THE FAMILY PLANNING METHODS

 Natural Family Planning : LAM and

Fertility Awareness-Based Method

- Involves no introduction of chemical or foreign material into the body or sustaining from sexual
intercourse during a fertile period (days on which the woman has the most likely chance to become
pregnant).
- WHO, refers to methods for planning or avoiding pregnancies to observation of the natural signs and
symptoms of the fertile and infertile phase of the menstrual cycle.
- The type of contraception “exclusively” endorsed by Catholic church.
- Disadvantage: any of the natural family planning method doesn’t prevent sexually transmitted
infections and HIV from acquiring.

- Natural methods are not the contraceptive method of choice for adolescents as they require a
great deal of thought and persistence.
 Modern NFP includes fertility awareness-based (FAB) methods and lactational amenorrhea
method (LAM)
 Withdrawal and calendar/rhythm method are traditional methods – no longer recommended
as these practices have been found ineffective and not evidence based.
 Traditional Methods: Abstinence - refraining from sexual intercourse.
The single most effective way of preventing pregnancy and STD.
Those who chose abstinence should consider having a backup method of contraception readily
available.

 Calendar (Rhythm) Method - requires a couple to abstain from coitus (sexual intercourse) on
the days of menstrual cycle when the woman is most likely to conceive (3 or 4 days before until
3 or 4 days after ovulation).
To plan for this, the woman keeps a diary for six menstrual cycles.
To calculate “safe” days, she subtracts 18 from the shortest cycle documented (this
represents the first fertile day), and she subtracts 11 from her longest cycle (this represents
the last fertile day).
 Ex: if she had six menstrual cycles ranging from 25 to 29 days, her fertile period would
be from 7th day (25 minus 18) to the 18th day (29 minus 11). A woman needs to avoid
coitus during these days.
Not reliable during: postpartum period, lactation, near menopause.
 Coitus Interruptus (Withdrawal) = involves premature withdrawal of penis from the vagina
before ejaculation.
Probably the oldest type of birth control practiced.
Reliability is low, because sperm are emitted or present in preejaculation fluid.
 Basal Body Temperature - relies on slight changes in basal body temperature (woman’s body
temperature at rest).
Just before the day of ovulation, a woman BBT falls about 0.5OF, and the time of ovulation,
her BBT rises a full degree (0.4 to 0.8OF) because of the influence of progesterone.
To use this method, the woman should take her temperature each morning immediately
after waking before she undertakes any activity.
She refrains from sexual intercourse for the next 3 days as soon as she notices a slight dip in
temperature. Followed by an increase.
 Because sperm can survive for at least 4 days in the female reproductive tract, it is usually
recommended that the couple combine this method with a calendar method, so that they
abstain for a few days before ovulation as well.
Not reliable during: infection, intake of antipyretics, immunizations, alcohol ingestion,
emotional upset, and sleeplessness.
 Cervical Mucus Method
(“Ovulation Method”, or “Billing’s Method”)
Use to predict ovulation by using the changes in cervical mucus that normally occur with
ovulation.
Before ovulation, the cervical mucus is thick and does not stretch when pulled between the
thumb and finger.
 Cervical Mucus Method
During ovulation, cervical mucus becomes copious, thin, watery, and transparent. It feels
slippery and stretches at least 1 inch before the strands breaks, a property known as
spinnbarkeit. The woman should abstain from coitus during this time.
Most useful for women who do not ovulate regularly (ex: women approaching menopause and
breastfeeding women).
BOM requires that the woman observe and record the following phases of menstrual cycle:
Basic infertile pattern (BIP)– observed after menstruation, the woman feels dry around the
genital area and does not have vaginal discharge or she may have unchanging pattern
Changing pattern of fertility – vaginal discharge becomes thinner and clearer and there is a
sensation of being wet and slippery, feeling of fullness or swelling of the tissues of the vulva
Peak of fertility – the last of the slippery sensation
Postovulatory infertile phase – lasts for about 14 days; the woman may feel dry again or may
have some discharge but there is no slippery sensation
 Symptothermal Method - identifies fertile periods by a combination of signs and symptoms.
The woman takes her temperature daily, analyzes her cervical mucus every day and observes
for other signs of ovulation such as mittelschmertz (midcycle abdominal pain).
 Standard Days Method
Standard days method (SDM) – is appropriate for the couple where the woman’s menstrual
cycle lasts for 26 to 32 days. This method requires tracking of menstrual cycle. The 1st day of
menstruation is counted as day 1. Days 8 through 19 are noted as fertile days when the
couple abstain from intercourse if they want to avoid pregnancy. A necklace, called SDM
beads is used as a memory aid by the woman, has a movable rubber marker to facilitate
tracking the menstrual cycle.
 Lactation Amenorrhea Method - exclusive breastfeeding for 3 -6 months naturally suppresses
ovulation process. Not reliable after 3 months of breastfeeding, when the infant is receiving a
supplemental feeding or not sucking well.
Criteria for LAM: A woman is practicing LAM when the following conditions are met:
1. Fully or nearly fully breastfeeding
2. Amenorrhea
3. Infant is less than 6 months old
Advantages
a. Can be started immediately after delivery
b. Economical and easily available
c. Does not require prescription
d. No side effects or precautions for use
e. No commodities or supplies needed
 f. Fosters mother-child bonding
g. Serves as a bridge to using other methods
h. Consistent with religious and cultural practices
Disadvantages
a. Fully or nearly fully breastfeeding pattern may be difficult for some women to maintain
b. The duration of the method's effectiveness is limited to a brief six-month postpartum period
c. There is no protection against sexually transmitted infections, including HIV

