FAMILY

PLANNING

 Different methods are grouped

according to effectiveness tiers that
reflect failure rates (WHO)

TOP TIER:
MOST EFFECTIVE

TOP TIER:
MOST EFFECTIVE

Long Acting Reversible

Contraception:
INTRAUTERINE DEVICES
most commonly used reversible
contraception worlwide
chemically inert
composed of nonabsorbable
materials

Levonorgestrel-releasing
intrauterine systems
Mirena and Skyla
releases progestin into the uterus
at a relatively constant rate
T-shaped radiopaque frames have
a stem wrapped with a cylinder
reservoir that contains the
levonogestrel

 Mirena
5 yrs of use ff insertion
(some) 7 yrs

Skyla
3yrs of use
slightly smaller overall dimension
sized to more approproately fit a
nulliparous uterus

 Paragard (T 380A IUD)

polyethylene and barium sufate Tshaped frame with copper, and 2
strings extend from the stem base
10yrs of use

IUD: Contraception Action

failure rates: <1%, similar to those of
tubal sterilization
intense local endometrial inflammatory
respose in induced within the uterus, esp
by copper-containing devices
Cellular and humoral components of the
inflammation are expressed in
endometrial tissue and in fluid filling the
uterine cavity and fallopian tubes

release of progestin
and copper
inflammation induction
decreased sperm and egg
viability

Copper IUD
-copper levels increase in the
cervical mucus of users
-decrease sperm motility and
viability
LNG-IUS
-long term progestin release leads to
endometrial atrophy, hinders normal
implantation

Adverse Effects

uterine perforation
device expulsion
menstrual changes
infection
miscarrage (if + pregnancy)
ectopic pregnancy

Perforation
identified by the tool travelling
further than the expected urine
length based on initial bimanual
examination
1/1000 insertions

Lost Device
expulsion is most common in the 1st
month
examination ~1mo after insertion,
usually after menses, to identify the
tails trailing from the cervix
palpation of the strings each month
after menses

 device may have been expelled,

perforated the uterus, or may be
malpositioned
NEVER ASSUME THAT THE
DEVICE HAS BEEN EXPELLED
UNLESS IT WAS SEEN

Transvaginal sonography
plain radiography of the AP
CT Scan
MRI

Menstrual Changes
dysmenorrhea
menorrhagia
Fe-deficiency anemia

>NSAIDs
>NSAIDs
> oral iron salts

LNG-IUS
irregular spotting for up to 6 mos after
placement
expect monthly menses to be lighter or even
absent

Pregnancy with IUD

ectopic pregnancy should be excluded
intreuterine pregnancy (</14wks AOG)
tail may be visible through the cervix, it
should be grasped and the IUD removed
by gentle outward traction
to reduce complications such as subsequent
abortion, chorioamnionitis, and preterm birth

 tail is not visible

attempts to locate and remove may result
in abortion
use of sonography

Viable fetus
no consensus
no evidence of inc fetal malformations

 Pregnant women with device in

utero who demonstrate any
evidence of pelvic infection
intensive antimicrobial therapy
prompt uterine evacuation

Delivery with device in place

appropriate steps should be taken at
delivery to identify and remove IUD

Insertion: Timing
immediately ff miscarriage, surgical
abortion, or delivery ( (-) infection )
risk for expulsion is slightly higher
outweighed by the advantage of
preventing future unplanned pregnancies

insertion near the end of normal

menstruation
could be done anytime

Insertion: Technique
contraindications identified
counseling and written consent
oral NSAID +/- codeine

TOP TIER:
MOST EFFECTIVE

Long Acting Reversible

Contraception:
PROGESTIN IMPLANTS
thin pliable progestin-containing
cylinders implanted subdermally
release hormone over many years
Etonogestrel Implant
Levonorgestrel Implants

Etonogestrel Implant: Implanon

single-rod implant with 68mg of
etonogestrel covered by an ethylene vinyl
acetate copolymer cover
medial surface of the upper arm 8-10cm
from the elbow in the biceps groove
aligned with the long axis of the arm
3yrs, replaced in the same site or in the
opposite arm
not radiopaque

Etonogestrel Implant: Nexplanon

radiopaque
inserter is designed to assist with
subdermal placement and evert
deeper insertions

Levonorgestrel Implants

Jadelle, Sino-implant II
highly effective
subdermally implanted
8cm above elbow
insertion techs varies on the
manufacturer instructions

Actions
Progestin supress LH and in turn block ovulation
thickens cervical mucus to retard
sperm passage
endomterial atrophy for unfavorable
implantation
following cessation, fertility is restored
rapidly

Side Effects
irregular uterine bleeding
metrorrhagia or menorrhagia
most common reason leading to
discontinuation

lipid metabolism, glucose levels,

hemostatic factors, liver function,
thyrid function and BP

Contraindications
breast cancer
pregnancy

TOP TIER:
MOST EFFECTIVE
Intrauterine devices
Implants
Female sterilization
Male sterilization

TOP TIER:
MOST EFFECTIVE

FEMALE STERILIZATION
usually accomplished by occlusion
or division of the FTs
Puerperal sterilization
Nonpuerperal sterilization

