Contraception and Family Planning😍

Family Planning

• Replacement level for total fertility rate: < 2.1

Family Planning Methods (FPM)

Target Couple vs. Eligible Couple:

Failure Rate:

Life table analysis:

• Best method.

Pearl’s index:

• Total no. of accidental pregnancies x 100 /
  Total women years of exposure

• Total no. of accidental pregnancies x 100 x 12 /
  Total women months of exposure

Contraception Pearl Index (Per 100 women years):

• Pearl index=(20/24 x100)x 1200=10/HWY

Types of Contraception:

• Reversible/Temporary Methods:
• Natural methods,
• Barriers,
• Emergency contraception
• OCP,
• Gossypol,
• Centchroman.

• LARC
• Long acting reversible contraceptives
• Implants,
• IUD
• Injectables

• Permanent Methods:
• Male sterilization (Vasectomy),
• Female sterilization (Tubectomy).

Mechanism of Action

Temporary Contraceptives

Natural Methods:

• Lactational amenorrhoea
• Amenorrhoea post childbirth.
• High failure rate.
• Ideal contraceptive of choice during lactation: 
• Progesterone only pills.

• Rhythm method:
• Based on calendar method.

• Basal body temperature:
• ↑Body temperature by 0.3 - 0.5°C d/t ovulation :
• Unsafe period.

• Billing’s method:
• Thinning of cervical mucus d/t ovulation.

• String of beads/Tirumala methods/Cyclobeads



• Adv: Used by illiterate women.
• Disadv:
• Not used in irregular, short (<26 days) or long (>32 days) cycle.

• Barriers:
• Prevents pregnancy & STD.
• Latex.
• Male condom.
• Female condom.
• Polyurethane, latex (better)

Long-Acting Reversible Contraceptives (LARC)

• Implants

• IUCD

• Injections

Barrier Methods

• Male condom
• Included in NFP
• Single ring; one-time use only

• Female condom
• FC-2 distributed by NACO to sex workers
• Two rings; generally one-time use only (max twice)

• Diaphragm
• Can be used up to 1 year by washing and drying
• kill sperm by ↓ surface tension

• Today sponge
• 1 g nonoxynol 9
• kill sperm by ↓ surface tension
• Can be used multiple times for 24 hours
• Mnemonic: Not (Nonoxynol) today (24 hours)

Ortho Evra → Transcutaneous Patch

• Norelgestromin + Ethinyl Estradiol

NuvaRing

• Etonogestrel + Ethinyl Estradiol

• Topical vaginal ring

Intrauterine Devices:

• 1st generation:



• Inert IUD Lippe’s loop,
• Grafenberg ring → 1st gen → 1st we learn to draw graph with silver pen

• 2nd generation:
• Copper containing: 
• CuT200, CuT380A, Cu375 (Multiload devices).

• 3rd generation:
• Hormonal IUD 

ㅤ	Progestasert	Mirena
Contains	Natural progestin	Levonorgestrel/LNG-20 (Synthetic)
Life span	1 year	5 years
Total hormone load	38 mg	52 mg
Rate of secretion	65 mcg/day	20 mcg/day
Characteristic	- Lowest expulsion rate - A/w ectopic pregnancy - Not preferred	- Lowest failure rate ↳ (<0.3/100 women years) - Lowest side effect

• 4th gen: Ginifix → Frameless IUD

Copper containing IUD:

 

 

ㅤ	CuT-380A Paragard	Cu multiload 375 device
Shape of device	T shaped	Inverted U shaped Bent arms with spurs - Spurs reduce expulsion
Life span	10 years	5 years (5 > 3)
Copper present	On the arms as well (A)	Only on the stem
Thread	Polyethylene (White)	Monofilament nylon (Blue green)

Feature	CuT 380A (Paraguard)	Mirena
Generation	2nd gen IUD	3rd gen IUD
Mechanism of Action	Prevents fertilization	Prevents implantation
Release Rate	Releases 50 mcg of copper per day ≥ 380 mm surface area of copper wire	Releases 20 mcg of Levonorgestrel (LNG) per day (no anovulation)
Side Effects/Benefits	Main side effect is bleeding	Helps reduce bleeding Used for AUB, endometrial hyperplasia (no atypia)
Infection Risk (PID)	Increased risk of infection (PID) at insertion	Thickens cervical mucus, decreasing PID risk
Ectopic Pregnancy	Causes ectopic pregnancy if it fails	Higher chance of ectopic pregnancy if it fails
Emergency Contraception	Can be used as emergency contraception	Cannot be used as emergency contraception
Life span	Copper T 380 A (Paraguard) ► 10 years [Multiload 375 ► 5 years]	5 years

• 380: Surface area of Cu on the IUD.

