Contraception

Fertility control which ideally

should be reliable, inexpensive,
safe and easy to use
 Characteristics of ideal
contraceptive
• Highly effective • Easily distributed
• No side effects • Administration by
• Independent of coitus health-care personnel
• Rapidly reversible is not required
• Cheap
• Widely available
• Acceptable to culture
and religions
 The failure rate of contraceptives
are traditionally expressed as the number of
failures per 100 women years (HWY).

HWY refers to the number of pregnancies

that would occur if a hundred women were
to use the contraceptive method for one
year.
• Pearl index = total no. of pregnancies X 1200
total no. of months of exposure

N.B: if the denominator is in months the quotient is multiplied by 13.

The pearl index estimates total no. of unplanned pregnancies per 100
woman years (HWY).

Life Table analysis – calculates failure rate for each month of use of
contraceptive method. It is a good method for comparing various
methods for specific length of time.

A woman-year is 12 menstrual cycles

Method failure – is failure attributable to a method if it is used perfectly and
reliably under ideal circumstances.

Patient failure – is attributable to less than ideal of that particular method

Long term contraception is any method that can be used for a month and
above.
Types of contraceptive methods
• Hormonal methods
• Intrauterine conceptive device
• barrier method
• Natural/traditional method
• Combined oral contraceptive pill
- Contains synthetic oestrogen and progesterone
• Dosage composition of oral contraceptive pill
Synthetic oestrogen:
Ethinyl oestradiol – 20; 30; 35; and 50mcg or mestranol – 50mcg

Synthetic progesterone:
1st generation:
Norethindrone, others – norethynodrel, ethynodiol diacetate, norethindrone enanthate,
norethindrone acetate (all convert to norethindrone before their activity).
2nd generation:
Norethisterone – 0.5; 1.0; and 1.5mg or levonogestrel – 0.15
and 0.25mg (i.e. norgestrel and levonorgestrel) levonorgestrel is the biologically active form.
3rd generation:
Gestodene – 0.075mg; desogestrel – 0.15mg or norgestimate
0.25mg.( where designed to enhance progestational activity and reduce androgenicity by
increasing biologic selectivity).
 Low dose pill contain 30-35mcg
• COC pill for 21 days with pill free interval of 7
day or the 28 day pill usually with 7 day
placebo

• Withdrawal bleeding usually occur during the

PFI – in some, this interval is enough to allow
follicular growth, especially if extended
beyond 7 days with resultant failure of
method. If COC is desire in such people
shorten the PFI for pill effectiveness
 COC pill
• Monophasic pill – same standard daily
dose of oestrogen and progestogen
throughout menstrual cycle
• Biphasic – incremental change in dose of
both hormone once
• Triphasic – incremental dose change
occur twice.
Note: the phasic pill where introduced in other to reduce the total dose
of progestogens and to improve cycle control – no evidence of
better cycle control. Infact failure rate with its use may be higher, if
the women get confused with how to cope with missed pills.
 Mode of action - COC
• Ovulation suppression – pituitary FSH
and LH, by oestrogen and progestogen in
the pill respectively.
• Cervical mucus change – prevent sperm
penetration
• Atrophic endometrium – hostile to
implantation
 Advantages of COC pill
• Menstrual – light menses; pain-free;
regular menses; Rx for premenstrual syn
• Reduce incidence of anaemia
• Reduce incidence of PID
• Protects against ovarian and endometrial
Cancer
• Decreases incidence of benign breast
lumps, functional ovarian cyst,
endometriosis and acne.
 Side effects of COC pill
Minor side effects
• Weight gain – fluid retention
• headache
• Nausea and vomiting
• Depressed libido
• Chloasma
• Mood change
• Mastalgia
• Breast enlargement
• Greasy skin
May improve in 3-6 month, pill
use is continued
Serious side effects
• Increased coagulability and
thrombotic tendency
• Increased risk of VTE – the risk
is high in obesity and PIH, but
unaffected by age, duration of
use or smoking. The risk of
VTE is highest with 3rd
generation progestogen
compared with 1st or 2nd
• Arterial diseases (hypertension,
cardiovascular accident and
coronary heart disease) are
less common but more serious
– related to age and worse with
smoking
•The BP is slightly raised in pill users
• Increased risk of breast cancer – risk persist for 10yr
after stopping pill use
• A small increase in the risk of developing squamous
ca of cervix after 5yr use of coc pill

