"Family planning could bring more benefits to more people at less cost than any other single technology now available to the human race."
Barrier contraceptives are family planning methods which act as barriers and prevent the union of sperm and ovum which is necessary for pregnancy.
From ancient times, people have been using all sorts of barrier methods.
Women used vaginal pessaries made of crocodile & elephant dung, pomegranate seeds, bee wax and numerous other plant & animal materials. Later they used half a lemon to cover up the cervical os.
Similarly men used to wear condoms made of intestines of animals.
The original methods have been replaced by new types, which are of five types.
A. Male condoms
B. Occlusive caps
C. Vaginal sponge
E. Female condoms
A. Male condoms:
These are the oldest and most widely used birth control devices in the world.
Also known as French letters, prophylactics, protectives or rubber sheaths, or by brand names like Nirod, Durex etc.
Male condom is a thin sheath usually made up of rubber (latex) that is placed on erect penis before intercourse.
Mechanism of action:
Condoms serve as a physical barrier, preventing sperms from entering the female genital tract.
They also serve as barriers for infectious microorganisms, preventing transmission of STDs(sexually transmitted diseases) and HIV from one sexual partner to another.
Condoms can be used by:
Men and women at risk of STDs / HIV.
Men and women of any reproductive age and parity who want to use condoms as a regular method of contraception.
Men and women needing a temporary method while waiting for a regular method.
Men and women who have sexual intercourse infrequently.
They are safe
Readily available in most places, need no prescription and no medical help for use.
Prevent both pregnancy and STDs like syphilis, gonorrhea, tricomoniasis, moniliasis, chlamydia, herpes etc and HIV when used consistently and correctly.
In later months of pregnancy they give protection against amniotic fluid infections.
Easy to initiate and discontinue.
Immediate return to fertility after stopping the usage.
They have virtually no side effects except rare allergy to latex.
When used for more than 5 yrs , decrease the chance of developing severe cervical dysplasia and cervical cancer according to Oxford/ FPA study in Briton.
Prelubricated condoms are sealed capsules containing glycerin are glycol. Silicon used to produce semi-dry lubricated condoms.
Spermicidal condoms are coated with nonoxynol-9 on inner and outer surfaces.
Poly urethane condoms also available in UK, USA and other countries.
Small sized condoms meant to cover only the glans of the penis called, American or Grecian cap are much less safe and not used now-a-days.
Typical average failure rate of condom as commonly used is 12%. But only 3% when used correctly and consistently.
If spermicidal condoms are used the failure rate is 3.6 / 100 women years among married couples who were using condoms for a longtime, average 16 yrs.
Only one medical condition prevents use of condoms , that is severe allergy to latex rubber which is very rare.
The average life span of condoms is 5 yrs, from the date of manufacture. They should be kept in cool & dry place. Sunrays , heat & moisture affect the condition of condoms.
They are used as means to retain spermicides in contact with cervical os. Spermicides must be used along with devices.
Women need to be instructed to use of the device by a doctor.
Usually manufactured from latex rubber and have got a storage and usage life.
They are of four types:
2.Cervical cap or check pessary
These are the most common form of occlusive caps. Easiest to fit & use.
The diaphragm is a soft latex rubber cup that should be used with spermicidal jelly or cream.
Available in sizes from 45 mm diameter to 105 mm. Most commonly used are 60, 65, 70, 75, 80 mm sizes, height varies from maker to maker.
The length from posterior vaginal fornix to symphysis pubis in cms minus one cm is the size of diaphragm generally suitable.
The women inserts a diaphragm into her vagina, fitting it over the cervix, shortly before the sexual intercourse and leaves it in place for at least 6 to 8 hrs after intercourse.
If sexual act vaginally is delayed more than two hours or intercourse is repeated after a few hours , an applicator full of spermicidal by cream or jelly should be introduced earlier as it takes time to dissolve.
Mechanism of action:
Diaphragm blocks sperm from entering the uterine cavity.
Spermicides provide additional protection by damaging the sperms.
Can be used by women of any reproductive age group and parity who want to use this method of contraception.
It can't be used within 6 wks after delivery because of chances of infection and as there will be laxity of tissues it will not stay in place.
Also in those people who are having allergy to latex it can't be used.
In women with history of toxic shock syndrome, better to avoid using diaphragm because if it retained in vagina precipitation of syndrome can occur.