• Mode of action: Prevents fertilization > implantation.

IUD Side Effects & Complications

• Vaginal bleeding – most common
• Physiological bleeding that resolves on 1ts own in 1-3 months
• Reassurance

• Abdominal pain – second most common
• 2nd most common side effect
• Most common cause of removal of IUD

• Pelvic infection

• Uterine perforation

• Pregnancy (contraceptive failure)

• Ectopic pregnancy

• Expulsion of IUD

Absolute Contraindications

• Suspected pregnancy.

• Ongoing PID.

• Undiagnosed vaginal bleeding.

• Cancer cervix, uterus, or adnexa or other pelvic tumors

Note:

• Previous ectopic pregnancy is not a c/I.

• Bleeding up to 3 days post IUD insertion:
• Reassurance + Iron folic acid tablets

Pelvic Inflammatory Disease (PID) with IUCD

• Most Common Cause of PID with IUCD:
• Actinomyces
• Management: Remove IUCD + Give antibiotics.

Other Infections with IUCD

• Initial Step: Oral antibiotics for 48-72 hours.

• If no response:
• IV antibiotics.
• If no response after 24 hours: Remove IUCD.

IUCD: Contraindications

• For both CuT & Mirena:
• Undiagnosed vaginal bleeding (Cervical Cancer, Endometrial Cancer, trophoblastic disease)
• Distorted uterine cavity (Fibroid)
• Active PID
• Suspected pregnancy

• Only CuT:
• Wilson's disease

• Only Mirena:
• Previous history of breast cancer
• Active liver disease

• Not Contraindicated (for both):
• Previous history of ectopic pregnancy
• Previous history of PID

Pregnancy with IUCD: Management

If female conceives with IUCD:

• Continuing pregnancy?
• No: Termination of pregnancy + IUCD removal.
• Yes:
• Thread Visible:
• Remove IUCD.
• Give antibiotics.
• Continue pregnancy.
• Thread Not Visible:
• Do not remove IUCD.
• Give antibiotics.
• Continue pregnancy.

Risks with pregnancy & IUCD:

• Increases risk of:
• Infection
• Preterm labor
• Intrauterine Growth Restriction (IUGR)
• Abortion

• Does NOT increase risk of: Teratogenicity

IUCD: Management of Missed Threads

Step 1: 

• Ultrasound (USG).

If not visible on USG: 

• Serial X-ray.

Based on X-ray:

• Coiled Thread (in uterus):
• Patient wants to continue: No intervention needed.
• Patient wants to remove: Hysteroscopic removal of IUCD.

• Perforation (out of uterus):
• IUCD in peritoneal cavity: Immediate removal of IUCD by laparoscopy.
• IUCD partly in uterus and partly in peritoneal cavity: 
• Removal by hysteroscopy + laparoscopy.

Oral Contraceptive Pills (OCPs):

Classification by Ethinyl Estradiol (EE) Dosing

• High dose: EE ≥ 50 mcg

• Low dose: EE = 30-35 mcg

• Very low dose: EE < 20 mcg

• Minimum effective dose: EE = 10 mcg

Non-Contraceptive Uses of OCP's

1. Irregular cycles: OCP is Drug of Choice (DOC)

2. Decrease blood loss in:
• Fibroids
• Adenomyosis
• Abnormal Uterine Bleeding (AUB)

3. DOC for:
• Primary dysmenorrhea
• Endometriosis (minimal to mild)
• Hirsutism
• Acne
• Hyperandrogenism

4. Manage premenstrual syndrome (PMS)
• OCPs are used but
• DOC for PMS: Fluoxetine (SSRI)

5. Progesterone in OCP's thickens cervical mucus, decreasing chances of:
• Pelvic Inflammatory Disease (PID)
• Sexually Transmitted Disease (STD)
• Ectopic pregnancy

• Most common PID with OCP use: Chlamydia

• Most common vaginitis with OCP use: Candidiasis

OCP's and Cancers

• Increases Risk
1. Hepatic adenomas
2. Breast cancer in perimenopausal females
3. Cervical cancer (Reversible risk)

