Family Planning: Ina S. Irabon, MD, Fpogs, FPSRM, Fpsge

Family planning
Ina S. Irabon, MD, FPOGS, FPSRM, FPSGE

Obstetrics and Gynecology
Reproductive Endocrinology and Infertility 
Laparoscopy and Hysteroscopy
Reference
u Comprehensive Gynecology 7th edition, 2017 (Lobo RA,

Gershenson DM, Lentz GM, Valea FA editors); chapter
13, Family Planning; pp 237-257.
Contraceptive effectiveness
u All contraceptive methods have a typical use effectiveness

(pregnancy rate given actual use, including occasional inconsistent or
incorrect use) and perfect use effectiveness (pregnancy rate given
correct and consistent use of a method with every act of intercourse)
u Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 13, Family Planning; pp 237-257.
TIER 1 METHODS: HIGHLY EFFECTIVE
(FEWER THAN 1 PREGNANCY PER 100
WOMEN IN 1 YEAR):
INTRAUTERINE DEVICES (IUDs), IMPLANTS, MALE AND
FEMALE STERILIZATION  
Long-acting reversible contraceptive (LARC)
METHODS  
u highly effective and immediately reversible with a rapid return to

fertility after removal.
u Very few medical contraindications to LARC exist.
u do not require frequent visits for resupply or incur costs after
placement (though upfront costs can be high).
u American Congress of Obstetricians and Gynecologists (ACOG)
recommends that LARC methods be offered as first-line contraception
to most women (ACOG, 2009).
u LARC methods currently available are: single-rod etonogestrel
subdermal implant (Implanon), the Copper T380A intrauterine device
(copper IUD), and several levonorgestrel intrauterine systems (LNG-IUS)
1. INTRAUTERINE DEVICES (IUD) 
u A safe and highly effective method of birth control with similar
rates of failure for typical or perfect use
u most commonly used reversible method of contraception
worldwide.
u First-year failure rates with the copper T 380A IUD and the
levonorgestrel-releasing IUD are less than 1%.
u correct high-fundal insertion lowers the incidence of partial or
complete expulsion.
u failure rates associated with IUDs are comparable to those achieved
with surgical sterilization.
Types of IUDs  
1. Copper T 380A IUD (Paragard)

u Because of the constant dissolution of copper (which on a daily
basis amounts to less than that ingested in the normal diet),
copper IUDs require periodic replacement (10 years)
u At the scheduled time of removal, for women desiring continued
contraceptive protection, the device can be removed and another
inserted during the same once visit.
Types of IUDs
2. LNG-IUS (LEVONORGESTREL INTRAUTERINE SYSTEM

(Mirena)
u 20 µg of levonorgestrel (LNG) is released into the
endometrial cavity each day.
u reduces menstrual blood loss and has been used
therapeutically to treat heavy menstrual bleeding.
Mechanisms of Action  
u All IUDs induce a local inflammatory reaction of the

