OBGYN - Family Planning

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Contents

Contraception

Objectives

  • Review basic statistics concerning population growth and pregnancy rates
  • Review basic contraceptive options
  • Review sterilization options

World population growth

  • Population growth is logarithmic since around 1950.
  • The world is growing at about 1.8% each year.
  • Every minute, a woman dies of pregnancy / childbirth complications.
    • 99% of these deaths occur in developing countries.
    • 1 million children left motherless.
  • Maternal mortality rates vary from 1/7 (Niger) to 1/17.4k (Sweden).


  • Birth control is controversial for three reasons:
    • Personal issues
    • Religious issues
    • Political issues

Counseling

  • Counseling about contraception is important.
  • 10% of women don't use birth control.
  • 53% of unintended pregnancies result from these 10% of women (who aren't using birth control).
  • Abortions are highest in those less than 15yo.
    • Abortions decrease as the woman ages to 30-34.
    • Abortions increase again from 35 and up.


  • In 2002 there were 6.4 million pregnancies.
    • 51% were intended
    • 49% were unintended
      • 22% were unintended births
      • 20% were elective abortions
      • 7% were fetal losses


  • Of unintended pregnancies that proceed to live births,
    • 1/4 are "unwanted"
    • 3/4 are "mistimed"


  • Of unintended pregnancies that proceed to live births, about 40% of women were using contraceptives at the time of conception.


Abortion rates

  • The United States of America aborts 22.9 of each 1000 fetuses.
  • Australia: 22.2 / 1000

Birth Controls

  • There are two categories of birth control: contraception (prevent conception) and implant preventors.
  • Contraceptions include:
    • OCPs
    • Norplant
    • Depo-Provera
    • Condoms
    • Diaphragm
    • Foam
    • Rhythm
    • IUDs
  • Implant preventors include IUDs and morning after pills.


  • The most commonly used birth control is tubal ligation making up nearly 50% of contraception use in "non-developed" countries.

Barrier methods

  • Barrier methods include: spermacides, condoms, diaphragms / cervical caps, and sponges


  • Spermacides
    • The active ingredient of spermacides is nonoxynol 9 or actoxynol-3.
      • Nonoxynol and actoxynol disrupt the spermatic cell membrane.
    • The failure rate of spermacides is 15-35%.
    • Patient compliance is generally high.


  • Condoms
    • Male condom failure rate is 5-8% (slippage / breakage) or 5-15%
    • Female condom failure rate is 3% (slippage / breakage) or 5-15%
    • Mechanism of action is to physically block sperm.


  • Diaphragms
    • Mechanism of action is to physically block sperm from gaining access to upper reproductive tract (uterus and fallopian tube.
    • Diaphragms can also hold spermicide.
    • Device must be inserted 1 hour before intercourse.
    • Diaphragm must remain in place for 6-8 hours post-coitus.
    • Failure rate is 10-25%
    • Benefits include:
      • Some protection agains STDs
      • Effective immediately
      • Does not affect breast feeding
      • Does not interfere with intercourse (can be inserted up to 6 hours pre-coitus).
      • No health risks.
      • No systemic side effects.
    • Contraindications include:
      • Hx of toxic shock syndrome
      • Allergy to rubber
      • Allergy to spermicides
      • Repeat UTIs
      • Uterine prolapse
      • Vaginal stenosis
      • Genital anomalies
    • Patient compliance is difficult


  • The sponge
    • Mechanism: contains spermicide
    • Benefits: small, disposible, works for 24 hours (regardless of coitus count)
    • Reintroduced to market in 2009.
    • Failure rate: 26-40%


Hormonal contraceptives

  • Hormonal contraceptives come as oral pills, as injectables, and as an intravaginal ring or a supradermal patch.
  • Injectable contraceptives include: 
**Combined injectible contraceptives (CICs)
    • Depo-provera
    • Norplant
    • Implanon

Oral contraceptive pills

  • Failure rate is <1%
  • OCPs can be progesterone only or a combination of estrogen and progesterone (combined oral contraceptives; COCs).


