1. Contraception
Winter 2017

2. 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 (CDC)
Contraceptive prevalence (Excel, pdf map) across the world (United Nations, 2012)
Contraceptive prevalence by method (WHO, 2015; page 10, Figure 4), or prevalence by method (United Nations, 2011)

3. 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)
Adolescent Fertility Rate (World Bank)

4. Contraceptive Issues
You Decide

5. Contraceptive Issues Effectiveness against pregnancy Side effects
Potential unidentified effects of contraceptive use over the long term
Cost
Religion
Interactions with other medications
Sexually transmitted infection protection
Convenience
Reversibility
Length of effectiveness
Benefits outside of contraception (e.g. using hormone-based contraception to regulate menstrual cycle, reduce menstrual pain, reduce heavy menstrual bleeding, reduce menstrual migraine)

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

7. Contraceptives – How They Work with Anatomy & Physiology

8. Sterilization

9. Sterilization 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)

10. 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

11. 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

12. Sterilization: Vasectomy
Cost: $ (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

13. Sterilization: Vasectomy
Animation (BUPA Health via YouTube, 2:36)
Video (vasectomymedical.com)
Vasectomy (vasovasostomy) reversal video (Vimeo.com, 4:00)

14. 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

15. 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

16. 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)

17. 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

18. 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)

19. Intrauterine Contraceptives (IUC’s)
IUC’s are made of flexible plastic, available only through prescription
Two types (U.S.)
ParaGard (copper-based IUC)
Hormone-based IUC’s
Mirena
Skyla
Liletta
Kyleena

20. 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

21. 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

22. 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: $ (Planned Parenthood)

23. Hormone 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

24. Hormone IUC’s: Mirena Insertion: Similar to ParaGard
Effectiveness: 99%+ against pregnancy
Cost: $ (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

25. Other Hormone—Based IUD’s
Skyla
Liletta
Kyleena
Differences (table 1, kff.org)
Effectiveness timeframe
Amount of progestin
(Picture = Skyla & Mirena)

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

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

28. 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

29. Contraceptive Barriers
Barriers generally have less effectiveness against pregnancy than sterilization, IUC’s, hormone contraceptive methods
Of all contraceptive methods, two barriers provide the greatest protection against sexually transmitted infections
External (“male”) condom
Internal (“female”) condom
Public domain image, created by Villy Fink Isaksen, was downloaded from Wikimedia Commons

30. External (“Male”) Condom
Available over the counter in many colors, types, sizes, with & without lubricant
Placed on an erect penis
Prevents ejaculate from entering vagina
Also used to prevent infection transmission
New condom for each act of intercourse
Expiration date
Typical effectiveness: 85-90%, “perfect use: 95%
Used for anal sex, but not FDA approved for that purpose
Public domain image at left was taken by ClaudiaM1FLERéunion, and downloaded via Wikimedia Commons

31. External (“Male”) Condom
Most are latex, free-$1 per condom in U.S.
Some are polyurethane
May transfer heat better than latex
More likely to break vs latex (7.2% vs 1.1% in Guttmacher Institute reference)
More expensive, ~$1+
Polyisopropene
Latex-like without latex
Lifestyles and Durex brands, ~$0.50+
Lambskin
Sheep intestinal membrane
Less effective against infection transmission (~$3)
Kitemark Condom Testing (National Geographic)

32. Internal (“Female”) Condom
FC2 nitrile condom, available over the counter
Two rings: closed, open ends
Inserted prior to intercourse, up to several hours
Prevents ejaculate from reaching vagina
Cost: $ per condom
New condom for each act

33. Internal (“Female”) Condom
Effectiveness: ~80% typical, 95% “perfect” (Planned Parenthood)
Animation
Used for anal sex, but not FDA approved for that purpose

