1. Contraception Fall 2015 Potpourri

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, 2010)methods Contraceptive methods in the U.S., 1995 vs. 2006-10 (CDC)methods Contraceptive prevalence (Excel, pdf map) across the world (United Nations, 2012)Excelpdf map Contraceptive prevalence by method (United Nations, 2011)prevalence by method

3. Why Does Contraception Matter? We (taxpayers) pay for many unexpected pregnancies Rates of unintended pregnancy (Guttmacher Institute) Rates of unintended pregnancy – How much (Guttmacher Institute) How much – How much, #2 (Guttmacher Institute, published 2/2015) How much, #2

4. Sterilization

5. 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)

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

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

8. 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) Before/after photos

9. 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

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

11. 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

12. Sterilization: Vasectomy Vas deferens must be isolated Similar to tubal ligation, the vas deferens can be cut and tied, clamped, cauterized, no scalpel technique Another form of contraception must be used for a few months

13. Sterilization: Vasectomy Cost: $350-1000 (plannedparenthood.com) Not currently covered via Affordable Care Act (arhp, 1/14)arhp 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

14. Sterilization: Vasectomy Animation (BUPA Health via YouTube, 2:36) Animation Open-ended (no scalpel) vasectomy (medicalvideos.us) Open-ended (no scalpel) vasectomy Video (vasectomymedical.com) Video

15. 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)

16. IUC ’ s: ParaGard ParaGard contains copper Copper prevents sperm from fertilizing an ovum Copper also makes implantation of fertilized ovum difficult Amount of copper released is less than needed in daily diet Copper intolerance or insensitivity would preclude use of ParaGard

17. 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 Effectiveness: 99%+ against pregnancy Requires monthly checking for IUD slippage

18. 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)

19. 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

20. 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

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

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

23. 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

24. 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)Mythbusters

25. Contraception: News, Interesting Info, Future, Past Silk Parasol (product website) Silk Parasol Caya – new diaphragm, 2015 (0:30-2:35, product website) Caya RAPE-AXE female condom (YouTube) RAPE-AXE

26. Contraception in the Future Nestorone – Estrogen and progestin – Gel or spray – Population Council Announcement, 2010 Population Council Announcement – Phase III trials (Antares Pharma) – Eventual availability? New vaginal ring – 90 days – Progestin + microbicide Microbicide = drug to reduce HIV, herpes, HPV – Human trials 2014

27. 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)vas deferens video – Vasalgel disrupts membranes of sperm so they cannot fertilize – One injection to last 10 years – Marketing challenges

28. Contraception: The Future Male pills (5-10 years) – Gendarussa – plant-based, interferes with sperm’s ability to fertilize egg Gendarussa – Anti-Eppin – interferes with sperm motility Anti-Eppin – “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

29. 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

30. Contraception: Impact of Heat on Sperm

31. 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)

32. 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)