FAMILY PLANNING

AND

CONTRACEPTION
Indications For
Contraception
 It aims at spacing pregnancies and choosing the
proper time for conception and childbirth.
 Medical Condition
 Severe and chronic maternal
 Cardiac
 Renal
 Liver diseases
Methods of Contraception
 Physiological Contraception
 Barrier Contraception
 Intra-Uterine Contraceptive Device (IUD)
 Hormonal Contraception
 Sterilization (Permanent Contraception)
Methods of Contraception
 Physiological Contraception:
 Safe period (calendar method)
 Coitus interruptus.
 Basal body temperature (BBT)
 Barrier Contraception:
 Mechanical methods:
 Condom (male & female latex condoms)

 Vaginal diaphragm
 Cervical cap.

 Chemical methods:
 Spermicidals as gel or sponge.
Methods of Contraception
 Intra-Uterine Contraceptive Device: (IUD)
 Non medicated IUD (Lippes loop)
 Medicated IUD (cupper– silver- gold - progesterone)
 Hormonal Contraception:
 Oral contraceptive pills OCP.
 I.M. Injectable contraception.
 Subdermal implants.
 Contraceptive vaginal ring.
 Sterilization: (Permanent Contraception)
 Female e.g. Tubal ligation.
 Male e.g. vas ligation
Physiological Methods
1. Coitus Interruptus:
 It is withdrawal and ejaculation outside the

vagina during intercourse.

 Simple
 Cheep
 Readily available.
 Efficacy is not high as the pre-ejaculatory fluid
may contain sperms.
 Can be improved by its combination with the
safe period.
Physiological Methods
2. The Safe Period:
 Unprotected intercourse before day 10 and after day 19

of the menstrual cycle.

 Suites intellectual couples, with regular menstrual cycles.

 Failure may be high on the long term especially if cycles

become irregular.
 Can be improved when coupled by the BBT chart or

urinary LH tests.
Physiological Methods
3. Prolonged lactation:
 60 % of females do not menstruate while

lactating in the 1st 6 months after labour.

 However, the period of anovulation is variable

making this method unreliable by itself.

Barrier Methods
 Physically or chemically preventing sperm egg
interaction with every sexual intercourse
Barrier Methods
 Advantages
 Easy to initiate and discontinue
 No systemic side effects
 No effects on future fertility, or present lactation
 Fairly reliable
 Failure rates < 10 HWY
 May prevent transmission of STDs
Barrier Methods
 Disadvantages
 Difficult to use consistently and correctly
 May interrupt sexual activity and pleasure
 Some require partner's participation
 Less effective than other modem methods
Male Latex Condom
 Pregnancy prevention rate up to 97% .
 Protect against STDs
Female Latex Condom
 As effective as the male condom.
Diaphragm
 The diaphragm fits obliquely in the vagina
Cervical Cap
 The cervical cap fits over the cervix
Diaphragm and Cervical
Cap
 More effective when used with spermicides
 First time must be fitted by trained provider
 Reusable (after cleaning)
 Can be inserted up to 6 hours before intercourse
 Not to be removed earlier than 6 hours after intercourse.
 No douching after intercourse
 Spermicides(Nonoxynol-
(9
 Work by inactivating the sperms
 Provided in the form of tablets, creams, gel, or
sponge.
 Failure rates are high reaching up to 30 /HWY.
 Commonly used in combination with other
methods as condom or diaphragm.
 Can cause allergic vaginitis.
Intrauterine Contraceptive
Device
 Composition:
 Polyethylene material (plastic) +
barium sulphate to render it radio
opaque.
 Additions include:
 Copper
 Copper + Silver
 Progesterone
 Two nylon threads are attached
to its lower stem and protrude out
of the cervix to be a marker for its
presence and facilitates its
removal.
Intrauterine Contraceptive
Device
 Mode of action:
 Endometrium: FB inflammatory reaction →
endometrium unsuitable for implantation.
 Sperms: Immobilize sperms,
 Fertilization: Speeds transport of ovum
 Prevent implantation by ↑ local production of
prostaglandins
 Copper: Competes with zinc leading to inhibition of
carbonic anhydrase & alkaline phosphatase activity
needed for implantation.
 Progesterone: produce atrophic endometrium on long
term uses.
Intrauterine Contraceptive
Device
 Types:
 Polyethylene
(inert): Lippes
loop double S
shaped (not used
any more).
 Cu T 380: (380 =
surface area of
the copper - 380
mm2). Duration of
action 6-8 years.
Intrauterine Contraceptive
Device
 Types:
 Nova T : Modified copper T
200 in which silver is added to
minimize fragmentation of
copper.
 Progesterone releasing IUD
 Progestasert = 65 mg/day.
 Levonova = 20 mg/day.
Intrauterine Contraceptive
Device
 Timing of insertion :
 By the end of menstruation or in the immediate
postmenstrual period.
 Postpartum (4-6 weeks after delivery).
 Postabortive (2-3 weeks after abortion, or end of 1st
menstruation).
Intrauterine Contraceptive
Device
 Technique of Insertion:
 Parts of the IUD: Loop, Outer barrel (insertion tube),
Plunger (rod).
 Patient Position: Lithotomy position
 Expose cervix and Grasp the anterior lip by a Volsellum.
 Sounding uterus to measure uterine length & direction.
 Push Technique: barrel is fixed & the plunger is pushed.
 Withdrawal Technique: Plunger is fixed & the barrel is
pushed in reverse direction then cut the threads short 5 cm
from the external os.
Intrauterine Contraceptive
Device
Intrauterine Contraceptive
Device
 Advantages
 Single choice method, with a long term protection.
 It does not affect lactation, in recently delivering
women.
 It does not affect or interfere with sexual intercourse
 Low failure rate: 0.5/HWY (Hundred Women Yearly).
Complications of IUD
 Bleeding:
 Post Insertion Bleeding:
 Mild, stops within few days in absence of