  • Oral contraceptive pills are taken 21 days with 7 days of placebo or no pill.
  • Combined oral contraceptives come in three types depending on their phase:
    • Monophasic: all 21 pills, all of which have some amount of estrogen / progesterone (E/P)
    • Biphasic: 21 active pills, 2 different combinations of E/P
    • Triphasic: 21 active pills, 3 different combinations of E/P


OCP mechanism of action
  • Presence of progesterone decreases FSH and LH levels, including the LH surge.
  • Without the LH surge, ovulation does not occur.
  • Furthermore the endometrial lining is thinner which makes implantation less likely.
  • The cervical lining is thickened which prevents spermatic penetration to the upper reproductive tract.


OCP Benefits
  • Contraceptive benefits of OCP:
    • Highly effective (failure rate <1%)
    • Effective immediately if started by day 7 of menstrual cycle.
    • Pelvic examination not required to initiate use.
    • OCPs do not interfere with intercourse.
    • Few side effects.
    • Convenient and easy.
    • Client can stop use at any time.
    • Can be provided by trained medical staff.


  • Non-contraceptive benefits of OCP:
    • Decrease menstrual flow.
    • Decrease menstrual cramps.
    • Improve anemia (?).
    • Protect against ovarian and endometrial cancer.
    • Decrease bening breast disease and ovarian cysts.
    • Prevent ectopic pregnancy.
    • Protect against some causes of pelvic inflammatory disease.


OCP Effectiveness
  • Perfect use is what is tested but then there is actual or typical use.
    • OCP (combined versions) are 97% effective when taken perfectly.
    • OCP (combined versions) are 92% effective upon actual use.
  • 10 million women are taking OCP; therefore each 1% decrease in effectiveness yields 100k unintended pregnancies
    • 8% decrease simply from perfect use to typical use.


OCP Contraindications
  • Absolute contraindications include:
    • History of vascular disease: pulmonary embolism, deep vein thrombosis, coronary vascular atherosclerosis
    • Systemic disease: lupus, chronic hypertension, liver disease, hypercholesterolemia, migraine headaches with auras.
  • Relative contraindications include:
    • Tobacco use
    • >35 yo
    • Depression
    • Seizures without auras


Injectables

  • Mechanism of action:
    • Suppress ovulation
    • Thicken cervical mucosa
    • Thin endometrium


  • Types of injectable birth controls include:
    • CICs (like OCPs)
    • Depo-Provera
    • Norplant
    • Implantation


  • Failure rate for injectables:
    • CICs: 0.1-1%
    • Depo-Provera: 0.1-0.6%
    • Norplant / Implanton: 0.2-0.6%


  • Injectable limitations
    • Side effects include: nausea, dizziness, breast tenderness, headaches, spotting, light bleeding
    • Effectiveness lowered in combination with other drugs
    • Can delay return to fertility
    • Serious side effects are possible
    • Do not protect against STDs
    • Change the menstrual bleeding pattern
    • User-dependent; that is, the client must return every 30 days.


  • Injectable benefits:
    • Highly effective
    • Effective immediately
    • Pelvic examination not required before use (as with OCPs)
    • Do not interfere with intercourse
    • "Few side effects" (though more than OCPs)
    • Can be provided by trained medical staff
    • No supplies needed by the client

Contraceptive Ring

  • NuvaRing
  • 2 inches in diameter
  • 120mg etonogestrel, 15mg ethinyl estradiol
  • As effective as OCP
  • One ring / cycle
    • 3 weeks in the vagina, 1 week without
  • Not a barrier!

Contraceptive patch

  • Ortho Evra
  • 150 mg norelgestromin, 20mg ethinyl estradiol
  • As effective as OCPs
  • Better compliance (90%) than OCPs (77%)
  • Three patches / cycle, one each week for three weeks; 1 week without patch.

Intra-uterine Devices (IUD)

  • Failure rate of 0.2-3%


  • Mechanism of action can be contraceptive or abortive.
    • Interferes with sperm ability to travel through uterine cavity.
    • Thickens the cervical mucus.
    • Intereferes with reproductive process before ova can reach the uterine cavity.
    • Modifies the endometrial lining to decrease implantation.


