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24.复件 Family Panning2008
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24.复件 Family Panning2008

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    • 1. Family Planning (计划生育)
    • 2. Contraception
      • The ideal method of contraception should be certain, without risk to health, acceptable and inexpensive.
    • 3. Contraception
      • Contraceptive methods may include
      • 1. hormonal contraception
      • oral hormonal contraceptives
      • injection, inplantation ,transdermal routes
      • 2 nonhormonal contraception
      • intrauterine devices
      • barrier
      • spermicidal preparations
      • physiologic-natural method
      • 3. Postcoital or emergency contraception
      • none of them is 100% effective and all are associated with some degree of risk.
    • 4. Conception requires Juxtaposition of the male and female gametes at the optimal stage of maturation Transportation of the conceptus to the uterine cavity at a time when the endometrium is supportive of its continued development and implantation.
    • 5. 精卵结合 子 宫 输卵管 卵巢 卵巢排卵 精 子 抑制排卵 杀灭精子,使精子失去活力 阻断精子和卵子相遇 改变子宫内膜使受精卵无法着床 避孕的有效途径 宫颈粘液变稠厚,精子不能穿透 阻断精子和卵子结合
    • 6. I. Oral contraceptives (1) Short-acting (2) Long-acting (3) Vacation pill II. Long-acting contraceptive injection III. Slow-releasing contraceptives IV. Transdermal patch Systemic Contraceptives Types of the systemic contraceptives
    • 7.
      • Oral contraceptives
      • 1. Short-acting Tablets ( 99.95% )
      • 1) Monophaser
      • 2) Biphaser
      • 3) Triphaser
      Systemic Contraceptives
    • 8. Components: (1) Estrogens: Ethinylestradiol , EE ( 炔雌醇 ) (2) Progestogens: Norethindrone, Megestrol, cyproterone etc. 1. Compound Norethindrone Tablets 复发炔诺酮片 ( 避孕片 1 号 ) Components: EE 35μg, Norethindrone 0.6mg 2. Compound Megestrol Acetate Tablets 复方甲地孕酮片 ( 避孕片 2 号 ) Components: EE 35 μg, Megestrol 1.0mg 3. Compound Levonorgesterel Tablets 复发左旋炔诺孕酮片 ( D- 甲炔诺酮片、 复方左旋 18 甲基炔诺酮片) Components: EE 30 μg, Levonorgesterel 0.15mg Tablets Monophasers
    • 9. Several kinds of the monophasic oral contraceptives are commonly available for use in China
      • 4. Compound Desogestrel Tablets (Marvelon)
      • 复方去氧孕烯片 ( 妈富隆 )
      • Components: EE 30 μg, Desogestrel 0.15mg
      • 5. Minulet( 敏定偶 )
      • Components: EE 30 μg , gestodene 75mg
      • 6. Diane -35( 达英 -35)
      • Components: EE 35 μg, cyproterone 2000mg
      • Less side effects: Nausea, breast, weight, acne,
      • hirsutism
    • 10. Rekers 1988 头疼 恶心 乳房胀痛 n = 808 side effects of Marvelon headache nausea Breast swealing pain
    • 11. Biphasers Ovidal (CTR24) 去氧孕烯双相片 Components: 1st phase (day 1 ~ 7): EE 40μg, Desogestrel ( 去氧孕烯 ) 0.025 mg 2 nd phase (day 8 ~ 21): EE 30μg, Desogestrel ( 去氧孕烯 ) 0.125mg Systemic Contraceptives
    • 12. Triphasic pills
      • Triphasic pills take advantage of the synergism between the estrogen and the potent progestogen so that low doses of the estrogen and very low doses of the progestogen could be used effectively .
    • 13. Tablet Triphasers Levonorgesterel Triphaser Tablets 左炔诺孕酮三相片 ( 左旋 18 甲三相片 ) Components: 1st phase (day 1 ~ 6): EE 30μg, Levonorgesterel ( 左炔诺孕酮 ) 0.050mg 2 nd phase (day 7 ~ 11): EE 40μg, Levonorgesterel ( 左炔诺孕酮 ) 0.075mg 3rd phase (day 12-21) EE 30μg, Levonorgesterel ( 左炔诺孕酮 ) 0.125mg Systemic Contraceptives
    • 14. Triphasic pills
      • imitating the physiological rise and fall of estrogens during the normal menstrual cycle .
