Indications, side effects and contraindications of various family planning methods

1. Contraceptives
methods
Dr Deepak Upadhyay
MBBS, MD, MBA(HCSM)
Department of Community Medicine
Rohilkhand Medical College & Hospital

2. Case No. 1
A couple has come to the post partum unit for
family planning advice. The husband is 24 years
old & the wife is 20 years old. Their only child is
a 4 months old baby girl who is exclusively
breast fed. On questioning the wife gives a
history of ectopic pregnancy 2 years back.

3. Case no 2
Shyama has come to the sub centre for family
planning advice. She is aged 30 year and has a
daughter aged 8 months. Her husband Kanai is
an alcoholic beats her regularly and refuses to
come to sub centre for F.P. advice. Shyama has
suffered from jaundice twice in the last 1 year.
Her menstrual history is normal.

4. Case no 3
Jaya 35 yrs. mother of 2 children came to you
for contraception advice. She don’t want
further child, but is afraid of operative
procedures. She want to know any other options
to prevent pregnancy.

5. Case no. 4
Ram kumar aged 45 yrs came to you with her
wife shyama aged 40 yrs. The couple has 2
children and they don’t want further
pregnancies. What all methods are available for
them? Which method will be most suitable for
them?

6. Case no 5
A newly married couple came to you for
contraceptive advice. They don’t want any child
in near future. They are worried about
misconceptions about barrier methods. Husband
has history of latex sensitivity.

7. The Female Reproductive System

8. The Male Reproductive System

9. Classification of Contraceptive
methods
• Permanent Methods
• Male sterilization
• Female sterilization
• Spacing methods
• Natural methods
• Barrier methods
• Intra uterine devices
• Hormonal contraceptives
• Emergency contraception
• Post conception methods

10. Natural Contraceptive Methods
1. Fertility Awareness methods
Calendar based methods
Standard day method
Calendar rhythm method
Symptom based methods
Cervical secretion method
Basal body temperature method
2. Withdrawal or Coitus interruptus
3. Abstinence
4. Lactation Amenorrhea

11. Abstinence
• Abstinence is the avoidance of any sexual
activity that could cause pregnancy.
• Advantages
• Completely effective
• Also prevent STD & RTI
• No associated health risk
• Disadvantage
• Non compliance is a big problem

12. Widthrawal or Coitus interruptus
• Deliberate removal of the penis from the
vagina before ejaculation so that sperm is not
deposited in or near the vagina.
• Advantage
– Natural method (Non expensive)
– No delay in return of fertility after use
• Disadvantage
– High failure rate (Drops of fluid secreted
by the penis when it first becomes erect
can contain enough sperm to cause
pregnancy)
– Withdrawal does not protect against STIs.

13. Lactional Amenorrhea Method (LAM)
• Based on amenorrhea due to the natural
effect of breast feeding on fertility
• Mechanism of Action
– High prolactin prevent ovulation
• LAM require 3 criteria (All required)
– Mother’s monthly bleeding has not return
– Baby is fully or nearly fully breast fed
– Baby is < 6 months age

14. • Advantage
– Natural method (No side effects)
– Support optimal feeding of child
– Non expansive
• Disadvantage
– Variable time period
– Return of fertility delayed
• Time period for which LAM can be practiced
safely is 6 months

15. Fertility Awareness methods
 Calendar based methods
(Based upon the tracking of days of the
menstrual cycle to identify the fertile period)
Standard day method
Calendar rhythm method
 Symptom based methods
(depending upon the sign & symptoms associated
with fertility)
Cervical secretion method
Basal body temperature method

16. Standard Days Method
• Assumes menstrual cycles are between 26 –
32 days and regular
• Fertile period is from 8th day to 19th day
• First day of menstrual bleeding is counted as
day 1.
• Cycle beads can be used