34. Barriers: Spermicide & Nonoxynol-9
Spermicides inserted before vaginal intercourse, to stop sperm movement
Nonoxynol-9 is ingredient in spermicides
Nonoxynol-9 originally designed to protect against HIV
In last 20 years, opposite appears to be reality
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
Concern continues (Smith-McCune, et.al., PLOS One, 2015)
FDA requires manufacturers to provide warning

35. Contraception: News, Interesting Info
Caya – new diaphragm, (0:30-2:35, product website)
Silk Parasol (path.org, Silk Parasol via product website)
Proposed panty condom in Uganda (monitor.co.ug, 2015)

36. Contraception: The Past
Male Contraceptive: Heat
Prolonged heat exposure can impair sperm production in testes
Ancient method
Effectiveness? Research by Voegeli in 1940’s:
116 degree bath
45 minutes
Every day
Three weeks
Six months of sterility

37. Contraception: Impact of Heat on Sperm

38. 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 ( )

39. Contraception
Hormonal Methods

40. Hormonal Contraceptives: Mechanism of Action
Synthetic estrogen and/or synthetic progesterone
Combination hormone contraceptives halt ovulation (release of egg)
No egg = no pregnancy
HybridMedical video: Ovulation (YouTube)

41. Hormone-Based Contraception
Estrogen
Usually ethinyl estradiol
Progestin
Many types
Types vary in terms of side effects
Blood lipids
Break-through bleeding
Weight gain/metabolism
Acne
Source: Dawn Stacey, About.com

42. Estrogen Estrogen suppresses development of follicle within ovary
Estrogen changes the endometrial lining, making the uterine environment less accommodating to a fertilized ovum

43. Estrogen Estrogen makes progestin activity stronger
Progestin manipulates one of the hormones responsible for ovulation
So, even if estrogen does not completely prevent follicle development, it works with progestin to prevent ovulation

44. Progestin Progestin thickens cervical fluid (cervical mucus)
Thicker fluid hampers sperm movement
Progestin also changes the endometrial lining in uterus
Reduces likelihood for egg implantation
Progestin-only methods may not inhibit ovulation
Varies from one cycle to another
Method dependent (Depo-Provera inhibits ovulation, minipills may not)
Effectiveness due to cervical fluid, endometrial changes

45. Bottom Line: Estrogen & Progestin Roles in Hormonal Contraception
Hormonal contraceptive methods work to prevent ovulation
Hormonal methods thicken cervical fluid to make sperm transport difficult
Hormonal contraceptive methods change the lining in uterus to make fertilized egg implantation difficult

46. Hormonal Contraceptives Side Effects
Estrogen effects
Progestin effects
Androgen effects

47. Hormone Contraceptive Side Effects
Estrogen: Hypertension, headache, breast fullness, irritability, nausea, vomiting, bloating, breakthrough bleeding
Progestin: Headache, breast tenderness, hypertension
Androgenic: Acne, weight gain, hair growth, fatigue, depression
Each person is different, so the above effects are guidelines
Chart (Dawn Stacey, about.com)
Side effects may change if the problem is dose-related
Source: Carl Rice, et.al., Selecting and Monitoring Hormonal Contraceptives: An Overview of Available Products, U.S. Pharmacist; 6:

49. Hormone Contraceptive Contraindications (especially combination methods)
Women 35 years and older who smoke
Women with history of cardiovascular issues should avoid estrogen
Epilepsy, if using specific medications
Obesity may be related to effectiveness issues (consider IUC)
Certain bariatric procedures
Migraine headaches
Breast cancer
Cervical cancer
STI if using IUD
This list not exhaustive
Reproductiveaccess.org chart

50. Hormone Contraceptive Benefits
Regulation of menstrual bleeding
Reduced risk of ovarian, uterine cancer
Reduced menstrual pain (pills, implant)
Control of excess hair growth
Reduced acne

51. Patch OrthoEvra, Xulane (generic)
Beige plastic patch applied to the skin
Once a week for three weeks
Stomach, upper arm, upper torso, buttocks
First day of menses or first Sunday after period starts
Releases estrogen and progestin
Effectiveness: 99%
Cost: $0-80/month (Planned Parenthood)
No STI protection
Some may have reaction to adhesive

