Family Planning is vital representative services

Awesome

1. Dr. Dawit Worku
Family planning

2. Introduction
•Pregnancy rates at 1 year approach 90 percent for
sexually active fertile women who do not use
contraception.
•one third—2.65 million—of all pregnancies were
unintended.
•contraception poses less risk than does pregnancy.
•Approximately 40% of unintended pregnancies occur
among women who do not desire pregnancy yet do
not use a method of contraception.
•Approximately 60% of unintended pregnancies occur
among women using some form of birth control.

3. Contraceptive Methods
•Oral steroidal contraceptives
•Injected steroidal contraceptives
•Intrauterine devices
•Transdermal and transvaginal steroidal
contraceptives
•Physical, chemical, or barrier techniques
•Fertility awareness based methods
•Breast feeding
•Permanent sterilization

11. Physical, chemical, and barrier
techniques

12. Coitus Interruptus
•withdrawal of the penis before ejaculation.
•One of the oldest contraceptive methods .
•has the disadvantage of demanding sufficient self.
•Failure may result from
-escape of semen before orgasm or
- the deposition of semen on the external female
genitalia near the vagina.

14. Postcoital Douche
•Plain water, vinegar, and a number of "feminine
hygiene" products are used as postcoital douches.
•the douche flushes the semen out of the vagina, and
the additives to the water may possess some
spermicidal properties.
•is ineffective and unreliable.
•sperm have been found within the cervical mucus
within 90 seconds after ejaculation.

15. Lactational Amenorrhea
•Ovulation is suppressed during lactation:
- elevates prolactin levels and reduces gonadotropin-
releasing hormone (GnRH) from the hypothalamus,
reducing luteinizing hormone (LH) release and thus
inhibiting follicular maturation.
- Endorphins induced by suckling induce a decline in
the secretion of dopamine.
•Effectiveness depends on:
-frequency and duration of nursing
- length of time since birth

16. •For maximum contraceptive reliability:
- feeding intervals should not exceed 4 hours during
the day and 6 hours at night.
-supplemental feeding should not exceed 5% to 10% of
the total amount of feeding.
•Six-month pregnancy rates : 0.45% to 2.45%
•Another method of contraception should be used
- from 6 months after birth, or
- sooner if menstruation resumes.

17. •Combination OCs generally is not advised during
lactation because they reduce the amount and
quality of breast milk.
•Progestin-only OCs, implants, and injectable
contraception do not affect milk quality or quantity.
•Breastfeeding reduces the mother's lifetime risk of
breast cancer by 30 %.

18. Male Condom
•cover for the penis during coitus and prevents the
deposition of semen in the vagina.
•materials used :
- latex rubber : most common
- polyurethane
- lamb ceca
•Thickness: 0.065–0.085 mm
•the non latex condoms may break more easily than
the latex Varieties.

19. •Condoms prelubricated with the spermicide
nonoxynol-9 are more effective than condoms
without spermicide.
•The risk of condom breakage is about 3%.
•Non contraceptive use:
1. protect against sexually transmitted infections (STIs)
and its sequel (tubal infertility).
- 40% reduction in infertility with consistent use of
barrier methods.

20. •Chlamydia trachomatis, herpes virus type 2, HIV,
and hepatitis B did not penetrate latex condoms but
did cross through condoms made from animal
intestine.
2. protection from cervical neoplasia : 60% to 80%
reduction.
•Latex allergy could lead to life-threatening
anaphylaxis in either partner from latex condoms.
•Nonlatex condoms be offered to couples who have a
history suggestive of latex allergy.

22. Female Condom

23. •made of polyurethane with 2 flexible rings at each
end
•Breakage may occur less often with the female
condom than the male condom.
- 0.6 percent breakage rate.
•slippage appears to be more common.
•have the advantage of being under the control of the
female partner.
•Prevent sexually transmitted diseases.

25. Vaginal Diaphragm

26. •a circular rubber dome of various diameters
supported by a circumferential metal spring .
•the rim is lodged deep in the posterior vaginal fornix,
and the opposite rim lies in close proximity to the
inner surface of the symphysis immediately below
the urethra .
cervix, vaginal fornices, and anterior vaginal wall are
partitioned effectively from the remainder of the vagina
and the penis.