And in certain anatomical abnormalities of cervix and vagina, where diaphragm cannot be retained in position it can't be used.
Diaphragm is a woman controlled method and possible to use without male partner's co-operation.
Offers contraception only when needed. So useful for irregular and unplanned sexual intercourse.
Effective if used correctly with every act of sexual intercourse.
It is having no systemic side effects. And has no impact on lactation.
Can be stopped at any time and can be inserted before sex to avoid interrupting of sex.
Provides some protection from STDs. And also reduces the risk of neoplasia. Contains menstrual flow when used during menses.
Initially the diaphragm requires fitting by a family planning provider, involving a pelvic examination.
A woman may need a different size diaphragm after the child birth.
Requires having the method on hand and taking correct action before each act of sexual intercourse.
Less effective contraceptive method than IUDs(intra uterine contraceptive devices) or systemic methods.
Interrupts sex if not inserted before hand. And may be messy to use.
The possible side effects usually are local irritation or allergic reaction to latex.
It should be washed with soap and clean water after every use. And needs careful storage to avoid developing of holes.
Requires a steady supply of spermicide, without it the diaphragm is not very much useful.
AIDS and other sexually transmitted diseases are not effectively prevented by this method.
Repeated usage and pressure on urethra while using increases the risk of urinary tract infections.
The failure rates of the diaphragm are 18 to 28% as commonly used and 6% when used consistently and properly with spermicide.
Diaphragms should be replaced anytime between 6 months to 2 yrs depending on its use.
The cervical cap is a thimble or dome shaped rubber appliance designed to cover the cervix, they remain in place by suction.
Conventional caps can be worn up to 48 hrs. They are usually made of latex, must be fitted by a provider at first time and can be difficult to insert or remove.
Cervical caps are available in four sizes between 22mm to 31mm.
Two new cervical caps are under development.
The first one is called fem cap, made of silicone, worn up to 48 hrs. Shaped like a hat with an upturned brim that lies against the vaginal walls around the cervix.
It is easier to insert than conventional caps. And there will be no pressure on urethra, unlike conventional diaphragms.
A strap is added to facilitate removal. And uses less spermicidal jelly, so less irritation.
But it is less effective than conventional cap with failure rate of 23 %, whereas conventional cap failure rate is 18 %.
Second new cervical cap is oves cap, made of silicone, can be left in place for three consecutive days.
Equipped with removal loop and it is disposable after one use.
It is a hemispherical, dome shaped rubber or plastic cap. Which fits into vaginal vault covering the cervix.
Rim will be thick but have no metal spring.
The sizes ranges from 50 to 75 mm in 5 mm steps .
Correct size for a particular woman is smallest one which fits evenly into the vaginal vault. Eg: Dumas cap, Plastic dumas cap.
It is a cervical cap made up of rubber , with fairly rigid flanged base to increase the degree of suction, when cap is put in place.
String will be attached for easy removal.
It is useful in case of cystocele & mild prolapse cases when diaphragm can't be retained. This is a good advantage of vinule cap.
Vinule cap sizes from 45 to 55 mm in 3 mm steps. Vinule pessary is the trade name.
C. Vaginal sponges:
Currently two contraceptive sponges called protectaid and pharmatex are available primarily in Canada and Europe.
A third, today sponge, was introduced to the U.S. market in 1983, was removed in 1995, but in expected to return.
Fourth one called Avert, is on clinical trials for contraceptive efficacy.
All four types are manufactured in one size, allowing women to buy them over the counter without the help of a provider.
Common qualities are blocking the cervix, trapping sperm and releasing the spermicides.
Effective for many hours, same as long as 24 hrs, regardless of number of sexual intercourse during this period.
Being able to insert them hours in advance but should be left in place at least six hours after last intercourse.
But should not leave them in place beyond the maximum recommended time.
The 'pharmatex sponge', marketed in Europe contains 60 mg of spermicide benzalkanium chloride(BZK).
The 'today sponge', contains 1000mg of spermicide nonoxynol-9(N-9).
Though spermicides kill pathogens, they can irritate vaginal lining developing vaginal abrasions that could facilitate HIV transmission.
The 'protectaid sponge', marketed in Canada, contains three spermicides N-9, BZK & sodium cholate in relatively small concentrations. .
