Contraceptive

Contraception means the prevention of pregnancy by interfering with the normal process of ovulation, fertilization, or implantation. The intentional prevention of conception is achieved by the use of various devices, sexual practices, chemicals, drugs or surgical procedures. This is an important measure for population control.

The literature suggests that contraception has been available from ancient times. The major texts of Ayurveda like Charak Samhita, Sushruta Samhita and Ashtanga Hridaya describe natural methods of contraception. The ancient Indian epics like Garuda purana (1000 BC), Bruhadaranyaka Upanishad (700 BC), Atharva veda (1000–900 BCE), Ayurveda texts like Rasa ratna samuchhaya (1400 A.D.), Bhavaprakasha (1600 A.D.), Yogaratnakara (1600 A.D.), and Bhaishajya Ratnavali (1900 A.D.) describe additional contraceptive options in the form of oral and local contraceptives practiced at the respective times.

In today’s medical practice, many forms of contraception are available. Benefits of contraception include decrease in unwanted pregnancies thereby reducing maternal deaths by as much as 40%. Contraception also helps in increasing time interval between pregnancies, which increases perinatal and infant survival. Contraception is available to both females and males. It can be reversible or permanent. Choice often depends on availability, prior experience, knowledge and comorbidities. This article focuses on contraceptive options described in Ayurveda and current practices.

Ideal contraceptive:

An ideal contraceptive method should be widely acceptable, inexpensive, simple to use, safe and effective. It should require minimal motivation, maintenance and supervision.

Classification:

The methods of contraception can be broadly divided into two.

1) Temporary methods- which includes,

a) Natural contraception (rhythm method, coitus interruptus, lactational amenorrhoea method etc.)

b) Barrier Methods (Mechanical- male condom, female condom, diaphragm, cervical cap, Chemical-vaginal creams, jelly, foam tablets etc.)

c) Intrauterine contraceptive devices

d) Steroidal contraception (oral, parenteral, device, patch)

2) Permanent Methods which includes,

a) Tubal occlusion

b) Vasectomy

Contraceptive options:

I. Natural Family Planning

These are convenient methods but carry a failure rate of up to 25%. With this, pregnancy can be prevented by using one or more of the following:

1. Abstinence method:

Ayurveda literature emphasises the regulated sexual life or abstinence as the best method of contraception. It is one of the three major pillars for sustenance of life. [ref. Ashtanga hridaya]

2. Breathing exercise:

Breathing exercise to be practiced during coitus in order to prevent conception is mentioned in “Bruhadaranyaka Upanishad”.

3. Safe period or rhythm method:

The description regarding fertile period and “safe period” is available in Ayurveda classics. The first 12 or 16 days of menstrual cycle are considered as fertile period (ritukala) and once this time period is over, the reproductive tract (yoni) gets constricted and do not promote the entry of sperm (shukra) into the uterus. [Su. Sa. Sharira Sthana 3/9] After ovulation, during progesterone dominant phase of menstrual cycle, cervical mucus becomes hostile to the sperms and prevent their entry into the uterus. So, this period can be considered as the safe period for coitus to avoid unwanted pregnancy.

In current practices, the safe period is applied by ‘rhythm method’, or ‘calendar method’.

A Menstrual calendar is maintained by writing down the first day of bleeding as Day One of the menstrual cycle. Normal cycle can range from 25 to 35 days. Ovulation generally occurs midcycle. The calendar must be maintained for extended period of time to ascertain average cycle length.

However, this do not assure 100% contraception because in a woman with excellent reproductive health, even the whole month may be considered as fertile period. [A. S. Sharira Sthana 1/46]

4. Basal body temperature method

Physiologically, the body temperature increases during ovulation. This method requires checking body temperature upon waking up every morning. During ovulation, the temperature should rise during ovulation. Intercourse should be avoided in this period to achieve contraception.

