Family Planning Methods

A backbone topic in Community Medicine and Obstetrics that NEET PG mines relentlessly for the Pearl Index of each method, OCP mechanism and contraindications (WHO MEC categories), Cu-T 380A insertion timing, sterilisation techniques, and emergency contraception windows. Master the numbers and the eligibility rules — that is where the marks live.

Definition & classification

Contraception is the deliberate prevention of pregnancy by reversible (spacing) or irreversible (terminal) methods. The cornerstone metric is the Pearl Index = number of accidental pregnancies per 100 women-years of exposure (HWY). A lower Pearl Index means a more effective method.

High-yield: Pearl Index = (Total accidental pregnancies × 1200) ÷ Total months of exposure. Denominator is woman-months; multiply by 1200 to express per 100 woman-years.

Broad classification:

1. Spacing (temporary) methods → barrier, intrauterine devices, hormonal (OCP, injectables, implants), natural/fertility-awareness, lactational amenorrhoea.
2. Terminal (permanent) methods → male sterilisation (vasectomy), female sterilisation (tubal ligation).
3. Miscellaneous → emergency (post-coital) contraception, abstinence, coitus interruptus.

Method	Typical-use failure (per HWY)	Perfect-use failure
No method	~85	85
Coitus interruptus	22	4
Calendar/rhythm	24	9
Male condom	18	2
Diaphragm + spermicide	12	6
Combined OCP	9	0.3
Cu-T 380A (IUCD)	0.8	0.6
LNG-IUS (Mirena)	0.2	0.2
DMPA injectable	6	0.2
Implant (Implanon)	0.05	0.05
Vasectomy	0.15	0.10
Tubal ligation	0.5	0.5

High-yield: The most effective reversible method is the subdermal implant / LNG-IUS (failure ~0.05–0.2). The implant has the lowest Pearl Index of all reversible methods.

Barrier methods

Physical or chemical barriers preventing sperm–ovum union; the only methods that also protect against STIs/HIV.

• Male condom — most widely used in India's national programme (Nirodh). Provides dual protection. Failure largely user-dependent (slippage, breakage, late application). Latex condoms are damaged by oil-based lubricants.
• Female condom, diaphragm, and cervical cap — must be used with a spermicide; diaphragm is fitted by a provider and left in situ ≥6 hours post-coitus.
• Spermicides — nonoxynol-9; used alone they have high failure and, with frequent use, may cause genital epithelial disruption increasing HIV risk.

High-yield: Condom is the only contraceptive offering reliable protection against STIs/HIV. Diaphragm raises the risk of urinary tract infection and, if left >24 h, toxic shock syndrome.

Intrauterine contraceptive devices (IUCD)

Types

Generation	Example	Active agent	Effective life
1st (inert)	Lippes Loop	None (foreign-body reaction)	Indefinite
2nd (copper)	Cu-T 200B	Copper	3–4 yr
2nd (copper)	Cu-T 380A	Copper (380 mm² Cu)	10 years
2nd (copper)	Multiload-375, Cu-T 375	Copper	5 yr
3rd (hormonal)	LNG-IUS (Mirena)	Levonorgestrel 20 µg/day	5 yr

Mechanism

Copper IUCDs act mainly before fertilisation: copper ions are spermicidal/spermo-immobilising and induce a sterile inflammatory endometrial reaction that is gametotoxic. LNG-IUS additionally thickens cervical mucus and causes endometrial atrophy.

Timing of insertion

High-yield (Cu-T timing): Ideal during/just after menstruation (cervix soft, pregnancy excluded), but can be inserted any time the woman is reasonably sure she is not pregnant.

**Stepwise insertion windows → ** Interval (during menses) → Post-partum immediate (within 10 min of placental delivery, "PPIUCD") → Post-partum within 48 h → then avoid until 4–6 weeks → Post-abortal (immediately after first/second-trimester abortion if no sepsis) → Post-coital (within 5 days as emergency contraception).

High-yield: If the post-partum window of 48 hours is missed, IUCD insertion is deferred to 4–6 weeks post-partum because of high expulsion and perforation risk in the interim.

Side effects / problems — bleeding (menorrhagia, the commonest cause of removal in copper IUCD), pain/cramps, expulsion (highest in first year), pelvic infection (risk concentrated in first 20 days), perforation (operator-dependent), and ectopic pregnancy risk if pregnancy occurs.

