Family Planning

Syed Muhammad Baqui Billah

Associate Professor, CM
SBMC
 Family planning
• WHO: The ability of individuals and couples to
anticipate and attain their desired number of
children and the spacing and timing of their births.
• Old books: A way of thinking and living that is
adopted voluntarily, upon the basis of knowledge ,
attitudes and responsible decision by individuals
(??) and couples, in order to promote the health
and welfare of the family group and thus
contribute effectively to the social development of
a country.
• Became lifestyle now
 Objectives
• To avoid unwanted births
• To bring about wanted births
• To regulate the intervals between pregnancies
• To control the time at which births occur in
relation to the age of the parents
• To determine the number of children in the
family
 Benefits
• Lower risk of
– Maternal death
– Anemia
– Poor pregnancy outcome
– Complications related to pregnancy, miscarriage or
unsafe abortion
– Educational and economic struggle
– Child illness and death
 Some terminologies
• Fertility: number of children born to a woman
• Fecundity: physiological potential of a woman to
bear children
• Eligible couple: Currently married couple wherein
the wife is in the reproductive age (15-49 years)
• Total Fertility Rate: Average number of children a
woman would have assuming that current age-
specific birth rates remain constant throughout
her childbearing years (2.3 since 2011)
 Some terminologies
• Gross reproduction rate: average number of
daughters a woman would have if she survived all
of her childbearing years (45 years), subject to
age-specific fertility rate and sex ratio at birth
throughout that period
• Net reproduction rate: average number of
offspring born to a female is she passed her
lifetime, subject to age-specific fertility and
mortality in a given year
 Couple-years of Protection (CYP)
• Estimated protection provided by FP methods
during a one-year period (CYP)
• Percent of eligible couples effectively protected
against childbirth by one or the other approved
methods of family planning
• Quantity of each method distributed to clients
times a conversion factor to yield an estimate of
the duration of contraceptive protection
provided per unit of that method
 Contraceptive Prevalence Rate

• Indicator of health, population, development

and women’s empowerment
• The percentage of women who are currently
using, or whose sexual partner is currently
using, at least one method of contraception,
regardless of the method used
• Usually reported for married or in-union
women aged 15 to 49
• Bangladesh CPR: 62 (2021)
Family Planning Methods
 Traditional Methods
• Fertility awareness: (natural FP/ safe period/
periodic abstinence)
• Calendar based
– Shortest cycle-18: 1st day of unsafe period
– Longest cycle-10: last lay of unsafe period
• Regular cycle: 28 days cycle
– 28-18: 10th day is 1st day of unsafe period
– 28-10: 18th day is last day of unsafe period
 Traditional Methods
• Calendar based: Irregular cycle (26-31 days)
– 26-18: 8th day is 1st day of unsafe period
– 31-10: 21st day is last day of unsafe period
• Symptom based:
– Cervical secretion: when a woman feels a little vaginal
wetness/sees the secretion, the period is supposed to
be fertile for the woman
– Basal body temperature: Resting body temperature
goes up slightly after ovulation
• Withdrawal/Coitus interruptus
– Ejaculates outside vagina
 Lactational Amenorrhea (LAM)
• For whom
– Mother feeds the child only breast milk (interval ≤4
hours in the day and ≤6 hours in the night)
– Age of the children should be below 6 months
– Menstrual cycle yet not started after child birth
• Starts after delivery up to 6 months after
childbirth
• Ideal pattern: Feed 8-10 times a day
• Weaning at the age of 6 months of the baby
• Go for any FP method after LAM
 Complications

• Ectopic pregnancy

• Embryonic abnormalities
 Short Acting
• Barrier: AKA occlusive method
• Condom: short acting contraceptive for males
• 87% effective commonly, 98% effective if used
properly
• Nowadays developed for females, but not
incorporated by government and not available
in Bangladesh
• Acts as mechanical barrier
 Barrier Method
• Physical
– Condom
– Diaphragm
– Vaginal sponge
• Chemical barrier
– Foams
– Jellies, cream & pastes.
– Suppositories
– Soluble films
 Advantage of Barrier

• Absence of side effect associated with the

pill & IUD
• Protection from sexually transmitted disease
• Reduce the incidence of PID
• Possibly some protection from the risk of
cervical cancer
 Hormonal Contraception
Oral pills

