AFJOG

African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 3 | 2025 | 30 GUIDELINES of ejaculations, three months after the procedure, a post vasectomy semen analysis with documented azoospermia will confirm effectiveness. Until such time another form of contraception must be used. Patients must be advised to use another form of contraception until azoospermia is proven. Effective re-anastomosis does not guarantee restoration of fertility due to the induction of antibodies. Intra-uterine contraceptive devices Both copper-containing and medicated devices are classified as LARCs and have excellent efficacy and continuation rates, but require a skilled healthcare provider to insert them. Levonorgestrel medicated intrauterine systems (IUS ) are available in two products in SA, namely Mirena ® and Kyleena ® , both highly effective as contraception, but only Mirena ® is also indicated and very effective as treatment for heavy menstrual bleeding in view of the larger total (52mg vs 19.5mg) and daily dose (20µg vs. 12µg) levonorgestrel dose. Kyleena® has fewer hormonal side effects (mostly due to the androgenic effects of the levonorgestrel), but also lower rates of amenorrhoea and more infrequent bleeding. It has a slightly thinner applicator (3.8mm vs. 4.4mm) and smaller frame size, making it very suitable for nulliparous women. Copper intrauterine contraceptive devices (IUCD) have been available for many years, have excellent safety, cost effectiveness, efficacy and continuation data and are registered for 5 or 10 years, dependent on the amount of copper it contains. In SA it is the most underutilised method. The most important limitations to use are an increase in menstrual volume and pain in some women and also an undeserved bad reputation based on fears of infection, infertility and ectopic pregnancy. The best available evidence has shown that there is no increased risk of pelvic infection or infertility when using the IUCD, and ectopic pregnancy is not increased. Infection related to insertion (usually in the presence of cervicitis) can occur within the first 3 weeks following insertion (7) and is very uncommon with meticulous insertion technique. Progestogen-only methods Progestogen intrauterine systems can also be classified under progestogen-only methods, but the mechanism of action is local rather than systemic. See above. Sub-dermal progestogen implants are highly effective LARC’s and were actively introduced in 2014 in South Africa initially as the etonogestrel implant, called Implanon®, a 4cm rod placed in the left upper inner arm by a trained health care provider. It has been replaced by Nexplanon® (pre-loaded thus easier to insert, and radio-opaque for easier location), which is bio-equivalent, still active for 3 years and contains 68mg of hormone. Heavy menstrual flow occurs in some women and there is ongoing concern of efficacy with concomitant use of efavirenz and rifampicin. Other methods include the levonorgestrel (LNG) implant consisting of 2 rods, effective for 5 years and seen in some immigrants. Injectable progestogens include the widely used 3-monthly or 12-weekly depot medroxyprogesterone acetate (DMPA) and the 2-monthly or 8-weekly norethisterone enanthate (NET-EN) and newer subcutaneous depo injections. Both are considered as LARCs, but the effectiveness is lower than the methods discussed above, mostly due to compliance. Concerns include undesired bleeding patterns, slow return to fertility, weight gain, headache and some effect on bone density. Progestogen dominance may assist to reduce endometriosis and endometrial overgrowth and these methods can be used in women with estrogen contra- indications. A subcutaneous contraceptive injectable containing 104 mg of DMPA is undergoing registration in SA. It is also used 12-weekly, has the same effectiveness and side effect profile as the DMPA IM, but has the benefit of being self-administered. Progesterone only pills are very short-acting and dependent on compliance. It should be taken with a maximum of three hours fluctuation every day. The quoted Pearl index is however similar to combination hormonal contraceptives. Side effects are very low, and the method is very useful when estrogen is contra-indicated, during breast feeding, peri-pubertal and peri-menopausal women. Combined hormonal methods There are various delivery mechanisms for combined hormonal contraceptives, which all work in similarly, usually by delivering a combination of estrogen and progestogen for 21 to 24 days, followed by 3 to 7 days without. These methods can also be used continuously especially in women with pre-menstrual progestogen withdrawal headaches, and some women have amenorrhoea in this way. Variation in side effect profile is mostly related to the type of progestogen and dosage of both hormones. While venous thromboembolism is the largest concern with combined methods, it is far more common in pregnancy and postpartum than with any contraceptive. (8) The WHO MEC must be used to ensure safe use before prescribing. (5) Combined oral contraceptives are divided into monophasic, biphasic, triphasic and quadriphasic preparations depending on the changes in hormone dosage over the cycle. The estrogenic component can be high, low or ultra-low dose. The progestogenic component is categorized according to the parent compound (testosterone; spironolactone; 19-nortestosterone) and when it was developed i.e. 1st generation; 2nd generation; 3rd generation and 4th generation. Vaginal contraceptive ring is placed in the vagina for three weeks out of four, where it releases a continuous dose. Contraceptive transdermal patch is also placed for three weeks and works similarly to the oral route; compliance may be improved. SPECIAL CLINICAL SITUATIONS Post-Partum contraception This opportunity to discuss, plan and offer contraception must not be missed, and a method should be provided before discharge as ovulation can occur before the 6-week visit. Sterilisation must have been discussed during pregnancy to prevent hasty decisions. IUCD’s are very safe and effective in this context, provided a few rules are followed, and are certainly underutilised. It can be inserted at the time of caesarean section, immediately