Family planning

Family planning

Family planning define as voluntary planning and action taken by individuals to prevent, delay or achieve a pregnancy

Family planning services include counseling and education, preconception care, screening and laboratory tests, and family planning methods (1).

There are two basic types of birth control physical methods and behavioral methods. Physical methods include barrier methods, hormonal methods, intrauterine devices and sterilization. Behavioral methods include abstinence, withdrawal, and fertility awareness methods. Some areas of the world use abortion as a means of birth control as well (2) .

Men and women have used contraception , in one form or another , for thousands of years .

There is no one methods that will suit everyone and individuals may use different types of contraception at different stages in their lives .

The characteristic of the ideal contraceptive are :

1\ highly effective .

2\ no side effects .

3\ independent of intercourse .

4\ rapidly reversible .

5\ cheap .

6\ widespread availability .

7\ acceptable to all cultural and religions .

8\ administration by healthcare personnel not required .

9\ easily distributed .

Family planning methods

Natural methods :

Interest in these methods is inereosing they are particularly attractive to people who hold certain moral conviction or mistrust more invasive methods ( ) .

1\Coitus interruptus:

This involves withdrawal of the penis prior to ejoculation and necessitatous tremenelous self control.

It is after referred to as ( being careful )or ( taking care ) and both partners may find this interruption of intercourse frustrating .

The methods is widely practiced but the failure rate is high ( ).

2\Methods involving abstention :

The following methods involve abstention from intercourse around the time of ovulation their us involves individual preparatory instruction careful observation of changes in the body and self control by both partners ( ) .

Observation of cervical mucus:

Following menstruation thick mucus blocks the cervical canal and act as barrier to spermatozoa , the women is aware of dryness at the vulva .

As estrogen level rise , the mucus absorbs water and nutrients , soften and begins to flow .

This mucus is opaque , white or creamy and gives a sensation of stickiness .

Around the time of ovulation the mucus become transparent , slippery , and capable of considerable stretching between finger and thumb .

This fertile mucus looks like raw egg white ( ) .

Progesterone subsequently causes the mucus to thicken and the sensation of stickiness and then dryness return.

Observation of mucus are made throughout the day .

The fertile phase begins when mucus is first noticed and ends four days after the last day of fertile mucus.

Failure rate high ( )

Observation of body temperature :

The temperature is taken immediately on waking every day .

Progesterone production following ovulation causes body temperature to rise by 0,2 c (0,4 f) .

Thus once three consecutive reading are higher than the previous six , it is unlikely that intercourse during the remainder of the cycle will result in pregnancy ( ) .

Palpation of cervix :

Around the time of ovulation the cervix rises in the vagina , soften and dilates slightly .

This is on estrogenic effect and some women are able to detect these change ( ) .

Calendar or rhythm method :

This is used calculate the period during which intercourse is most likely to result in pregnancy .

The remainder of the cycle used to be called the safe period .

This method assumes that ova remain capable of being fertilized for up to 48 hours after ovulation , and that spermatozoa are viable within female for 72 hours during the fertile phase ( ).

The women record the length of six menstrual cycles .

Her first fertile day is calculated by subtracting 20days from the length of her shortest cycle and her last fertile day by subtracting 10days from the length of her longest cycle .

Thus if her cycle varied between 25 and 31days she would be fertile between day 5 and 21 .

Amongst advocates of natural family planning calendar calculation alone is falling from favor( ).

Symptothermal method:

The symptothermal method combines temperature charting with observation of cervical mucus and use of the fertile phase .

Other cyclical symptoms such as ovulation pain ,breast tenderness and cervical change may be recorded. The failure rate is high( ).

3\ Vaginal douching :

Douching after intercourse will not prevent pregnancy as spermatozoa can reach the internal cervical us within 90 second of ejaculation ( ).

4\ Lactation amenorrhea method:

This means the absence of period duo to breast feeding .

After giving birth a woman normally experiences at time of infertility until her body is ready for another pregnancy , if do not breastfeed it is short , if exclusively breastfeed for body the average length of infertility is 14 month .

If fertility returns during the first 6 months while breastfeeding a lot , it usually starts with menstruation before the first ovulation that provide a warning that fertility returning .

