Family Planning

It is a basic human right.It is need of the hour not only at personal level but as a mankind to limit our family size for our future generation to enjoy the life. Research shows that adequate focusing to family planning in countries like India can not only reduce poverty and hunger but also avert 32% of maternal and approximately 10% of childhood death respectively. Investment in family planning is the most intelligent step India can take to overall socio-economic fabric of the society and reap high returns on investment and drive the country’s growth.

CONTRACEPTION:-

The term contraception means the process to avoid being pregnant due to the intercourse. It includes

1. Temporary and
2. Permanent.

1) TEMPORARY:-

These are used to delay pregnancy for birth spacing. Ideally there should be interval of 5 years between pregnancy. A minimum of 2 year is required by a female to replace the iron lost during delivery. Also a minimum of 2 years a baby should be breastfeed. It is also used by couples who have strong desire for no further child.

A) Barrier method:- This method prevents sperm penetration into the uterine cavity.

I) MECHANICAL

• Male -Condom.
  • Protests against sexually transmitted disease.
  • Suited for infrequent sex.

• Female :–
  1. Female condom ( Femidom )
     • Protects against sexually transmitted disease and Pelvic inflammatory disease.
     • Expensive
     • Multiple use can be done with washing, drying and lubricating.
  2. Diaphragm
  3. Cervical Cap

II) CHEMICAL :- These are spermicidal agents containing surfactants like nonoxynol-9, octoxynol, benzalkonium, menfegol and enzyme inhibiting agents available as cream, jelly and Foam tablets.

B) NATURAL CONTRACEPTION:-

I) Calender /Rhythm method:- The basis behind this is to avoid intercourse around ovulation.The safe period is calculated from the first day of menstrual period until the 10th day of cycles and from 18th to 28th day .To remember “NO SEX FROM NINE TO NINETEEN “ of menstrual period.

II) Withdrawal ( coitus interruptus ):- It requires withdrawal of penis shortly before ejaculation

• Requires enough self control by male partner.
• Chances of failure is more. Precoital prostatic secretion may contain sperm and 1 sperm is enough to change the future!!!
• Accidental chance of sperm deposition into the vagina and considerable anxiety to both partner.

III) Breastfeeding/ Lactational amenorrhea:- When the mother is fully breastfeeding a birth control measure should be used in the 3rd postpartum month and with partial or no breastfeeding in 3rd postpartum week.

C) INTRAUTERINE CONTRACEPTIVE DEVICES (IUCD):-It is an effective , reversible and long term method of contraception. It has a nylon thread attach to its lower end which protrudes through the cervical canal into vagina, where it can be felt by the patient herself or the doctor.It is of three types:-

• Non medicated inert devices:- examples Lippes loop and Saf T-coil.
• Medicated (Bioactive) Copper carrying devices:- examples Copper T 200, Copper T 220, Copper T 380, Nova T ,etc. They are effective from 3 to 5 years. Approximately 50mcg of copper is eluted daily in the uterus. Copper T 380 A is effective for 10 years. Nova T for 5 years.
• Hormone containing IUCD either releasing
  1. Progestasert and
  2. Levonorgesterol. They are effective for 5 years. They can be safely recommended for nursing mothers.

TIME OF INSERTION:- It is preferable to withhold insertion for 6 weeks postpartum till the uterus involutes to pre-pregnancy size. It is recommended to insert 2-3 days after menstrual period is over. During lactation amenorrhea, it can be inserted immediately following termination of pregnancy by suction, evacuation or D & E or following spontaneous abortion. It is Out Patient Department ( OPD ) procedure and can be done even by a trained paramedics without anaesthesia.

D) STEROIDAL CONTRACEPTIONS:-

1) COMBINED ORAL CONTRACEPTIVES (COC PILLS):- The combined oral steroidal contraceptives are the most effective temporary method of contraception. In the COC pills the combination commonly used Progestins are either Levonorgestrel or norethisterone or desogestrel. Estrogens are principally ethinyl esterodiol or mestranol. Presently “Lipid friendly” third generation Progestins namely desogestrel, gestodene and norgestimate are available in market.

HOW TO USE :-New users should start their pill pack on day 1 of their cycle. One tablet is taken daily preferably at bed time for consecutive 21 days. During the first cycle of use, patient should use an additional method to prevent chance of being pregnant. After 21 days of continuous use , 7 day break. Start new pack irrespective of bleeding the next week same day. Thus, a simple regime of “3 week on and 1 week off” should be religiously followed. For pack of 28 tablets there should be no break between packs. 7 of the pills are either iron or vitamin preparation. If she forgets to take a tablet from “ 21 tablets”, she should take 2 tablets the following day. If she forgets to take the tablets more than once in a cycle she is no longer adequately protected and must use a barrier method during that cycle.

The pill should be started on the day after abortion. Following the child birth in non-lactating women it should be started after 3 weeks and in lactating women it is to be withheld for 6 months.