5. Cervical mucus method

The cervical mucus/vaginal discharge changes in quantity, quality and consistency throughout menstrual cycle. During the first few days of the cycle there is minimal discharge which increases to the largest amount during ovulation. At that time the discharge thickens and can be stretched between fingers, known as Spinbbarkeit test. Intercourse should be avoided during that period.

6. Lactation amenorrhea method

Breastfeeding supresses ovulation. It is considered to an effective method of contraception only if the mother is exclusively breastfeeding the baby at regular intervals.

7. Positions of sexual intercourse

Left lateral, right lateral and elbow-knee positions are not recommended for a fruitful coitus and conception. So, these positions may not result conception in the ideal way. [Cha. Sa. Sharira Sthana 8/6] More research studies are needed to assure the contraception in these methods.

8. Withdrawal method

In this, the couple proceeds with intercourse in the usual way until the moment of ejaculation, when the male withdraws and ejaculates outside the vagina or the external genitalia.

Drawbacks of this method:

• Needs great motivation and self-control in the male partner.

• The female partner may develop sexual neurosis as female satisfaction/ orgasm may not be achieved.

• The pre-ejaculate (fluid that is secreted for lubrication, in males,) may contain few sperms which may lead to unwanted pregnancy.

• One or both partners may not feel completely satisfied by the sexual experience.

II. Oral contraceptives

The “Atharva veda” describes certain drugs to make a person impotent which is administered by chanting some verses as a punishment to the person committing social sins.

These recipes suppress or delay ovulation. Once the functioning of reproductive hormones (raja) is suppressed or altered, it prevents the conception. Food and beverages that are excessively hot in potency cause disturbances in the reproductive physiology especially in the growth and development of follicles/ovum (andopachaya). [ Ka. Sa. Kalpa Sthana 7/32]

Table 1: Oral contraceptives in Ayurveda Drugs Period of menstrual cycle Vehicle/After drink (anupana/prakshepa) Dose / Duration Powder of Piper longum Linn(pippali), Embelia ribes(vidanga), borax(tankana) First 12-16 days (ritu kala) Milk 12- 16 days Flowers of Hibiscus rosasinensis (japa) First 12-16 days(ritu kala) fermented rice water (Kanji) and Old jiggery(48g) 3 days Root of Amaranthus spinosus (tanduliyaka) after the stoppage of menstrual bleeding Rice water. 3 days Leaves of Abes webbiana (talisa) and red orche (gairika) 4th day of menstruation Not specified 12 g, 1 day Extract of Berberis aristata (rasanjana), Iris germanica Linn. (shweta vacha),and Terminalia chebula (haritaki) Not specified Cold water Not specified (probably for the whole month) Paste of leaves of Cesampelus pareira (patha) After the stoppage of menstrual bleeding Not specified Not specified 3 years old jaggery Not specified Not specified Continuously for 15 days Decoction of Plumbago zeylanica (chitraka) From the 4th day of menstrual cycle/after the stoppage of bleeding Rice water 3 days Decoction of Nauclea cadamba/ Nauclea parvifolia (kallambha) and the feet of jungle flies. From the 4th day of menstrual cycle/after the stoppage of bleeding Not specified 3 days 19.5 g of marking nut/semicarpus anacardium or seeds of Terminalia bellerica (bibhitaki) boiled in rice water. From the 4th day of menstrual cycle/after the stoppage of bleeding) Not specified 7 days Ashes of stem of Euphorbia neriifolia (sehunda) 21 days Not specified 1 tola(12 gm)

Curcuma longa (haridra) rhizome having knots 3 days during menstruation, and continued for 3 more days Not specified 1 rhizome/day, (total 6 days)

Powder of Carum carvi (krishna jeeraka), Hedchim spicatum (kachura), Mesua ferrea (nagakesara), Terminalia chebula (haritaki), Ngella sativa (kalonji), Myrica nagi (kayaphala) 7 days Not specified In the size of Ziziphus fruit

