FAMILY PLANNING

Julie Ann M. Valencia, MD

 Fertility

Awareness Methods
Hormonal Contraceptives
Intrauterine Device (IUD)
Emergency Contraception
Lactation

FERTILITY AWARENESSBASED METHOD

NATURAL

FAMILY PLANNING

Involve sexual abstinence during the

fertile time
FERTILITY

AWARENESS
COMBINED METHODS (FACM)
Occasionally using a barrier during the

fertile time
Pregnancy

rate 20% (1st year)

Standard Days Method

Avoid unprotected
intercourse during
days 8-19
Women must have
regular monthly
cycle of 26-32
days

Calendar Rhythm
Method

Counting the number

of days in the shortest
and longest menstrual
cycle in a 6-12 month
span
Shortest cycle: subract
18
Longest cycle: Subtract
11
Example: 25-45 days
25-18 = 7
45-11 = 34 days 734 FERTILE DAYS

Temperature Rhythm Method

Relies on slight
changes in the basal
body temperature
before ovulaton
Sustained 0.4 degree
Fahrenheit increases
Intercourse is avoided
from day 1 of menses
through the 3rd day
after the increase in
temperature

Cervical Mucus Rhythm

Method
Billings Method
Awareness of vaginal
dryness or wetness
Amount and quality of
cervical mucus
Abstinence from the
beginning of menses
until 4 days after
slippery mucus is
identified
3% - 1st year failure
rate

Symptothermal Method

Changes in
cervical mucus
onset of fertile
period

Changes in basal
body temperature
end of fertile
period

Lactation

Ovulation during
1st 10 weeks after
delivery is unlikely

HORMONAL
CONTRACEPTIVES
Oral
Injectable
Transvaginal-ring
Transdermal patch

Estrogen plus Progestin

Contraceptives
Most

frequently used method

Progestins:
Prevent ovulation by suppressing LH
Thicken cervical mucus
Render endometrium infavorable for

implantation
Estrogen:
Suppresses FSH release
Stabilizes endometrium

Dosage
Estrogen:

20-50 ug, most 35 ug

Progestin:
Monophasic: amount remains constant
Phasic pills: reduce the amount of total

progestin per cycle

Administration
Taken

daily (21-81 days)

Pill-free interval (4-7 days)
withdrawal bleeding is expected

Usage
Pill

Usage:

1st day of menses

Sunday start first Sunday that follow

menses onset, and a back up method x

1 week
Quick start - any day, back up method
used during 1st week

 Pill

usage:

Should be taken at the same time each day

dose missed effect not diminished

with monophasic COCs
Several doses missed or if lower-dose
pill used:
pill may be stopped, restarted after

withdrawal bleeding;
Barrier technique used until menses

DRUG INTERACTION
Effectiveness is influenced
by COCPs

Analgesics

Diazepam
Alprazolam

Acetaminophen
Aspirin
Meperidine
Morphine

Anticoagulants

Temazepam

Antihypertensives
Cyclopenthiazide
Metoprolol

Antibiotics
Troleandomycin
Cyclosporine

Antidepressants
Imipramine

Anti-inflammatories
Corticosteroids

Dicumarol, warfarin

Tranquilizers

Antiretrovirals

Bronchodilators
Aminophylline
Theophylline
Caffeine

DRUG INTERACTION Reduce

COCP Efficacy

Antituberculous
Rifampin

Antifungals
Griseofulvin

Anticonvulsants
and Sedatives

Tetracycline,

Phenytoin,

mephenytoin,
phenobarbital,
primidone,
carbamazepine,
ethosuximide

Antibiotics
doxycycline
Penicillins
Ciprofloxacin
Ofloxacin

Antiretrovirals

Some Benefits of Combined

Estrogen Plus Progestin Oral
Contraceptives
Increased

bone density
Reduced menstrual blood loss and anemia
Decreased risk of ectopic pregnancy
Improved dysmenorrhea from endometriosis
Fewer premenstrual complaints
Decreased risk of endometrial and ovarian cancer
Reduction in various benign breast diseases
Inhibition of hirsutism progression
Improvement of acne
Prevention of atherogenesis
Decreased incidence and severity of acute salpingitis
Decreased activity of rheumatoid arthritis

Adverse Effects
Lipoproteins and Lipids:
serum triglycerides and
cholesterol, HDL
LDL
Carbohydrates:
May be used in nonsmoking, diabetic
women younger than 35 yrs old with
no associated vascular disease