• Decreases Risk
• Mnemonic: OCP → ↓ CEO cancer
1. Endometrial cancer
• Due to endometrial thinning and anovulation
2. Colorectal cancer
3. Ovarian cancer
• Due to anovulation
4. Ovarian cyst
5. Benign breast disease

• No Effect
• Liver cancer

Absolute Contraindications for OCP's (WHO Category 4)

• Mnemonic: Banks Have Various Schemes To Provide Home Loans During May
• Known/suspected breast cancer
• Uncontrolled hypertension (Severe ≥160/110)
• (Medically controlled hypertension in non-smoking female of any age is not a contraindication)
• Undiagnosed vaginal bleeding
• Smoker ≥35 years of age
• Known/suspected thromboembolism
• History of
• Cerebrovascular Accident (CVA)
• Myocardial Infarction (MI)
• Conditions predisposing to it
• malignancy,
• lupus anticoagulant present
• prolonged immobility due to trauma or surgery
• Family history of idiopathic thromboembolism in parent or sibling
• Pregnancy or history of peripartum cardiomyopathy
• Severe hypercholesterolemia, hypertriglyceridemia
• Presently impaired liver function/liver cancer/acute or chronic cholestatic liver disease
• Diabetes with vasculopathy
• Migraine with aura
• Also contraindicated in:
• Breastfeeding
• Post-partum females (<21 days)

Note on OCPs

• 1 pill/day

• Start between Day 1 and Day 5 of menstrual cycle

• Maintain high levels of estrogen and progesterone for 21 days

• Stoppage: Fall in estrogen + progesterone levels induces menses
• Day of menses is the new Day 1 for the next cycle

• Most common side effect:
• Irregular/Breakthrough Bleeding
• Most common with low-dose pills
• Due to less estrogen

• Elective surgery with anticipated immobilization:
• OCPs stopped 4 weeks prior.

• Return of fertility
• ≤ 3 months → Rapid

Mala N, Mala D: 

• Ethinylestradiol 30 mcg + Levonorgestrel 0.15 mg.
• 21 hormonal pills + 7 ferrous fumarate (Iron) tablets.
• EE → FF

• Mala N:
• Mnemonic: N → Nation → Free
• Free of cost, by GOI.

• Mala D:
• Mnemonic: D → Delivery
• Home delivery contraceptive by ASHA worker.

Missed Pill

Pills Missed	Next Step
Missed 1/2 pill	- 1 pill to be taken ASAP - Normal schedule to be continued - No back up contraceptives required
Missed ≥3 pills (1st/2nd week)	- 1 pill to be taken immediately - Complete pack as per schedule - Back up contraception × 7 days - If h/o intercourse in previous 72 hrs: Emergency contraception
Missed ≥3 pills (3rd week)	- In addition to above points: - After completing pack as per schedule → Start a new pack immediately, discard 7 iron tablets (Don’t wait for menses; skip non-hormonal pills)

Non-Contraceptive Benefits of OCPs (BENEFITS)

• O: Decreased Ovarian cyst (DOC for PCOD).

• B: Decreased Benign Breast Disease.

• E: Decreased Endometriosis.

• N: Decreased Neoplasia (Endometrial and ovarian cancers).

• E: Decreased Ectopic pregnancy.

• F: Decreased Fibroid.

• I: Decreased Iron deficiency Anemia.

• T: Decreased Premenstrual Tension Syndrome.

• S: Decreased Skeletal Disease (Osteoporosis).

Side Effect

• Increased Risk of:
• Cervical Cancer (Reversible)
• Breast Cancer.

• Decreased Risk of:
• Endometrial Cancer.
• Ovarian Cancer.

Polycystic Ovarian Disease (PCOD)

• OCPs are DOC for regulating menstrual cycle.

• Metformin used to reverse insulin resistance.

• Ovulation inducers used to induce ovulation.
• Aromatase inhibitors (e.g., Letrozole) is DOC.
• Clomiphene citrate can also be used.

Centchroman/Chhaya/Saheli:

• Active component: 
• Ormeloxifene.

• Dose: 
• 30 mg tablets taken biweekly (twice in a week) x 3 months
  → then Weekly.

• MoA: 
• Selective Estrogen Receptor Modulator (SERM), 
• Non-hormonal, non-steroidal.

• S/E:
• Menstrual irregularities,
• Mood changes,
• Hot flushes.

