FAMILY PLANNING METHODS

OUTLINE:
I. II. III. IV. V. Hormonal Methods Emergency Contraception Mechanical Methods Natural Methods Surgical Methods

Family Planning Methods

MENSTRUAL CYCLE

Days 114: Follicular Phase

The follicular phase begins on the first day of menses. All hormone levels are low. Without any negative feedback, GnRH from the hypothalamus causes FSH release from the pituitary. FSH stimulates maturation of granulosa cells in the ovary. The granulosacells secrete estradiol in response.

 Estradiol inhibits luteinizing hormone (LH) and FSH due to negative feedback. In the meantime, the estradiol secretion also causes the endometrium to proliferate.

Day 14: Ovulation

A critical level of estradiol triggers an LH surge. The LH surge causes the oocyte to be released from the follicle. The ruptured follicle then becomes the corpus luteum, which secretes progesterone.

Days 1428: Luteal Phase

The corpus luteum secretes progesterone for only about 11 days in the absence of human chorionic gonadotropin (hCG). Progesterone causes the endometrium to mature in preparation for possible implantation. It becomes highly vascularized and glandular secretions Progesterone also causes inhibition of FSH and LH release.

 If fertilization does not occur, the corpus luteum involutes, progesterone and estradiol levels fall, with subsequent endometrial sloughing (menses). The hypothalamic-pituitary axis is released from inhibition, and the cycle begins again.

Hormonal Contraceptives

Basic Principle

Inhibit Ovulation Add exogenous hormone (estrogen and progesterone) Cause a negative feedback to prevent FSH and LH production

 Estrogen suppresses follicle-stimulating hormone (FSH) and therefore prevents follicular emergence. Maintains stability of endometrium.

 Progesterone prevents luteinizing hormone (LH) surge and therefore inhibits ovulation.
Thickens cervical mucus to pose as a barrier for sperm. Alters motility of fallopian tube and uterus. Causes endometrial atrophy.

 These contraceptives are currently available in a wide variety.

oral injectable transdermal(patch)and transvaginal(ring) forms

Oral Contraceptives

 Oral contraceptives are a combination of

estrogen and progestin or progestin only (mini-pill)

The other forms contain progestins alone or a combination of estrogen and progestin.

Male hormonal contraceptive???

Mechanisms of Action

The contraceptive actions of combination oral contraceptives are multiple. The most important effect is to prevent ovulation

 Progestin prevents ovulation by suppressing luteinizing hormone. Progestins also thicken cervical mucus, thereby retarding sperm passage.

 Estrogen prevents ovulation by suppressing the release of follicle-stimulating hormone. A second effect is to stabilize the endometrium, which prevents breakthrough bleeding.

 The net effect of estrogen and progestin is

extremely effective ovulation suppression, inhibition of sperm migration through thickening of cervical mucus, and creation of an unfavorable endometriumfor implantation.

 Thus, estrogen plus progestin containing combined oral contraceptives provide virtually absolute protection against conception when taken daily for 3 out of every 4 weeks.

Pharmacology
Estrogen Progestin

Ethinyl Estradiol Mestranol (less commonly)

19-nortestosterone derivatives

Dosage

Over time, the estrogen and progestin contents of COCs have been reduced remarkably to minimize hormone-related adverse effects. Daily estrogen content varies from 20 to 50 g of ethinylestradiol, most contain 35 g or less.

Phasic Pills

The amount of progestin varies.

Monophasic formulation where the progestin dose remains constant during the cycle. Biphasic and Triphasic - the progestin and in some, the estrogen dose varies during the cycle.

Administration

With the exception of one preparation, COCs are taken daily for a specified time (21 to 81 days) and then omitted for a specified time (4 to 7 days) called the "pill-free interval. During these pill-free days, withdrawal bleeding is expected.

Pill Usage

Ideally, women should begin COCs on the first day of a menstrual cycle, in which case a backup contraceptive method is unnecessary.

Sunday Start

Begin pills on the first Sunday that follows menses onset Back-up method is needed for 1 week to prevent conception.

Quick Start Method

COCs are started on any day, commonly the day prescribed, regardless of cycle timing. A back-up method is used during the first week.

 For maximum efficiency, pills should be taken at the same time each day.

