Contraception

Contraception is a deliberate attempt to avoid pregnancy. Pregnancy occurs when the egg meets the sperm and the zygote (the product of the sperm and egg meeting), attaches itself to the lining of the uterus and starts growing. Keeping this process in mind, there are basically five ways to avoid getting pregnant:

• The most obvious method is to avoid having sexual intercourse. i.e. abstinence from any penis-to –vagina contact. A refinement of this method is to avoid. Penis-to –vagina contact during the fertile days of woman’s cycle (rhythm method, fertility awareness method)
• Another simple method is to prevent the egg from meeting with the sperm. This includes the Various barrier methods (male and female condoms, diaphragm and cervical cap ) and the permanent methods –vasectomy (male sterilization) and tubul ligation (female sterilization)
• A third way is to prevent the woman from producing eggs and/or the man from producing sperm. Examples of this include hormonal methods such as oral contraceptive pills, injectibles and implants under the skin. The anti –fertility vaccines being developed for men and women would also fall in to this category.
• In yet another approach the fertilized egg (zygote) can be prevented from implanting (attaching) itself to the uterine wall. Examples include intra-uterine devices (IUDs) and non –steroidal pills
• The fifth way involves the removing of the embryo even after conception and implantation have taken place. Examples include induced abortion and abortifacient pills.

Thus, different contraceptives work  in different ways to prevent pregnancy and each person  should choose a method that suits her or his requirements without posing any danger to her/his health and life. Furthermore, this is not a decision one can make for one’s entire life.

Factors to be kept in mind when choosing an appropriate contraceptive

• The effectiveness i.e. what are the chances of getting pregnant
• Is the contraceptive safe, or are there any serious side effects?
• Does it have any long term adverse effects?
• Will it affect breast feeding? Will the effect of the contraceptive be passed on in breast milk?
• Will it affect the health of future children the woman may bear?
• Whether the contraceptive has special contraindications e.g. not to be used by women with irregular bleeding, or those with Reproductive Tract Infections (RTIs)
• Whether control over the contraceptive is in the hands of the user, or is it dependent on the health service provider?

Natural methods (Avoiding genital –to-genital contact especially during fertile days)

The safest and easiest way to prevent pregnancy would of course be by not having sex at all. The next best way would be avoid genital –to-genital contact, without which sex can still be a pleasurable experience. For ages, women have known that it is possible to get pregnant only on a few days of the month. So, they have known that it sexual intercourse is avoided on those days, they can avoid getting pregnant. Today the following methods are available to avoid pregnancy without the use of any artificial means of birth control.

• The rhythm (calendar) method: according to this method a woman is considered fertile after 10 days of the start of the menstrual cycle, hence sexual intercourse is avoided during these 10 days. The ‘safe period’ thus is considered to be the week during, before and after menstruation. This is an unreliable method because it does not take into account variations in the menstrual cycle. The rhythm method assumes that all women have 28 day-cycles, and that ovulation occurs in the middle of the month. However, each individual woman has different cycle length, and ovulation may take place at different times. It is only slightly better than using no method at all.
• Cervical mucus/Billings ovulation method: most women have some amount of secretion (Mucus) from the vagina most times of the month. This is the perfectly healthy sign. The mucus varies in quantity, consistency and colors. It may be sticky and whitish at times, and at other times it may be slippery and transparent. The nature of this mucus varies with the stage of the menstrual cycle. Soon after menstruation, the mucus is usually scanty, relatively dry, thick flaky and whitish. As an egg begins to ripe in one of the ovaries, the hormone estrogen circulating in the body makes the mucus transparent, stretchy and slippery. The slipperiness and stretchiness is maximum during ovulation and a day after. Thus the slippery and stretchy kind of vaginal mucus is woman’s first usual and obvious sign of her fertile days. A woman can determine her fertile and infertile days by noticing the changes in character of cervical mucus by testing some of it on her fingers at about the same day.
• Basal body temperature: A woman can also note her body temperature at the same time early every morning the temperature of the body soon after sleep is called basal body temperature towards the middle of the month, immediately during ovulation this temperature will rise significantly (about 1-2 degrees F) and stay that way until next period.  If this method is used exclusively, it necessitates avoidance of genital to genital contact in the entire period before the temperature rise that is, a period of about 1-16 days. Once ovulation has taken place, other 2 days are considered fertile.  Thus the days on which sexual intercourse is safe are relatively few. In addition the daily trouble of taking temperature makes the method a cumbersome one.

