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Emergency contraceptive methods. The copper intrauterine device (IUCD).
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The copper intrauterine device (IUCD) • The IUCD is the most effective method of emergency contraception, with a failure rate of less than 1%. Implantation of the fertilized oocyte is avoided if the IUCD is inserted within 5 days of UPSI or earliest estimated date of ovulation. • This provides the clinician a much longer time range in which to offer emergency contraception. For example, in a regular 28-day cycle, the IUCD can be fitted up to day 19 of the cycle. It can then be left in place for use as a regular method of contraception, or removed during the next menstrual period.
Coitus interruptus • Technically coitus interruptus should not be considered a form of contraception as it potentially has a high failure rate. It involves withdrawal of the penis from the vagina prior to ejaculation, and couples should be made aware of emergency contraception. Many euphemisms are used when referring to this, such as ‘being careful’ or the ‘withdrawal method’. 90% effectiveness as a contraceptive. Failure is due to the small amount of semen that may leak from the penis prior to ejaculation with the potential of penetrating the ovum. The success of this method depends on the man exercising a great amount of self-control and is based on trust and honesty. This method is used widely throughout the world by different cultures and is the oldest form of contraception, being referred to in the Old Testament of the Bible.
Fertility awareness (natural family planning) • The study of fertility awareness, previously (and sometimes still) referred to as natural family planning, is a fascinating observation of the way in which the female body works to produce the optimum conditions for conception. • Natural Family Planning includes all the methods of contraception based on the identification of the fertile time in the menstrual cycle. The effectiveness of these methods depends on accurately identifying the fertile time and modifying sexual behaviour. To avoid pregnancy, the couple can either abstain from sexual intercourse or use a barrier method of contraception during the fertile time. Natural methods are attractive to couples who do not wish to use hormonal or mechanical methods of contraception. The midwife can provide the appropriate FPA leaflet, signpost the couple to the local contraception clinic or find local information on fertility awareness. • The method can also be used as a guide to women wishing to become pregnant, by concentrating sexual intercourse on the days they are most fertile. The fertile time lasts around 8–9 days of each menstrual cycle. The oocyte survives for up to 24 hours • a second oocyte could, occasionally, be released within 24 hours of the first. In addition, state that as a sperm can live inside a female body for up to 7 days, this means that should sexual intercourse occur 7 days before ovulation, a pregnancy could result.
Fertility awareness methods • Physiological signs of fertility are: • cervical secretions (Billings or ovulation method) • basal body (waking) temperature • cervical palpation • calendar calculation.
Cervical secretions • Following menstruation the vagina will become dry. As oestrogen levels rise, the fluid and nutrient content of the secretions increases to facilitate sperm motility, consequently a sticky white, creamy or opaque secretion is noticed. As ovulation approaches the secretions become wetter, more transparent and slippery with the appearance of raw egg white that are capable of considerable stretching between the finger and thumb. The last day of the transparent slippery secretions is called the peak day, which coincides closely with ovulation. Following ovulation, the hormone progesterone causes the secretions to thicken forming a plug of mucus in the cervical canal, acting as a barrier to sperm. The secretions will then appear sticky and dry until the next menstrual period. • When practising this method of contraception, the cervical secretions are observed daily. The fertile time starts when secretions are first noticed following menstruation and ends on the third morning aher the peak day. If the secretions are used as a single indicator of fertility, the presence of seminal fluid can make observation difficult. Changes in secretions will be affected by seminal fluid, menstrual blood, spermicidal products, vaginal infections and some medications .
Postpartum considerations • In the first 6 months following childbirth, the majority of women who are fully breastfeeding will be able to rely on the lactational amenorrhoea method (LAM) for contraception. Women who wish to continue using natural methods of contraception should begin observing cervical secretions for the last two weeks before the LAM criteria will no longer apply (i.e. 5 months and 2 weeks postpartum), in order to establish their basic infertile pattern.
Basal body temperature • A woman can calculate her ovulation by recording her temperature immediately on waking each day. Should the woman have arisen during the night, she must take at least • 3 hours rest before recording her temperature. Aher ovulation, the hormone progesterone produced by the corpus luteum causes the temperature to rise by about 0.2 • °C. The temperature remains at this higher level until the next menstrual period. The infertile phase of the menstrual cycle will begin on the third day aher the temperature rise has been observed. points out that the temperature can be affected by infection, therefore care needs to be taken when interpreting temperature charts.
Postpartum considerations • A mother with the demands of a new baby may find difficulty in recording her temperature at the same time every day. Consequently many women prefer to rely on examining cervical secretions, or combine noting secretions with cervical changes at this time.
Cervical palpation • Changes in the cervix throughout the menstrual cycle can be detected by daily palpation of the cervix by the woman or her partner. Aher menstruation the cervix is low, easy to reach, feels firm and dry and the os is closed. As ovulation approaches, the cervix shortens, sohens, sits higher in the vagina and the os dilates slightly under the influence of oestrogen.