      • The dose of progestogens decreases 30-40% during the cycle.
      • Less side effects than tablets monophasers
    • 15.  
    • 16. Biologic action of oral contraceptives
      • Suppression of follicle-stimulating hormone(FSH)
      • Suppression of luteinizing hormone (LH)surge and thus prevent ovulation
      • Alteration of cervical mucus , thick, viscid, and scanty making it less penetrable by spermatozoa.
      • They alter motility of the muscle of the uterus and ovi-
      • ducts, altering transport of both ova and sperm.
      • Induction of an atrophic change in the endometrium that is probably not conducive to implantation.
    • 17. Advantages of the pill
      • There is no doubt that the pill properly taken is the most efficient contraceptive available and is ideal for most healthy women under the age of 35.
      • For many women it has abolished the problems of dysmenorrhea and menorrhagia .It also seems likely the pill protects women against benign breast lesion , functinal ovarian cyst, ectopic pregnancy, ovarian cancer, endometrial cancer and pelvic inflammatory disease. The progression of endometriosis is suppressed.
    • 18.
      • 1. Abnormal uterine bleeding
      • Breakthrough bleeding
      • If happens in the first half cycle: add EE ( 炔雌醇 )
      • 50-150μg/day for 2 weeks.
      • If happens in the second half cycle: increase o.c. by
      • 0.5-1 tablet/day for 2 weeks.
      • 2) Cessation of menstruation
      • Amenorrhea: discontinue o.c. and try ovulation induction
      • 3) Hypomenorrhea (月经过少)
      • No treatment or EE 50-100 μg/day for 22 days
      Side effects
    • 19. 2. Morning sickness-like reaction VitB6 20mg, VitC 100mg, anisodamine ( 山莨菪碱 )10mg tid po for 7 days. 3. Weight gain P (containing weak androgen activity): stimulating anabolism ( 合成代谢) E: causing sodium and water retention 4. Pigmentation (moth patch) ( 蝴蝶斑 ) 5. Others Headache, breast swelling pain, appetite increase, skin rash, pruritus ( 瘙痒 ), etc. Side effects
    • 20.
      • Complications of oral contraceptives
    • 21. Venous thrombosis
      • The pill causes an increase in the platelet count and of platelet adhesiveness, and a decrease antithrombins in the blood, coagulation factors Ⅶ and Ⅹ and fibrinogen increase.
      • Estrogen component of the pill is believed to be responsible.
    • 22. Venous thrombosis
      • The progestin decreases the high-density lipoproteins and increases the low-density lipoproteins.
    • 23. hypertension
      • Some women develop hypertension when taking the pill. Oral contraceptives may increase the release of renin precursors from the liver and result in hypertension in a small percentage of women. Therefor the blood pressure should be checked before starting it and at regular intervals while it is being taken.
    • 24. amenorrhea
      • Most women have a withdrawl flow ( anovulatory) periods, and usually ovulatory cycles return as soon as the pills are stopped. In a few women “postpill amenorrhea”occurs, and may persist for several months. This is seen particularly in women who had irregular menstrual cycles or episodes of amenorrhea before starting oral-contraceptives
    • 25.
      • Most of these patients will resume regular menstruation spontaneously within 6 months, and only a few will need treatment with clomiphne or gonadotrophins to induce ovulation and return to normal cycles.
    • 26. Metabolic effects
      • Clucose tolerance is reduced by oral contraceptives, as it is in pregnancy.
    • 27. Hepatic function
      • This may be affected by both estrogen and progestogens. Women who have a history of cholestasis of pregnancy, or with abnormal liver function such as may follow hepatitis should not be give oral-contraceptives, until liver function tests have returned to normal. women who develop jaundice or itching with the pill must discontinue it.
    • 28. heart disease
      • Existing heart disease such as a congenital defect, is not necessarily a contraindication, but patients with pulmonary hypertension should not be given oral combined preparations. Pregestogen-only compounds may be an alternative.
    • 29. Varicose veins
      • Varicose veins without evidence of deep thrombosis are not a contraindication to the use of the pill.
    • 30. cancer and tumor
      • There is no evidence that oral-contraceptives cause cancer in the cervix or body of the uterus.
      • Wheather it can increase the risk of breast cancer remains controversial.
