Family Planning

1. Family Planning

What is Family Planning (FP) ?

Family Planning involves planning the number, frequency and timing of pregnancy. In other words it is a program to regulate the number and spacing of children in a family through the practice of contraception or other methods of birth control.

What are the various methods of FP ?

There are several contraceptive choices available to a couple. FP methods can be broadly classified into Reversible (Temporary) methods and Irreversible (Permanent) methods.

What are Reversible FP methods ?

Also known as Spacing methods, these are temporary in nature, hence do not have any permanent contraceptive effect.

Reversible (Temporary Methods)
 



 Natural                         Barrier                     Intra Uterine                   Non Hormonal                 Hormonal
Methods                    Methods                     Devices                         Contraceptives                Contraceptives

 

What are Irreversible FP methods ?

Also known as Sterilization, these are permanent methods. They need to be carefully thought about and opted for. This FP method is best for people who have already completed their family.

                                   Irreversible (Permanent)
 



  Vasectomy (Men)                                                 Tubectomy (Women)

 

 

 

REVERSIBLE / SPACING (TEMPORARY METHODS)

 

What are natural methods of family planning ?

  • Periodic abstinence: A group of methods that are based on avoiding sexual intercourse during the fertile time (time when a woman can conceive.) A woman's fertile time is identified through observing, recording and interpreting natural signs and symptoms associated with the menstrual cycle. These methods include the standard days method, calendar (rhythm) method, cervical mucus (or ovulation) method, and basal body temperature method.

 

  • Withdrawal (coitus interruptus): A method where sexual intercourse is interrupted and the penis is withdrawn from the vagina before ejaculation.
  • Lactational Amenorrhea (LAM: LAM is a temporary method of contraception based upon breast-feeding. Sucking during breast-feeding releases natural hormones which prevents ovulation acting as a protection against pregnancy.

 

How do natural methods of family planning work? (mechanism of action)

They prevent sperm from uniting with an egg by avoiding intercourse around the time of ovulation or by withdrawing the penis from the vagina before ejaculation. In this method a woman should be aware of her fertility.

For whom are natural methods of family planning appropriate?

  • Couples willing and motivated to learn how to observe, record and interpret the woman's fertility signs
  • Couples who accept the potential for unintended pregnancy
  • Couples with no/little access to modern contraceptive methods
  • Couples with religious/philosophical reasons not to use other methods
  • Women with regular menstrual cycles
  • Women unable to use other contraceptive methods
  • Men willing to practice withdrawal

 

What are the advantages and disadvantages of Natural Methods of Family Planning ?

Advantages

  • Have no medical side effects
  • Immediate return to fertility
  • Free and readily available
  • Use increases knowledge of female reproductive physiology
  • Use may improve communication between partners

Disadvantages

  • High failure rate
  • Require high motivation and ability to follow instructions
  • Require partner's cooperation
  • Couple practicing periodic abstinence must abstain from intercourse for a significant period of time every month
  • No protection from STIs/HIV
  • May be difficult to detect a woman's fertile period (close to menarche, close to menopause, during breastfeeding, or in women with irregular cycles)

What is meant by Barrier method ?

This method stops the sperm from uniting with the egg and acts as a barrier. Different barrier methods are male condom or female condom, Foam tablets or Spermicidal jellies.

What is a Male Condom ?

A condom is a contraceptive choice available to men and women. It acts as a barrier to the passage of seminal fluid into the vagina. Condoms also protect from RTI/STI. A Condom is made of a thin latex sheath, which is rolled over the erect penis of the male partner before sexual intercourse. It prevents the sperms from entering into vagina and coming in contact with the female egg.

When should a Male Condom be used ?

  • A Condom should be used at the beginning of each act of intercourse by unrolling on the erected penis.
  • A Condom should not be re-used.

 

How should a Male Condom be used ?

  • The Condom should be rolled over the erect penis before the penis is in the vagina. The rim of the condom should be rolled all the way to the base of the penis, leaving half inch of an empty space at the top by pinching the tip of the condom as it is rolled over the penis. No air should be left in the tip of the condom.
  • After intercourse, the condom should be held at the rim as the penis is being withdrawn so that no semen is split anywhere near the opening of the vagina.
  • The penis should be withdrawn soon after ejaculation because once the penis returns to its flaccid state, the condom may slip off and pregnancy may result.
  • If using spermicide, it should be applied to the outside of the condom.
  • The condom should be checked before being thrown away to see whether it is torn or not. If torn, the woman should use a spermicidal tablet or cream immediately, otherwise an emergency contraceptive pill within 2 days or an IUCD within 5 days should be used.
  • Oils or petroleum jelly should not be used as lubricants, because they can cause deterioration of the condom.