The 'Avert sponge' is expected to have 100mg of N-9.
The protectaid and Avert sponges have the advantages of being wet. Water is not needed before they are used.
Some studies are showing that using N-9 containing today sponge are less likely to have contracting chlamydial infection and gonorrhea.
But women using N-9 sponge developed genital ulcers important risk factor for HIV infection.
Failure rate of N-9 impregnated Today sponge is 17 %. 14% for nulliparous and 27% for parous women.
For protectaid sponge it is 23 %for typical use.
Spermicides are chemical barriers that consists of two components: a spermicidal chemical, most commonly nonoxynol-9 and a delivery base.
Spermicides can be delivered through foam, cream, jelly, film, suppositories or tablets.
They can be used either alone or with another contraceptive method.
Mechanism of action:
They will inactivate or kill sperm, making fertilization unlikely and also act as mechanical barriers.
Should be introduced ½ hour before the sexual act, including 10 minutes time to allow the tablet to melt. No douching is permitted with in 8 hrs.
Can be used by:
Women who cannot or do not want to use hormonal methods.
Couples who have sexual intercourse infrequently.
Women wanting a method that they control.
Breast feeding women who need contraception.
Should not be used by:
Women having cervical cancer (awaiting treatment)
High risk of HIV.
Spermicides are effective at preventing pregnancy when used consistently and correctly.
They are safe, with no systemic side effects.
Easy to initiate and discontinue with immediate return to fertility.
Do not require clinical visit while starting or partner co-operation while using.
Spermicides are not effective as other methods in typical use.
Side effects like local irritation can occur, especially if used several times a day.
May interrupt sexual activity. Usage can be messy.
Can make yeast infection or urinary tract infections more common because of repeated use and local aberrations.
Formally thought to reduce the risk of STDs but research found no protection against them.
The failure rate of spermicides when commonly used is 21%. 6% when used correctly and consistently.
E. Female condoms:
The female condom is a thin, soft, loose fitting polyurethane plastic pouch that lines the vagina.
It has two flexible rings, one inner ring at the closed end used to insert the device inside the vagina and to hold it in place and outer ring which remains outside the vagina and covers the external genitalia.
Because the device is made from polyurethane, the female condom can be used with any type of lubricant without compromising the integrity of the device.
Women tended to accept the device more favorably than did men.
But overall difficulties of insertion decreased as experience with device increased , and use became more comfortable and acceptable in practice.
Female controlled, more comfortable to women , less decrease in sensation than with the male latex condom.
Female condom offers greater protection as it covers both internal and external genitalia.
More convenient than male latex condom that it can be inserted pre-coitus.
Stronger than the male latex condom , as polyurethane is 40% stronger than latex.
Female condom is not aesthetically pleasing.
The coverage of external genitalia had a decidedly negative impact on the device's aesthetics and acceptance.
Some people dislike of the appearance of the device, noise associated with use and size of the device.
Partner resistance may be seen in some cases.
Difficulties in insertion and removal can occur.
There are few cases of slipping of the penis between the device and woman's body or slippage and breakage of device itself.
It is relatively expensive than other methods.
Effectiveness: Typical failure rate is 21% as commonly used. But only 5% when used correctly and consistently.
Male condoms , made up of polyurethane (plastic) , new designs as looking fitting with a possible longer shelf life and improved sensation and compatibility with oil based lubricants.
New types of diaphragm made up of silicon are also coming into market.
The diaphragm used without spermicide and worn continuously removed only for washing is under study.
'Lea's shield', a new cup shaped barrier that covers cervix with valve that allows the draining of cervical secretions and menstrual flow , has a 'u' shaped loop for easy removal. Made of silicon rubber it can be worn up to 48 hrs.
The gynaeseal diaphragm tampon, available in Australia, has as inner chamber and an outer pouch. The inner chamber has a one-way valve that allows menstrual fluids to pass through and cervical secretions are collected in outer pouch.
IUCDS (Intra uterine contraceptive devices):
Intrauterine device is a small, flexible plastic frame which is effective, safe, convenient method of temporary sterilization.
It is inserted into the uterus through the vagina.
IUDs also called IUCDs in general are called the loops (after Lippes loop which is no longer used)
Their usage started in ancient times where Arabs and Turks used to insert pebbles into the uteri of camels in caravan.
