Obstetrics & Gynecology: Contraception Nozer Sheriar, Mala Arora, Paul D Blumenthal, Ritu Joshi
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Contraception Through the Ages: A Brief Historical Overview

1 Ameya C Purandare MD DNB FCPS DGO DFP MNAMS FICMCH FICOG *
Fellowship in Gyn Endoscopy (Germany), Purandare Hospital, KJ Somaiya Medical College, Bombay Hospital and Medical Research Centre, Masina Hospital, Mumbai, Maharashtra, India
2 Kirti R Bendre MD DGO
KJ Somaiya Medical College, Mumbai, Maharashtra, India

ABSTRACT

Man always desired to control the power of procreation. Various methods were initiated around the world to prevent conception. In this article, we have tried to track this journey in finding the ideal method of contraception. Contraception can be achieved by a variety of methods. Some methods never become popular due to religious obstacles as well as sociocultural myths and beliefs. Methods relying on behavioral discipline, such as abstinence and coitus interruptus, are difficult to achieve, hence not popular. Barrier contraception became an easier choice early in history. The major change came with the evolution of oral contraceptive pills, especially with its lowered hormonal content. The 20th century welcomed the era of intrauterine contraceptive devices (IUCD). The invention of hormonal intrauterine device offered a new dimension to contraception with excellent credentials. Surgical methods such as no-scalpel vasectomy (NSV), and tubal ligation have made their individual mark in the contraceptive journey. However, the quest for an ideal contraceptive still continues.
 
INTRODUCTION
From the dawn of mankind, women and men have wanted to be able to decide, when and whether to have a child. Contraceptives have been used throughout human history in various forms. Family planning has always been widely practiced even though, the methods used before the 20th century were not always as safe or effective as those available today. It has also been dominated in societies by social, political, or religious codes that require people to “be fruitful and multiply”.
 
BEHAVIORAL METHODS
2The earliest methods of family planning were based on sexual behavior, such as timing of intercourse only during low fertility periods and lactation as well as abstinence.
 
Continuous Abstinence
From menarche till marriage women were expected to be abstinent.1,2 This practice also ensured paternity of their children.36 Abstinence is the only contraceptive with 0% failure rate.
 
Outercourse
This term can be used to encompass a wide variety of sexual behaviors. It is often used to describe sexual body rubbing that gratifies without penetration, hence carries little risk of pregnancy.
Mallanaga Vatsyayana, from India, wrote the world's greatest literary celebration of procreative and nonprocreative sex “Kama Sutra”, the most complete encyclopedia of sex practices in the ancient world. Written in 400 CE, Vatsyayana's Kama Sutra describes “erotic practices” including outercourse in the life of ancient Hindus in India.7,8
Outercourse had a major revival in America during the 1940s and 1950s. During those years, virginity was considered very important for unmarried women. Outercourse in the back seat of a car by teenagers of the 1950s allowed a young woman to have sex while remaining “technically” a virgin.9
 
Withdrawal
Withdrawal prior to ejaculation can be achieved in three ways:
  1. Coitus interruptus: It is the Latin name for withdrawal with ejaculation occurring outside the vagina.
  2. Coitus reservatus: It is the Latin name for withdrawal without ejaculation. Both methods have been practiced since ancient times,35,8 and find reference in the Bible spilled his seed on the ground. However, Muslims and some Jews and Christians consider it a sin to ejaculate without reproductive possibility, i.e., masturbation and coitus interruptus. In ancient China and India, men were encouraged to practice coitus reservatus because it was believed that 3ejaculation caused a great loss of yang, the essence of masculinity. “Excessive” ejaculation would diminish vigor. Coitus reservatus is still practiced in order to maintain a balance of yin and yang.10
  3. Coitus obstructus: Chinese men who were unable to “reserve” their ejaculations were taught to firmly press the urethra between the scrotum and the anus with a finger as they ejaculated. This technique, in fact, forces the semen into the bladder, from which it is excreted in urine. This form of coitus reservatus is called coitus obstructus.35
However, since a man's pleasure was in ejaculation, having sex without ejaculation was not sinful by many theologians. Hence, coitus reservatus was the only sinless sex a Christian man could have.7
 
Calendar Method
In the 17th and 18th centuries, women observed their cervical mucus to understand their fertility period. They observed that monitoring the quality of their cervical mucus could help them avoid or plan a pregnancy.11 Australian Dr John and Dr Evelyn Billings studied the cervical mucus and included it in the symptothermal method of contraception, which combines the use of cervical mucus, the basal body temperature, and the calendar method.35
 
Lactational Amenorrhea Method
It has been used for spacing pregnancies by extended breastfeeding. Complete breastfeeding can postpone ovulation and menstruation. However, affluent women in Europe appointed wet nurses and did not breastfeed. This explains why affluent women in history had many more children than their common counterparts.12
Wet nurses were also common in South America during the same period. Usually, the women who served as wet nurses were African-American slaves13 who may have welcomed extended breastfeeding as a way to avoid breeding.
 