endometrium, creating an environment that is hostile to
sperm so that fertilization of the ovum does not occur.
u Although this sterile inflammatory reaction is the only
mechanism of inert IUDs, medicated IUDs containing either
copper or levonorgestrel produce additional local effects
that increase their efficacy in preventing pregnancy.
Mechanisms of Action  
Copper IUD
u Copper markedly increases the extent of the inflammatory reaction,
allowing it to accumulate throughout the uterine lumen and penetrate the
cervix and probably the fallopian tubes.
u this affects the function and viability of gametes at many levels,
preventing fertilization and lowering the chances of development of any
zygote that may be formed before it reaches the uterus.
u copper impedes sperm transport and viability in the cervical mucus.
LNG-IUS
u The progestin thicken cervical mucus à impedes sperm penetration and
access to the upper genital tract.
u decreases tubal motility and also produces a thin, inactive endometrium.
u low levels of circulating steroid sometimes inhibit ovulation.
Insertion of IUD 
Timing
u IUD can be safely inserted in any of the following
scenarios:
u (1) on any day of the cycle provided the woman is not pregnant
u (2) immediately postabortion
u (3) immediately postpartum following either vaginal or cesarean
section delivery.
u Immediate postpartum insertion carries a higher risk of IUD expulsion,
particularly in the case of an LNG-IUS following vaginal delivery, with
expulsion rates up to 24%
u the copper IUD can be used as emergency contraception for up to 5 days
following unprotected intercourse.
Adverse Effects of IUD 
Uterine Bleeding
u heavy or prolonged menses or intermenstrual bleeding –
u may be produced by an increased rate of prostaglandin release in the
presence of the intrauterine foreign body.
u Stimulation of uterine contractions by prostaglandins may prolong menses
u bleeding usually diminishes with time, as the uterus adjusts to the
presence of the foreign body.
u In contrast, there is a 60% reduction of MBL during the use of the LNG-
IUS.
Perforation
u usually at the fundus
u Rare but potentially serious complication
u Perforation always begins at the time of insertion.
u Perforation of the uterus is best prevented by straightening the
uterine axis with a tenaculum and then measuring the cavity with a
uterine sound before IUD insertion.
Complications Related to Pregnancy
u A pregnancy with an IUD in place is rare.
u Among the few IUD users who do become pregnant, an extrauterine
location is more likely than among pregnant women without an IUD.
u a pelvic ultrasound must be done to locate the pregnancy.
u In the event of an intrauterine pregnancy, the device should be removed
regardless of whether the pregnancy is desired or undesired.
u If a pregnancy occurs and the IUD is not subsequently removed, the
incidence of spontaneous abortion is approximately three times greater
than would occur in pregnancies without an intrauterine device.
Infection in the Nonpregnant IUD User
u the placement process, not the device itself or its thread, creates a
transient risk of infection, as does any transcervical procedure.
u Positive gonorrhea or chlamydia screening tests that occur with an IUD
already in place (i.e., more than 3 weeks after insertion) can usually be
successfully treated without removing the IUD.
u For a symptomatic patient continuing an IUD, an antibiotics regiment for
PID approved by the Centers for Disease Control and Prevention (CDC)
should be used until the woman becomes symptom free.
u If the infection does not improve or if there is evidence of tuboovarian
abscess, the device should be removed
Contraindications to IUD 
u (1) pregnancy or suspicion of pregnancy

u (2) acute PID
u (3) postpartum endometritis or infected abortion
u (4) known or suspected uterine or cervical malignancy
u (5) genital bleeding of unknown origin
u (6) a previously inserted IUD that has not been
*both copper and levonorgestrel IUDs can and should be offered to young
or nulliparous women.
2. Subdermal Implants (etonogestrel) 
u among the most effective methods of contraception available,

with an effectiveness equal or superior to that of sterilization
and IUDs.
u consist of one or more thin rods containing a progestin hormone.
u Insertion is performed in the outpatient setting, and the entire
procedure takes less than 5 minutes.
u After skin infiltration with local anesthesia, the implant is
inserted superficially into the subcutaneous tissue of the upper
arm using a trocar; insertion site is closed with adhesive,
without the need for suture
2. Subdermal Implants  
u When the implant is inserted in any area of subcutaneous tissue, the
steroid diffuses into the circulation at a relatively constant rate.
u Superficial insertion enhances the ease of removal; deeply implanted
implants are more difficult to remove.
u the implant can be inserted on any day during a woman’s cycle provided
she is not pregnant.
u Ovulation inhibition is the main mechanism of action of this implant and
thickening of the cervical mucus also occurs.
u Ovulation is completely inhibited for at least 30 months after insertion,
u Following removal of the implant, serum etonogestrel levels decline
rapidly and are undetectable within 1 week after removal àOvulation
resumes rapidly
PERMANENT CONTRACEPTION: STERILIZATION  
1. Male Sterilization
u Male sterilization, or vasectomy, is a safe and highly effective outpatient
procedure that takes about 20 minutes and requires only local anesthesia.
u the vas deferens is isolated and cut; the ends of the vas are closed, either by
ligation or by fulguration, and then replaced in the scrotal sac.
u this occlusion of the vas prohibits sperm from passing into the ejaculate àthe
ejaculate is therefore sperm free, but otherwise unchanged.
u About 13 to 20 ejaculations must occur after the operation before the
ejaculate will be sterile.
u the absence of sperm is confirmed with a semen sample. Until that time,
another method of birth control must be used.
2. Female Sterilization
u Sterilization for women blocks fertilization by cutting or occluding the
fallopian tubes and preventing the union of the sperm and egg.
u highly effective
2. Female Sterilization
Falope ring/silastic band
Filshie clip
TIER 2 METHODS: VERY EFFECTIVE (6
TO 12 PREGNANCIES PER 100 WOMEN
IN 1 YEAR)
INJECTABLES, PILLS, PATCH, RING
INJECTABLE SUSPENSIONS (Depot
medroxyprogesterone acetate/DMPA)  
u Medroxyprogesterone acetate (MPA) is a 17-acetoxy-6-methyl derivative of