In 11th century Islamic scientists first reported intra uterine pessaries for humans.
Richard Richter (1909), German physician introduced first ring shaped IUD made of silk worm gut. Ota in 1934 in Japan, made a ring with small disc in the centre with 3 spokes.
Jack Lippe, from Buffalo, NewYork in 1962, designed the first ever plastic IUD, which was used widely further added barium sulphate to make it radio-opaque so that it can be detected in X-rays.
The criteria of choice:
Every Couple needs to consider what issues are important to them in making a wise contraceptive choice.
6 steps in counseling are,
Greet the person,
Ask them about themselves,
Tell them about choices,
Help them to make an informed choice,
Explain fully how to use the chosen method,
Return visits should be welcomed.
Categories of IUD's(intra-uterine contraceptive devices):
A. Inert intra-uterine contraceptive devices: Lippes loop, Saft coil, Chinese single coil ring, Mahua ring, Ota ring etc.
B. Copper releasing intra-uterine contraceptive devices: Cu 7, Cu T200, Multiload copper 250, MLCu 375, Cu T 380A, Cu T380S, Nova T and Cu T220C.
C.Harmone releasing intra-uterine contraceptive devices: Progesterone IUD (Progestasert) and Levonorgestrel IUD (Mirena, LNG 20)
D.Newer intra-uterine contraceptive devices.
A.Inert intra-uterine contraceptive devices:
It is a double 'S' shaped polyethylene loop impregnated with barium sulfate (for radiopacity) and the tail is made of fine nylon.
Lippes loop was available in four sizes – A,B,C,D
Push out method was used for the insertion of the lippes loop .
In 1967, Lernes and Davis designed dalkon shield with larger area of contact with the endometrium but later withdrawn due to its severe infection rate.
B.Copper releasing intra-uterine contraceptive devices;
By 1970's bioactive devices or first generation devices were developed. With plastic frames which were carriers of either metals, hormones or anti bleeding agents.
Jaime Zipper and Howard Tatum, in 1969 deviced first Cu T & Cu 7 with 200 sq mm of copper.
To improve the life span and effectiveness, second generation Cu releasing IUDs were invented in 1974.
The higher doses of copper with silver or copper sleeves, reduce the chance of fragmentation of copper.
Cu Safe 300:
CuSafe 300 is a T-shaped copper containing IUD with flexible, uniquely shaped arms, transverse arms curve inward to reduce uterine tissue irritation.
Flexible design facilitate easier and less painful insertion and removal, but the curved, "fundal-seeking" arms also resist expulsion.
Life span of CuSafe 300 is 5 yrs.
Fincoid-350 is devised in Finland, it is designed to resist accidental expulsion.
It is having two parts: curved horizontal arms, and a copper coated vertical stem. The horizontal arms lock into a groove on the vertical stem. The resultant movable joint easily constricts and expands with uterine contractions, adjusting to variations in uterine size and shape.
The Sof-T, which is manufactured in Switzerland, has soft, flexible knobs, occlusion bodies, on each end of its flexible transverse arms. These knobs theoretically block the entrances into the fallopian tubes.
Failure rate is 0 to 1.3/ 100 women years.
Multiload Mark II
It is the updated version of original multiload 375, developed in Netherlands, having 375 mm2 copper as the original ML-375. But shorter, more flexible with less expulsion rate than original multiload 375.
Having three improvements than original multiload 375 : prevents IUD being pushed beyond the inserter, functions as a uterine sound and one handed expulsion action. These innovations decrease the uterine perforation.
Life span of multiload mark II is 5 yrs.
Gyne Fix (Cu fix 390):
It is frameless IUD with Six 5mm copper sleeves and proximal end with a knot, which is pierced 1cm into the fundal myometrium of the uterus.
ICFD (Intra cervical fixing device):
It is 4cm copper coated polyethylene frame with 5mm projection at the distal end anchored to the inner cervical wall with modified tenaculum.
It can be removed by sponge forceps but some difficulty in disengaging may occur.
C.Harmone releasing intra-uterine contraceptive devices:
In 1973, hormonal IUDs with effective life span and lower failure rate (eg. Progestasert and LN 20) were invented.
Progestasert contains 38mg of progesterone dispensed in silicone oil. And delivers 65 micrograms/day.