Contraindication to COC pill

• Absolute contraindication :-
3. Cardiovascular diseases – ischaemic heart dz;
valvular heart dz; arterial thrombosis; venous
thrombosis; known predisposition to thrombosis.
4. Cerebrovascular dz – past cerebral haemorrhage;
current transient ischaemic attack; focal migraine.
5. Significant hypertension (pulm hypertension)
• hyperlipidaemia Relative contraindication
• Family hx of arterial dz
• Acute or chronic Liver dz
• Diabetes mellitus
– recurrent cholestatic
• Obesity
jaundice; Dubin-Johnson
• Increasing age
or Rotor syn; liver tumour;
• Smoking
gallstones or porphyria
• Generalised migraine
• Pregnancy
• Prolonged immobilization
• Oestrogen dependent • hyperprolactinaemia
tumour – breast cancer
• Hx of trophoblastic dz
• Undiagnosed genital tract
bleeding
 Progestogen only contraception

• Mini-pill – used continuously daily, with no

PFI, contains levonogestrel 30-75mcg
• Injectable – depot medroxyprogesterone
acetate, 150mg every 12-13 week or
norethisterone oenanthate 200mg every 8
week
• Implants – norplant; implanon; uniplant
• Hormone releasing IUCD
 Mechanism of action (POP)
• Thicken cervical mucus – reduce sperm penetration
• Endometrial atrophy – poor implantation
• Inhibits ovulation – high dose of injectable POP

Side effects
• Increased incidence of irregular menstrual
bleeding.(20% discontinue POP)
 Indications for POP Relative contraindications
contraindication to oestrogen • Severe obesity –
CVD; migraine; DM; mild HT. reduced efficacy and
aggravate wt gain
smoking; obesity; family hx of
• Breast cancer
arterial dz
• Severe hypertension
Breastfeeding women • Chronic liver disease
• Molar pregnancy until
Contraindications to POP urine is free of hCG
Absolute contraindications • Hx of recurrent ovarian
cyst.
• Pregnancy – high dose
androgenic progestogen (NET-
EN) may masculinize a female
fetus
• Undiagnosed genital bleeding
• Current cardiovascular dz
 Side effect of POP
• High incidence of Long term effect of POP
functional ovarian cyst • DMPA protects against
• Irregular vag bleeding endometrial carcinoma;
• Headache; nausea; may also protect against
bloating; breast ovarian cancer (no data)
tenderness; mood • The risk of breast cancer
change is increased after 5yr of
• Oily skin & acne – with use, but after 5yr of non-
the more androgenic use, the risk become
levonorgestrel and same with that in non-
norethisterone users
 Injectable Progest Only method
• Norethisterone • Mode of action – due to
oenanthate (NET-EN) high dose, inhibit
Warm before it can be ovulation
drawn up for After 1yr of injectable use
administration. • 80% - ammenorrhea or scanty
menses
Dose – i.m 200mg x 8 week • 2% - menorrhagia which may be
• Depot Rx temporary with oestrogen
(COC)
medroxyprogestrone
acetate (DMPA) – 150mg
x 12 week
New injectables
• Cyclofem (HRP-112) – 25mg
medroxyprogestone acetate +
oestradiol cypionate 5mg
• Mesygina (HRP) – 50mg NET-EN
+ oestradiol valerate 5mg
 Side effects of injectable
• Delayed return of fertility after stoppage –
may be up to 1yr
• Abnormal vag bleeding may continue after
stopping method
• Weight gain
• Reduced bone mineral density –
reversible
 Progestogen only implants
Non-biodegradable implants
• Norplant – long acting hormonal method, comprised 6 flexible
silastic caps – 3.4cm x 2.4mm and contains 36mg of
levonorgestrel
Usually inserted subdermally by minor surgery, in the inner aspect
of the non-dominant arm. 70-80mcg---12months
Norplant releases 30-35mcg /24hr after 18months
• Highly effective----2nd year----30—40mcg
• Last for 5years
• Fertility returns rapidly after removal (serum levonorgestrel clear within 120hrs of
removal)
• Low failure rate
Draw back
• It is expensive
• Menstrual disturbance – ammenorrhea; menorrhagia (50%
discontinue for this reason) worse during 1 year of use, thereafter improves
st

