Definition and the scope of family planning is having children as much as the married couples want when they want and prevention of pregnancy when they don’t want. There are many methods for this. Which method would be most appropriate varies from person to person. Therefore, individuals who wish to avoid pregnancy should choose the most convenient prevention method and have full information about the method they will use in consultation with their physicians.
When comparing the effectiveness of family planning methods, we use a rate called "Pearl Index". Pearl index, is the failure rate observed in 100 women. With an easier expression, it is the rate of the women who get pregnant within a year using the method among 100 women.
1. NATURAL METHODS
It is defined as the application of some of the rules together, which enable or prevent pregnancy with couples’ awareness of fertility . World Health Organization, defines the natural family planning as planning or prevention of pregnancy by observing the natural symptom and signs of menstrual cycle in fertile and infertile periods.
Basal body temperature method
Body temperature increases between 0.2 – 0.5 ° C with the effect of Progesterone hormone after ovulation. Everyday body temperature is recorded regularly, after detecting body temperature which courses above a certain level for 3 days successively, next days are accepted as safe.
It is based on the principle of not having sexual intercourse in days which are assumed to be the ovulation days that occurs between the 14th and 21st days after the menstruation in women having regular menstruation. Pearl index is 20%, in other words, the success rate is 80%.
Cervical mucus amount increases during ovulation and gains a thin, clear and elongated structure when enclosed between two fingers. This method is based on the principle of not having sexual intercourse in days when the structure and amount of mucus indicate ovulation period.
It is the pulling back the penis from the vagina of the woman and ejaculate outside during sexual intercourse. This method is difficult to apply, individuals must be experienced and be clearly committed on this issue, and be psychologically ready for it. Otherwise, the success rate is lower, success rate of preventing pregnancy is 81%.
If the mother breastfeeds her baby within the following 6 months after delivery not less than 60 minutes a day with frequent intervals in the absence of menstruation, it is accepted that ovulation has not started yet. Since this doesn’t mean that every mother not having menstruation also doesn’t ovulate, it is not a very reliable method.
2. BARRIER METHODS
This includes all the methods that mechanically prevent the sperm reach the uterus.
It is the rubber sheath that is worn to the penis after erection during sexual intercourse. It prevents the semen within the sperm enter vagina of the woman after ejaculation. Beside family planning, most important advantage of this method is providing protection against sexually transmitted diseases. Rupture of the condom during intercourse or realizing that there is a hole in the condom require you to use an additional method. When used alone, success rate of the method is 88%.
Placed on woman's cervix before sexual intercourse, it’s a hat-like rubber tool. Application of spermicide (sperm-killing agent) to the cervix, physically prevents the sperm remain live. The advantage of this method is its application to the body without any damage and women’s ability to have sexual intercourse with an ongoing menstruation by using the diaphragm. When used alone, success rate of the method is 82%.
These are the agents applied into the vagina which may be cream, suppository or foam form that inhibit the survibval of the sperm. Since their efficiency is not high when used alone (79%), their usage with other barrier methods increases their efficiency .
Activation of the ovaries and pituitary gland is prevented by administering low dose hormone. Ovulation , consequently pregnancy don’t occur.
Birth Control Pills
a. Combined Oral Contraceptives
These are based on preventing pregnancy as a result of suppression of the natural equilibrium by externally administered low dose of estrogen and ovulation (progesterone) hormones existing in the female body. Since estrogen and progesteron hormones enter the body even in low doses, characteristics of feminity continues without interruption. This method which have high protection ratio as high as 99% should be used everyday regularly in order to be effective. One of the great advantages of birth control pills their prevention of anemia by reducing the amount of menstrual bleeding. In some women this reduction is such evident that menstrual bleeding may be in the form of spotting, coffee ground, this is not a condition to be worried about. Birth control pills reduce menstrual pain and the likelihood of ovarian and uterine cancer. The most common side effect when used for the first time is nausea. Taking drugs just before sleeping time enables women tolerate this effect more easily. The second most common side effect seen while using the pills is intermediate bleedings. Vast majority of the intermediate bleedings seen while using birth control pill is mostly seen in cases when the female hormone estrogen is in low doses within the drug. In this case pills should not be discontinued but proceeded. In case of no reduction in the complaints, switching to another drug by consulting to a physician may be considered. Some women may complain of gaining weight. This may be avoided by using a lower dose drug. The pills should be taken at the same time every day as much as possible. When taking the pill is forgotten, it should be taken as soon as it is remembered. When the pill is forgotten to be taken for 2 days successively, efficiency of the method would be reduced and using an additional prevention method is required. Before starting using the pills, pregnancy test should be done in order to detect possible pregnancy. There are various drugs available in the market. Some include 21 pills in one box. First box should be started within the first 5 days of menstruation (preferably first day). After using it for 21 days, next 7 days no pill is taken and menstrual bleeding occurs within this period. New box is started after 7 day drug-free period. 28 pills are drugs that are intended for use without a break. Hormone is not present in the final pills of the box, menstruation starts while receiving these pills.
It should not be used in patients with breast cancer, blood clot, cardiac and liver diseases. It should be used under control in breast-feeding mothers, smokers, people with diabetes, high blood pressure, migraine and depression.
b. Mini-Pills (Progesterone-only pills)
These are the pills which doesn’t contain female hormone (estrogen) but only ovulation hormone (progesterone). They provide contraception with the principle of preventing ovulation and preventing the passage of the sperm by thickened cervical fluid. Success rate is 97%. Most remarkable advantage of this method is its usage during breast-feeding period when estrogen containing pills can’t be used and it’s also significant that these may be also by women who can’t use estrogen due to any condition.
c. Morning after pills
These methods are not suitable for routine use, but is used in cases of necessity. Taking the pill in the first 72 hours following to unprotected sexual intercourse, prevents the ovum settle inside the uterus even in the presence of fertilized ovum. But it is known that preventiveness of the morning after pills is reduced if taken after the first 24 hours in daily practice.