      • The long-term use of oral-contraceptives is associatid with benign hepatic tumors.
    • 31.
      • Babies born to women who have taken the pill after pregnancy has started show no increase in the incidence of congenital abnormalities.
    • 32. lactation
      • Combined oral-contraceptives affect lactation in some women , reducing the volume and quality of the milk. Progestogen-only preparations, given either orally or by injection, may be prefered during breast feeding.
    • 33. Surgical operations
      • Most surgeons advise discontinuation of pills containing estrogen for 2 months before surgical operations to avoid any possible risk of thrombosis.
    • 34. Systemic Contraceptives Contraindications 1. Malignant or precancerous diseases and patients with uterine or breast masses 2. Hematopathy and thrombotic diseases 3. Severe cardiovascular diseases 1) P->lipid metab ->coronary artherosclerosis 2) E->blood coagulation↑->myocardiac infarction 3) E->renin activity↑->hypertension
    • 35. 4. Endocrine diseases: diabetes, hyperthyroid dysfunction 5. Lactation 6. Oligohypomenorrhea or older than 45 years old 7. older than 35 years old smoking wemen 8. delivery within half a year or menses not recovery 9. Hepatitis and nephritis 10. Psychotic ( 精神病患者 ) Systemic Contraceptives Contraindications
    • 36.
      • The commonest regimen starts on day1- 5 of a cycle. A pill is taken each day for 21 days.
      • During the interval withdrawal bleeding usually occurs.
      • Whether or not bleeding occurs,repeating the course after the interval of 7 days.
      • The pill should be taken at the same time .
      use direction
    • 37.
      • If the woman forgets to take the pill one night ,she should take it the next morning .
      • She should be warned the ovulation may not be inhibited in the first cycle of treatment.
      • If “breakthrough bleeding”occurs, this can be controlled by increasing the dose of estrogen, or by changing to another preparation which contains a different proportion of estrogen to progestogen.
      use direction
    • 38. 2. Long-acting Tablets (96% ~ 98%) Components: Quinestrol , Progestogens 1) Compound Quinestrol Monthly Tablets 复方炔雌醚片 ( 长效避孕片 1 号,复方炔雌醚月服片 ) Components: Quinestrol 3mg Chlormadinone acetate ( 氯地孕酮 ) 12 mg 2) Three in one Compound Quinestrol Monthly Tablets 三合一炔醚片 Components: Quinestrol 2mg Chlormadinone acetate ( 氯地孕酮 ) 6 mg Norgesterel ( 炔诺孕酮 ) 6 mg Systemic Contraceptives
    • 39.
      • Use direction
      • the first month : D5 and D10
      • next months : once a month
      • Side effects
      • Stop use
    • 40. Long-acting contraceptive injection 1. Compound Hydroxyprogesterone Caproate Injection 复方己酸羟孕酮避孕针 ( 避孕针 1 号 ) Components: Hydroxyprogesterone Caproate 250mg Estradiol Valerate 5mg 2. Compound Megestrol Acetate Injection ( Inj.Mego-E ) 复方甲地孕酮避孕针 ( 美尔伊避孕针、甲孕雌醇避孕针 ) Components: Megestrol 25mg 17β-Estradiol 3.5mg
    • 41. 3. Norethisterone Enanthate Injection 庚炔诺酮避孕针 Components: Norethisterone Enanthate 炔诺酮庚酸酯 200mg can be used in lactation menstrual disorder ↑ Long-acting contraceptive injection
    • 42. in the first month : D5 and D12 next months: D10-D12 menstrual onset 12-16 days after injection side effcts: irregular bleeding , menorrhagia in the first 3 months treatment : hemostatic , estrogen, short –acting OC Long-acting contraceptive injection
    • 43. 1. Hypodermic implant ( 皮下埋植剂 ) (1) Norplant I (99.8%) (D- 炔诺孕酮埋植剂 I 、 左炔诺孕酮埋植剂 I) Levonorgestrel ( 左旋炔诺孕酮) 36mg×6 . For 5 years (2) Norplant II (D- 炔诺孕酮埋植剂 I 、 左炔诺孕酮埋植剂 I) LNG 70mg×2 . For 3 years no estrogen , can be used in lactation implanted on 7 days of menstrul cycle side effct: irregular blot bleeding , amenorrhea treatment : hemostatic , estrogen Slow-releasing contraceptives
    • 44.  