Reduces the menstrual flow. Needs to be replaced every year, increases the risk of ectopic pregnancy.
Levonorgestrel IUD 20 (LNG20, MIRENA, LEVONOVA):
Levonorgestrel IUD 20 is a longer acting harmone releasing device.Vertical arm has steroid capsule with 40-60mg of levonorgestrel , releasing 20 micrograms/day.
Mirena has 52mg of LNG, with this stable plasma level of 150-200pg/mg can be attained
Failure rate is – 0.09/100 women years.
Eligibility criteria (by WHO) to use IUCD'S:
Category 1: No restriction on use
Category 2: Advantages overweigh risks
Category 3: Risks overweigh advantages
Category 4: Do not use.
Women coming into this category are not having any restriction in usage of IUCD's .
These are women with age >20 yrs, parous ladies, obese ladies, with history of headaches, with cardiovascular complications, with chronic diseases – thyroid, epilepsy, DM(diabetes mellitus), jaundice, hepatitis, malaria, non pelvic TB, cirrhosis etc.
Women with Gynaecological/Obstetrical conditions like – breast feeding women, women delivered 4wks back, with benign breast disease, CIN(Cervical intraepithelial neoplasia), cervical ectropion, prior pelvic surgery e all can use.
Women coming into this category can use IUCD's as advantages overweigh risks.
These are women with age < 20 yrs, with Gynaecological/Obstetrical conditions like nulliparity, menorrhagia/dysmenorrhea, endometriosis, past PID(pelvic inflammatory disease), fibroids, post partum < 48 hrs, post abortal.
Also women chronic diseases like : thalassemias, iron deficiency anemia, sickle cell disease.
Women with STD/HIV : (advice condom use) vaginitis without cervical pus/discharge.
Women coming into this category should use IUCD's with caution as risks overweigh advantages.
Women in post partum period between 48 hrs to 4 wks, with benign gestational trophoblastic diseases, HIV positive or AIDS pts or women with increased risk of HIV / AIDS.
Women coming into this category should not use IUCD's.
These are women with pregnancy, puerperal and post abortal sepsis, active PID, malignant GTD's(gestational trophoblastic diseases), unexplained vaginal bleeding, cervical, ovarian and endometrial cancer
And also women with chronic diseases like : known pelvic TB, current STD or within 3 months.
Division of IUCD's according to pregnancy rates(failure of contraception) (WHO-1987:
Group I : pregnancy rate > 2/100 women years, Eg. lippes loop, Cu 7, Cu T 200.
Group II : pregnancy rate <2 & >1/100 women years, Eg. Nova T, ML Cu 250, CuT220.
Group III : pregnancy rate <1/100 women years, Eg. Cu T380A, Cu T380S, ML Cu 375, LNG 20.
Mechanism of action of IUCD'S:
IUCD'S act by inducing biochemical and histological changes in the endometrium there by preventing implantation.
They also prevent implantation through enzymatic reaction, by increasing tubal motility and by impairing sperm motility.
Hormonal IUDs : they act by forming thick cervical mucus, there by preventing entry of sperms. By creating anovulation and by leading to insufficient luteal phase.
Preinsertion clinical management
Personnale: have to select the person according the categories they belong to as listed above.
The best time for IUCD insertion will be, because it's dangerous to insert an IUD into a pregnant woman, the procedure can be scheduled during the monthly period. This eliminates the possibility of pregnancy and also cervix is slightly dilated during your period, so insertion will be easier.
In non pregnant women IUCD may be inserted at any time during the menstrual cycle, provided the woman is using another effective birth control method consistently, or have had a negative pregnancy test.
IUCD can be inserted at any time during the menstrual cycle, if the woman haven't had sex since her last period.
IUCD can be inserted within six days of unprotected sex, as a post ¬intercourse (emergency) contraceptive.
If the woman is just been pregnant, she can have an IUCD inserted.
Woman can use IUCD immediately after or within 3 weeks of an uncomplicated first trimester miscarriage or immediately (within 10 minutes) following childbirth—by either vaginal or cesarean delivery .
IUCD can be used six weeks after giving birth if the woman is breastfeeding.
IUCD can also be used six weeks postpartum, if the woman haven't had a period return, is not breast feeding, and has had a negative pregnancy test.