Adverse Effects
Protein:
Sex hormone binding globulin
bioavailable testosterone
Angiotensinogen production pillinduced hypertension
Fibrinogen, Factors II, VII, IX, X XII,
XIII

Adverse Effects
Hepatic effects
Cholestasis and cholestatic jaundice
are uncommon
Active hepatitis is a contraindication
to COC use
Nutrition
plasma levels: Ascorbic acid, Folic
acid, Vitamin B6, B12, Niacin,
Riboflavin and Zinc

Adverse Effects
Neoplasia
Protective against ovarian and endometrial
cancer
Linked to development of hepatic focal nodular
hyperplasia and benign hepatic adenoma
No evidence for risk of hepatocellular cancer
Relative risk of cervical dysplasia and cervical
cancer is
rates of benign breast disease
Does not increase risk of breast CA for carriers
of BRCA1 or BRCA2

Adverse Effects
Cardiovascular Effects
risk of DVT and pulmonary embolism
Not recommended for women >35 yrs old and
smoker
Not associated with ischemic and hemorrhagic
strokes in nonsmoking <35 yrs old
May be considered for women with migraines
that lack focal neurologic signs if <35 yrs old
nonsmokers and healthy
Not associated with risk of myocardial
infarction

Adverse Effects
Reproduction
>90% begin to ovulate within 3 months of
discontinuation
Not teratogenic
Infection
Did not decrease incidence of PID but modify
its clinical severity
Lower rates of bacterial vaginosis
Increased rates of Chlamydia trachomatis
infection but not Neisseria gonorrhea

Adverse effects
Mood changes
Low dose Estrogen formulations are not
associated with depression or premenstrual
mood changes
Other Effects
Progestin - serum free testosterone levels and
inhibits 5-reductase
Estrogen - SHBG circulating androgens
Hyperpigmentation
Cervical mucorrhea
formation of uterine leioyomas

TRANSDERMAL PATCH
May be applied to buttock,
upper outer arm, lower
abdomen, or upper torso
(breasts avoided)
Initiation same for COCs,
new patch applied weekly x
3 weeks
Patch-free week
withdrawal bleeding
Remain effective for up to 9
days
Should weigh <90kg
No risk factors for CV
disease and
thromboembolism

TRANSVAGINAL
ADMINISTRATION
NuvaRing
Flexible intravaginal hormonal
contraceptive ring
Contains Ethinyl estradiol +
Etonogestrel (15ug and
120ug/day respectively)
Placed within 5 days of
menses
Removed after 3 weeks for
week to allow withdrawal
bleeding
Vaginitis, leukorrhea, ringrelated events are common
May be removed for
intercourse but should be
replaced within 3 hours

PROGESTATIONAL
CONTRACEPTIVES
Oral
Mini-pills
Taken daily
Do not inhibit ovulation
Alteration on cervical mucus and effects
on the endometrium
Should be taken at the same time
everyday
Higher incidence of irregular bleeding
and pregnancy rate

PROGESTATIONAL
CONTRACEPTIVES
Benefits:
Do not cause or exacerbate hypertension
Excellent choice for lactating women
100% effective with breastfeeding for up to 6

months
Disadvantages:
If taken 4 hours late, a back-up form of

contraception must be used for the next 48

hours
frequency of functional ovarian cyst
Irregular uterine bleeding

PROGESTATIONAL
CONTRACEPTIVES
Contraindication:
Unexplained uterine bleeding
Known breast CA, benign or malignant

liver tumor, acute liver disease

PROGESTATIONAL
CONTRACEPTIVES
Injectable Progestin Contraceptives
Depot Medroxyprogesterone acetate
(DepoProvera), 150 mg every 3 months
Pregnancy rate - 0.3%

Norethisterone

enanthane (Norigest), 200

mg every 2 months
Ovulation inhibition, increased cervical
mucus viscosity, creates unfavorable
endometrium
Should begin within first 5 days following
menses

PROGESTATIONAL
CONTRACEPTIVES
Benefits
3-month dosing schedule
Minimal to no lactation impairment
Not shown to increase risk for DVT, stroke or CV

disease
Disadvantages:
Irregular menstrual bleeding
Prolonged anovulation after discontinuation
Weight gain
Breast tenderness
Loss of bone mineral density