Postpartum considerations • Hormonal changes in pregnancy take around 12 weeks to sefle postpartum. The cervix will not revert completely to its pre-pregnant state as the os will remain slightly dilated even in the infertile time.
Calendar calculation • The calendar method is based on observation of the woman's past menstrual cycles. When commencing to use this method, the specialist practitioner and the woman should examine the previous six menstrual cycles • The shortest and longest cycles over the previous six months are used to identify the likely fertile time. The first fertile day is calculated by subtracting 21 days from the end of the shortest menstrual cycle. In a 28-day cycle, this would be day 7. The last fertile day is calculated by subtracting 11 days from the end of the longest menstrual cycle. In a 28-day cycle, this would be day 17. Cycle length is constantly reassessed and appropriate calculations made. • indicate that the calendar method is not sufficiently reliable to be recommended as a single indicator of fertility, but is useful when combined with other indicators of fertility. Ovulation usually takes place 14 days before the first day of the next menstrual period. Therefore a woman who has a 28- day cycle would ovulate on approximately day 14 of her cycle and a woman who has a 30- day cycle would ovulate on approximately day 16 of her cycle.
Postpartum considerations • Calendar calculations must be recalculated once normal menstruation has recommenced. • Symptothermal method • This is a combination of temperature charting, observing cervical secretions and calendar calculation, with the option of observing cervical palpation in order to identify the most fertile time. also includes in this method the observation of ovulation pain or ‘mittelschmerz’ and cyclic changes such as breast tenderness. Use of more than one indicator increases the accuracy in identification of the fertile time. When combining indicators, a couple should avoid sexual intercourse from the first fertile day by calculation, or the first change in the cervix until the third day of elevated temperature, provided all elevated temperatures occur after the peak day.
Fertility monitoring device • These hand-held computerized devices monitor luteinizing hormone (LH) and oestrone- 3-gluronide (a metabolite of oestradiol) through testing the urine. The most well known in the UK is the ‘Persona’ monitoring device which is about 94% effective and will detect from the urine test when a woman is fertile, indicating this through a series of lights. A green light indicates the infertile phase and a red light indicates the fertile phase, therefore barrier methods must be used should sexual intercourse be contemplated. A yellow light indicates that the database requires more information and a further urine test is required.
Postnatal considerations • The fertility monitor is not recommended as a method of contraception during lactation. The manufacturers of the Persona recommend that a woman has had two normal menstruations with cycle lengths from 23 to 35 days before using the monitor at the beginning of the third period
Lactational amenorrhoea method (LAM) • It is thought that the action of the infant suckling at the breast causes neural inputs to the hypothalamus. This results in the inhibition of gonadotrophin release from the anterior pituitary gland, leading to suppression of ovarian activity. The delay in return of postnatal fertility in lactating mothers varies greatly as it depends on paferns of breastfeeding, which are influenced by local culture and socioeconomic status. The time taken for the return of ovulation is directly related to sucking frequency and duration. The maintenance of night-feeds and the introduction of supplementary feeds also affects the return of ovulation.
The lactational amenorrhoea method (LAM) is a very effective method of contraception when used according to the Bellagio consensus statement • Research data concludes that there is over 98% protection against pregnancy during the first 6 months following birth if a woman is still amenorrhoeic and fully or almost fully breastfeeding her baby • In order to confirm that LAM remains effective as a contraceptive method, the woman should be asked if three questions still apply. • Mothers who work outside the home can still be considered to be nearly fully breastfeeding, provided they stimulate their breasts by expressing breastmilk several times a day.
The LAM is not recommended for use aher 6 months following birth, because of the increased likelihood of ovulation. Studies throughout the world have been conducted on the effectiveness of LAM as a contraceptive, confirming a rate of over 98% protection against pregnancy suggesting it is a viable option for some postnatal breastfeeding women.
Male and female sterilization • This is the choice of contraception for many couples once they have decided their family is complete. Sterilization should be viewed as permanent, although in a few cases reversal of the operation is requested. Couples requesting sterilization need thorough counselling to ensure that they have considered all eventualities, including possible changes in family circumstances. Although consent of a partner is not necessary, joint counselling of both partners is desirable. The procedure is available on the NHS for both sexes but waiting times can vary. There are no alterations to hormone production following sterilization in males or females and some couples find the freedom from fear of pregnancy very liberating.
Female sterilization • An estimated 600 million women worldwide have undergone female sterilization During the procedure (Fig. 27.12), the uterine tube is occluded using division and ligation, application of clips or rings, diathermy or laser • treatment. • FIG. 27.12 Female sterilization. • The operation is performed under local or general anaesthetic. The procedure can be performed via a laparotomy, minilaparotomy or laparoscopy. It can also be performed vaginally using a hysteroscope. The procedure usually requires a day in hospital. • Women are advised to continue to use contraception for four weeks following the procedure, or in the case of hysteroscopic sterilization (Essure) contraception should continue for 3 months, aher which successful tubal blockage is confirmed by hysterosalpingography The couple should be advised to seek medical help urgently if they suspect pregnancy following sterilization because of the increased risk of • ectopic pregnancy if the procedure is unsuccessful.