 

PSS range of condoms- Sawan, Milan & Bliss

What is a Female Condom ?

Female condoms are made of very thin polyurethane plastic pouch about 17cm(6.5”) in length. That is sturdier than male latex condoms and is a soft, loose fitting sheath with flexible rings at each end. One ring is at the closed end of the sheath and serves as an insertion mechanism and anchor inside the vagina. The outer ring forms the external edge of the device and remains outside the vagina after insertion.  It lines the entire vagina thereby preventing seminal fluid containing sperms from entering the uterine cavity and preventing pregnancy. Also, this design may reduce the potential for transfer of infectious organisms between sex partners, particularly genital ulcer diseases.

The Female condom is a highly effective barrier method in preventing pregnancy, provided it is used correctly and consistently.

“ This barrier method may be especially useful for women at risk of STDs who have difficulty convincing male partners to use latex condoms”


 

How should a Female Condom be used ?

  • The female condom must be properly positioned before any contact occurs between the penis and vagina or rectum. The female condom may be used for both vaginal and rectal sexual intercourse.
  • Squeeze the smaller ring and insert into the vagina. The large end should be placed over the vaginal opening to protect outer genitalia infection.
  • Be sure that the penis goes directly into the large ring to preclude unprotected sexual contact between the penis and the vagina or rectum.
  • Remove the condom immediately after sexual intercourse and before standing up. To avoid semen leakage twist the large outer ring  and carefully pull the condom out and dispose it.

 

What are the basic things to remember about Condom ?

  • Condoms should not be kept in places with extreme temperatures either hot or cold.
  • Use a new condom for each act of sexual intercourse.
  • Do not use a male condom and female condom at the same time.
  • Do not throw used condoms into the toilet as they can clog pipes.

 

What are Foam Tablets or Spermicidal Jellies ?

Spermicides are barrier birth control methods that are bought over the counter. Once inserted, these contraceptives kill sperm. Vaginal spermicides are available in several forms: spermicidal jelly, cream, foam tablets, suppositories, sponge and film. Most use the chemical nonoxynol-9 against sperm. Spermicides provide lubrication and can be used with other methods of birth control.  They are most effective when used consistently and correctly with a barrier method of birth control, like a condom. Spermicides are 71-82% effective as birth control. Used alone, spermicide does not protect against HIV/AIDS.

 

What is an Intra Uterine Contraceptive Device ?

 

It is a device made of polyethylene/ plastic, which is inserted in the uterus for prevention of pregnancy. The different types of IUD’s are –Copper T, CuT-380A, ML-375, Nova T, Progestasert and LNG 20. The most common IUCD available is Copper T (CuT) in which a thin copper wire is coiled around the vertical stem of T. It causes changes in the uterus lining and hence prevents the implantation of the fertilized egg. It also decreases sperm motility, thereby preventing fertilization in the fallopian tube. A complete examination by the doctor is essential before an IUCD is inserted. It can be left in the uterus for 3 years after which it has to be removed and reinserted, if required.

Facts about IUD

 

  • IUCD is effective immediately after insertion. The string should be checked frequently atleast after the menstrual period every month.
  • Possibility that the first and probably the second periods may be earlier than the scheduled date but there is nothing to panic.It is normal.
  • Check pads and toilet during menstruation as expulsion could occur during this time.

When should IUD be inserted ?

 

  • Preferably on the 5th day of the menstrual cycle as bleeding associated with the insertion is likely to cause less anxiety.
  • Anytime convenient except during pregnancy
  • Immediately after a first trimester spontaneous or legally induced abortion, with antibiotic cover.
  • During lactation
  • Immediately post-partum within 72 hours or at six weks post natal checkup visit.

What are Non – Hormonal Contraceptives ?

Non Hormonal Oral Contraceptives like Saheli are non-steroidal. The have weak estrogenic with potent anti-estrogenic properties. They inhibit preparation of uterine cavity for implantation of fertilized ovum and accelerate ovum transport. A pill is taken twice a week for three months and is followed by once a week dose, on the same day each week.

 

What are OCPs ?                   

OCP’s or Oral Contraceptive Pills are an efficient and reversible contraceptive choice available to women. It is the best birth spacing method that is available to women. OCP’s are a combination of female sex hormones, which are normally present in a woman’s body. PSS product - ECROZ

What role does Hormone play in Pregnancy ?