 Barrier Methods - are forms of birth control that work by the placement of a chemical or other
barrier between the cervix and advancing sperm so that sperm cannot enter the uterus or
fallopian tubes and fertilize the ovum.
 Chemical Barriers
Spermicide is an agent that causes the death of spermatozoa before they can enter the
cervix. They also change the vaginal pH to a strong acid level, a condition not conducive for
sperm survival. The gels, creams, sponges, films, foams, and suppositories are inserted into
the vagina no more than 1 hour before coitus for the most effective results.
They should remain in place for 6 hours after intercourse to ensure sperm destruction.
Ex: cocoa butter and glycerin-based vaginal suppositories, nonoxynol-9 and octoxynol.
Contraindicated in women with acute cervicitis.
Disadvantage: associated with candidiasis (yeast vaginitis), and irritating to vagina and penis
during coitus. They do not protect against STDs.
 Mechanical Barriers - block the entrance of sperm into the cervix.
- Diaphragm = is a circular rubber disk that is placed over the cervix before intercourse.
Is prescribed and fitted initially by a physician, nurse practitioner, or nurse-midwife to ensure
a correct fit.
The diaphragm should be checked when:
a. The woman gains or losses weight more than 15 lbs
b. Pregnancy, miscarriage, elective termination of pregnancy
c. Cervical surgery
d. Should remain in place for at least 6 hours after intercourse.
e. Should be washed in mild soap and water, dried gently, and stored in its protective case.
f. Caution them not to accidentally tear the diaphragm with long or sharp fingernails.
Contraindications:
- History of toxic shock syndrome (TSS; staphylococcal infection introduced through the vagina)
- Allergy to rubber or spermicides
- History of recurrent UTIs
- Presence of acute cervicitis or a papillomavirus infection
- Prolapsed uterus, retroflexed, or anteflexed, cystocele, or rectocele
- Women over age 35 have a higher incidence of cystocele or rectocele than younger women so
diaphragms may not be the ideal contraceptive for them.
Cervical Caps - are made of soft rubber, are shaped like thimble with a thin rim, and fit snugly over
the uterine cervix.
The precautions for use are the same as for diaphragm use, except they can be kept in place longer.
Cervical caps, like diaphragm, must be fitted individually b y a health care provider.

Contraindicated in a woman who has:

- An abnormally short or long cervix
- A previous abnormal Pap smear
- A history of TSS
- An allergy to latex or spermicide
- A history of pelvic inflammatory disease, cervicitis, or papillomavirus infection
- A history of cervical cancer
- An undiagnosed vaginal bleeding
To prevent Toxic Shock Syndrome using a diaphragm, advise women to:
Wash their hands thoroughly with soap and water before insertion or removal.
Do not use a diaphragm during a menstrual period.
Do not leave a diaphragm in place longer than 24 hours.
Be aware of the symptoms of TSS, such as elevated temperature, diarrhea, vomiting, muscle aches,
and a sun-burn-like rash
If symptoms of TSS should occur, immediately remove the diaphragm and call a health care
provider.

