contraception and infertility

1. PRESENTED BY:-
MS. ABHILASHA
CHAUDHARY

2. CONTRACEPTION

3.  Contraception means all measures temporary
or permanent,designed to prevent pregnancy
due to the coital act.

4. Mainly two types of contraceptive methods
 Temporary ( Spacing Methods)
 Terminal ( Permanent Methods; Sterilization
Methods)

5. These are subclassified into five groups
 Barrier methods.
 Intrauterine devices.
 Hormonal methods.
 Postconceptional methods.
 Miscellaneous method.

6. These are subclassified into two:-
 Vasectomy.
 Tubectomy.

7. Barrier method
 Act as barrier between the sperms and the
ovum and sperm.
Three types
 Physical method.
 Chemical method.
 Combined method.

8. PHYSICALMETHODOF CONTRACEPTIVES
Available for both-
 Male.
 Female.
In MALE
Male Condom
 It is cylindrical shaped.
 Measuring 15 to 20 cm length, 3 cm
diameter, and 0.003 cm thick.
 It is closed at one end with a teat- end and
open at the other end, with an integral rim.

9.  Condom
 This condom is a thin sheath that covers the
penis to collect sperm and prevent it from
entering the woman's body. Male condoms
are generally made of latex or polyurethane

11.  Advantages
 Cheaper with no contraindications.
 No side effects.
 Easy to carry,simple to use and disposable.
 Protection against sexually transmitted
diseases, eg. Gonorrhea, Chlamydia, HPV and
HIV.
 Protection against pelvic inflammatory
disease.
 Useful where the coital act is infrequent and
irregular.

12.  Disadvantages
 May accidentally break or slip off during
coitus
 Allergic reaction
 To discard after one coital act.
Failure Rate: 15 to 20 per 100 women years of
exposure

13. PHYSICALMETHODS OF CONTRACEPTIVES
IN FEMALE
 Female condom
 Diaphragm
 Cervical Cap

14. A sheath made up of thin, transparent, soft
plastic, closed at smaller end and opened at
the wider end.

16.  Advantages of female condom
 Protect against sexually transmitted diseases
and PID
 Disadvantages
 It is expensive

17.  An intravaginal device made of latex with
flexible metal or spring at the margin
 Diameter varies from 5-10 cm
 It requires a medical or paramedical
personnel to measure the size of the device.

18.  Diaphragm should completely cover the
cervix.
 Device is introduced up to 3 hours before
intercourse and is to be kept for at least 6
hours after the last coital act.

20.  Advantages of diaphragm method
 Cheap
 Can be used repeatedly for a long time
 Reduces PID/STI to some extent

21. Disadvantages.
 Requires help of a doctor or paramedical
person to measure the size required.
 Risk of vaginal irritation and urinary tract
infection are there.
 Not suitable for women with uterine prolapse.

22.  It is thimble shaped. It is like diaphragm but
smaller.
 It covers the vaginal portion of the cervix,
thus acting as a barrier.
 Woman inserts the cervical cap with
spermicide, in the proper position in the
vagina before having sexual intercourse.

23. These are the contraceptives that a women
places in her vagina shortly before sex. These
are all spermicides. These methods are
grouped as follow
 Foams.
 Creams, jellies, pastes.

24.  The foam tablets contain the spermicide
‘Chloramine-T’ or Phenyl mercuric acetate.
 A few drops of water are poured on it and
then introduced high up the vagina.
 Foam is produced and spreads to all parts of
vagina. The commercial name is ‘Today’.
 This contains Nonoxynol-9 spermicides,
which paralyses the sperm.
 The effect lasts for about 1 hour.

25. Creams and Paste
These have a soapy base.
Jelly
 This has an acqueous base.
 They also contain Chloramine T or Phenyl
mercuric acetate.
 For example Delfen cream, volper cream,
orthogynol jelly, perception jelly, etc.

26. Merits
 They are simple, safe and easy to use.
 They offer contraception just when needed.
 Do not require medical assistance.
Demerits
 Burning or irritation
 Local allergic reaction and urinary tract
infection.
Failure rate
 It is quite high, i.e. 25 pregnancy per 100
women.

