Family planning and emergency contraception

Family planning is the ability of individuals and couples to control their number of children and the spacing between births, which may involve measures of family planning services and reproductive medicine, including contraception, infertility counseling, STI counseling, and infertility treatment. A reproductive life plan (RLP) is the set of goals individuals or couples develop with regard to the wish and timing to have children based on their personal values, priorities, and resources. Family planning counseling can assist individuals and couples with developing and following their RLP. Preconception counseling is provided to individuals and couples planning to conceive in the near future and typically involves risk assessment, the promotion of a healthy lifestyle, and physical assessment. Emergency contraception is a means of preventing unwanted pregnancy in the event of unprotected intercourse or contraception failure. Measures include intrauterine devices (effective if used within 5 days of intercourse) and oral medications (antiprogestins, progestins, combined regimens; effective if used within 3 days of intercourse).

General principles ^[1][2][3]

• Definition: the ability of individuals and couples to control their number of children and the spacing between births, which may involve measures of family planning services and reproductive medicine, including contraception, infertility counseling, STI counseling, and infertility treatment.
• Goals ^[1][4]
  • Improve pregnancy planning and spacing
  • Prevent unintended pregnancies
  • STI prevention
• Family planning services include:
  • Fertility counseling
  • Reproductive life plan and preconception counseling
  • Pregnancy testing and counseling (see “Pregnancy” and “Prenatal care”)
  • STI counseling (see “Prevention” in “Sexually transmitted infections” and "Human immunodeficiency virus infection")
  • Preventive health counseling (e.g., breast cancer screening, cervical cancer screening)

Reproductive life plan (RLP) counseling ^[5]

• Definitions
  • Reproductive life plan: a set of goals regarding the wish and timing to have children based on personal values, priorities, and resources
  • Family planning counseling: counseling on the use of contraceptives and infertility treatment to prevent pregnancy or attain the desired number of children and determine the spacing of pregnancies.
• Goals of family planning counseling ^[6]
  • Encourage individuals to make informed decisions about their reproductive goals.
  • Discuss contraceptive methods and potential barriers to contraception based on the individual's preferences.
    • Inquire about contraceptive methods used and provide education on how they may affect an RLP.
    • Discuss effective contraceptive methods and emergency contraception for individuals who are not planning on becoming pregnant.
    • See also "Hormonal contraceptives" and "Nonhormonal contraception."
  • Provide pregnancy testing and counseling, including current vaccination status (see “Immunizations and pregnancy” below)
  • Discuss pregnancy spacing to reduce adverse outcomes ^[7][8]
    • The ACOG recommends an interval of at least 18 months between delivery and the next pregnancy.
    • An interpregnancy interval of < 6 months should be avoided due to increased risks of adverse maternal (e.g., mortality, severe morbidity) and fetal (e.g., SGA, preterm delivery) outcomes.
    • Other factors (e.g., fertility decreasing with age) may outweigh the, at most moderate, risk associated with interpregnancy intervals of 6–18 months.

Infertility counseling ^[9][10][11]

• Definition: evaluation for couples who have not conceived after one year of unprotected vaginal intercourse and counseling for individuals and couples who are sterile or are not physically able to conceive (e.g., individuals with reproductive organs disorders, e.g., Mullerian agenesis)
• Goals
  • Offer counseling on optimizing fertility (i.e., sexual and lifestyle practices relating to conceiving) ^[12]
  • Provide counseling and offer an appropriate treatment plan to support individuals and couples with fertility problems (i.e., infertility, sterility)
  • Offer counseling on preventing tubal infertility due to STIs
  • Provide counseling on assisted reproductive technology

General principles ^[13][14][15]

• Definition: : a form of medical counseling provided to couples of reproductive age who are planning to conceive
• Goals
  • Identify and address any modifiable factors that may negatively affect pregnancy and childbirth
  • Educate couples about risks and how to mitigate them.
• Key components
  • Risk assessment (e.g., immunizations, medication use, genetic carrier screening, environmental risks)
  • Healthy lifestyle promotion (e.g., counseling on proper nutrition, regular exercise, smoking cessation, alcohol use)
  • Medical and psychosocial intervention and counseling (e.g., chronic disease management, folic acid supplementation, psychosocial risks)
  • Physical assessment

