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Contraception part2

Barrier contraception
Condoms
Male condoms are cheap and widely available.
They protect against STIs including HIV. They
are the only reversible male method. Typical
failure rates are in the region of 24%
The female condom is a lubricated
polyurethane condom that is inserted into the
vagina. It also protects against STIs.
Diaphragm and cap
These are latex or non-latex devices that are inserted into
the vagina to prevent passage of sperm to the cervix.
Caps fit over the cervix whereas diaphragms form a
hammock between the post-fornix and the symphysis
pubis. Caps and diaphragms are often used in conjunction
with a spermicide.
Disadvantages are that women need to be taught how to
insert and remove the device and typical failure rates in
the region of 18% are reported .increased vaginal
discharge and urinary tract infections.
Spermicides
Spermicide alone is not recommended for
prevention of pregnancy as it is of low
effectiveness.
Nonoxynol 9 (N-9) is a spermicidal product sold as a
gel, cream, foam, sponge or pessary for use with
diaphragms or caps. no longer recommended for
women who are at high risk of HIV infection.
Emergency contraception
Emergency contraception (EC) to protect women from
unwanted pregnancy following UPSI or contraceptive failure.
The two main forms are:
• Oral EC—LNG or ulipristal (ellaOne® ).
• Copper IUCD EC.
Levonogestrel (LNG EC)
• Consists of a single oral dose of 1.5mg of LNG.
• If taken within 72h of unprotected coitus it is estimated to
prevent 85% of expected pregnancies.
• It may also be used more than once in a cycle • It does not
provide contraceptive cover for the remainder of the cycle,
another method of contraception must be used.
Side effects
• Nausea.
• Vomiting only affects 1%.
• Erratic PV bleeding.
Ulipristal
• Progesterone receptor modulator.
• within 120h of UPSI.
• once per cycle.
• Due to mode of action may impair the effectiveness of
progestagen containing contraceptives for the remainder of
the cycle and so alternative contraceptive methods are
advised.
Copper IUCD
• IUCD acts as an emergency contraceptive by inhibiting
fertilization by direct toxicity.
• Affects implantation by inducing an inflammatory
reaction in the endometrium.
• The copper content may also inhibit sperm transport.
• within 120h following UPSI.
• Failure rates are less than 1%.
The risks and complications for IUCD EC are similar to
IUCD use in general. It can be removed after the next
menstruation or retained for ongoing contraception.
Female sterilization: preoperative
considerations
the most commonly used method of contraception in
women over 40yrs of age.
History and examination
• reasons for sterilization, menstrual history, current
contraception, obstetric history, previous abdominal
surgery, chronic medical conditions, and drug history.
• The patient’s BMI and abdominal examination
Counselling
It is important to establish that the woman is taking the decision
of her own free will.
• Alternatives to procedure must be discussed•
• effective contraception until her first period following
sterilization.
• The commonest reason for failure •
• Reassure that there is no increased risk of heavier periods in
women >30yrs of age. •
• Laparoscopy and tubal occlusion with Filshie clips is usually the
method of choice •
• Counselling must be supported by printed information leaflets.
Consent for female sterilization
• Written informed consent • Patient must fully
understand that the procedure is permanent •
• Lifetime risk of failure with tubal occlusion is
1:200:.
• In case of failure: increased risk of ectopic
pregnancy
• There is a risk of injury to the blood vessels,
bowel, and bladder
• with laparoscopic surgery ,possibility of a
laparotomy
Women at higher risk of regret
• Under the age of 30yrs: current RCOG recommendation
to avoid.
• Who do not have children.
• Who decide during pregnancy.
• Who have had recent relationship loss.

Female sterilization: the procedure


Preoperative—mandatory checklist
• Document LMP.
• Check current contraception
• Pregnancy test must be performed
• if any doubt about certainty of wishes or risk of
pregnancy, the procedure should be abandoned.
Intraoperative
• Day case laparoscopic procedure
• Usually general anaesthesia
• Laparascopic mechanical occlusion of the tubes
by either Filshie clips or rings: diathermy
• When a mini-laparotomy is used, any effective
surgical or mechanical method of tubal occlusion
(a modified Pomeroy procedure may be preferable
for post-partum sterilization
Postoperative
• method of occlusion used and any procedural
complications.
• advised to use effective contraception till her next
menstrual period.
Special circumstances
• Sterilization post-partum or post-abortion carries a
higher risk of regret and possibly increased failure rates.
• In cases of sterilization at the time of CS, counselling
and consent should be taken at least 1wk before the
procedure.
Other techniques
Hysteroscopic methods for sterilization Essure is
the only form of hysteroscopic tubal occlusion. It
involves placing a metal micro-insert in the
fallopian tubes under hysteroscopic guidance.
This causes tubal blockage by subsequent
fibrosis.