Family planning

Clinic of Reproduction and Gynecology

PAM

Methods of family planning

Periodic abstinence Barrier contraceptivesOral contraceptivesProgestin injectionsSubdermal implantsEmergency contraceptionIntrauterine device (IUD) SterilizationInduced abortion

Physiological infertility

“Shortly” after menarche (first menstrual bleeding) After newborn delivery and during breastfeeding“Shortly” before menopauseThe highest chance to become pregnant – sex 1 or 2 days before ovulation (28% - 30%)Fecundability 20% per cycle

Factors affecting negative effect of breastfeeding on fertility

Time lapsed from delivery Duration and frequency of breastfeedingNutrition Social and cultural determinantsTo sum up – breastfeeding does not protect against unwanted pregnancy

Efficacy (Pearl index)

IUD 0,1 (0 –1) OC 0,2 (0 –3) Progestin injection 0,1 (0 –1)Morning after pill 3 (2 – 5)Condom 4 (1 – 7)Periodic abstinence 10 (3 – 15)

Action of oral contraceptives

Inhibition of GnRH release Inhibition of ovulationChanges in the fallopian tubes – motility, epithelial structure, oviductal fluid – impaired transport of sperm, oocytes and embryosChanges in the endometrium – endometrium becomes thin – impaired implantation Changes in the cervix – mucous becomes thick – sperm hardly penetrates

OC

Benefits of OC

Lower incidence of ovarian cystsLower incidence of ovarian malignanciesLower incidence of endometrial malignanciesLower incidence of anemiaLower incidence of endometriosis, osteoporosis and RALower incidence of ectopic pregnanciesLower incidence of PID

OC as a treatment modality

Dysfunctional uterine bleedingIrregular cycles, hypermenorrhoe PMS

Ovarian hyperandrogenismAcneHirsutism

Minor adverse effects of OC

Breakthrough bleedingAmenorrhea and oligomenorrheaNausea and vomitingBreast tendernessMood disordersWeight gain (fluid retention)Altered sexual drive

Major adverse effects of OC

Impaired thyroid functionDeep vein thrombosis and thromboembolismHypertension Altered glucose metabolismCholelithiasis

(?) breast malignancies (?)

Contraindications to OC

ABSOLUTESmoking after 35yrAcute liver diseaseUncontrolled hypertensionDM with vascular changesHistory of thromboembolic eventPregnancyUndiagnosed vaginal bleedingEstrogen-dependent malignancy

RELATIVEDepressionMigraine headacheSmoking before 35yrMore than 35 yrVaricose veinsPlanned surgery

STOP OC immediately in case of:

Calf pain Chest painMigraineCholelithiasis Prolonged immobilization (e.g. bone fractures)

Drug interaactions of OC

anticonvulsants antibiotics

penicillin tetracyclincephalosporin sulfonamides

Emergency contraception

Up to 1 h LNG 0,75 mg (1 tabl.) orally (Postinor)

Up to 72 h LNG 0,25 mg + EE 0,5 mg „2x2x2” orally (Gravistat 250, Stediril 50)

IUD

OC (two components) synthetic estrogen and progestin)

Monophasic Gravistat 50μg EE + 0,25 mg levonorgestrel Cilest 35μg EE + 0,25 mg norgestimateMarvelon 30μg EE + 0,15 mg desogestrelMinisiston 30μg EE + 0,125 mg levonorgestrelFemoden 30μg EE + 0,075 mg gestodenLogest 20μg EE + 0,075 mg gestodenMercilon 20μg EE + 0,150 mg desogestrelDiane-35 35μg EE + 2 mg cyproterone acetate

OC (two components) synthetic estrogen and progestin)

Sequential Biphasic

Anteovin 50μg EE + 11 tabl. 0,05 mg LNG50μg EE + 10 tabl. 0,125 mg LNG

TriphasicTriquilar, Tri- Regol, Trisiston

30μg EE + 6 tabl. 0,05 mg LNG40μg EE + 5 tabl. 0,075 mg LNG30μg EE + 10 tabl. 0,05 mg LNG

Long-acting formulations

Progestin injections (MP 0,15 i.m. q 3mo)

Subdermal implants IUD + progestin (LNG)

Barrier methods

For males:Condom

For women:DiaphragmCervical capVagninal foam, cream, suppositories (contain nonoxynol-9 – kills and immobilizes sperm)

Condom

PROTECTION against STDs (AIDS included)Easy to useCheapAlmost no side-effects (minor local allergic reactions to latex)Prevention malignancies of the cervix

Disadvantages of condoms

Impaired sexual satisfactionAllergyNot comfortable in use

Physiological bases for periodic abstinence

The first probable day of expected ovulation14 – 2 = 12 day

The last possible day of expected ovulation14 + 2 = 16 day

Sperm survival (48 h) 12 – 2 = 10 day

Oocyte capability of being fertilized (24 h) 16 + 1 = 17 day

Fertile span of time 10 - 17 day of the cycleThe “tuned” method is called SYMPTOTHERMAL (+

BBT, cervical mucous)

IUD

BenefitsDoes not affect the natural cycleEffectiveMakes women being controlled regularly

Adverse effects Bleeding and painPIDPerforation of uterusExpulsion

Contraindications to IUD

PIDPregnancyVaginal bleeding of unknown origin Planned pregnacy

IUD candidate

34 yo and overSmoker2 children and no further reproductive plans

OC candidate

Less then 30 yoNo childrenSingle sexual partner Planes to become pregnant in the futureDysfunctional uterine bleeding

Condom and spermicide candidate

Less then 20 yoNo childrenIrregular sexual activity

Progestin injections

BreastfeedingPlans further pregnancies