BARRIER METHODS
 
The Condom
Since ancient times, condoms have been used, as a method of birth control, and as a protective measure against sexually-transmitted diseases. Condoms have been made from a variety of materials; prior to the 19th century, chemically-treated linen and animal tissue (intestine or bladder) were used. Rubber condoms gained popularity in the mid-19th century. In the second half of the 20th century, condoms became increasingly important in efforts to fight the acquired immunodeficiency syndrome (AIDS) pandemic.4
Historians disagree about how condoms got their name. Some say a “Dr Condom” supplied an 18th century king with animal-tissue sheaths to keep him from fathering illegitimate children and getting diseases from prostitutes.14 Others claim the word comes from a “Dr Condon” or a “Colonel Cundum.” It is more likely that the word derives from the Latin condon, meaning “receptacle.”14,15 The oldest condoms were found in the foundations of Dudley Castle in England. They were made of animal gut and dated back to 1640.15
Rubber condoms were mass-produced after 1843, when Charles Goodyear patented the vulcanization of rubber. By 1924, the condom was the most commonly prescribed method of birth control,16 and by World War II, military leaders had a more realistic attitude about condoms. Concerned that “our boys” would bring home diseases and infect their wives, they aggressively promoted the use of condoms. Government training films urged soldiers “Do not forget to put it on before you put it in”.
After learning in the early 1980s that human immunodeficiency virus (HIV) is a sexually-transmitted infection, the use of condoms was encouraged to prevent transmission of HIV. Despite opposition by some political, religious, and other figures, national condom promotion campaigns occurred in the United States and Europe. These campaigns increased condom's use significantly.
 
Female Condom and Vaginal Sponge
Various civilizations practiced the insertion of substances in the vagina to absorb semen and promote contraception. Few examples are:
  • South Africa: Vegetable seedpods
  • Africa: Plugs of grass and crushed roots
  • Japan China and South Sea Islands: Wads of seaweed, moss, and bamboo
  • Ancient Greece: Empty halves of pomegranates16,17
  • A contraceptive sponge came in the American market in 1983 and quickly became one of the most popular over-the-counter barrier methods
  • The Today sponge is impregnated with spermicide designed to block and absorb semen as well as immobilize sperms.
 
Contraceptive Foams, Creams, Jellies, and Suppositories
In India, women used rock salt soaked in oil for birth control in the 1st century. They also used honey, ghee (clarified butter), and seeds of the palasha (a kind of native berry).14
Greek physician Aetios suggested, in the 6th century that women smear their cervices with cedar resin combined with myrtle, lead, alum, or wine. He also suggested that their partners coat their penises with alum, pomegranate, gallnut, or vinegar to immobilize sperms.5
Arab women in the 10th and 11th century used a paste of honey, elephant dung, and water.17 Egyptian women by 1550 made cotton-lint tampons and soaked them in fermented juice of acacia plants to prevent pregnancy.14
 
Diaphragms and Cervical Caps
As mentioned above, covering the cervix with a variety of substances could prevent pregnancy.14,17 In 1838, German gynecologist Friedrich Wilde created rubber “pessaries” for individual patients with custom-made molds. Wilde's pessaries resembled today's cervical caps. By 1864, the British Medical Association was able to list 123 kinds of pessaries. By 1941, a diaphragm was developed in Germany,16 which was considered as the most effective method of contraception. With the invention of the contraceptive pill and the intrauterine device (IUD), the diaphragm and cervical cap fell out of favor during the 1960s. The reasons for current low usage of diaphragms is the need for correct fit, hassle of cleaning and storage, and the risk of developing toxic-shock syndrome if the device is left in place for longer than 24 hours.
 