18. Calendar Method
• Useful in women with irregular cycles
• Fertile period
– Last day = (Longest cycle – 10)th day
– Ist day = (Shortest cycle – 20)th day
• Ovulation occur 14 days before the starting
of menstrual bleeding

19. Cervical secretion method (Two days
Method)
• Check for cervical / vaginal secretions every
day
Fertile period
• During the period of secretion / change in
the consistency of secretion
• Less chances of pregnancy during dry days

20. Basal body temperature method
• The woman takes her body temperature at
the same time each morning before eating /
drinking anything
Fertile period
• Body temperature dips down during / just
before ovulation
• Just after Ovulation body temperature rises
0.4oF – 1oF
• Ovum remain viable for 4 days
• Sperm may live for 7 days

21. MOA fertility awareness methods
Reduce chances of fertilization of ovum during
period of viability of ovum
Advantages
Natural method
Non expensive
Disadvantages
Need client training
Does not prevent from STD / RTI

22. Barrier methods
• Three types
– Physical barriers method
• Male condoms, Female condoms, Diaphragm,
cervical cap
– Chemical barriers method
• Foams, Jelly, Creams, Suppositories
– Combined barriers method

23. Barrier contraception and
spermicides
Male
• Male condom
– Latex
– polyurethane
Female
• Female condom
• Diaphragm
• Cervical cap
• sponge

24. Male Condoms
• Worn on a man’s penis.
• Catches ejaculated
sperm.
• Better if used with
spermicide.
• Use with Water-Based
Lubes
• 2 types
– Latex based
– Polyurathran

25. Male Condoms
Non contraceptive benefits of condom
• Prevent STD / RTI
• Used during vaginal USG
• Can be used in vaginal examination
• Promote male involvement in fertility
regulation

26. Female Condoms
• Worn in the woman’s vagina.
• Prevents sperm from reaching the uterus.
• Made with polyurethane.
– It’s stronger than latex condoms.
• Two rings
– Smaller inner ring
– Larger outer ring
• Can be inserted up to 8 hours prior to
intercourse; can remain in place up to 8
hours

28. Diaphragms
• Is a circular, dome-
shaped piece of thin
rubber cup that covers
the cervix.
• Used with spermicide
• Female must get fitted
by a doctor.

29. Cervical Caps
• It is placed in the vagina
and it fits snugly on the
cervix.
• It can be retained in the
vagina for 48 hours.
• It’s only available by
prescription (Female
must get fitted by a
doctor)

31. The Cervical Shield
• The shield works just
like the diaphragm
and cervical cap for
preventing pregnancy.
• The shield is only
available with a
prescription.

32. The Sponge
• The sponge contains
the spermicide
nonoxynol-9.
• It is placed in the
vagina and sits below
the cervix.
• Self administration

33. Physical barrier methods
MOA
• Prevent contact of sperm with ovum
Advantage
• Safe , no hormonal side effects
• Easy to use, no need of specialist for use
• Prevent STD / RTI
Disadvantage
• Decrease sexual sensation
• Latex sensitivity
• Need user dedication
• Social stigma

34. Chemical barrier methods
(Spermicides)

35. Chemical barrier methods
(Spermicides)
• Consist of a base combined with either
nonoxynol-9 or octoxynol
• Surfactant that destroys the sperm cell
membrane / prevent motility
• Forms available : vaginal foams, suppositories,
jellies, films, foaming tablets, and creams.

36. Chemical barrier methods
(Spermicides)
• Failure rate is about 26% within the 1st year
of use.
• Advantages : ease of application , available
over the counter , inexpensive and it
augments the contraceptive efficacy of the
cervical cap and diaphragm .
• Disadvantages : minimal protection against
STDs , risk of vaginal irritation and allergic
reaction.

