Contraception Fall 2016

Contraception Variety of methods Categorized by methodology Barriers Hormonal methods Fertility awareness methods Sterilization Contraceptive issues vary across countries Contraceptive methods in the U.S. (Guttmacher Institute, 2012) Under Affordable Care Act, rate for uninsured women reduced 1/3 Contraceptive methods in the U.S., 1995 vs. 2006-10 (CDC) Contraceptive prevalence (Excel, pdf map) across the world (United Nations, 2012) Contraceptive prevalence by method (United Nations, 2011)

Why Does Contraception Matter? We (taxpayers) pay for many unexpected pregnancies Rates of unintended pregnancy (Guttmacher Institute) How much (Guttmacher Institute) Youth comparisons in Germany, France, Netherlands (Advocates for Youth)

You Decide Contraceptive Issues

Contraceptive Issues Effectiveness against pregnancy Cost Side effects Religion Life choices Availability Sexually transmitted infection risk Reversibility Ease of use Spontaneity

Contraceptives – How They Work Dependent Upon Category Barriers Hormone-Based Methods Sterilization Fertility Awareness Methods

Sterilization

Sterilization Female sterilization: 700,000/year (emedicinehealth.com) Sterilization = permanent contraception Women undergo tubal ligation or implant Men undergo vasectomy The second most common contraceptive method used in the United States (men’s and women’s methods combined) No formalized data collection system exists Data retrieved from surveys, questionnaires Female sterilization: 700,000/year (emedicinehealth.com) Vasectomies: 500,000/year (WebMD)

Sterilization: Vasectomy Vasectomy blocks sperm from traveling through the vas deferens, preventing sperm from mixing into semen No glands or organs are removed Effectiveness: 99%+ Considered irreversible

Sterilization: Vasectomy Vas deferens must be isolated The vas deferens can be cut and tied, clamped, cauterized, no scalpel technique Another form of contraception must be used for a few months

Sterilization: Vasectomy Cost: $0-1000 (plannedparenthood.com) Not currently covered via Affordable Care Act Planned Parenthood may provide no- or low-cost vasectomies; state plans may offer benefit (Oregon, e.g.) Side effects: bruising, sensitivity/pain, sperm leaking from tubes may lead to small lump (usually clears up on its own), antibodies to sperm may develop, reducing chances of fertility in a reversal Complications: rare, usually associated with infection (fever, pus/blood from incision site, swelling, pain); ends of tubes may grow back together (very rare); decreased sexual desire (4 out of 1000 cases per Planned Parenthood) - no apparent physical cause

Sterilization: Vasectomy Animation (BUPA Health via YouTube, 2:36) Video (vasectomymedical.com)

Sterilization: Tubal Ligation Surgical technique Animation (1:35+) Close fallopian tubes, preventing egg from traveling to uterus, preventing sperm from reaching egg Neither organs nor glands are removed Effectiveness: 99%+ Considered irreversible

Sterilization: Tubal Ligation Tubal sterilization: Tubes can be tied and cut (Pomeroy technique) Tubes can be cauterized Tubes can be clipped, clamped These incision methods often performed after childbirth/abortion

Sterilization: Tubal Ligation Cost: $0-3000 Side effects: thought by many to be rare; hormonal imbalance may lead to increased menstrual bleeding, cramping; adhesions Complications: infection, internal bleeding, ectopic pregnancy Before/after photos (private Flickr account)

Sterilization: Implants Non-incision method No general anesthesia Under an hour Coils inserted into fallopian tubes In following months, coils and tissue grow together, forming barrier to prevent sperm from reaching egg

Sterilization: Implants Side effects: expulsion of coil inserts, risk for ectopic pregnancy, cramping, menstrual changes, nausea/vomiting Animation (YouTube) Thousands of complaints regarding implant complications reported to FDA (NY Times, 2015)

Intrauterine Contraceptives (IUC’s) IUC’s are made of flexible plastic, available only through prescription Three types (U.S.) ParaGard (copper) Mirena (hormone) Skyla (hormone)

IUC’s: ParaGard ParaGard contains copper Copper prevents sperm from fertilizing an ovum Appears to be disagreement on whether ParaGard also causes inflammatory response in uterine cavity Copper may also affect the ovum, reducing its ability to become fertilized (Medscape) Amount of copper released is less than needed in daily diet Copper intolerance or insensitivity would preclude use of ParaGard