28. •very effective when used in combination with
spermicidal jelly or cream.
•The spermicide is applied to the cervical surface
centrally in the cup and along the rim.
•can be inserted hours before intercourse.
•if more than 2 hours elapse, additional spermicide
should be placed in the upper vagina.
•should not be removed for at least 6 hours after
intercourse.
•should not be left in place for longer than 24 hours .

29. •has the disadvantages of
1. requiring fitting by a physician or a trained
paramedical person .
2. Weight alterations and deliveries might change the
vaginal diameter.
diaphragm users must be assessed yearly during the
routine pelvic examination.
3. increased risk of urinary tract infections due to
pressure of the rim against the urethra

31. Cervical Cap

32. •small cuplike diaphragms placed over the cervix that
are held in place by suction.
•can be self-inserted.
•If properly fitted and used correctly, the cap is
comparable in effectiveness to the diaphragm.

34. Spermicides and Microbicides

35. •Marketed variously as creams, jellies, suppositories,
film, and foam in aerosol containers.
•The active ingredient is nonoxynol-9 or octoxynol-9.
•Spermicides must be deposited high in the vagina in
contact with the cervix shortly before intercourse.

36. •Duration of maximal effectiveness is usually no more
than 1 hour.
•Douching should be avoided for at least 6 hours after
intercourse.
•Do not provide protection against sexually
transmitted infections.

38. Fertility-Awareness Based Methods
(rhythm or natural family planning)

39. •a method that involves identification of the fertile
days of the menstrual cycle and avoiding intercourse
or use of a barrier method during those days.
•ovum remains in the tube for approximately 1–3
days after ovulation.
•sperm can live up to 6 days in the reproductive tract
•the fertile period is from the time of ovulation to 2–3
days thereafter.
•Accurate prediction or indication of ovulation is
essential to the success of the periodic abstinence
method.

40. Standard Days Method

41. •is based on self-reported regular monthly cycles of
26 to 32 days.
•Ovulation ordinarily occurs 14 days before the first
day of the next menstrual period but not necessarily
14 days after the onset of the last menstrual period.
•An overlap of 1–2 days of abstinence either way
increases the likelihood of success.

42. •avoid unprotected intercourse during cycle days 8
through 19.
•the most commonly used method of periodic
abstinence, it is also the least reliable.
failure rates as high as 35% in 1 year's use.

45. Temperature method

46. •Recording the basal body temperature (BBT).
•The vaginal or rectal temperature must be recorded
upon awakening in the morning before any physical
activity is undertaken.
•The third day after the onset of elevated temperature
is considered the end of the fertile period.
•0.3–0.4 °C (0.5–0.7 °F) elevation of BBT following
ovulation.

47. •during each menstrual cycle, intercourse is avoided
until well after the ovulatory temperature rise.
the woman must abstain from intercourse from the first
day of menses through the third day after the increase
in temperature.
•is not a popular method, but with excellent
compliance, the unwanted pregnancy rate is only
about 2 percent the first year.
•Disadv
long abistenance period

48. Temperature method

50. The combined temperature and
calendar method

51. The cervical mucus (Billings)
method
•depends on awareness of vaginal "dryness" and
"wetness".
•uses changes in cervical mucus secretions as
affected by menstrual cycle hormonal alterations to
predict ovulation.
Under estrogen influence, the mucus increases in
quantity and becomes progressively more slippery and
elastic until a peak day is reached.

52. •Abstinence is required from the beginning of menses
until 4 days after slippery mucus is identified.
•Difficulty in evaluating mucus in the presence of
vaginal infection .

53. The symptothermal method
•Combines features of both the cervical mucus and
the temperature methods.
•The first day of abstinence is predicted either from
- the calendar, by subtracting 21 from the length of the
shortest menstrual cycle in the preceding 6 months, or
- the first day mucus is detected
•The end of the fertile period is predicted by use of
basal body temperature i.e. 3 days after the thermal
shift.
•If used properly is the most effective of all the
periodic abstinences .