37. Intra Uterine Devices

38. • These are devices inserted in uterine cavity
and prevent pregnancy for the time of use.
• Three generations
– First generation / Non medicated IUDs
• Made of polyethylene
• No biologically active agent
– Second generation / Copper bearing
IUDs
• A small, flexible plastic frame with
copper sleeves / wire around sleeves
– Third generation / Hormone containing
IUDs
• A T shaped device that release
hormone every day

39. • Concept in early Mesopotamian civilization –
rounded stones in Female Camel uterus
• First person to successfully use IUD in
women – Prof. Ernst Von Grafenberg in 1929
• Gained popularity during Lippe’s loop

40. 1st Generation IUDs
• Inert devices
• No biologically active agent
• Example – Lippe’s Loop
• Double “S” shaped
• Made of polyethylene and impregnated with
barium sulphate
• Duration of action – as long as used
• MOA – Foreign body reaction in
endometrium, thus making the uterine cavity
inappropriate for implantation
• Failure rate – 13/100 women year

42. 2nd Generation IUDs
• Developed to decrease the removal rate /
complication (expulsion)
• Smaller in size and medicated (Copper)
• Some have ionic sliver in core (Cu T 380 A)
• Eg - Cu T 380 A, Multi-load devices
• Duration of action–depend upon type of Cu T
– Cu T 380 A – effective for 10 yrs.
• MOA – Non septic inflammatory changes in
endometrium + Cu affects sperm motility
• Failure rate < 1 / 100 women years

44. 3rd generation IUDs
• Developed to decrease the menstrual blood loss
• Release hormone continuously
• MOA – Non septic inflammatory changes in
endometrium + progesterone suppress
endometrial growth
• Progestasert
– Hormone release(progesterone) - 65µg/day
– Max chances of ectopic pregnancy
– Effectiveness – 5 yrs
• Mirena
– Hormone release (Levonorgesterol) -
20µg/day
– Effectiveness – 5 yrs
– Minimal bleeding

46. Insertion of IUDs
Timing
• Normal non pregnant women
– Within 10 days of beginning of menstrual
bleeding
• After child birth
– Either within 48 hr or 4 weeks after the
delivery
• After miscarriage
– Either within 12 days or 4 weeks after the
miscarriage
• For emergency contraception
– Within 5 days after unprotected sex

47. Insertion of IUDs
• Technique
– First measure cavity with uterine sound
– No touch technique
– Pull technique
• Ideal candidate for IUD
– At least one children
– No h/o pelvic disease
– Normal menstrual periods
– Willing to check IUD tail
– Access to follow up
– Monogamous relationship

48. • Advantages
– Simplicity: no hospitalization required
– Inexpensive
– Long duration of effectiveness
– No systemic side effects
– No need of continuous motivation

49. Contraindications
– Absolute
• Suspected pregnancy
• PIDs
• Previous h/o ectopic pregnancy
• Undiagnosed vaginal bleeding
• Pelvic pathologies
– Relative
• Anemia
• Fibroid uterus or distorted uterine
cavity

50. Side effects
• Bleeding
– Menorrhagia – commonest side effect
– Metrorrhagia
– Irregular bleeding
• Pain
– Most common cause of IUD removal
– Mild – controlled with analgesics
– Generally disappear within 3 month
• Pelvic Infections
– Mainly due to unhygienic conditions
– Should be treat with antibiotics
– If not controlled – remove the IUD

51. • Uterine perforation
– Most commonly with
• Wrong technique
• Wrong timing (between 48 hrs to 6 wks
postpartum)
– Detected by
• USG – Ideal
• X-ray
– Treatment – Removal of IUD
• Ectopic pregnancy
– Second most common cause of ectopic
pregnancy
– More with Progestasert

53. • Pregnancy
• Expulsion
• Fertility after removal
Warning sign for IUD removal (PAINS)
• P – Period Late
• A – Abdominal pain
• I - Infection
• N – Not feeling well
• S – String missing

