Family planning

Family planning is the management of reproduction by individuals and couples to prevent pregnancy, optimize pregnancy spacing, determine the number of children conceived, and/or address infertility with the use of family planning services. A reproductive life plan establishes family planning goals in alignment with the individual's personal values and priorities and should be discussed with all individuals of reproductive age, regardless of race, ethnicity, sexual orientation, gender identity, or current contraception use. If preventing pregnancy is the goal, contraceptive options are provided, including emergency contraception. If pregnancy is the goal, guidance on achieving pregnancy, pregnancy spacing, and basic infertility management are offered as needed; preconception care is also provided to optimize physical and mental health. Family planning services also include diagnosis of pregnancy and counseling on pregnancy options, STI care, and other adult health maintenance related to reproductive health.

See also “Contraception.”

• Determine the individual's reproductive life plan, i.e., their goals related to conceiving or preventing pregnancy, in alignment with their values and priorities. ^[4][5]
• Offer the following as needed: ^[5]
  • Contraception and emergency contraception
  • For individuals wanting to conceive, offer guidance on preconception care, including:
    • Timing of conception, including pregnancy spacing
    • Optimizing management of preexisting medical, psychiatric, and gynecological conditions
    • Advice on how to achieve pregnancy
  • Infertility counseling and basic evaluation ^[4][5]
  • Pregnancy diagnosis and follow-up (including for unintended pregnancy)
• Address adult health maintenance related to reproductive health, including:
  • STI care (STI screening, STI prevention)
  • Cancer screening (breast cancer screening, cervical cancer screening)
  • Immunizations (e.g., HPV vaccine, HepB vaccine)
• See also “Reproductive health care for transgender individuals.”

Review an individual's reproductive life plan at every visit, as it may change. ^[5]

Because almost half of pregnancies in the US are unplanned, all individuals who can become pregnant are advised to take folic acid supplementation. ^[6]

Preconception care is intended to prepare an individual for a planned pregnancy and reduce the risk of adverse outcomes by optimizing health. ^[4]

General principles ^[4][5][7]

• Should be provided at any clinical encounter to anyone who wishes to conceive
• Many of the principles are the same as prenatal care.
• Comprehensive care includes:
  • Identification and treatment of physical and mental health conditions that may affect pregnancy
  • Genetic carrier counseling
  • Counseling on timing of conception
  • Ensuring patients are up-to-date with recommended immunizations, especially MMR and varicella vaccines
  • Preconception counseling on diet and lifestyle recommendations

Common chronic medical conditions that affect pregnancy ^[4][5][7]

Optimize control of medical conditions before conception. ^[4]

Teratogenic medications

• Screen both partners for use of teratogenic medications (see also “Pharmacotherapy during pregnancy”). ^[4][7][11]
• Make medication adjustments before discontinuing contraception.
  • Consider changing to safer medication, reducing the dose, or, if safe, stopping the medication.
  • Consult a specialist if there are no safe alternatives or the medication should not be stopped.

Genetic carrier screening ^[4][12]

• Offer to all individuals seeking preconception care ^[4]
• Provide or refer for genetic counseling prior to testing. ^[12]

Recommended tests ^[4]

• Spinal muscular atrophy and cystic fibrosis testing ^[4]
• Additional testing is considered for individuals with:
  • A family history of:
    • Genetic disorders (e.g., familial adenomatous polyposis, fragile X syndrome) or major congenital anomalies ^[4][7]
    • Cancers associated with hereditary cancer syndromes (e.g., ovarian, breast, colon) ^[4]
  • Descent from a racial or ethnic group with an increased prevalence of certain autosomal recessive disorders ^[4][12]

Individuals may choose to decline recommended genetic testing (e.g., for cultural or religious reasons). ^[12]

Further management

If genetic testing is positive:

• Offer testing to their reproductive partner (especially for autosomal recessive disorders). ^[12]
• Refer for further genetic counseling if: ^[12]
  • The individual has an autosomal dominant genetic disorder
  • Both the individual and their partner are carriers of an autosomal recessive disorder

• Gynecology referral is required for management of conditions that may affect fertility, e.g.: ^[13]
  • Leiomyomas ^[14][15]
  • Endometriosis ^[16]
  • Polycystic ovary syndrome
• Specialist referral is required for individuals with a history of obstetric complications, e.g.: ^[5][17]
  • Miscarriage or stillbirth
  • Preeclampsia
  • Premature birth
• Individuals with previous high-risk pregnancies or pregnancy loss may require additional psychological support. ^[17]