Absolute contraindications — pregnancy, active PID/STI, unexplained vaginal bleeding, distorted uterine cavity, suspected genital malignancy, and (for LNG-IUS) current breast cancer.

Hormonal methods

Combined oral contraceptive pills (COCs)

Contain ethinyl oestradiol + a progestogen, taken 21 days with a 7-day hormone-free interval.

Mechanism (multi-level): primarily inhibition of ovulation (suppress LH surge and FSH) → thickened cervical mucus (anti-sperm) → atrophic/unreceptive endometrium → altered tubal motility.

High-yield: The principal mechanism of COC is suppression of ovulation, mediated chiefly by the progestogen suppressing the LH surge; oestrogen suppresses FSH and stabilises the endometrium.

Non-contraceptive benefits — reduced risk of ovarian and endometrial cancer, benign breast disease, functional ovarian cysts, ectopic pregnancy, PID, dysmenorrhoea, and iron-deficiency anaemia; regularises cycles and treats acne/PCOS.

Risks — venous thromboembolism (oestrogen-driven), hypertension, slightly increased risk of cervical and (early-data) breast cancer, hepatic adenoma.

WHO Medical Eligibility Criteria (MEC) categories

Category	Meaning	Action
1	No restriction	Use freely
2	Benefits > risks	Generally use
3	Risks > benefits	Not recommended unless no alternative
4	Unacceptable health risk	Do not use

High-yield (COC = MEC category 4 / absolute contraindications):

• Smoker ≥15 cigarettes/day AND age ≥35 years
• Current/history of VTE, DVT or pulmonary embolism
• Migraine with aura (any age)
• Active breast cancer (current)
• Severe hypertension (≥160/100) or vascular disease
• Known ischaemic heart disease / stroke
• Active liver disease, hepatocellular adenoma/carcinoma
• <21 days post-partum (esp. if breastfeeding)
• Major surgery with prolonged immobilisation
• Diabetes with end-organ damage

Mnemonic for COC absolute contraindications – "My CLOTH BURNS": Migraine with aura, Cardiac/ischaemic disease, Liver tumour, Old smoker ≥35 + ≥15/day, Thromboembolism, Hypertension severe, Breast cancer, Undiagnosed bleeding, Nursing <6 wk, Surgery with immobilisation.

Missed pill rule: 1 missed pill → take it as soon as remembered, continue normally. ≥2 missed → take the most recent, use backup contraception for 7 days; if in week 3, skip the pill-free interval.

Progestogen-only methods

• Progestogen-only pill (POP / "minipill") — taken continuously without a break; relies more on cervical mucus thickening. Ideal in lactating women and where oestrogen is contraindicated. Strict timing (within 3 h window for traditional POP).
• DMPA (Depot medroxyprogesterone acetate) — 150 mg IM every 3 months; under India's Antara programme. Causes amenorrhoea, possible reversible bone mineral density loss, and a delay in return of fertility (up to 6–12 months). NET-EN is every 2 months.
• Subdermal implants — Implanon/Nexplanon (etonogestrel, 3 yr), Norplant (levonorgestrel, 5 yr); the most effective reversible method.
• Centchroman (Ormeloxifene/Saheli) — India's indigenous non-hormonal SERM; taken twice weekly for 12 weeks then once weekly. Acts by creating asynchrony between endometrial development and ovulation.

High-yield: Centchroman (Ormeloxifene) is the once-a-week non-steroidal oral contraceptive marketed as Saheli/Chhaya; it is a SERM and a favourite single-best-answer in Indian PSM papers.

Natural / fertility-awareness & LAM

• Calendar (rhythm) method — abstain during the fertile window (~day 8–18 of a 28-day cycle); high failure.
• Basal body temperature — rises 0.3–0.5°C after ovulation (progesterone effect).
• Cervical mucus (Billings) method — fertile mucus is clear, stretchy (spinnbarkeit).
• Lactational amenorrhoea method (LAM) — effective ONLY if all three hold: exclusive breastfeeding + amenorrhoea + infant <6 months.

High-yield: LAM is ~98% effective only when all three LAM criteria are met simultaneously.