Patient medical history ^[13]

• Medical history: review history and identify chronic medical conditions that may affect pregnancy (e.g., hypothyroidism, diabetes mellitus, chronic hypertension)
  • Hypothyroidism
    • Screen individuals planning to conceive with risk factors for thyroid disease (e.g., age > 30 years, obesity, history of head or neck radiation). ^[16]
    • Treat individuals planning to conceive with elevated TSH with L-thyroxine until TSH levels are normal.
  • Diabetes mellitus
    • Educate affected individuals about the importance of maintaining normal glycemic levels before and during pregnancy.
    • Assess for complications of diabetes (e.g., retinopathy, nephropathy).
    • Aim for an HbA1c < 6.5%. ^[17]
  • Hypertension
    • Assess for retinopathy, renal disease, and ventricular hypertrophy.
    • Avoid using ACE inhibitors and angiotensin receptor blockers, as they are teratogenic.
  • STIs
    • HIV-infection
      • Screen all individuals planning to conceive for HIV.
      • Initiate antiretroviral therapy in all individuals with HIV.
      • Counsel individuals with HIV regarding the risk of vertical transmission.
    • Other infections: STIs, tuberculosis (screen individuals planning to conceive with a high risk and manage as appropriate)
• Family history: Assess for hereditary risk factors (e.g., BRCA-positive breast cancer, familial adenomatous polyposis, cystic fibrosis) and refer couples with a positive history for genetic counseling (for more information, see “Genetic carrier screening” below and “Genetic counseling”).
• Medication history
  • Review current medications, including alternative medicine preparations (e.g., herbal medicine, naturopathy) and nutritional supplements.
  • Discontinue teratogenic drugs and switch to safer medications, if possible.
  • Adjust the regimen of necessary medications and consider using the lowest dose possible for potentially harmful agents.
• Immunizations and pregnancy
  • Before pregnancy
    • Measles, mumps, rubella (MMR vaccine), and varicella vaccine
      • Screen all pregnant individuals for immunity with antibody titers.
      • Nonimmune pregnant individuals should receive vaccination.
      • Counsel to avoid conceiving for 28 days after the last vaccine dose.
  • During pregnancy
    • MMR vaccine
      • Screen all individuals for previous rubella infection at their initial prenatal examination.
      • Nonimmune individuals should receive vaccination in the postpartum period.
      • Postpartum vaccination avoids the risk of congenital rubella syndrome.
    • Influenza: The annual inactivated influenza vaccine is safe in all trimesters and should be offered to all pregnant individuals.
    • Tetanus, diphtheria, and pertussis (Tdap vaccine): individuals who wish to conceive should receive the Tdap vaccine according to the guidelines.
    • Hepatitis B vaccine: Vaccinate pregnant individuals with high risk for hepatitis B.
• Psychiatric disorders
  • Review history of psychiatric disorders.
  • Inform about the risks of medication during pregnancy.
  • Screen pregnant individuals with no history of mental health conditions for anxiety and depression.

The administration of MMR vaccine, varicella vaccine, human papillomavirus vaccine, and zoster vaccine is contraindicated during pregnancy.

Genetic carrier screening

• Preconception counseling should also cover carrier screening.
• Patients may choose whether to decline some or all of the recommended genetic testing (e.g., for cultural or religious reasons).
• If an individual is found to be a carrier, their reproductive partner should also be offered testing for the condition in question (especially autosomal recessive disorders).
• Further genetic counseling should be offered if both partners are found to be carriers of a genetic condition (for more information, see “Genetic counseling” and “Pedigree analysis”).

