CONTRACEPTION

Vaginal Diaphragm

Consists of thin, nearly hemispherical dome made of rubber or latex material, with a circular, covered metal spring at the periphery. These are available under the names of ortho diaphragm, komex diaphragm.

How they act?
Used as means to retain spermicides in contact with the cervical os and not as a sperm-proof mechanical barriers.

Method of fitting
The instructor (Gynecologist or specially trained nurse) chooses the appropriate size after internal examination. The cap should be introduced two hours-? before the sexual act. An applicator full of spermicidal cream or jelly should be introduced vaginally or a foam pessary introduced at least 15 minutes earlier as it takes time to dissolve.

Advantages

• Female oriented and entirely harmless.
• No gross medical side effect.
• Doesn’t interfere with sexual pleasure.
• Like condoms, diaphragms can prevent spread of sexually transmitted diseases, although less effectively.

Disadvantages

• Use of spermicides with occlusive caps is found to be messy and unacceptable for some women.
• Infection may set in if caps are not removed for a long time.
• It is suitable only for a small group of intelligent, highly motivated women.
• Occlusive caps do not prevent spread of AIDS.

Aftercare and Follow-up

• After intercourse, the vaginal diaphragm shouldn’t be removed 6 – 8 hours of the last act and shouldn’t be kept for more than 24 hours.
• After removal, vaginal diaphragm should be cleaned with soap and water, dried thoroughly and kept in a good well fitting container.
• Can be re-used for average 50 times or up to 6 months.

Failure Rate
Less than 2%, when used as per manufacturer’s instructions.

Cervical Cap
Cervical caps are small thimble or dome shaped rubber appliances designed to cover the cervix i.e.: opening of the mouth of uterus. They remain in place by suction. The degree of suction depends on the tightness of the fit. They are available under the names are Orthocervical cap, Miler cervical cap, etc. They are not much used in practice.

Spermicides
Spermicides are chemical agents capable of destroying sperms. Spermicides alone are not very effective in preventing pregnancy and are not recommended alone. Their main role is to improve the contraceptive effect of other barrier methods. They are mostly used along with diaphragms, cervical caps and condoms. The most commonly used spermicidal agent is Nonoxyonol-9.

Different Types

• Chemical suppositories E.g.: Ortho foams. Today vaginal tablet ?
• Contraceptive creams and jellies e.g.: Delfen cream, Volper cream.
• Foam tablets: e.g.: Durafoam tablets, "Today" in India.
• C-films: which are 5-cm squares of water soluble, semitransparent plastic impregnated with spermicide agent called Nonoxynol- 9. It is inserted high up in vagina just before coitus. They are active for two hours.

Advantages

• Can be purchased without any prescription.
• Easily available and easy to use.
• Relatively cheap.
• They give some protection against sexually transmitted diseases.
• They can be used for added lubrication.

Disadvantages

• Messy to use so is not liked by some couples.
• Failure rate is high 10 – 30%.
• Spermicides do increase the risk of urinary tract infection.

Failure Rate
Average failure rate is 10 – 30 %

NOTE: When used with barrier methods like condoms, diaphragms; spermicides increases the contraceptive effect.

Implants

• Norplant small tiny tubes containing hormone progesterone is implanted under the skin by a small surgery under local anesthesia.
• It prevents release of eggs. No eggs. No pregnancy
• It also causes thickening of cervical mucus preventing (hindering) the entry of sperms into the cavity of uterus.

Failure rate
More than 99% (failure rate is less than 1%). More than 99% (failure rate is less than 1%).

Advantages

• Highly effective, relatively cheap over a period of time, reversible.
• Protection starts within 24 hours of insertion.
• Easy to use, no after care is needed.
• It is effective in long run and protection is given for 5 years.
• There is no problem with sex interference or handling.
• There are no estrogenic side effects as with combined oral contraceptive pills. Link to oral contraceptive pills in preventing pregnancy.
• It may help in preventing anemia.
• It is best suitable for mothers who are breast-feeding. It doesn’t alter the quality or quantity of breast milk secretion or no adverse effects in breast fed infant.

Disadvantages

• It must be inserted and removed by trained health care personnel.
• It has side effects – irregular bleeding, prolonged menstrual bleeding and amenorrhoea (absence of menses) in more than 60% of users.
• Headache.
• It may cause transient ovarian cysts in 10% users.
• Removal may be difficult at times.
• Return to fac------- tales a few months (unlike pills, where it is quickee)

Injections
Many women cannot take Oral Contraceptives regularly, leading to a failure rate of 2 – 8 % per year, though the pills are almost 100% effective. In India, and many other countries, some women have more faith in injections than in oral medicines. There are two types of injectable steroid contraceptives.

• Progesterone only contraceptive injections
  DMPA or Depo-Provera.
  NET – EN
• Combined Contraceptive injections: (once a month injections)
  Cyclofem
  Mesigna

How do they act?

• Inhibits the release of the egg.
• Thickening of mucus at the mouth of the uterus, which hinders entry of sperms inside.
• Making the inside lining of uterus less suitable for implantation of fertilized egg.

Contra-indications
If suspicious of:

• Pregnancy,
• Cancer of the breast or genital tract,
• Abnormal uterine bleeding,
• Diabetes.

Failure rate
1% failure rate.

Advantages

• Suitable for women who have more faith in injections than in oral medications.
• One injection 2 monthly or 3 monthly.
• No regular medication is required.
• Doesn’t interfere with sex play.
• It reduces menstrual blood flow and prevents anemia.
• It is most suitable for lactating women because it doesn’t have any bad effect on breast milk secretion.
• It causes weight gain of 1-3 kg in fair percentage of woman, which is an advantage in thin ladies, but sometimes the weight gain is much more.
• Best suited for patients of sickle cell disease (abnormality in the shape of red blood cells).
• DMPA use protects against the risk of cancer of the endometrium (inside lining of the uterus).

Side Effects

• Periods are commonly affected by contraceptive injections. It is common for them to become irregular or stop all together. Some users have reported excessive periods.
• Weight gain of average 1 – 3 kg has been noted.
• The return of fertility is of longer duration.
• Headache.
• Bone mineral loss after prolonged use.

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