Puerperal Tubal Sterilization

performed in conjunction with
cesarian of vaginal delivery
technically simple and
hospitalization need not be
prolonged
FTs are more accessible for several
days after delivery

Surgical Technique
Parkland Method

A. An avascular site in the mesosalpinx adjacent to the fallopian tube is perforated with a
small hemostat. The jaws are opened to separate the fallopian tube from the adjacent
mesosalpinx for approximately 2.5 cm.
B. The freed fallopian tube is ligated proximally and distally with 0-chromic suture. The
intervening segment of approximately 2 cm is excised, and the excision site is inspected
for hemostasis. This method was designed to avoid the initial intimate proximity of the cut
ends of the fallopian tube inherent with the Pomeroy procedure. (From Word, 2012, with
permission.)

 Pomeroy Method
During
ligation
of
a
midsegment tubal loop, plain
catgut is used to ensure
prompt absorption of the
ligature
and
subsequent
separation of the severed
tubal ends.

Long-Term Complications
Contraceptive Failure
surgical errors
fistulous tract or spontaneous
reanastomosis may from between
stumps

Nonpuerperal (Interval)
Surgical Tubal Sterilization
ligation and resection at laparotomy
application of permanent rings, clips,
or inserts to the fallopian tubes by
laparoscopy or heteroscopy
electrocoagulation of tubal segment
(laparoscope)

Long-Term Complications
Contraceptive Failure
equipment failure
(electrocoagulation/clips)
reanastomosis
already pregnant during surgery

Transcervical Sterilizatioin

Intratubal devices

Intratubal Chemical Methods

quinacrine pellets

TOP TIER:
MOST EFFECTIVE

MALE STERILIZATION
Vasectomy
vas deferens lumen is disrupted to block
passage of sperm from the testes
small incision
needle puncture in the scrotum
Failure: unprotected coitus too soon after
ligation, incomplete occlusion, recanalization

SECOND TIER:
VERY EFFECTIVE
Combination pill
Vaginal Ring
Patch
DMPA
Progestin-only pill

SECOND TIER:
VERY EFFECTIVE
Combination pill
Vaginal Ring
Patch
DMPA
Progestin-only pill

COMBINATION HORMONAL
CONTRACEPTIVES
Mechanism of Action
suppression of hypothalamic
gonadotropin-releasin factors
blocks pituitary secretion of FSH and
LH
inhibit ovulation

PROGESTIN
cervical mucus thickening
retard
sperm
passage

endometrium
unfavorable for
implantation

prevents ovulation

ESTROGEN
suppresion of FSH release
blocks ovulation

Administration
taken daily for a specified time
(21-81 days)

replaced by placebo for a specified

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

 1st day of a menstrual cycle

additional contraceptive method is
unnecessary.

Sunday start
more traditional schedule
requires pill initiation on the first Sunday
following the onset of menses

quick start method

start on any day of the cycle, commonly the
day prescribed, regardless of cycle timing

Side Effects

Altered Drug Efficacy

Metabolic Changes
Cardiovascular changes
Neoplasia
Others

SECOND TIER:
VERY EFFECTIVE
Combination pill
Vaginal Ring
Patch
Injectable Progestin
Progestin-only pill

TRANSVAGINAL RING
NuvaRing
made from ethinyl vinyl acetate
54mm X 4mm
releases wthinyl estradiol and
progestin etonogestrel
absorbed across the vaginal epithelium

Insertion
ring is compressed and threaded
into the vagina
placed within 5 days of menses
onset
removed for 1 wk after 3 wks of use
to allow withdrawal bleeding

Side effects
vaginitis
70%- ring is felt during intercourse
can be removed and relaced within
3hrs

SECOND TIER:
VERY EFFECTIVE
Combination pill
Vaginal Ring
Patch
Injectable Progestin
Progestin-only pill

TRANSDERMAL PATCH
inner layer
contains an adhesive and hormone matrix

outer layer
water resistant

buttocks, upper outer arm, lower

abdomen, upper torso
breast is avoided

 Initiation is same with as for COCs

New patch is applied weekly for 3
wks
Patch-free week -> withdrawal
bleeding

THIRD TIER:
EFFECTIVE
Combination pill
Vaginal Ring
Patch
Injectable Progestin
Progestin-only pill

INJECTABLE PROGESTIN
depot medroxyprogesterone actete
DPMA, Depo-Provera
150mg q3mos

norethisterone enanthate
200mg q2mos

Depot medroxyprogesterone
actete (DMPA)
ovulation inhibition
increased cercival mucus viscosity
unfavorable endometrium
initial injection: within 5 days of
menses onset

Side effects
irregular menstrual bleeding
prolong anovulation ff
discontinuation
risk for stroke if with severe hpn
weight gain
loss of bone mineral density

SECOND TIER:
VERY EFFECTIVE
Combination pill
Vaginal Ring
Patch
Injectable Progestin
Progestin-only pill

PROGESTIN-ONLY PILLS

mini pills
taken daily, same time of the day
do not reliably inhibit ovulation
effectiveness depends more on cervical
mucus thickening and endometrial
atrophy
contraindication: pregnancy and known
breast cancer

