CONTRACEPTION &

FAMIY PLANNING
DR NAILA MEMON
IDEAL CONTRACEPTIVE
Inexpensive
Easy and simple to use with minimum side effects
Rapidly reversible
Readily available
Highly effective.?
Can be administered by non-healthcare personnel.
Contraceptive effectiveness
Difficult to determine :
1. Perfect VS typical use (method failure and patient
failure)
2. Correct VS incorrect use
3. long term VS short term
Pearl index
Method used for determination of pregnancy failure
rate:

Pregnancy rate = no. of pregnancies x100women/12

months of use
classifications
A. Natural Methods
Periodic abstinence
Withdrawal
Lactational Amenorrhea Method
Standard days method
Calender rhythm method
B. Barrier Methods
C. Hormonal
D Intrauterine Devices
E.. Sterilization
HORMONAL
CONTRACEPTION
Objectives

Combined pills
Progestin pills (minipills)
Subdermal patches
Injections
Vaginal ring
Oral contraceptive pills
World wide used

very convenient method

Reversible methods
Combined
Composition
Combination of Estrogen & Progesterone
Ethinyl Estradiol (most commonly used
nowadays)
Levonorgestrel, Norethindrone,

Intake
21 days: 1 pill/day
Last 7 days: free
Minipills

Used for 28 days, no breaks

Same time of the day
POP: Suitable for -
Older women,
Heavy smokers,
Hx/Predisposition to VTE,
Pts with HTN,Valvular heart ds., DM, or Migraine,
Breastfeeding women < 6mo postpartum (delay
until =/> 3w postpartum to avoid risk of heavy
bleeding).
Starting the POP
No previous contraception= start on day 1,
Changing from COC= start the day following last pill (
no pill-free period),
After childbirth= start anytime > 3w,
If weight > 70 kg= Consider Desogestrel or 2 tabs/d
of any other POP( unlicensed)
 Mechanism of action

Combined :
most effective method because they inhibit midcycle gonadotropin surge
and prevent ovulation

Progestin only pills:

dont mainly not inhibit ovulation

Both types act by -altering cervical mucus making it thick viscid and scanty
-alter endometrium so not fit for implantation
- alter ovarian responsiveness to gonadotropin stimulation
How to prevent ovulation?
Interfere with the release of GnRH from
hypothalamus so it will suppress LH & FSH
In high concentration they will inhibit pituitary gland
directly
Progestin only pills don't inhibit ovulation mainly
because a lower dose of progestin is used in
preparations less than combine forms it is important
to be taken at the same time of the day to ensure that
blood level do not fall below the effective levels
Short-term side-effects
OESTROGENIC EFFECTS
Breast tenderness (3.6%),
Nausea ( 1.5%),
Dizziness
Cyclical wt. gain
Bloating
Vaginal discharge without
infection
use a more progestogen- Use a more oestrogen-dominant
dominant pill
PROGESTOGENIC EFFECTS
Depression(3.9%),
Premenstrual tension
Dry Vagina
Sustained wt. gain
Decreased libido
Lassitude
Acne
pill
 Estrogen cause pigmentation and high level of
estrogen may accelerate the development of
gallbladder disease in young female but not increase
the risk of acute cholelithiasis
Progestin : because they are structural related to
testosterone they produce androgenic effects like
increase weight and acnes
 Metabolic effects
combined chemical clinical

HDL increase cardiovascular

LDL decrease disease ?
TG increase
Progestin only
HDL decrease
LDL increase
TG decrease
NONCONTRACEPTIVE BENEFITS
BENEFITS FROM ANTIESTROGENIC EFFECTS
OF PROGESTERON:
1-decrease menses blood loss & improve anemia
2- risk of adeno CA of uterus
3- estrogen receptors in breast so risk
begnin breast disease ?
BENEFITS FROM INHIBITION OF OVULATION
(dysmenorrhea )
use as therapy of severe dysmenorrhea
OTHER BENEFITS: risk (PID,Rhumatoid a, bone
loss)
complications