• Missed pill:
• <7 days:
• Taken within 7 days + Alternate contraceptives.
• >7 days:
• Stop regime, use alternate contraception, start as new user.

• Every 7 days, Soman goes to oormila. if he forgets, start as a new user (Vaishna’s code)

LNG Pill/ Ezy Pill/ i-Pill:

• 1.5 mg Levonorgestrel.

• Single dose within 72 hrs of intercourse.

Injectables:

• Depot Medroxy Progesterone Acetate (DMPA)/Antara:
• Dose: 150 mg IM, 3 monthly injection.
• Advantages:
• Discrete
• ↓ Blood loss:
• Beneficial in anemia.
• Follow up dose:
• Before 2 weeks to 4 weeks after due date.
• No additional contraceptive.

• Norethisterone enanthate (NET-EN):
• Dose: 200 mg IM, 2 monthly.

DMPA Injection

• Name: ANATARA (National Family Planning program)

• Dose: 150 mg

• Route: Intramuscular (IM)

• Frequency: Every 3 months

• Window Period: 4 weeks

• Action: Anovulation

Benefits & Drawbacks

• Advantages:
• Decreases seizure frequency.
• Decreases sickling in Sickle Cell Anemia (SCA).

• Disadvantages:
• Delayed return of fertility.
• Decreased bone mineral density.
• Irregular bleeding.

Scheduling & Management

• Scenario 1:
• On Schedule
• Patient arrives: 1st October (scheduled date)
• Action:
• Give DMPA injection.
• No pregnancy test (UPT) or backup contraception required.

• Scenario 2:
• Within Window Period
• Patient arrives: 2 weeks earlier or 4 weeks after of scheduled date (15th September to 28th October)
• Action:
• Give DMPA injection.
• No UPT or backup contraception required.

• Scenario 3:
• After Window Period
• Patient arrives: After 4 weeks of scheduled date
• Action:
• Rule out pregnancy.
• Give DMPA injection.
• Use backup contraception for 7 days.

Implants

• Implants are an alternative to injections for contraception.

Norplant

• A subdermal hormonal contraceptive.
• Norplant:
• Contains 6 Silastic capsules,
• each with 36 mg Levonorgestrel (LNG).
• Norplant R2: Contains 2 capsules, each with 75 mg LNG.

• Mechanism & Effectiveness
• Capsules or rods are inserted beneath the forearm skin.
• They prevent ovulation.
• Effectiveness: 5 years.

• Disadvantages
• Irregularities of menstrual bleeding (M/C)
• Surgical procedures required for insertion and removal.
• Implants are not available under National family welfare programs.

Contraceptives of Choice (COC)

• Breast feeding females:
• POP: Anytime after delivery.
• Antara: After 6 weeks of delivery.
• OCP: After 6 months of delivery.

• Non-lactating females:
• Antara: Anytime after delivery.
• OCP: After 3 weeks of delivery.

• All females (Irrespective of breastfeeding or not):
• IUCD: Within 48 hrs or after 6 wks of delivery.
• Female sterilization: Within 1 week or after 6 weeks.
• Emergency contraceptives: After 4 weeks.

Recent Advances

Nayi Pahel Kit

• For newlywed couples

• Cost: Rs 220

• Under Mission Parivar Vikas

• Contents
• Jute bag
• Marriage registration form
• Nirodh condoms
• Mala N
• Emergency contraceptive pills
• Pregnancy test kits
• Grooming or hygiene kit
• Information card
• Pamphlet

• ASHA incentive
• Rs 100 per kit

• Not included
• Chhaya and Antara
• Under Mission Parivar Vikas

Mission Parivar Vikas (MPV):

Nishchay:

• Pregnancy testing kit.

Fixed day approach/sterilization days:

• Monthly: PHC.

• Fortnightly (once every two weeks): CHC.

• Weekly: Sub-district hospitals.

• Twice weekly: District.

Medical Eligibility Criteria (MEC) wheel:

• Formulated by WHO.

• 9 contraceptives are assessed.

