Tutorial 20C: Barriers, Emergency Contraceptive, Sterilization

Question 1

What is the function of a condom?

Answer 1

• Thin rubber barrier that fits over erect penis and catches sperm when man ejaculates
• Best used with lubricant (water based)
• 2-5% chance of getting pregnant (depending on correct and consistent use)
• DO NOT USE oil-based lubricant or some anti thrush creams

Question 2

What should you not use at the same time as using a condom?

Answer 2

1. oil-based lubricant
2. anti-thrush creams

Question 3

What are the advantages to using condoms?

Answer 3

• Easy to use, easy to carry
• Use only when needed
• Helps protect against STIs
• Available from Family planning clinics and other health care providers
• Can buy from pubs, clubs, pharmacies, and many shops
• Cheaper on prescription

Question 4

What are some disadvantages to using condoms?

Answer 4

• Some people are allergic to rubber
• Must be put on when penis is erect and before sex
• Some people say it reduces sexual feeling
• Risk of:
  
  • slipping off
  • breaking

Question 5

What is the function of using a diaphragm?

Answer 5

• Dome shaped silicone barrier fits inside vagina over the cervix
• Used with spermicide jelly that kills sperm
• 6-16% Chance of getting pregnant: dependant on
  
  • whether you use spermicide
  • how carefully you follow the instructions
• Health concerns: more bladder infections for some women

Question 6

What are the advantages to using a diaphragm as contraception?

Answer 6

• Can be put in several hours before sex
• Used only when needed
• Helps protect against STIs

Question 7

What are the disadvantages of using a diaphragm as contraception?

Answer 7

• First fitting should be by an experienced nurse or doctor
• Some women find it hard to put in and take out
• Can be messy
• Spermicide may irritate vagina or penis
• Must be left in place at least 6 hours after sex
• Increase in bladder infections in some woman

Question 8

What is a possible Emergency Contraceptive Scenario for the osce?

Answer 8

• Scenario: young woman comes in because she had unprotected sexual intercourse (or condom broke) with her partner 48 hours ago. She is not using any form of contraception, not even COC.
• Take a brief menstrual history from her to determine whether she has/has not ovulated (she had regular 28 days cycle, LMP 14 days ago; therefore it is possible that she might have ovulated – making her suitable candidate for ECP)
• Explain everything about ECP to her (indications, efficiency, mechanism of actions, side effects, STIs)

Question 9

What are the indication for using the Emergency contraceptive pill (ECP)?

Answer 9

within 72 hours of unprotected intercourse to prevent pregnancy (not used as regular contraception) if it is possible that the woman could get pregnant from the intercourse.

MoA of ECP: inhibition of ovulation

Question 10

What is the efficacy of the ECP?

Answer 10

The closer to intercourse the better (doesn’t have to be used the “morning after”).

• At 24 hours it is >95%
• At 48 hours it is 85%
• At 72 hours it is 58%.

Question 11

What are the side effects associated with the ECP?

Answer 11

• Main side effect is nausea.
  
  • If the patient vomits within three hours then another dosage is indicated.
• If already pregnant, ECP doesn’t interfere with d_eveloping baby._
• STIs: contraceptive pills do not protect against STIs and should not be used as such. Condoms are advised for protection against STIs unless with a stable partner and both have been found negative for STIs

Question 12

What is the follow up regime after using an ECP?

Answer 12

Return in 3-4 weeks for:

• pregnancy test.
• Discuss her future contraception choices (encourage use of condoms for infection, COC to prevent unwanted pregnancies)
• She might ask about her options re copper IUD

Question 13

What types of emergency contraception are available?

Answer 13

1. ECP
2. Copper IUD

Question 14

What role does the Copper IUD have as an emergency contraceptive?

Answer 14

• Copper IUD can be used up to 5 days following unprotected intercourse for the prevention of pregnancy.
  
  • It prevents implantation of the embryo.
• Contraindications include PID/active infection (gonococcal, chlamydia); undiagnosed vaginal bleed, uterine anatomical abnormalities, risk of bacterial endocarditis, copper allergy (obviously).
• Complications include expulsion, PID, uterine rupture, increased menstrual bleeding, lost threads (needs USS to see if in uterus)
• Will taking the ECP affect my next period? Women should get a period within one month of ECP use. It may be a week earlier or later than it normal is. Also, some women get unexpected bleeding (intermenstrual).

Question 15

What are the contraindications to Copper IUD use?

Answer 15

• PID/active infection (gonococcal, chlamydia)
• undiagnosed vaginal bleed
• uterine anatomical abnormalities
• risk of bacterial endocarditis
• copper allergy (obviously).

Question 16

What are the risks associated with using the Copper IUD?

Answer 16

• expulsion
• PID
• uterine rupture
• increased menstrual bleeding
• lost threads (needs USS to see if in uterus)

Question 17

What are the “sterilisation” options for contraception?

Answer 17

1. Tubal Ligation: Filshie clips are placed on the fallopian tubes laproscopically.
2. Essure: Micro-inserts into the proximal part of the fallopian tubes transcervically, which expand and cause fibrosis,
   
   • confirmed on hysterosalpingogram 3 months later.
3. Hysterectomy: Also it will cause sterilization, this is an operation reserved for indications other that contraception.

Question 18

What are some feautres surrounding female sterilisation?

Answer 18

• Approximately 25% of couples rely on sterilization as a means of contraception.
• “Permanent”- Can be reversed, poor results.
• Both have failure rates of approximately 0.5%: 1/200 women falling pregnant after the procedure.
• Indications: Must be sure that there will be no regrets after procedure, usually for older women who have completed their family or when disease contraindicates pregnancy.
• Does not eliminate risk of ectopic.
• Essures have a perforation and expulsion rate of 2%, and a 14% chance of not being inserted at the 1st attempt. Irreversible, IVF required to conceive.

Question 19

What are the side effects/risks of female sterilisation?

Answer 19

1. Permanent - can be reversed but with poor results
   
   1. Essure is completely irreversible. IVF required to concieve.
   2. woman must have no regrets prior to the procedure
2. Failure rates of 0.5%.
   
   1. 1/200 woman fall pregnant following the procedure
3. Increased risk of Ectopic Pregnancy if they do fall pregnant
4. 2% risk of: perforation and expulsion
5. 14% change of essures not being inserted at first attempt

Question 20

What are some important factors associated with using Essures as a form on sterilisation?

Answer 20

1. 2% perforation and expulsion rate
2. 14% change of not being inserted properly in the first attempt
3. Irreversible - require IVF to concieve

Question 21

What are the sterilisition options available to males?

Answer 21

1. Vasectomy: Ligation and removal of small portion of the vas deferens.
   
   1. Can be performed in clinic under local anesthesia.
   2. Sterility not confirmed until azoospermia confirmed by 2 samples, may take up to 6months.
2. Male Depot: Similar effects as women, reducing gonadotrophin drive to the testes.
   
   1. Usually requires exogenous testosterone to prevent side effects.

Question 22

What is natural contraception?

Answer 22

Using the menstrual cycle combined with sperm survival times, Temperature rises in ovulation, or looking for changes in cervical mucous to indicate ovulation.

Includes:

1. menstrual cycle timing
2. sperm survival times
3. temperature rise during ovulation
4. changes in cervical mucous which indicates ovulation