Effectiveness:

It is 98% in first 6 months

Hormonal contraceptive:

Contraceptive involving preparations of the hormones estrogen and progesterone are available in several delivery systems ,oral contraceptive pills-long acting injections and intradermal implants ( ).

Oral contraceptive:

Are hormonal agents consisting of combination of estrogen and progestin or progestin alone.

Primarily they act at the central nervous system level to inhibit ovulation by suppressing the follicle .stimulation hormone (FSH) and luteinizing hormone (LH).

Secondary ,endometrial development ,tubal motility the influence of progestin ,the cervical mucus become thick viscous ,and unreceptive to spermatozoa ( ).

The lowest failure rate with consistent accurate usage of pills is 0,1%.

The oral contraceptive pills do not protect against human immune deficienancy virus (HIV) or other sexual transmitted disease , they may contribute to higher sexual transmitted disease rates because barrier methods commonly are not used, and woman may have increased sexual activity when protected from unwanted pregnancy ( ).

Large number of oral contraceptive pills are available , with differing combination

Of estrogen or progestin doses ,there are three types:

1\ Triphasic which contain two to three different combination of estrogen and progestin .

2\ Combination pills , which contain estrogen and progestin ,available at the standard or low (micro) dosage .

3\ Progestin only (mini pills) ( ).

Triphasic only contraceptive:

Pills containing two to three different combination of estrogen and progestin has been available in the united starts since 1984 .

These pills usually increase progestin three phase during the cycle, and some alter estrogen dosage as well.

Triphasic oral contraceptive pills are available in 21 and 28 days regimen .

Failure rates have been reported as somewhat higher than for low dose combination pills .

Triphasics have 12% to 20% lower progestin dose than combination pills .

This cause fewer progestin side effects ( ) .

Combination oral contraceptive pills:

The combined oral contraceptive pills contain synthetic steroid hormone estrogen and progestin in varying amounts depending on which preparation is prescribed .

Everyday pills contain 28 days pills in the packet , 21 of which are active monophasic pills contain no wilt the seven remaining pills contain no hormones only are thus inactive ( ).

Also available are biphasic and triphasic pills in which the dose of steroids administered varies in two or three phase throughout the packet to mimic the natural fluctuations of the hormones during the menstrual cycle .

Mode of action :

Estrogen and progesterone suppress follicle stimulation hormone ( FSH ) and luteinizing hormone ( LH ) production causing the ovaries to go into arresting state ovarian follicles normally take place .

Progesterone also causes cervical mucus to thicken ,making penetration by spermatozoa difficult .

The pills also renders the endometrium unreceptive to implantation by the blastocyst these actions provide additional contraception in the event of break though ovulation occurring ( ).

Effectiveness:

Provided that the pills is taken correctly and consistenly , is absorbed normally and interaction with other medication does not affect it is metabolism ,it is reliability is almost 100% ( ) .

Advantages of the combined oral contraceptive pill include:

1\ Regular ,lighter , less painful periods ;

As the normal menstrual cycle is inhibited and the usual proliferation of the endometrium dose not occur.

2\ Possible reduction in premenstrual symptoms.

3\ Protection against pelvic inflammatory disease ,because of thickened cervical mucus .

4\ Decreased incidence of ectopic pregnancy .

5\ Protection against ovarian and endometrial cancers .

6\ Prevention of ovarian cysts and fibroid .

Over recent rears the steroid dosage of all oral contraceptives has been greatly reduced or modified in order to minimize the disadvantages of the pill( ).

Disadvantages of the combined oral contraceptive pills:

1\ Venus or arterial thrombosis .

2\ Hypertension the pill cause slight rise in blood pressure in most user .

3\ Breast tenderness .

4\ Nausea.

5\ Headache.

6\ Progressive Weight gain .

7\ Depression.

8\ Myocardial infarction.

9\ Cervical dysplasia.

10\ Hair loss or growth ( ).

Contra indication to combined oral contraceptive pills include :

1\ Pregnancy.

2\ history of arterial or venous thrombosis or predisposing factors such as immobility .

3\ Hypertension .

4\ Focal or crescendo migraines.

5\ Current lever disease.

6\ Undiagnosed abnormal vagina bleeding.

7\ Hydatiform mole (until serum human chorionic gonadotrophin is no longer detectable .

8\ Smoking if the woman is over 35 years old.

9\ Body mass over 30.

10\ Cerebrovascular or coronary artery disease.

