 The modern scientific forms of natural family

planning include the following except:

 a. rhythm
 b. cervical mucous (Billings )
 c. symptothermal
 d .standard days (SDM).
 A.These are called fertility awareness
methods. The woman learns how to tell
when the fertile time of her cycle starts
and ends.
 cervical secretions
 feel of cervix
 bbt
NFP: Mechanism of Action

For contraception:
 Avoid intercourse during the fertile phase
of the menstrual cycle when conception is
most likely.
For conception:
 Plan intercourse near mid-cycle (usually
days 1015) when conception is most
likely.
NFP: Contraceptive Benefits

 Can be used to prevent or achieve pregnancy

 No method-related health risks
 No systemic side effects
 Inexpensive
NFP: Noncontraceptive
Benefits
 Improved knowledge of reproductive
system
 Possible closer relationship between
couple
 Increased male involvement in family
planning
BILLINGS METHOD

 A woman records what SHE FEELS

AND SEES
 Peak day is last day of wetness
 Fertile days end 2 days after the peak
BASAL BODY
TEMPERATURE
 Temp is taken daily and recorded.
 Discard the 1st 5 readings.Draw a
horizontal line across the highest temp
from day 6-10.This is the coverline.
 Continue taking temp until there’s a
thermal shift .
 Draw a vertical line between says 2-3 of
the shift. Woman is safe from day 3
onwards.
 NFP: Client Instructions for
BBT Method continued
 The infertile phase begins on the evening of the third consecutive
day that temperature stays above the cover line (Thermal Shift
Rule).
 Abstain from sexual intercourse from beginning of menstrual
period until beginning of infertile phase.
 If any of 3 temperatures falls on or below cover line during 3-day
count, this may be a sign that ovulation has not yet taken place.
To avoid pregnancy, wait until 3 consecutive temperatures are
recorded above cover line before resuming intercourse.
 After infertile phase begins, you may stop taking temperature until
next menstrual cycle begins and continue to have intercourse until
first day of next menstrual period.
SYMPTOTHERMAL METHOD

 Combination of Billings and BBT

 Woman is safe from the 3rd day of the
shift or the peak whichever comes later
NFP: Conditions Requiring
Precautions
 Irregular menses
 Persistent vaginal discharge
 Breastfeeding
NFP: Limitations

 Moderately effective (125 pregnancies per

100 women during the first year of use)
 Effectiveness depends on willingness to
follow instructions
 Considerable training required to use
correctly
 Requires trained provider (nonmedical)
 Requires abstinence during fertile phase to
avoid conception
NFP: Limitations continued

 Requires daily record keeping

 Vaginal infections make cervical mucus
difficult to interpret
 Basal thermometer needed for some
methods
 Does not protect against STDs (e.g.,
HBV, HIV/AIDS)
NFP: Who May Require
Additional Counseling
Women:
 Whose age, parity or health problems make
pregnancy a high risk
 Without established menstrual cycles
(breastfeeding, immediately postabortion)
 With irregular menstrual cycles (calendar
method only)
 Whose partner will not cooperate (abstain)
during certain times in the cycle
 Who dislike touching their genitals
STANDARD DAYS METHOD
 The brown beads of the necklace used
in SDM represent the :
 a.1st day of menses
 b. fertile period
 c. safe period
 The brown beads represent the safe
period
 Red –menses
 White –fertile period
 FOR WOMEN WITH CYCLES
RANGING FROM 26-32 DAYS
 MUST BE STRONGLY MOTIVATED
LACTATION AMENORRHEA
 LAM: Mechanisms of Action
Frequent intense suckling
disrupts secretion of
gonadotrophin releasing
hormone (GnRH)

Irregular secretion of GnRH

interferes with release of
follicle stimulating hormone
(FSH) and leutinizing
hormone (LH)
Decreased FSH and LH
disrupts follicular
development in the ovary to
suppress ovulation

