Contraception

Contraception Fertility control which ideally should be reliable, inexpensive, safe and easy to use

Characteristics of ideal contraceptive • • • • • • •

Highly effective No side effects Independent of coitus Rapidly reversible Cheap Widely available Acceptable to culture and religions

• Easily distributed • Administration by health-care personnel is not required

The failure rate of contraceptives are traditionally expressed as the number of failures per 100 women years (HWY).

HWY refers to the number of pregnancies that would occur if a hundred women were to use the contraceptive method for one year.

•

Pearl index = total no. of pregnancies X 1200 total no. of months of exposure

N.B: if the denominator is in months the quotient is multiplied by 13. The pearl index estimates total no. of unplanned pregnancies per 100 woman years (HWY). Life Table analysis – calculates failure rate for each month of use of contraceptive method. It is a good method for comparing various methods for specific length of time. A woman-year is 12 menstrual cycles Method failure – is failure attributable to a method if it is used perfectly and reliably under ideal circumstances. Patient failure – is attributable to less than ideal of that particular method Long term contraception is any method that can be used for a month and above.

Types of contraceptive methods • • • •

Hormonal methods Intrauterine conceptive device barrier method Natural/traditional method

• Combined oral contraceptive pill - Contains synthetic oestrogen and progesterone • Dosage composition of oral contraceptive pill Synthetic oestrogen: Ethinyl oestradiol – 20; 30; 35; and 50mcg or mestranol – 50mcg

Synthetic progesterone: 1st generation:

Norethindrone, others – norethynodrel, ethynodiol diacetate, norethindrone enanthate, norethindrone acetate (all convert to norethindrone before their activity).

2nd generation:

Norethisterone – 0.5; 1.0; and 1.5mg or levonogestrel – 0.15 and 0.25mg (i.e. norgestrel and levonorgestrel) levonorgestrel is the biologically active form. 3rd generation:

Gestodene – 0.075mg; desogestrel – 0.15mg or norgestimate 0.25mg.( where designed to enhance progestational activity and reduce androgenicity by increasing biologic selectivity).

Low dose pill contain 30-35mcg • COC pill for 21 days with pill free interval of 7 day or the 28 day pill usually with 7 day placebo • Withdrawal bleeding usually occur during the PFI – in some, this interval is enough to allow follicular growth, especially if extended beyond 7 days with resultant failure of method. If COC is desire in such people shorten the PFI for pill effectiveness

COC pill • Monophasic pill – same standard daily dose of oestrogen and progestogen throughout menstrual cycle • Biphasic – incremental change in dose of both hormone once • Triphasic – incremental dose change occur twice. Note: the phasic pill where introduced in other to reduce the total dose of progestogens and to improve cycle control – no evidence of better cycle control. Infact failure rate with its use may be higher, if the women get confused with how to cope with missed pills.

Mode of action - COC • Ovulation suppression – pituitary FSH and LH, by oestrogen and progestogen in the pill respectively. • Cervical mucus change – prevent sperm penetration • Atrophic endometrium – hostile to implantation

Advantages of COC pill • Menstrual – light menses; pain-free; regular menses; Rx for premenstrual syn • Reduce incidence of anaemia • Reduce incidence of PID • Protects against ovarian and endometrial Cancer • Decreases incidence of benign breast lumps, functional ovarian cyst, endometriosis and acne.

Side effects of COC pill Minor side effects • Weight gain – fluid retention • headache • Nausea and vomiting • Depressed libido • Chloasma • Mood change • Mastalgia • Breast enlargement • Greasy skin May improve in 3-6 month, pill use is continued

Serious side effects • Increased coagulability and thrombotic tendency • Increased risk of VTE – the risk is high in obesity and PIH, but unaffected by age, duration of use or smoking. The risk of VTE is highest with 3rd generation progestogen compared with 1st or 2nd • Arterial diseases (hypertension, cardiovascular accident and coronary heart disease) are less common but more serious – related to age and worse with smoking

•The BP is slightly raised in pill users • Increased risk of breast cancer – risk persist for 10yr after stopping pill use • A small increase in the risk of developing squamous ca of cervix after 5yr use of coc pill Contraindication to COC pill • Absolute contraindication :3. Cardiovascular diseases – ischaemic heart dz; valvular heart dz; arterial thrombosis; venous thrombosis; known predisposition to thrombosis. 4. Cerebrovascular dz – past cerebral haemorrhage; current transient ischaemic attack; focal migraine. 5. Significant hypertension (pulm hypertension)