11\ Malignancy of the breast or reproductive tract.

12\ Diabetes.

13\ Gallbladder disease .

14\ Sickle cell disease.

15\ Cardio vascular risk factors( ).

Using the pills:

When initially commencing the pill, the very first pill is usually taken in the first day of the menstrual period .

If a 21 day pill has been prescribed , the contraceptive effect is immediate , provide that the remainder of pills in the packet are taken correctly .

If the pill is initially commenced on any day other than the first day of the period ,additional contraception such as should be used in the conjunction with the pill for the first 7 days .

There after one pill is taken daily , care being taken to take the pills in the correct order .

Vaginal bleeding will usually occur when the inactive pills are taken ,which are usually denoted by a different coloured section on the pill packet.

It is important to emphasis taking the pill at an easily remembered time each day .

If a pill is forgotten ,the woman will then have some idea of when the previous pill was taken and how late she is in taking the next pill ,she can take the pill immediately and continue the packet as normal( ).

Preconception consideration :

As the pill disrupts vitamins and mineral metabolism ,some authorities advise stopping the pill 2- 3 months before attempting to conceive ( ).

Postpartum consideration:

The combined oral contraceptive pill reduce milk supply , therefore not recommended for use in the early months in lactating women ( ).

Progestin only pills (Mini pills ) :

Oral contraceptive are the most popular hormonal contraception .

Administration of the hormones to alter the normal changes in the menstrual cycle is the basis of hormonal , with the mini pills containing of pregnancy only progestin ( ).

Progestin only pills contraception were introduced to avoid the side effect of estrogen in the combined pill ( ).

Mode of action:

The progestin only pills exerts it is contraceptive effect at deferent level .

The main action was thought to be thickening of cervical mucus , making it impenetrable to spermatozoa , and modification of endometrium thus preventing implantation .

It also has a variable effect on the uterine tubes ( ) .

Side effect of progestin only pill:

1\ Variation in cycle length.

2\ Headache .

3\ Weight gain.

4\ Breast discomfort.

5\ nausea.

6\ Hypertension.

Advantages of progestin only pill:

1\ Few metabolic side effect .

2\ can be used during lactation .

3\ Probable reduction in premenstrual symptoms .

4\ Protection against pelvic inflammatory disease ( ).

Contra indication to use progestin only pill:

1\ Undiagnosed vaginal bleeding .

2\ Liver disease .

3\ Ectopic pregnancy ( ).

4\ Pregnancy .

5\ Sever arterial disease.

6\ Hydatiform mode ( ).

Using the progestin only pill:

The progestin only pill is taken every day , there are no pill , free days thus tablet are taken throughout periods .

If a pill is forgetting , the woman has only 3 hours in which to remember to take it , this is because the effect on cervical mucus is at it is maximum between 4 and 22 hours after the tablet has been taken .

The tablets should be taken at same time each day( ).

Effectiveness :

The effectiveness of the progestin only pills is dependent upon meticulous compliance .

The failure rate of this method is clearly related to age ( ) , effectiveness about 99,5 % .

Progestogen injection :

Long acting , injectable progestin .

It is a method of choice for many women .

Mode of action :

There are two types of injection are Depo-Provera and noristerat both type are given by deep intramuscular injection ( ).

It alter the cervical mucus so that it becomes hostile to sperm and impairs ovulation and implantation ( ).

Depo- provera is the most commonly used injectable and is given in a 150mg dose at 12 week intervals ( ).

Using ijectable progestin :

The initial injection is given within the first 5 days of the menstrual period .

If given on day 1 the contraceptive effect is immediate ,however ,if given at any other time then additional contraceptive should be used for the next 7 days ( ).

Side effect of injectable progestin ;

1\ Menstrual spotting .

2\ Headache .

3\ weight gain .

4\Impair glucose tolerance .

5\ Development of breast cancer .

6\ Osteoporosis .

7\ Nausea and vomiting .

8\ Depression( ).

Effectiveness of injection :

About 99% .

The contraceptive patch ( Evra) :

It is sticky patch you put in your skin , and it releases two hormone( progestin –estrogen), that stop you from getting pregnancy , it is light pink in color .

Use of contraceptive patch:

It comes in the form of a self –adhesive patch , and you just stick it on a clean ,dry , non hairy area of the skin .

