This document discusses various methods of contraception. It begins by explaining that contraception is important for effective pre-pregnancy care, especially for high-risk women. It then provides details on many contraceptive methods, including natural/fertility awareness methods, barrier methods, hormonal methods, and long-acting reversible contraception (LARC) methods like IUDs, implants, and injections. For each method, it discusses effectiveness rates, mechanisms of action, administration instructions, benefits, risks, and other relevant details. The document emphasizes the importance of selecting the appropriate contraceptive method based on each individual woman's needs and circumstances.

1. Contraception
Making the Choice
Dr Buvanes Chelliah
MD (UKM) MOG (UKM)
Obstetrician & Gynaecologist
Sarawak General Hospital

2. Contraception is a stepping stone for
effective Pre pregnancy care
especially for high risk women

3. Millennium Development Goals
(MDGs)

4. MMR 1950-2008
Further reduction of
maternal mortality will be a
challenge and will need the
support of other disciplines
for specialized skills,
multidisciplinary case
management, and
prevention of pregnancies
of known high-risk factors.

5. TYPES OF CONTRACEPTION

7. TYPES OF CONTRACEPTION
 Natural FP/Fertility
awareness method
 Calender
 Ovulation method
 Symptothermal
 Hormone monitoring
 Barrier methods
 Male condom
 Female condom
 Diaphragm
 Cervical cap
 Sponges & spermicides
 Combined Hormonal
contraception
 COCPs
 Extended-period:
Seasonale*
 Combined Hormonal Patch :
EVRA*
 Combined Hormonal Ring :
Nuva Ring*
 Progestogen-only pills
 Long Acting Reversible
Contraception (LARC)
 Non hormonal LARC
 Hormonal LARC

8. TYPES OF CONTRACEPTION
 Non-Hormonal LARC
 Copper IUD
 Frameless IUD*
 Hormonal LARC
 Injectable contraception
 Progestogen only
injectables
○ DMPA
○ NET-EN
 Combined injectable
contraceptive
○ Cyclofem/ Lunelle*
○ Mesigna*
 Implant
 Implanon (etonogestrel
implant)
 Norplant/ Jadelle*
(levonorgestrel implant)
 Intrauterine system (IUS)
 LNG IUS : MIRENA
 Sterilisation
 Female : BTL, Hysteroscopic
sterilization: ESSURE*
 Male : Vasectomy (scapel &
no-scapel), IVD implant *,
IVD clips*.

9. Failure rates of various contraceptive
methods
Method Typical Use Perfect Use
COCP 8 0.3
POP 8 0.3
IM Depo Provera 3 0.3
IUCD
- Copper
0.8
0.6
- Mirena
0.2
0.2
Implanon 0.05 0.05
Tubal Ligation (♀) 0.5 0.5
Vasectomy (♂) 0.15 0.1
Condom 15 2
Coitus Interruptus 18 4

10. So…which one to choose?

11. Natural family planning
 Calender
WHO define “the voluntary avoidance of intercourse by a couple during the
fertile phase of the menstrual cycle in order to avoid a pregnancy”
 Lactational amenorrhoea method (LAM)

12. CALENDAR METHOD
 General rule
 Cycle length is recorded for
the min of 6 cycles
 Likely fertile days are then
calculated allowing for the
survival of sperm and ova
 First fertile day : shortest
cycle – 20
 Last fertile day : longest
cycle – 10
 Example :
 If cycles of 26-32 days,
periodic abstinence should
be practice from day 6 to
day 22
Pregnancy rate of 40
per 100 women years

13. CALENDAR METHOD
 Require long periods
of sexual abstinence
 Provide low & varying
levels of efficacy
 Do not provide any
protections against
STIs
Not suitables for:
 Cycle length <23 days
or > 35 days
 PCOS
 Breastfeeding
 Menopausal
symptoms
 Women taking
hormonal medication

14. LACTATIONAL AMENORRHOEA
METHOD (LAM)
 Exclusive BF during the
first 6 months after last
childbirth
 Induced amenorrhea
FAILURE RATE 2 IN 100
WOMEN

15. Male condom
Failure rate
2-15/100 WY

16. ONLY WORKS IF APPLIED IN
THE RIGHT TRACK!!!!!!

17. Combined Oral Contraceptives
Pills (COCP)
Failure rate of 0.2-0.3 per 100 woman-years.
Examples of COCP
available in Malaysia:
• Regulon
• Rigevidon
• Microgynon
• Mercilon
• Marvelon

