Family PlanningFamily Planning DI WEN DI WEN M.D., Ph.D.M.D., Ph.D.

Professor & Chairman Professor & Chairman Department Of Obstetrics & GynecologyDepartment Of Obstetrics & Gynecology Renji Hospital Affiliated to SJTU School of MedicineRenji Hospital Affiliated to SJTU School of Medicine

Birth Control, Birth Control,

Pregnancy, Pregnancy,

and Childbirth:and Childbirth:

Managing Your Managing Your

FertilityFertility

Hormonal methodsHormonal methods– Oral contraceptivesOral contraceptives– PillsPills– Depo-ProveraDepo-Provera– Ortho-EvraOrtho-Evra– Nuva ringNuva ring– Lunelle and Norplant Lunelle and Norplant (currently off the market)(currently off the market)

Methods of Fertility ManagementMethods of Fertility Management

Surgical methods of sterilizationSurgical methods of sterilization– FemaleFemale– Tubal ligationTubal ligation– MaleMale– VasectomyVasectomy

Methods of Fertility ManagementMethods of Fertility Management

Other methods of contraceptionOther methods of contraception– IUDsIUDs– ProgestasertProgestasert– ParaGuardParaGuard– WithdrawalWithdrawal– Emergency contraceptive pillsEmergency contraceptive pills– Emergency minipillsEmergency minipills– Abstinence and “Outercourse”Abstinence and “Outercourse”

Methods of Fertility ManagementMethods of Fertility Management

• EffectivenessEffectiveness

• Compliance and desire to avoid pregnancyCompliance and desire to avoid pregnancy

• Frequency of intercourseFrequency of intercourse

• Patient’s agePatient’s age

• Cost of methodCost of method

• Side effectsSide effects

• Patient’s perceptions and misperceptionsPatient’s perceptions and misperceptions

• Patient’s concomitant drug usePatient’s concomitant drug use

• Patient’s health status and habitsPatient’s health status and habits

Contraceptive VariablesContraceptive Variables

Oral ContraceptivesOral Contraceptives

• Oral contraceptive:Oral contraceptive:– Combined oestrogen/progestogenCombined oestrogen/progestogen– Progestogen onlyProgestogen only

• Depot progestogen:Depot progestogen:– Injections(Progestogen)Injections(Progestogen)– Subcutaneous silicone implants Subcutaneous silicone implants – Vaginal: Silicone rings releasing oestrogenVaginal: Silicone rings releasing oestrogen– and progestogen and progestogen

Hormonal MethodsHormonal Methods

• Prevents ovulation.Prevents ovulation.

• FSH secretion is depressed FSH secretion is depressed

• LH peak is abolished.LH peak is abolished.

• Urinary androgen excretion is Urinary androgen excretion is

much increased.much increased.

• Changes in cervical mucus make Changes in cervical mucus make

sperm penetration less likely.sperm penetration less likely.

Oral ContraceptionOral Contraception

• FormulationsFormulations– MonophasicsMonophasics– BiphasicsBiphasics– TriphasicsTriphasics

• Mechanism of actionMechanism of action– Suppress ovulationSuppress ovulation– Alter cervical mucus and endometriumAlter cervical mucus and endometrium

OC Formulations & Mechanism of ActionOC Formulations & Mechanism of Action

• No significant increased risk No significant increased risk

among current or former usersamong current or former users

• Small increased risk of breast Small increased risk of breast

cancer diagnosiscancer diagnosis

• Link to earlier diagnosis of breast Link to earlier diagnosis of breast

cancercancer

OC Health Risks-breast CancerOC Health Risks-breast Cancer

• Numerous studies have linked OC use aNumerous studies have linked OC use and cervical neoplasiand cervical neoplasia