HORMONAL METHODS
 
The Pill
According to ancient Greek myth, Persephone, the goddess of spring, refused to eat anything but pomegranate seeds after she was stolen from her mother, Demeter, raped by the god of death; and kidnapped to the underworld. Medical historians now suspect that she only ate pomegranate seeds as it has some contraceptive properties.
In the 7th century BC, a brisk contraceptive trade developed in the part of North Africa that is now known as Libya. The flowering plant Silphium grew there. Silphium belonged to the genus Ferula and was such a reliable contraceptive that it fetched an exorbitant price at shipping ports all over the ancient world. It is depicted on silver coins of the era. Despite its staggering price, the demand for Silphium was inexhaustible. By the 1st century, the plant became very scarce from overharvesting, and by the 4th century, it was extinct.1820
Women all over the world use various plants, fruits, or seeds either for preventing pregnancy or as abortifacients. Papaya seeds are crushed and used in India as an abortifacient. It contains the enzyme papain which may interact with the hormone progesterone to prevent/disrupt a pregnancy.
Animal experiments in the late 1930s demonstrated that high-dose progesterone could arrest ovulation. Chemist Dr Carl Djerassi synthesized progestin from an extract of Mexican wild yam root in the late 1940s, and the concept of arresting ovulation in women became reality.6
Oral contraception was revived in 1940s and 1950s by Margaret Sanger who closely followed scientific research on the possibility of a contraceptive pill and even personally funded some of it. Dr Gregory Pincus was an American biologist and researcher who coinvented the combined oral contraceptive pill. He along with Min Chueh Chang confirmed that progesterone can act as an inhibitor of ovulation. Pincus was fascinated by Sanger as she revealed the struggles of poor women who had to endure many pregnancies. She in fact influenced him to create a successful contraceptive. The turning point came when Katharine Dexter McCormick (1875-1967) contributed financial support for research to produce an oral contraceptive pill. This direct sponsorship allowed Pincus and his colleagues to pursue research at a fast pace. In 1953, the first human trials began in Puerto Rico, which unlike many US states had no laws against contraception. The first marketed pill, Enovid 10, contained 9.85 mg of the progestin norethynodrel and 150 μg of the estrogen mestranol. The first pill was far from perfect but its effectiveness, simplicity, and ease of use extended the benefit to millions of women for the first time, offering them a sense of freedom.21
In the 1970s, the hormonal content of the pill was revised and the cycle regimen developed. Ethinyl estradiol (EE) content has now decreased from 50 μg to 30–35 μg, which significantly reduces the incidence of venous thrombosis. Subsequently, pills containing EE 20 μg were developed, which did not further decrease adverse events but increased the incidence of breakthrough bleeding.
More than 15 years ago, the Food and Drug Administration (FDA) proclaimed that “more studies have been done on the pill to look for serious side effects than have been done on any other medicine in history”.21 That scientific scrutiny has continued to this day. The pill of today, as well as other more recent combined hormone methods, the patch, and the ring offer safety and effectiveness with significantly lowered doses of hormones.
 
Depot Medroxyprogesterone Acetate
Three years after the pill became available, family planning researchers were developing ways to make it possible for women to benefit from an equally effective hormonal method without taking a pill everyday.22 More than 30 million women worldwide have used depot medroxyprogesterone acetate (DMPA) since it was introduced in 1969. In1992, the FDA approved DMPA as a long-acting, injectable progestin-only contraceptive for use in the US.
 
Emergency Contraception
In ancient history, the following postcoital methods are described:
  • Removal of ejaculate from the vagina manually before fertilization can take place14
  • 7In another method, the woman would get up abruptly, sneeze and blow her nose several times, then shout loudly and jump backwards several times23
  • Ancient Hebrew women were able to expel ejaculate from their vagina with forceful contractions of their vaginal muscles
  • Postcoital douching with acidic water
  • Induce menstruation before fertilization or implantation can take place. Many herbal recipes to induce menstruation were taught by Hippocrates.
Pills for emergency contraception (EC) were first prescribed by Dr Albert Yuzpe, a Canadian obstetrician, in the 1970s. Yuzpe's regime of the pill has been used by millions of women to avoid unintended pregnancy.24 In 1999, the US FDA approved the first progestin-only EC which was known as “Plan B”. After World Health Organization (WHO) conducted a large trial comparing Yuzpe regime with levonorgestrel (LNG) in 1998, combined estrogen-progestin products were gradually withdrawn from some markets in favor of progestin-only EC, although Yuzpe regime products are still available in some countries. Ulipristal acetate 30 mg pill can also be used for EC within 120 hours of unprotected intercourse.
 