 

During a woman's monthly cycle, hormones produced by a gland in the brain cause the ovaries (small organs where the egg cells are produced and stored) to release the hormones oestrogen and progesterone. Oestrogen and progesterone cause the ovaries to release an egg (ovulation), which travels through the fallopian tube - where it can be fertilised by sperm - and the egg then travels on to the womb.

Oestrogen and progesterone also thicken the lining of the womb (the endometrium) and increase its blood supply, preparing it for pregnancy. If the egg is fertilised it can implant in the lining, where it develops during pregnancy. If pregnancy doesn't occur, the levels of oestrogen and progesterone drop. The lining of the womb and the egg are shed, coming out of the vagina as a period (menstruation). It is this drop in oestrogen that makes the cycle to start again.
The combined contraceptive pill contains artificial (synthetic) versions of hormones. They mimic the action of oestrogen and progesterone on the body. When taken correctly, the pill interferes with the normal cycle to prevent pregnancy.

How does OCP work ?

  • preventing the ovaries from releasing an egg
  • thickening the mucus at the cervix (neck between the vagina and womb) making it more difficult for sperm to enter the womb and fertilise the egg
  • making the lining of the womb unsuitable for a fertilised egg to implant on to

 

What are the different type of OCPs ?

  1. Combined – Contain fixed doses of estrogen and progestogen.
  2. Progestogen only Pill – Not available in India, contains only progestogen
  3. Phasic – The doses of the hormones vary during different phases of the menstrual cycle.

 

 

Who can take the pill ?

 

Young, newly wedded or unmarried women who can fulfill medical, eligibility checklist can take OCP

When can one take OCP’s ?

 

  • Pills can be taken after unplanned, unprotectedcoitus as emergency contraceptive after consulting the doctor .
  •  A  dose of 4 tablets of a low dose pill within 72 hours of un protected intercourse followed by 4 more tablets 12 hours later.
  • OCP’s can be taken as post Abortal, immediately after an abortion.

What are the benefits of having Oral Pills ?

A. Contraceptive benefits

  • Ideal Spacing method
  • Useful in nulliparas (A woman who has never given birth)
  • Useful immediately after abortion / MTP
  • May be used as a post-coital contraceptive or for postponing periods.
  • Wait-in period before terminal method

B. Menstrual benefits

  • Regular cycles
  • Pain-free cycles
  • Lighter bleeding during cycles

C. Non-contraceptive benefits

  • Decreased anemia
  • Decreased risk of ectopic pregnancy, pelvic inflammatory disease, benign breast disease, ovarian cysts, carcinoma of ovary and endomentrium
  • Improvement in Rheumatoid Arthritis  
  • Improvement of acne in some women

What might be the side effects of having Oral Pills ?

Side effects are rare with low doses. Some may report nausea, break-through bleeding and sore breasts. But these are temporary limited to 2-3 days.

 

Please Remember – Pills do not provide protection against STI/ STI Infections. Use Condoms for protection.

 

What is Injectable Contraceptive (IC) ?

Injectable Contraceptive is a method that provides protection from pregnancy when women receive injections at regular intervals. These injections contain Progestin, which is similar to the natural hormone Progesterone that a woman’s body produces.

Injectable provide safe, effective and convenient contraception. 

Types of injectable contraception

1. Progestin Only Injectable (POI)

Depomedroxyprogesterone acetate (DMPA)- every 3 months
Norethisterone enanthatate (NET-EN)- every 2 month

2. Combined Injectable Contraceptive (CIC)- every month. Contains hormones oesstrogen and progesterone like COC pills.

Out of all these DMPA and NET-EN are the officially registered products in our country and easily availabe in the private sector.

What is DMPA ?

It is an injectable progesterone (long lasting steroidal preparation), which gives protection from pregnancy for three months. It contains 150 mg of Depo medroxy progesterone acetate in 1ml aqueous microcrystalline suspension.

How does DMPA act ?

It prevents ovulation.
It prevents implantation by altering the endomentrium.
It thickens the cervical mucus and so prevents the sperms from entering the uterine cavity.
It alters tubal motility and either hastens or delays transport of fertilized ovum and prevents nidation.

How is DMPA administered?

• DMPA is an aqueous suspension and is given by deep Intra Muscular Injection. • A single injection will prevent pregnancy for 3 months.

When to start? 

• Within 7 days of start of menstrual bleeding.
• Immediately following or within 7 day of an abortion.
• After childbirth-
• Fully or nearly fully breast feeding/partially breast feeding- 6 weeks after childbirth.
• Not breast feeding- less than 4 weeks after childbirth 

Who can take DMPA ?