  • IUD advantages:
    • Non-hormonal
    • Failure rate of only 0.2-3%
    • Effective immediately
    • Long-term (up to 10 years)
    • Does not interfere with intercourse
    • Immediate return to fertility upon removal
    • Does not affect breast feeding


  • IUD contraindications
    • Pregnancy (risk of ectopic pregnancy)
    • Unexplained vaginal bleeding
    • PID
    • Purulent discharge
    • Distorted uterine cavity
    • Malignment trophoblast disease
    • Pelvic TB
    • Genital tract cancer
    • GU tract infection


Sterilization

  • Sterilization is the most common method of birth control among married couples.
  • Sterilization is the most common method of birth control globally.
  • Only 1% regret sterilization.
  • Failure rate is 1-2% over 10 years


  • 10% of couples choosing sterilization choose vasectomy
    • Failure rate of vasectomy is 0.1%

Miscellaneous

  • Laction is a good birth control, too.
    • Lactation failure rate is 2% for the first 6th months.
    • Mechanism of action is disruption of GnRH release because of frequent, intense suckling at the nipple.
    • Disrupted GnRH means disrupted LH / FSH release which means no ovulation.
    • Limitations
      • Does not protect against STDs
      • No longer effective once menses begin again
      • Hard to maintain because of social aspects of breast feeding


  • NFP / Rhythm birth control
    • Requires that couples be highly motivated to maintain compliance.
    • Failure rate is 1-45%.
    • NFP can be monitored by several methods: calendar, basal body temperature (BBT), cervical mucus method (Billings), or symptothermal (BBT + Billings)


  • Withdrawal method birth control
    • One of the oldest methods.
    • Failure rate is 20-25%

Emergency Contraception

  • "Morning after" pill
    • Debates over whether it is a contraceptive or an abortifacent
  • IUD
    • Abortifacent

Morning After Pill

  • There are two medicinal methods for emergency birth control:
    • The Yuzpe method is 2 tablets of 0.25 mg loveonogestrol at 0 and 12 hours.
    • The Plan B method is 1 tablet of 0.75 mg levonorgestrel at 0 and 12 hours.
      • Plan B has less n / v
      • Plan B is more effective


Male alternatives

  • Traditional methods
    • Periodic Abstinence
      • High contraceptive efficacy if rules followed perfectly
      • Typical 1st year failure rate: 20%
      • Limited Acceptability: low reliability, inflexibility
    • Non-Vaginal Ejaculation
      • Historically the major pre-industrial method of family planning
      • Limited Reliability: requires skill and self-control
      • Typical 1st year failure rate: 20%
    • Vasectomy
      • Relative Contraindications: bleeding disorders, allergy to anesthestics, scrotal pathology
      • Excises a segment of vas deferens
      • Failure Rate: 0.1% - wait as long as three months
  • Condom


  • Modern methods
    • Vas Occlusion
      • "reversible vasectomy"
      • Lower efficacy than true vasectomy
    • Heating
      • Principle: brief elevations of testicular temperature suppresses spermatogenesis
      • Concept: tight scrotal support – remains to be clinically proven
    • Immunocontraception
      • Sperm Vaccination – men and women
    • Chemical (non-hormonal)
      • Target the rapidly proliferating germinal epithelium with drugs, heat, ionising radiation, thereby disrupting mitosis and/or meiosis


  • Hormonal
    • WHO Studies utilized weekly testosterone enanthate injections
      • Provides both gonadotropin suppression and androgen replacement
      • Contraceptive Failure Rate of about 8%
      • Adverse Affects: cardiovascular & prostatic diseases, mood changes
    • Other Studies looked at Androgen Combination regimens:
      • Non-androgens (estrogen, progestins) to suppress gonadotropins with testosterone
      • GnRH Blockades with testosterone add-back
      • FSH Blockades



Family Planning

Family Planning John W. Stutsman, MD Asst. Professor of Clinical OB/GYN Medical Director, Planned Parenthood of Indiana jostutsm@iupui.edu December 12, 2011


In the Beginning…. acm13 • Pubarche upper teens

• Breastfed 3-4 yrs

• 50% reached teens – Disease

– Starvation




… and Now… world-population-historical-small

7 Billion and counting! World-Population-1800-2100

Adolescent Pregnancy birthrategraph2 US CDC: Recent Trends in Teenage Pregnancy in the United States

Adolescent Pregnancy


preggraph Kmietowicz Z, BMJ 2002, June 8; 324 (7330):1354


Unintended Pregnancy in USA At risk 

# women 
Unintended preg 
Rate (per 1000)

+ contraception 

38,106,259 
1,488,800 
39

No contraception 

4,555,514 
1,612,000 
354

Outcome 

# women 
Avg $ 
Total $

Birth 

1,364,000 
2877 
3,924,228,000

Abortions 

1,302,000 
612 
796,824,000

Fetal loss 

434,000 
612 
265,608,000

Total 

3,100,000 
4,986,660,000

Trussell J, Contraception 2007; 75(3): 168-170

Reproductive Health Plan ? 