CVS:
DVT
Myocardial infarction
Stroke
Neoplastic effects
Breast CA
Endometrial CA : protection related to duration of use
Ovarian CA : decrease risk duration related
Liver adenoma and CA?
Pituitary adenoma : mask symptoms produced by
prolactinoma amenorrhea and galactorrhea
colorectal CA: protection
Liver cyst and adenoma
Contraindications

Absolutes

Histoy of vascular disease (thromboembolism)

Systemic diseases (affect vascular system) SLE , DM
with retinopathy or nephropathy
Undiagnosed uterine bleeding
Increase serum TGs
Heart failure rare because incidence of heart diseases
are mostly after menopause
Smoking in female more than 35y
Contraindications

Relatives:

Migraine headache
Undiagnosed amenorrhea and depression
Smoking in female less than 35 y
VAGINAL RING

Steroids absorbed though vaginal epithelium directly

into circulation
Contain ethniyl estradiol and etonogestreland
Place in vagina for 21 days and remove 7 days to
allow withdrawal bleedings
TRANSDERMAL PATCH

It releases norelgestromin & ethinyl estradiol

Weekly applied, for 3 weeks, and the last week of the
cycle is a patch-free week
Normal activities can be done while using the patch
LONG ACTING
CONTRACEPTIONS
 Sub dermal implants:
Need trained personal for insertion and
removal.
Out patients procedure.
99.5% effectiveness rate.
Requires no user motivation so compliance
not problem.
Amennorhoea is common
 Subdermal implantation for continuous release

Effective for up to 3 years

Rapid return of fertility

Problems
Menstrual irregularity
Weight gain
Surgical implantation & removal
Norplant Implant
INJECTABLE SUSPENTIONS
Depomedroxyprogesteron(DMPA)
IM,SC every 3 months
doesn't increase risk of breast ca

Other types: medroxyprogesteron acetate (AMP)

 IUD
-IUD is the world's most widely used method of
reversible birth control.
3 TYPES:
1- Inert ( no longer recommended because of
painful and heavy periods).

2-Copper Releasing (paragard).

3-Progesterone Releasing (IUS):

A-Progestasert (progesterone T) 1976 - 2001.

B-Mirena (levonorgestrel).
Intrauterine Contraception Devices:
1. Most commonly used reversible
- Method of Contraception
worldwide
- effective > 97%.
- The newer devices have failure
rate < 0.5%
 2. Copper bearing IUCD
- Consist of a plastic frame with copper wire
around the stem.
- Surface of the copper determine the
effectiveness and active life of the device.
- Most IUCD licensed for use over 5-10 years
and because of gradual absoption of copper,
these IUCD renewed after 3-5 years.
Copper Salt give some protection against bacterial
infection.
Mechanism of Action:
- All IUCD cause a foreign body reaction in the
endometrium with increased prostaglandin
production and Leucocyte infeltration. This reaction
enhanced by copper which effect endometrial
enzymes and oestrogen uptake and also inhibit
sperm transport.
- Alteration of uterine and tubal fluid impairs the
viability of the gametes.
- The progesterone IUCD (LNG.IUS) cause endometrial
suppression and change in the cervical mucus and
utro tubal fluid impair sperm migration.
Clinical uses

Long-term contraception

Women with contraindications to COC

Emergency contraceptive (1:1000 )

menorrhagia , endometriosis, chronic

pelvic pain, dysmenorrhea , anemia.
 Absolute Contraindications

-Pregnancy.
-Post partum puerperal sepsis
-Immediately post-septic abortion
-Undiagnosed abnormal vaginal bleeding.
-Suspected gynecological malignancy.
(Cervical cancer, Endometrial cancer)
-Current STDs.
-Current PID.
-anatomical abnormalities
EMERGENCY CONTRACEPTION

After intercourse and before implantation

Indication: failure of condoms
Unprotected intercourse
Within 72 hours after unprotected intercourse
Levonorgestrel Combined
Prescription
Single dose, the earlier the better
Prevented 75% of unplanned pregnancies

IUD Emergency Contraception

Within 5 days after unprotected intercourse
Copper IUD
NATURAL, PHYSICAL AND
SURGICAL METHODS
Periodic Abstinence
calendar method
Natural methods

Lactational amenorrhea
Definition
Efficacy
Advantages
Disadvantages
Barrier methods of contraception

Two types :

1. Physical barrier methods, such as condoms,

diaphragm, and cervical caps, that prevent pregnancy
by blocking the entry of sperm into the upper genital
tract;

2. Chemical barrier methods (spermicides) that kill

or inactivate sperm on contact. ( less effective , used
in combination , no STDs protection )
Barrier methods of contraception
easily available, reversible, and have fewer side
effects than hormonal methods.

effective and acceptable if used consistently and

correctly.