Barrier methods (methods that prevent the egg from meeting the sperm)

Barrier methods work by literally forming a barrier between sperm and egg. The following kinds of barriers are currently available

Male condom: This is cylindrical latex sheath worn on penis during intercourse. It blocks the release of sperms into the vagina. It is unrolled into the erected penis before any vagina to penis contact because long before the ejaculation occurs, the man may discharge a few drops of fluid which may contain sperm, or could transmit STDs. After ejaculation occurs, the penis should be carefully withdrawn from the vagina so as to spill any semen in or near the vagina. The condom is then unrolled and disposed of. A condom should not be used more than once. The male condom is any of the effective and safe method of contraception. It has no side effects on the man or the woman. Condoms are also highly effective in preventing AIDS and other STDs. Another advantage of a condom as a spacing method is that it is completely reversible. Condom is most widely used contraceptive.

Some people, especially men, feel that condoms reduce the spontaneity and pleasure of sex. In addition some people are allergic to latex rubber. If condoms are of poor quality, or have been stored too long, especially in a hot place, they may tear or leak. If there is not enough lubrication during sexual intercourse, or if the condom is incorrectly used, it may also tear, E.g. if it is not rolled on smoothly. The reluctance on the part of many men to share the responsibility of birth control is a major reason why many men do not use condoms, even when they are so effective. However if putting on the condom becomes part of sex play, it can even become a pleasurable activity. Considering that condoms are so safe and have the added advantage of protecting against HIV and other STDs, it is worthwhile putting in a lot of effort encouraging men to use condoms.

Diaphragm: The diaphragm invented in the nineteenth century, was a major breakthrough in giving women control over their fertility. The diaphragm is a circular, dome-shaped rubber disc with a firm rim inserted into the vagina to cover the cervix and block the entrance of sperm. The initial fitting of the diaphragm is done by a doctor/health worker, since the diaphragm is available in different sizes ranging from 2 to 4 inches, depending on the size of the upper vagina. Once the diaphragm of the right size is fitted, the woman herself inserts and removes it when necessary. It should be put in place before any sexual contact is made and left there for at least six hours after intercourse so that the spermicide can kill the sperms that are left in the vagina. Afterwards it is removed, washed with soap and water, thoroughly dried and kept away until the next use.

The possible problems with the diaphragm itself may push forward and cause cramps in the uterus or bladder of the urethra. For some women, this can lead to urethritis or recurrent cystitis. It should not therefore be used by women who are prone to urinary tract infections or those who have a prolapsed uterus. However a significant advantage of the diaphragm is that it is under the control of the woman. The diaphragm is not easily available in India and is a bit expensive. However, it must be remembered that a diaphragm is reusable and lasts about three years, if well maintained

The cervical cap: This is a thimble-shaped rubber cap that fits snugly over the cervix. Like the diaphragm the cervical cap keeps sperm out of the uterus. The cap is designed to create an almost air tight seal around the cervical opening. Suction, or surface tension, hugs it close to the cervix. Unfortunately the cervical cap is not available in India.

