4th years

1. Family planning
Dr. Lubna Almaghur MRCOG
Introduction:
 Important topic in final exam’s (written, oral, and clinic).
 Basic knowledge is essential for any field of medicine. (Drug interactions, contraindications to
pregnancy).
 Common knowledge for family consultation.
Objectives:
 To be able to list the different types of contraceptives.
 To understand how each method works? Its advantage, disadvantage, indications and
contraindications.
Types of family planning:
1. Contraception: reversible.
a. Hormonal;
• Combined oral contraceptives COC
• Progesterone only pills POP
• Hormonal implant.
• Progesterone injection.
• Mirena coil (intra uterine system).
b. Mechanical; intrauterine contraceptive device
c. Barrier;
• Male condom .
• Female condom.
• Cervical cap.
• Diaphragm.

2. d. Natural;
• Lactational amenorrhea.
• Fertility awareness.
• Coitus interuptus.
2. Sterilization: permanent.
a. Male sterilization; vasectomy.
b. Female sterilization; tubal ligation.
Contraceptives
The ideal contraceptive: should be…
 100% effective.(pearl index = zero)*
 No side effects.
 Does NOT interfere with intercourse.
 Reversible.
 Cheap.
 Does not require health personnel
*pearl index = number of pregnancies per 100 women years.
Such a method does NOT exist so the choice of contraception will depend on…
 The couple’s preference.(NOT DOCTER’S!!!!)
 Presence of contraindication’s.
Combined oral contraceptives:
COC contain both oestrogen (ethinylestradiol in different doses) and progesterone (different types).
Each pack contains 21 tablets. The woman should start on the first day of the menstrual cycle taking one
tablet every day for 3 weeks followed by a one week break during which the woman will have
withdrawal bleeding (not true menstruation), after one week the woman should start a new pack
regardless of her bleeding.

3. Some packs contain 28 tablets with 21 active tablets and 7 placebo tablets at the end. In this case the
woman takes a tablet every day without a break.
Mechanism of action:
1. Inhibits ovulation: this is the main mechanism of action, High levels of oestrogen and
progesterone will suppress higher centers leading to decrease FSH and LH.
2. Thickening of cervical mucus secretions due to effect of progesterone. . (secondary action)
COC as a contraceptive:
Advantage:
 Highly effective.
 Not related to intercourse.
 Immediately reversible.
Disadvantage:
 Compliance: The woman needs to remember to take her tablets.
 There is a long list of contraindications restricting its use.
Non contraceptive benefits for the pill:
 Cycle control: improves all cycle disorders (dysmenorrhea, menorrhagia, irregular cycles).
 Reduces functional ovarian cysts.
 Reduces PID.
 Reduces benign breast diseases.
 Reduces acne and hirsuitism.
 Reduces risk of ovarian cancer and endometrial cancer.
Side effects of COC:
a. Oestrogenic: nausea, dizziness, bloating, leukorrhea. If these symptoms persist change to a
tablet with lower dose of oestrogen.
b. Progestogenic: vaginal dryness, weight gain, depression, breast tenderness. if these symptoms
persists change to a tablet with different progestogen.

4. c. Breakthrough bleeding: is bleeding while the woman is taking the pills before she has
withdrawal bleeding. If this persists and pathological causes of bleeding are excluded then
change to another pill with a higher dose of oestrogen or a different progestogen.
Complications:
1. DVT (Deep venous thrombosis): Using COC increases the risk of DVT however the overall risk is
still low (30/100 000users) and is less then the risk of thrombosis with pregnancy.
2. Arterial disease and stroke.
3. Breast cancer: There might be a slight increase in the risk of breast cancer in women using COC
this is insignificant in young women with no other risk factors. The base line risk will return back
to normal 10 years after stopping the pill.
4. Cervical cancer: the association between COC and cancer cervix is unclear but they may act as a
cofactor for speeding the transmission from normal epithelium to CIN to cancer. However
routine smears will detect CIN before it changes to cancer.
5. Liver adenoma: this is a very rare tumor in both pill users and non pill users.
Contraindications:
One of the disadvantages of the COC is the long list of contraindications.
Absolute:
 Family or personal H/O DVT
 Thrombophilia
 BMI >39
 Bed bound.
 >50 years.
 Hypertension.
 Migrane with aura
 Heavy smoking >40/day
 Sever diabetes.
 Liver disease.
 Undiagnosed genital tract bleeding.