    • 45.  
    • 46. (1) Megestrol Acetate-Silica Gel Circle (97%) 甲硅环、甲孕酮硅胶避孕环 Megestrol 200 ~ 250mg For 1 years 哺乳期首选 Contraceptive vaginal ring
    • 47. 3. Slow-releasing injectable microglobes and microcapsules – 0.1mm For 3 months IV. Transdermal patch Systemic Contraceptives
    • 48. Intrauterine Devices
      • The main benefits of IUD
      • A high level of effectiveness
      • A lack of associated systemic metabolic effets
      • The need for only a single act of motivation for long-term use
      • Particularly suitable for the older woman who has contraindications to the combined pill
    • 49. Intrauterine Devices
    • 50. 1. IUD made with inert materials Stainless steel, nylon, etc Fewer adverse reactions, but higher expulsion rate and pregnancy rate 2. IUD added with active substances 1) IUD with copper TCu-200 (1 year cumulative rate) Expulsion rate: 5.61% Pregnancy rate: 1.51% Removal rate (due to adverse effects): 9.22% Removal rate (due to other reasons): 3.62% ‘ Overall failure rate’ 19.96% 2) IUD with progestogens , zinc, PG synthetase inhibitor 3. Third generation IUD : Anchoring IUD Types of IUD
    • 51. Mechanism 1.Primarily an aseptic inflammation reaction- foreign body macrophage ,Leukocytes ↑ - blastokinin ↓ - implantation ↓ 2.Prostaglandins velocity of embryo transport ≠ endometrial development 3. oppressed ischemic endometrium -> plasminogen ↑ - fibrinolysis ↑- blastula dissolve . IUDs
    • 52.
      • Mechanism
      • IUD with active substances
      • IUD with copper:
      • (1) alkaline phosphatase and carbonic anhydrase change ->
      • DNA synthesis ↓ glycogen metabolism ↓,interfere endometrial cell metabolism -> implantation ↓
      • (2) Toxic effect on sperms
      • 2. IUD with progestogens:
      • (1) Atrophic change in the endometrium
      • (2) Change in the cervical mucus
      • (3) Interference with metabolism in sperms
      IUDs
    • 53. IUDs 1. Timing 1) 3-7 days after completion of menstruation and no recent sexual intercourse. 2) Immediately after an artificial abortion (<10 cm) 3) 3 months after a normal vaginal delivery 4) 6 months after a cesarean section 5) Day 3 of menses for progestin containing IUD 2. Selection of IUDs: depending on space of uterine cavity Procedures
    • 54. Method
    • 55.  
    • 56.  
    • 57. Postoperative care
      • Rest for 3 days.
      • Don’t intercourse and take a tub bath for 2 weeks.
      • Regular follow-up examinations are essential to detect expulsion.
    • 58.
      • Pregnancy suspected
      • Infection of the reproductive tract
      • (3)Tumours of the reproductive tract or uterus malformation
      • (4) Cervical imcompetence, severe old laceration
      • of cervix and severe uterine prolapse
      • (5) Severe generalized diseases
      • (6) Polymenorrhea or menorrhagia
      Contra-indications IUDs
    • 59. 1 ) Uterine bleeding Mechanical compression injuries Increased PGs and activated fibrinolysis Indomethacin ( 消炎痛 ) 25-50mg tid po aminohexanoic acid ( 氨基己酸 ), 2-4g tip po 云南白药 , 0.4g tid po Severe menorrhagia causing anaemia and requiring removal of the device 2) Pain or discomfort Colicky pain may occur for a time after insertion, particularly if the device is large. If dysmenorrhoea occurs, prostaglandin synthetase inhibitors relieve the symptom. Otherwise the possibility that it is caused by infection must be thought. Adverse effects
    • 60. Complications of IUDs
      • 1. Perforation of the uterus
      • 2. Expulsion or displacement
      • 3. pelvic inflammatory disease
      • 4.Pregnancy with an IUD in place
      • 5. incarceration
    • 61. Perforation of the uterus
      • The incidence varies with the experience of the operator.
      • Perforation is easy to occur:
      • (1) In the postabortal and puerperal state, myometrial is soft
      • (2) anteflexion or retroflexion of uterus
    • 62. Perforation should be suspected
      • with a difficult or painful insertion.