54. Follow up
• Post insertion follow up visit (3 to 6 wks)
• Look for
– Client satisfaction
– Bleeding changes
– Abdominal pain
– Vaginal discharge
– Position of thread and IUD
– Sign and symptom of pregnancy
• Educate about
– Warning signs
– Checking of thread routinely

55. Removal of IUD
• Indication
– Client wish
– Missing thread
– Pregnancy
– Uncontrolled side effects of IUDs
– Change of contraceptive methods
• Removal technique
– With alligator forceps or IUD hook
– Laparoscopic removal

56. Missing thread
Causes
• Torn thread – remove the IUD + advice on
contraception methods
• Expulsion
– Partial - remove the IUD + advice on
contraception methods
– Complete – check for pregnancy + advice on
contraception methods
• Pulled up – check for pregnancy
– Perforation - remove the IUD + advice on
different contraception methods
– Pregnancy - remove the IUD

58. Hormonal Contraceptives

59. Classification
• Oral pills
– Oral Combined pills (OCP)
– Progestogen only pills (POP)
– Post coital pills
– Once a month (Long acting) pills
– Male pills
• Depot (slow release) formulations
– Injectable
– Subcutaneous Implants
– Vaginal rings
– Skin Patch

60. Combined oral pills
• Contains two hormone
– Progestin – Artificial preparation of
natural hormone “Progesterone”
– Estrogen - Artificial preparation of natural
hormone “Estrogen”
• MOA
– Prevent ovulation by blocking secretion of
gonadotropins
– Progestin – Make cervical mucus thick &
also inhibit tube motility

61. Type of OCPs
Name Progestin Amount (mg)
EE = 0.05 mg
1. Norlestrin
2. Orgalutin
Norethisthisterone acetate
Lynestrenol
2.5
2.5
EE = 0.05 mg
1. Ovaral
2. Orlest
Levonorgestrel
Norethisthisterone acetate
0.25
1.0
EE = 0.03 mg
1. Mala – D
2. Yasmin
3. Choice
Levonorgestrel
Drospirenone
Norgestrel
0.15
3.0
0.3
EE = 0.02 mg
1. Familon Desgestrel 0.15

62. • When to start
– Start from the 5th day after menstrual
bleeding starts
• In post partum period –
– Avoid OCP during breast feeding
– From 5th day after starting menstrual
bleeding
• Duration of use
– As long as contraception needed
– Not recommended after 40 yrs of age

63. Advantages / Benefits
• Contraceptive use
• Protection from
– Endometrial CA
– Ovarian carcinoma
– Benign breast disorders
• Fibrocystic disease
• Fibro adenoma
– PID
– Iron deficiency anemia
– Ovarian cysts
• Also used in
– Menstrual bleeding
disorders
– Menstrual cramps
– Ovulation pain
– Hirsudism
– Symptoms of PCOD
– Symptoms of
Endometriosis

64. Side effects
Mostly due to estrogen component
• Changes in bleeding
patterns
– Irregular bleeding
– Lighter bleeding
– Infrequent bleeding
– Absent bleeding
• Headache and Migraine
• Dizziness and nausea
• Weight gain
• Breast tenderness
• Acne
• Increase risk of
– Venous thrombosis
– Cerebral
thrombosis
– Pulmonary
embolism
– Carcinoma cervix
– Hepatocellular
adenoma
– Hypertension

65. Contraindications
• Absolute
– Cancers of breast & genitals
– Liver diseases
– h/o thromboembolism
– Cardiac abnormalities
– Congenital hyperlipidemia
– Undiagnosed vaginal bleeding
• Relative
– Smoking & age > 35 yrs
– DM & Chr. Renal disease
– Migraine & epilepsy
– Gall bladder diseases

66. How to use OCP
• Start taking pill from 5th day from menstrual
bleeding starting
• Take one pill each day
• Take pill at the same time every day
• Follow the arrow at the back of pack
• Duration of use
– 28 pills pack – start new pack after
finishing the pack
– 21 pills pack – start new pack 7 days after
finishing the old pack