31
 lactation amenorrhea

 A 25 year old G1P1breastfeeding mother

wants to use LAM. What conditions must
she fulfill ?
 The baby gets at least 85 % of feedings
from the breast ,day and night
 No menses
 Baby is less than 6 months old
 COCs act by :
 a. preventing ovulation
 b. thickening the cervical mucous
 c .disrupting existing pregnancy
 COCs: Mechanisms of Action

Suppress ovulation

Reduce sperm transport

in upper genital tract
(fallopian tubes)

Change endometrium making

implantation less likely

Thicken cervical mucus

(preventing sperm
penetration)

36
Types of COCs

 Monophasic: All 21 active pills contain

same amount of Estrogen/Progestin
(E/P)
 Biphasic: 21 active pills contain 2
different E/P combinations (e.g., 10/11)
 Triphasic: 21 active pills contain 3
different E/P combinations (e.g., 6/5/10)

37
How to Start

 OCPs can be started on:

 a. any of the 1st 5 days of menses
 b.3-6 wks after childbirth if not
breastfeeding
 c. within a wk after an abortion
 d. any other time as long as she’s not
pregnant
 COCs: Contraceptive Benefits
 Highly effective when taken daily (0.151 pregnancies per
100 women during the first year of use)
 Effective immediately if started by day 7 of menstrual
cycle
 Pelvic examination not required to initiate use
 Do not interfere with intercourse
 Few side effects
 Convenient and easy to use
 Client can stop use
 Can be provided by trained nonmedical staff

1
Hatcher et al 1998. 39
COCs: Noncontraceptive
Benefits
 Decrease menstrual flow (lighter, shorter periods)
 Decrease menstrual cramps
 May improve anemia
 Protect against ovarian and endometrial cancer
 Decrease benign breast disease and ovarian cysts
 Prevent ectopic pregnancy
 Protect against some causes of PID

40
 Other advantages include:
 very effective if used correctly
 regulates menses
 can be used by any age group
 prevents iron deficiency anemia
 helps prevent ovarian cysts ,ectopic
pregnancy
 COCs can be used by the following
except :
 a. those with irregular period
 b. varicose veins
 c. Tb
 d. Bp=140/90
 If initial BP reading is 140/90 prescribe
condom and ask her to come back.If BP
remains elevated ,prescribe another
method.
 If BP drops she can use COCs.
 Missed PILLS ?
 1.pill-take 1 as soon as you remember
 2 pills in the 1st wk –avoid sex ,use
backup method
 2 pills in the 2nd wk-take a pill ASAP ,take
next pill at usual time, continue taking
the rest as usual
 3rd wk-go straight to the next pack
 Your patient has severe vomiting within
2 hours of intake of pills. What do you
advise?
 a. just take anti-emetics
 b. proceed with the missed pell regimen
 c. a + b
C
 the effect of vomiting is similar to those
missing a pill
 Your patient is afraid to take OCPs
because of a family history of breast Ca.
What do you advise
 OCPs are protective towards ovarian
and endometrial Ca
 Results for breast and cervical Ca are
equivocal. Some show that they are
more common among pill users ,some
do not.More studies are being
conducted.
 Can a smoker take the pill ?
 Yes ,as long as she’s less than 35 years
of age .Older women should choose
another method. If she cannot stop she
can take the POP. Caution all smokers
its dangerous to their health.
 COCs: Conditions Requiring
Precautions (WHO Class 3)
COCs are not recommended unless other methods are not available or acceptable if a woman:
 Is < 3 weeks postpartum (even if not breastfeeding)

 Has unexplained vaginal bleeding (only if serious problem suspected)

 Has high blood pressure ( 160/100 and < 180/110)

 Has a history of breast cancer

 Has symptomatic gall bladder disease

 Is taking drugs for epilepsy (phenytoin or barbiturates) or tuberculosis (rifampin)