• Combined pill
• Progestogen only pill
• Post-coital pill
• Once-a-month pill
• Male pill
 Oral Pills
• Combined oral contraceptives (COC)
• Contains low doses of 2 hormones
– Progestin and estrogen
– Like the natural progesterone and estrogen
– OCPs, OCs, combined pills
– Most commonly used contraceptive
– Common brand: Sukhi (3rd gen), Femicon,
Nordette-28, Ovostat Gold etc.
Combined oral pill (Sukhi)

Levonorgestrel
0.15 mg
Estradiol
0.03 mg
Ferous fumarate
75 mg
 Mode of action
• Prevent release of ovum from the ovary
• Estrogen inhibits secretion of FSH via negative
feedback on the anterior pituitary, thus
suppresses development of ovarian follicles
• Progestin inhibits secretion of LH thus prevents
ovulation; also makes the cervical mucus less
suitable for the passage of sperm
• 93% effective commonly, 99% effective if used
properly when no mistakes in pill taking (3/1000
women during the first year)
 Contra-indications
Absolute:
Relative:
 Known or suspected
pregnancy  Diabetes Mellitus
 Acute or chronic obstructive  Chronic hypertension
liver disease
 Chronic headache
 Ca. breast/genitalia
 Thromboembolism or
thrombophlebitis
 Cardiac abnormalities
 Undiagnosed uterine bleeding
 Smoking women over 35 years
 Hypertension
Major surgery with prolonged
immobilization
 Adverse Effects
• Cardio-vascular effect

• Carcinogenesis

• Metabolic effects

• Common unwanted effects

• Other adverse effects-liver disease

Instructions for users
 Progestin only pill (POP: mini pill)
• Contains very small amount of progestin
• Best suited for breast feeding women as they
don’t reduce the quantity of milk
• Apon (National FP program), Minicon (by SMC)
• Inhibits secretion of LH thus prevents ovulation
• Alters the endometrium to discourage
implantation
• Interferes with the coordinated contraction of
the cervix
• > 99% effective if used properly
Progestin only pill (mini pill)

Norgestrel
0.075 mg
 Emergency Contraception

• AKA ‘morning after’ pill or post-coital conception

• Delays release of eggs from ovum (ovulation)
• No effective if a woman is already pregnant
• “Emcon-1” (National FP program), “Norix”,
“Tulip”, “Peuli” (Others)
Post-coital Pill

Norgestrel
1.5 mg
Post-coital pill
 Depot formulations
• Injectable
• Sub-cutaneous
• Vaginal rings
 Injectable
• Depot Medroxyprogesterone Acetate: DMPA
– Bangladesh National FP program 3 monthly for women
– 150 mg in 1ml per vial (IM: old & subcutaneous: new)
– No estrogen, can be used throughout breastfeeding
period, 99.7% effective
– Depo Provera (BNFP), Syana Press (private)
– Suitable time: within 5 days of menstrual period
• Nonethisterone Enanthate: NET-EN
– Commercial name: Noristerat (Not available in
Bangladesh)
 Advantage and Disadvantage
• Advantage
– Only 4 shots per year
– Very effective and reversible
– 80% reduction risk of endometrial cancer
• Disadvantage
– Bleeding irregularities
– Lower bone density
– No protection against STD/AIDS
– Return to fertility delayed after discontinuation (30
weeks-1 year)
 Implant
• Small flexible rods
• Placed just under the skin of the upper arm
• Jadelle: two rod implant, 150 mg Levonorgestrel
(75 mg in each rod)
• Implanon: one rod implant 68 mg etonogestrel
• Protection
– Up to 5 years with Norplant II
– Up to 3 years with Implanon
• Implanon NXT: New one rod implant, 3 years
protection
Jadelle (Norplant II) Implanon
 Mode of action
• Thickens the cervical mucus, making it difficult
for sperm to pass through
• Stops ovulation in about half of the menstrual
cycles
• Prevents ovulation
• 99.95% effective
• Reversible
• No daily pill
• Quality and quantity of breast feeding not
affected
 Disadvantage