Female condom: the female condom is a soft, loose –fitting sheath made of polyurethane closed at one end. It works by blocking the release of sperm into the vagina. The condom is inserted into the vagina before sexual intercourse. A flexible polyurethane ring is located at either end of the device, one at the closed end that covers the cervix and the other at the open end which remains outside the vagina. The ring outside the vagina adds to the protective effects of the female condom by creating a barrier between the labia and the base of the penis. The female condom should be inserted before any sexual contact is made. After intercourse it must be removed with care to prevent any sperm from spilling in to the vagina before the woman stands up. The female condom combines the features of a condom and a diaphragm. It is inserted into the vagina in much the same way as a diaphragm, without having to take care to directly cover the cervix. Like the male condom, the female condom can be used only once.

The female condom not only covers the vaginal walls but the cervix as well. As such like the male condom it is not only an effective contraceptive for preventing pregnancy but is also an excellent safe guard against HIV and other STDs. Amongst its other plus points is that it can be inserted in advance of intercourse, so that there is no need to interrupt intercourse, it comes in a standard size and does not need fitting by a doctor. The main disadvantage of the female condom is the cost.

Spermicide: spermicides are chemicals applied into the vagina, which work by inactivating or killing the sperms.  They are available in the form of foams, tablets (eg. Today) jellies and creams (eg.Delfen) the spermicide is inserted into the vagina with the help of an applicator immediately before sexual intercourse. They are not usually used on their own but could be used to increase the effectiveness of condoms or diaphragms. The lowest expected failure rate for spermicides used alone is 6%, while the typical failure rate is 26%. These spermicides   do not generally have any serious side effects, though some women may experience genital irritation or allergic reactions.

Injectable Contraceptives : The Injectable Contraceptives contain synthetic hormones resembling the natural female hormones. When administered (IM/SC) there is a slow release of hormone into the blood stream and it provides protection from pregnancy for a long duration of time to the client. Depot MedroxyProgesterone Acetate can be given through intramuscular route (DMPA IM) or subcutaneous route (DMPASC). Under the National Family Planning program, DMPA injectable contraceptive  (Antara) have been added to the basket of choice. It is a highly effective contraceptive method. However, it does not protect against STI/RTI and HIV infection. Return of fertility takes 7-10 months from date of last injection.

Traditionally used methods

Breast feeding: After childbirth it takes some time such as few months in most cases, for the woman to start menstruating again and ovulation to occur. This period during breast feeding when there is an absence of menstruation is termed Lactational amenorrhea. It is prolongs in women who carry out complete  breast-feeding that is when a woman nurses her baby on demand during day and night giving exclusive breast –feed without any top feed. During Lactational Amenorrhoea the chances of getting pregnant are reduced. However it should be noted that ovulation takes place before the first menstruation. Hence, it is possible to get pregnant even without experiencing a menstrual period.

Coitus interrupts/withdrawal: In this method, the penis is withdrawn from the vagina before ejaculation so that the sperm is not deposited inside the vagina. Withdrawal is not an effective method because the timing can go wrong and contact with the vagina and vaginal lips may be difficult to avoid, further as soon as the erection appears a small amount of sperm is released which can be sufficient to cause pregnancy.

Methods that prevent fertilization

Intra Uterine Device (IUD): An IUD is usually a small, flexible plastic device that fits into the uterus. Most contain either copper or synthetic progesterone. The IUD is inserted in the woman’s uterus through the cervix. Once it is an place, the strings (usually two) of the IUD extend down into the upper vagina. By inserting a finger into her vagina and touching the strings, a woman can check if the IUD is still in place.

The working of the IUD is not yet fully understood. IUDs (especially those that contain copper) cause an inflammation or chronic low-grade infection in the uterus. These changes may damage or destroy sperm or interfere with their movement in a woman’s genital tract making fertilization impossible. IUDs may also speed the movement of the egg in the fallopian tube, causing the egg to arrive in the uterus too soon to be able to join with sperm. Even if fertilization does occur, the disturbance caused by the foreign body in the uterus prevents implantation.

