cervical or endometrial cancer. Perforation can occur at the time of insertion, particu-larly during puerperium rare with withdrawal than push-in technique(MCQ) Menorrhagia is controlled with NSAID drugs. Expulsion may occur in 5 to 15% due to small size of IUCD common during the puerperal period or following MTP of a large gestation size. (MCQ) PID occurs usually in the 4 weeks of insertion Actinomycosis is an infection commonly associated with IUCD. Misplaced IUCD the tail of the IUCD is not seen through the os causes are(MCQ) o uterus has enlarged through pregnancy o thread has curled inside the uterus o perforation has occurred o IUCD is buried in the myometrium o it has been expelled

A plain radiograph or pelvic ultrasound is used to diagnose If it is inside, the uterine sound or another IUCD inserted in the uterine cavity will show on radiograph its proximity to the misplaced IUCD and perforation can be diagnosed Abnormal shape or location of IUCD on radiograph indicates likely perforation. Hysteroscopy is useful not only to locate it but also for its retrieval If the IUCD is in the uterine cavity, it can be retrieved with Shirodkar's hook, a curette or through a hysteroscope. In case of perforation, a laparotomy is needed, because Copper T causes adhesions to the omentum or a gut and cannot be retrieved easily through a laparoscope. Pregnancy. occurs with IUCD in situ in 1 to 3 per 100 woman years. If this happens, it is important to do ultrasound and rule out ectopic pregnancy(MCQ) The uterine pregnancy can cause severe infection It is therefore mandatory to remove the IUCD if the tail is visible through the os. While doing so, the risk of abortion should be explained to the woman. If the thread of the IUCD is not seen, termination of pregnancy is offered, not because IUCD has any teratogenic effect but because the risk of uterine infection is considerable. (MCQ) Ectopic pregnancy It occurs in 1:30 pregnancies in woman wearing IUCD. because IUCD has a local contraceptive action on the uterus and prevents a uterine pregnancy but does not protect against tubal or ovarian pregnancy Progestasert has the highest incidence of ecto-pic pregnancy (six to nine times more than Copper T). (MCQ) PID also contributes to the occurrence of an ectopic pregnancy. Advantages of IUCD It is coital-independent. (MCQ) newer IUCDs being as effective as oral contraceptives. hree per cent failure rate at the end of 1 year is reduced to less than 1% at the end of 5 years. There is no user failure. (MCQ) o There is no evidence of reduced fertility following its removal. o About 75% women conceive within 6 months of its removal

almost 90% conceive within a year. (MCQ) There are no systemic ill effects, unlike oral contraceptives No adverse effect on lactation is observed. Copper T is inserted free of cost in government hospitals in India. (MCQ)