Source: WHO 1996. 51

 COCs: Who Should Not Use
(WHO Class 4)
COCs should not be used if a woman:
 Is pregnant (known or suspected)
 Is breastfeeding (< 6 weeks postpartum)
 Is jaundiced (symptomatic viral hepatitis or
cirrhosis)
 Has ischemic heart disease or stroke
(current or history of)
 Has blood clotting disorders (deep vein
thrombophlebitis or pulmonary embolus)
Source: WHO 1996. 53
 COCs: Who Should Not Use
(WHO Class 4) continued
COCs should not be used if a woman:
 Is a smoker and age 35 years or older
 Has diabetes (> 20 years duration)
 Has headaches (migraine)
 Has high blood pressure (> 180/110)
 Has breast cancer
 Has liver tumors
 Has to undergo major surgery with
prolonged bed rest
Source: WHO 1996. 54
 POPs: Mechanisms of Action

Suppress ovulation

Reduce sperm transport

in upper genital tract
(fallopian tubes)

Change endometrium making

implantation less likely

Thicken cervical mucus

(preventing sperm
penetration)

55
 A breast feeding mom who is a smoker
on her 5th week postpartum wants to
take the POP. What precautions will you
tell her
 POPs can be used by smokers
 Must be started on the 6th week
postpartum
 Must be taken at the same time everyday
 There is no rest period in between packs
 Higher risk for ectopic pregnancy (1 0f 10 )
 Does not affect flow of breast milk
 Does it matter what time of the day she
takes her POP?
 Yes,if she's not breastfeeding. Since
POP contains minimal hormone there’s
danger of ovulation if she takes it later
than 3 hours.If this happens she take the
missed pill as soon as she remembers
and use a back-up method.
 POPs: Drug Interactions
Most interactions relate to increased liver metabolism of levonorgestrel:
 Rifampin (tuberculosis)
 Anti-epilepsy (seizures):
 Barbiturates, phenytoin, carbamzepine (but not valproic acid)
 Griseofulvin (long-term use only)

59
POPs: Conditions for Which
There Are No Restrictions
 Blood pressure (< 180/110)
 Diabetes (uncomplicated or < 20 years
duration)
 Pre-eclampsia (history of)
 Smoking (any age, any amount)
 Surgery (with or without prolonged bed rest)
 Thromboembolic disorders
 Valvular heart disease (symptomatic or
asymptomatic)
60
POPs: Warning Signs

Return to clinic if any of the following

occur:
 Delayed menstrual period after several
months of regular cycles (may be sign of
pregnancy)
 Severe lower abdominal pain
 Heavy or prolonged bleeding
 Migraine headaches

61
 POPs: Conditions Requiring
Precaution (WHO Class 3)
POPs are not recommended unless other methods are not available or
acceptable if woman:
 Is breastfeeding (< 6 weeks postpartum)
 Has unexplained vaginal bleeding (only if serious problem suspected)
 Has breast cancer (current or history)
 Is jaundiced (active, symptomatic)

Source: WHO 1996. 62

DMPA

 T he breastfeeding mom mentioned

earlier wanted to try DMPA instead.
Upon further questioning you find out
she has a BP of 170 /110 and a Hb of 9.
Her FBS is 140 gm .What will you tell
her?
PICs: Mechanisms of Action

Suppress ovulation

Reduce sperm
transport in
fallopian tubes

Change endometrium

Thicken cervical
mucus (prevent
sperm penetration)
Types of PICs

 Depo-Provera (DMPA): 150 mg of

depot-medroxyprogesterone acetate
given every 3 months
 Noristerat (NET-EN): 200 mg of
norethindrone enanthate given every 2
months
PICs: Use in Breastfeeding
Women
 May increase quantity of breastmilk
 Have no effect on:
 Initiation or duration of breastfeeding
 Quality of breastmilk
 Growth and development of infants
 Long-term growth and development of
children through adolescence
 PICs: Contraceptive Benefits

 Highly effective (0.31 pregnancies per 100

women during first year of use)
 Rapidly effective (< 24 hours) if started by day 7
of menstrual cycle
 Intermediate-term method (2 or 3 months
protection per injection)
 Pelvic examination not required to begin use
 Do not interfere with intercourse