Each patch lasts a week , so you need to change it every seven days .

After using (Evra) for three weeks you have a week break – during which time you will have a period .

So life three weeks on and one week off .

Advantages of contraceptive skin patch:

1\ You do not have to remember to take a pill each day.

2\ The hormones are reaching you through your skin and not through stomach ( nausea not occur ) .

3\ Easy to put by mother .

Disadvantages of contraceptive skin patch:

1\ The patch may come off ,possibly without you noticing .

2\ Some women skin react badly to the patch , skin irritant at the point of application .

3\ The patch do not control period pain in the way that the pill does .

Side effect of contraceptive skin patch :

1\ Beast discomfort .

2\ Spotting ( slight blood loss from the vagina ).

3\ Headache .

4\ Nausea.

5\ Migraine headache.

6\ Flu- like symptoms

Effective of contraceptive skin patch :

It is thought to be more than 99 % , but it would be less if you forgot to change patches .

Sub dermal implants:

Norplant has been available in uk since 1993

It consists of six silastic rods inserted subdermally in the upper arm , whichrelease the progestogen levongesrel , and last for five years .

Insertion and removal of Norplant must be done by at rained health care professional ( ).

Mode of action:

Norplant act by suppressing ovulation it also stimulate the production of thick cervical mucus which inhibit sperm penetration( ) .

Using implants:

Implants are capsules containing progestogen that are inserted under local anesthetic in to the inner aspect of the non-dominant upper arm.

The steroid is released at constant rate only this steady circulating blood level ensures high contraceptive efficacy by producing a cervical mucus blockade , which prevents sperm penetration .

The implant should be inserted during the first 5 days of the menstrual cycle and no additional contraceptive cover will be required ( ).

Advantages of Norplant :

1- Long acting effect .

2\ Ease of reversible.

3\ Lake of interference with intercourse and estrogen side effects.

4\ High effectiveness in prevent pregnancy .

5\ No need for users control( ) .

Side effect of Norplant :

1\ Bleeding (irregular bleeding) .

2\ Visibility .

3\ Potential scar formation.

4\ Headache .

5\ Nausea .

6\ Weight gain .

Contra indication to use Norplant:

1\ Undiagnosed vagina bleeding .

2\ Pregnancy .

3\ Active thrombophlebitis or thromboembolic disorders .

4\ Liver disease .

5\ Coronary artery or corebrovascular disease .

6\ Breast cancer .

Effectiveness of Norplant:

There have been no reported pregnancies with the single rod implant.

Norplant has accumulative effectiveness about 99% .

Emergency contraception :

Emergency contraception is used after intercourse has taken place and before implantation has accrued

There is considerable interest in increasing provision and up take of emergency contraception particularly among young women as it is thought to have significant potential in the reduction of unplanned pregnancies.

Emergency contraception should be considered if unprotected intercourse has accrued , if there has been failure of barrier methods ( ) .

Types of emergency contraception :

1\ Hormonal emergency contraception :

Combination of 100 mg thinly oestradiol and 500 mg levonorgestrel is taken twice , the two doses being 12 hours apart and started within 72 hours of unprotected intercourse .

Nausea and vomiting are common side effects and there are very few contra indication to it is use .

The mechanism of action is not exactly known but probably involves disruption of ovulation or corpus luteal function depending on the time in the cycle when hormonal emergency contraception taken ( ) .

2\ Intrauterine for emergency contraception :

A copper-bearing intrauterine device can be inserted for emergency contraception .

It is effective up to five days following the anticipated day of ovulation and can be used to cover multiple episodes of intercourse .

The intrauterine device prevents implantation and the copper ions exert an embryo toxic effect .

The normal contraindication to on intrauterine device apply and if there is risk of sexually transmitted infection .antibiotic should be give ( ).

Male hormonal contraception :

Commonly known as the male pill researchers have found several effective formulation and delivery methods –shots , implants ,gels ,and pills –it is effective and safe .

Mode of action :

Male hormonal contraceptive attempt to block or severely reduce the production of sperm , they accomplish this by stopping the secretion of a man's reproductive hormones in the brain and testes .

When levels of testosterone in the testes are low , sperm production slows or halts .

Side effects of male contraceptive :

1\ Weight gain .

2\ Increased acne .

3\ Change in mood .