Any woman in good health may take DMPA provided she is

Not pregnant
In the age group 18-40 yrs (can be given to women below 18 yrs and over 40 yrs however caution needs to be exercised in this situation)
Not have history of unexplained vaginal bleeding.
Not have history of heart attacks or strokes.
Not suffering from jaundice/liver disease within 6 months prior to the 1st dose of DMPA
Not have reproductive tract or breast malignancy.
Having blood pressure below 160/100 mm of HG.

Following women can also take DMPA.

Women who are breast-feeding.
Are infected with HIV, have AIDS, or are on antiretroviral (ARV) therapy. These women should use condoms along with the injection. Used consistently and correctly, condoms help prevent transmission of HIV and other STIs.

What are the Non – Contraceptive Benefits of DMPA ?

Decreased menstrual flow
Decreased menstrual cramps
Protects against endometrial and ovarian cancer
Prevents development of uterine fibroid.

 What are the side effects of DMPA?

Changes in menstrual bleeding pattern- initially some women have irregular bleeding but most women have scanty or no monthly bleeding. Menstrual pattern return to normal after stopping injection.
Weight gain- insignificant.
Affects bone density- reduces bone density, however it returns to normal levels 2-3 yrs after stopping DMPA
Delayed return to fertility- DMPA users take 6-9 months to become pregnant after the last injection.

 

What is Emergency Contraceptive (EC) ?

Emergency contraceptive pill is taken following an act of un protected sex to prevent pregnancy. It is most often called the “Morning after Pill” EC is a post coital contraceptive based on the fact that even one act of un protected sex can result in pregnancy.

When to use EC ?

  • Non-use or in consistent use of any contraceptive method during sexual intercourse.
  • Condom breakage/slippage
  • Missed two or more Oral contraceptive Pills
  • Expulsion or displacement of IUD
  • Slippage of diaphragm or surgical cap
  • Failure of withdrawal technique
  • Miscalculation of safe period
  • Missed regular contraceptive injection
  • Sexual assault /rape
  • EC is to be used within 72 hours.

 

IRREVERSIBLE/ PERMANENT METHODS

What is Sterilization ?

Sterilization is an irreversible and permanent family planning method. It is a contraceptive choice for men and women who do not want to have more children or couples who have already completed their family.

What is Vasectomy ? How Male Sterilization is done ?

Sterilization in males is known as vasectomy.

Sperms are produced in the two testicles lying in the loose fold of skin called scrotum behind the penis. The tube called vas deferens starts from the testes and passing through abdomen it collects secretion from prostate and other glands before it passes through the penis and opens outside at the urethra. Urine is carried through the same tube.

Semen is made up of sperms (30%) and secretion of prostate and seminal vesicles (70%). Vasectomy involves the sealing of the tubes through which the sperms pass before ejaculation. This blocking does not interfere with attaining orgasm.

During Vasectomy, a 1 cm incision is made either at the central part or on either side of scrotum after applying local anesthesia, which numbs the area.  Then the tubes which carry the sperms are located and blocked.. A dressing is then applied at the site of the incision. It is a simple procedure done under local anesthesia. It takes only 5-10 minutes and the person can return home after resting for an hour. Also Vasectomy does not interfere with the man’s masculinity or sexual activity.

What is No-Scalpel Vasectomy (NSV) ?

This is the puncture technique of during male Sterilization without use of any knife. It is an effective method with less discomfort and very few complications. In this there are no incisions or stitches, therefore both the procedure and recovery is much faster.

How does the new operation of NSV differ from the old vasectomy ?

In the old method two cuts were made in the scrotum to bring out the vas deferens, which is then tied off. At the end of the procedure, these cuts have to be stitched. In the new NSV procedure, the vas are brought out through a tiny puncture which does not require any stitches. The procedure is nearly painless, less invasive and faster.

Are there any complications doctor ?

No surgery is without complications. But NSV has very few complications as compared to the old method, and is very safe.

Are there any chances of failure ?

Very few, more when one does not follow the doctor’s advice about the precautions. One is protected from failure when you observe the precautions.

What precautions one must take to prevent failure ?

It is important to use some form of contraception up to 10-14 weeks or 20 ejaculations whichever is earlier, after Vasectomy. The reason is that the vas empties itself of all the sperms that remain in it after the operation. A semen test is necessary to confirm the absence of sperms in the semen and the success of the vasectomy.

What other precautions must I take ?