1
Trussell et al 1998. Note: This efficacy rate refers only to DMPA.
 If systolic BP below 160 and diastolic
below 100 ,ok to use DMPA.IF higher
better to use another method.
 It can cause mild glucose intolerance but
can be used by women without vascular
disease .
 A 16 year old wants to use DMPA
because no one can tell she’s using it.
What will you tell her?
 At present there’s concern that DMPA
use in girls below 18 might affect bone
development and cause osteoporosis.
 Can a pregnant woman use DMPA?
 It is best avoided but it is not harmful to
the mother nor to fetus. One study
suggests that the baby may be born
SGA.
 What to do if she’s late for her injection
and sexually active ?
 Check for pregnancy.
 If not pregnant ,continue and use back
up method
 Disadvantages of DMPA
 causes changes in menstrual bleeding
 delayed return to fertility
 Breast tenderness ,headaches
,moodiness ,nausea, hair loss ,less sex
drive ,acne
PICs: Limitations
 Changes in menstrual bleeding pattern
 Irregular bleeding/spotting initially in most women
 Weight gain ( 2 kg) is common
 Although pregnancy is unlikely, if pregnancy occurs, it is
more likely to be ectopic than in a nonuser
 Resupply must be available
 Must return for injections every 3 months (DMPA) or 2
months (NET-EN)
 Return to fertility may be delayed for 79 months (on
average) after discontinuation
 PICs: Management of Irregular
Bleeding
Prolonged spotting (> 8 days) or moderate
bleeding:
 Reassurance
 Check for gynecologic problem (e.g.,
cervicitis)
 Short-term treatment:
 COCs (30-50 µg EE) for 1 cycle1, or
 Ibuprofen (up to 800 mg 3 times daily x 5
days)
Remind client to expect bleeding after completing COCs.
1
 PICs: Conditions Requiring
Precautions (WHO Class 3)
PICs are not recommended unless other methods are not
available or acceptable if a woman:
 Is breastfeeding (< 6 weeks postpartum)

 Is jaundiced (symptomatic viral hepatitis or cirrhosis)

 Has high blood pressure ( 180/110)

 Has ischemic heart disease (current or history)

 Has had stroke

 Has liver tumors (adenoma or hepatoma)

 Has diabetes (> 20 years duration)

Source: WHO 1996.

 PICs: Who Should Not Use
(WHO Class 4)
PICs should not be used if a woman:
 Is pregnant (known or suspected)
 Has unexplained vaginal bleeding (if
serious problem suspected)
 Has breast cancer

Source: WHO 1996.

 Another form of available injectable:
 NET EN (norethindrone enanthate )
 given every 2 months
 1ml preparation ,200mg
 30% develop amenorrhea
 pregnancy rate=0.4% (1/250)
 no effect on glucose tolerance

PATCH

 What should you look out for with the

patch?
 A woman using the patch is exposed to
more estrogen than those taking the pill.
There is a higher risk of blood clots and
cardiovascular problems especially if the
client is a smoker.
 Male Condoms: Mechanisms
of Action
Prevent sperm from
gaining access to female
reproductive tract

Prevent microorganisms
(STDs) from passing from
one partner to another
(latex and vinyl condoms
only)

83
CONDOMS

 How can a woman get her sex partner to

use a condom?
 Condoms prevent pregnancy as well as
STI .
 Prevents premature ejaculation
 Not just for prostitutes
 Easy to use
Types of Male Condoms

 Latex (rubber)
 Plastic (vinyl)
 Natural (animal products)