4\ Altering a man's androgen metabolism is a depressed level of high-density lipoprotein cholesterol in the blood .

How long would it take to reverse :

The contraceptive effect of the all male hormonal contraceptives regimens is completely reversed within 4 – 6 months .

Effectiveness of male contraceptives :

The contraceptive efficacy of sever oligospermia is 99 % .

Intrauterine contraceptive device :

Modern intrauterine devices are highly effective contraceptives .

Fitting of on intrauterine devices should be carried out by trained health care personnel only and is brief procedure associated with minimal discomfort ( ).

Types of intrauterine device :

Original intrauterine device were large plastic inert devices ( lippes loop or safe-T coil ) which often caused heavy and painful menstrual period .

-Most women nowadays will use the smaller copper bearing intrauterine devices that are available in various shape and size .

-Hormone –releasing intrauterine devices are also available ( ) .

Mode of action :

The intrauterine contraceptive devices create an inflammatory response , with increased number of leucocytes destroying spermatozoa and ova .

Gamete viability is further impaired by alteration of uterine and tubal fluids

Copper effects endometrial enzymes , glycogen metabolism and estrogen uptake , thus rendering the endometrium hostile to implantation ( ).

Advantages of intrauterine contraceptive devices :

1\ high rate of effectiveness .

2\ continuous pregnancy prevention .

3\ protection against pelvic inflammatory diseases .

4\ dramatic reduction menstrual blood loss .

Side effects of intrauterine devices :

1\ pelvic inflammatory infection due to contamination by pathogens at the time of insertion.

2\ Sever dysmenorrhea .

3\ Uterine perforation .

4\ Increase risk of ectopic pregnancy .

Contra indication to intrauterine device :

1\ Previous pelvic inflammatory disease .

2\ Previous ectopic pregnancy .

3\ Known malformation of the uterus .

4\ Copper allergy ( ) .

5\ Pregnancy .

6\ Endometrial or cervical malignancy .

7\ Valvular heart disease .

8\ Anemia .

9\ Sever dysmenorrheal .

10\ Rh-negative blood type ( ) .

Effectiveness of intrauterine device :

The failure rate is less than 0,2 -2\100 \women \year .

Barrier methods :

1\Male condom :

Are thin sheaths of latex rubber or processed collage nous tissue that are placed over the penis to act as mechanical barrier to prevent sperm from entering the vagina .

Also effective in preventing infection .

Condom are a male methods of contraception ( ).

Many varieties of condom are available , including latex , hypoallergenic and polyurethane ( ).

Using a condom :

The condom is rolled on to the erect penis must be applied before any genital condom occurs as some semen may escape prior to ejaculation .

About 1 cm of air –free space must be left at the tip to accommodate the ejaculate .

Care should be taken when handling the condom to prevent tearing .

Some sheaths are impregnated with spermicides which increases their efficacy ( ) .

Side effect of condom :

1\ Allergic reaction .

2\ Decreased sensation of men .

Contra indication to condoms :

1\ Allergy to latex or collagenous tissue .

2\ Inability to maintain erection .

3\ Inability to use properly .

Effectiveness of male condom :

This is dependent 0n the age and experience of the user and failure rates very widely between 1 and 10 per 100 users/ year .

Female condom :

The female condom is a thick polyurethane sheath , 7 inches long with

flexible ring at each end .

The inner ring , at the closed end of the condom , sever as the means of insertion and covers the cervix ( ) .

The second ring of the devise remains outside , and thus cover part of the perineum and provides protection to the labia during intercourse ( ) .

They offer particularly good protection against infection they cover the whole of the vulva and vagina ( ) .

Effectiveness :

About 95 % .

Diaphragm :

This a thin rubber dome with a circumference of metal to help maintain it is shape ( ) .

The diaphragm prevents passage of sperm into cervix , the woman must be fitted with a diaphragm at which time she is given instruction about it is use ( ) .

Using the diaphragm:

When in place , the rim of the diaphragm should lie closely against the vaginal walls and rest between the posterior fornix and the symphysis pubis .

Before insertion , spermicide should be applied .

After insertion thin additional spermicide is required , should be left in place for at least 6 hours after the last intercourse.

On removal , the diaphragm should be washed with mild soap , dried , and inspected for damage (

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د/منتصر محمد عبدالله صالح / نهر النيل / شندى

Family planning

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