Missed a dose?

If one dose is missed, contraception is likely not diminished with higher-dose monophasic COCs. Doubling the next dose will minimize breakthrough bleeding and maintain the pill schedule.

 If several doses are missed or lower-dose pills are used, the pill may be stopped, and an effective barrier technique used until menses. The pill may then be restarted after this withdrawal bleeding.

 Alternatively, a new pack can be started immediately following identification of missed pills, and a barrier method used as a back-up method for 1 week. If there is no withdrawal bleeding, the woman should continue her pills but seek attention to exclude pregnancy.

Regular Use

21 sequentially and individually wrapped, color-coded tablets containing hormones, followed by7inert tablets of another color. Keep a pills and toothbrush close to each other.

Safety

In general, oral contraceptives have proven to be safe for most women.

BENEFICIAL EFFECTS

 When used reliably, there is no more effective rapidly reversible form of contraception than the combined estrogen plus progestin pill.

 Some of the associated non contraceptive benefits include the following:

1. Increased bone density. 2. Reduced menstrual blood loss and anemia. 3. Decreased risk of ectopic pregnancy. 4. Improved dysmenorrhea from endometriosis. 5. Fewer premenstrual complaints.

6. Decreased risk of endometrial and ovarian cancer. 7. Reduction in various benign breast diseases. 8. Inhibition of hirsutism progression. 9. Improvement of acne. 10. Prevention of atherogenesis. 11. Decreased incidence and severity of acute salpingitis. 12. Improvement in rheumatoid arthritis.

ADVERSE EFFECTS

Lipoproteins and Lipids

Increase triglycerides and total cholesterol Oral contraceptives are not atherogenic. LDL cholesterol levels >160 mg/dL or risk factors for cardiovascular disease - alternative contraceptive methods are recommended.

Carbohydrate Metabolism

There are limited effects on carbohydrate metabolism with current low-dose formulations in women who do not have diabetes.

Neoplasia

Most studies indicate that overall, COCs are not associated with an increased risk of cancer Protective effect against ovarian and endometrial cancer

 The relative risk of cervical dysplasia and cervical cancer is increased in current COC users, but this declines after use is discontinued. Following 10 or more years, risk returns to that of never users.

 It is unclear whether COCs contribute to the development of breast cancer.

Cardiovascular Effects

Significant cardiovascular risks!

Thromboembolic disease myocardial infarction, and stroke.

For women with prior history of these events, COCs should not be considered. These complications are increased in women older than 35 years and who smoke, COCs are not recommended for this population.

 Oral contraceptives containing low-dose estrogen and low-androgenic progestins are not associated with an increased risk of myocardial infarction in nonsmokers.

Reproduction

At least 90 percent of women who previously ovulated regularly begin to do so within 3 months after discontinuance of oral contraceptives. There is no evidence that COCs are teratogenic

TRANSDERMAL ADMINISTRATION
Ortho-Evra

Applied on the skin

1 patch per week for 3 weeks 1 patch free week

EthinylEstradiol Progestin
For people less than 90 kg

Transvaginal

Estrogen Progestin Releasing Vaginal Ring

Placed within 5 days of menses onset and lasts for 3 weeks

Intramuscular

Lunelle

Pulled out of the market

Progestational Contraceptives
Mini pills

Advantages: Minimal Coagulation related Side effects, Good for lactating women Disadvantage: Does not reliably inhibit ovulation
Need to be taken precisely at the same time of the day, within 4 hours otherwise A back up plan for contraception should be considered.

Injectable progestin

Medroxyprogesterone = Depro-Provera = 150 mg every 3 months NorethisteroneEnanthate = Norigest = 200 mg every 2 months

Disadvantage: Infertility for a long period of time

Side effects should be evaluated further

EMERGENCY CONTRACEPTIVES

HORMONAL EMERGENCY CONTRACEPTION

Highly effective and decreases the risk of pregnancy by 75% Three types currently available: 1. Progestin only 2. Estrogen + Progestin 3. Ulipristal

PROGESTIN ONLY PREPARATION

Thought to prevent pregnancy mainly by preventing ovulation Will not work if you are already pregnant and will not affect a pregnancy that has started Can be used more than once even in the same menstrual cycle 75% effective in preventing pregnancy