85
 Male Condoms: Limitations

 Moderately effective (314 pregnancies

per 100 women during the first year1)
 Effectiveness as contraceptives depends
on willingness to follow instructions
 User-dependent (require continued
motivation and use with each act of
intercourse)
 May reduce sensitivity of penis, making
maintenance of erection more difficult
1
Trussell et al 1998.
86
Male Condoms: Contraceptive
Benefits
 Effective immediately
 Do not affect breastfeeding
 Can be used as backup to other methods
 No method-related health risks
 No systemic side effects
 Widely available (pharmacies and community
shops)
 No prescription or medical assessment necessary
 Inexpensive (short-term)

87
Who Can Use Male Condoms
 Men who wish to participate actively in family planning
 Couples who need contraception immediately
 Couples who need a temporary method while awaiting
another method (e.g., implants, IUD or voluntary
sterilization)
 Couples who need a backup method
 Couples who have intercourse infrequently
 Couples in which either partner has more than one
sexual partner (at high risk for STDs, including HBV and
HIV/AIDS), even if using another method

88
 How to Remove a Male
Condom
After ejaculation and
while penis is still
hard, hold base of
condom and carefully
withdraw penis from
vagina. Pull condom
off penis gently, being
careful semen does not
spill out.

Source: WHO 1997.

90
 Male Condom Use: What to
Say
When He Says
When he says:
“I’ll lose my erection by
the time I stop and put it
on.
“By the time I put it on; I
won’t be in the mood.”
“It’s so messy and it
smells funny.”
Source: AIDSTECH, AMREF and National AIDS Control Programme 1992.
You can say:
“I can help you put it on.
That should give you lots
of extra sensations and
help keep you in the
mood.”
“Well, sex is like that. But
this way we’ll be safe.”
91
 Male Condom Use: What to
Say
When He Says
When he says: You can say:
“Condoms are “STDs, especially
unnatural, fake, a AIDS are a turnoff
total turnoff.” too.”
“You never asked “This will help to
me to use a prevent infection
condom before.” or reinfection.”

Source: AIDSTECH, AMREF and National AIDS Control Programme 1992. 92

 Male Condom Use: What to
Say
When He Says
When he says: You can say:
“Just this once.” “Once is all it takes.”
“I don’t have a “I do.”
condom with me.”

Source: AIDSTECH, AMREF and National AIDS Control Programme 1992. 93

 Male Condom Use: What to
Say
When He Says
When he says:
“I can’t feel anything. It’s
like wearing a raincoat.”
“I know I’m clean
(disease-free); I haven’t
had sex with anyone in _
months.”
Source: AIDSTECH, AMREF and National AIDS Control Programme 1992.
You can say:
“I know there is some
reduced sensation, but
there is still plenty of
sensation left.” (Open
condom and feel how thin
it is.)
“Thanks for telling me. As
far as I know, I’m disease-
free too. But I’d still like to
use a condom since either
of us could have an
infection and not know it.”
94
 Male Condoms: Management
of Common Side Effects
Allergic reactions, although uncommon, can be uncomfortable and possibly dangerous.
 Allergic reaction to condom or local irritation to penis:

 Ensure that condom is not medicated.

 If reaction persists, consider natural condoms (lambskin or gut) or another method.1

 Help client choose another method.

 Allergic reaction to spermicide:

 If symptoms persist after intercourse and no evidence of STD, provide another spermicide or a nonmedicated condom or
help client choose another method.

1
Natural condoms do not provide protection against STDs (e.g., HBV, HIV/AIDS) and should
95
not be used by those at risk.
Male Condoms: Client
Instructions
 Use a new condom every time you have
intercourse.
 Use a spermicide with condom for maximum
effectiveness and protection.
 Do not use teeth, knife, scissors or other
sharp utensils to open package.
 The condom should be unrolled onto erect
penis before penis enters vagina, because
pre-ejaculatory semen contains active sperm.