Male Condom - is a latex rubber or synthetic sheath that is placed over the erect penis before coitus to
trap sperm. Recommended for male who do not maintain a monogamous relationship.
Advantage: they are one of the few “male responsibility” birth control measures available, nor
health care visit or prescription is needed. It prevents the spread of STD and HIV.
Disadvantage: decreased sensation, the interruption of sexual foreplay to apply the condom, and
the need to quickly remove the penis from the vagina after ejaculation to remove the condom.
Contraindications: sensitivity to latex

Reminder!
A condom should be positioned so that it is loose enough at the penis tip to collect the ejaculate.
The penis (with the condom held carefully in place) must be withdrawn before it begins to
become flaccid after ejaculation. If not withdrawn this time, sperm may leak from the now
loosely fitting sheath into the vagina.
Female Condoms - are latex sheaths made of polyurethane and prelubricated with a spermicide.
The inner ring (closed end) covers the cervix, and the outer ring (open end) rests against the vaginal
opening.
The sheath may be inserted any time before sexual activity begins and then removed after
ejaculation occurs.
Advantage: it offers protection against pregnancy and infection (STD and HIV).
Disadvantage: expensive than male condoms, have not gained popularity because of their bulk and
difficulty in use.

 Hormonal Methods - hormones that cause such fluctuations in a normal menstrual cycles that
ovulation does not occur. Hormonal contraceptives can be administered orally, vaginally,
transdermally, or by implantation, or through injection.
Oral route - Must be prescribed by a physician, nurse practitioner, or nurse-midwife after a pelvic
examination or Pap smear.
Combination Oral Contraceptives (Combined Estrogen-Progestin Pill)
Estrogen acts to suppress follicle stimulating hormone (FSH) and LH, thereby suppressing ovulation.
Progesterone causes a decrease in a permeability of cervical mucus, thereby limiting sperm
mobility and access to ova. Progesterone also interferes with tubal transport and endometrial
proliferation to such degrees that the possibility of implantation is significantly decreased
Because COCs are not effective for the first 7 days, advise women to use a second form of
contraception during the initial 7 days on which they take pills.
After women stop taking COCs, they may not be able to become pregnant for 1 to 8 months,
because the pituitary gland requires a recovery period to begin cyclic gonadotropin stimulation
again. Ovulation can be stimulated by Clomiphene citrate (Clomid) therapy to restore fertility.

Progestin-only Oral Contraceptives

The “mini pill”, contains progestin (norethindrone) only and must be taken every day at the same
time each day.
A backup method of contraception must be used for 48 hours if pills are taken 3 or 4 hours late.
It is less effective in inhibiting ovulation but seems to prevent sperm transport by causing cervical
mucus to thicken.
Advantage: it doesn’t have a negative effect on lactation. Women may take progestin-only pills
during breastfeeding.
Disadvantage: the need to take the pill at approximately the same time every day.

 Transdermal route
Transdermal contraception refers to patches that slowly but continuously release a combination of
estrogen and progesterone.
Patches are applied each week for 3 weeks. No patch is applied the fourth week.
During the week on which the woman is patch-free, a menstrual flow will occur.
Disadvantage: less effective in women who weigh more than 90 kg (198 lbs).
Contraindicated for women with thromboembolic disease
Patches may be applied to one of the following four areas:
Upper outer arm
Upper torso (front or back, excluding the breasts)
Abdomen
Buttocks
They should NOT be placed on
any area where make-up, lotions, or creams will be applied
at the waist where bending might loosen the patch
anywhere the skin is red or irritated or has an open lesion.
If the patch has been loose for 24 hours or longer, she should use a back-up contraception method
such as a condom or spermicide, for the first week of the cycle.

