Contraceptive education is a major component of good preventive health care, and should be included as a part of all health maintenance visits for women of reproductive age and all men.

The effective control of reproductivity is required so that a woman may reach her individualistic goals other than giving birth.

On the other hand, the vast increase of human population in this century is threatening human being.

The Effects of Excessive Birthgiving on Maternal Health For the mother: maternal death,

complications of pregnancy and delivery, gynecological diseases, malnutrition, anemia

For the child: infant death, low birth weight, malnutrition, infectious diseases, retardation of physical growth, congenital anomalies

Key pointsPregnancy before 18 years, after 35 years oldThe short interval between deliveries;<2

yearsMore than 4 deliveriesAll increase the complications of

pregnancy, delivery and post-pregnancy

FAMILY PLANNING• Is having the number of children one can look

after when couples or individuals really want it.

• It helps to prevent unwanted pregnancies, to plan ahead the interval between two pregnancies, to decide when and what number of children the family should have considering their age and socio-economic status and to help couples who are infertile to have babies.

BENEFITSPlanning the interval between two

pregnancies freely and consciouslyPreventing abortionsDecreasing maternal deathDecreasing the negative effects of rapid

population growing on economic development, nutrition,habitation, education and environmental factors.

HORMONAL CONTRACEPTIVES• Hormonal contraceptives are among the most

popular, reversible methods.• These methods include the combination oral

contraceptives (COCs, progestine only pills (POPs), transdermal contraceptive patch, vaginal contraceptive ring, injectable depot medroxyprogesterone acetate (DMPA), ethanogestrel implant, and the levonogestrel intrauterine system.

COMBINATION ORAL CONTRACEPTIVESKey Points: Very low dose pills have not been

shown to confer any added safety benefit, but they do have comparable efficacy and potentially decrease estrogenic side effects in women who have not tolerated higher dose COCs.

COMBINATION ORAL CONTRACEPTIVES• Higher dose COCs should be reserved for

patients currently taking medications that can interfere with the pills contraceptive effectiveness or for short term treatment of certain menstrual disorders.

• The risks and efficacy of the extended 91 day regimen are similar to those associated with the 28 day regimen.

COMBINATION ORAL CONTRACEPTIVESCOCs can decrease menstrual cramping and

blood flow, eliminate ovulatory pain (mittelschmerz), supress symptomatic endometriosis, and alter menses.

COCs can reduce vasomotor symptoms in perimenopausal women.

COCs can decrease acne and hirsutism.

COMBINATION ORAL CONTRACEPTIVESThe incidence of VTE increases slightly with

COC use, but it is significantly less than the risk of VTE in pregnancy.

If breakthrough bleeding persists after 3 months of COC use, the patient should take a different COC formulation.

COMBINATION ORAL CONTRACEPTIVES• COCs should not be used in women with focal

(asymmetric) neurologic auras, and they should be discontinued in women who have progressive headaches while taking them.

• COCs should not be prescribed for women who have uncontrolled hypertension or smokers older than 35 years.

PROGESTIN ONLY PILLS• Key Points: POPs are associated with fever

serious complications than COCs.• POPs are less effective, cause more

breakthrough bleeding, and confer fewer non-contraceptive health benefits than COCs.

• POPs are preferable to COCs for lactating women.

• POPs may be used in women who have contraindications to estrogens or are intolerant to estrogenic side-effects

Transdermal Contraceptive Patch• The patch is as effective as combination oral

contraceptives (COCs) and has similar side effects, risks, and benefits with the exception of effect unique to a transdermal system.

• The contraceptive patch is associated with fewer contaceptive failures than contraceptive pills because of better compliance.

Transdermal Contraceptive Patch• The patch is a good choice for women who

have troubles remembering to take pills daily.• The patch may be less effetive in women

weighing more than 90 kg.• Users may have breath symptoms, vaginal

spotting, and dismenorrhea in the first 2 months of use.

• Local skin irritation is the second most common side effect exprienced by patch users and often lead to discontinuing the patch.

Vaginal Contraceptive RingThe NuvaRing is a soft, flexible ring made

of ethylene vinyl acetate that delivers 15 µg of ethinyl estradiol and 120 µg of etonogestrel in a controlled- release fashion.