18. Mode of Action COCP
 Suppression of ovulation
 By prevention of ovarian follicular maturation
 By interrupting the oestrogen-mediated positive
feedback on the hypothalamic-pituitary axis
thus preventing LH surge
 Thicken the cervical mucus
 Reduce sperm penetrability
 Alteration of the endometrium
 Thin endometrium preventing implantation

19. Non-contraceptive benefits

20. ENSURING SUCCESS ……
ADMINISTRATIVE ISSUE
ISSUES AROUND SUCCESS
OF OCP
SIDE EFFECTS
BATTLING MYTHS RIGHT SELECTION
OF PATIENT

21. Administration Issue : When to
start COCP?
Timing of initiation is a commonly encountered
confusion
 2 different packaging : 28days (1week of placebo or sugar pills) or
21days (7d pill free period)
 7d of pill free period/placebo - women will have a ‘withdrawal bleed’
 Best to be taken at same time every day
 Contraception is immediate if starts the pills on D1 menses
 If 1st pill after D2 , other contraception needed for 7 days
 If vomiting or diarrhoea : extra contraception
 If taking antibiotics : extra contraception
 Post partum (not BF) : start day 21 after delivery
 Post termination/ERPOC : within 7 days of termination

22. Administration Issue : When to
start COCP?
 For COCP containing 20 mcg/30mcg
EE
• If 1 or 2 pills are missed at anytime,
take the pill ASAP (NO NEED EXTRA
COVER, DO NOT STOP)
• If 2 or more pills are missed in the:
 1st week, needs emergency
contraception if unprotected sex
and use condoms for 7 days
 2nd week, use condom for 7
days
 3rd week, use condom for 7 days
and continue with next packet
without a break
 Missed pills in first week :
EM + Condom for 1/52
 Missed pills in second /
third week : Condom for
1/52

23. RIGHT PATIENT SELECTION….
• GRANDMULTIPARA
• DESIRE LONG TERM
CONTRACEPTION
• PREVIOUS HISTORY OF FAILED
COCP
•UNTOLERABLE SIDE EFFECTS
•POOR EDUCATION/SOCIAL
BACKGROUND
• COMPLIANCE IS AN ISSUE
• RISK OUT WEIGHS BENEFIT

24. Absolute Contraindication
WHO Category 4
• Pregnancy
• Cerebrovascular accident
• Thromboembolism
• Liver diseases
• Estrogen-dependent tumours (breast cancer)
• Undiagnosed genital tract bleeding
• Recent trophoblastic disease
• Ischaemic heart disease

25. BATTLING MYTH !!!
WEIGHT GAIN
HORMONAL DISTURBANCES
INFERILITY

26. PROGESTOGEN-ONLY PILLS (POP)
femulen Ethynodiol dA 500ug
noriday norethisterone 350ug
micronor noresthisterone 350ug
neogest Levonogestrel* 37.5ug
microval Levonogestrel* 30ug
norgestone Levonogestrel* 30ug
 Suitable for women with
 Lactation ,VTE, migraine, older women who smoke
 Hpt, valvular heart disease and DM– avoids oestrogenic S/E of
COCP, Sickle cell disease,SLE and other autoimmune disease

27. MODE OF ACTION : POP
 Main effect : Thicken cervical mucus thus
decreased sperm penetrability of cervix
 Reduce receptivity of endometrium to
implantation
 Reduction in ovulation
 Suppress ovulation in ~40%, this is unpredictable and
varies between cycles resulting in irregular menstruation
 50% have regular ovulatory cycles with normal luteal
phase and a normal menstrual cycle
 10-15% of women have complete inhibition of ovarian
activity and are amenorrhoeic
 New : Cerazette 97% inhibit ovulation
 Reduce fallopian tube motility
Failure rate 0.3-5/100
women years

28. POP : ADMINISTRATIVE ISSUE
 One pill daily taken continuously without a break
 Best to be taken at same hour every day (within 3 hrs at the
most)
 Contraception is immediate if starts the pills on D1 menses, no
eXtra
 If 1st pill after D5 , eXtra contraception needed for 2 days
 If taking antibiotics : do not effect the efficacy of POP
 If taking Rifampicin/EID : reduction of efficacy dt increased
metabolism of POP
 Post partum (not BF) : start day 21 after delivery (regardless
BF)
 Post termination/ERPOC : on the day of abortion or TOP

29. POP : ADMINISTRATIVE ISSUE
MISSED PILLS
 If ˃ 3hours late or 27hours since last dose
 Take missed pill ASAP
 Take subsequent pill at the usual time
 Use extra contraception for the next 2days
 If vomit within 3 hours of ingestion
 Take another pill immediately
 Use extra contraception for the next 2 days
An estimated 48hrs of POP use was deemed necessary to achieve the
contraceptive effects on cervical mucus