The Intrauterine Device
Tiny stones were inserted into the uterus of each female camel to prevent pregnancy during long caravan journeys across the desert.35 During the 9th century, a Persian physician recommended inserting paper in the shape of a probe, tied with a string, and smeared with ginger water. In certain rituals, the Maori people of New Zealand put small pebbles into women's vaginas to make them “sterile as stones”.14
During 1909s, in Germany, IUDs were manufactured from the silkworm gut. They were effective but caused serious infections leading to dangerous pelvic inflammatory diseases. During the 1920s and 1930s, ring-shaped devices of gut, gold, and silver were made, but infection was still a major problem.25
In 1926, a German physician, Ernst Gräfenberg, produced the G-ring, a ring-shaped device that was widely distributed and successfully used.25 Jack Lippes, a gynecologist from Buffalo, invented the Lippes Loop in the early 1960s. The Lippes Loop was an instantaneous success, and was used worldwide.35,25 These inert IUDs are known as first-generation IUDs. The Dalkon Shield was developed by the Johns Hopkins School of Medicine and released in 1971. It had a multifilament string that facilitated ascending infection. The incidence of pelvic sepsis and septic abortions was high among its users, hence it was withdrawn from the market in 1974 by the FDA.
The development of the first copper-bearing IUD was announced in 1969 by Dr Zipper and Dr Tatum. These were called second-generation IUDs. The multiload IUD invented by the Dutch gynecologist Dr Willem van Os in 1974 8was very successful. The copper-bearing devices, although adding a new dimension to intrauterine contraception, did not solve the problem of menorrhagia, which is the most important reason why women request IUD removal. This problem was finally solved in 1977 with the introduction of the first hormone-containing IUD. The first progestin-releasing IUD was Progestasert with a life of 1 year. LNG-releasing IUD was approved by the FDA in the year 2000. These are the third-generation IUDs.
The IUD of today has become safer than ever before, and it has excellent credentials. Both the WHO and the American Medical Association name it among the safest, most effective, and least expensive reversible methods of birth control available to women.
 
PERMANENT METHODS
 
Vasectomy
In the early 1900s, vasectomy was performed for men with hereditary diseases, mental retardation, and prisoners of war.
The first recorded vasectomy was performed on a dog in 1823.26,27 A short time after that Harrison of London performed the first human vasectomy; however, the surgery was not done for sterilization purposes, but to bring about atrophy of the prostate. Vasectomy began to be regarded as a method of birth control during the Second World War. The first vasectomy program on a national scale was launched in 1954 in India.
The no-scalpel vasectomy (NSV), originally developed in China in 1974, was first introduced in the US in 1984. It is an innovative approach to exposing the vas deferens using two specialized surgical instruments. A recent Cochrane Review concluded that the NSV is superior as compared to traditional incisional technique as it resulted in less bleeding, hematoma, infection, pain, and a shorter-operative time.
 
Tubal Sterilization
The first tubal ligation in the US was performed in Toledo, Ohio, USA in 1880. It was performed with a cesarean section to prevent any future high-risk pregnancies.28,29 Until the mid-1970s, tubal ligation usually involved major abdominal surgery which required general anesthesia.
Laparoscopy, which became popular in the early 1970s, drastically changed the entire picture. With laparoscope, tubal ligation could be performed through a small incision. General anesthesia was no longer mandatory. It also reduced the duration of hospital stay. During the same decade, surgical advances resulted in safe, less invasive female sterilization procedures when childbearing was no 9longer desired. Most importantly, insurance companies began to cover female sterilization procedures, making the procedure accessible to millions of women in the US previously unable to afford the surgery.
In India, sterilization has been an important component of Family Welfare Program. The camp approach was introduced in fourth 5-year plan. After the introduction of laparoscope, many camp tubal ligations were done laparoscopically.
In 2002, Essure® became the first permanent contraceptive system to be approved by the US FDA.30 The Essure® system is a minimally-invasive alternative for permanent female sterilization. Essure® utilizes a transcervical hysteroscopic approach to place permanent microinserts into the Fallopian tube ostia bilaterally. Ongoing research will be needed to address its safety profile in the long-term.
 
CONCLUSION
The quest for an ideal contraceptive still continues. The significance of contraception is not just to reduce the burden of population, but it also has an important role in reducing maternal mortality and ensuring better health of mothers and children, thus contributing to a better society.
“Birth control is the first important step woman must take toward the goal of her freedom. It is the first step she must take to be man's equal. It is the first step they must both take toward human emancipation.”31
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