• Persistent ovarian follicle; headache (10-30%); weight gain; acne; hair loss hirsuitism; mood change
 Norplant II (Jadelle) – 2 silastic rods, same 36mg of levonogestrel as well as
release rate, advantages – easy insertion and removal

• Implanon – replacing norplant NT 1435 (Nestorone)

Single capsule – 68mg A single implant, protects for 2yrs
etonorgestrel (3 keto- • Can be used by breastfeeding
desogestrel) – releases 67mcg mother – when taken orally, it
per day for 3yrs is not biologically active. It is
Same efficacy and side effect as rapidly inactivated by hepatic first pass
metabolism.
norplant
• Less effect on lipoproteins
Easy to insert and remove
(3 keto-desogestrel is the biologically active
• 16-methylene-17-acetoxy-19
metabolite of desogestrel) norprogesterone
The maximum serum level is attained on day 4
after insertion and thereafter slowly fall for
the remaining lifespan of implant.
Following removal, serum level clears within 1
week

Uniplant – contains nomegestrol

acetate
Gives one year protection
 Biodegradable implants
• Capronor I, II, III
Capronor II – 2 capsule each in a 4cm polymer of caprolactone and contains
levonorgestrel 18mg – protects for 1yr
Capronor III – single copolymer capsule of caprolactone and trimethylene carbonate
blend
Contains 32mg levonogestrel – protects for 1yr
• Annuelle (NET implant)
Contains 4-5 pellets of 90% norethindrone and 10% cholesterol
Each pellet contains 35mg NET and each pellet is 8mm in length
Protects for 1yr

Intrauterine contraceptive device (IUCD)