PROGESTIN IMPLANTS

Levonorgestrel Implants
Implanted subdermally

Etonorgestrel implants
Medial surface of the

upper arm, 6-8 cm from

the elbow, within 5 days
of onset of menses
Used for 3 years and then
replaced
Return of ovulation is
rapid
Most frequent adverse
event: Prolonged and
frequent bleeding

INTRAUTERINE DEVICE
Chemically

inert nonabsorbable
material and imprenated with barium
sulfate for opacity
Chemically active continuous
elution of copper or progestin

INTRAUTERINE DEVICE

Mirena
Levonorgestrel, 20

ug/day
T-shaped
radioopaque frame

Paragard
Polyethylene and

barium sulfate, Tshaped frame

wound with copper

INTRAUTERINE DEVICE
Use

and forget 10 years for

Paragard, 5 yrs for Mirena
Risk of pelvic infection decreased
Contraceptive effect decreases the
absolute number of ectopic
pregnancies by 50%

INTRAUTERINE DEVICE
Efficacy
Ability to prevent pregnancy is similar

overall to that of tubal sterilization

Levonorgestrel system
Typical-user failure rate of 0.1% after 1 year
of use
<0.5% cumulative pregnancy rate by 5 years

INTRAUTERINE DEVICE
Contraceptive

action

Intense local endometrial inflammatory

response
Decreased sperm and egg viability
Makes endometrium a hostile site for
implantation of blastocyst
Copper levels increase mucus and lower sperm
motility and viability
Glandular atrophy and stromal decidualization
Create scant vsicous cervical mucus that
hinders sperm motility

INTRAUTERINE DEVICE
Benefits:
Fertility not impaired
risk of endometrial cancer
No increased risk of genital tract or

breast neoplasia
Insertion: 6-8 weeks after delivery to
reduce expulsion rates and minimize risk
of perforation

Contraindications
Pregnancy

or suspicion of pregnancy
Abnormalities of the uterus resulting in distortion of the
uterine cavity
Acute pelvic inflammatory disease or a history of pelvic
inflammatory disease unless there has been a subsequent
uterine pregnancy
Postpartum endometritis or infected abortion in the past 3
months
Known or suspected uterine or cervical neoplasia, or
unresolved abnormal cytological smear
Genital bleeding of unknown etiology
Untreated acute cervicitis or vaginitis, including bacterial
vaginosis, until infection is controlled
Woman or her partner has multiple sexual partners

Contraindications
Conditions

associated with increased susceptibility to

infections with microorganismsthese include but are not
limited to leukemia, acquired immune deficiency
syndrome (AIDS), and intravenous drug abuse
History of ectopic pregnancy or condition that would
predispose to ectopic pregnancy
Genital actinomycosis
A previously inserted IUD that has not been removed
Additionally,

the ParaGard T 380A (because of its copper

content) should not be inserted when one or more of the
following conditions exist:
Wilson disease
Copper allergy

BARRIER METHODS

Male Condom

Effective contraception
Reservoir tip and addition of

spermicidal lubricant

Should be used with every

coital contact
Should be in place before
contact of the penis with
tha vagina
Wihdrawal must occur
with the penis erect
Base of the condom must
be held during withdrawal
3-8% slippage and
displacement rate

 Infection

prevention

Considerable protection but not absolute

against STIs
HIV, gonorrhea, syphilis, herpes, chlamydia,
trichomoniasis
Decreased risk for bacterial vaginosis
Blocks transmission of HPV

Female Condom
Polyurethane sheath
with one flexible
polyurethane ring at
each end
Male condoms should
not be used
concurrently
0.6% breakage rate
3% slippage and
displacement rate
Impermeable to HIV,
cytomegalovirus and
Hepatitis B viurus

Spermicide
Cream,

jellies, suppositories, films,

aerosol foam
Physical barrier and chemical
spermicidal
Nonoxynol-9 or octoxnol-9
Must be depsoited high in the vagina
in contact with cervix shortly before
intercourse
Duration: 1 hour
Does not provide protection against

Diaphragm plus
Spermicide
Circular latex
dome supported
by circumferential
latex-covered
metal spring
Can be inserted
hours before
intercourse
Should not be
removed for at
least 6 hours after

Contraceptive Sponge
Nonoxynol-9
impregnated
polyurethane disc, with
dimple on one side and
satin loop on the other
Can be inserted for up
to 24 hours prior to
intercourse
Should remain in place
for 6 hours after
intercourse
Spermicidal, covers the
os, absorbs semen