You must take adequate rest and resume normal work 48 hours after surgery. You should also not wet the operation area for the same period. You can resume all activities including cycling by one week following surgery. Take the medicines as prescribed. Since these will prevent any infection/pus discharge from wound. In case you feel a lot of pain or swelling you must immediately report to a doctor.

What are the effects on sex after this operation ?

No charge will occur from whatever it is for you now. In some cases people find it better because the fear of pregnancy is gone. Fears of lowering of sexual pleasure are founded. The nerves that regulate sexual pleasure are within the abdomen and we operate outside the abdomen. Your body will continue to produce male hormones and same amount of semen but the sperms will not be transmitted to your partner during the sex.

Can I work as hard as before ?

Surely you can. This operation has absolutely no relationship with physical strength as that depends on your nourishment and exercise.

What happens to the sperm after the vasectomy ?

Sperms continue to be produced, as before but since they do not come out of the body after the operation they get absorbed into the body. This is a normal process, which occurs, even in non-vasectomised men who do not have sex for sometime.

What is Tubectomy ? How Female Sterilization is done ?

Sterilization in women is called Tubectomy. Also referred to, as Tubal Sterilization is a surgical procedure done on women as a permanent method of contraception. Gynaecologists, general surgeons
and laparoscopic surgeons perform Tubectomy.

The Fallopian Tubes are two in number and are attached on either side of the uterus at one end and the other end is open in the abdomen. The length of each Fallopian tube is about 10cm.When the ovum or egg is released from the ovary, it is picked up by Fallopian tube through which it moves into the uterus. If sperms are present in the Fallopian tubes, the ovum is fertilized and the resulting embryo is transmitted to the uterus where it is embedded. In short, we can say that Fallopian tubes are channels through which the eggs from the ovaries travel to the uterus. In Tubectomy the tubes are blocked or divided to prevent the eggs from entering the uterus. This prevents any future pregnancies to occur after the surgical procedure.
 

 

Tubectomy can be performed in two ways (1) Laparoscopic method and (2) Minilap technique.

What is Minilap technique ?

Mini-laparotomy or Mini lap is the conventional method of Tubectomy. It involves opening the abdomen through a small incision and both the fallopian tubes are tied and cut under vision. Local anesthesia is given by injection. The mini-lap method needs hospitalization for two days. It is useful for post-childbirth tubectomy, when the womb is still high in the abdomen and easy to

What is Laparascopic method ?

Currently, Laparoscopy is the most popular method of female sterilization in non-pregnant women. It is performed under General Anesthesia. The actual procedure is done in an operating room, either in a hospital or a surgical center. The surgery takes about half an hour.

1. In the Laparoscopy procedure, the abdomen is filled with carbon dioxide gas by introducing a needle so that the abdominal wall balloons away from the uterus and tubes.

2. The surgeon makes a small cut just below the navel and inserts a laparoscope, a small telescope-like instrument.

3. A second incision is made just above the pubic hairline to allow the entrance of another small instrument that can help with closure of the fallopian tubes.

4. Usually Falope/ Silastic rings or Filshie clips are placed on the fallopian tubes to block the tubes. Sometimes the tubes are cut and clipped

5. The skin incision is then closed with one stitch or a tape. The patient may feel well enough to go home from the outpatient surgery center in a few hours.

 

What is the best time to have a tubectomy done?

Tubectomy should be done best within a week after menstruation. Post partum sterilization is performed within 72 hrs of completion of a vaginal delivery.

Are there any precautions to be followed before a tubectomy?

Refrain from sexual intercourse for at least 4 days before tubectomy. If having sexual intercourse, use a condom.

Why are these precautions essential before undergoing Tubectomy surgery?

The sperms of semen are alive for 48-72 hours. If the women had sex about 2 days before operation, these sperms would be available in the Fallopian tubes and may fertilize the ova or egg. This fertilised ovum maybe implanted inside the uterus
and she may become pregnant even after tubectomy.

There is another aspect of presence of viable sperms in the Fallopian tubes. These sperms may remain trapped at the far end of the Fallopian tubes and fertilize an ovum, even after Tubectomy. This fertilized ovum will not be able to pass into the uterus and hence will impregnate the thin Fallopian Tube resulting in ectopic pregnancy. This is a dangerous condition because ectopic pregnancy may result in rupture of Fallopian tube, severe hemorrhage and sometimes even death if not detected early enough.

Will tubectomy protect against sexually transmitted diseases (STDs)?

It's important to know that sterilization won't protect you against sexually transmitted diseases
 

(STDs). Always use a condom during each sexual activity to prevent STDs.

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