Powder of seeds of Brassica campestris a (sarshap), Amaranthus spinosus (tandula), sugar candy (sharkara)- pound with rice water. Not specified Milk Not specified

In current medical practices, two synthetic female hormones, oestrogen and progesterone are used to prevent pregnancy by inhibiting ovulation. These are also known as ‘birth control pills’. Some injectable steroid contraceptives like progesterone only contraceptive injections including DMPA or Depo-Provera and Nexplanon are also in practice. Adverse effects: III. Barrier methods Some methods to make the reproductive tract rough and dry, in order to prevent conception are mentioned in Atharva veda. This may cause alterations in the normal pH, or nature of cervical mucus to prevent the entry of sperms, or altering the receptivity of endometrium to prevent the implantation of zygote. This may be considered as vaginal barrier method. Table 2: Local contraceptives in Ayurveda Drugs Mode of administration Powdered seeds of Butea monosperma(palasha) along with honey . Applied as vaginal paste during fertile period(ritukala) Piece of rock salt + oil Vaginal insertion before coitus. Wood of Azadiracta indica(nimba) Vaginal fumigation before coitus/ during fertile period. Powdered root of Datura metel(dhattutra) Vaginal filling before coitus. Root of Datura metel(dhattutra) collected on 14th day(dark night) of lunar month Tie in waste before coitus.

In current practices, male condoms and vaginal diaphragms are used in barrier methods. IV. Intra uterine contraceptive devices In females, causing obstruction to vessels of the reproductive tract (yoni) using a special type of stone is mentioned for inducing sterility. This may be considered as a primitive form of intra uterine contraceptive devices. Now a days, Intra Uterine Device (IUD) is inserted into uterine cavity and left for contraception. These are made from polypropylene impregnated with barium sulphate. The commonly used devices are Copper T 200 (Cu T-200), Copper T (Gravigard), Multi load copper – 250 (ML Cu – 250 ) and Multi load Copper – 375 (ML Cu- 375). These are used for 3 to 5 years of contraception. V. Surgical procedures for sterility Infliction of crush injury to the two chords situated near the scrotum or the scrotum itself is also mentioned in Atharva veda. This shows the references of vasectomy and castration respectively. In current practices, sterilization in males is achieved through vasectomy. In females, various procedures like laparotomy, culdotomy, laparoscopy are opted for sterilization. These methods are irreversible and opted for permanent contraception. VI. Emergency contraception This method can be used in the form of oral tablets or IUD. It is indicated in cases of unprotected intercourse, condom failure, noncompliance with other methods and rape. This method should be reserved for emergency situations and should not be used as an ongoing method of contraception on regular basis because it has a high failure rate and can cause irregular menstrual bleeding. Abortifacients: Some drugs having the abortifacient action are used for inducing bleeding per vagina in case of accidental conception. The table 3 lists the drugs for oral administration and table 4 shows locally used drugs in vagina to induce bleeding. Table 3: Oral drugs for inducing bleeding per vagina/ abortion Drug Vehicle(anupana) Scraped lime powder from the walls of temple(devalaya churna) – 12 g water Root of Plumbago zeylanica(chitraka) and leaf juice of Vitex negundo Linn(nirgundi) honey Seeds of carrot(Daucus carota)+Roots of Cajanus cajan Linn(tuwari)+lead oxide(sindura) water Faeces of mare mixed with fermented rice water(kanji) and filtered+rock salt+ Apium graveolens Linn(ajamoda)+oil of Brassica nigra(asuri)+Aconitum ferox(visha) not specified Paste of fried leaves of Celastrus panniculata(jyotishmati) and flowers of Hibiscus rosasinensis(japa) water Paste of Cedrus deodora(devadaru) and Cynodon dactylon(durva) aling with paste rice grain. water