30. Disadvantages of POP
 Strict adherence to the rules of pill taking
is essential
 Pattern of bleeding is unpredictable
 Associated with increased incidence of
ovarian follicular cysts and increased risk
of ectopic pregnancy compared to COCP
 but decreased compared to sexually active
non-contraceptive user

31. new* Cerrazette®
 Released in 2003
 Contain 3rd generation of
progestogen – desogestrel
 97% - inhibits ovulation
 Window period of 12 hours
instead of 3 hours
 Taken every day with no break
 Useful for younger women who
cannot or do not wish to take
oestrogen containing products
or women who cannot tolerate
other POPs.

32. LONG TERM REVERSIBLE
CONTRACEPTION
Non-Hormonal
Copper IUD
Hormonal
Injectable contraception
Progestogen only injectables
Implant
Implanon
Norplant/ Jadelle*
Intrauterine system (IUS)
LNG IUS : MIRENA

33. INTRAUTERINE DEVICES (IUD)
NON-HORMONAL
HORMONAL

34. COPPER IUD
 1st generation
 Copper seven
 Copper T 200
 2nd generation
 Multiload 250
 Nova T
 3rd generation
 Copper T380A
 Multiload 375*

35. Cu T 380 or T Safe 380A
 Licensed for 8 years in
the UK
 First choice of IUCD
 Low expulsion rate
 8/100 women over 5
years
Low failure rate
1.4-2.2/100 women years

36. Multiload Cu 375
 Licensed for 5 years
 Twice as likely to result
in pregnancy compared
to Cu T 380
 similar expulsion rate

37. Copper IUD
 Efficacy is dependent
on the surface area of
copper
 MOA :
 Inhibiting fertilization by direct
toxicity
 Inflammatory reaction w/in
endometrium induce anti-implantation
effect
 Copper is toxic to ovum and
sperm
 Copper in cervical mucus
inhibits sperm penetration.

38. Complications of Copper IUD use
 Expulsion
 Most common 1st 3
months after insertion and
often during menses
 Perforation
 Risk 2/1000 insertions
 Pelvic infection
 Although 6 fold increase in
risk of developing PID in
the first 20 days, the
overall risk is low unless
there’s exposure to STIs
 Bleeding pattern and
pain
 Spotting,light bleeding,heavier
or longer periods common 3-6
months
 Pregnancy
 Exclude ectopic pregnancy
( risk 1:25 with IUCD)
 If threads are visible,IUCD
should be removed up to
12weeks
 With IUCD left in situ : 2nd TS
abortion, PTL, infxn
 Removal aw small risk of
abortion

39. Injectable Contraception
Progestogen-only injection

40. INJECTABLE CONTRACEPTION
 Preparations
 MDPA : Depo-provera (depot
medroxyprogesterone acetate)
 NET-EN : norethisterone
enantate
 MOA:Mainly; inhibition of
ovulation
 Thickening of cervical mucus
prevents sperm penetration
 Changes in endometriummaking
environment unfavourable for
implantation
DMPA 150mg
Deep IM injection
Every 3 months +/- 2 weeks
Failure rate 0.25-0.5/100
woman years

41. Benefits
Suitable for women
 who forget to take pills, particularly travellers,
due to frequent changes in time zones, missed
pills are likely or where suboptimal
compliance is expected
 Who wish for a secret or ‘private’ method
 In whom oestrogen is contraindicated:
○ mild to moderate hypertension
○ diabetes mellitus in the absence of vascular disease
○ age >35yo & smoking

42. Side effects & Risks
 **Menstrual disturbances
(amenorrhea, spotting,
infrequent bleeding or prolonged
bleeding)
 Amenorrhoea becomes more
likely with ↑ duration of use
○ 30% after 3rd dose
○ 70% after 12th dose
 **Weight gain (probably due to
progestogen ↑ appetite)
 headaches, dizziness, breast
tenderness and mood changes
 ** reasons for discontinuation
 Delay in return to normal
fertility
 Following a final injection of
DMPA, ovulation returns after
6-12 months, may be as long
as 24 months
 Following discontinuation:
 78% conceive by 12 months
92% conceive by 24 months
 Thought to be due to slow
metabolism of the drug from
the microcrystalline deposits
in muscle tissue
 Osteoporosis

43. IMPLANTS

44. Implant
Trade name Progesterone
Implanon etonogestrel 1 rod
Norplant levonorgestrel 6 rods
Jadelle levonorgestrel 2 rods