•

hyperlipidaemia

• Acute or chronic Liver dz – recurrent cholestatic jaundice; Dubin-Johnson or Rotor syn; liver tumour; gallstones or porphyria • Pregnancy • Oestrogen dependent tumour – breast cancer • Hx of trophoblastic dz • Undiagnosed genital tract bleeding

Relative contraindication • Family hx of arterial dz • Diabetes mellitus • Obesity • Increasing age • Smoking • Generalised migraine • Prolonged immobilization • hyperprolactinaemia

Progestogen only contraception • Mini-pill – used continuously daily, with no PFI, contains levonogestrel 30-75mcg • Injectable – depot medroxyprogesterone acetate, 150mg every 12-13 week or norethisterone oenanthate 200mg every 8 week • Implants – norplant; implanon; uniplant • Hormone releasing IUCD

Mechanism of action (POP) • Thicken cervical mucus – reduce sperm penetration • Endometrial atrophy – poor implantation • Inhibits ovulation – high dose of injectable POP Side effects • Increased incidence of irregular menstrual bleeding.(20% discontinue POP)

Indications for POP contraindication to oestrogen CVD; migraine; DM; mild HT. smoking; obesity; family hx of arterial dz Breastfeeding women

Contraindications to POP Absolute contraindications • Pregnancy – high dose androgenic progestogen (NETEN) may masculinize a female fetus • Undiagnosed genital bleeding • Current cardiovascular dz

Relative contraindications

• Severe obesity – reduced efficacy and aggravate wt gain • Breast cancer • Severe hypertension • Chronic liver disease • Molar pregnancy until urine is free of hCG • Hx of recurrent ovarian cyst.

Side effect of POP • High incidence of functional ovarian cyst • Irregular vag bleeding • Headache; nausea; bloating; breast tenderness; mood change • Oily skin & acne – with the more androgenic levonorgestrel and norethisterone

Long term effect of POP • DMPA protects against endometrial carcinoma; may also protect against ovarian cancer (no data) • The risk of breast cancer is increased after 5yr of use, but after 5yr of nonuse, the risk become same with that in nonusers

Injectable Progest Only method • Norethisterone oenanthate (NET-EN) Warm before it can be drawn up for administration. Dose – i.m 200mg x 8 week • Depot medroxyprogestrone acetate (DMPA) – 150mg x 12 week New injectables

• •

Cyclofem (HRP-112) – 25mg medroxyprogestone acetate + oestradiol cypionate 5mg Mesygina (HRP) – 50mg NET-EN + oestradiol valerate 5mg

• Mode of action – due to high dose, inhibit ovulation After 1yr of injectable use • 80% - ammenorrhea or scanty menses • 2% - menorrhagia which may be Rx temporary with oestrogen (COC)

Side effects of injectable • Delayed return of fertility after stoppage – may be up to 1yr • Abnormal vag bleeding may continue after stopping method • Weight gain • Reduced bone mineral density – reversible

Progestogen only implants Non-biodegradable implants • Norplant – long acting hormonal method, comprised 6 flexible silastic caps – 3.4cm x 2.4mm and contains 36mg of levonorgestrel Usually inserted subdermally by minor surgery, in the inner aspect of the non-dominant arm. 70-80mcg---12months Norplant releases 30-35mcg /24hr after 18months • Highly effective----2nd year----30—40mcg • Last for 5years • Fertility returns rapidly after removal (serum levonorgestrel clear within 120hrs of removal)

• Low failure rate Draw back • It is expensive • Menstrual disturbance – ammenorrhea; menorrhagia (50% discontinue for this reason) worse during 1 year of use, thereafter improves st

•

Persistent ovarian follicle; headache (10-30%); weight gain; acne; hair loss hirsuitism; mood change

Norplant II (Jadelle) – 2 silastic rods, same 36mg of levonogestrel as well as release rate, advantages – easy insertion and removal

• Implanon – replacing norplant Single capsule – 68mg etonorgestrel (3 ketodesogestrel) – releases 67mcg per day for 3yrs Same efficacy and side effect as norplant Easy to insert and remove (3 keto-desogestrel is the biologically active metabolite of desogestrel) The maximum serum level is attained on day 4 after insertion and thereafter slowly fall for the remaining lifespan of implant. Following removal, serum level clears within 1 week

Uniplant – contains nomegestrol acetate Gives one year protection

NT 1435 (Nestorone) A single implant, protects for 2yrs • Can be used by breastfeeding mother – when taken orally, it is not biologically active. It is rapidly inactivated by hepatic first pass metabolism.