• Inert IUCD (non-medicated) – Lippes loop; Margulies spiral; Saf-T-coil; Dalkon
sheild (has highest risk of PID)
• Often cause heavy and painful menses – due to large surface area
• Once fitted, they can be left in-situ until menopause
• Mode of action – induces local endometrial inflammation which prevents implantation
 Medicated IUCD
• Copper – to increase • Hormone releasing IUCD –
effectiveness and reduce Mirena contain
surface area, hence reduced levonorgestrel 52mg on it’s
side effects – stem. Releases 20mcg/day
dysmenorrhoea & • Can be in-situ for 5yr
menorrhagia
1st Generation Benefit – decreased menstrual
loss due to endometrial
• Cu 7 atrophy
• Cu T-200 Mode of action of medicated IUCD
2nd Generation - Copper ion released inhibits
capacitation of the sperm
• Multiload Cu-250 - May be spermicidal
• Nova T - Cu ion induces severe
3rd Generation inflammatory reaction, with
increase in prostaglandin thereby
• Multiload Cu 375 impairing implantation of the
• Cu T-380A (gold standard for embryo
assessing other IUCD) – may be in-situ - It may also reduce sperm ascent to
for 10-12yrs the fallopian tubesl
 New development in IUCD – to reduce side effects
and expulsion rate
• Cu SAFE-300 – smaller, lighter T- • Mechanism of action
shaped copper IUCD – designed
for insertion without plunger – • Prevents implantation
more towards uterine fundus • Inflammatory response – with
following contractions increase in macrophage,
• Flexigard 330 – frameless Copper leucocytes, prostaglandins which
IUCD – consist of 6 small copper are toxic to sperm and egg
beads threaded onto nylon which • It interfere with sperm transport
get embedded to the depth of 1cm
in the uterine fundus.
• T-shape Cu device with each arm
expanded into soft ball – designed
to block the ostia of the fallopian
tubes
• Cu Fix PP330 – designed for post
partum use – has a biodegradable
anchor that imbeds in the uterine
muscle
 Side effects
• Menstrual – increase flow (80ml with
Lippes loop and 50-60ml with Cu devices),
• Pain at insertion/dysmenorrhoea
• Uterine perforation (during insertion)
• Expulsion (up to 1-7 per 100
women in 1st year of use)
• Ectopic pregnancy – IUCD reduces
the risk of ectopic pregnancy in users
by 80% compared to non-users
• LNG-IUS reduces the risk by 90%
• IUCD gives less protection against
ectopic preg than either hormonal or
barrier methods
• Pelvic infection – highest in 1st 20
day after insertion – risk can be
reduced by – aseptic technique; proper
selection of recipient ( no multiple
sexual partners; do bacteriological
screening before insertion
Timing of insertion & removal
• Can be inserted at any time of the
cycle in women on effective
contraception – or else insert in the 1st
7 days of menstrual cycle
• Postpartum insertion – delay until after
8 weeks of delivery – reduce risk of
perforation and expulsion
• Post abortal – immediately after
Removal
• Remove during the late luteal phase or
in the 1st 7 days
• For menopause women – live in-situ
for 1yr after last menses
• Remove in the presence of pelvic
actinomycosis
Note: because of the tendency of copper to promote
intraperitoneal adhesions, it is mandatory that copper
devices should be removed when it perforate
 Pregnancy occurring with IUCD in-situ
• Pregnancy occurring with IUCD in- • Following failure to remove the IUCD
situ is associated with spontaneous and the pregnancy proceed there is
abortion in 55% of cases. This still an increased risk of spontaneous
abortion is also occasionally pre-term labour or intra-uterine death
complicated by severe infection. due to fetoplacental infection.
• Such pregnancy is unplanned, but it • However, those who do not abort may
may not be wanted. If the pregnancy progress to term, with the IUCD
is wanted – ensure that the IUCD is expelled usually lying beneath the
removed, so as to reduce the risk of placenta.
abortion. The IUCD is removed by
pulling on the tail in the vagina or
using hysteroscope if tail is invisible
(it is safe and effective).
• If the patient elect to continue with
the pregnancy, and it is impossible to
remove the IUCD, then the decision
to terminate or continue with the
pregnancy should be left to the
woman and her partner.
 Vaginal contraceptive rings
• A recent development
• Undergoing multi-centre trials
• Evolved clinically from vaginal
rings
• The steroids impregnated on the
rings are efficiently absorbed
through the vaginal epithelium.
• Advantages – its offers long-term
contraception which is under
patient control, it is independent of
intercourse, no daily
administration, has good
contraceptive effect and mild
adverse effect ( erosion, genital
infections and inconveniences
during sexual intercourse), it can
be discontinued easily.
Vaginal rings provides same long-term
contraception as injectables and
implants.
• Procedure – ring is placed in
the vaginal vault around the
cervix.
• The steroid release rate is a function of
the ring surface area, solubility of the
steroid in silastic, and the distance the
steroid has to diffuse to reach the
surface of the ring.
• Types of vaginal
contraceptive rings:
- Homogenous ring
- Shell ring
- Core ring
• Homogeneous ring – it requires a
large steroid load, the steroid
release rate decreases with time –
as the steroid on the surface is lost,