Lifestyle modifications

• Recommend maintaining a normal body weight prior to conception.
• Encourage regular moderate-intensity exercise.
• Nutrition
  • Screen for sufficient intake of macronutrients and micronutrients (calcium, iron, vitamin B₁₂, vitamin B₉, vitamin D).
  • Ensure vitamin A is not taken in excess
  • Recommend intake of 0.4 mg of folic acid daily, ideally 4 weeks prior to conception, and continue for at least the first 2–3 months of pregnancy.
• Substance use
  • Screen all pregnant individuals and couples for recreational drug use (including alcohol and tobacco).
  • Educate patients about adverse effects of recreational drug use on male and female fertility as well as maternal and fetal health.
  • Provide assistance and/or refer to specialists for recreational drug use cessation.

Management of exposures ^[14][18]

• Exposure to harmful agents
  • Advise patients to assess workplace and household for potentially harmful agents (e.g., heavy metals, solvents, chemicals).
  • Educate the patient about the avoidance of harmful agents and refer them to occupational medicine programs as needed.
• Exposure to violence
  • Screen for family violence at each visit.
  • If ongoing abuse is identified, providers should:
    • Provide community resources to the patient
    • Report the case as appropriate

Physical assessment

• Physical examination
  • Periodontal examination ^[19]
  • Thyroid examination
  • Cardiovascular examination
  • Breast and pelvic examinations
• Laboratory studies
  • CBC, glycemia
  • Urinalysis
  • Blood type and screen
  • Other: TSH, HIV, gonorrhea, and chlamydia

Emergency contraception (EC) refers to measures taken to prevent pregnancy within 5 days of unprotected intercourse or contraception failure (e.g., condom breakage, missed oral contraceptives).

Approach

• EC is indicated for individuals who have had unprotected intercourse or contraception failure and who do not wish to conceive. ^[20]
• Type of emergency contraceptives are based on the following:
  • Contraindications (e.g., cardiovascular disease, migraines, liver disease, obesity)
  • Wish for long-acting contraception
• EC should be initiated as soon as possible to maximize efficacy.

Intrauterine devices for emergency contraception ^[21]

General

• Does not disrupt embryo implantation or already established pregnancies
• Indications
  • Individuals who meet standard criteria for an IUD
  • Individuals who desire long-acting contraception
  • Individuals who have a BMI ≥ 30

Types

• Copper intrauterine device
  • Most effective emergency contraception method
  • Mechanism of action: prevents fertilization by interfering with sperm and ovum viability and function ^[20][22]
  • For more information, see “Nonhormonal copper device.”
• Progestin intrauterine device: prevents fertilization by interfering with sperm and ovum function and transport ^[23]

Adverse effects

• Abnormal uterine bleeding and/or menstrual changes
• Dysmenorrhea
• Pelvic pain following insertion

Oral emergency contraception medication ^[20][21][24]

General

• Most effective when taken within 3 days of unprotected intercourse (ulipristal acetate can be taken within 5 days)
• Does not disrupt embryo implantation or already established pregnancies
• Significantly less effective in obese ; (BMI ≥ 30 kg/m²) or overweight ; (BMI 25–29.9 kg/m²) individuals ^[24][25]
• For more information on the mechanisms of action, see “Pharmacodynamics” in "Hormonal contraceptives."

Types

• Antiprogestins (ulipristal acetate) ; ^[26]
  • Most effective oral emergency contraception method
  • Requires a prescription in the US
  • Administered as a single dose
• Progestins (levonorgestrel) ^[24]
  • Available as an over-the-counter medication in the US
  • Typically administered as a single dose or as two doses over one day
• Combined oral contraceptives pills (Yuzpe regimen)
  • Usually a combination of ethinyl estradiol and levonorgestrel
  • Inhibits the LH/FSH → prevents estrogen surge → inhibits LH surge → prevents ovulation
  • Requires a prescription in the US
  • Typically administered as a single dose or as two doses over one day

Adverse effects

• Headache, fatigue, dizziness
• Nausea, vomiting
• Breast tenderness, dysmenorrhea, menstrual changes (e.g., earlier onset of menstrual bleeding associated with levonorgestrel use, delayed onset of menstrual bleeding related to ulipristal acetate use)