Cervical Cap, Leas

shield

Cervical cap
Flexible, cup-like device

made of natural rubber and

fitted around the base of
cervix
Allowed to remain in place
for up to 48 hours
Should be used with
spermicide

Leas shield
Reusable, washable barrier

made of silicone
Inserted prior to intercourse
and must be left in place for
8 hours

EMERGENCY
CONTRACEPTION
Estrogen-Progestin Combination
(Yuzpe Method)
Ethinyl estradiol 100ug +
levonorgestrel 0.5 mg
1st dose: within 72 hours of
intercourse
2nd dose: 12 hours after the 2nd dose
Nausea and vomiting
3.2% Pregnancy rate

Progestin only (Plan B)

2 tablets: 0.75 mg levonorgestrel
1st dose: within 72 hours
2nd dose: 12 hours after the 1st dose
1.1% Pregnancy rate

CONTRACEPTIVE FAILURE RATES

DURING 1ST YEAR OF USE
METHOD

PERFECT USE

TYPICAL USE

Combination pill

0.3

Progestin-only pill
0.5
("mini-pill")
Intrauterine devices:

Mirena levonorgestrel 0.1

device

0.1

ParaGard T 380A

0.6

0.8

Patch

0.3

Depot
0.3
medroxyprogesterone

3.1

CONTRACEPTIVE FAILURE RATES

DURING 1ST YEAR OF USE
METHOD

PERFECT USE

TYPICAL USE

Combined injectable

0.5

Levonorgestrel
implants

0.05

0.05

NuvaRing vaginal ring 8

0.3

Female sterilization

0.5

0.5

Male sterilization

0.1

0.15

Spermicides

18

29

CONTRACEPTIVE FAILURE RATES

DURING 1ST YEAR OF USE
METHOD
Periodic abstinence

PERFECT USE

TYPICAL USE

Calendar
Ovulation method

9
3

20

Symptothermal

Postovulation

Withdrawal
Cervical cap

27

Parous women
Nulliparous women

26
9

32
16

CONTRACEPTIVE FAILURE RATES

DURING 1ST YEAR OF USE
METHOD

PEFRFECT USE

TYPICAL USE

Parous women

20

32

Nulliparous women

16

Diaphragm and
spermicides

16

Male

15

Female

21

Emergency
contraception

>75% reduction

Sponge

Condom

STERILIZATION
Female

Sterilization

Puerperal tubal sterilization

Nonpuerperal Surgical Tubal Sterilization

Male

Sterilization

Vasectomy

Female Sterilization
Puerperal

Tubal Sterilizaton

Immediately following delivery

Failure rates
Surgical errors:
transection of round ligament or partial transection
of tube
Fistulous tract or spontaneous reanastomosis
between severed tubal stumps

Female Sterilization
Nonpuerperal

Tubal sterilization

ligation and resection at laparotomy

application of a variety of permanent

rings, clips, or inserts to the fallopian

tubes, by laparoscopy or hysteroscopy
electrocoagulation of a tubal segment,
again usually through a laparoscope

Female Sterilization
Failure

Rates

Surgical errors: 30 to 50% of cases

An occlusion method failure:
Fistula formation, especially with electrosurgical
procedures
Faulty clips
Fallopian tube may spontaneously reanastomose
Equipment failure
Luteal phase pregnancy.
Proper placement of clips is documented, and

no reason is found

Female Sterilization Long

term Complications
Ectopic

Pregnancy

Any symptoms of pregnancy in a woman

after tubal sterilization must be

investigated, and an ectopic pregnancy
should be excluded
Postubal

Ligation Syndrome

Menorrhagia and intermenstrual

bleeding following sterilization

Male Sterilization
Through a small incision or
alternatively through a
puncture in the scrotum, the
lumen of the vas deferens is
disrupted to block the
passage of sperm from the
testes
Compared with vasectomy:

female tubal sterilization has a

20-fold increased complication

rate, a 10- to 37-fold failure
rate, and costs three times as
much

Sterilization following
vasectomy is not immediate:
3 months or 20 ejaculations

Male Sterilization

Failure rate during

the first year is 9.4
per 1000
procedures but
only 11.4 per 1000
at 2, 3, and 5
years

unprotected
intercourse too
soon after ligation
incomplete
occlusion of the
vas deferens
recanalization

THANK YOU!