68. Missed pills
• For pills with 0.03 mg
• Delayed pill – take 1 pill as soon as possible
• Missed 1 or 2 pills - take 2 pills as soon as possible
• Missed 3 pills or more
– During 1st or 2nd week
• Take hormonal 2 pills as soon as possible
• Use alternate method for next 7 days
• Consider Emergency contraceptive, if had sex in
past 5 days
– During 3rd or 4th week
• Take hormonal 2 pills as soon as possible
• Use alternate method for next 7 days
• Consider Emergency contraceptive, if had sex in
past 5 days
• Use all hormonal pills then start new pack instead of
using non hormonal pills

69. Progestin only pills
• Also known as “Mini Pills”
• Contain very low doses of progestin
• Can be used during breastfeeding
• MOA
– Thickening cervical mucus
– Prevent ovulation
• Bleeding abnormalities are common side
effect
• Start any time & to be taken regularly

70. Once a month (long acting) pill
• Contain long acting estrogen “Quinestrol”
with short acting progestin
• Irregular bleeding tendencies major side
effects
Male Contraceptive pill
• Contain “Glossipol”
• Preventing spermatogenesis
• Interfering with sperm maturation
• Affect constitution of seminal fluid

71. Injectable hormonal contraceptives
• Two types
– Progestogen only injectables
• DMPA (Depot-medroxyprogesterone
acetate)
• NET -EN (Norethisterone enantate)
• DMPA-SC (DMPA depo-SubQ provera
104)
– Combined Injectable contraceptives
• (Medoxyprogesterone acetate + estradiol
cypionate) combinations
• (Norethisterone enantate + estradiol
valerate) combinations

72. DMPA
(Depot-medroxyprogesterone acetate)
• Dose - 150 mg intra muscular (I/M)
• Cycle – every 3months
• Can be used during Lactation
• Injection can be delayed up to 4 weeks
DMPA – SC
• Dose – 104 mg Subcutaneous (S/C)
• Site – Upper thigh / Abdomen
• Cycle – every 3months

73. • Side effects
– Irregular bleeding
– Weight gain
– Delayed return of fertility
• Advantages
– Long Contraceptive effect
– In endometrial Ca and Uterine fibroids
– PIDs & Iron deficiency Anemia
– Crisis in Sickle cell anemia
– Endometriosis

74. NET - EN
(Norethisterone enantate)
• Dose – 200mg intra muscular (I/M)
• Cycle – every 2 months
• Can be used during Lactation
• Injection can be delayed up to 2 weeks
• Side effects – same as DMPA with lesser
amount
• Advantages
– Long Contraceptive effect
– Iron deficiency Anemia

75. Combined Injectable contraceptives
• Contain 2 hormones
– Estrogen
– Progestin
• Cycle – 1 month
• Route – Intramuscular

76. Subcutaneous implants
• Small plastic rods containing progestin
hormone
• Placed subcutaneously in the upper arm
• Effectiveness – 5 yrs
• Example
– Jadelle – 2 rods for 5 yrs
– Norplant – 6 capsule for 5 yrs

78. Vaginal ring
• A flexible ring placed in the upper vagina
• Contain 2 hormones
• Placed in situ for 3 weeks followed by 1 week
gap before placing next ring
• Example - Nuvaring

79. Combined patch
• A small adhesive patch
• Replaced every week
• Contain 2 hormones
• Use 3 patch continuously followed by 1 week
gap before placing the patch again
• Example – Evra and Ortho Evra

80. Emergency Contraception

81. Emergency contraception
(EC)
Emergency contraception (EC) is any method
of contraception which is used after
intercourse and before the potential time of
implantation.
Also known as:
• Morning-After Pills
• Post coital Contraception
• Secondary Contraception