• Findings are difficult to interpretFindings are difficult to interpret

OC Health Risks-cervical CancerOC Health Risks-cervical Cancer

• Nonfatal venous thromboembolismNonfatal venous thromboembolism– Similar low risk of VTE associated with all low-dose OCsSimilar low risk of VTE associated with all low-dose OCs

• Myocardial infarctionMyocardial infarction– No increase in riskNo increase in risk– Further studies may prove OCs protectiveFurther studies may prove OCs protective

• StrokeStroke– No increase in riskNo increase in risk

OC Health RisksOC Health Risks

• Reduced risk of ovarian and endometrial cancerReduced risk of ovarian and endometrial cancer• Menstrual benefitsMenstrual benefits• Improvement in benign breast conditions and oImprovement in benign breast conditions and o

varian cystsvarian cysts• Improvement in acneImprovement in acne• Reduced incidence and severity of PIDReduced incidence and severity of PID• Protection against ectopic pregnancyProtection against ectopic pregnancy• Maintenance of bone densityMaintenance of bone density

OC Noncontraceptive BenefitsOC Noncontraceptive Benefits

• Thrombophlebitis or thromboembolic disordersThrombophlebitis or thromboembolic disorders• Past history of DVT or thromboembolic disordersPast history of DVT or thromboembolic disorders• Cerebral vascular disease or coronary artery diseaseCerebral vascular disease or coronary artery disease• Known or suspected carcinoma of the breastKnown or suspected carcinoma of the breast• Carcinoma of the endometriumCarcinoma of the endometrium• Undiagnosed abnormal genital bleedingUndiagnosed abnormal genital bleeding• JaundiceJaundice• Hepatic adenomas or carcinomasHepatic adenomas or carcinomas• Known or suspected pregnancyKnown or suspected pregnancy• Smoker over age 35Smoker over age 35

OC ContraindicationsOC Contraindications

• NauseaNausea

• Breast tendernessBreast tenderness

• Menstrual changesMenstrual changes

• Weight gainWeight gain

• HeadacheHeadache

OC Side EffectsOC Side Effects

• Formulation:Formulation:– Contains norethindrone or nogestrelContains norethindrone or nogestrel– 28 days of active hormones28 days of active hormones

• Candidates:Candidates:– Women who cannot or will not take estrogeWomen who cannot or will not take estroge

nn– Postpartum and lactating womenPostpartum and lactating women

Progestin-Only PillsProgestin-Only Pills

Currently available:Currently available:– Injectable DMPA (Depo-Provera)Injectable DMPA (Depo-Provera)– Copper IUD (Paragard)Copper IUD (Paragard)– Progestin IUD (Mirena)Progestin IUD (Mirena)

Long-Acting ContraceptivesLong-Acting Contraceptives

DMPA InjectionsDMPA Injections

• Menstrual changesMenstrual changes

• Delayed return of fertilityDelayed return of fertility

• AlopeciaAlopecia

• Reduced libidoReduced libido

• Weight gain?Weight gain?

• Depression?Depression?

DMPA Side EffectsDMPA Side Effects

• Loss of bone mineral density?Loss of bone mineral density?• Lowered HDL levelLowered HDL level• Protection against endometrial cancer, Protection against endometrial cancer,

no impact on risk of other types of cancno impact on risk of other types of cancerer

• Reduces PMS symptoms, iron-deficienReduces PMS symptoms, iron-deficiency anemia, risks of PID, ectopic pregnacy anemia, risks of PID, ectopic pregnancyncy

DMPA Health Risks & BenefitsDMPA Health Risks & Benefits

Levonorgestrel ImplantsLevonorgestrel Implants

Side effects & risksSide effects & risks

• Irregular bleedingIrregular bleeding

• AmenorrheaAmenorrhea

• HeadacheHeadache

• Hair lossHair loss

• Weight gainWeight gain

• Functional ovarian Functional ovarian

cystscysts

BenefitsBenefits• Improvement of dysmImprovement of dysm

enorrheaenorrhea• Improvement of PMSImprovement of PMS

Implant Side Effects,Implant Side Effects, Health Risks & Benefits Health Risks & Benefits

