Family Planning

Clifford dela CruzHarmony QuePaula Valera

INTRAUTERINE DEVICES

Main benefits• High levels of

effectiveness• Lack of systemic side

effects• Single act for long term

use • Does not require frequent

use

Failure Rates

• Copper T 380A IUD and levonorgestrel IUD– Less than one 1%

• Clinician dependent– Correct insertion– Lower incidence of expulsion– Lower pregnancy rates

• Cumulative pregnancy rate– Copper T 380A IUD- 1.7% (12 years)– LNG-UIS -1.1% (5 years)

Major adverse events

• Pregnancy• Expulsion • Removal for bleeding or pain

• More suited for older parous women who wish to prevent pregnancies

Types of IUDS

• 1960s- plastic polyethylene with barium sulfate

• 1970s- smaller devices• 1980s- Copper IUDs were made (T380A,

T220C, Multiload CU250, CU375)

• Copper 380A is approved- 12 years effectiveness

• T Shaped devises– Levonorgestrel

Intrauterine System (LNG IUS) • 20 mg of LNG is released

onto the endometrial cavity• Thickens cervical mucus

Mechanism of Action

• Spermicide– Inflammatory reaction,

1000% increase of leukocytes– Phagocytosis of the sperm,

impedes cell transport and viability

– Hence prevents fertilization– Inflammation disappears

upon removal

Time of Insertion

• Any day of the cycle• Much preferred after the cycle to avoid

bacterial growth

Adverse Effects

• Uterine bleeding– Copper T 380A causes 55% increase of menstrual

blood loss• Perforation of uterine fundus

Complications related to Pregnancy

• No evidence of congenital anomalies• Increase of fetal death not increased• No conclusive evidence that IUDs cause sepsis

during pregnancy• Ectopic pregnancy is increased to threefold if

woman becomes pregnant with IUD in place• Increased risk of prematurity with pregnant

women with IUD in place

Contraindications

• Pregnancy or suspicion of pregnancy• PID• Postpartum endometritis• Infected abortion• Known/suspected uterine or cervical malignancy• Genital bleeding• Untreated acute cervicitis• Previously inserted unremoved IUD

Overall Safety

• Not associated with endometrial or cervical carcinoma

• May be associated with reduction in risk of these neoplasms

STERILIZATION

Popular choice

• If the wife is older than 30• Couple has been married more than 10 years• Couple does not desire to have more children

Male Sterilization

• Vasectomy – Procedure

• Vas deferens is isolated and cut

• Ends of the vas are closed either by ligation and fulguration

– Complications• Hematoma• Sperm granulomas• Spontaneous

reanastomosis

Female Sterilization

• Tubal ligation– Pomeroy– Modified Irving

INDUCED ABORTION

• Still not legal in the Philippines• Done in selected states in the US and in some

countries in Europe

• Three principal methods– Transcervical evacuation– Induction of labor– Major operations

• Curettage methods– Vacuum aspiration – more common in the first

trimester• Endometrial aspiration• Dilatation of cervix

– Dilatation and evacuation- more common beyond first trimester• Greater amount of cervical dilatation

• Induction of Uterine Contractions– More common in 2nd trimester abortions– Methods• Infusion of hypertonic solution in amniotic cavity• Administration of prostaglandin E2 (misoprostol)

• Major Operations– Hysterotomy and hysterectomy

Pharmacologic Agents

• Progesterone antagonists– Examples

• Mifepristone– Mechanism of action

• High receptor affinity prevents progesterone from binding to its receptors

• Inhibits the action of circulating progesterone

• Endometrial decidua degeneration, cervical softening, promoting contractions

• Prostaglandin analogues– Misoprostol– Binds to myometrial cells to cause

contractions leading to expulsion of tissues

– Also causes cervical ripening and dilatation of cervix

• Antimetabolite– Methotrexate– Blocks dihydrofolate

reductase (enzyme for DNA synthesis), inhibiting growth of rapidly dividing cells

– Must be followed by a uterotonic to increase uterine contractions and expulsion of products of conception

Complications

• Infection• Heavy uterine bleeding• Uterine perforation• Mortality < 1/100,000• Slight complications: <6 weeks or less• Beyond 10 weeks: complications increase

progressively with gestational age