complications.
 Menorrhagia:
 Common in the 1st few cycles and may continue

during the whole time of using IUD.

 Due to increase prostaglandins or increased

fibrinolytic activity.
 Irregular Vaginal Bleeding:
 Uterine pathology, Pelvic infection, partial

expulsion.
Complications of IUD
 Pelvic Pain:
 During or after insertion:
 Slight cramping pain is normal.
 Severe pain: Disparity in size, Abnormal position,
Perforation, Forcible dilatation.
 Backache : Pelvic congestion. Cervicitis. Utero-sacral
ligament.
 Acute Abdominal Pain with IUD in place: Abortion, Ectopic
Pregnancy, PID.
 Pelvic Infection:
 PID, Cervicitis, endometritis, parametritis, salpingitis.
 Threads of IUD may carry the organism to inside the
uterus.
 Treatment: Antibiotics, then removal of IUD.
Complications of IUD
 Vaginal Discharge:
 Watery, mucoid → pelvic congestion - cervical erosion.
 Mucopurulent → cervicitis → remove IUD + antibiotics.
 Vaginitis → treat while IUD in place.
 Expulsion:
 Usually in the 1st 6 months after insertion.
 It may be complete → expelled out the cervix.
 It may be incomplete → within the uterus but not
properly placed.
 Treatment → Removal and reinsertion of a new IUD.
Complications of IUD
 Perforation:
 at the time of insertion.
 Bleeding and pain may be present
 Threads will not felt by the patient.
 Pregnancy on IUD:
 When the loop is displaced intracervically leaving the fundus
bare and unprotected.
 Management includes:
 If threads are visible, IUD is removed & pregnancy allowed to

continue with an abortion rate 25%.

 If threads are not visible, IUD is left in place and pregnancy

allowed to continue with an abortion rate of around 50%.