PROGESTIN ONLY PREPARATION

Plan B
Consists of 2 tablets each containing 0.75 mg levonorgestrel First dose taken within 72 hours after intercourse and the second dose 12 hours later

OVRETTE METHOD

Mini pill progestins are more effective than combination estrogen-progestin pills Consists of 20 pills taken as 1 dose within 72 hours of unprotected intercourse followed in 12 hours by a second dose of 20 pills Each dose of 20 pills contains 1.5 mg of norgestrel Proven to be effective and less likely to cause nausea & vomiting

HOW TO USE

TYPE

SINGLE PILL TWO PILLS

Take one pill as soon as possible within 72 hours and up to 120 hours of unprotected sex. If vomiting occurs within 2 hours of taking the pill, contact your health care provider about taking another pill Take one pill as soon as possible within 72 hours and up to 120 hours of unprotected sex. Take the second pill 1224 hours after the first pill. If vomiting occurs within 2 hours of taking either dose, contact your health care provider about whether you need to repeat that dose.

ESTROGEN-PROGESTIN COMBINATIONS

Combination emergency contraceptive pills are not as effective in preventing pregnancy as the progestin-only pills. Higher risk of nausea and vomiting Progestin-only methods are preferred over combination emergency contraceptive pills

ESTROGEN-PROGESTIN COMBINATIONS

Preven Emergency Contraceptive Kit

Contains a pregnancy test & 4 tablets Each tablet contains 50g of ethinyl estradiol and 0.25 mg levonorgestrel 2 tablets are taken within 72 hours of intercourse, followed 12 hours later by the second dose More effective the sooner it is taken after unprotected intercourse

LOCALLY AVAILABLE BRANDS

Femenal Nordiol Nordette Rigevidon 21 + 7

MECHANISM OF ACTION

Main Mechanism: Inhibition or delay of ovulation Others: Alteration of the endometrium, sperm penetration & tubal motility

ULIPRISTAL

Affects how progesterone works in the body. Thought to delay or prevent ovulation Research suggests that it may prevent more pregnancies than progestin-only pills when taken as directed. Should be taken only once during a menstrual cycle. May decrease the effectiveness of hormonal birth control methods

HOW TO USE:

Take one pill as soon as possible within 120 hours of unprotected sex. If vomiting occurs within 3 hours of taking the pill, contact your health care provider about taking another pill.

MIFEPRISTONE & EPOSTANE Epostance blocks progesterone production while Mifepristone interferes with its action. Implantation prevented by either mechanism results in so-called menstrual induction. Mifepristone
Effective up to 17 days after intercourse Fewer side effects vs. Yuzpe regimen More effective than Yuzpe (crude pregnancy rate of 0.6% vs. Yuzpes 3.6%) More widely available Medical abortion pill (Mifeprex)

AVAILABILITY

Ulipristal and combination birth control pills are available only by prescription. Progestin-only pills can be bought at a pharmacy without a prescription if you are 17 years or older and by prescription if you are younger than 17 years.

SIDE EFFCTS

Next period may not occur at the expected time Bleeding or spotting in the week or month of treatment Abdominal pain and cramps Breast tenderness Headache Dizziness Fatigue Usually go away within a few days

FOLLOW-UP CARE

Consult if you have not had your period within a week of when you expect it Progestin-only pills and combination pills do not harm a pregnancy or the health of the baby if you are already pregnant. Currently, there is little information about whether ulipristal can harm a pregnancy if you are already pregnant. Lower abdominal pain + vaginal spotting/bleeding lasting > 7 days may be signs of miscarriage or ectopic pregnancy

NAUSEA AND VOMITING

Major problem due to estrogen content Prescribe an oral antiemetic at least 1 hour before each dose
Meclizine 50 mg per orem Metoclopramide 10 mg per orem

If vomiting occurs within 2 hours of a dose, the dose must be repeated.