Protect against STD

Natural Methods:
1.) Calendar Method (Safe period)
- relies upon the fact that there are certain days during
the menstrual cycle when conception can occur
following ovulation, the ovum is viable within
reproductive tract for a maximum of 24 hrs.
- The life spam of sperm is longer 3 days.
- During 28 day menstrual cycle, ovulation occur around
day 14. This means that coitus must be avoided from
8th to 17th day.
- Failure rate is high so many couples find it difficult to
adher to this method.
2.) Ovulation method (The billings method)
- Ovulation prediction can be enhaced by several
complementary methods including *Basal body
temperature (BBT) rise in progesterone following
ovulates rise temp. BBT 0.2-0.4C, until the onset of
menstruation .
* Cervical mucus several days before ovulation
mucus appearance of raw egg white, clear, slippery
and stretchy (spinnbarkeit). The final day of fertile
mucus is considered to be the day when ovulation is
most likely to occur and abstinence must be
maintained from first day of fertile mucus until 3 days
after the peak day. The end of the fertile period is
characterized by appearance of (infertile mucus)
which is scanty and viscous.
*Failure rate of natural method mucus and BBT and
Calendar method 2.8 %.

3-personal fertility monitors: small devices able to

detect urine concentration of oestrone and LH
indicate start and end of fertile period.
- Failure rate 6.2%.
- Disadvantage provide no protection from STD .
 How to use Standard Days
Method
Every morning move
the rubber ring to the
next bead.
THE RED BEAD
is day 1 of cycle. Always move the ring in
On the first day of your the direction of the
period, move the rubber arrow.
ring onto the red bead. WHITE BEAD
Each bead DAYS
Mark a calendar to help
represents a day are days when
remember.
of your you CAN get
menstrual cycle pregnant.
BROWN BEAD Use a condom or
DAYS do NOT have
are days when sex on these
pregnancy days to prevent
is unlikely. pregnancy.
You can have sex on these days.
No condom needed. Are you ready to
When your next period starts, choose this
move the ring to the red bead method?
again. Skip over any remaining
 What to remember
Move the rubber ring one bead forward every
day
Always use condoms or avoid sex on
fertile white bead days
Come back if:
You get your period early Dark brown
(it starts before you put the ring on bead

the dark brown bead)

You get your period late Last brown

bead
(it does NOT start by the day after
you put the ring on the last brown
bead)
You have unprotected sex Anything else I can
repeat or explain?
on a fertile white bead day Any other
questions?
Male condoms

It is one of the most popular mechanical barriers.

Among all of the barrier methods, the condom
provides the most effective protection of the genital
tract from STDs. Its usage has increass because of the
concern regarding the acquisition of HIV and STDs.
Male condoms
Increasing the efficacy :

reservoir tip
The addition of spermicidal
lubricant to the condom. (water-based not oil-based)
the addition of an intravaginal spermicidal agent .
Female condoms

It contains 2 flexible rings. The ring at the closed end

of the sheath serves as an insertion mechanism and
internal anchor that is placed inside the vaginal canal.
The other ring forms the external patent edge of the
device and remains outside of the canal after
insertion.
Female condoms

- Mechanism of action :
Prevents passage of sperm
and infections into the vagina
( protection against STDs )

Can be inserted up to 8 hours

prior to intercourse; can remain in
place up to 8 hours
Female condoms
- Efficacy
Pregnancy rates for the female condom range
between 5 and 21 per 100 women per year.
(higher than male condoms)

To increase efficacy Simultaneous use of both the

female and male condom is not recommended

Re-use is not recommended .

Diaphragm
The diaphragm is a shallow latex cup
with a spring mechanism in its rim to hold it
in place in the vagina

It is inserted before intercourse so that the

posterior rim fits into the posterior fornix and
the anterior rim is placed behind the pubic bone.