• Screen for intimate partner violence; reproductive coercion is a common manifestation. ^[4]
• Screening for and management of psychiatric conditions and substance use is similar to in pregnancy; see “Prenatal psychosocial screening.” ^[4]
• Optimize management of mental health conditions before conception.
• For individuals with preexisting mental health conditions, liaise with psychiatry to consider: ^[18][19][20]
  • Trial of medication discontinuation or dose reduction
  • Modifying medications to avoid polypharmacy and teratogenic medications
  • Additional psychological support
• Advise complete abstinence from tobacco products, alcohol, and recreational drug use.

Provide education (similar to prenatal patient education) on diet, exercise, and safe environments.

• Advise individuals to maintain a normal body weight prior to conception. ^[7]
• Discuss dietary recommendations, including:
  • Vitamin and mineral supplementation in pregnancy, including:
    • Initiating prenatal folic acid supplementation at least 1 month before conception ^[4][7]
    • Sufficient intake of other micronutrients (e.g., calcium, iron, vitamin B₁₂, vitamin B₉, vitamin D) ^[4]
  • Dietary restrictions during pregnancy, e.g., reduced intake of seafood with potentially high levels of mercury ^[7]
• Recommend 150 minutes of moderate-intensity exercise or 75 minutes of vigorous activity per week. ^[7]
• Avoid teratogenic exposures, e.g.:
  • Teratogenic medications, alcohol, recreational drugs, and tobacco products (including secondhand smoke) ^[21]
  • Environmental risk factors, e.g., lead paint, asbestos, pesticides, bisphenol A, organic solvents, and radiation exposure ^[4][7]

For individuals planning conception, advise on the optimal timing of the first and any subsequent pregnancies.

Optimal timing

• Advise individuals to address risk factors for adverse outcomes (e.g., optimize management of medical conditions, complete recommended immunizations, start folic acid supplementation) before trying to conceive.
• Recommend delaying conception in individuals who:
  • Received a live vaccine (e.g., MMR, varicella vaccine) in the previous 28 days ^[22]
  • Recently traveled to an area with high risk for Zika ^[23]
  • Recently used teratogenic medications, e.g., methotrexate for ectopic pregnancy ^[24]
  • Had bariatric surgery in the previous 12–24 months ^[7]
• Individuals can try to conceive immediately after stopping contraception. ^[25][26]

Pregnancy spacing

• Pregnancy spacing is intended to reduce the risk of adverse pregnancy outcomes, including: ^[27]
  • Maternal outcomes (e.g., mortality, severe morbidity) ^[28]
  • Fetal outcomes (e.g., SGA, preterm birth) ^[29]
• An interval of at least 18 months is recommended between a live birth and the next pregnancy. ^[27][30]
• Individuals can try to conceive as soon as they are ready after:
  • Miscarriage or induced abortion ^[31]
  • Stillbirth ^[17][32]
• Tailor counseling as needed. ^[4]
  • Shorter interpregnancy intervals are associated with a higher risk of adverse pregnancy outcomes in women with prior:
    • Preterm deliveries
    • Cesarean deliveries ^[4]
  • Intervals of 6–18 months between delivery of a live birth and the next pregnancy may be considered in certain situations. ^[4]

• Fertility awareness-based methods of contraception may be used to identify the fertile window. ^[5][33]
• Advise individuals to have intercourse every 1–2 days during the fertile window. ^[5][33]
• Conception rates per cycle vary based on age; advise both individuals to seek infertility evaluation if they have not conceived after: ^[4]
  • 1 year if the woman is aged ≤ 35 years of age
  • 6 months if the woman is aged > 35 years of age ^[13]

Advise individuals to make an appointment once they become pregnant to ensure correct determination of gestational age and estimated date of delivery. ^[4]

• Definition: an evaluation for couples who have not conceived after 1 year of unprotected vaginal intercourse if the woman is ≤ 35 years of age or 6 months if > 35 years of age, and counseling for individuals and couples who are infertile, sterile, or not physically able to conceive (e.g., same-sex couples, individuals with reproductive organ disorders such as Mullerian agenesis) ^[4]
• Goals
  • Offer counseling on optimizing fertility (i.e., sexual and lifestyle practices relating to conceiving). ^[37]
  • 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.