5.  Trophoblastic disease: until beta HCG is undetectable.
 Breast feeding.
 More than 2 relative contraindications.
Relative:
 BMI 30-39
 Reduced mobility.
 Age >35.
 Migrane without aura.
 Smoker<40/day
 DM with no complications.
Drug interactions:
1. Enzyme inducing agents e.g. antiepileptics.
2. Broad spectrum antibiotics.
These drugs cause failure of the contraceptive effect of the COC.
Progesterone only pill (POP):
 Is given as an every day pill.
 One tablet given every day starting from the first day of period with no break.
 The tablet should be taken at approximately the same time every day. +/_ 3 hours.
 28 tablets per pack.
How does it work?
Increase cervical mucus secretion to prevent penetration of sperms.
POP as a contraceptive:
Advantage:
 Used in lactation.

6.  Not related to intercourse.
 Immediately reversible.
 Less contraindications than COC.
Disadvantage:
 Needs to be taken at the same time every day (compliance problem).
 Irregular bleeding.
 Progesteronal side effects.
 Less efficient than COC. (pearl index of 1-3 compared with 0.1-1)
Contraindications:
 Liver adenoma.
 Breast cancer.
 Acute porphyria.
 Recent trophoblastic disease: until BHCG is undetectable.
 Undiagnosed vaginal bleeding.
Cerazette
This is a POP that can inhibit ovulation in 97% of cases so it is a very effective contraceptive. It is useful
in women who need highly effective oral contraception but have a contraindication to the COC.
Injectable progesterone only contraceptives:
There are two main injectable contraceptives
 Depoprovera: medroxyprogesterone acetate injection every 12 weeks.
 Noristerate: every 8 weeks
They are given as deep inter-muscular injections during the first 5 days of the cycle.
Because Depoprovera is given every 12 weeks it is the one most commonly used.
How does it work?
Increase cervical mucus secretion to prevent penetration of sperms.

7. Depoprovera as a contraceptive:
Advantage:
 highly effective (pearl index0.1-2).
 Amenorrhea.*
 Less problems with compliance: only 4 injections per year.
 Improves period related problems.
Disadvantage:
 Amenorrhea.*
 Irregular bleeding initially in the first few months.
 Delay in return of fertility: after stopping the injection it may take up to one year for the women
to conceive(average 6 months)
 Progesterone side effects can not be reversed.
*most women develop amenorrhea after the first couple of injections this could be an advantage or
disadvantage according to the woman’s preference.
Contraceptive implant:
A silastic rode inserted in subdermally into the posterior arm where it secretes progestogen. It is
effective for 3 years.
How does it work?
Increase cervical mucus secretion to prevent penetration of sperms.
Implant as a contraceptive:
Advantage:
Highly effective: pearl index = 0
Disadvantage:
• Irregular bleeding.
• Progesterone side effects.
Intrauterine contraceptive device IUCD:

8. A copper containing device which is inserted into the uterus under aseptic technique without
anesthesia. It is effective for 3-10 years according to the type of device inserted.
Mechanism of action:
• Prevents fertilization by direct toxic effect on the sperm.
• Prevents implantation by inducing an inflammatory response in the endometrium.
IUCD as a contraceptive:
Advantage:
• Highly effective: pearl index = 1-2
• Safe.
• Not related to intercourse.
• No compliance necessary.
• Reversible.
Disadvantage:
 Requires medical professional for removal and insertion.
 May be difficult to insert in nulliparus.
Complications:
 Expulsion.
 Perforation: rarely occurs at the time of insertion, if the coil enters the abdominal cavity it will
require removal by laparoscopy or laparotomy.
 Infection: may occur within 3 weeks of insertion.
 Menorrhagia: patient with IUCD may experience heavy prolonged menstruation.
Contraindications:
• Distortion of the uterine cavity.
• Undiagnosed genital tract bleeding.

9. • Acute pelvic inflammatory disease.
Note: IUCD does NOT increase risk of ectopic pregnancy but if a patient with IUCD gets pregnant she is
more likely to have an ectopic pregnancy than if she has no IUCD.
Intrauterine contraceptive system (Mirena)
Similar in appearance to IUCD but contains no copper, instead it slowly releases progesterone locally
into the endometrium.
It is inserted into the uterus as an IUCD however, it acts as a hormonal contraceptive not as a
mechanical contraceptive.
How does it work?
Increase cervical mucus secretion to prevent penetration of sperms.
Mirena as a contraceptive:
Advantage:
• Highly effective: pearl index = 0.5
• Safe.
• Not related to intercourse.
• No compliance necessary.
• Reversible.
• Progesterone side effects are minimal compared with other hormonal contraceptives because it
is locally acting.
• Reduces menstrual loss (it is licensed for treatment of menorrhagia).
Disadvantage: expensive.
Contraindications:
• Distortion of the uterine cavity.
• Undiagnosed genital tract bleeding.
Barrier contraceptives:
1. Male contraceptive: it is the commonest barrier contraceptive.