 Vaginal insertion
Vaginal ring (Nuva Ring) is a silicone ring that surrounds the cervix and continually releases a
combination of estrogen and progesterone.
It is inserted vaginally by the woman and is left in place for 3 weeks, then removed for 1 week.
Menstrual bleeding occurs during the ring-free week.
The hormones released are absorbed directly by the mucus membranes of the vagina.
Advantage: safe for woman with liver disease
Effectiveness is equal to that of COCs
Disadvantage: vaginal discomfort, and irritation
 Implantation
 Norplant system is five subdermal implants, rods the size of pencil lead that are embedded just
under the skin on the inside of the upper arm.
The implants are inserted with the use of a local anesthetic, during the menses or no longer than
day 7 of the menstrual cycle to be certain that the woman is not pregnant at the time of insertion.
Disadvantage:
Weight gain
Irregular menstrual cycle such as spotting, breakthrough bleeding, amenorrhea, or prolonged
periods
Depression
Scarring at the insertion site
Need for removal
Advantage: higher compliance rate than COCs
Can be safely used during breastfeeding
Contraindication:
Undiagnosed uterine bleeding

 Injection
A single intramuscular injection of Medroxyprogesterone acetate (Depo-Provera), a progesterone,
given every 12 weeks inhibits ovulation, alters the endometrium, and changes the cervical mucus.
Do not massage the site of injection after administration.
Advantage: can be safely used during breastfeeding

 Intrauterine Devices
An intrauterine device is a small plastic object that is inserted into the uterus through the vagina.
Mechanism of action: it creates a local sterile inflammatory condition that prevents implantation.
When copper is added to the device, sperm mobility appears to be affected as well.
The device must be fitted by a physician, nurse-practitioner, or nurse-midwife, who performs a Pap
smear and pelvic examination.
The device is inserted before a woman has had coitus after a menstrual flow, so the health care
provider can be assured that the woman is not pregnant at the time of insertion.
The device is inserted in a collapsed position, then enlarged to its final shape in the uterus when the
inserter is withdrawn. The woman may feel a sharp cramp as the device is passed. The attached
string protrudes through the cervix into the vagina.
Types:
Copper T380 (ParaGard) = a T-shaped plastic device wound with copper
LNG-IUS (Mirena) = holds a drug reservoir of progesterone in the stem
Advantages
It is effective for 10 years, only one insertion is needed
The device does not need daily attention or interfere with sexual enjoyment.
Appropriate for women who are at risk for complications associated with COCs.
Disadvantage:
Not recommended for women with an increased risk of contracting STIs, such as those who
have multiple sexual partners
Not recommended for women who have never been pregnant because their small uterus can
be punctured with insertion.
Not recommended for women who have a history of having had PID.
Signs of Pelvic Inflammatory Disease:
  Fever, low abdominal tenderness, and pain on intercourse
Contraindicated for women whose uterus is distorted in shape.
Not advised for women with severe dysmenorrhea (painful menstruation), menorrhagia
(bleeding between menstrual periods), or history of ectopic pregnancy.

 Surgical Methods (Sterilization)

Is any process that permanently renders the individual infertile.
Counseling should be done especially intensive for men and women younger than 25 years of age,
because the possibility of annulment, death of a sexual partner, loss of a child, or remarriage could
change a person’s philosophy toward childbearing in the future.
Neither vasectomy nor ligation provides protection against STDs or HIV.

Vasectomy
a small incision or puncture wound is made on each side of the scrotum. The vas deferens at that
point is then located, cut and tied, cauterized, or plugged, blocking the passage of spermatozoa.
Done under local anesthesia
Apply ice to the site after surgery, and pain can be managed by taking a mild analgesics.
Spermatozoa that were present in the vas deferens at the time of surgery can remain viable for as
long as 6 months.
Therefore, birth control method is used for 1 week until two negative sperm reports have
been obtained.
10 – 20 ejaculations provide proof that all sperm in the vas deferens have been eliminated.

Tubal ligation
= referred to as “bilateral partial salpingectomy”, is a procedure in which the fallopian tubes are
cut, tied, cauterized, plugged, capped, coagulated, or clipped, thus preventing the sperm from
reaching the egg.

Laparoscopy = a common procedure to achieve tubal ligation, after a menstrual flow and before
ovulation, an incision as small as 1 cm is made just under the woman’s umbilicus with the woman
under general or local anesthesia.
A lighted laparoscope is inserted through the incision, carbon dioxide is then pumped into
the incision to lift the abdominal wall upward and out of the line of vision.
Coldoscopy= tubal ligation done with a tube inserted through the posterior fornix of the vagina.
A woman may notice abdominal bloating for the first 24 hours because of carbon dioxide
infused.
A woman will still have a monthly menstrual flow.
Woman should view tubal ligation as a permanent, irreversible procedure.
Complications:
Bowel perforation
Hemorrhage
Contraindication:
Umbilical hernia
Obesity