27.  An IUD is a small stiff but flexible, nontoxic,
polyethylene plastic frame, incorporated with
Barium sulphate, copper prevents conception.
 The IUD has two strings, made up of nylon,
which hang through the opening of the cervix
into the vagina, to check by the user to know
whether it is in situ or not.

29.  First generation IUDs.
 Second generation IUDs.
 Third generation IUDs.

30.  It is a double – S. shaped device made up of
polythene, which is non toxic non tissue
reactive and extremely durable.
 It is a an old method of I.U.D which is not
used nowadays

31.  During 1970s, it was found that metallic
copper has a strong antifertility effect.
The different copper bearing IUDs are:
 Earlier devices- T Cu200, T Cu 200 B
 Newer devices- T Cu-220 C, T Cu- 380 A

32.  These are also “T” shaped devices, made up
of permeable, polymer membrane,
incorporated with a slow releasing
progesterone hormone, which prevents
pregnancy, i.e.LNG- 20.

33.  IUDs cause foreign body reaction resulting in
cellular and biochemical changes.
 It cause hyperemia, edema and infiltration of
leukocytes in the endometrium of uterus.
 So the viability of the ovum is impaired, thus
reducing the chance of fertilization.

34.  Postplacental insertion:- This means insertion
of IUD immediately following delivery of the
placenta. This can be done at any time
between 10 minutes and 48 hours after
childbirth.

35.  Postpartum insertion:- Insertion of IUD
about 6 to 8 weeks after delivery. This also
called post puerperal insertion.
 Postabortum insertion:- Insertion of IUD
about 12 weeks after abortion.
 However, following spontaneous abortion,
IUD can be inserted after the first menstrual
period.

36.  Postcesarean section insertion:- Insertion of
IUD, about 6 to 8 weeks after cesarean
section.

37.  Inexpensive and reversible
 Simplicity in techniques of insertion and most
cost effective of all methods.
 Prolonged contraceptive protection after
insertion.
 Systemic side effect minimal
 Reversibility to fertility is prompt after
removal
 Does not interfere with lactation.

38.  Menstrual change ( bleeding)
 Pain
 Pelvic infection
 Uterine perforation
 Expulsion
 Ectopic pregnancy

39.  Absolute contraindications are pregnancy,
STDs
 Previous ectopic pregnancy
 Pelvic pathology such as infections, tumors,
bleeding disorder
 Congenital defects in the uterus
 Cancer of cervix
 Relative contraindications are multiple sexual
partners and anemia.

40. Failure Rate:- It is 2 to 3 per 100 WY.
Restoration of fertility after removal
 Fertility is not impaired after removal of IUD,
provided there is no episode of PID.
 70% of IUD users conceive within one year of
removal.

41.  COMBINED ORAL CONTRACEPTIVES (PILLS)
 The combined oral steroidal contraceptives is
the most effective reversible method of
contraception. In the combination pill, the
commonly used progestins are either
levonorgesterrel or norethisterone or
desogestrel and the estrogens are principally
confined to ethinyl- oestradiol .

42.  Mode of action
 Inhibition of ovulation
 Producing static endometrial hypoplasia
 Alteration of the character of the cervical
mucus
 Interferes with tubal motility and alters tubal
transport.

43.  Sideeffects
 Nausea, vomiting, headache and leg cramps
 Mastalgia
 Weight gain
 Chloasma and acne

44.  Advantages of combine oral contraceptives
 Highly effective
 Good cycle control
 Well tolerated in majority
 Reversibility rate is prompt

45.  Disadvantages of combined oral
contraceptives
 Requires education and motivation
 Requires initial check up and periodic
supervision
 Inconvenience caused in its use due to daily
schedule
 Risk of drug interactions
 Costly but free supply through government.

46. Missed pills:- Pills should be taken every day to
be most effective. If not taken correctly there
will be a risk of becoming pregnant.
 Missed 1 Pill:- She should take it as soon as
she remembers and take the rest as usual.
 Missed 2 pills or more, in the first two rows(
i.e. the first 14 pills):- She should take one
pill as soon as she remembers and the rest as
usual. Use another method also.