• •

Less effect on lipoproteins 16-methylene-17-acetoxy-19 norprogesterone

Biodegradable implants • Capronor I, II, III Capronor II – 2 capsule each in a 4cm polymer of caprolactone and contains levonorgestrel 18mg – protects for 1yr Capronor III – single copolymer capsule of caprolactone and trimethylene carbonate blend Contains 32mg levonogestrel – protects for 1yr • Annuelle (NET implant) Contains 4-5 pellets of 90% norethindrone and 10% cholesterol Each pellet contains 35mg NET and each pellet is 8mm in length Protects for 1yr

Intrauterine contraceptive device (IUCD) • • •

Inert IUCD (non-medicated) – Lippes loop; Margulies spiral; Saf-T-coil; Dalkon sheild (has highest risk of PID) Often cause heavy and painful menses – due to large surface area Once fitted, they can be left in-situ until menopause

•

Mode of action – induces local endometrial inflammation which prevents implantation

Medicated IUCD • Copper – to increase effectiveness and reduce surface area, hence reduced side effects – dysmenorrhoea & menorrhagia 1st Generation • Cu 7 • Cu T-200 2nd Generation • Multiload Cu-250 • Nova T 3rd Generation • Multiload Cu 375 • Cu T-380A (gold standard for

assessing other IUCD) – may be in-situ for 10-12yrs

• Hormone releasing IUCD – Mirena contain levonorgestrel 52mg on it’s stem. Releases 20mcg/day • Can be in-situ for 5yr Benefit – decreased menstrual loss due to endometrial atrophy Mode of action of medicated IUCD - Copper ion released inhibits capacitation of the sperm - May be spermicidal - Cu ion induces severe inflammatory reaction, with increase in prostaglandin thereby impairing implantation of the embryo - It may also reduce sperm ascent to the fallopian tubesl

New development in IUCD – to reduce side effects and expulsion rate •

•

•

•

Cu SAFE-300 – smaller, lighter Tshaped copper IUCD – designed for insertion without plunger – more towards uterine fundus following contractions Flexigard 330 – frameless Copper IUCD – consist of 6 small copper beads threaded onto nylon which get embedded to the depth of 1cm in the uterine fundus. T-shape Cu device with each arm expanded into soft ball – designed to block the ostia of the fallopian tubes Cu Fix PP330 – designed for post partum use – has a biodegradable anchor that imbeds in the uterine muscle

• Mechanism of action • •

•

Prevents implantation Inflammatory response – with increase in macrophage, leucocytes, prostaglandins which are toxic to sperm and egg It interfere with sperm transport

Side effects •

Menstrual – increase flow (80ml with Lippes loop and 50-60ml with Cu devices),

•

Pain at insertion/dysmenorrhoea

•

Uterine perforation (during insertion)

•

Expulsion (up to 1-7 per 100 women in 1st year of use)

•

Ectopic pregnancy – IUCD reduces

•

LNG-IUS reduces the risk by 90%

•

IUCD gives less protection against ectopic preg than either hormonal or barrier methods

•

Pelvic infection – highest in 1st 20 day after insertion – risk can be

the risk of ectopic pregnancy in users by 80% compared to non-users

reduced by – aseptic technique; proper selection of recipient ( no multiple sexual partners; do bacteriological screening before insertion

Timing of insertion & removal •

Can be inserted at any time of the cycle in women on effective contraception – or else insert in the 1st 7 days of menstrual cycle • Postpartum insertion – delay until after 8 weeks of delivery – reduce risk of perforation and expulsion • Post abortal – immediately after Removal • Remove during the late luteal phase or in the 1st 7 days • For menopause women – live in-situ for 1yr after last menses • Remove in the presence of pelvic actinomycosis Note: because of the tendency of copper to promote intraperitoneal adhesions, it is mandatory that copper devices should be removed when it perforate

Pregnancy occurring with IUCD in-situ •

•

•

Pregnancy occurring with IUCD insitu is associated with spontaneous abortion in 55% of cases. This abortion is also occasionally complicated by severe infection. Such pregnancy is unplanned, but it may not be wanted. If the pregnancy is wanted – ensure that the IUCD is removed, so as to reduce the risk of abortion. The IUCD is removed by pulling on the tail in the vagina or using hysteroscope if tail is invisible (it is safe and effective). If the patient elect to continue with the pregnancy, and it is impossible to remove the IUCD, then the decision to terminate or continue with the pregnancy should be left to the woman and her partner.