82. The History of EC
• 1960’s: first documented use, oral
contraceptive pills used off label
• 1997: FDA announces that oral
contraceptives are safe to use off label as EC
• 1998: The first product dedicated to EC is
marketed (Preven)
• 1999: Plan B (Single dose dedicated product)
is approved by the FDA

83. EC is Not a New Idea….
• “Traditional” methods for post coital
contraception have been used for decades
– High doses of vitamin C, aspirin or
chloroquine
– Douches of coca cola, tequila, baking soda,
urine

84. Women Who May Need Emergency
Contraception (Primary Users)
Women who:
– Have unplanned, unprotected intercourse
– Leaked or broken condom
– Missed multiple COC pills
– Waited > 16 weeks beyond last injection (DMPA)
– Failed in using withdrawal method of
contraception (ejaculation in vagina or external
genitalia)
– Failed to abstain when needed while using NFP
– Incorrectly used a diaphragm or the diaphragm
or cervical cap dislodged, broke or tore, or was
removed early
– Are rape victims

85. Other Situations When Emergency Contraception
May Be Used
(Secondary Users)
Although EC is intended for primary users, there may
be other situations or circumstances when other
users may need EC.
The other users may be women who:
– Are sexually active adolescents in need of
contraception
– Are currently not using a contraceptive
– Have intercourse infrequently
– Are postpartum (before menses returns)
– Are over age 35 (presumed decreased fertility)
– Are post abortion (before menses returns)

86. Emergency Contraception
Methods
Oral Pills (MORNING AFTER PILLS)
 Combined Oral Contraceptives (COCs): (Yuzpe’s
method)
 Very low dose (0.02 mg EE & 0.1 mg LNG)
 Low-dose (0.03 mg EE and 0.15 mg LNG)
 High-dose (0.05 mg EE and 0.25 mg LNG)

87.  Only Progestin containing Pills:
 Levonorgestrel only dedicated pill
1.5 mg LNG
0.75 mg LNG
 Minipills
0.03 mg LNG
0.0375 mg LNG
0.075 mg norgestrel

88.  Progesterone receptor modulator
 30 mg Ulipristal acetate
IUDs
Anti progestin (Mifepristone)

89. Emergency Contraception:
Morning After Pills
• Mechanisms of action
– May alter endometrium (mixed
proliferative /secretory pattern)
– May block ovulation
– May alter tubal motility
• Effectiveness
– 2% failure rate when used correctly
• Safety
– No long-term problems in nearly all women
– Nausea (and vomiting) most common short-
term side effect (due to estrogen)

90. Combined oral Contraceptive pills
Step III
If no menses within 3 weeks, consult the doctor
Step II
Take another dose after 12 hrs of first dose
Step I
Take recommended no of Tablets within 72 hrs

91. Dose and No. of tablets
Composition
Pills to take
First dose After 12 hours
Very low dose
(0.02 mg EE & 0.1 mg LNG
5 5
Low-dose
(0.03 mg EE and 0.15 mg LNG)
4 4
High-dose
(0.05 mg EE and 0.25 mg LNG)
2 2

92. Progesterone containing Pill
Step II
If no menses within 3 weeks, consult the doctor
Step I
Take recommended no of Tablets within 72 hrs

93. Dose and No. of tablets
Composition
Pills to take
First dose After 12 hours
Levonorgestrel only dedicated pill
1.5 mg LNG 1 -
0.75 mg LNG 2 -
Minipills
0.03 mg LNG 50 -
0.0375 mg LNG 40 -
0.075 mg norgestrel 40 -

95. Selective progesterone receptor
modulator
• Ulipristal Acetate
• MOA (By preventing progesterone from
occupying its receptor)
• Suppress maturation of the endometrium
necessary for implantation
• Inhibit or delay ovulation
• Dose
– 1 tablet (30 mg) within 72 hours of
unprotected sexual intercourse