Emergency (post-coital) contraception

Method	Timing	Notes
Levonorgestrel 1.5 mg	within 72 h (best <24 h)	Most used; OTC; delays/inhibits ovulation
Ulipristal acetate 30 mg	within 120 h (5 days)	Progesterone-receptor modulator; more effective late
Yuzpe regimen (EE + LNG)	within 72 h	Older, more nausea
Copper IUCD	within 5 days	Most effective EC; also gives ongoing contraception

High-yield: The copper IUCD inserted within 5 days is the most effective form of emergency contraception (failure <1%). Levonorgestrel EC works mainly by inhibiting/delaying ovulation and does NOT disrupt an established pregnancy (not abortifacient).

Surgical / terminal methods

Female sterilisation

• Pomeroy technique — a loop of tube is ligated with absorbable (catgut) suture and the loop excised; the commonest classical method, often via minilaparotomy ("minilap") post-partum.
• Modified Pomeroy, Parkland, Irving, Madlener, Uchida are variants.
• Laparoscopic — application of Falope (Yoon) ring or Filshie clip.
• Timing: interval, post-partum (within 7 days, usually 24–48 h via minilap as the uterus is high and tubes accessible), or concurrent with caesarean/abortion.

High-yield: Pomeroy is the classic tubal ligation technique using absorbable suture; minilap is the preferred approach for post-partum sterilisation in India's programme.

Male sterilisation (vasectomy)

• Ligation/occlusion of the vas deferens; simpler, safer, cheaper than female sterilisation.
• No-scalpel vasectomy (NSV) is promoted in the national programme.
• NOT immediately effective — requires ~3 months or 15–20 ejaculations to clear residual sperm; confirm with semen analysis (azoospermia) before relying on it. Use backup contraception meanwhile.

High-yield: Vasectomy is not effective immediately; the man is azoospermic only after ~3 months / 20 ejaculations — the single most-tested vasectomy fact.

Complications & key differential considerations

• IUCD with pregnancy — if strings visible and pregnancy <12–14 wk, remove the device to reduce septic abortion/preterm risk; high background ectopic risk.
• COC and surgery/immobilisation — stop 4 weeks before major elective surgery (VTE risk).
• DMPA — counsel about reversible bone loss and fertility delay; not first-line for adolescents needing rapid reversibility.
• Differentiating EC mechanisms — LNG/ulipristal act pre-ovulation (contraceptive, not abortifacient); mifepristone in higher dose is abortifacient (distinct concept).

Recently asked / exam angle

• Pearl Index calculation and ranking methods by failure rate (implant lowest among reversible; "no method" ~85).
• COC absolute contraindications — migraine with aura, smoker ≥35 yr & ≥15/day, history of VTE — repeatedly tested as "WHO MEC category 4."
• Cu-T 380A — effective life 10 years; PPIUCD insertion within 48 h, else defer to 6 weeks.
• Most effective emergency contraception = copper IUCD within 5 days; LNG-EC window 72 h, ulipristal 120 h.
• Centchroman/Ormeloxifene — once-weekly non-hormonal SERM (Saheli).
• Pomeroy technique uses absorbable suture; minilap for post-partum sterilisation.
• Principal COC mechanism = ovulation suppression.
• DMPA schedule (every 3 months) and BMD/fertility-delay side effects under Antara.
• LAM criteria triad.
• Single-rod implant Implanon = lowest Pearl Index reversible method.

Rapid revision

1. Pearl Index = pregnancies × 1200 ÷ total months of exposure; lower = better.
2. Most effective reversible method = implant / LNG-IUS (≈0.05–0.2).
3. Only STI-protective method = condom.
4. Cu-T 380A lasts 10 years; PPIUCD within 48 h, else wait 6 weeks.
5. Copper IUCD acts mainly before fertilisation (spermicidal copper + sterile inflammation).
6. COC works chiefly by ovulation suppression.
7. COC MEC-4: migraine with aura, VTE history, smoker ≥35 & ≥15/day, active breast cancer, severe HTN.
8. DMPA = IM every 3 months; causes amenorrhoea, reversible bone loss, delayed fertility.
9. Centchroman (Ormeloxifene/Saheli) = once-weekly non-hormonal SERM OCP.
10. LNG emergency pill within 72 h, ulipristal within 120 h, copper IUCD (most effective) within 5 days.
11. Pomeroy = absorbable suture; minilap for post-partum female sterilisation.
12. Vasectomy is effective only after ~3 months / 20 ejaculations (confirm azoospermia).