progesterone that has increased progestogenic potency and is longer acting
u DMPA, the long-acting injectable formulation of MPA, consists of a crystalline
suspension of MPA. DMPA is an extremely effective contraceptive and involves
three mechanisms of action:
u (1) inhibition of ovulation by suppressing levels of FSH and LH and
eliminating the LH surge;
u (2) thickening of cervical mucus inhibiting sperm from reaching the oviduct;
u (3) altering the endometrium, which causes atrophy.
u When used correctly and consistently, the chance of pregnancy is 0.2%. Typical
failure rates are around 6%.
u contraceptive dosage:
u 150 mg IM (injection deep into the gluteal or deltoid muscle)
u 104 mg subcutaneous (injected into the subcutaneous tissue of the
anterior thigh or abdominal wall).
u MPA can be detected in the systemic circulation within 30 minutes
after its IM injection.
u Return of fertility:
u resumption of ovulation is delayed on average for 6 months to 1 year after a
single injection.
u median delay to conception is 9 to 10 months after the last injection
u Clinical Side Effects  
1. Bleeding Patterns
u In the first 3 months after the first injection, about 30% of women
experience amenorrhea and another 30% to 40% have irregular bleeding
and spottingà Usually light, the bleeding does not cause anemia.
u As the duration of therapy increases, the incidence of frequent
bleeding steadily declines and the incidence of amenorrhea increases.
u Clinical Side Effects
2. Weight Changes
u About one fourth of women using DMPA gain weight, usually in the first 6 months of use.
3. Headache
u the most frequent medical event reported by DMPA users and a common reason for
discontinuation of its use.
4. Bone Loss
u Because DMPA suppresses production of estradiol, bone remodeling is increased and may
resemble menopause.
u bone loss is reversible after stopping DMPA use.
ORAL CONTRACEPTIVES  
 
u Because of their effectiveness and ease of administration, oral

contraceptives (OCs) became the most widely used method of reversible
contraception
u All the formulations marketed after 1975 contain less than 50 µg of EE and
3 mg or less of one of several progestins.
u the most widely used methods combine EE with one of several synthetic
progestins.
u the major effect of the progestin component is to inhibit ovulation, but
progestins also contribute other contraceptive actions such as thickening
of the cervical mucus and thinning of the endometrium.
u the major effects of the estrogen are to maintain the endometrium and
thus prevent unscheduled bleeding as well as to inhibit follicular
development through a synergistic effect with the progestin.
 
u three major types of OC formulations include:
u daily progestin-only pills (POPs), also known as minipills
u fixed- dose (monophasic) combination pills: same dose combination of an
estrogen and progestin each day
u multiphasic combination pills: pills containing several different dose
combinations (biphasic, triphasic, or four phasic)
u Many combination OC formulations provide active pills continuously for 21 days
(3 weeks) followed by a 7-day hormone-free interval (HFI).
u most products are packaged with inactive spacer (placebo) pills during the
HFI to improve compliance. (Some brands provide an iron supplement in
the spacer pills.)
 