Incidence of septic abortion may be increased if IUD is left in
place.
Missed IUD
 Threads not felt by the patient nor seen by the gynaecologist
 Causes:
 Expulsion
 Threads indrawn into the uteriencavity
 Perforation
 Pregnancy
 Management:
 If threads detected on speculum examination → nothing is
done.
 If not detected & IUD visualised inside the uterus by U/S
 left or
 remove by crocodile forceps or by D & C.
Missed IUD
 If IUD not visualised inside the uterus → plain X-ray
after excluding pregnancy
 Absence denotes expulsion.
 Presence denotes perforation
 It
can be removed by laparoscopy or
minilaparotomy.
 If pregnancy → management during pregnancy
Contraindications for
IUCD
 Pregnancy
 Irregular vaginal bleeding
 Menorrhagia
 History of PID
 History of ectopic pregnancy
 Uterine anomalies : septate or bicornuate .
 Uterine cavity pathology e.g. submucous myoma
 HORMONAL CONTRACEPTION
(Oral Contraceptive Pills (OCP
1. Combined OCP
 Combined OCPs

(COCs - Low dose Pills - Monophasic pills):

 Eestrogen (ethinyl estradiol (EE): 30 mcg.)
 Progestogen (levonorgestrel, desogestrel: 75 mcg.)
 once daily for 21 days & 1 week rest, starting D 3-5 of
the menstrual cycle
 The next cycle is expected to occur 3-4 days after the
last pill
(Oral Contraceptive Pills (OCP
 Triphasic Combined OCPs:
(21 days & 1 week rest) :
 1st 6 days → 30 mcg oestrogen + 50 mcg
Progestogen
 2nd 5 days → 40 mcg oestrogen + 75 mcg
Progestogen
 Last 10 days → 30 mcg oestrogen + 125 mcg
Progestogen
Mode of Action of
Combined OCP
 Estrogen → inhibition of ovulation
 Progestogen:
 Contraceptive effect:
 Endometrial glandular atrophy and stromal

oedema
 Cervical mucous become thick and hostile to

sperm penetration
 Altered tubal motility and secretions → affect

oocyte transport
 Prevent endometrial hyperplasia
 Induces cyclic bleeding with excellent cycle control
(Oral Contraceptive Pills (OCP
Progestogen only pills (POPs-MiniPills)
 Dose: one tablet daily continuously at the same time,
irrespective of menstruation.
 Mode of action: It acts by the contraceptive effect
progestogen (see above)
 Higher incidence of menstrual irregularities and ectopic
pregnancy.
 Does not affect lactation, therefore may be suitable for
lactating women but progestogen is excreted in milk in
minimal amounts (limits its use).
Advantages of OCPS
 Most effective (Failure 0.1-1/HWY)
 Excellent cycle control
 Cheap and readily available
 No long term adverse effects on fertility
 No effects on sexual intercourse
 Non contraceptive benefits:
 Treatment of DUB.
 Postponing next menstruation (delaying an expected
cycle).
 Treatment of spasmodic dysmenorrhoea.
 Associated with less incidence of:
 PID
 Non neoplastic cysts of the ovary
 Endometrial carcinoma
 Epithelial ovarian cancer.
 Complications of OCPS
1. Menstrual Disturbance:
 Spotting: specially midcycle

 TTT: continue the cycle & use higher dose of hormones next
cycle
 Breakthrough Bleeding similar to menstruation

 TTT: stop and on 4th day start new course with higher doses
 Hypomenorrhea: gestagens cause glandular atrophy.

 Treatment: stop if unacceptable

 Amenorrhea: TTT

 Exclude pregnancy.
 Stop the pills & shift to another way of contraception.
 If not resumed within 3 months (post pill amenorrhea) →
give progesterone to induce withdrawal bleeding then induce
ovulation with clomiphene citrate.
Complications of OCPS
2. Metabolic Effects:
 Cardiovascular System:

 Thromboembolic Disorders: is increased due to

especially postoperative
 Ischaemic Heart disease: in predisposed patients
 Hypertension: Mainly systolic in predisposed patients.
 Liver: impaired liver functions, cholestasis, gall stones.