      • most perforation cause no symptoms and are only suspected when the tail of the device can not be found.
    • 63.
      • An x-ray then reveals extrauterine lodgement.
      • Hysteroscopy, hysterosalpingography and ultrasonography are usually used to detect the “misplaced “IUD
    • 64. Expulsion or displacement
    • 65.
      • An intraperitoneal IUD should be removed by laparoscopy, colpotomy or laparotomy.
      • If the IUD embedded in the myometrium, it can be removed by the hysteroscopy.
    • 66. expulsion
      • It is most likely to occur during the first year after insertion.
      • Symptoms of expulsion include the string of the device is lengthen, uterine cramps or abnormal bleeding.
    • 67. infection
      • About 2 percent of women using IUD develop pelvic infection . In some cases this was pre-existing, but not recognized when the device was inserted.
      • The device should be removed.
      • Some gynaecologists advise not to use the IUD in the nullipara as it may flare up pelvic inflammatory desease and cause subsequent sterility.
    • 68. Pregnancy with an IUD in place
      • Uterine pregnancy with a device in place have increased risk of abortion 25% if the IUD is removed and 50% if it is not .
      • If the device is left in place and pregnancy continues, fetal malformation is most unlikely, but there is a risk of uterine infection
      • It is now advised that the device should be removed.
    • 69.
      • With an IUD in place, the rate of ectopic pregnancy increases from 1 in 250 pregnancies to 1 in 50.
    • 70. progesterone-releasing IUD
      • The rate of pregnancy with device in place is low , and the expulsion rate is also low.
      • The main side effects are amenorrhea and drop blood.
      • It has a much higher ectopic pregnancy rate than the copper IUD.
    • 71. Indications of removal IUD
      • Side effects and complications
      • Use other contraceptive methods
      • Pregnance with IUD
      • Menopause for one year
      • Plan to pregnance
    • 72. Types: (1) Male condom ( 安全套 ) (2) Female condom (3) Vaginal spermicides Nonoxynol-9 ( 壬苯醇醚膜 ) (95%) 乐乐迷避孕膜 Mechanism: Damage sperm membrane Usage: Insert into vagina 3-5 min before coitus Barrier methods
    • 73.  
    • 74. (1) Coitus interruptus ( 体外排精 ) (2) The safe period ( 安全期 ) (3) Postcoital douche ( 性交后冲洗 ) (4) Prolongation of lactation Natural methods
    • 75. Natural methods
      • Sperm can survive in the female genital tract for 2 to 3 days and the egg can be fertilized up to 48 hours after ovulation.
      • Ovulation ordinarily occurs 14 days before
      • the fist day of the next menstrual period. The fertile interval should be assumed to extend from 4-5 days before ovulation to 4-5 days after ovulation.
    • 76. Mucus assessment
      • when ovulation is imminent , the cervical mucus is thin and watery, and intercourse should be avoided.
      • After ovulation the mucus becomes thick and viscid due to the effect of progesterone, signifying the fertile time is over.
    • 77. Postcoital contraception
      • To avoid the unintended pregnancy, emergency contraception should be used several hours or days after unprotected intercourse .
    • 78. Mechanism 1. Prevent or postpone ovulation 2. Interfere with fertilization or implantation Methods 1 Morning-after pill ( 98% ) ( <3 days ) Steroid or nonsteroid hormones. 2. Morning-after IUD insertion Postcoital Contraception
    • 79. Steroid hormones
      • Combined pill :contain estrogen and progestogen
      • Progestin pill
      • Estrogen pill
      • Taken within 72 hours of intercourse and repeated in 12 hours.
      • Side effect
      • Nausea
      • Voiming
      • irregularly uterine bleeding
    • 80. Steroids (1) Levonorgestrol Tablets ( 左炔诺孕酮片 ) 毓婷 Levonorgestrel 0.75mg twice (12h) (2) Anordrin Tablets (53 号抗孕片 ) (Sugar coated) Anordrin ( 双炔失碳酯 ) 7.5mg twice . (3) Compound Levonorgesterel Tablets 复方左旋炔诺孕酮片 (EE 30 μg, LNG 0.15mg) 4 tablets twice (12h) Postcoital Contraception
    • 81. nonsteroid hormones Mifepristone(RU486)
      • Antiprogestin
      • One tablet (25mg dose) are taken within 5 days of intercourse. It’s effectiveness is about 70-80%.