u OCs have a 1% failure rate with perfect use and an 8% failure rate with
typical use.
u Accidental pregnancies occurring during OC use probably do not occur
because of missing just one to two pills, but rather because initiation of
the new cycle of medication is delayed for a few days or because a greater
number of tablets are missed.
u Women should be advised that the most important pill to remember to
take is the first one of each cycle
  Mechanism of Action
u Combination oral contraceptives suppress gonadotropins.
u the estrogen component prevents a rise in FSH and enhances the effect of the
progestin component, which inhibits ovulation and LH surge.
u Changes in the cervical mucus (which prevent sperm transport into the uterus), the
fallopian tube (which interfere with gamete transport), and the endometrium (which
reduce the likelihood of implantation) represent secondary contraceptive effects of the
progestin component.
u Contraceptive steroids prevent ovulation mainly by interfering with release of
gonadotropin-releasing hormone (GnRH) from the hypothalamus.
u bleeding that users of combined OCs experience during the hormone-free interval is
called withdrawal bleeding
u Bleeding that occurs during the time that active pills are ingested is called
breakthrough bleeding.
u Unscheduled (breakthrough) bleeding and absence of withdrawal bleeding
(amenorrhea) occur as a result of insufficient estrogen to support the endometrium.
 
Metabolic effects
u most frequent symptoms produced by the estrogen component include
nausea (12%), breast tenderness (9%), and headache (18%) à Reduction in
EE dose to below 50 µg has greatly reduced the incidence of all of these
estrogenic side e ects.
u OCs decrease androgen levels, which tends to reduce acne.
u Weight gain represents a common complaint of women using hormonal
contraception.
CONTRACEPTIVE PATCH  
 
u contraceptive skin patch Ortho Evra contains 75 µg ethinyl estradiol and 6 mg

norelgestromin.
u One patch is applied to the skin each week for 3 consecutive weeks
and no patch for the following week of a 4-week cycle to allow withdrawal
bleeding.
u the patch may be applied to one of four anatomic sites: buttocks, upper outer arm,
lower abdomen, or upper torso excluding the breasts.
u Like OCs, the primary mechanism of action is the inhibition of gonadotropin release
and prevention of ovulation.
u Contraceptive effectiveness and metabolic and clinical effects, including irregular
bleeding, are similar to combination oral contraceptives.
CONTRACEPTIVE VAGINAL RING 
u CONTRACEPTIVE VAGINAL RING

u Steroids pass easily through the vaginal epithelium directly into the
circulation.
u Flexible ring-shaped device containing 2.7 mg of ethinyl estradiol and 11.7
mg of etonogestrel
u the contraceptive ring (NuvaRing) is placed in the vagina for 21 days and
then removed for up to 7 days to allow withdrawal bleeding.
u Like oral contraceptives, the main mechanism of action is inhibition of
gonadotropins and prevention of ovulation.
TIER 3 METHODS:EFFECTIVE (18 OR
MORE PREGNANCIES PER 100 WOMEN IN
1 YEAR)
BARRIER METHODS, LACTATIONAL AMENORRHEA, PERIODIC
ABSTINENCE, COITUS-RELATED METHODS
BARRIER METHODS  
Diaphragm and Cervical Cap

u diaphragm is a thin, dome-shaped membrane of latex rubber or
silicone with a flexible spring modeled into the rim
u à spring allows the device to be collapsed for insertion and then allows
for expansion within the vagina to seat the rim against the vaginal wall,
creating a mechanical barrier between the vagina and the cervix.
BARRIER METHODS  
Diaphragm and Cervical Cap

u A cervical cap is a cup-shaped silicone or rubber device that fits
around the cervix à should be fitted to the cervix by a clinician.
u the diaphragm and cervical cap should be used with a spermicide and
be left in place for at least 8 hours after the last coital act.
u Failure rate during the first year of use for the diaphragm ranges from
13% to 17% among all users and may be as low as 4% to 8% with perfect
use.
BARRIER METHODS  
Male Condom
u the latex and polyurethane male condoms are the only method with
FDA-approved labeling that supports use of the product to prevent
both pregnancy and the transmission of sexually transmitted infections
(STIs).
u condom should be applied to the erect penis before any contract with
the vagina or vulva.
u the tip should extend beyond the end of the penis by about half an
inch to collect the ejaculate.
u typical use failure rate is around 15%
BARRIER METHODS  
Female Condom
u female condom consists of a soft, loose fitting polyurethane sheath
with two flexible rings.
u One ring lies at the closed end of the sheath and serves as an insertion
mechanism and internal anchor for the condom inside the vagina.
u the outer ring forms the external edge of the device and remains
outside the vagina after insertion, thus providing protection to the
introitus and the base of the penis during intercourse
u inserted prior to the onset of sexual activity and left in place after
ejaculation has occurred.
u typical use failure rate at 1 year is estimated to be 21%
LACTATIONAL AMENORRHEA METHOD (LAM)  
u Because prolactin inhibits gonadotropin pulsatility, nursing women