• InertInert• Copper bearingCopper bearing

• Progestogen releasingProgestogen releasing

Intra Uterine DevicesIntra Uterine Devices

IUDsIUDs

• Risks:Risks:– Perforation of the uterus (rare)Perforation of the uterus (rare)– Infection (antibiotic prophylaxis not needed)Infection (antibiotic prophylaxis not needed)

• Expulsion rates:Expulsion rates:– Copper T (Paragard) = 6%Copper T (Paragard) = 6%– Progesterone-releasing IUDs = 3~8%Progesterone-releasing IUDs = 3~8%

IUD Insertion RisksIUD Insertion Risks

• Copper T: increased menstrual bleediCopper T: increased menstrual bleeding and dysmenorrheang and dysmenorrhea

• Mirena: irregular bleeding and spottiMirena: irregular bleeding and spotting before eventual amenorrheang before eventual amenorrhea

IUD Insertion Side EffectsIUD Insertion Side Effects

• Multiple sexual partnersMultiple sexual partners• PregnancyPregnancy• Abnormalities of the uterusAbnormalities of the uterus• PIDPID• Postpartum endometritis or septic abortionPostpartum endometritis or septic abortion• Uterine or cervical malignancyUterine or cervical malignancy• Undiagnosed genital bleedingUndiagnosed genital bleeding• Vaginitis or cervicitisVaginitis or cervicitis• Increased susceptibility to infectionIncreased susceptibility to infection• Previously inserted IUD still in placePreviously inserted IUD still in place

IUD: Major ContraindicationsIUD: Major Contraindications

• Increased menstrual loss.Increased menstrual loss.

• InfectionInfection

• PregnancyPregnancy

• ExpulsionExpulsion

• TranslocationTranslocation

Complications of IUDSComplications of IUDS

• CondomsCondoms– Male latex, polyurethane, animal skinMale latex, polyurethane, animal skin– Female polyurethaneFemale polyurethane

• DiaphragmsDiaphragms• Cervical capCervical cap• SpermicidesSpermicides

Barrier ContraceptivesBarrier Contraceptives

Male CondomsMale Condoms

How to How to Use a Use a CondomCondom

Figure 6.1

The Female CondomThe Female CondomBrand Name: RealityBrand Name: Reality

The DiaphragmThe Diaphragm

The Cervical CapThe Cervical Cap

SpermicidesSpermicides

• CreamsCreams• FilmsFilms• FoamsFoams• JelliesJellies• PessariesPessaries• SpongesSponges(All of these are mainly Nonoxynol based.) (All of these are mainly Nonoxynol based.)

SpermicidesSpermicides

• Also called periodic abstinence or fertiliAlso called periodic abstinence or fertility awarenessty awareness

• Calendar (“rhythm”) methodCalendar (“rhythm”) method• Cervical mucus (ovulation or billings) mCervical mucus (ovulation or billings) m

ethodethod• Basal body temperature methodBasal body temperature method• Symptothermal methodSymptothermal method

Natural Family PlanningNatural Family Planning

• 24 hours are allowed for ovum 24 hours are allowed for ovum

survivalsurvival

• 3 days are allowed fro the sperms3 days are allowed fro the sperms

• Coitus must be avoided from the Coitus must be avoided from the

99thth to the 15 to the 15thth day day

Rhythm Method(“safe Period”)Rhythm Method(“safe Period”)

Figure 6.4

The Fertility CycleThe Fertility Cycle

Billings’ MethodBillings’ Method

Identify the peri-ovulatory phase by nIdentify the peri-ovulatory phase by noting the vaginal sensations associated oting the vaginal sensations associated with changes in cervical mucus.with changes in cervical mucus.