The pills are contradicted in many medical situations :-

• Circulatory disease (Past or present)
• Thromboembolic disorder (current or past)
• Smoker over 35 years, diabetes
• Migraine
• Women having liver diseases
• Thyroid disease
• Lactating women
• Monilial vaginitis

Also many drugs interfere with the absorption of COC pills and they are not without side effects. Hence consultation with Gynaecologist is must before starting the combined oral contraceptives and informing doctors about taking COC pills is must before getting any medication prescribed.

2) PROGESTIN ONLY CONTRACEPTION (POP/MINI PILL):-

In this there is no estrogen compound and contains low dose of Progestin in any one of the formulation:-

• Norethisterone 350mcg
• Desogestrel 75mcg
• Lynestrenol 500mcg
• Norgestrel 30 mcg

It has to be taken daily without a break, at the same time with a margin of 3 hours on both side of the fixed time. Delay in intake for more than 3 hours the woman should take missed pill immediately and the next one as scheduled but take extra measures for 2 days. Strict daily compliance is the main drawback.

POPs is started 21 days postpartum even by lactating mother and soon after abortion .The woman needs to take precaution in the first 2 days in the first cycle.

With advantages, it does have some drawbacks and contraindications, hence start after consulting gynaecologist.

3) INJECTABLE PROGESTINS:- To overcome the strict daily compliance, depot injection of Progestogens have been prepared.The formulation available are Depot Medroxyprogesterone Acetate (DMPA) and Nor ethisteroneenanthate (NET-EN).The injection is given deep intramuscular.

• DMPA 150mg is given every 3 months.
• DMPA 300mg every 6 months
• NET-EN 200mg given at 2 monthly interval

The injection is started with in a month in a non-lactating and during 3rd month in lactating mother. Consult your Gynaecologist before starting it as it has its own benefits , side effects and contraindications.

4) IMPLANTS:-Implants containing various amount of progestogen incorporated into silastic capsules are inserted subdermally between biceps and triceps muscle 6-8 cm above the elbow in the inner aspect of the non-dominant hand.They are of following types

1. orplant I :- It contains 6 capsules containing Levonorgestrel last for 5 years.
2. Norplant II:-It contains 2 capsules containing Levonorgestrel provides contraception for 3 to 5 years.
   The implants are inserted on 1st day of menstrual cycle, within 5 days of abortion and 3 weeks after delivery.One should use barrier method in first 7 days of insertion.It is 5-10 minutes procedure done under local anaesthesia.It is removed at the end of its use or earlier if side effects are more by making incision.
3. CAPRONOR:-They are biodegradable single capsule containing Levonorgestrel.It works for 1 year and requires no removal.
4. SILASTIC VAGINAL RINGS:-As the very name suggests the silastic rings are impregnated with Progestogen and self inserted into vagina.Kept in situ for 3 weeks and removed for a week around menstrual cycle. Some newer one are left for 3 months at a stretch.

5) SKIN PATCHES:-These are hormonal patches applied over buttocks, abdomen but not on breast.They elutes 150 mcg of Norelgestromin and 20 mcg of EE2 daily and the hormone last for 7 days.Three patches are used for consecutively for 21 days with 1 week patch free interval.

6) CENTCHROMAN:- Developed by Central Drug Research Institute, Lucknow under the name “Saheli”. It is 30 mg tablet started on the first day of menses and taken twice weekly for 12 weeks and weekly thereafter.

7) POSTCOITAL CONTRACEPTION:-Also known as “Emergency Contraception “needed to prevent pregnancy after unprotected intercourse, condom rupture, missed pill ,delay in taking Progestin only Pills ( POPs ) for more than 3 hours, sexual assault or rape.
The following are the preparation available :-

• Two tablets of high doses of combined containing 100mcg ethinyloestradiol and 1 mg norethisterone or 500mcg Levonorgestrel taken within 72 hours of intercourse followed by 2 tablets taken 12 hours later.
• Ethinyloestradiol 2.5 mg twice daily for 5 days starting within 72 hours of intercourse.
• Levonorgestrel ( LNG ) 0.75mg 1 tablet within 72 hours of unprotected intercourse and another 12 hours later or 2 tablets as a single dose.
• Mifepristone:-A single dose of 100 mg to be taken within 17 days of intercourse.
• Centchroman:-Two tablets 30 mg each total 60mg taken twice in 24 hour within 24 hours of intercourse can prevent pregnancy.
• Copper T (IUCD):-Inserted within 5 days of sex.

All preparations and methods have pregnancy rate within 0-2%.

2) PERMANENT METHOD:- Sterilization is a surgical permanent method done with the purpose with the purpose of preventing future pregnancy permanently, suited for those couples who have completed their family size.The process can be done in both male and female.

1. Male sterilisation ( Vasectomy ):-It involves dissecting the vas deferens and disrupting the sperm passage.The sperms are stored in the reproductive tract for upto 3 months till then alternative contraception should be used.It is better than female sterilization.
2. Female sterilization (Tubal Ligation):-It is the process of occlusion of the Fallopian tubes.
   Timing of operation:-
   • Postpartum sterilization can be done within the first week when the mother is already in the hospital setup.
   • Interval sterilization can be done any time after 6 week of delivery or anytime when women is not pregnant.
   • It can be combined with Caesarean section and Medical Termination of Pregnancy ( MTP)