Postpartum considerations • Should sterilization occur around the time of birth, it is vital that the woman receives thorough counselling prior to the procedure to avoid any regret later on. Women are ohen advised to wait 6 weeks aher the birth before undergoing the procedure. The FRSH (2009a) suggest that if sterilization is going to be undertaken at the same time as an elective caesarean operation, then one week or more should be provided for counselling and decision-making before the procedure finally takes place. • Guillebaud and MacGregor (2013) suggest that a waiting period of 12 weeks is desirable to ensure that the couple will have no regrets over the sterilization. • The failure rate for female sterilization is 1 in 200 Reversal of the sterilization is not usually available though the NHS in the UK and can be difficult and expensive to obtain privately. Women considering sterilization should be made aware of the availability of LARC methods, which are highly effective but reversible.
Male sterilization (vasectomy) • The procedure of male sterilization involves excision or removal of part of the vas deferens, which is the tube that carries sperm from the testes to the penis). • A small cut or puncture to the skin of the scrotum is made to gain easier access to the vas deferens. The tubes are cut and the ends closed by tying them or sealing them with diathermy. The wound on the scrotum will be very small and stitches are not usually required. In the UK the operation is carried out in an outpatients department or clinic sefing. It is usually completed under local anaesthetic and takes around 10–15 minutes. Men are advised to refrain from excessive physical activity for about one week and to avoid heavy lifting following the procedure.
It may take some time for sperm to be cleared from the vas deferens; it can take approximately 12 weeks aher the operation for this to occur. Consequently, the semen must be tested to confirm that it no longer contains sperm and sometimes further tests are necessary to confirm the absence of sperm. Sexual intercourse can take place during this period but contraception must be used until a negative sperm result is confirmed. • The failure rate of male sterilization is 1 in 2000 (FPA 2010c). Careful counselling needs to take place before the procedure is carried out. Reversal of vasectomy is not usually available through the NHS and Andrews (2005) quotes around a 50% success rate in achieving a pregnancy following successful reversal within 10 years of the procedure being undertaken. • The future of contraception and sexual health services • In the UK the government remains commifed to developing confidential, non- judgemental, integrated sexual health services, including STI screening and treatment, contraception, termination of pregnancy, health promotion and prevention (HM Government 2010). A recent Department of Health (DH) publication, ‘A framework for sexual health improvement in England’ (DH 2013), sets out a clear strategy for tackling sexual health issues such as STIs and teenage pregnancy. However, current financial challenges mean that the FSRH (2012) are concerned that budget cuts and changes to commissioning processes may compromise access to and quality of contraceptive and sexual health services for the forseeable future.
In response to the Social Exclusion Unit Report many NHS Trusts now provide clinics and projects for young people, and improved access to contraceptive and sexual health services has led to a decrease in the conception rate of the under-18s. One of the specific targets of this report was to reduce the teenage pregnancy rate by 50% by 2010. The actual statistics showed a 13.3% decline in conceptions to the under-18s and 25% reduction in births in this same age group. Plans to decrease teenage conceptions further continue (DH 2010). With strict adherence to the Fraser guidelines (Guillebaud and MacGregor 2013), teenagers under the age of 16 can receive advice and treatment from a contraceptive and sexual health practitioner. • have emphasized the need to promote long acting reversible contraception (LARC). This recommendation will encourage more women to use a form of contraception that does not have to be remembered on a daily basis. • There is a trend in the UK for many women to have their children later in life and to have much smaller families. Throughout the world, couples will seek to find new ways to limit their family size as the need to reduce population growth continues
Ongoing developments • An extended regimen of combined contraceptive pills for 84 days, e.g. Seasonale, has been confirmed to be safe. Seasonale is a COC pill that has the equivalent of Microgynon • 30 but is packaged in four packets to be taken consecutively followed by a pre- determined pill-free interval It is currently licensed in many countries, including the USA, and may be available in the UK soon. Other similar products include Seasonique. Alternative delivery systems reducing the need for daily pill-taking are being explored. Subcutaneous injections (depo-subQ) and chewable tablets are being developed for progestogens. Research into biodegradable implants (which would be particularly useful in low income countries) and the use of transdermal spray for the delivery of a potent progestogen is ongoing. The Population Council is considering research into proteomics and an immunological approach to contraception. Effective methods for men are still problematic and the long-awaited male pill is still not imminent Gene blockers (reducing sperm mobility), the male patch and heat-based methods are amongst those being developed. Long acting testosterone injections with implanted progestogens or semen blocking methods may be available in the future