COPPER-CONTAINING INTRAUTERINE DEVICES

If inserted within 5 days after unprotected intercourse, the failure rate was 1%. Also puts in place an effective 5- to 10- year method of contraception Placed and removed by a health care provider

MECHANICAL METHODS OF CONTRACEPTION

INTRAUTERINE DEVICES (IUD)

TWO TYPES OF IUDs:

CHEMICALLY INERT Composed of nonabsorbable material, most often polyethylene Impregnated with barium sulfate for radiopacity

CHEMICALLY ACTIVE Continuous elution of copper or a progestational agent At the present, only type of IUD available

Two devices currently approved in the USA:

Unwanted pregnancies during the 1st year of perfect use are 0.6% for ParaGard T 380A and 0.1% for Mirena.

Coppercontaining Typical failure rate = 0.8%

Levonorgestrelcontaining Typical failure rate = 0.1%

MECHANISM OF ACTION
Sterile inflammatory reaction inside the endometrial cavity interferes with sperm function so fertilization is less likely to occur In the unlikely event that fertilization does occur, the same inflammatory actions are directed against the blastocyst Endometrium is transformed into a hostile site for implantation.

EFFECTIVENESS
1-year continuation rates equal to those of oral contraceptives Effectiveness is similar to that of tubal sterilization

ADVANTAGES OF IUD:

Both ParaGard & Mirena are use & forget effective reversible methods that do not have to be replaced for 10 and 5 years, respectively Not abortifacients Risk of pelvic infections is markedly reduced with the currently used monofilament string & with techniques to ensure safer insertions

ADVANTAGES OF IUD:

Mirena reduces menstrual blood loss and be used to treat menorrhagia. Can be used by women with contraindications to combination oral contraceptives Bottomline: Long lasting, low maintenance

ADVERSE EFFECTS:

Uterine perforation and abortion Uterine cramping and bleeding Menorrhagia Infection

CONTRAINDICATIONS: Pregnancy or suspicion of pregnancy Abnormalities of the uterus Acute PID or history of PID Postpartum endometritis or infected abortion in the past 3 months Known or suspected cervical malignancy Genital bleeding of unknown etiology Untreated infections in the lower genital tract Multiple sexual partners Previous IUD that has not yet been removed

BARRIER METHODS

MALE CONDOMS

KEY STEPS TO ENSURE MAXIMAL CONDOM EFFECTIVENESS: Must be used in EVERY coital act Placement occurs BEFORE contact of penis with the vagina Withdrawal with penis still erect Base of the condom must be held during withdrawal Use of either intravaginal spermicide or a condom lubricated with spermicide

ADVANTAGES:
Widely available Inexpensive Portable No effect on womans hormones Can be used while breastfeeding

DISADVANTAGES:
Without spermicide, 18 out of 100 women will become pregnant within the first year of typical use. Some individuals are sensitive to latex

FEMALE CONDOMS

Impermeable to HIV, CMV, and Hepatitis B virus 0.6% breakage rate ~3% slippage and displacement rate (vs. 3-8% for male condoms) 60% acceptability rate for women, 80% in men Higher pregnancy rate vs. male condoms Can be inserted up to 8 hours before sex

SPERMICIDES

Creams, jellies, suppositories, films and foam in aerosol containers Physical barrier to sperm penetration Chemical spermicidal action Nonoxynol-9, Octoxynol-9 Must be deposited high in the vagina in contact with the cervix shortly before coitus Duration of max. effectiveness is usually no more than 1 hour Douching should be avoided for at least 6 hours after coitus

DIAPHRAGM

Circular rubber dome of various diameters supported by a circumferentially placed metal spring Placed in the vagina so that the cervix, vaginal fornices, and anterior vaginal wall are partitioned effectively from the remained of the vagina & penis Very effective when used in combination with a spermicide Available only by prescription Remain in place for 6 hours but not more than 24 hours

CONTRACEPTIVE SPONGE

Doughnut-shaped device made of soft foam coated with spermicide Releases spermicide in small amounts for 24 hours Inserted into the vagina to cover the cervix Can be worn up to 30 hours total and can be placed 24 hours before intercourse Less effective in women who have given birth Toxic shock syndrome (rare)

CERVICAL CAP

Small plastic dome that fits tightly over the cervix and stays in place by suction Should be used with a spermicide Can be inserted 6 hours before sex Left in place for 6 hours after sex but not more than 48 hours Less effective in women who have given birth

Natural Methods

Continuous Abstinence

Abstaining from vaginal intercourse at any time The only 100% effective way to prevent pregnancy!