52. NuvaRing Insertion of ring into vagina
Remains in place for three weeks
Releases estrogen and progestin
Cost: $0-80/month (Planned Parenthood)
Insertion (YouTube, 0:45-1:20)
Effectiveness: 99%+
No STI protection

53. Nexplanon/Implanon
Nexplanon most recent version (easier insertion/removal)
A single implant in the upper arm
Progestin-only method
Works for three years (up to four)
Effectiveness: 99%+
Cost: $0-800 (Planned Parenthood)
No STI protection
Sensitive Implanon insertion video (YouTube, 2:08)
Sensitive Nexplanon insertion video (YouTube, 0:39)

54. Depo-Provera/Depo-subQ Provera 104 (“Depo”)
Progestin-only
Hormone injected every three months
Arm
Buttocks
Cost: $0-100 per shot plus exam fees
Effectiveness: 94%
No STI protection
”Black box” warning for increased osteoporosis risk

55. Contraceptive Pills
Chewable pill (Femcon Fe) - discreet; also helps when swallowing pills is difficult
Continuous cycle pills (Seasonique, Amethyst) – no placebo pills
Natazia – estradiol valerate used instead of ethinyl estradiol

56. Emergency Contraception
Available over the counter
A variety of pills
Copper IUD
No age restrictions
Source: Emergency Contraception, Princeton University

57. Fertility Awareness Methods
No prescriptions, contraceptive purchases required
Methods track ovulation
Strategy: if sperm are not near egg when it is released, fertilization cannot occur
Ovum lives for ~24 hours after being released
Sperm can live for ~6 days
Pregnancy chances ~7 days out of cycle (five days before ovulation plus 1-2 days after)
Image by Dafne Cholet, via Flickr

58. Fertility Awareness Methods - Effectiveness
Generally, 75-80% effectiveness, with perfect use, up to 95%, depending upon methods (outside of abstinence) used
“Effectiveness” - based on pregnancies among 100 male-female couples engaging in vaginal intercourse for one year
Effectiveness can increase when using more than one FAM, or additional non-FAM contraceptives
No sexually transmitted infection prevention

59. Abstinence No “sex” What does this mean?
Effectiveness depends on interpretation of term

60. Withdrawal
During vaginal intercourse, penis is removed from vagina before ejaculation
“Coitus interruptus”
“Pull-out” method

61. Temperature Method Track temperature every morning
Look for slight drop in temperature occurring immediately before ovulation
At ovulation, small temperature (.1 degree) increase
Track for three months, every morning, before relying on method
Use chart to look for trends, expect daily fluctuations
Tracks when ovulation has happened, but cannot be used to predict ovulation

62. Temperature Method Day 10: 98.5 Day 17: 98.8 Day 11: 98.4 Day 18: 99.0

63. Calendar Method Use monthly cycles to predict “safe” and “unsafe” days
Calendar, app, website tool
Count cycle days
Day #1 = first day of menses
Last day = day before menses returns
Count for eight cycles before use
If all cycles <27 days, don’t use
Subtract 18 from shortest cycle
Subtract 11 from longest cycle
Apply to calendar

64. Calendar Method Cycle 1: 25 Cycle 2: 27 Cycle 3: 28 Cycle 4: 28
Shortest day: 25
Longest day: 29
Unsafe days: #7-18

65. Symptothermal, Standard Days Methods
Symptothermal: combination of calendar, temperature, and cervical fluid/mucus monitoring
Standard Days method: uses specific “CycleBeads” tool to track
CycleBeads App (YouTube)

66. Fertility Awareness Contraindications
Irregular cycles
Multiple partners
Sexually transmitted infections (discharge)
Unable to abstain on “unsafe” days
Adolescence, breastfeeding, menopause
Use after hormone-based contraceptive, at least for several months