Birth control injections, patches
a. Monthly injections
when these drugs including both estrogens and progesterone regularly performed every month, protective ratio is high. Since injections should be done once a month, patient’s compliance is easier when compared to taking pills. Misuse of the pills and forgetting taking these pills are not experienced when injections are used. It is recommended to use within the first 7 days of menstruation (preferably the first day). Its usage is not recommended in breast-feeding mothers since it reduces the amount and the quality of the milk.
b. 3 months injections
This method having the highest prevention rate among other hormonal methods, include only progesterone hormone. It effects with the principle of suppressing the ovulation and preventing the passage of the sperms by condensed cervical secretions. Disadvantage of these medicaments Administered by intramuscular injection is metrorrhagia, is more common than other methods during usage.
c. Subcutaneous Implants
Progesterone level in the blood reaches the level prevent pregnancy following to first 24 hours inserting the progesterone containing capsule like a 40 mm long - 2 mm thick match stick subcutaneously. In this method providing protection for about 5 years , intrauterine layer becomes thinner and pregnancy is prevented with progesterone content of the capsule. Most common problem of this method is irregular bleeding. After a while, the amount of bleeding gradually decreases and after a period of menstrual bleeding may not even occur. This situation which is unacceptable for some women, should be reminded for women who want to use the method. Headache, nausea, increase in acne, breast tenderness and mood changes due to High progesterone hormone levels in the blood should be kept in mind.
d. Birth control patches
These provide protection with the similar principle of birth control pills. Each box contains 3 bands. These bands are sticked into one of. the arm, leg, hip region each a week. Formation of ovulation is prevented with the hormones secreted to the blood from where it adheres. Side effects most commonly occurs as bleeding disorders same as it is in all hormonal methods. Skin sensitivity of may occur where the patch is adhered, thus sticking each plasters to different parts of the body is recommended. When the patch is displaced, it should be tried to stick on the same location, if it doesn’t stick, a new patch should be placed and kept until the day it will be removed and then it must be replaced with a new one. If the patch has not contacted the skin more than 24 hours, a new box should be started and an additional method shoul be used for a week.
It is a ring in diameter of 5.4 mm in 4 mm thickness which is a protection method including estrogen and progesterone like pills. The ring inserted to the vagina is removed after using it for 3 weeks and menstruation occurs within this one week of unused period. Placing the ring is extremely simple, its hormone content is low, the effectiveness is high and metrorrhagia is much less common than pills. The most common problem in women using vaginal rings, vaginal discharge and increase in infection. This vaginal ring is not available in our country yet.
INTRA-UTERINE DEVICES (SPIRAL)
The Copper Intrauterine Device
Today, spiral is considered as the safest method of birth control by the World Health Organization. With the copper on its arms and body, it inhibits sperm motility, reduces the fertilization ability of the sperm and most importantly , it prevents the adhesion of pregnancy to the intra-uterine layer by creating foreign body reaction within the uterus. The prevention may continue up to 10 years and its usage is safe since its misuse of the method is not possible. Since the thin string from the bottom of the spiral is cut in a length that remains in the cervix during installation, it will not make any problems during sexual intercourse and when the spiral is prompted to be removed, it can be easily removed by pulling this string. The most common side effects of the spiral is increased amount of menstrual bleeding and prolonged menstrual period is lengthening. This effect is triggered by foreign body reaction towards the copper and in whom it may develop can’t be determined in advance. Another disadvantage of the spiral is it promotes sexually transmitted diseases. When these diseases are not diagnosed earlier, may cause adhesions in the tubes, problems in getting pregnant in the future and ectopic pregnancy. Therefore, it is not recommended as the first prevention method for women who has not given birth previously but it is an ideal method for breast-feeding women.
It shows the effect by releasing daily 20 micrograms of the total 52 mg progesterone hormone derivative it comprises in its arms. This hormone level is sufficient to thin the intra-uterine layer, prevent ovulation and development of pregnancy. In this method, which provides about a 5-year of protection, most common problem is menstrual irregularities seen in the first month after installation. Over time, the amount of menstrual bleeding and spotting in between the periods are reduced, or even no menstrual bleeding occurs in some women. Therefore, it can be used as the first choice for women who suffer from anemia due to a large amount of menstrual bleeding and prolonged menstruation. Because it has a bit thicker insertion apparatus comparing to copper spiral, preferably inserting it during menstruation would cause less pain.
It’s the ligation procedure of the tubes which carry the ovum into the uterus in women. Since the result is irreversible, is an appropriate method for couples who don’t desire children in the future. Tubal ligation does not cause any physical, mental or sexual change. Retention is close to 100%. While this method which can be performed concomitantly during caesarean delivery , it can be also performed in a separate session, with a small incision or by closed procedure (laparoscopic). In women who want to get pregnant again, tubes can be ligated to each other again by microsurgery, but instead of these kind of surgeries with a low chance of success , IVF treatment is widely used.
It is the process of permanent deterioration of transition of the sperm cells from the testicles to the regions where they are stored at in males. After this process, the external appearance of the liquid discharged during ejaculation does not change at all, but there is no sperm cells in the fluid , thus pregnancy does not occur. In this method with a retention rate of close to 100%, the result is also irreversible same as tubal ligation in females and IVF treatment by collecting the sperms from the testicles comes to the fore in case of child request. Advantage of this method is its high retention ratio and that it can be performed under local anesthesia in a short time.