Natural Family Planning 75-99% success rate depending on patient compliance Based on the timing of sex during a womans menstrual cycle Methods:
Basal body temperature Ovulation/cervical mucus Symptothermal Lactational amenorrhea Calendar rhythm Standard Days Method

Basal Body Temperature

Record BBT every morning as soon as wakign up Temp should be increased by 0.3-1F for 3 consecutive days (progesterone surge)
Indicates ovulation

Time to abstain or have protected sex if no desire to conceive

Ovulation/Cervical Mucus (Billings Method)

During ovulation, mucus becomes clearer, profuse, wet, stretchy and slippery
Peak day of fertility

After peak day, mucus becomes thicker and goes away May have sex after 4 days from the peak day to avoid conception

Symptothermal

BBT + Billings Check for other signs of ovulation:

Abdominal cramps, spotting, changes in position or firmness of cervix

Abstain from sex from the day you fi st notice signs of fertility until the third day after the elevation in temperature

Lactational Amenorrhea

Exclusive breastfeeding for 6 months postpartum

Calendar Rhythm

Assumptions:
Ovulation occurs 14 days after the onset of the last menstrual period (2) Sperm viability ~72 hours Egg viability ~24 hours

For regular cycles

Standard Days

Standard Days

Day 8 -19
increased fertility and increased chance of conception

All other days within each cycle

low risk of conception

When your next period begins, mark that day as Day 1 of the next cycle. Then go back to the previous cycle on the calendar and count the total number of days in the previous cycle. Put a square around the total number of days for each cycle. So if a cycle was 30 days long, the last day will be marked 30. Only one cycle per year can be less than 26 days, or more than 32 days.

Natural Family Planning

Advantages Disadvantages

No side effects Low cost Reversible No impact on breastfeeding

Abstinence is not always easy Requires cooperative and committed couple No protection against STIs Takes time to learn fertility awareness

Sterilization
Male and Female

Sterilization

Elective surgery Leaves male or female unable to reproduce Male type: Vasectomy Female type: Tubal occlusion or ligation

MALE STERILIZATION: VASECTOMY

Vasectomy

Excision of a small section of both vas deferens, followed by sealing of the proximal and distal cut ends Done under local anesthesia Takes about 20 minutes Ejaculation still occurs Less complications, less failure rate, cheaper than tubal occlusion

Vasectomy

To ensure sterility:
Use contraception for 12 weeks or 20 ejaculations with 2 consecutive negative sperm counts prior to sexual intercourse

Failure of Vasectomy

Failure rate:
1st year 2nd to 5th years 9.4 per 1,000 procedures 11.4

Reasons:
Unprotected sex soon after procedure Incomplete occlusion of vas deferens Recanalization

Transient Sperm Reappearance

Low sperm counts (<10,000/mL) in men who have been documented to have azoospermia after vasectomy Due to slow release of sperm in distal vas deferens or formation of microchannels with sperm granulomas Usually not sufficient to cause pregnancy

Restoration of Fertility

50% success rate Depends on time from vasectomy and surgical skill

Long-Term Effects

Regrets Concerns about accelerated atherogenesis, myocardial infarction, prostate cancer, testicular cancer
No studies to prove strong association between vasectomy and these disease entities

FEMALE STERILIZATION: BILATERAL TUBAL OCCLUSION

Bilateral Tubal Occlusion

Interval or postpartum/puerperal An interval tubal occlusion should be performed in the follicular phase of the menstrual cycle in order to avoid the time of ovulation and possible pregnancy.

INTERVAL TUBAL STERILIZATION

Interval Tubal Sterilization

Techniques consist of:

Ligation and resection at laparotomy Application of rings or clips at laparoscopy Electrocoagulation of tube segments, through laparoscopy

Done via laparoscopy, laparotomy, minilaparotomy , or colpo/culdotomy

Laparoscopic Methods of Occlusion

Electrocoagulation Mechanical
Banding Clipping

Electrocoagulation

Cauterize 3-cm zone of isthmus Most popular method Most difficult to reverse Unipolar (lowest long-term failure rate but highest complication rate) or bipolar current