• Client can’t start of stop use on her own

• Need trained provider to remove
• Minor surgical procedure needed to insert and
remove
• No protection against STD/AIDS
• Spotting/bleeding during monthly periods
• Weight gain
• Hair loss or growth in face
 Intrauterine Contraceptive Device
(IUCD)
• Commonly known as IUCD or IUD
• Small flexible plastic device
• Inserted into uterine cavity
• Cause chemical changes in the uterus that
damages sperm and ovum, thus prevents
fertilization
• Very effective
 Intrauterine Contraceptive Device
(IUCD)
• Commonly known as IUCD or IUD
• Small flexible plastic device
• Inserted into uterine cavity
• Cause chemical changes in the uterus that damages
sperm and ovum, thus prevents fertilization
• Two types
– Copper bearing IUD (T-380): 10 years protection, in BNFP
program
– T-200: 5 years protection, not available in Bangladesh
– Progesterone containing IUD: Levonorgestrel containing IUD,
not in FP program but available in private section, used for
 IUCD
• Two types Medicated

Non-medicated

3rd generation
1st generation 2nd generation
- 2nd & 3rd generation (medicated IUCD)

e.g.: 2nd generation: copper-T

3rd generation: Hormone releasing IUD.
Cu-T( 2 generation)
nd
3 generation
rd

Progestasert
Or
levonorgestrel
 Mechanism of Action
IUCD-foreign body reaction

Cellular & bio-chemical

changes(endometrium)

Impair viability of gamete

Prevents fertilization
 Medicated IUCD-(Cu-T)

Cellular and bio-chemical changes in the

uterus

Alter the bio-chemical composition of the

cervical mucus

Affect sperm motility, capacitation and survival

• Hormone-releasing-

Increase the viscosity of cervical mucus-prevent

sperm penetration

High level progesterone in the endometrium-

create unfavorable condition
 Time of Insertion
• Within 5 days of beginning of menstruation

• Before insertion: must confirm that the

acceptor is not pregnant
 Duration of protection
• 3 years

• 5 years

• 10 years (widely use in Bangladesh)

 Ideal candidate for IUCD
• Who gave birth of at least one child
• Has no history of pelvic disease
• Has normal menstrual period
• Is willing to check the IUCD tail
• Has access to the follow-up and treatment of
potential problem
• Is in a monogamous relationship
 Contraindications of IUCD
Absolute
• Suspected pregnancy
• PID
• Vaginal bleeding of undiagnosed etiology
• Ca of cervix, uterus or adnexa
• Pelvic tumour
• H/O ectopic pregnancy
 Contraindications (cont.)
Relative
• Anaemia
• Menorrhagia
• h/o PID
• Purulent cervical discharge
• Uterine distortion
• Unmotivated person
 2nd generation IUCD
Advantages of CU-T

• Low expulsion rate

• Lower incidence of side effect

• Easier to fit even in nulliparous women

• Better tolerated by nulliparous women

• Increase contraceptive effectiveness

• Effective as post coital contraceptives

 3 generation IUCD
rd

• Progestasert
• Levonorgestrel

Advantages
1. Low pregnancy rate
2. Less no. of ectopic pregnancies
3. Lower menstrual blood loss & fewer days of
bleeding
 Side-effects
• Bleeding
• Pain
• Pelvic infection
• Uterine perforation
• Pregnancy
• Ectopic pregnancy
• Expulsion
 Post-Conception Methods
• Menstrual Regulation
– 7-8 weeks best time
– Max: 10 weeks
• Menstrual Induction
– Prostaglandin
• Actually it is not contraception, it is
concepticidal (terminology invented)
 Abortion

Termination of pregnancy before the viable

age of foetus (before 28 weeks)

It can be termed as homicide if not medico

legally indicated
 Terminal Methods
• Male sterilization

• Female sterilization
 Sterilization Guidelines

• Age
– Husband not <25 or >50 years
– Wife not <20 or >45 years
• Couple must have 2 living children
• If ≥3 living children, relax the lower limit of age
 Male Sterilization

• Acceptor not immediately sterile after the

operation
• Approximately 30 ejaculations should
have to be taken in place
 Complications
• Operative : pain, scrotal haematoma, local infection
• Sperm granules: pain and swelling

• Spontaneous recanalization:

• Auto immune response:

• Psychological: may complain of headache, fatigue

 Female Sterilization
• AKA tubal sterilization, tubal ligation, tubectomy,
minilap etc.
• Fallopian tubes are blocked or cut and ligated
• Eggs released from the ovaries cannot move
down the tubes, so no fertilization
• Suprapubic or sub-umbilical approach used
• Effective immediately after the operation
• No need to take daily FP methods
 Disadvantage
• Being a permanent method, no turning back if
the couple desire for children
• Need trained doctors and assistants
• Does not prevent STD/AIDS
• Auto-recanalization can occur
• Normal or Ectopic pregnancy if recanalization
Thank you very much