THIRD TIER:
EFFECTIVE
Condom
Diaphragm with spermicides
Fertility awareness

THIRD TIER:
EFFECTIVE
Condom
Diaphragm with spermicides
Fertility awareness

CONDOM: Male
contraceptive efficacy
reservoir tip and spermicide

provides considerable but not

absolute protection against STDs if
used properly

CONDOM: Female
synthetic nitrile sheath with one flexible
polyurethane ring at each end
open ring remains outside the vagina
closed internal ring is fitted under the
symphysis like a diaphragm
ff use, outer ring is twisted to seal the
condom
impermeable to HIV and other STDs

THIRD TIER:
EFFECTIVE
Condom
Diaphragm with spermicides
Fertility awareness

DIAPHRAGM WITH
SPERMICIDES
circular latex dome of a various
diameters supported by a
circumferential latex-covered metal
spring
effective with use of spermicide

Application
Spermicide on the dome cup and
along the rim
positioned, cup facing the cervix
one rim is lodged deep in the
posterior vaginal fornix
opposite rim fits behind the inner
surface of the symphysis and
immediately below the urethra

Side effect
toxic shock syndrome, rare
slightly rate of urinary infections
urethral irritation by the ring under the
symphysis

THIRD TIER:
EFFECTIVE
Condom
Diaphragm with spermicides
Fertility awareness

FERTILITY AWARENESS
attempts to identify the fertile days each
cycle and advise sexual abstinence
during these days
limited efficacy

Standard Days
Calendar Rhythm
Temperature Rhythm
Cervical Mucus
Symptothermal Methos

Standard Days
avoid unprotected intercourse
during cycle days 8-19
women must have regular monthly
cycles of 26-32 days

Calendar Rhythm
counting the # of days in the
shortest and longest menstrual
cycle during 6-12mos span
shortest cycle: -18 to calculate the
1st fertile day
longest cycle: -11 to identify the last
fertile day

Temperature Rhythm
relies on slight changes in the basal
body temperature that usually occur just
before ovulation
0.4F increase

intercourse should be avoided until well

after the ovulatory temperature rise
abstinence from the 1st day of menses
until the 3rd day after the temp increase

Cervical Mucus
Two-Day Method or Billings Method
awareness of vaginal "dryness" and
"wetness"
After menses opaque, thick, sticky (dry
stage)
Close to ovulation slippery, lubricative,
transparent
Peak of ovulation easier for sperm to travel
up
After ovulation dry mucus

 Billings Method
abstinence from the beginning of
menses until 4 days after slippery
mucus is identified

Two-Day Method
intercourse is considered safe if a
woman did not note mucus on the day
of planned intercourse or the day prior

Symptothermal Method
combine
changes in cervical mucus-onset of fertile
period
changes in basal body temp-end of fertile
period
calculations to estimate time of ovulation

more complex to learn and apply

does not appreciably improve efficacy

FOURTH TIER:
LEAST EFFECTIVE
Spermicides
Sponge

FOURTH TIER:
LEAST EFFECTIVE
Spermicides
Sponge

SPERMICIDES
creams, jellies, suppositories, films,
aerosol foam
temporary protection
provides a physical barrier to sperm
penetration and a chemical spermicidal
action
nonoxynol-9 or octoxynol-9
do not provide STD protection

 deposited in the vagina in contact

with the cervix shortly before
intercourse
duration of effectiveness
no more than 1hr
reinserted before repeat intercourse

douching avoided </ 6hrs after

coitus

FOURTH TIER:
LEAST EFFECTIVE
Spermicides
Sponge

SPONGE

one-size-fits all
nonoxynol-9-impregnated disc
2.5cm thich 5.5cm wide
dimple on one side and satin loop
on the other side
can be inserted up to 24hrs before
intercourse

 provides contraception regardless

of coital frequency
should remain in place 6hrs after
intercourse
more convenient but less effective
than diaphragm or condom
SE: irritation, discomfort, vaginitis

EMERGENCY
CONTRACEPTION
Hormonal Emergency Contraception
Copper-Containing IUD

EMERGENCY
CONTRACEPTION
Hormonal Emergency Contraception
Copper-Containing IUD

HORMONAL EMERGENY
CONTRACEPTION
minimum of 100mcg ethinyl estradiol
and 0.5 mg of leveonorgestrel in
each of 2 doses
sufficient dose is achieved by 2 or
more pills
1st dose: within 72hrs (up to 120 hrs)
2nd dose: 12 hrs later

 progestin-only regimens:
1.5mg of levonogestrel
2 doses: 1st: within 72 hrs (up to
120hrs); 2nd: 12 hrs later or 24 hrs

Major Mechanism
inhibition or delay of ovulation
more effective the sooner it is taken
and risk of pregnancy up to 94%
SE: nausea and vomiting
oral antiemetic may be taken 1 hr
before each dose

EMERGENCY
CONTRACEPTION
Hormonal Emergency Contraception
Copper-Containing IUD

COPPER-CONTAINING
DEVICES
if placed up to 5 days after
unprotected coitus, failure rates
approximates 0.1%

 ..end