Table 4: Local drugs for inducing menstrual flow/ abortion Drug Mode of administration The stem of leaf of Ricinus communis (eranda patra danda) Vaginal insertion Root of Boerhavia diffusa (punarnava) Vaginal insertion Root of Clitorea ternata (Shweta aparajita) Vaginal insertion Aerial roots of Cardiospermum helicacabum Linn(Sharngeshta/Kakadani) Vaginal insertion Combination of Lagineria vulgaris (iksvaku), Baliospermum montanum (danti), Piper longum (pippali), Jaggery, Randia dumetorum (madanaphala), Fermented liquid (kinva), Glycyrrhiza glabra (yashti madhu) and Latex of Euphorbia nerifolia (snuhi kshira) Vaginal suppository

Current researches

The following table no. 5 reviews pharmacological research studies on single drugs mentioned in contraceptive formulations in Ayurveda. Table 5: Researches on contraceptive herbs Drug Observations Embelia ribes (vidanga) Root powder in 100g/kg in rats exhibited 100% inhibition of pregnancy in albino rats. Embelin 50-100mg/kg in rats from day 1 to day 7 of pregnancy showed 85.71% anti-implantation activity, significant anti-estrogenic and progestational properties. Abies webbiana (Talisa) Benzene and alcoholic extracts of leaf produced 51% anti- implantation activity. Azadiracta indica (nimba) Bark extract had shown in vitro spermicidal activity. Daucus carota (grinjana) Extracts of the seeds showed petroleum, ether, benzene, alcohol & water showed 85%, 95%, 92%,50% anti-implantation activity respectively. Hibiscus rosasinensis ( Japa) Alcoholic extract of flower showed 50-60% inhibition of pregnancy at 200mg/kg dose.Benzene extract produced 100% antifertility effect in 250mg/kg. Plumbago rosea / Plumbago zeylanica(chitraka) Root powder in a dose of 100mg/100g from Day 1 to Day 7 of pregnancy in albino rats showed 100% antifertility activity. Terminalia arjuna(arjuna) Anti-zygotic, anti-implantation, abortifacient activities. Mesua ferrea(Nagaksara) Flowers exhibited anti-implantation activity in female rats.

The Central Council for Research in Ayurvedic Sciences (CCRAS), working under the Ministry of AYUSH carried out the screening of many herbal and herbo-mineral drugs for the contraceptive activity under the Research Scheme for screening of contraceptive agents. • A compound drug called AYUSH AC-V, which is a combination of Abes webbiana(talisa patra) and red orche (gairika), showed 100% anti-implantation effect on multigravida rats. • Another coded drug called AYUSH AC-IV, Embelia ribes (vidanga), Laccardia lacca (laksha), Areca catechu (puga) and Saraca asoka (ashoka) in equal parts, 1gm/day in two divided doses in 281 women for 15 days (D4-D18). There was no pregnancy reported even after 10th cycle. • The various clinical trials conducted by CCRAS, the combination of Piper longum Linn(pippali), Embelia ribes(vidanga), borax(tankana) known as “pippalyadi yoga” was tested in 722 women in tablet form 1g/day. It effectively prevented pregnancy in 98.42%. • Oil of Azadiracta indica A Juss (nimba), 1 ml intra vaginally before each coitus, tested in 225 women with proven fertility showed 98.7% result in prevention of pregnancy and in a dose of 3 ml (intra vaginally before each coitus) showed 100% result in prevention of pregnancy during the study period of 12 cycles. • “Praneem”, a purified extract from the dried seeds of Azadirachta indica (Neem), extract from the pericarp of fruits of Sapindus species and quinine hydrochloride, showed contraceptive efficacy in rabbits and monkeys after intra vaginal application. Precoital application of the cream provided complete protection against pregnancy in rabbits in the 1st 30 minutes after application. The conception rate was acceptable at 60 minutes (7%), but thereafter it climbed to unacceptable levels (28.6% at 90 minutes and 75% at 12 hours). References