The woman inserts the vaginal ring and typically leaves it in place for 3 weeks, then removes it to allow a withdrawal bleed.

Vaginal Contraceptive Ring• Advantages of the vaginal ring includes a

simple dosing schedule and a lower incidence of breaktrough bleeding and nausea compared to COCs.

• The risks of the vaginal ring are theoretically the same as those for COCs,although no serious events were reported in a 1 year multicenter study.

• Although device related events rarely occur, they were the most common cause of discontinuation in clinical trials.

Injectable Depot Medroxyprogesterone Acetate• By 6 months of use of injectable depot

medroxyprogesterone acetate(DMPA), most women have decreased mensturual flow or no menses, decreased menstrual cramps, and less anemia.

• DMPA decreases pain in women with endometriosis and decreases the risk of cicle-cell crisis in womwn with cicle- cell disease.

• WHO suggest that there should be no restriction on the ration of use of DMPA among women 18-45 years old.

Injectable Depot Medroxyprogesterone Acetate• The manufacturer suggest that because of

potential loss of bone density, DMPA should not be used longer than 2 years unless other birth control methods are inadequate.

• Irrerular bleeding is especially common during the first 6 months of DMPA use.

• Patients who discontinued DMPA can have a long return to fertility.

Etonogestrel Implant• Implanon is inserted subdermally in the inner

upper arm.• Implanon is effective within 24 hours of

insertion and provides up to 3 years of highly reliable contraception.

• Implanon can be removed at any time, providing a rapid return to fertility after removal.

• Implanon requires significantly less time and effort for insertion and removal than norplant, reducing the risk of related complications.

Levonorgestrel-Releasing Intrauterine System• The approved life span of the levonorgestrel-

releasing intrauterine system (LNG-IUS) is 5 years, although the protection with the system in place may last at least 7 years.

• LNG-IUS can help treat heavy menses and prevent the risk of anemia.

• Irregular bleeding or spotting is a common, self-limited side effect of the LNG-IUS within the first several months of use.

Male CondomsPolyurethane condoms are thinner and

stronger than latex condoms, less likely to degrade when exposed to oil-based products, and offer wearers icreased sensivity.

Polyurethan condoms cost more and may actually be more likely to slip and break during intercourse than latex condoms.

Male Condoms• Latex and polyurethan condoms offer

significant protection against bacterial and viral sexually transmitted infections; natural mebrane condoms do not.

• Frequent exposure to nonoxynol 9 spermicide can cause genital irritation without adding significant benefit in protection against unpalanned pregnancy or prevention of sexually transmitted infections.

Male CondomsNon latex condoms are associated with a

higher rate of breakage compared to latex condoms. However, non latex condoms still provide an acceptable contaceptive alternative for people with allergy, sensivity,or preferances that prevent the use of latex condoms. Level of evidence A.

Female CondomsThe female condoms can be inserted up to 8

hours before intercourse.It can be used safely by patients with

sensitivity or allergy to latex.

DIAPHRAGM• The diaphragm is a dome-shaped, latex

rubber cap with a flexible ring that is filled with contraceptive jelly or cream and inserted into the vagina so that it is placed over the cervix.

• The diaphragm is a barrier device that prevents sperm from entering the cervix.

• The use of spermicide with the diaphragm might not increase contraceptive efficacy.

DIAPHRAGM• The diaphragm works best for women with

normal shaped cervices and normal pelvic musculature; diaphragm fitting requires a clinic visit.

• Women should insert the diaphragm immediately before or up to 6 hours before intercourse and should leave it in place at least 6 hours after intercourse.

• Advantages are low cost, safety, and possible protection from PID and fertility.

• Disadvantages include possible vaginitis, yeast infections, and increased risk of UTIs.

CERVICAL CAP• The Prentif cervical cap is no longer produced in

the United States.• Two other FDA-approved barrier contraceptives,

are available by prescription only, the FemCap and Lea’s Shield.

• The FemCap is made of silicone rubber and comes in one size.

• Lea’s Shield and the FemCap are safe alternatives for women with medical contraindications to hormonal contraception.

• The FemCap has a higher pregnancy failure rate but a lower rate of urinary tract infections than the diaphragm.