45. IMPLANON®
68mg etonogestrel
Biodegradable single rod
implant
Initial release rate of
60-70μg/day and ↓ to
25-30μg at the end of 3
years

46. IMPLANON®
 Inserted subdermally in the groove between biceps and
triceps in the non-dominant hand about 8-10cm from the
medial epicondyle
 Can be administered up to day 5 of menses without the need
for additional contraception
 License for 3 years – efficacy may be lower during the 3rd
year in overweight women
 Inhibit ovulation by prevention of LH surge, also affect
cervical mucus thickening and endometrium

47. BENEFIT OF IMPLANON
 Independence of user
compliance
 Rapid return to
fertility
 90% of women ovulate
within 30 days
 Efficacy not being
affected by broad-spectrum
antibiotics
Failure rate <0.1/100
woman years

48. SIDE EFFECTS of IMPLANON
 Menstrual disturbances
 Improve over 3-5 months
 NSAIDs and low dose COCs are generally effective
treatment strategies for implanon related bleeding
 2.5-5% of women suffer from alopecia,
emotional lability, depressive symptoms and
dysmenorrhea
 >5% of women suffer from headache, acne and
breast pain
 Little or no increase risks of VTE
 No evidence to suggest clinically significant effect on
BMD
 Prophylactic abs to prevent endocarditis are not
needed for insertion and removal of implants

49. LNG – IUS (MIRENA)

50. LNG-IUS : MIRENA®
 Long-acting, rapidly
reversible
 52mg levonorgestrel
released at the rate of
20mcg/ day
 Frame is rendered radio-opaque
by impregnation
with barium sulphate
 Licensed for contraception
for 5 years

51. LNG-IUS Mechanism
 The contraceptive effect
is achieved by
 Works primarily by its
effect on endometrium
preventing implantation
 endometrial glandular and
stromal atrophy and
endometrium
unresponsive to oestrogen
 Changes in the cervical
mucus which prevent
ascent of spermatozoa
Failure rate of 0.09/100
women years

52.  May be fitted up to 7 day of
menstrual cycle without
need of additional
contraception
 Or at any time in the
menstrual cycle with
barrier contraceptives for
the next 7 days (exclude
pregnancy first)

53. Side effects/ complications
of LNG-IUS
 Difficult insertion
especially in nulliparous
woman
 Bleeding pattern
 Irregular bleeding & spotting
common during 1st 6-8mths
 By 1 year amenorrhoea or
light bleeding ensues
 Amenorrhoea
 Some women may regard this
as abnormal – counseling
important
 Increased incidence of
functional ovarian cysts
compared to copper IUD
users
 Progestogenic SE –
oedema/ headache/ breast
tenderness/ acne – subside
after a few months
 Expulsion – commonly
occurs during first month
following insertion

54. STERILIZATION
 Female
 Mini Laparotomy
○ The Pomeroy method
○ The Parkland technique
○ The Ushida method
○ The Irving method
○ fimbriectomy
 Laparoscopic
○ Filshie clip
○ Hulka clip
○ Falope ring
 Hysteroscopic
○ Chemical method:
quinacrine
○ Mechanical method
 Ovabloc®
 Essure® device

55. STERILISATION
 A permanent and usually an irreversible
 Counselling, written information, its risks,
benefits & failure rates should be
provided
 Discussion & information should be given
re: other methods of contraception.
 Both men and women should be informed
that reversal are rarely provided.

56. PRO & CONS OF BTL
ADVANTAGES
 99% effective in the first
year following the
procedure
DISADVANTAGES
 Difficult to reverse (meant to
be PERMANENT)
 If pregnancy does occur it
carries a 33% chance of being
an ectopic pregnancy
 Expose to risk of anaesthetic /
surgical complication
 More difficult than vasectomy
(complication: 1-4% with
BTL)

57. EMERGENCY CONTRACEPTION

58. EC regimes
Oral EC
 Yuzpe regime:
 100μg EE & 500 μg LNG
(2Doses, 12h apart)
 LNG only
 Single dose of 1.5mg
LNG or 0.75mg x2 in
12h apart
 Will prevent 85% of
expected pregnancies
 (If taken w/in 72h of
unprotected coitus)
 SE : N,V (if vomit w/in
2h,take further dose ASAP)
 Erratic PV bleed first 7
days
Copper IUCD
 IUCD EC should be inserted
w/in 72h following UPSI.
 Failure rate < 1%
 It can be removed after the next
menstruation or retained for
ongoing contraception.

59. THANK YOU