Mechanical

Similar safety rates 1-year pregnancy rate of 1.7 per 1,000 women

Clipping

Spring-loaded Hulka-Clemens clip (Wolf clip) or silicone-lined titanium Filshie clip applied at a 90-degree angle on the isthmus Most easily reversed Highest failure rate among mechanical means

Banding

A length of isthmus is drawn up into the end of the trocar, and a silicone band, or Fallope ring, is placed around the base of the drawnup portion of fallopian tube

Complications of Interval Sterilization

Anesthetic complications Inadvertent injury of adjacent structures Pulmonary embolism Sterilization failure with subsequent intrauterine or ectopic pregnancy Laparoscopic conversion to laparotomy

Failure of Interval Sterilization

Reasons:
Surgical errors 30-50% of cases Fistula formation, especially with electrocautery Faulty clips not occlusive enough Reanastomosis Defective equipment defective elctrical current Luteal-phase pregnancy

Luteal-Phase Pregnancy

Pregnancy diagnosed after tubal sterilization but conceived before Occurs around 2-3/1000 sterilizations Prevented by performing sensitive pregnancy tests prior to the procedure or performing the procedure during the follicular phase

POSTPARTUM OR PUERPERAL TUBAL STERILIZATION

Postpartum Tubal Sterilization

Oviducts are accessible at the umbilicus directly under the abdominal wall for several days after delivery May perform immediately after or 12-24 hours postdelivery

Techniques in Postpartum Tubal Occlusion

Pomeroy Parkland Madlener Irving Kroener Uchida

Irving

Isthmus is cut Proximal end buried in myometrium Distal end buried in mesosalpinx Most difficult Least likely to fail

Pomeroy

Segment of isthmus is lifted and sutured at the approximated base Resulting loop excised Leaving a gap between proximal and distal ends Most popular Simplest

Parkland

A window is made in the avascular mesosalpinx by blunt dissection 2-cm midsegment of isthmus is ligated with chromic 0 suture proximally and distally; then excised

Madlener

Similar to the Pomeroy but without the excision Segment of isthmus is lifted, crushed and tied at the base Rarely used because of high failure rates

Kroener Fimbriectomy

Resection of the distal ampulla and fimbriae following ligation around the proximal ampulla Rarely used because of high failure rates

Uchida
1. Epinephrine injected beneath serosa of isthmus 2. Mesosalpinx reflected off the tube

Uchida
3. Proximal end ligated and excised; distal not excised 4. Mesosalpinx reattached to proximal stump

Failure of Postpartum Tubal Sterilization

Reasons:
Surgical errors such as transection of round ligament isntead of oviduct Fistula formation between severed tubal stumps or spontaneous reaanastomosis

Data from the U.S. Collaborative Review of Sterilization (CREST) shows the cumulative probability of pregnancy per 1000 procedures for five methods of tubal sterilization.

OTHER METHODS OF STERILIZATION

Partial or Total Salpingectomy

Removal of all or part of the fallopian tubes

Hysterectomy

Vaginally or abdominally <1% failure rate Pregnancy after = ectopic pregnancy Difficult to justify in the absence of other indications

Transcervical/Intratubal Sterilization

Using hysteroscopy to visualize ostia and obliterate them with compounds/devices; scarring prevents sperm entry Essure
Polyester/nickel/titanium/steelc oil implanted in the proximal fallopian tube 99.8% efficacy Needs alternative contraception until occlusion proven by hysterosalpingogram 3 months after

Transcervical/Intratubal Sterilization

Other compounds used:

Methylcyanoacrylate Quinacirne pellets carcinogenic Erythromycin 36% failure rate

Long-term Complications of Tubal Sterilization

Ectopic pregnancy
About of pregnancies after failed electrocoagulation were ectopic; 10% in ring, clip, or tubal resection

Posttubal ligation syndrome

Menorrhagia, intermenstrual bleeding , cycle irregularity, dysmenorrhea, pelvic pain, ovarian cyst

Reversal of Tubal Sterilization

Success rates depend on age of woman, amount of tube remaining and technology used 80% pregnancy rate with tubal reanastomosis 30% pregnancy rate with neosalpingostomy for fimbriectomy reversal Almost 10% of those who undergo reversal have an ectopic pregnancy.