• Inference:

Score	Inference
1	Method can be used
2	Used with caution
3	Not used unless indicated
4	Not used/Contraindicated

• Knowledge attitude and practice criteria
• In family planning

Post Partum Contraception

Rule of 3: When to Start Contraception in a Postpartum Female

• Not breastfeeding/Partially breastfeeding:
• 3 weeks after delivery

• Exclusively breastfeeding:
• 3 months after delivery

• List of contraceptives which can be given from day 1 of delivery:
• Condoms
• Centchroman
• SERM → Ormeloxifene
• Progesterone only pills
• Progesterone implants

Other Contraceptives and the Time at Which it is Given

OCPS:

• Decrease breast milk in breastfeeding females

• Increased risk of thrombosis in breast feeding and non-breastfeeding females

• Absolutely C/I at < 21 days (Post delivery)

• Non-breastfeeding:
• Can start: ≥ 3 weeks of delivery
• Ideally: ≥ 6 weeks of delivery

• Exclusively breastfeeding:
• Can start: ≥ 6 weeks of delivery
• Ideally: ≥ 6 months of delivery

DMPA:

• Leads to osteoporosis

• Breastfeeding: Give ≥ 4 weeks of delivery

• Non breastfeeding: Day 1

Emergency Contraception:

• After 4 weeks

Tubectomy/Tubal ligation:

• Mini laparotomy is done.
• (modified Pomeroy technique)

• Postpartum ligation: After 24 hours till 1 week

• Interval ligation: After 6 weeks

• Laparoscopic tubal ligation is C/I in post partum period

Permanent Contraceptives

Tubectomy & Vasectomy:

Non-scalpel vasectomy:

• S/E:
• Infection, pain,
• Psychological.
• Sperm granules:
• Painless granular sensation in testicular area,
• 2 weeks post vasectomy,
• Self limiting.
• Spontaneous recanalization (<0.3%):
• Cause for vasectomy failure.
• Auto immune response d/t anti-sperm antibody:
• Present in 55% post vasectomy males by 5 years
• Return of fertility after recanalization: Low.
• Sterile
• 3 months > 30 20 ejaculations after vasectomy.

Tubectomy: 

• M/c contraceptive used in India (36%).

Male Sterilization

Vasectomy

• Minimum of vas deferens is removed and ends are ligated.

• Remove ≥1 cm of vas deferens, and ligate both ends.

• Safe and simple procedure.

• Barrier method must be used post vasectomy:
• Until 3 months or 20 ejaculations.

• Avoid heavy weight lifting post-op.

• Most common cause of failure:
• Misidentification of vas deferens.

Eligibility

• Married or ever married

• Age <60 years

• At least 1 child >1 year old

• No previous sterilization (self/spouse)

• Sound mind

• Mentally ill patients:
• Certified by psychiatrist
• Statement on soundness of mind by guardian/spouse

Service Offered

• Conventional vasectomy – Trained MBBS doctor

• No-scalpel vasectomy (NSV) – Trained MBBS doctor
• Widely used now
• Vas deferens is the structure that is divided

Complications

• Failure rate: 0.15 per 100 person-years

• Operative: Pain/infection

• Sperm granulomas:
• Appear after 10–14 days
• Usually subside

• Autoimmune response:
• Antibodies to sperm may form
• No clinical significance

• Psychological issues

• Spontaneous recanalization: 0–6%

Female Sterilization

Eligibility Criteria

• Married or ever married

• Age 22–49 years

• At least 1 child >1 year old

• No history of sterilization (self/spouse)

• Sound mind

• Mentally ill patient:
• Certified by psychiatrist
• Statement by legal guardian/spouse

Service

• Laparoscopic sterilization: By DGO, MD (Gynobs), or MS (Surgery)

• Minilaparotomy
• Modified Pomroys
• By trained MBBS doctor
• 2 indications
• Postpartum
• 2nd trimester MTP

• Hysteroscopic method:



• Essure
• TAKE 3 MONTHS
• non scalpel vasectomy
• essure
• dmpa action

Timing of Sterilization

Note

• Best time for IUCD insertion: During menses
• Receptive time: After delivery

• Husband's permission not required for MTP/IUCD insertion

Tubal Ligation

 

 

Pomeroy Technique

• Most Common:
• Single ligature used.
• Tube ends cut.

• Disadvantage:
• Cut ends close.
• Risk of fistula.
• Leads to failure.

Uchida's Procedure

• Subserosal Dissection:
• Serosa lifted by needle.
• Saline injected.
• Then serosa incised.
• Tube resected.
• Serosa sutured again.

• Advantage:
• Less fibrosis.
• Fewer adhesions.
• Muscle Cut ends within serosa.

Irving's Procedure

• Tube Burial:
• One end buried in uterine musculature.
• Other end buried in mesosalpinx.

Parkland technique

Madlener