The most commonly used IUD in India today is the copper-T. These IUDs are used for about two to three years, after which they have to be changed. The IUD should be inserted inside the uterus by a doctor, during the menstrual period or soon after to ensure that there is no pregnancy at the time of insertion. The IUD is very effective as a contraceptive. However, it could have several side effects some of them severe.

• Severe cramps and pain beyond the first three to five days after insertion.
• Heavy menstrual bleeding, or bleeding between periods, possible contributing to anemia
• In rare cases, perforation of the uterus wall.  Embedding may also occur if the lining of the uterus grows around the IUD. Embedded IUDs  cause more pain during removal, sometimes necessitating a D&C procedure (Dilation and Curettage)
• Pelvis inflammatory disease (PID), which is an infection in the uterine lining, uterine wall fallopian tube, ovary, uterine membrane, broad ligaments of the uterus, or membranes lining the pelvic wall. Caused by a variety   of infectious organisms including gonorrhea and Chlamydia. It is twice as likely to occur in women using IUDs as in women using no contraception.
• Ectopic pregnancy is more likely ( with copper IUDs there is a 3% chance) in women using IUDs. An ectopic pregnancy (pregnancy outside the uterus, usually in the fallopian tube) is a serious problem that can cause haemorrhage, and lead to infection, sterility and sometimes death. (When emergency medical care is not available)
• IUDs should be chosen as a contraceptive after careful consideration, if one has never had a child; it is advisable not to get an IUD inserted. It is not appropriate for women prone to genital infections, those with a history of ectopic pregnancy, those suffering from severe dysmenorrhoea (painful menstruation) or women who are anemic.

Most health centers and hospitals pressurize women to get IUDs inserted immediately after a delivery or abortion. However, this can be extremely dangerous.

Non-steroidal pill-centechroman: Marketed in India by the brand name Saheli or choice 7, non- steroidal pills work by accelerating the passage of the ova into the uterus. It works even if fertilization has already occurred. Non –steroidal pills are promoted as an ideal contraceptive by the government. However, through not a hormonal pill it does change the estrogen-progesterone functions of a woman’s body. Centchoroman is also known to have caused ovarian cysts in some users.

Abortion:

An abortion is the ending of a pregnancy before full term, by expulsion of the foetus from the uterus. A spontaneous abortion or miscarriage is the natural termination of pregnancy. An induced abortion is also called Medical Termination of Pregnancy (MTP). Despite using contraceptives, a pregnancy may result, or, the pregnancy may be the result of rape, incest, or a coerced sexual encounter. In these situations, a woman may decide to have an abortion. From time immemorial abortion has been used as a means of fertility control. External massage, performing arduous physical activity, scraping the uterus with a sharp object, consuming abortifacient herbs and potions have been means by which women have attempted to end unwanted pregnancies. Many societies have imposed strict religious sanctions against abortion viewing it as the taking away of life, although abortion is still illegal in many countries, the women’s movement the world over has articulated legal, safe, affordable and accessible abortion as a right. Induced abortion was legalised in India by the Medical Termination of Pregnancy Act, 1972. During an abortion, the foetus and the placenta are removed through the cervix. Depending on the stage of pregnancy different methods of abortion may be used.

Suction: It is suitable for a six to eight week pregnancy, in this method a cannula or tube that is connected to a suction pump is inserted through the cervix under either local or general anesthesia. By suction the foetal tissue is removes within a few minutes. It does not require a hospital stay.

D&C (dilation and curettage): For pregnancies of 8 to 16 weeks the cervix is dilated by a diluting rod and then the uterus are scraped clean with a curette, all under general anesthesia.

Induced labour: For advanced pregnancies of about 16-20 weeks, usually a solution of saline, urea or prostaglandin is injected into the amniotic sac to cause premature labour and expel the foetus. This procedure is carried out under local anesthesia and requires hospital stay for a day or two.