96
Male Condoms: Client
Instructions continued
 If the condom does not have an enlarged end
(reservoir tip), about 12 cm should be left at
the tip for the ejaculate.
 While holding on to the base (ring) of the
condom, withdraw penis before losing
erection. This prevents condom from slipping
off and spilling semen.
 Each condom should only be used once.
 Dispose of used condoms by placing in a
waste container, in latrine or burying.
97
 Female Condoms:
Mechanisms of Action
Prevent sperm from
gaining access to female
reproductive tract

Prevent microorganisms
(STDs) from passing from
one partner to another

99
Female Condoms:
Contraceptive Benefits
 Effective immediately
 Do not affect breastfeeding
 Do not interfere with intercourse (may be inserted up to 8
hours before)
 Can be used as backup to other methods
 No method-related health risks
 No systemic side effects
 No prescription or medical assessment necessary
 Controlled by the woman

100
IUD

 Types:
 Copper bearing
 Hormone releasing (Mirena )
 Inert (Lippes loop)
Types of Medicated IUDs

Copper-releasing: Progestin-releasing:

 Copper T 380A  Progestasert

 Nova T  LevoNova (LNG-
 Multiload 375 20)
 Mirena

103
 Copper IUDs: Mechanisms of
Action

Interfere with
reproductive process
Interfere with ability before ova reach
of sperm to pass uterine cavity
through uterine
cavity
Change
Thicken cervical endometrial
mucus lining

105
 IUDs: Contraceptive Benefits

 Highly effective (0.60.81 pregnancies per

100 women during the first year of use for
Copper T 380A)
 Effective immediately
 Long-term method (up to 10 years
protection with Copper T 380A)
 Do not interfere with intercourse
 Immediate return to fertility upon removal
 Do not affect breastfeeding
1
Trussell et al 1998.
106
 Who Can Use IUDs
Women of any reproductive age or parity who:
 Want highly-effective, long-term contraception
 Are breastfeeding
 Are postpartum and not breastfeeding
 Are postabortion
 Are at low risk for STDs
 Cannot remember to take a pill every day
 Prefer not to use hormonal methods or should not use them
 Are in need of emergency contraception

107
 A 19 year old G0 came to you asking for
an IUD. She’s on her 14 day of the
cycle .Will you insert one ?
 A woman who never a pregnancy may
use an IUD altho’ it’s not the best
method for her. There is no minimum or
maximum age for its use. You may
insert one even if the woman is not
menstruating as long as your sure that
there is no pregnancy.
 Can a patient get an IUD just after
pregnancy or abortion?
 Yes ,it can be inserted after a vaginal
delivery or placed inside the uterus
during a CS. The person who does this
MUST BE PROPERLY TRAINED in this
method.
 Same is true post abortion. You must be
sure there is no infection before
insertion.
 Incidence of expulsion is higher.
 A patient complaining of heavy vaginal
menses came to your clinic.She has an
IUD for the past year.How will you
manage her?
 1.Reassure her that heavier menses is
more common among IUD users
especially during the 1st 6 months.
 2.Rule out any gyne problem
 3.Give iron supplements
 4.If patient desires ,remove or ifanemia
is severs remove.Help her choose
another method.
 A woman with an IUD comes to you
complaining of a lower abdominal
pain.Oral temp is 38.5 C ,with cervical
motion tenderness .Sex partner was
recently diagnosed with urethritis.
 Give the diagnosis and management .
 Consider PID.
 Treat immediately considering the range
of pathogens.
 Treat sexual partner.
 The IUD can stay in place if she
improves BUT if symptoms persist or
she develops an abscess remove.
 Schedule ff-up
 What to do if patient gets pregnant?
 If strings are visible and pregnancy is
less than 13 weeks, remove to avoid
risk of infection and pre mature birth
.Patient must be told removal can cause
abortion.
 If strings not visible or pregnancy is more
than 13 wks, observe closely. There’s an
increased risk of abortion or infection.
 The partner complains of the strings.
 Explain that he can really feel them
 cut them shorter
 Remove the IUD and provide another
method
NO TOUCH TECHNIQUE

