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
  • Provide pregnancy testing and counseling
  • Discuss child spacing to reduce adverse pregnancy outcomes
• RLP questionnaire examples ^[5]
  • Timing of planned pregnancy
    • Are you planning to conceive within the next year?
    • How many (more) children would you like to have and when?
      • Inquire about current vaccination status.
      • Provide guidance on pregnancy spacing (the optimal time between delivery and the next pregnancy is 12–18 months). ^[7]
  • Contraceptive methods
    • Inquire about contraceptive methods used and provide education on how they may affect an RLP.
    • Discuss effective contraceptive methods and emergency contraception for women who are not planning on becoming pregnant.
    • See also "Hormonal contraceptives" and "Nonhormonal contraception."

Infertility counseling ^[8][9][10]

• 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) ^[11]
  • 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 ^[12][13][14]

• 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 women and men about risks and how to mitigate them reduction
• Key components
  • Risk assessment (e.g., immunizations, medication use, genetic 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 ^[12]

• Medical history: review history and identify chronic medical conditions that may affect pregnancy (e.g., hypothyroidism, diabetes mellitus, chronic hypertension)
  • Hypothyroidism
    • Screen women with a desire to conceive with risk factors for thyroid disease (e.g., age > 30 years, obesity, history of head or neck radiation). ^[15]
    • Treat women with a desire to conceive with elevated TSH with L-thyroxine until TSH levels are normal.
  • Diabetes mellitus
    • Educate affected women 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%. ^[16]
  • 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 women for HIV.
      • Initiate antiretroviral therapy in all women with HIV.
      • Counsel women with HIV regarding the risk of vertical transmission.
    • Other infections: STIs, tuberculosis (screen women at high risk and manage as appropriate)
• Family history: assess family history of genetic conditions and cancer (e.g., breast cancer, endometrial cancer, colon cancer) and refer couples with a positive history for 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 women for immunity with antibody titers.
      • Nonimmune women should receive vaccination.
      • Counsel to avoid conceiving for 28 days after the last vaccine dose.
  • During pregnancy
    • Influenza: Women who wish to conceive should receive the annual inactivated influenza vaccine.
    • Tetanus, diphtheria, and pertussis (Tdap vaccine): Women who wish to conceive should receive the Tdap vaccine according to the guidelines.
    • Hepatitis B vaccine: Vaccinate women with high risk for hepatitis B.
• Psychiatric disorders
  • Review history of psychiatric disorders.
  • Inform about the risks of medication during pregnancy.
  • Screen women with no history of mental health conditions for anxiety and depression.

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

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 women 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 ^[13][17]

• 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 ^[18]
  • 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. ^[19]
• 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 ^[20]

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 ^[19][21]
  • For more information, see “Nonhormonal copper device.”
• Progestin intrauterine device: prevents fertilization by interfering with sperm and ovum function and transport ^[22]

Adverse effects

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

Oral emergency contraception medication ^[19][20][23]

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 ^[23][24]
• For more information on the mechanisms of action, see “Pharmacodynamics” in "Hormonal contraceptives."

Types

• Antiprogestins (ulipristal acetate) ; ^[25]
  • Most effective oral emergency contraception method
  • Requires a prescription in the US
  • Administered as a single dose
• Progestins (levonorgestrel) ^[23]
  • 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)