The abortion pill: Medical abortion is possible through the combined use of the drugs mifepristone and misoprostal and its use has recently been legalised in India. Mifepristone ( also known as RU 486) is the anti-abortion pill but it has been found to be unreliable on its own and hence is followed 2 to 3 days later with a prostaglandin (misoprostol). The RU-486 is effective in initiating abortion only in the first six to eight weeks pregnancy. The abortion pill should be taken only under medical supervision, as it could cause uncontrolled bleeding. Some of the known side effects include uncontrolled vomiting and nausea, and severe bleeding that could lead to a collapse. It could take up to 12 days for abortion to take place and the woman could bleed all that while. Moreover, since RU-486 is effective only for very early pregnancy, it has not been studied as to what could be the impact on the foetus in case abortion in case abortion does not occur.

Hormonal methods

Hormonal methods work by influencing the hormones estrogen and progesterone in the body and thereby stopping ovulation or sperm production. They also have the effect of thickening the cervical mucus (which prevents sperm from entering the uterus), and in some cases also cause changes in the uterus and fallopian tubes that prevents fertilization. Hormonal methods disturb the delicate balance of hormones on the body. They may have serious side-effects and may impact various parts of the body other than just the reproductive system, i.e., they can cause systematic changes. However, government contraceptive providers promote them as an ideal contraceptive method because they are highly effective and easy to administer.

Oral contraceptives: Different oral contraceptives include

Combined oral contraceptive: combined oral contraceptive pills contain two hormones, estrogen and progesterone, in different proportions. They prevent pregnancy primarily by inhibiting the development of the egg in the ovary by raising the level of estrogen at the beginning of the cycle. Today’s low dose combination pills (like Mala-D) are relatively safer than the high dose combination pill (like Oral). However, combined OCs is not suitable for all women.

Progesterone –only pill: while combines oral contraceptives stop ovulation, progesterone-only pills prevent pregnancy by increasing the cervical mucus, slowing down the motility of the sperm as well as the egg and not allowing the uterine lining to develop properly. The pill has many advantages such as high effectiveness, convenience, no interference with sexual intercourse and proven reversibility. However there are several unpleasant side-effects which should be noted.

Injectable contraceptives: Depo provera (Depot Medroxyprogesterone Acetate) and Net En (Norethisterone Enanthate) are progesterone-only injectable contraceptives. The contraceptive effect of Depo Provera lasts for three months, and that of Net En for two months.

Injectable seem to be a convenient method of birth control. However, there are many short-term side-effects and long- term health hazards associated with the use of injectibles. Since they are delivered in very high doses and their effects are long-acting the seriousness of their side-effects far outweighs those of the pill. Much as the woman may want the effect of injectibles cannot be withdrawn until it wears off in two-three months. Presently injectibles have not been licensed for introduction in the National Family Welfare Programmes. They were registered in 1994 for use only by private practitioners and for ‘social marketing’ by NGOs.

The health hazards associated with the use of progesterone-only injectibles include:

• Menstrual disturbances ranging from prolonged spotting and excessive bleeding to complete absence of bleeding.
• Atherosclerosis-thickening of blood vessels and cardiovascular disease
• Thromboembolism –development of blood clots at unexpected sites resulting in damage to heart, lungs and brain etc.
• Osteoporosis/loss of bone density, resulting in higher incidence of fractures.
• Weight changes
• Other metabolic changes resulting in changes in sugar levels, depression fatigue, loss of sexual desire etc.
• Return of fertility is not predictable(a serious limitation in spacing method)
• Cancer risk-an unresolved issue
• Adverse effects on the foetus(in case of accidental pregnancy)

Emergency contraceptive pill or morning after pill:

After unprotected sex, emergency oral contraception can prevent pregnancy. It is also called morning –after or post-coital contraception. It is of particular relevance in situations where woman has been forced to have sex against her will (rape), a condom has broken or unplanned sex has taken place. Emergency contraception can be used only up to 72 hours (3 days) after the occurrence of unprotected sex. Four standard dose or low –dose oral contraceptives such as Mala-D or Mala-N can be taken for emergency contraception. A morning after pill consisting of the drug levonorgestrel has also been introduced in the family planning programme, two of which should be taken within four days of unprotected sex.