How important is it to you to avoid pregnancy now?

? 

What would you do if you became pregnant now?

? 

What is your desired family size?

? 

What is your intended timing for pregnancy?

? 

Are there health issues that you need to address before you become pregnant?


Essential Components of Contraceptive Counseling bcp 1.jpg

AutoShape 9_pptX AutoShape 10_pptX AutoShape 11_pptX AutoShape 12_pptX AutoShape 13_pptX Expert Clinical Advisory Committee for A Case-Based Approach to Addressing Hormonal Contraception. 2008.

Method 

Typical Use 
Perfect Use 
% using at 1 yr

No method 

85 
85

Spermicides 

29 
18 
42

Withdrawal 

27 
4 
43

Rhythm methods 

25 
5

Diaphragm 

16 
6 
57

Female condom 

21 
5 
49

Male condom 

15 
2 
53

OCP/POP 

8 
0.3 
68

Transdermal CHC 

8 
0.3 
68

CVR (CHC) 

8 
0.3 
68

DMPA 

3 
0.3 
56

Copper-T IUD 

0.8 
0.6 
78

LNG IUS 

0.2 
0.2 
80

ENG implant 

0.05 
0.05 
82

Female sterilization 

0.5 
0.5 
100

Male sterilization 

0.15 
0.10 
100

Cumulative Annual Failure Rates


5-Yr Costs Associated with Contraceptive Methods in the Managed Payment Model Macintosh HD:Users:crmyers:Desktop:stutsman:Fig. 13-1.tif

Barrier Methods

• Spermacides

• Condoms

• Diaphragm & Cervical Caps

• Sponges


chastity

Spermacides • Active Ingredient – Either Nonoxynol 9 or Actoxynol-3

– 15 mins before, up to one hour



• Failure Rate – 15 to 35%



• Patient Compliance – HIGH




36 Spermacide1 vcf2

The Sponge • Small, disposable; contains spermacide

• Once in place, can provide contraception for 24hrs no mater how often coitus occurs

• Today Sponge off US market in 1995 but reintroduced in May ‘09

• Other Brands available worldwide

• Failure Rate: 26-40%


sponges elaine01-black_dress

Condoms • Male Condom – Slippage/Breakage Rate: 5-8%

– Failure Rate: 5-15%

– 80% male US teens use condom w/1st act • CDC, Oct. 12, 2011




• Female Condom – Slippage/Breakage Rate: 3%

– Failure Rate: 5-15%




40 43 FCondom FCondom2 Copy of FCondom7 39

Diaphragms

• Mechanism of Action

• Failure Rate: 10-20%

• Benefits

• Precautions

• Patient Compliance: – Inserted 1 hr before

– Left in place for 6-8 hrs post-coitus




37 Diaphragm1 Diaphragm2 Diaphragm3 Diaphragm6

Hormonal Contraceptives • Oral Contraceptive Pills (OCPs) – Combined oral contraceptives (COCs)

– Progestin-only pills (POPs)



• Transdermal Patch (Ortho Evra)

• Contraceptive Vaginal Ring (NuvaRing)

• Injectable – Combined Injectable Contraceptives (CICs) • Off US market 2002, Cyclofem in other markets



– Depot medroxyprogesterone acetate (Depo-Provera)



• Implant – Norplant (not in USA) = levonorgestrel

– Implanon -> Nexplanon = etonogestrel




Mechanism of Action of Hormonal Contraception hpopic • Ovulation prevention

• Tenacious cervical mucous

• Decrease uterine and fallopian tube motility

• Decrease endometrial glycogen stores



Secondary Benefits of OCP • Effective contraception – Fewer ectopic pregnancies and abortions



• Regulate menses – Less flow/anemia, less dysmenorrhea

– Prolonged/continuous dosing




• Less salpingitis/PID w/ +GC/CT

• Less acne and hirsuitism

• Decrease benign breast disease

• Decrease risk of endometrial cancer

• Decrease risk of ovarian cancer



Contraindications to CHC • Pregnancy

• Smoking (>15/day) and age >35

• Prior DVT or high risk group – Prolonged immobility



• Uncontrolled/poorly controlled HTN

• Current breast or hepatic cancer

• Peripartum cardiomyopathy

• Migraine with aura

• Vascular disease – h/o MI or CVA




Intrauterine Device…Contraceptive…System • Two types in US – LNG IUS

– Copper T (380 A)



• Mechanism of action –

.