55. Intrauterine Contraceptive Devices

56. two devices currently approved
ParaGard T 380A : copper-containing
Mirena : levonorgestrel-
containing

57. ParaGard T 380A
•a T-shaped device.
•36 mm in length and 32 mm
in diameter.
•contains 380 mm2 of copper
on its vertical and side arms.
•Two monofilament strings.
•lifespan of at least 10 years.

58. Mirena
•is approved for 5 years of use.
•levonorgestrel-releasing device.
•releases levonorgestrel into the
uterus at a relatively constant rate
of 20 ug/d.
•Two monofilament strings.

59. Mechanism of Action
•have not been defined precisely.
•intense local inflammatory response induced
in the uterus
“ biologic foam” within the uterine cavity that
contains strands of fibrin, phagocytic cells, and
proteolytic enzymes
- phagocytosis of sperm
- impedance of sperm migration or capacitance

60. •Levonorgestrel is thought to produce endometrial
atrophy as well as an intrauterine inflammatory
response.
•Interference with successful implantation of the
fertilized ovum, which at one time was believed to be
the main mode of action, is less important.
- The IUD is not an abortifacient
•Their effectiveness is similar overall to that of tubal
sterilization .
•Annual rates of pregnancy, expulsions, and medical
removals decrease with each year of use.

62. Insertion
•The patient's history .
•Physical examination.
•Cervical culture for Neisseria gonorrhoeae, and a
test for chlamydia are performed.
•Premedication with oral prostaglandin inhibitors such
as ibuprofen.
•Antibiotic prophylaxis has not been found beneficial.
•Usually is inserted during menses to be sure the
patient is not pregnant.

63. •The cervix is exposed with a speculum
- T he vaginal vault and cervix are cleansed with a
bactericidal solution
- A paracervical block
•The uterine cavity measured with a uterine sound.
•cervix is grasped with a tenaculum and gently pulled
downward

64. •the outer sheath of the inserter is withdrawn a short
distance to release the arms of the T and is then gently
pushed inward again to elevate the now-opened T
against the fundus.
•The outer sheath and the inner stylet of the inserter are
withdrawn
•the strings are cut to project about 2 cm from the
external cervical os.

69. Pregnancy with Retained IUD
•Should be removed as it will reduce subsequent
complications if the woman chooses to continue the
pregnancy.
- miscarriage rate of 54 percent with the device left in
situ compared with 25 percent if promptly removed.
- miscarriages with an IUD in place are more likely to
be septic than those without an IUD .
- preterm delivery of 20 % compared with about 5 %
with removal.

70. •Fetal malformations have not been reported to be
increased with a device in place.
•If the tail is not visible, attempts to locate and
remove the device may result in pregnancy loss.
•Lost Device:
- expelled device
- perforation
- tread in the uterine cavity along with a normally
placed device

71. Benefits
•provide excellent contraception without continued
effort by the user.
•protect against ectopic pregnancy.
- If pregnancy occurs in an IUD wearer, it will be
ectopic in about 5% of cases.
•The levonorgestrel T, by releasing levonorgestrel,
reduces menstrual bleeding and cramping.
•reduced risk of endometrial cancer.
•Improvement in symptoms of endometriosis.

72. Contraindications to IUD use
•Pregnancy
•puerperal sepsis
•PID or sexually transmitted diseases current or
within the past 3 months
•endometrial or cervical cancer
•undiagnosed genital bleeding
•uterine anomalies and
•fibroid tumors that distort the endometrial cavity
•Copper allergy and Wilson's disease

73. Infection with HIV
•is not considered a contraindication for IUD use.
•No increase in:
- pelvic infection
- female to male transmission
- viral shedding has been found among HIV-1 infected
women.

74. Adverse Effects
•Uterine Perforation
- occur at a rate of approximately 1 per 1,000
insertions.
- most perforations occur at the time of insertion.
- devices may migrate spontaneously into and through
the uterine wall.
•Cramping and Bleeding
- soon after IUD insertion.