10. 2. Female condom: Inserted in the vagina and removed immediately after intercourse.
3. Cervical cap: inserted into the vagina before intercourse so that it covers the cervix and
removed at least 6 hours after.
4. Diaphragm: insertion is similar to the cervical cap.
Spermicides are used with barrier methods to improve success rate but not used alone.
Advantage of barrier methods:
 No medical supervision is necessary.
 Minimum adverse effects.
 Decrease risk of STD : this is the case in male and female condoms however, cervical cap and
diaphragm leave a large area of the vagina exposed therefore they do NOT protect against STD.
Disadvantage of barrier methods:
 Latex allergy.
 High failure rate: pearl index = 2-15
 Interferes with intercourse.
 Female barrier contraceptives require the woman to be familiar with her anatomy to be able to
insert it so the method has not gained popularity and is not commonly used.
Natural contraception:
1) Lactation:
Is not an effective contraception , it has a 2%conception rate only if…
 Amenorrhea is present.
 Full lactation.
 Feeding on demand.
 Less than six months
If any of these criteria is not applicable than the conception rate is even higher.
2) Fertility awareness:
The idea is to avoid intercourse at time of ovulation.

11. How to predict the time of ovulation?
 Safe period: calculating the approximate time of ovulation from the length of the cycle. It is
difficult if the woman has irregular cycles.
 Increase temperature: an 0.20
C increase in temperature occurs after ovulation.
 Cervical secretion: change in the cervical secretions from watery to thick after ovulation
 Persona: is a mini laboratory kit that can measure LH in the urine therefore indicate when
ovulation occurs.
Combining these methods together reduces failure rate.
Safe period:
In a 28 day cycle ovulation will occur at day 14 +/- one day so intercourse should be avoided on days 13-
14 and 15.
1-2-3-4-5-6-7-8-9-10-11-12-13-14-15-16-17-18-19-20-21-22-23-24-25-26-27-28
However if a sperm was present in the female genital tract on day 13 then fertilization may occur,
because the sperm can survive 3-5 days in the female genital tract intercourse should be avoided 5 days
earlier.
1-2-3-4-5-6-7-8-9-10-11-12-13-14-15-16-17-18-19-20-21-22-23-24-25-26-27-28
After ovulation the ovum remains 12-24 hours available for fertilization and so 2 more days are added to
the expected day of ovulation
1-2-3-4-5-6-7-8-9-10-11-12-13-14-15-16-17-18-19-20-21-22-23-24-25-26-27-28
So in a 28 day cycle the unsafe period is from day 8 to day 18, if the cycle is variable then the unsafe
period is the time between the ( shortest cycle -19 days)to the ( longest cycle -10days)
Advantage:
 No medical supervision.
 No side effects.
 Cheap.
Disadvantage:
 Needs compliance from both partners.

12.  High failure rate especially in young couples.
Post-coital contraception “emergency contraception”
Use of contraception to prevent fertilization or implantation after intercourse
Needed in cases of unprotected intercourse, condom accidents, missed pill or rape.
They are not a substitute for regular contraception.
Types:-
 Hormonal: progesterone only + combined.
 IUCD
Progesterone only emergency contraception:
 Can be used up to 72 hours after intercourse, but is more effective if used earlier
 Successful in 98-99%.
 Probably acts by delaying ovulation.
 Levenogestrel 1.5mg stat.
 Side effects nausea and vomiting
Combined oestrogen and progesterone emergency contraceptive:
 Can be used up to 72 hours after intercourse.
 Less commonly used
 Effective in 97%of cases.
 Microgynon 30 X8 tablets.
 Nausea and vomiting more than the progesterone method.
IUCD:
 Can be used up to 5 days after intercourse.
 Successful in 99.9%of cases.

13.  Most probably acts by prevention of implantation.
 Risk of infection.
Sterilization
Male sterilization (vasectomy):
• Ligation of the vas deference
• Easier procedure than tubal ligation.
• can be done as out patient under local anesthesia.
• More easily reversible.
• May require up to 3 months to be effective.
Female sterilization (tubal ligation):
• Can be done by mini-laparotomy, laparoscopy, or hysteroscopy.
• Carries the risk of complications of the procedure as well as complications of anesthesia.
• Has a failure rate 1:300.
• Failure rate is higher if done during cesarean section.
• In case of failure there is increase risk of ectopic.