Its side effects include nausea, vomiting and disruption of the next menstrual period; it is not very clear how emergency contraception works. It is thought to prevent ovulation, and may also contribute to disrupting fertilization if it has already occurred. However, it is not 100% effective. The average chance of pregnancy due to one act of unprotected intercourse in the second or third week of the menstrual cycle is 8% and after emergency contraception it gets reduced to 2%.

It is important to remember that in case emergency contraception does not work, the chances of birth defects in the foetus cannot be absolutely ruled out. Hence, it is important to be very cautious in the use of emergency contraception, ensuring there is adequate backup of legal and safe abortion services.

Permanent methods

Permanent methods in men and women involve permanent blocking or cutting off the tubes which carry the egg/sperm. With new medical techniques, re-canalization (rejoining of tubes) can be performed, but it is not always possible or successful, so these methods for all practical purposes are irreversible. Sterilization is very highly effective. It is appropriate for people who have attained the desire family size and are sure that they do not want any more children.

Vasectomy/male sterilization:

Vasectomy is a surgical method of sterilization for men. It blocks the vas deferens in the male so that sperms cannot travel to the penis with semen. The man however continues to ejaculate and it does not affect his sexual performance in any way. Adequate and sensitive counseling can help to alleviate anxieties about ‘manhood ‘and sexual performances.

In ‘no-scalpel’ vasectomy, only a tiny hole is made on both sides of the scrotum to expose the vas deferens which is then cut, tied or clipped under local anesthesia.

Vasectomy is a minor and simple surgery, but the man rest at least 48 hours after the operation. And should not lift any heavy objects for a week. One should resume sexual intercourse only after all signs of discomfort have gone, in any case not before a week. An alternative method of birth control must be used for at least 2 to 3 months after the operation, as sperm can live in the sperm duct for up to 3 months. In case the operation is followed by high fever, excessive or continued bleeding, swelling or pain a doctor must be consulted immediately.

It is safer and simpler for a man to be sterilized because the male genetalia, unlike that of the female is external. Hence vasectomy involves less interference to body organs and fewer complications. Recent studies indicate that men who have had a vasectomy may have an increased risk of prostate cancer,. There are no other major log-term risks associated with vasectomy.

Tubectomy/Female sterilization :

Under this method or a small incision is main in the abdomen to gain access to the woman’s fallopian tubes that are then cut, tied or clipped. This is done under local anesthesia. it blocks the fallopian tubes in the female so that the eggs produced by the ovaries cannot  unite the sperm. Female sterilization is very effective if performed properly, though complications can and do arise. This could include infections, internal bleeding, and perforation of the uterus and/or the intestines. It could also lead to heart problems, irregular bleeding, severe menstrual pain, and the need for repeated D&Cs or even a hysterectomy. A doctor should be immediately considered in such a case. Proper precautions need to be taken before and during sterilization. One needs to rest for about 48 hours after the operation. Normal activity can be resumed within 2-3 days but one must not lift heavy objects for about a week. Sexual intercourse can usually be resumed after a week.

The risks of Tubectomy are the same as those for any major abdominal surgery- cardiac irregularity, cardiac arrest, infection, internal bleeding, and perforation of a major blood vessel. These risks increase manifold when Tubectomy is performed in settings where due care is not taken, for example in family planning ‘camps’ where a huge number of women are sterilized. Mobile camps are even more problematic since the possibility of monitoring and follow up does not exist. Laparoscopic techniques may involve specific problems such as internal burn injuries of punctures to other organs or tissue, skin burn, puncturing of the intestine, perforation of the uterus, and carbon dioxide embolism (which may cause immediate death).

Source: Portal Content Team