96. Copper IUCD
• MOA
– Prevention of implantation by causing non
septic inflammation in endometrium
– Spermicidal and Blastocidal action of
copper
• Can be inserted within 5 days after the act
of unprotected coitus
• Can be removed when menses occur
• Failure rate <1%
• Main primary complications
– Uterine cramps/ bleeding
– Risk of infection

97. IUDs: Instructions for Use as
Emergency Contraception
• Step 1:
– Insert IUD within 5 days of unprotected
intercourse.
• Step 2:
– If no menses (vaginal bleeding) within 3
weeks, the client should consult the clinic
or service provider to check for possible
pregnancy.
• Step 3:
– If pregnancy not prevented, counsel client
regarding options.

98. ANTIPROGESTINS
• Different action from its use in medical
abortion, same dose
• A single 600 mg dose of Mifepristone (RU-
486) within 72 hrs after unprotected
intercourse is highly effective
• Fewer side-effects than Yuzpe
• May cause uncontrolled bleeding

99. Terminal Methods of
contraception
(STERILIZATION)

100. Sterilization
-intended to be permanent
• Male
– Vasectomy
• Traditional method
• Non scalpel vasectomy

101. Vasectomy
• Local anesthesia
whenever possible
• Involves division of the
vas deferens.

102. VASECTOMY

103. Vasectomy
• Men should be advised to use contraception until
azoospermia is confirmed
1. Testing should be done after 8 weeks of
vasectomy
2. 2 samples not less than 4 weeks apart should
be clear of sperm
or
1. At least 30 ejaculations are required to clear
sperm
2. At least 3 months after vasectomy
• Not associated with testicular cancer or heart
disease
• Nearly 75% of men who undergo vasectomy will
develop anti-sperm antibodies

104. Non Scalpel Vasectomy
Local Anaesthesia is
given
Vas deferens fixed
by a ring forceps so
that only minimal
amount of tissue is
present in the ring

105. • Skin directly
overlying the vas
in the ring forceps
is punctured
• Puncturing hole is
enlarged to about
twice the diameter
of vas deferens

106. Delivering the
vas out of the
puncture hole

107. • Ligaturing the
ends of vas &
excising a small
segment
• Tied ends are
pushed back into
scrotum
• Opposite vas is
also manipulated

108. At the end of the procedure a tiny
puncture hole results, which doesn’t
require any closure

110. POST OPERATIVE CARE
• Wear a T bandage for 15days
• Avoid bathing 24hrs after the operation
• Keep the site clean & dry
• Avoid cycling or lifting heavy weights for
15 days
• Use contraceptives until aspermia has
been established
• Have stitches removed on 5th day after
operation

111. ADVANTAGES OF NSV
• No incision, no stitch
• Minimal dissection using only 3 instruments
• Chance of complications reduced from 2%
to 0.3%
• Safer, convenient, acceptable method
• Cheaper compared to tubectomy

112. Complications
• Immediate
– Haematoma (1-2%)
– Wound infection
(up to 5%)
– Failure
• Late
– Anti sperm antibody (75%)
• Thought to be in response
to leakage of sperm
• Harmless unless
restoration of fertility is
desired
– Sperm granuloma
• Presumably also in
response to leaked sperm
• Painful and persistent
• Can be effectively excised
– Chronic testicular pain
• Unknown cause

113. FEMALE STERILIZATION
Tubectomy

114. • Female
– Laparoscopic
• Filshie clip
• Hulka clip
• Falope ring
– Mini Laparotomy
• The Pomeroy method
• The Parkland technique
• The Ushida method
• The Irving method
• Fimbriectomy
– Hysteroscopic
• Chemical method: quinacrine
• Mechanical method