 CHO Metabolism: impairment, diabetes

 Lactation: Decreased milk production

Complications of OCPS
3. Other Side effects:
 Nausea & Vomiting:

 Headache:

 Irritability & Depressive mood:

 Weight Gain

 Breast Engorgement, Tenderness, Enlargement

 Acne
 May improve
 May worsen or appear
 Skin Pigmentation: Choloasma similar to pregnancy.
 Change in Libido
 Vaginal Discharge
 Eye Symptoms:
 Edema of the cornea
 Transient optic nerve ischaemia
Absolute Contraindications for
OCP
 Thrombophlebitis or thromoembolic disease.
 History of DVT
 Coronary heat disease.
 Cerebrovascular accidents or strokes.
 Benign or malignant Liver disease
 Malignancy of the female genital system.
 Abnormal genital bleeding
 Suspected or known carcinoma of Breast or
 History of benign neoplasms of the Breast.
Relative Contraindications for
OCP
 Superficial thrombophlebitis
 Varicose veins
 Migraine headache
 Hypertension
 Diabetes mellitus.
 History of liver disease
 Gall bladder stones
 Age > 35 years
 History of: Pre-eclampsia, Diabetes with pregnancy,
Cholestasis with pregnancy.
 Injectable
Contraceptives
Progestin-only Injectables Combined Injectables

DMPA NET-EN Mesygyna Cyclofem

(Depot- (Norethisterone 50 mg DMPA + 25 mg DMPA +
medroxy- enanthate) 5mg estradiol 5 mg estradiol
progesterone valerate cypionate
acetate)

months 3 months 2 month 1

Protection Protection Protection
 Injectable
Contraceptives
 Nature: Long acting progestogen
 Mechanism of Action:
 Direct inhibition of FSH, LH.
 Progesterone effect on the endometrium & cervical
mucous (difficult sperm penetration
 Side effects:
 Irregular vaginal bleeding is the commonest complaint
 Amenorrhea may occur during the course.
 Weight gain in some cases.
 Subdermal Implants
 Capsules placed under the skin of a woman’s arm that slowly
release a progestin into the bloodstream
 Slowly released progestogen.
 Inserted in the upper arm.
 Biodegradable or non-biodegradable e.g. norplant.
 5 year contraception.
 Menstruation is scanty or absent.
 Side effects → Irregular bleeding.
 After 5 years the capsules should be removed
 Vaginal Rings
 Ring introduced by end of cycle
and left in the vagina for 21 days
 It is slowly releasing hormone
device
 At first gestagens were used but
now combined oestrogen +
gestagens rings are available.
 Hormones are absorbed from the
vaginal mucosa, enter the
circulation and act as OCP
Female Sterilization
 Permanent contraception
 Surgical tubal occlusion to prevent egg fertilization
 Indications:
 Medical reasons contraindicating pregnancy
 In selected cases when all other methods of contraception fail or
are contraindicated
 Techniques:
 During C.S.
 By mini-laparotomy
 By laparoscopy (rings - clips - bipolar diathermy)
 By colpotomy (vaginal tubal ligation)
 Complications:
 Pelvic congestion (post ligation syndrome).
Female Sterilization
Male Sterilization
 Surgical ligation of the vas deferens
 Medical: GOSSYPOL (the male pill), inhibits
spermatogenesis
Contraception For Lactating
Females
 Physiology:
 During lactation about 40-60% experience
amenorrhea and anovulation in the 1st few
months.
 Mechanism:
 Prolactin is an anti-gonadotropin.
 Contraception Methods
For Lactating Females
 IUD: the most ideal
 Injectables: 150 mg DMPA
 Progestogen only pill (POPs): Very suitable.
 Natural Methods
 Barrier Methods
 Chemical Methods
 Combined Pills (COCs): Not ideal
 Antagonize & block prolactin receptors.
 Change in quality & quantity of milk.
Emergency (Post Coital)
Contraception
 Use of a method after unprotected intercourse If
 Dysfunctional Method (broken condom)
 Incorrect use (missed pills)
 Options for Emergency Contraception
 Morning after pill (EE + Progesterone) 2
tablets /12 hrs.
 IUD Insertion
 RU 486. Mifepristone Antiprogesterone effect
Emergency
Contraceptive Pills
 Progestin-only Pills Regimen
 First dose (0.75 mg levonorgestrel) as soon as possiblewithin 72
hours
 Repeat dose after 12 hours
 Combined OCC Regimen
 Each = at least 0.1 mg of ethinyl estradiol and 0.5 mg of
levonorgestrel
 First dose must be taken within 72 hours
 Repeat dose 12 hours after first dose
 Side Effect include: nausea, vomiting , headaches,
dizziness, fatigue, breast tenderness, irregular bleeding
and spotting