Counseling the woman before insertion of IUCD:
Before insertion of IUCD the woman should empty the bladder, perineum should be draped.
Per speculum examination done by the medical person to note any infection or local lesions or menstrual flow.
Pap smear taken to rule out any premalignant conditions.
Per vaginal examination done to know the position of cervix, position and size of uterus, to know the mobility of uterus and to make out any adnexal masses.
Then the anterior lip of the cervix held with vulsellum and the uterus is sounded to know the length and version.
Procedure for loading the IUCD eg. Cu-t:
IUCD should be loaded not more than five minutes before insertion.
Have to bend the arms of the Cu-t between thumb & index finger and push the insertion tube to pick up the folded arms. Check the position of the plastic adjustable collar accordingly.
Then we have to gently introduce the inserter until the adjustable collar snugly fits the external os.
Then hold the plunger firmly with left hand and outer inserter tube is retracted over the plunger with right hand for about 2 cms , withdraw the plunger and inserter tube. Then cut the threads.
Instructions after the procedure
Patient should be informed that she can have cramping pain, vaginal discharge, heavier menstrual periods and bleeding between the periods. But all this will settle down normally.
Checking the IUD should be done, once a week in the 1st month then after each menstrual period. She should not pull the strings.
When to visit a doctor after insertion of IUCD:
When the patient is having missed menstrual period.
When she got exposed to STDs.
When the strings are missing or the strings seeming shorter or longer than before.
Increased pain and bleeding bothering the patient.
When she wants removal of the device at any time.
When she wants go for other method of family planning.
Complications of IUCD'S:
Increased bleeding is seen in – 50% of cases.
Pain: is the one of the most common cause of IUCD removal.
Expulsion is seen in – 2-8% of cases in the first year.
Vaginal discharge: sometimes foul smelling troublesome vaginal discharge can occur.
Acute and chronic salpingo-oophoritis noted in – 1% of cases.
Perforation seen in – 1.2/1000 insertions.
Infections like – actinomycosis, endometritis etc can occur.
Pregnancy rate is – 2% in 1st year, but later it can increase.
Ectopic pregnancy(ovarian ) seen in – 0.25-1.5/1000 women years.
When to remove the IUCD:
After expiry of the effective life span of the device we have to remove it.
If pelvic pain and cramping or abnormal or excessive bleeding troubling the patient the device should be removed.
In patient having acute pelvic inflammation the device should be removed.
In case of Displacement of the IUD, it should be removed.
When the woman is pregnant the device should be removed.
In case of uterine or cervical malignancy the device should be removed.
When the woman attains menopause – after one year the device should be removed.
In case of non-physical reasons – like patient is having desire of pregnancy, husband's death, or at request the device can be removed.
Technique of removal of IUCD, eg.Cu T: Threads are held by artery forceps and steady traction applied to bring it out.
Missed IUCD eg.Cu T:
To diagnose the missed IUCD, pregnancy should be excluded first . Then sounding of the uterine cavity should be done to feel the missed device in the cavity.
Straight X-ray with radio-opaque sound can detect missed device and its position.
Hysteroscopy can be done for direct visualization.
If tail is not seen, cervix is cleaned, cavity probed with sound, cervix steadied with vulsellum, dilated and vaccum curette applied.
If it fails, general anaesthesia given and IUD is curetted, with long Spencer Wells forceps.
If probing can not detect the device there are two possibilities
1. IUCD is expelled.
2. Has perforated the uterus.
IUCD can be removed by culdoscopy , colpotomy, laproscopy or laprotomy depending on the position. Hysteroscopic guided removal is the best procedure.
Advantages of IUCD'S:
Only one time motivation is enough for a long time protection.
There will be no problem of disposal privacy.
As there is no interference with sexual act, so acceptable to many people.
There are no much of systemic side effects.
Return of fertility is immediate, so better choice as a temporary contraceptive method.
No effect on breast milk, so can be used by the lactating mothers.
No drug interactions and also some devices helps in preventing ectopics .
Disadvantages of IUCD'S:
High initial cost compared with other cheap alternatives.
Trained personnel needed for the insertion of the device.
Insertion is sometimes painful and some patients may bleed.
Expulsion may occur unknowingly if the patient is not cautious about the device, leading to failure.
IUCD'S offer no protection against STD/HIV.