75. •Menorrhagia
- Menstrual blood loss is commonly doubled with
use of the ParaGard device .
- 10 to 15 percent of women using the copper
device have it removed for this problem.
- the Mirena device is associated with progressive
amenorrhea.
•Infection
- the rate of diagnosis of PID was about 1.6 cases
per 1,000 women per year, the same as in the
general population.

76. •Exposure to sexually transmitted pathogens is a
more important determinant of PID than is wearing
an IUD.
•The only pelvic infection that has been unequivocally
related to IUD use is actinomycosis.

77. Hormonal Contraceptives

78. Hormonal Contraceptives
•available in a wide variety of forms:
- pill, injection, transdermal patch, implant, and a
transvaginal ring.
•No reliable male hormonal contraceptives have been
developed .
•"The Pill"consist of :
- a combination of estrogen and progestin, or
- a progestin only pill—the mini-pill.

79. Estrogen Plus Progestin
Contraceptives
•Combination oral contraceptives (COCs) are the
most frequently used method of hormonal
contraception.
•Types: monophasic, multiphasic.
- Monophasic: the same dose of estrogen and
progestin administered each day.
- Multiphasic: varying doses of steroids are given
through a 21-day cycle.
•OCs can be started on the first day of menstruation
or on the Sunday after a menstrual period.

80. •Taken daily for 3 weeks and then stopped for 1
week, during which time there is withdrawal uterine
bleeding.
•Extended-cycle products
- Longer durations, 12 weeks, of active hormone
administration active hormone or pills followed with 1
week of inert pills.
- designed to minimize withdrawal bleeding
- Seasonale and Seasonique

81. Mechanisms of Action
A) Suppression of hypothalamic gonadotropin-
releasing factors
prevents pituitary secretion of FSH and LH.
prevention of ovulation
B) Progestins
- thicken cervical mucus to retard sperm passage.
- render the endometrium unfavorable for implantation.

83. Pharmacology
•The estrogens available are ethinyl estradiol.
•Currently available progestins are 19-
nortestosterone and aldosterone derivatives.
•Dosage
- daily estrogen content varies from 20 to 50ug of
ethinyl estradiol, most pills contain 35ug or less .
•If several doses are missed the next dose is doubled
and an effective barrier technique is added for the
subsequent 7 days.

84. •Drugs decrease the contraceptive effectiveness of
COCs:
- Phenytoin , rifampin , antiretroviral, Griseofulvin,
•In general, oral contraceptives have proven to be
safe for most women.

86. Benefits of Combination Estrogen Plus
Progestin Oral Contraceptives
•Increased bone density
•Reduced menstrual blood loss and anemia
•Decreased risk of ectopic pregnancy
•Improved dysmenorrhea from endometriosis
•Fewer premenstrual complaints

87. •Decreased risk of endometrial and ovarian cancer
•Reduction in various benign breast diseases
•Inhibition of hirsutism progression
•Improvement of acne
•Decreased incidence and severity of acute
salpingitis
•Decreased activity of rheumatoid arthritis

88. Possible Adverse Effects
•Liver Disease
- Cholestasis and cholestatic jaundice , NOT
COMMON
- subside when the COCs are stopped
•Thromboembolic disease
-3 to 9 events per 100,000 users annually
•Myocardial infarction (MI)
- in the presence of risk factors
- prescribing combination oral contraceptives to women
over 35 years who smoke is not recommended.
•Cervical, breast ca?

89. •Contraindications for use of oral contraceptives
-pregnancy
- undiagnosed vaginal bleeding
- prior history of VTE, MI, or stroke
- Women at increased risk for cardiovascular sequelae,
such as active systemic lupus erythematosus,
uncontrolled diabetes, or hypertension, and cigarette
smokers over age 35 years;
- current or prior breast cancer; and
- active liver disease.

90. Progestin-Only Pill (Minipill)
•Low dose of progestin
•0.3 mg of norethindrone per day
•Do not contain estrogens
•Also called ”mini pills”
•Work primarily by:
_ Thickening cervical mucus
_ endometrial activity goes out of phase

91. •The side effects attributable to the estrogen
component of conventional oral contraceptives are
eliminated .
•pregnancy rate of approximately 2–7 pregnancies
per 100 woman-years.
•Doesn’t permit a certain margin of patient error.
- a delay of 2–3 hours diminishes the contraceptive
effectiveness for the for coming 48 hours.
•are associated with irregular bleeding.
•are ideal for women for whom estrogen is
contraindicated.