steroid must travel a greater
distance to reach the diffusion
medium.
• Shell ring – uses low dose steroid
load. The steroid is included in a
narrow zone just below the surface
of the ring – the distance the steroid
must travel to reach the surface of
the ring remains relatively constant.
• Core ring – the steroid is in the
centre of the ring material – can
either be a continuous ring or
discrete deposit of steroid.
The contraceptive rings can be used for
3-12months
• Type of steroid impregnated on rings
a) Progestogen only ring
- Levonorgestrel impregnated ring:
continuous low dose (20mcg/day).
- Natural progesterone: can be left in-
situ for 90 days before replacement
– prolongs lactational amenorrhoea,
supports lactation, it is ineffective
during weaning and so change to
other method of contraception.
- ST 1435 (Nestorone) ring – inserted
for 3 weeks, followed by one week
ring free interval. Less metabolic
effect.
b) Combined oestrogen-progestogen rings
- levonorgestrel/ethinyl oestradiol
- 3 keto-desogestrel/ethinyl oestradiol
used on a 3-week-in/1-week-out
schedule for three cycles
- Norethindrone/ethinyl oestradiol
- ST 1435/ ethinyl oestradiol
 Barrier methods
• Male condom – one
of the oldest and most
popular form of
contraception – widely
available; cheap; free of
side effects with
exception of few allergy,
no medical supervision
needed, protect against
STI
• Types – latex and non-latex
• Latex – lubricated or plain, teat ended
• Non latex – polyurethrane and plastics:
stronger and less likely to rupture
during use
Advantages:
Prevention of STI and HIV
Prevention of cervical cancer
Most are lubricated with
spermicides –nonoxynol-9 –
a non-ionic surfactant which alters
sperm surface membrane
permeability with resultant osmotic
changes and death.
Spermicide lubricant on condom are
carried on inert base which itself
alters sperm motility.
Spermicides also occurs in forms –
creams; jellies; foaming tablets;
pessaries or aerosols (very
expensive).
Spermicide
Advantage – does not need medical
supervision for use.
Disadvantage – it is coitus related and
relatively ineffective when used alone.
Therefore usually combined with other
methods condoms and vaginal
diaphragms
Spermicide should not be used alone, has
high failure rate –can be used in
perimenopausal women who sparingly
have coitus.
Other spermicides – octoxynol-9; menfegol
Vaginal barrier methods
Female condom (femidon or femshield)
• A pouch made of polyurethrane sheath,
with 2 polyurethrane rings, one at the
introitus and the other in the vaginal
vault.
• Available in one size only
• Has no spermicidal lubricant
• Designed for single use
• Its expensive and not widely available
• Failure rates same as for male condom
Diaphragm and cervical cap
• Less popular than condom
• Do not confer enough protection from
HIV
• Selecting the right size is quite difficult
• Must be fitted by a doctor or a nurse.
• There are 3 style of diaphragm spring –
flat spring, arcring spring and hinged
spring.
Cervical cap (Femcap)
- Made of silicone, shaped like the sailor’s
cap, it fits over the cervix. It has a
broad rim that create a protective seal.
It can be worn for up to 48hrs. It is
used with the spermicide to improve
effectiveness.
There are 3 types:
4. Small – for nulliparous women
5. Medium – for women who have been
pregnant, but no vaginal delivery.
6. Large – for women who have had a
vaginal delivery.
Requires professional fitting and training for use
Lea’s shield
- Made of flexible silicone rubber, it combines
the features of vaginal diaphragm and
cervical cap. It can be worn for up to 48hrs,
it is used with spermicide. It has a soft valve
which allows passage of cervical secretions
and a loop to aid insertion and removal of
the device.
- Usually available in one size which fits all.
- Lea’s shield is concave like the diaphragm,
but thicker and slightly enlongated rather
than rounded. It fits snugly into the pubic
bone and cul-de-sac, thus preventing
dislodgement during coitus.
Diaphragm
• It is a shallow latex cup, with a
spring mechanism in its rim to
hold it in place in the vagina.
• It is available in various
diameter. Prior to use a pelvic
examination and the diagonal
length of the vaginal canal must
be measured to determine the
size for an individual.
• It is inserted before coitus, such
that the posterior portion of the
rim fits into the posterior fornix
and the anterior behind the pubic
bone, prior to insertion,
spermicidal cream is introduced
into the inside of the dome which
then covers the cervix.
• Once introduced, it provides
effective contraception for 6hrs –
it must be left in-situ for 6hrs
after coitus.
• If a longer interval as elapsed
without removal, spermicide
must be introduced using an
applicator.
• It prevents pregnancy by acting
as a barrier to sperm ascent to
the cervix.
Advantages:
- Not an hormonal device
- Contraception controlled by the woman
Disadvantages:
- Requires professional fitting
- Prolonged usage following multiple
sexual act increases risk of UTI
- Prolonged usage for > 24hrs predisposes
to infection (toxic shock syndrome).
- Vaginal erosion may follow poor fitting
device.
- High failure rate – hence requires formal
training prior to use.
- It may develop odour, if not properly
cleaned.