IUC’s: Paragard Requires insertion into uterus by healthcare provider Takes only a few minutes Insertion may cause cramping, dizziness Once inserted, may remain in place for ten years Patient should not feel IUD Since no hormones present, monthly cycle should remain unchanged Insertion video Effectiveness: 99%+ against pregnancy Requires monthly checking for IUD slippage

IUC’s: ParaGard Side effects: heavier and longer periods, cramping, spotting in between periods May lessen after a few months on ParaGard Complication risks: pelvic inflammatory disease shortly after insertion, perforation of uterus, expulsion Copper may provide protective benefit against endometrial cancer Cost: $0-1000 (Planned Parenthood)

IUC’s: Mirena Hormonal method (pregestogen) Intrauterine device Lasts for five years Mirena: Prevents sperm from fertilizing ovum Prevents release of egg Changes uterine lining

IUC’s: Mirena Insertion: Similar to ParaGard Effectiveness: 99%+ against pregnancy Cost: $0-1000 (Planned Parenthood, Bedsider.org) Side effects: Abdominal cramping (10% of users during first few months), acne, breast tenderness, headache, mood changes, back pain May lessen after a few months As use continues, less menstrual bleeding Complication effects: ovarian cysts, pelvic inflammatory disease shortly after insertion, perforation of uterus, expulsion

IUC’s Internal Birth Control- IUD’s (via Youtube) Insertion of IUC (Medialvideos.us)

Barrier Contraceptive Methods Physical barriers Prevent sperm from entering cervix Block sperm from fertilizing ovum

Barrier Contraceptive Methods Historically, pessaries used Objects or substances inserted into vagina Pregnancy prevention effectiveness Infection effectiveness Current barrier methods: spermicide, male condom, female condom, diaphragm, cervical cap, sponge

Barriers: Spermicide Nonoxynol-9 Ingredient in spermicides, may be included in condom packaging Originally thought nonoxynol-9 protected against HIV In late 1990’s, early 2000’s, nonoxynol-9 was no longer thought to provide that protection Among commercial sex workers in Africa, Thailand Frequent use Nonoxynol-9 may increase risk for disease transmission Increases vaginal irritation, which can lead to lesions/sores Lesions typically result in disease transmission vulnerability 2007: FDA required manufacturers to provide warning Effect of Coke on Sperm Motility Mythbusters (1:04-4:00)

Contraception: News, Interesting Info, Future, Past Silk Parasol (path.org, Silk Parasol via product website) Proposed panty condom in Uganda (monitor.co.ug, 2015) Caya – new diaphragm, 2015 (0:30-2:35, product website) RAPE-AXE female condom, reportedly not available (YouTube)

Contraception in the Future Nestorone Estrogen and progestin Gel or spray Population Council Announcement, 2010 Phase III trials (Antares Pharma) Eventual availability? New vaginal ring 90 days Progestin + microbicide Microbicide = drug to reduce HIV, herpes, HPV The Ring Study & ASPIRE Press release – reduction of HIV by ~30% (2/2016)

Contraception: The Future Vasalgel (human trials in 2016-2017, per Parsemus Foundation) Similar to India’s RISUG:Reversible Inhibition of Sperm Under Guidance Contraceptive method for men, not available in U.S. Injection into vas deferens of male (video, wired.com, :34) Vasalgel disrupts membranes of sperm so they cannot fertilize One injection to last 10 years Marketing challenges

Contraception: The Future Male pills (5-10 years) Gendarussa – plant-based, interferes with sperm’s ability to fertilize egg Video (via YouTube, 8:00) Anti-Eppin – interferes with sperm motility “Clean sheets” pill - Inhibit ejaculation but allow orgasm Short-term (<24 hours) method via pill, or longer-term via implant If no ejaculate, STI risk may decrease

Contraception: The Past Male Contraceptive: Heat Prolonged heat exposure can impair sperm production in testes Ancient method Effectiveness? 116 degree bath 45 minutes Every day Three weeks

Contraception: Impact of Heat on Sperm

Contraception: Impact of Heat on Sperm Dada, R, Gupta, NP, & K. Kucheria. Deterioration of Sperm Morphology in Men Exposed to High Temperature. Journal of the Anatomical Society of India. Vol. 50, No. 2 (2001-07-2001-12)

Contraception: Impact of Heat on Sperm Upper left: coiled tail Upper right: bent tail Lower left: double head Lower right: triple head Dada, R, Gupta, NP, & K. Kucheria. Deterioration of Sperm Morphology in Men Exposed to High Temperature. Journal of the Anatomical Society of India. Vol. 50, No. 2 (2001-07-2001-12)