93. Hormonal Contraception by Injection

94. Hormonal Contraception by Injection
•Depot medroxyprogesterone acetate (DMPA)
- 150 mg administered intramuscularly into the gluteus
maximus or deltoid every 3 months.
- suppression of ovulation by suppressing the surge of
gonadotropins and thickening cervical mucus, thinning
of the endometrium .
- the contraceptive activity actually persists for
approximately 4 months after an injection

96. Side effects
•Reduction in bone mineral density
- adequate calcium intake should be encouraged for
DMPA users, particularly young patients and longer-
term users.
•Irregular bleeding
- during the first 6 months of use.
- up to 70% of users experience no menses after 1
year.
•Mood change and depression
•Delay in the return to baseline fertility
- may take an average of 10 months.

97. Progestin Implants

98. •a progestin is delivered by a subdermally implanted
device containing the drug.
•there are two preparations:
- The Norplant System
- The Implanon System
•Causes ovulation suppression, cervical mucus
thickening, and an atrophic endometrium.

99. The Norplant System

100. •contains levonorgestrel in six elastic containers.
•Its contraceptive effectiveness persists for 60
months.
•The capsules are placed under the skin of a
woman’s upper arm.
•Allegations of illness related to the silicone-based
rods created a climate of litigation around this
system and currently it is no longer available.

101. The Implanon System
•is a single rod subdermal
implant .
•A 68 mg of the
etonogestrel and an
ethylene vinyl acetate co-
polymer cover .

103. Vaginal Ring ( Nuval ring)
•5 cm in diameter and 4
mm thick
•releases ethinyl estradiol
and etonogestrel at fairly
constant rates.
•worn for 3 weeks per
month
•0.65 pregnancies per 100
woman-years.

104. Transdermal Patch
•is 20 cm2
•ethinyl estradiol and
norelgestromin

105. Emergency Contraception

106. Hormonal Emergency Contraception
•morning after pill
•consists of :
- COCs (The Yuzpe method)
- progestin-only product (Plan B)

107. Estrogen-Progestin Combinations(The
Yuzpe method )
•Tablets are taken within 72 hours of intercourse,
followed 12 hours later by a second dose.
•more effective the sooner they are taken after
unprotected sex.
•decrease the risk of pregnancy by up to 94 percent .

108. •Nausea and vomiting are major problems due to
high-dose estrogen .
- oral antiemetic at least 1 hour before each dose.
•If a woman vomits within 2 hours of a dose, the dose
must be repeated.
•0.05 mg ethinyl estradiol 0.25 mg levonorgestrel

109. Progestins Only(Plan B)
•consists of two tablets each containing 0.75 mg
levonorgestrel.
•The first dose is taken within 72 hours of unprotected
coitus and the second dose 12 hours later.
•mini-pill progestins are more effective than
combination estrogen-progestin pills.
- pregnancy rate of 1.1 compared with 3.2 percent .

110. Copper-Containing Intrauterine
Devices
•when an IUD was inserted up to 5 days
after unprotected coitus, the failure rate
is 1 percent.

111. Mifepristone (RU 486) and Epostane
•blocking progesterone production (epostane), or
interfering with its action (mifepristone).
•more effective than the Yuzpe regimen.
- crude pregnancy rates of 0.6 versus 3.6 percent

112. Sterilization

113. Female sterilization
•Tubal sterilization at the time of
laparotomy
•Postpartum minilaparotomy soon after
vaginal delivery
•Interval minilaparotomy
•Laparoscopy
•Hysteroscopy

114. Surgical Technique
•Pomeroy technique
•have failure rates of 1 to 4
per 1,000 cases.

115. Vasectomy
•permanent contraception for men
•0.15 pregnancies per 100 men in the
first year after the procedure.
•condoms or another effective family
planning method consistently for at
least the first 20 ejaculations or for 3
months after the procedure.