Long-Acting spermicide-releasing
diaphragms – gives a burst of
spermicide release immediately
following vaginal placement and
thereafter followed by a decrease
dose release.
pH-sensitive release device – these are
vaginal barrier devices that release
spermicides following a stimulus such
as deposition of semen into the
vagina which increases the vaginal
pH. The device releases baseline
spermicide doses at normal vaginal
pH
Protectaid – this is a new vaginal sponge designed
to protect against STD
• It contains ‘F-5 gel’ which comprises low doses
of nonoxynol-9, benzalkonium chloride and
sodium cholate.
• Nonoxynol-9 and benzalkonium are spermicidal
and microbicidal, while sodium cholate is
antiviral.
• The sponge inactivates HIV, chlamydia and
trichomonas
Vaginal sponge
2. It is made of polyurethrane and
contains 1ng of nonoxynol-9.
3. Shaped like a mushroom cap and fits
over the cervix.
4. It is for single use, with a maximum
insertion time of 24hrs. It was originally
designed for 48hr use and to be a
reusable device but this was not
achieved due to poor efficacy.
Advantage:
- Continuous spermicide release for 24hrs.
- No waiting time after insertion before coitus.
- No prescription needed.
Disadvantage:
- High failure rate due to dislodgement.
- Inadequate spermicide release for the entire
24hrs
- Vaginal discomfort – itching and irritations
- Difficult removal – change in texture.
- A bad odour if left for a long period
- It absorbs seminal plasma and vaginal fluid
encouraging bacteria growth – toxic shock
syndrome
- Allergic type reaction – cervical erosion and
cervicitis
 Natural/Traditional family planning methods
• It involves abstinence from
intercourse during the fertile zone of
the menstrual cycle
• The different methods are
determined by the method used in
identifying the fertile zone
• 5. Hand-held monitor (kitchen method) – uses
Calender or Rhythm method – the woman
calculates the fertile period, from the length of her
normal menstrual cycle. ( the 1st day of her fertile
period is calculated by substracting 20 days from
her shortest duration of menstrual cycle and the last
day of the fertile period is calculated by substracting
11 days from her longest duration menstrual cycle.
E.g a woman with menstrual cycle duration varying
between 25-31days would have a fertile zone,
extending between 5-20day of menstrual cycle – i.e
25-20=5; 31-11=20) intercourse should be avoided
during the fertile zone.
• Mucus or Billings method – use the changes in the
quality and quantity of the cervical mucus, due to the
fluctuating concentrations of circulating oestrogen
and progesterone
3. Symtothermal method – uses the
temperature change during the menstrual
cycle, due to progesterone, which
commences at ovulation. This recognises the
end of the fertile period. This method restricts
intercourse until 48hrs after the BBT has
risen by 0.5 0C (no coitus until after BBT rise for 48hrs).
4. Other methods used to determine the fertile
period includes – ovulation pain; position of
the cervix; degree of cervical os dilatation.
disposable urine dipsticks to test for
oestrone-3-glucuronide and LH
concentrations and the ratio of both is used to
define the start and the end of the fertile
period. A red light is displayed on days when
intercourse should be avoided.
• Coitus interruptus – this is when there is
withdrawal just before ejaculation during
intercourse – requires self control.
• Lactational amenorrhea method (LAM) –
breastfeeding delays the resumption of fertility after
childbirth. The duration of delay is dependent on the
frequency and duration of breastfeeding episodes