typically remain amenorrheic for a variable length of time after giving
birth..
u the criteria for successful use of LAM are:
1. exclusive breastfeeding (no supplements) for up to 6 months after delivery
2. Infant is < 6 months
3. Postpartum Amenorrhea
u When used correctly, the failure rate in the first 6 months post-
partum is less than 2%.
PERIODIC ABSTINENCE  
u Calendar Rhythm method:
u the period of abstinence is determined by calculating the length of the individual
woman’s previous menstrual cycle and makes three assumptions:
u (1) the human ovum can be fertilized for only about 24 hours after ovulation,
u (2) sperm can fertilize for 3 to 5 days after coitus, and
u (3) ovulation usually occurs 12 to 16 days before the onset of menses.
u fertile period: SHORTEST cycle MINUS 18 days; LONGEST cycle MINUS 11 days
u EXAMPLE: LONGEST CYCLE IS 35 DAYS; SHORTEST CYCLE IS 26 DAY

FERTILE PERIOD: DAYS 6 TO 24 (AVOID INTERCOURSE)
PERIODIC ABSTINENCE  
u BASAL BODY TEMPERATURE
u woman must abstain from intercourse from the cessation of menses until the
third consecutive day of elevated basal temperature, or when she is
postovulatory.
➢ Cervical mucus method

➢ Intercourse can occur after menses ends until the first day that
copious, slippery mucus is observed to be present and again 4
days after the last day when the characteristic mucus was
present.
➢ Symptothermal method
➢ Combination of the calendar, temperature, and cervical
mucus methods
COITUS-RELATED METHODS  
u Spermicides
u active agent is a surfactant that immobilizes or kills sperm on contact by
destroying the sperm cell membrane.
u Spermicides must be placed into the vagina before each coital act, often
in combination with a barrier contraceptive to increase effectiveness.
u nonoxynol-9 spermicide
u Coitus Interruptus (Withdrawal)
u Removal of the penis from the vagina prior to ejaculation to prevent
pregnancy
u can fail because of the small numbers of sperm present in some
preejaculate
Thank you!
youtube channel: Ina Irabon
www.wordpress.com: Doc Ina OB Gyne

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Family planning

Ina S. Irabon, MD, FPOGS, FPSRM, FPSGE

u Comprehensive Gynecology 7th edition, 2017 (Lobo RA,

u All contraceptive methods have a typical use effectiveness

u highly effective and immediately reversible with a rapid return to

1. Copper T 380A IUD (Paragard)

2. LNG-IUS (LEVONORGESTREL INTRAUTERINE SYSTEM

u All IUDs induce a local inflammatory reaction of the

u (1) pregnancy or suspicion of pregnancy

u among the most effective methods of contraception available,

u Medroxyprogesterone acetate (MPA) is a 17-acetoxy-6-methyl derivative of

u Clinical Side Effects

u Because of their effectiveness and ease of administration, oral

u contraceptive skin patch Ortho Evra contains 75 µg ethinyl estradiol and 6 mg

u CONTRACEPTIVE VAGINAL RING

Diaphragm and Cervical Cap

Diaphragm and Cervical Cap

u Because prolactin inhibits gonadotropin pulsatility, nursing women

u EXAMPLE: LONGEST CYCLE IS 35 DAYS; SHORTEST CYCLE IS 26 DAY

➢ Cervical mucus method

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u Clinical Side Effects  