• High doses of combined OCsHigh doses of combined OCs• High doses of progestin-only pillsHigh doses of progestin-only pills

Emergency contraceptive pills prevent pregnancy by inEmergency contraceptive pills prevent pregnancy by inhibiting or delaying ovulation. They may also alter thibiting or delaying ovulation. They may also alter the endometrium, making it inhospitable to the implhe endometrium, making it inhospitable to the implantation of ova. They may alter sperm or ovum tranantation of ova. They may alter sperm or ovum transport.sport.

• IUDIUDThe mechanism of action of the IUD as emergency contrThe mechanism of action of the IUD as emergency contr

aception remains undefined.aception remains undefined.

Emergency ContraceptionEmergency Contraception

NEW METHODS: OrthoEvra “The Patch”NEW METHODS: OrthoEvra “The Patch”

Surgical Methods Surgical Methods

1.Laparoscopic sterilisation 1.Laparoscopic sterilisation Rings,Clips-Bipolar Rings,Clips-Bipolar

diathermy,Laserdiathermy,Laser

2.Tubal ligation2.Tubal ligation

Artificial AbortionArtificial Abortion

Definition:Definition: An abortion that is brought about intAn abortion that is brought about int

entionally(family planning et al.), Also centionally(family planning et al.), Also called an induced or therapeutic abortioalled an induced or therapeutic abortionn

The termination of a pregnancy befoThe termination of a pregnancy befor the 24r the 24thth week. week.

Abortion of MethodsAbortion of Methods

Vacuum aspiration – 1Vacuum aspiration – 1stst trimest trimest

Dilation and Evacuation (D&E) – 2Dilation and Evacuation (D&E) – 2ndnd trim trimesterester

Dilation and Curettage (D&C) – 2Dilation and Curettage (D&C) – 2ndnd trimes trimester4)ter4)

Figure 6.7

AmniocentesisAmniocentesis

Abortion of MethodsAbortion of Methods

Prostaglandin or induction abortions – 2Prostaglandin or induction abortions – 2ndnd trimeste trimesterr

Hysterotomy – removal of the fetus surgicallyHysterotomy – removal of the fetus surgically

Intact dilation and extraction (D&X) – late term aboIntact dilation and extraction (D&X) – late term abortionrtion

Mifepristone (RU-486) – induces abortion by blockiMifepristone (RU-486) – induces abortion by blocking progesterone used with Misoprostil (a prostang progesterone used with Misoprostil (a prostaglandin)glandin)

ComplicationsComplications

*Incomplete uterine evacuation*Incomplete uterine evacuation*Uterine perforation and/or damage to *Uterine perforation and/or damage to

abdominal viscera.abdominal viscera.*Sepsis.*Sepsis.*Haemorrhage.*Haemorrhage.*Rhesus isoimmunisation*Rhesus isoimmunisation

Mifepristone(RU 486) 600mg orallyMifepristone(RU 486) 600mg orally ++Gemeprost (PGGemeprost (PG analogue analogue ) 1mg vaginally ) 1mg vaginally (36-48 hours later)(36-48 hours later)

Medical TerminationMedical Termination

• Approximately 8% of these abortions Approximately 8% of these abortions require surgical followuprequire surgical followup

• Abdominal pain:20% requiring opiate Abdominal pain:20% requiring opiate analgesiaanalgesia

• Blood lossBlood loss

Side effectSide effect

Late complicationsLate complications

• InfertilityInfertility• Effect on future pregnanciesEffect on future pregnancies• Psychological sequelaePsychological sequelae• Rhesus isoimmunisationRhesus isoimmunisation

DI WEN DI WEN M.D., Ph.D.M.D., Ph.D.

Professor & ChairmanProfessor & Chairman Department of Obstetrics & GynecologyDepartment of Obstetrics & Gynecology Renji Hospital Affiliated to SJTU School of MedicineRenji Hospital Affiliated to SJTU School of Medicine

Thanks for Your AttentionThanks for Your Attention