SPERMICIDES• The active ingredient in spermicides in

nonoxynol 9, which disrupts the cell membrane of sperm.

• Spermicides are sold over the counter in the United States and are available in several delivery systems.

• The spermicide-containing sponge (Today Sponge) is available over the counter, is inserted by the patient, and is left in the vagina for at least 6 hours after intercourse.

SPERMICIDES• The sponge is effective immediately and up to

24 hours after insertion; it should not be left in the vagina for more than 30 hours after intercourse.

• Studies of nonoxynol 9 and its effect on STI and HIV transmission have yielded conflicting results.

• WHO and CDCP have recommended against the use of spermicides with nonoxynol 9 alone for the sole purpose of preventing sexually transmitted infections.

FERTILITY AWARENESS-BASED METHODS• Fertility awareness-based methods rely on

identifying potentially fertile days; couples must abstain from intercourse or use barrier contraception on fertile days to prevent pregnancy.

• Fertility awareness methods can be used to aid couples who are trying to conceive. They can also be used to detect fertility problems.

FERTILITY AWARENESS-BASED METHODSThese methods are not recommended for

women with menstrual irregularities, persistent reproductive tract infections, or other medical conditions that can affect the signs of fertility.

THE LACTATIONAL AMENORRHEA METHOD• The lactational amenorrhea method (LAM) is

nearly 98% effective as a contraceptive method for women who exclusively or almost exclusively breast-feed and who have not experienced their first post-partum menses for the first 6 months after birth.

• Exclusive and almost exclusive breast-feeding means the baby receives no or only small amounts of liquids infrequently in addition to breast milk.

THE LACTATIONAL AMENORRHEA METHOD• Successful use of LAM as a contraceptive

method is highly dependent upon consistent suckling stimulation at the breast.

• LAM provides health benefits for the infant and the mother, as well as promoting bonding between the mother and infant.

• LAM is a less reliable method of contraception after 6 months post-partum or if supplemental feedings have been introduced, and women should be encouraged to seek an additional method of pregnancy prevention at this time.

COITUS INTERRUPTUS ( WITHDRAWAL)• Coitus interruptus involves withdrawing the

penis from the vagina before ejaculation.• Coitus interruptus requires a high-degree of

motivation, commitment, and self-control during the time of intercourse when both partners may be highly excited, making it prone to incorrect or inconsistent use.

• The effectiveness of this method, even with perfect use, is uncertain.

STERILIZATION• Essure is a coil device with polyethylene fibers that

is placed into the proximal fallopian tubes and results in a fibrotic tissue growth reaction, effectively causing occlusion of the tubes.

• Vasectomy is a male sterilization procedure during which the vas deferens is resected, clipped, or occluded to prevent sperm from moving from the testes into the seminal fluid.

• No-scalpel vasectomy is faster and less invasive than traditional vasectomy, requires few instruments, and can be performed easily in the outpatient setting.

Emergency Contraception • Emergency contraception is any method of

pregnancy prevention used after an act of inadequately protected intercourse.

• Widespread use of emergency contraception could greatly reduce the rate of unintended pregnancy.

• Methods of emergency contraception inclue the Yuzpe method (combined hormonal), a progestin-only regimen, or placement of a copper-T intrauterine device.

Emergency Contraception • Emergency contraception is not an

abortifacient because it does not act to disrupt an established pregnancy.

• A progestin-only regimen has a lower incidence of side effects, is more effective, and easier to use than the combined hormonal regimen.

• Recent evidence indicates that the progestin-only regimen can be given as a single dose of 1.5 mg levonogestrel up to 120 hours after an inadequately protected intercourse with good efficacy.

Emergency Contraception If a combined hormonal regimen is used for

emergency contraception, an antiemetic medication should be taken an hour before the first dose of combined hormonal pills.

• Physcian who wish to increase the availability and use of emergency contraception can offer advanced discription for it.(Level of evidence:A).

Abstinance• The definition of abstinance can vary from

forgoing all sexual behavior to refraining only from vaginal or anal intercourse. Abstinance can also be primary or secondary.

• Patient who choose to abstain often need support and encouragement.

• Patient who choose abstinance should also be encouraged to practice negotiating and planning skills before entering into an intimate relationship.

THANK YOU FOR YOUR ATTENTION