•

•

Following failure to remove the IUCD and the pregnancy proceed there is still an increased risk of spontaneous pre-term labour or intra-uterine death due to fetoplacental infection. However, those who do not abort may progress to term, with the IUCD expelled usually lying beneath the placenta.

Vaginal contraceptive rings • • • •

•

A recent development Undergoing multi-centre trials Evolved clinically from vaginal rings The steroids impregnated on the rings are efficiently absorbed through the vaginal epithelium. Advantages – its offers long-term contraception which is under patient control, it is independent of intercourse, no daily administration, has good contraceptive effect and mild adverse effect ( erosion, genital infections and inconveniences during sexual intercourse), it can be discontinued easily.

Vaginal rings provides same long-term contraception as injectables and implants.

• Procedure – ring is placed in the vaginal vault around the cervix. •

The steroid release rate is a function of the ring surface area, solubility of the steroid in silastic, and the distance the steroid has to diffuse to reach the surface of the ring.

• Types of vaginal contraceptive rings: - Homogenous ring - Shell ring - Core ring

•

•

•

Homogeneous ring – it requires a large steroid load, the steroid release rate decreases with time – as the steroid on the surface is lost, steroid must travel a greater distance to reach the diffusion medium. Shell ring – uses low dose steroid load. The steroid is included in a narrow zone just below the surface of the ring – the distance the steroid must travel to reach the surface of the ring remains relatively constant. Core ring – the steroid is in the centre of the ring material – can either be a continuous ring or discrete deposit of steroid.

The contraceptive rings can be used for 3-12months

• Type of steroid impregnated on rings a) Progestogen only ring - Levonorgestrel impregnated ring: continuous low dose (20mcg/day). -

Natural progesterone: can be left insitu for 90 days before replacement – prolongs lactational amenorrhoea, supports lactation, it is ineffective during weaning and so change to other method of contraception.

-

ST 1435 (Nestorone) ring – inserted for 3 weeks, followed by one week ring free interval. Less metabolic effect.

b) Combined oestrogen-progestogen rings - levonorgestrel/ethinyl oestradiol - 3 keto-desogestrel/ethinyl oestradiol used on a 3-week-in/1-week-out schedule for three cycles - Norethindrone/ethinyl oestradiol - ST 1435/ ethinyl oestradiol

Barrier methods

• Male condom – one

of the oldest and most popular form of contraception – widely available; cheap; free of side effects with exception of few allergy, no medical supervision needed, protect against STI

•

Types – latex and non-latex

• •

Latex – lubricated or plain, teat ended Non latex – polyurethrane and plastics: stronger and less likely to rupture during use

Advantages: Prevention of STI and HIV Prevention of cervical cancer

Most are lubricated with spermicides –nonoxynol-9 –

a non-ionic surfactant which alters sperm surface membrane permeability with resultant osmotic changes and death. Spermicide lubricant on condom are carried on inert base which itself alters sperm motility. Spermicides also occurs in forms – creams; jellies; foaming tablets; pessaries or aerosols (very expensive).

Spermicide Advantage – does not need medical supervision for use. Disadvantage – it is coitus related and relatively ineffective when used alone. Therefore usually combined with other methods condoms and vaginal diaphragms

Spermicide should not be used alone, has high failure rate –can be used in perimenopausal women who sparingly have coitus. Other spermicides – octoxynol-9; menfegol

Vaginal barrier methods Female condom (femidon or femshield) • A pouch made of polyurethrane sheath, with 2 polyurethrane rings, one at the introitus and the other in the vaginal vault. • Available in one size only • Has no spermicidal lubricant • Designed for single use • Its expensive and not widely available • Failure rates same as for male condom Diaphragm and cervical cap • Less popular than condom • Do not confer enough protection from HIV • Selecting the right size is quite difficult • Must be fitted by a doctor or a nurse. • There are 3 style of diaphragm spring – flat spring, arcring spring and hinged spring.