115. TUBECTOMY: TYPES

116. Laparoscopic Sterilization
• Filshie clip
– Made of Titanium lined by silicone rubber
– Destroyed 4 mm of tube
– Failure rate 2-3/1000 procedures
• Hulka – Clemen clip
– A stainless steel spring with 2 plastic jaws made
of Lexan
– Destroyed about 3 mm of tube
– 1 year pregnancy rate of 2/1000 women
• Falope ring
– Made of silicon rubber and using special design
applicator
– Placed over the loop of tube
– It destroyed 2-3 cm tube and difficult to applied
if tube is thick / fibrotic
– Ischemia of loop give significant post op pain

118. MINI LAPAROTOMY

119. The Pomeroy method
• A loop of the isthmic portion of the tube is
elevated using babcock and ligated and cut at its
base.
• The cut ends of the tube are cauterized

120. 1.The Pomeroy method

121. The Parkland technique
• A 2-3 cm fenestration is made beneath the
isthmic portion of the tube
• Tube is ligated at both sites, 3 cm apart.
• 3 cm portion of the tube is removed.
• Care must be taken not to pull on the suture
during ligation or during transection of the tube
because this can lead to shearing of the tube
from underling mesentery resulting in bleeding

122. 2. The Parkland technique

123. The Uchida method
• Injection of vaso-constricting solution beneath
the serosa of the tube about 6 cm from the
utero-tubal junction.
• The tube is ligated proximally and distally about
3cm apart and cut.
• Ligated proximal stump is allowed to retract into
the mesosalphinx and the mesosalphinx is closed
with purse-string suture.
• Ligated distal stump remained exteriorized.

124. 3.The Uchida method

125. The Irving method
• A fenestration is made beneath the tube about
4cm from the utero-tubal junction.
• The tube is ligated proximally and distally about
3cm apart and resected.
• A deep pocket is created in the myometrium on
the posterior surface of uterus.
• Ligated proximal end of the tube are sutured
deep into the myometrial tunnel.
• Ligated distal stump remained exteriorized.

126. 4. The Irving method

127. HYSTEROSCOPIC
STERILISATION

128. 1.Quinacrine
• Blind introduction of pellets of quinacrine into
the uterine cavity via an intrauterine device
inserter.
• The pellets dissolve near the both cornua,
with some solution entering the tubes and
causing a fibrotic reaction
• It involves the insertion of 252mg of
quinacrine on two occasions one month apart
• Quoted efficacy of 98% at 2 years

129. 2.Ovabloc
intra-tubal device
• The procedures involves high pressure
injection of viscous silicone into the ostium via
a catheter.
• The silicone conforms to the shape of the
ampulla of the tube and cures in
approximately 5 minutes.

130. 2.Ovabloc
intra-tubal device
• The silicone contains radio-opaque silver
powder which enables a radiological check for
correct placement
• Bilateral placement takes around 30 minutes
• The woman is asked to use contraception for
3 months, at which point a further plain X-ray
is performed to exclude migration and
expulsion
• Insertion failure rate at 17%
• Expelled in 5% of cases

132. Essure®
• The procedure involves
the hysteroscopic
application of a micro-
insert into the intramural
portion of the fallopion
tube
• Each device consists of a
4 cm long nickle-titanium
alloy outer coil within
which lie polyethylene
terephthalate(PET)
fibres
• The procedure time from
insertion to removal of
the hysteroscope is
around 9 minutes

133. • The PET fibres induce a fibrous
reaction in the tube whick peaks
at around 3 weeks.
• Patients are instructed to use
alternatives contraception for 3
months after the procedure.
• A plain X-ray or HSG is done at
this point to check continued
correct placement.
• 99.74% effectiveness with
usage over 5 years

135. Reversal of sterilisation
• Reversal of female sterilization
– Involves laparotomy
– Does not always work
– Microsurgical techniques are associated with
around 70% success
– Carries a significant risk of ectopic pregnancy
(up to 5%)
• Reversal of vasectomy
– Technically feasible in many cases with
patency rates of almost 90%
– Pregnancy rates are much less (up to 60%)
perhaps as a result of the presence of
antisperm antibodies