Family Planning: Definition, Classification, and Intrauterine Device (IUD)

1. Definition of Family Planning

"A way of thinking and living that is adopted voluntarily, upon the basis of knowledge, attitudes and responsible decisions by individuals and couples, in order to promote the health and welfare of the family group and thus contribute effectively to the social development of a country."

• (a) To avoid unwanted births
• (b) To bring about wanted births
• (c) To regulate the intervals between pregnancies
• (d) To control the time at which births occur in relation to the ages of the parents
• (e) To determine the number of children in the family

Note: Family planning is NOT synonymous with birth control - it is broader. Per a WHO Expert Committee (1970), it includes proper spacing/limitation of births, advice on sterility, sex education, genetic counselling, premarital consultation, screening for reproductive cancers, marriage counselling, and adoption services.

• Park's Textbook of Preventive and Social Medicine, p. 579

2. Classification of Contraceptive Methods

I. Spacing Methods

II. Terminal Methods

1. Male sterilization - vasectomy / non-scalpel vasectomy (NSV)
2. Female sterilization - laparoscopic tubal ligation / tubectomy

The present approach in family planning is to provide a "cafeteria choice" - offering all methods so that an individual can choose according to their needs and wishes.

• Park's Textbook of Preventive and Social Medicine, p. 581

3. Intrauterine Device (IUD)

3.1 Definition

3.2 Types of IUDs

Copper T380A (ParaGard) IUD - note copper wire on stem and copper bands on cross arms, total copper surface area 380 mm²

3.3 Mechanism of Action

• Cause the formation of a "biological foam" within the uterine cavity (fibrin, phagocytic cells, proteolytic enzymes)
• Stimulate prostaglandin formation - causing smooth muscle contraction and inflammation
• Copper ions produce an even greater local inflammatory response
• Alter surface morphology of endometrial cells (microvilli of ciliated cells)
• Major alterations in uterine protein composition, preventing sperm passage - primarily prevent fertilization

• Released levonorgestrel at ~20 µg/day (declining to 10 µg/day by year 5)
• Thickened and scant cervical mucus - prevents sperm penetration
• Endometrial atrophy
• Intrauterine inflammatory response
• About 85% of cycles remain ovulatory

3.4 Efficacy

3.5 Benefits

• Excellent long-term contraception with no continued effort required
• Both copper T380A and LNG-IUDs protect against ectopic pregnancy
• LNG-IUD reduces menstrual bleeding and cramping - used for menorrhagia (alternative to hysterectomy in Europe and UK)
• LNG-IUD effective for endometriosis, adenomyosis, uterine fibroids
• Reduces risk of endometrial cancer
• Fertility returns rapidly after removal (1-year pregnancy rate: 89 per 100 for women <30 years)

3.6 Risks and Complications

• Risk increased only in the first 20 days after insertion (WHO prospective study)
• Beyond 20 days, PID rate = 1.6 per 1,000 women/year (same as general population)
• Risk is primarily from STI exposure, not IUD itself
• HIV is NOT a contraindication for IUD use

• IUDs reduce absolute risk of ectopic by preventing most pregnancies
• But if pregnancy occurs with IUD in situ, risk of ectopic is higher (relative risk increased)

• 36-month cumulative expulsion rate: ~10 per 100 users
• Higher in females aged 14-19 years
• Higher after postplacental insertion (24-27%)

• Risk: ~1 per 1,000 insertions
• Higher risk when breastfeeding (RR 4.7 vs. non-lactating at ≤36 weeks postdelivery)

3.7 Contraindications (WHO Category 4 - Unacceptable Health Risk)

• Pregnancy
• Puerperal sepsis
• Active PID / purulent cervicitis
• Endometrial or cervical cancer
• Undiagnosed genital bleeding
• Gestational trophoblastic disease (with persistent elevated β-hCG)
• Uterine anomalies / fibroids distorting the endometrial cavity
• Copper-specific: Copper allergy, Wilson's disease

3.8 Insertion Technique (Key Steps)

1. Expose cervix with speculum; cleanse with bactericidal (iodine) solution
2. Measure uterine cavity with uterine sound - cavity should be ≥6 cm from external os
3. Grasp cervix with tenaculum (mandatory to prevent perforation); straighten cervical-uterine angle
4. Introduce IUD-loaded inserter through cervical canal
5. Release IUD arms at fundus; withdraw inserter; cut strings to ~2 cm from external cervical os

3.9 IUD in Pregnancy

• Berek & Novak's Gynecology, pp. 721-728
• Park's Textbook of Preventive and Social Medicine, p. 580