Cervical cap (Femcap) - Made

of silicone, shaped like the sailor’s cap, it fits over the cervix. It has a broad rim that create a protective seal. It can be worn for up to 48hrs. It is used with the spermicide to improve effectiveness. There are 3 types: 4. Small – for nulliparous women 5. Medium – for women who have been pregnant, but no vaginal delivery. 6. Large – for women who have had a vaginal delivery. Requires professional fitting and training for use

Lea’s shield -

-

Made of flexible silicone rubber, it combines the features of vaginal diaphragm and cervical cap. It can be worn for up to 48hrs, it is used with spermicide. It has a soft valve which allows passage of cervical secretions and a loop to aid insertion and removal of the device. Usually available in one size which fits all. Lea’s shield is concave like the diaphragm, but thicker and slightly enlongated rather than rounded. It fits snugly into the pubic bone and cul-de-sac, thus preventing dislodgement during coitus.

Diaphragm • It is a shallow latex cup, with a spring mechanism in its rim to hold it in place in the vagina. • It is available in various diameter. Prior to use a pelvic examination and the diagonal length of the vaginal canal must be measured to determine the size for an individual. • It is inserted before coitus, such that the posterior portion of the rim fits into the posterior fornix and the anterior behind the pubic bone, prior to insertion, spermicidal cream is introduced into the inside of the dome which then covers the cervix. • Once introduced, it provides effective contraception for 6hrs – it must be left in-situ for 6hrs after coitus.

•

•

If a longer interval as elapsed without removal, spermicide must be introduced using an applicator. It prevents pregnancy by acting as a barrier to sperm ascent to the cervix.

Advantages: - Not an hormonal device - Contraception controlled by the woman Disadvantages: - Requires professional fitting - Prolonged usage following multiple sexual act increases risk of UTI - Prolonged usage for > 24hrs predisposes to infection (toxic shock syndrome). - Vaginal erosion may follow poor fitting device. - High failure rate – hence requires formal training prior to use. - It may develop odour, if not properly cleaned.

Long-Acting spermicide-releasing diaphragms – gives a burst of spermicide release immediately following vaginal placement and thereafter followed by a decrease dose release. pH-sensitive release device – these are vaginal barrier devices that release spermicides following a stimulus such as deposition of semen into the vagina which increases the vaginal pH. The device releases baseline spermicide doses at normal vaginal pH Protectaid – this is a new vaginal sponge designed • • •

to protect against STD It contains ‘F-5 gel’ which comprises low doses of nonoxynol-9, benzalkonium chloride and sodium cholate. Nonoxynol-9 and benzalkonium are spermicidal and microbicidal, while sodium cholate is antiviral. The sponge inactivates HIV, chlamydia and trichomonas

Vaginal sponge 2. It is made of polyurethrane and contains 1ng of nonoxynol-9. 3. Shaped like a mushroom cap and fits over the cervix. 4. It is for single use, with a maximum insertion time of 24hrs. It was originally designed for 48hr use and to be a reusable device but this was not achieved due to poor efficacy. Advantage: Continuous spermicide release for 24hrs. No waiting time after insertion before coitus. No prescription needed. Disadvantage: High failure rate due to dislodgement. Inadequate spermicide release for the entire 24hrs Vaginal discomfort – itching and irritations Difficult removal – change in texture. A bad odour if left for a long period It absorbs seminal plasma and vaginal fluid encouraging bacteria growth – toxic shock syndrome Allergic type reaction – cervical erosion and cervicitis

Natural/Traditional family planning methods • •

•

•

It involves abstinence from intercourse during the fertile zone of the menstrual cycle The different methods are determined by the method used in identifying the fertile zone Calender or Rhythm method – the woman calculates the fertile period, from the length of her normal menstrual cycle. ( the 1st day of her fertile period is calculated by substracting 20 days from her shortest duration of menstrual cycle and the last day of the fertile period is calculated by substracting 11 days from her longest duration menstrual cycle. E.g a woman with menstrual cycle duration varying between 25-31days would have a fertile zone, extending between 5-20day of menstrual cycle – i.e 25-20=5; 31-11=20) intercourse should be avoided during the fertile zone. Mucus or Billings method – use the changes in the quality and quantity of the cervical mucus, due to the fluctuating concentrations of circulating oestrogen and progesterone

