Family planning Clinic of Reproduction and Gynecology PAM

Methods of family planning Periodic abstinence Barrier contraceptives Oral contraceptives Progestin injections Subdermal implants Emergency contraception Intrauterine device (IUD) Sterilization Induced abortion

Physiological infertility “Shortly” after menarche (first menstrual bleeding) After newborn delivery and during breastfeeding “Shortly” before menopause The highest chance to become pregnant – sex 1 or 2 days before ovulation (28% - 30%) Fecundability 20% per cycle

Factors affecting negative effect of breastfeeding on fertility Time lapsed from delivery Duration and frequency of breastfeeding Nutrition Social and cultural determinants To sum up – breastfeeding does not protect against unwanted pregnancy

Efficacy (Pearl index) IUD 0,1 (0 –1) OC0,2 (0 –3) Progestin injection0,1 (0 –1) Morning after pill3 (2 – 5) Condom 4 (1 – 7) Periodic abstinence10 (3 – 15)

Action of oral contraceptives Inhibition of GnRH release Inhibition of ovulation Changes in the fallopian tubes – motility, epithelial structure, oviductal fluid – impaired transport of sperm, oocytes and embryos Changes in the endometrium – endometrium becomes thin – impaired implantation Changes in the cervix – mucous becomes thick – sperm hardly penetrates OC

Benefits of OC Lower incidence of ovarian cysts Lower incidence of ovarian malignancies Lower incidence of endometrial malignancies Lower incidence of anemia Lower incidence of endometriosis, osteoporosis and RA Lower incidence of ectopic pregnancies Lower incidence of PID

OC as a treatment modality Dysfunctional uterine bleeding Irregular cycles, hypermenorrhoe PMS Ovarian hyperandrogenism Acne Hirsutism

Minor adverse effects of OC Breakthrough bleeding Amenorrhea and oligomenorrhea Nausea and vomiting Breast tenderness Mood disorders Weight gain (fluid retention) Altered sexual drive

Major adverse effects of OC Impaired thyroid function Deep vein thrombosis and thromboembolism Hypertension Altered glucose metabolism Cholelithiasis (?) breast malignancies (?)

Contraindications to OC ABSOLUTE Smoking after 35yr Acute liver disease Uncontrolled hypertension DM with vascular changes History of thromboembolic event Pregnancy Undiagnosed vaginal bleeding Estrogen-dependent malignancy RELATIVE Depression Migraine headache Smoking before 35yr More than 35 yr Varicose veins Planned surgery

STOP OC immediately in case of: Calf pain Chest pain Migraine Cholelithiasis Prolonged immobilization (e.g. bone fractures)

Drug interaactions of OC anticonvulsants antibiotics penicillin tetracyclin cephalosporin sulfonamides

Emergency contraception Up to 1 h LNG 0,75 mg (1 tabl.) orally (Postinor) Up to 72 h LNG 0,25 mg + EE 0,5 mg „2x2x2” orally (Gravistat 250, Stediril 50) IUD

OC (two components) synthetic estrogen and progestin) Monophasic Gravistat50μg EE + 0,25 mg levonorgestrel Cilest 35μg EE + 0,25 mg norgestimate Marvelon30μg EE + 0,15 mg desogestrel Minisiston30μg EE + 0,125 mg levonorgestrel Femoden30μg EE + 0,075 mg gestoden Logest20μg EE + 0,075 mg gestoden Mercilon20μg EE + 0,150 mg desogestrel Diane-3535μg EE + 2 mg cyproterone acetate

OC (two components) synthetic estrogen and progestin) Sequential Biphasic Anteovin50μg EE + 11 tabl. 0,05 mg LNG 50μg EE + 10 tabl. 0,125 mg LNG Triphasic Triquilar, Tri- Regol, Trisiston 30μg EE + 6 tabl. 0,05 mg LNG 40μg EE + 5 tabl. 0,075 mg LNG 30μg EE + 10 tabl. 0,05 mg LNG

Long-acting formulations Progestin injections (MP 0,15 i.m. q 3mo) Subdermal implants IUD + progestin (LNG)

Barrier methods For males: Condom For women: Diaphragm Cervical cap Vagninal foam, cream, suppositories (contain nonoxynol-9 – kills and immobilizes sperm)

Condom PROTECTION against STDs (AIDS included) Easy to use Cheap Almost no side-effects (minor local allergic reactions to latex) Prevention malignancies of the cervix

Disadvantages of condoms Impaired sexual satisfaction Allergy Not comfortable in use

Physiological bases for periodic abstinence The first probable day of expected ovulation 14 – 2 = 12 day The last possible day of expected ovulation = 16 day Sperm survival (48 h) 12 – 2 = 10 day Oocyte capability of being fertilized (24 h) = 17 day Fertile span of time day of the cycle The “tuned” method is called SYMPTOTHERMAL (+ BBT, cervical mucous)

IUD Benefits Does not affect the natural cycle Effective Makes women being controlled regularly Adverse effects Bleeding and pain PID Perforation of uterus Expulsion

Contraindications to IUD PID Pregnancy Vaginal bleeding of unknown origin Planned pregnacy

IUD candidate 34 yo and over Smoker 2 children and no further reproductive plans

OC candidate Less then 30 yo No children Single sexual partner Planes to become pregnant in the future Dysfunctional uterine bleeding

Condom and spermicide candidate Less then 20 yo No children Irregular sexual activity

Progestin injections Breastfeeding Plans further pregnancies