Barrier contraception and the combined oral contraceptive pill (COC) depend on correct and consistent use by the patient, but long-acting reversible contraception (LARC) does not depend on everyday concordance.
Sterilisation is a permanent method of contraception, so it can be indicated for those women who do not wish to have any more children.
LARC options include the copper IUD, progestogen-only intrauterine system (IUS), progestogen-only injectable contraceptives and progestogen-only subdermal implants.1
It is important to take the patient's preferences and needs into account when discussing LARC. Effective communication is essential and should be supplemented by good quality written material.
Information should be culturally appropriate, and accessible to those with physical or sensory needs and those who do not speak English.
The pregnancy rate associated with the copper IUD is very low (less than 20 per 1,000 in five years). However, heavey or painful bleeding is likely. The IUD may expelled in less than 1 in 20 women in five years.
The pregnancy rate associated with the progestogen-only IUS is very low (less than 10 per 1,000 in five years).
The licensed duration of IUS use as a contraceptive is five years.
Irregular bleeding is common during the first six months and oligomenorrhoea or amenorrhoea are likely by the end of the first year.
The IUS may be expelled in less than 1 in 20 women five years. A new system, with a lower dose of progestogen, and a three-year licence is now available.
Progestogen-only injectable contraceptives
The pregnancy rate associated with injectable contraceptives, when given at the recommended intervals, is very low (less than 4 per 1, 000 in two years) and the pregnancy rate with depot medroxyprogesterone acetate (DMPA) is lower than that norithesterone enantate (NET-EN).
DMPA should be repeated every 12 weeks, NET-EN every eight weeks.
It is important to note that there could be a delay of up to a year in return of fertility after stopping the use of injectable contraceptives.
Amenorrhoea is likely during the use of injectable contraceptives.
This is more likely with DMPA than NET-EN. DMPA use may also be associated with weight gain of up to 2-3kg over one year.
Progestogen-only subdermal implants
Nexplanon has replaced the previously used Implanon.
Ideally, the implant should be inserted in the non-dominant arm.
This provides up to three years of highly effective contraception. It is generally well tolerated and well accepted. There is a rapid return of fertility following removal.
Sterilisation for men and women2 is a permanent procedure. Female sterilisation is usually no longer done on the NHS as an elective procedure.
What is tubal occlusion?
This procedure blocks or cuts the fallopian tubes, so eggs can no longer be fertilised by sperm.
What does it involve?
Tubal occlusion is usually performed as a day case in hospital. The laparoscopy route is the most common and is carried out under general anaesthesia.
Hysteroscopic sterilisation is a new approach. This involves inserting a titanium coil into the fallopian tubes through the vagina and uterus.
The woman must use contraception for at least three months after this procedure. A test is performed to ensure the tubes are blocked.
What are the risks?
Most risks in tubal occlusion are minor and can be dealt with at the time of the procedure. Other complications, for example, bowel, bladder or blood vessel injury, are uncommon but more serious and may require a laparotomy.
What is a vasectomy?
This procedure blocks or cuts the vas deferens. The man will still be able to ejaculate, but his semen will no longer contain any sperm.
What does it involve?
Vasectomy is usually performed under local anaesthetic. One or two small cuts are made in the scrotum to reach the vas deferens.
A semen sample should be given at least eight weeks after the procedure to check it has been successful.
What are the risks?
Vasectomy carries less risk than tubal occlusion. Complications include pain in one or both testicles, which can be immediate or delayed. In most cases, any pain is usually mild and no further action is required.
How well do they work?
Vasectomy carries a better success rate than tubal occlusion. The failure risks are 1:2,000 and 1:200 respectively.
Can they be reversed?
Sterilisation is permanent and there is no assurance of successful reversal. The best chance of reversing tubal occlusion seems to be when clips or rings are used and the reversal is done by microsurgery.
- Dr Abdelrahman is an ST4 in obstetrics and gynaecology, Antrim Area Hospital, Northern Ireland Deanery
1. NICE. CG30. Long-acting reversible contraception. London, NICE, October 2005. www.nice.org.uk/CG30
2. Royal College of Obstetricians and Gynaecologists. Male and female sterilisation. London, RCOG, 2004.