3. Symtothermal method – uses the

temperature change during the menstrual cycle, due to progesterone, which commences at ovulation. This recognises the end of the fertile period. This method restricts intercourse until 48hrs after the BBT has risen by 0.5 0C (no coitus until after BBT rise for 48hrs). 4. Other methods used to determine the fertile period includes – ovulation pain; position of the cervix; degree of cervical os dilatation. 5. Hand-held monitor (kitchen method) – uses disposable urine dipsticks to test for oestrone-3-glucuronide and LH concentrations and the ratio of both is used to define the start and the end of the fertile period. A red light is displayed on days when intercourse should be avoided.

• •

Coitus interruptus – this is when there is withdrawal just before ejaculation during intercourse – requires self control. Lactational amenorrhea method (LAM) – breastfeeding delays the resumption of fertility after childbirth. The duration of delay is dependent on the frequency and duration of breastfeeding episodes and the timing of the introduction of food ( complementary or supplementary) other than breast milk.

Voluntary surgical contraception (VSC) •

•

•

VSC also known as sterilization is the most common form of family planning world wide. VSC could be for female as in bilateral tubal ligation or male as in vasectomy. Vasectomy has a clear advantage over bilateral tubal ligation because Vasectomy is safer, cheaper and performed under local anaesthesia and the efficacy can be checked easily with the analysis of seminal fluid for presence of sperm. While the disadvantage is that fertility of the male continues beyond that of the female The ratio of female to male sterilization is 3:1 world wide.

Female sterilization (bilateral tubal ligation) BTL usually involves blocking both fallopian tubes. Occasionally female sterilization entires bilateral salpingectomy and hysterectomy, when there are other coexistent gynaecological pathology. APPROACH TO BTL - Laparotomy (during C/S) - Minilaparotomy - Laparoscopy Types of BTL - Intrapartum BTL - Postpartum BTL - Interval BTL - Post-abortion BTL

• •

•

•

Intrapartum BTL – is done concurrent with Caesarean section. Postpartum BTL – usually following vaginal delivery (within 48hrs), using minilaparotomy with the transverse crescentic or medline vertical incision at the lower border of the umbilicus. Laparoscopic method is not used due to the large uterus, fallopian tubes and increased vascularity of the pelvis at this period. Interval BTL – done at a time unrelated to pregnancy (3 months after delivery) using laparoscopy or minilaparotomy with the med-line incision above the pubis symphysis (vertical or transverse measuring 2.53cm) Post abortion BTL – shortly after induced abortion (6-8weeks after) so as to reduce failure rate, but not immediately after as there is increased risk of infection.

Advantage of laparoscopy or minilaparotomy - Safer - Short hospitalization - Quick recovery - Better cosmetic result Management prior to VSC - Counsel patient – permanent nature of VSC, alternative methods (vasectomy for husband), risk of surgery (anaesthesia), failure of procedure, increased relative risk of ectopic gestation. - Obtain informed consent – preferably written. - History taking - Physical exam - Lab investigation – pregnancy test, PCV, urinalysis.

Emergency contraception Definition (WHO): EC is the method of preventing pregnancy within a few hours or a few days after unprotected sexual intercourse. Importances of EC - Prevents unwanted pregnancy - Serves women’s health needs - Advances reproductive self-determination.

Methods of EC • Yuzpe regimen – 100mcg of ethinyl oestradiol and 0.50mg of levonorgestrel within 72hour of coitus and repeated 12 hours later • Levonorgestrel – 0.75mg orally repeated 12hours later, with first dose within 72hr. • Intrauterine contraceptive device • Mifepristone – an orally active synthetic 19-norsteroid, with potent antiprogestional and antiglucorticoid activity. The effect depends on the time of administration in relation to the menstrual cycle. Follicular phase – inhibit or delay ovulation, early luteal phase – inhibit progesterone, thereby preventing secretory changes in the endometrium and impairing implantation

Mode of action of EC • Mode of action varies because it is used at different period during the menstrual cycle. - Delaying or inhibiting ovulation - Inhibiting fertilization - Inhibiting implantation of fertilized egg

Situations that require EC • • • •

Fail contraception – burst condom Rape Does not want a pregnancy Refugees that cannot adequately use family planning.