Pregnancy rate per hundred woman year (hwy) (of hundred women that use it in a year's time, how many will get pregnant)

= Total accidental pregnancies x 1200

Total months exposure

• WD before ejaculation
• Requires strong motivation (esp. from man)
• High failure rate
• Used: people not allowed to use contraception (eg. Catholics)

• Avoid intercourse between day 10 and day 18 of cycle
• Not applicable to women who do not know when they ovulate: eg. Cycles <20 days or irregular cycles
• BBT may help (basal body temperature)
• Failure rate 24/hwy: difficulty in predicting when ovulation occurs in next cycle
• Limited time for intercourse
• Can look at nature of cervical mucus - difficult

1. Menses
2. Dry days (if any - infertile)
3. Wet mucous days - ovulation - thick mucous or dry days (fertile phase)
4. Dry days (infertile phase)
5. Menses (again)

• Barrier method
• Especially useful when coitus occurs infrequently and at irregular intervals
• Some protection against venereal disease (not for female vulva, only vaginal wall)
• Coincident use of spermicides advisable (increases efficacy) - most condoms contain spermicide
• Higher failure rate than 'Pill' due to user failure
• Note: failure due to (1) Method failure: eg. Sterilisation (2) User failure: eg. Condom, 'Pill'

• Not 100% occlusive
• Decreased popularity these days
• Used with spermicides
• Strong motivation from woman
• Reasonable intelligence
• Eg. Caps, diaphragms, sponge (different sizes; measured by Dr)
• Cap: more difficulty; have to ID cervix first
• Cap + diaphragm: must remain in vagina for 6hr after intercourse
• Sponge: must remain in vagina for 10 hours, has rubber-band for removal
• Insertion: squeeze to increase longitudinal diameter, insert, expands in vagina, one end of diaphragm against posterior fornix, other side against pubic symphysis

• Two types:

1. Inert e.g. Lippes
2. Bioactive e.g. copper T or 7 or levonorgestrel IUCD; need renewal every 3-5 years

• S/E: menorrhagia, pain
• Inert: only for women sensitive to copper

1. Simple (must see Dr)
2. Little motivation (must have check-ups to check IUCD thread present)
3. Non-coitus-related (cf. condom, diaphragm)
4. Local effect (even levonorgestrel IUCD)
5. 90% conceive within 1 year of removal

1. Inhibition of sperm migration in the upper female genital tract
2. Inhibition of ovum transport in Fallopian tube
3. Inhibition of fertilisation
4. Inhibition of implantation (can be used as post-coital method; causes foreign-body reaction in endometrium)

• Cu T 380 A (number refers to dosage of Cu)
• Cu T 220 C
• Multiload 250 & 375
• Nova T
• Preferred over inert devices
• Different types

1. Lippes loop
2. Copper 7
3. China ring: inert
4. Multiload
5. Copper T: most common (aka Gynae-T)

1. Smaller and easier to insert
2. Less side effects
3. Lower pregnancy rate: <1/HWY (b/c impregnated with higher copper level)

• Contains levonorgestrel which is slowly released from vessel in neck of IUCD
• Highly effective (very high local concentration, no systemic effects)
• Makes endometrium atrophic (similar to progesterone contraceptive pill)
• Reduces menstrual blood loss (can treat menorrhagia) but there is a higher incidence of intermenstrual bleeding/ spotting

1. Expulsion: once expelled, no contraceptive effect
2. Bleeding
3. Pain: during period, foreign body present
4. Perforation: usually during insertion (inserted too far); can migrate through myometrium into pelvic or peritoneal cavity
5. Pelvic infection: as with any foreign body (low risk); usually occurs at insertion or change of IUCD
6. Pregnancy

• Most common complication requiring removal; may present with:

1. Increased menstrual flow
2. Longer periods
3. Intermenstrual bleeding

• Management of bleeding problems

1. Use smaller IUCD or LNG IUCD
2. May improve after several cycles
3. NSAID: part of Tx for menorrhagia
4. Anti-fibrinolytic agents
5. Oral iron: if anaemic
6. Remove IUCD

• Woman with IUCD have higher chance of ectopic pregnancy (because IUCD so effective at preventing implantation) but IUCD does not CAUSE ectopic pregnancy
• Increased risk of

1. Spontaneous abortion
2. Septic second-trimester abortion
3. Premature delivery

• Remove IUCD if thread accessible (irrespective of whether woman wants to remain pregnant of not)
• Exclude ectopic pregnancy (US)

1. 1. Does not increase overall risk of ectopic pregnancy
2. Protects against IU pregnancy better than ectopic
3. Increased ectopic to intrauterine pregnancy ratio

• No significant increase in low risk women
• IUCD-related PID rare beyond 20 days after insertion

1. Women with multiple sexual partners
2. Active or recent PID
3. Known or suspected pregnancy
4. Undiagnosed abnormal vaginal bleeding
5. Suspected/confirmed genital tract malignancy
6. Congenital uterine abnormality or fibroids that prevent proper placement: eg. Bicornuate uterus, septum (increased chance of expulsion), uterus didelphys - double-uterine cavity (IUCD in one uterine not effective)

• Combination of oestrogen and progestogen taken daily for 21 days followed by an interval of 7 days
• Oestrogen - Ethinyl oestradiol 20 to 30 ug per tablet
• Progestogens: levonorgestrel; gestodene; desogestrel
• Failure rate < 0.1/HWY

• Suppression of ovulation by inhibiting gonadotrophin secretion from the pituitary
• Thickening of cervical mucus
• Reduction of endometrial receptivity