• Very effective – 0.2-0.8 failure rate annually = BTL





IUD


IUD6 IUD4

Emergency Contraception Options • EE and progestin – Up to 72 hrs postcoital



• Levonorgestrel – Up to 72 hrs postcoital



• Ulipristal acetate – Up to 120 hrs postcoital



• IUD – Up to 120 hrs postcoital






Emergency Contraception: Indications • Intercourse within past 72-120 hours without contraceptive protection (independent of time in the menstrual cycle)

• Contraceptive mishap – Barrier method dislodgment/breakage

– Expulsion of IUD

– Missed oral contraceptive pills



• Sexual assault

• Exposure to teratogens (eg, cytotoxic drug)


ACOG Practice Bulletin. Int J Gynecol Obstet. 2002;78:191-198.

Hormonal Emergency Contraception • Not new concept – 1920’s- Veterinarians used high doses of estrogen for dogs and horses

– 1960’s- DES and other estrogens prescribed for human postcoital use

– 1972- “Yuzpe method” • 100 mcg ethinyl estradiol

• 0.5 mg levonorgestrel





Plan B (levonorgestrel 0.75 mg)

EC Methods • Hormonal – Yuzepe – up to 72 hours postcoital • 100 mcg EE + 50 mcg LNG po q 12 hrs x 2



– Levonorgestrel – up to 72 hours postcoital • 0.75 mg q 12 hrs x 2, or 1.5 mg po x 1



– Ulipristal acetate – up to 120 hours postcoital • 30 mg po




• IUD (Copper T) – Place up to 120 hours postcoital




Proportion of Pregnancies Prevented by Levonorgestrel vs. Yupze, by Timing of Treatment


Task Force on Postovulatory Methods of Fertility Regulation. Lancet. 1998;352:428-433. Levonorgestrel Yuzpe Timing of Treatment (hours)



58% 31% 36% 85% 95% 77%

Emergency Contraception


Table 1. Efficacy of emergency contraception (UPA and LNG) in randomized controlled trials and meta-analyses according to time from unprotected intercourse to intake of emergency contraception. 

LNG: Levonorgestrel; RCT: Randomized controlled trial; UPA: Ulipristal acetate. Adapted from [12].

Trial type 

Odds ratio and 95% CIs  
p-value

RCT Creinin et al. 2006 n = 1546 

0.50 (0.18–1.24) 
0.135

RCT Glasier et al. 2010 n = 1899 

0.57 (0.29–1.09) 
0.091

Meta-analysis <24 h n = 1184 

0.35 (0.11–0.93) 
0.035

Meta-analysis <72 h n = 3242 

0.58 (0.33–0.99) 
0.046

Meta-analysis <120 h n = 3445 

0.55 (0.32–0.93) 
0.025


Permanent Birth Control Options • Vasectomy

• Tubal ligation

• Hysteroscopic Tubal Sterilization



Image 3


Image 2



Essure micro-insert in fallopian tube after 3 months



Essure Placement


Elective Abortions Year 

# Abortions 
/1000 births 
/1000 women

1974 

762,476 
272 
23.0

1990 

1,429,577 
345 
24.0

2006 

846,181 
236 
16.1

2007 

827,609 
231 
16.0

• 1961 – 300 abortion-related maternal deaths – 2006 = 6 abortion-related maternal deaths



• Abortion related maternal death rate = 0.72-1.0/100,000

• Maternal Mortality Rate = 15.1/100,000



Number of Abortions per 1,000 Women aged 15-44 in US


Medication Abortion Regimen 

Success (%) 
Gest age (days)

RU486 600mg M 400mcg po 

92 
49

RU486 200mg M 800mcg vag 

95-99 
63

MTX 50mg/m2 M 800mcg vag 

92-96 
49

M 800 vag (up to 3 doses) 

80-88 
56
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