    • 82. Morning – after IUD insertion
      • Intrauterine insertion of a copper IUD within 5 days of coitus is an effective method to prevent continuation of the pregnancy.
      • It is one of the most effective methods of emergency contraception.
      • Concern about introducing pathogens into the upper genital tract with IUD insertion limit its widerspread use.
    • 83. Methods: 1. Minilaparotomy (经腹) 2. Laparoscopy (腹腔镜术) Sterilization :Tubal ligation ( 结扎术 )
      • Contra-indications:
      • Acute illness
      • Severe illness that can not tolerate surgery
      • Infection
      • Severe neurosis ( 神经官能症 )
      • Twice or more 37.5℃ within 24 hours
    • 84. Minilaparotomy (经腹)
    • 85.  
    • 86. Permanent sterilization
      • When a patient comes with a request for sterilization, the most important duty of the gynaecologist is to ensure that her motives are clear, that she understands its risks and its probable irreversibility.
      • The patient must be told the side effects and complications, such as dysfunctional uterine bleeding, emotional regret, dyspareunia, decreased libido and dysmenorrhea.
      • The patient should understand that sterility can not be guaranteed.
      • If sterilization reversal is not success, in vitro fertilization is an alternative solusion.
    • 87. 1. Drug induced 2. Surgical Vacuum suction ( 6 ~ 10 weeks ) Surgical curettage ( 11 ~ 14 weeks ) Artificial abortion ( 人工流产 )
    • 88. Drug induced abortion ( 药物流产 )
      • Combination therapy with Mifepristone
      • and Misoprostol
      • Indications:
      • Pregnancy within 7 weeks, age < 40
      • (2 ) Refusal of surgical abortion
      • (3) Surgical abortion difficult or with high risk:
      • Within half year of a cesarean section or lactating,
      • surgical abortion lately, gential tract malformation,
      • perforation history
      • Method:
      • Mifepristone ( 米非司酮 ) 50mg/day for 3 days
      • Misoprostol ( 米索前列醇 ) 0.6mg on the 4 th day morning
    • 89. Mechanism: Mifepristone competes with progesterone for P receptors on decidua ( 蜕膜 ). Misoprostol causes uterine contraction. Complete abortion rate: ≥ 90% Side effects and complications: (1) Digestive tract symptoms (2) Pain caused by uterine contraction (3) Bleeding usu. > 14 days or even 2 months (4) Infection Drug induced abortion ( 药物流产 )
    • 90. Contraindications:
      • 1. To mifepristone : endocrine disease (adrenal gland, diabetes , thyroid gland), Hematopathy and thrombotic diseases, hepatic and renal function , tumor , hypertension
      • 2.To misoprostol : heart disease , glaucoma , asthma , gastrointestinal dysfunction
      • 3. Pregnancy with an IUD in place
      • 4. Ectopic pregnancy suspected
      • 5. anaemia (hemoglobin <100g/l)
      • 6. hyperemesis gravidarum
      • 7. medicine :rifampicin , barbitone , antiepileptic , antidepressants , indomethacin
      •   
    • 91. Surgical Abortion ( 人工流产术 )
      • Contra-indications:
      • Acute or severe illness
      • Acute infection of reproductive tract
      • Hyperemesis gravidarum ( 妊娠剧吐) with acidosis
      • Twice 37.5℃ within 24 hours
      • Methods:
      • 1. Vacuum aspiration ( 负压吸引 )
      • For pregnancy within 10 weeks.
      • 2. Surgical curettage with forceps ( 钳刮术 )
      • For pregnancy for 11-14 weeks
    • 92.  
    • 93.  
    • 94.
      • Complications
      • Artificial abortion syndrome
      • tachycardia , cardiac dysrhythmia , blood pressure ↓, perspiration , dizziness , faint - vagus excite - Atropine 0.5-1mg
      • 2. Uterine perforation
      • 3. Bleeding during the operation
      • 4. amnionic fluid embolism
      • 5. Retention of conceptus
      • 6. Postoperative infection
      Surgical Abortion ( 人工流产术 )
    • 95. Uterine perforation
    • 96. Retention of conceptus
    • 97. For newly married couples: For couples with one child: For couples with two or more children: For lactating women: For perimenopausal women: Selection of Contraception Methods
    • 98. thanks