• Nausea & vomiting (caused by oestrogen)
• Dizziness & headache
• Breast tenderness
• Fluid retention and weight gain
• Intermenstrual spotting/bleeding (may disappear after a few cycles) - esp. if forget to take a few pills, other drugs to affect absorption, vomiting/ diarrhoea

• Increased risk of thromboembolism, cardiovascular diseases (CVA and myocardial infarction) - must take Fam Hx (increased risk in Caucasians)
• Slightly increased risk of breast cancer and liver tumours (controversial - cervical cancer)
• Breast cancer: 1:10,000 to 1100,000 ('Pill' mostly used by age-group that are at decreased risk for breast cancer - therefore negligible increase in risk)
• Jaundice and liver dysfunction

• Pregnancy
• Smoking in women over 35 (if no Hx of diseases, smoking etc - can continue low-dose 'Pill' until menopause)
• Past or present evidence of thromboembolic disorders
• Complicated valvular heart disease
• Focal migraine
• Liver tumours
• Acute liver disease or cirrhosis
• DM with vascular complications including hypertension
• Moderate or severe hypertension with BP > 160/100 mm Hg
• Hypertension with vascular disease

• Mild hypertension 140-159/90-99 mm Hg
• History of hypertension when BP cannot be evaluated
• Chronic liver disease other than severe cirrhosis
• Symptomatic biliary tract disease
• Known hyperlipidaemia

• Highly effective form of contraception and protects against ectopic pregnancy
• Reduction in risk of ovarian cancer
• Reduction in risk of endometrial cancer (progesterone protects endometrium)
• Menstrual benefits : Reduction in
• amount of blood loss

1. Mid-cycle pain (suppresses ovulation - cause of mid-cycle pain)
2. Menstrual irregularity
3. Pre-menstrual tension and dysmenorrhoea

• Reduction in PID
• Protects against benign breast tumour
• Protection against ovarian cyst uterine fibroids and osteoporosis

• Renders endometrium unsuitable for implantation and cervical mucus impenetrable to sperm
• Irregular menses
• Avoid side effects of oestrogen
• Suitable for breast feeding (oestrogen causes decreased lactation)
• E.G. Microlut - 0.03 mg Levonogrestrel ("Mini-Pill")
• Even if late for 3hr, has decreased efficacy

• Medroxyprogesterone acetate
• Norethisterone oenanthate

• Inhibition of ovulation
• Cervical mucus
• Endometrium

Disadvantages

• High incidence of amenorrhoea or menstrual irregularity
• Weight gain (androgen effect of progesterone)
• Slow return of fertility after discontinuation (slower return with increased duration of use)

• Convenient - one injection/3 months
• Less metabolic side effects than combined pills

• Capsules containing levonogrestrel implanted under skin (inner side of upper arm)
• Implant lasts for 5yr
• Low failure rate (<1/100WY)
• Most common side effect: excessive bleeding and intermenstrual bleeding
• Rapid return of fertility on removal (lower hormonal dose released each day cf. depot method)
• Minimal metabolic effects

1. Intercourse unexpected
2. Rape
3. Failure of barrier methods

• Not recommended by regular use

1. High failure rate
2. S/E

• 2 tablets of oral contraceptive pills
• (100 ug EE 1 mg norgestrel)
• within 72 hours of coitus
• Another 2 tablets 12 hours later
• Pregnancy rates 0.2% - 2.6%

1. Method limitation
2. Other intercourse earlier than 72hr ago
3. High dosage causes vomiting -> vomit pill out, lost contraceptive efficacy

1. Highly effective pregnancy rate < 0.1%
2. Can be used 5 days after intercourse
3. Continued contraception

• Bleeding; pain; infection

• 2 doctors have to certify that there is a genuine indication
• Department of Health has to be notified
• The abortion can only in performed in gazetted hospitals/facilities (cannot be done in clinic)

1. Surgical methods: Suction evacuation
2. Medical method (<9 wks): Mifepristone + PG

• Incomplete abortion: 0.05% - 3.6% (<1% in most series)
• Uterine perforation: 0.01% - 0.6%
• Excessive bleeding: 0.01% - 11.2%
• Pelvic infection: 0.06% - 2.9%
• Cervical injury: 0.004% - 8%

• Usually PG analogues (misoprostol vaginally) are used
• Complications:

1. Drug-related: vomiting, diarrhoea, fever
2. Haemorrhage
3. Infection
4. Uterine rupture and cervical tears

• Opportunity for discussion
• Other alternatives
• Risk of abortion
• Procedure
• Future contraception
• Psychological
• Contraception and sterilisation are much safer than abortion.

• Tubal operation - by laparoscopy, minilaparotomy or laparotomy
• Hysterectomy: only if other indications

• Interval: low regret rate (eg. Large family already)
• Postpartum (24-36 hours): before uterus involution
• Post-abortal: high regret rate
• C-section: if already had 2-3 C-sections and have completed family
• Other gynaecological operation: eg. Cystectomy

• Cut ends and stitch together, stitches dissolve -change of recanalisation
• Apply clip: less damage to tubes

• Complications due to laparoscopy or laparotomy - visceral damage; bleeding; wound complications including pain and infection
• Failure (about 1 in 200 lifetime risk)
• Ectopic pregnancy
• Mortality rate: 1 in 10,000 (due to operation itself)

• Vasectomy: less invasive, clinic-setting, local anaesthetic

• Simple operation
• Requires less skill
• Quick
• Local anaesthesia
• Less complication
• Easier to reverse
• Mortality <1 in 100,000

• Not immediately effective; 2 negative semen tests at 8 and 12 weeks
• Spontaneous recanalisation; More common

• Alternative methods of contraception
• Surgical procedure
• Risks
• Sterility not guaranteed
• Irreversible and permanent - age of woman, stability of marriage, number and health of children
• Choice of male or female sterilisation