Spermicidal cream is applied to the inside of the

dome, which fits against the vaginal wall.
Diaphragm
It prevents pregnancy by acting as a barrier to the passage of
semen into the cervix

provides effective contraception for 6 hours.

After intercourse, the diaphragm must be left in place for at

least 6 hours.

Effectiveness depends on the age of the user, continuity of use,

and the use of spermicide along with the diaphragm. Failure
rate is estimated to be 20% .
Diaphragm
Relative Contraindications :

- Latex allergy

- Uterine prolapse

- Repeated UTIs
Diaphragm
Disadvantages :

- Prolonged use increase the risk of UTI

- More than 24 hours use is not recommended

due to the possible risk of TSS.

- Might cause vaginal erosions if not placed properly .

- Requires a professional fitting (trained provider is needed) .

Cervical cap
a cup-shaped latex device that fits over the base of the
cervix.

The cap must be filled one third full with spermicide

prior to insertion

Inserted 8 hours before coitus and can be left in place

for as long as 48 hours.
Cervical cap
Acts as both mechanical barrier to sperm and as a chemical agent
with the use of spermicide .

Pregnancy rates range between 4 and 36 per 100 women per year.

Effectiveness depends on the parity of women due to the shape of

the cervical os.

Disadvantages : cervical erosions and vaginal spotting , risk for TSS

, requires professional fitting and training for use , high failure rate ,
and candidates must have a history of normal results of pap smears.
Spermicides
consist of a base combined with either nonoxynol-9
or octoxynol

Surfactant that destroys the sperm cell membrane

Forms available : vaginal foams, suppositories,

jellies, films, foaming tablets, and creams.
Spermicides
Failure rate is about 26% within the 1st year of use.

Advantages : ease of application , available over the

counter , inexpensive and it augments the
contraceptive efficacy of the cervical cap and
diaphragm .

Disadvantages : minimal protection against STDs ,

risk of vaginal irritation and allergic reaction.
 Sterilization
Sterilization :female sterilization and male vasectomy are permenant
metod of contaception and highly effective

They are generally chosen by relatively older couple who are sure
that they copleted their family.
Also individual who carry a genetic disorder may choose to be
strlizer.

28% of reproductive age women undergo tubal ligation and 10% of

men undergo vasectomy.
Sterilization methods include:

1- Vasectomy in males.

2- Tubal Ligation in females .

Tubal Ligation
This involve mechanically blockage of
both fallopian tube to prevent the
sperm reaching and fertilizing the
oocyte

sterilization performed by
laparoscopically(under GA) or through
a suprapubic mini-laparotomy

Failure rate: 0.5%

Tubal Ligation
Advantages:

intended to be permanent
highly effective
safe
quick recovery
lack of significant long-term side effects
cost effective
 Tubal Ligation
Disadvantage:

possibility of patient regret

difficult to reverse

future pregnancy could require assisted reproductive

technology (such as IVF)

more expensive than vasectomy

 Cont.
Complication:
A women may experienced anasthetic problem or may be
damage to intra-abdominal during the procedure.

NOTE:
ectopic pregnancy can be a late complications
and any sterilized women who misses her period and has
symptom of pregnancy should seek
medical advice.
 Vasectomy
Mechanism of action:
Vasectomy involve division of the vas deferens on each
side to prevent the release of sperm during
ejaculation.
Easier than tubal ligation.

Usually done under local anesthesia.

Failure rate: 0.1%.

 Vasectomy
Advantages:

permanent
highly effective
safe
quick recovery
lack of significant long-term side effects
cost effective; less expensive than tubal ligation
 Vasectomy
Disadvantages:

reversal is difficult, expensive, often unsuccessful

not effective until all sperm cleared from the
reproductive tract (may take up to 12 w)

no protection from STDs

Cont.
Complication of vasectomy:
Immediately bleeding, wound infection and hematoma
may occur.

At the cut of vas deferns small lump will apear as a

result of a local inflammation response this is called
sperm granuloma it needs surgica excision.
Cont.
some men develop anti-sperm antibody following
vasectomy
THANK YOU