 Load the inserter while still in the sterile

package
 Clean the cervix with antiseptic before
insertion
 Don’t touch the vaginal wall with the
sound or inserter
 Pass the sound or inserter through the
cervix only once
REMOVING theIUD
 Reasons for removal:
 patient’s request
 side effects
 medical reasons :
 pregnancy
 PID
 perforation
 partial expulsion
 abnormal bleeding
 menopause
 IUD has reached expiration date
 Checking the IUD
 once a week during the 1st month
 after manses
 if patient notices symptoms
 missed period
 exposure to STI
 longer strings /something hsrd in the vagina
 increasing pain
 IUDs: Conditions Requiring
Precautions (WHO Class 3)
IUDs are not recommended unless other
methods are not available or acceptable if
a woman has:
 Benign trophoblast disease
 More than one sexual partner
 A partner who has more than one sexual
partner

Source: WHO 1996. 121

BTL

 Should BTL / Vasectomy be offered only

to couples of a certain age / with a
certain number of children ?
 Is the partner’s consent necessary ?
 No.The client must not be limited to
temporary methods because of age or
parity.
 The partner’s consent is not needed
.The person has the right to make his/
her own decision .
Types of Tubal Ligation

 Postpartum
 Minilaparotomy (Infraumbilical)
 Interval
 Laparoscopy

124
Tubal LIGATION: Anesthesia

 Local anesthesia of choice

 Spinal–only in select cases
 obese
 associated (documented) pelvic pathology
 allergy to local anesthesia
 medical problems

126
 Who Can Use Tubal
LIGATION
Women:
 Who are age > 22 and < 45
 Who want highly effective, permanent protection against
pregnancy
 For whom pregnancy would pose a serious health risk
 Who are postpartum
 Who are postabortion
 Who are breastfeeding (within 48 hours or after 6 weeks)
 Who are certain they have achieved their desired family size
 Who understand and voluntarily consent to procedure

127
When to Perform
Tubal Ligation Procedure
 Anytime during the menstrual cycle you can be
reasonably sure the client is not pregnant
 Days 6–13 of menstrual cycle (proliferative phase
preferred)
 Postpartum: Within 2 days or after 6 weeks
If delivered at home and immunized (tetanus toxoid), can
be performed under antibiotic cover (if no sepsis).
 Postabortion: immediately or within 7 days, provided no
evidence of pelvic infection

128
 Tubal ligation: Contraceptive
Benefits
 Highly effective (0.51 pregnancies per 100 women during first year of use)
 Effective immediately
 Permanent
 Does not interfere with intercourse
 Good for client if pregnancy would pose a serious health risk
 Simple surgery, usually done under local anesthesia
 No long-term side effects
 No change in sexual function (no effect on hormone production by ovaries)

1
Trussell et al 1998. 129
Tubal Ligation:
Noncontraceptive Benefits
 Does not interfere with breastfeeding
 Decreased risk of ovarian cancer

130
 Tubal LIGATION: Conditions
Requiring Precautions (WHO
Class 3)
 Unexplained vaginal bleeding (until evaluated)
 Acute pelvic infection
 Acute systemic infection (e.g., cold, flu, gastroenteritis, viral hepatitis)
 Anemia (Hb < 7 g/dl)
 Abdominal skin infection
 Cancer of the genital tract
 Deep venous thrombosis

Appropriate precautions include delay of procedure until condition

improves or resolves.

Source: WHO 1996. 131

Warning Signs for
Tubal Ligation Clients
Return to clinic if following problems occur:
 Fever (greater than 38°C or 100.4°F)
 Dizziness with fainting
 Persistent or increased abdominal pain
 Bleeding or fluid coming from the incision
 Signs or symptoms of pregnancy

132
 Tubal Ligation: Client Issues
 The client should make the decision for sterilization voluntarily.
 The client has the right to change her mind anytime prior to the
procedure.
 The client should understand that voluntary sterilization (VS) is
a permanent (not easily reversible) method.
 No incentives should be given to clients to accept VS.
 A standard consent form must be signed by the client before
the VS procedure.
 Spousal consent is not required.