and the timing of the introduction of food ( comple-
mentary or supplementary) other than breast milk.
Voluntary surgical contraception
Female sterilization (bilateral tubal
(VSC) ligation)
• VSC also known as sterilization is BTL usually involves blocking both
the most common form of family fallopian tubes.
planning world wide. Occasionally female sterilization
• VSC could be for female as in entires bilateral salpingectomy
and hysterectomy, when there
bilateral tubal ligation or male as are other coexistent
in vasectomy. Vasectomy has a gynaecological pathology.
clear advantage over bilateral
tubal ligation because Vasectomy
APPROACH TO BTL
is safer, cheaper and performed
under local anaesthesia and the - Laparotomy (during C/S)
efficacy can be checked easily - Minilaparotomy
with the analysis of seminal fluid - Laparoscopy
for presence of sperm. While the
disadvantage is that fertility of the Types of BTL
male continues beyond that of the - Intrapartum BTL
female - Postpartum BTL
• The ratio of female to male sterilization is - Interval BTL
3:1 world wide.
- Post-abortion BTL
• Intrapartum BTL – is done concurrent
with Caesarean section.
• Postpartum BTL – usually following
vaginal delivery (within 48hrs), using
minilaparotomy with the transverse
crescentic or medline vertical incision
at the lower border of the umbilicus.
Laparoscopic method is not used due
to the large uterus, fallopian tubes
and increased vascularity of the
pelvis at this period.
• Interval BTL – done at a time
unrelated to pregnancy (3 months
after delivery) using laparoscopy or
minilaparotomy with the med-line
incision above the pubis symphysis
(vertical or transverse measuring 2.5-
3cm)
• Post abortion BTL – shortly after
induced abortion (6-8weeks after) so
as to reduce failure rate, but not
immediately after as there is
increased risk of infection.
Advantage of laparoscopy or minilaparotomy
- Safer
- Short hospitalization
- Quick recovery
- Better cosmetic result
Management prior to VSC
- Counsel patient – permanent nature of
VSC, alternative methods (vasectomy for
husband), risk of surgery (anaesthesia),
failure of procedure, increased relative
risk of ectopic gestation.
- Obtain informed consent – preferably
written.
- History taking
- Physical exam
- Lab investigation – pregnancy test, PCV,
urinalysis.
 Emergency contraception
Definition (WHO):
EC is the method of preventing pregnancy
within a few hours or a few days after
unprotected sexual intercourse.
Importances of EC
- Prevents unwanted pregnancy
- Serves women’s health needs
- Advances reproductive self-determination.
 Methods of EC
• Yuzpe regimen – 100mcg of ethinyl oestradiol and 0.50mg
of levonorgestrel within 72hour of coitus and repeated 12
hours later
• Levonorgestrel – 0.75mg orally repeated 12hours later,
with first dose within 72hr.
• Intrauterine contraceptive device
• Mifepristone – an orally active synthetic 19-norsteroid, with
potent antiprogestional and antiglucorticoid activity. The
effect depends on the time of administration in relation to
the menstrual cycle. Follicular phase – inhibit or delay
ovulation, early luteal phase – inhibit progesterone,
thereby preventing secretory changes in the endometrium
and impairing implantation
 Mode of action of EC
• Mode of action varies because it is used at
different period during the menstrual cycle.

- Delaying or inhibiting ovulation

- Inhibiting fertilization
- Inhibiting implantation of fertilized egg
 Situations that require EC
• Fail contraception – burst condom
• Rape
• Does not want a pregnancy
• Refugees that cannot adequately use
family planning.