133
Tubal Ligation: Limitations
 Must be considered permanent (success of reversal
cannot be guaranteed)
 Client may regret later (age < 35)
 Small risk of complications
 Short-term discomfort and pain following procedure
 Requires trained physician (gynecologist or surgeon for
laparoscopy)
 Slightly decreased long-term effectiveness
 Increased risk of ectopic pregnancy
 Does not protect against STDs (e.g., HBV, HIV/AIDS)

134
 A 35 year G2P2 wants to have a BTL but
is concerned that she will get fat, and
weak. She is afraid that she might lose
her libido.How can you reassure her?
 After BTL the woman will look and feel
the same.She can have sex as before.In
fact it will be better because the fear of
pregnancy is no longer there.She will be
as strong as ever.
 Can BTL be reversed?
 It is possible for some women ,those
with enough tube left .However reversal
is difficult, and expensive .When
pregnancy occurs ,the risk of ectopic
pregnsncy is increased.Because of
these reasons , it is considered a
permanent method .
VASECTOMY

 Is it better for a man to undergo

vasectomy or for a woman to undergo
BTL?
 Each couple must decide on the method
they want.Both are very effective ,safe
,and permanent. Vasectomy tho’ is
simpler and safer to perform .It is less
expensive and slightly more effective .
Tubal Ligation: Who May
Require Additional Counseling
Women:
 Who cannot withstand surgery
 Who are uncertain of their desire for
future fertility
 Who do not give voluntary, informed
consent

140
Vasectomy: General
Information
 Vasectomy does not provide protection from pregnancy
until after 3 months, 20 ejaculations or when no sperm
are seen in a microscopically examined semen
specimen.
 Vasectomy will not affect sexual performance because
the testes still function normally.
 Vasectomy does not provide protection against STDs,
including AIDS. If either partner is at risk, the couple
should use condoms even after vasectomy.

141
Who Can Use Vasectomy
Men:
 Of any reproductive age (usually 50)
 Who want a highly effective, permanent contraceptive
method
 Whose wives have age, parity or health problems that
might pose a serious health risk if they become pregnant
 Who understand and voluntarily consent to the procedure
 Who are certain they have achieved their desired family
size

142
Vasectomy: Contraceptive
Benefits
 Highly effective (0.10.15 pregnancies per 100 women
during the first year of use)
 Permanent
 Does not interfere with intercourse
 Good for couples if pregnancy or tubal occlusion would
pose a serious health risk to the woman
 Simple surgery done under local anesthesia
 No long-term side effects
 No change in sexual function (no effect on hormone
production by testes)

143
 No-Scalpel Vasectomy
Failure rate:
 0.20.4%
Complications
 Hematoma
 Infection
 Epididymitis
Overall < 2%
Mortality < 0.001%

Source: Carignan 1995. 144

Vasectomy: Client Issues
 The client should make the decision for sterilization
voluntarily.
 The client has the right to change his mind anytime prior
to the procedure.
 The client should understand that voluntary sterilization
(VS) is a permanent (not easily reversible) method.
 No incentives should be given to clients to accept VS.
 A standard consent form must be signed by the client
before the procedure.
 Spousal consent is not required.

146
 Vasectomy: Limitations
 Must be considered permanent (not reversible)
 Client may regret later
 Delayed effectiveness (requires up to 3 months or 20 ejaculations)
 Risks and side effects of minor surgery, especially if general anesthesia is used
 Short-term discomfort/pain following procedure
 Requires trained physician
 Does not protect against STDs (e.g., HBV, HIV/AIDS)

147
Vasectomy: Postoperative
Problems
 Wound infection
 Hematoma
 Granuloma
 Excessive swelling
 Pain at incision site

149
 What advise to give post –op
 rest for 2 days
 avoid heavy work /lifting for a few days
 pain relievers may be used to ease
any pain
 wear snug underwear for 2-3 days to
support the scrotum
 put cold compress
 What if he complains of pain and
swelling?
 check the site for infection
 clean the wound
 give antibiotics