47.  Missed 2 pills or more in the third row:- She
should take the pill as soon as she
remembers and takes a rest as usual
meanwhile she must also use another method
such as condoms for 7 days or avoid
intercourse for one week.


48.  Missed any pill in the fourth row:- She should
throw the missed pill away and take the rest
as usual. Start a new packet as usual on the
next day. Thus, forgetting to take placebos,
she is still protected from pregnancy.

49.  PROGESTIN ONLY CONTRACEPTION (MINIPIL)
 It contains very low dose of progestin in any
one of the following form – levonorgestrel 75
micro gram, norethisterone 350 micro gram.

50.  Mechanism of action
 It works mainly by making cervical mucus
thick and viscous, therby prevents sperm
penetration.

51.  Advantages of minipill
 Sideffects attributed to oestrogen in the
combined pill are totally eliminated
 No adverse effect on lactation and hence can
be suitably prescribed in lactating women.
 Reduce the risk of PID and endometrial
cancer.

52.  Disadvantages of minipill
 Acne, mastalgia,headache,breakthrough
bleeding.
 Simple cyst of ovary may be seen.

53.  Emergency Oral Contraception can prevent
pregnancy.
 Therefore, often it is called ‘ morning after’
contraception.
 should not be used in place of family
planning methods.
 Used to prevent unplanned pregnancy.

54. Used under the following circumstances:
 Unprotected intercourse.
 Rape, sexual assault
 Failure of contraceptive method such as
rupture of condom, displacement of IUD,
missing two or more mini pills.
 Premature ejaculation among couples
practicing coitus interruptus.

55.  This emergency method is recommended
within 48 to 72 hours of unprotected
intercourse.
 They act by stopping ovulation or by
interfering with implantation of the ovum.

56.  Consists of a set of 6 small, silicon rubber
soft capsules, about the size of a small
match- stick, each containing 35 mgm of
synthetic progestogen ( Levonorgestrel).
 provide contraceptive effect for at least 5
years.

58.  Mechanism of action
 It inhibits ovulation.
 It has got its supplementary effect on
endometrium and cervical mucus as well.

59.  Insertion
 The capsule is inserted subdermally, in the
inner aspect of the non dominant arm,6-8 cm
above the elbow fold. It is inserted between
biceps and triceps muscles

60.  Advantages
 Highly effective for long term use and rapidly
reversible.
 Suited for women who have completed their
family but do not have permanent
sterilization.

61.  Disadvantages
 Frequent irregular menstrual bleeding
 Spotting
 Amenorrhoea
 Difficulty in removal is felt occasionally.

62. Effectiveness
 Contraception is provided for 5 years
approximately.
Failure Rate
 The 1-6 pregnancies per 100 women years.

63. DMPA ( Depo-Provera)
 Depot Medroxyprogesterone Acetate (DMPA),
is similar to the hormone called
progesterone, which is produced in the body
by the ovaries.
 Provides protection against pregnancy for
12 weeks.

64. Action
 Mainly works by stopping the ovaries from
releasing an egg (ovulation).
Effectiveness
 99% and 94% effective.

65. When to give
 Contraceptive injection is given as an
injection into the buttock, or sometimes into
the muscle of the upper arm.
 It is usually given during the first five days of
the menstrual cycle .

66. Side Effect
 Bleeding often becomes irregular and can
sometimes last longer than before, but heavy
bleeding is not very common.
 Weight gain.

67. BEHAVIORAL METHOD

68.  Oldest and probably the most widely
accepted contraceptive method used by
man
 It necessitates withdrawl of penis shortly
before ejaculation.
 96 percent effective.

69.  Advantages of coituss
interruptus(withdrawl)
 No appliance is required
 No cost.

70.  Disadvantages of coitus interruptus
 Requires sufficient self control by the
man
 Women may develop anxiety neurosis,
vaginismus or pelvic congestion.
 Chance of pregnancy is more :
 precoital secretion may contain sperm
 accidental chance of sperm deposition
into the vagina

71.  This method is based on identification of
the fertile period of a cycle and to abstain
from sexual intercourse during that period.

73.  Advantages of rhythm method
 No cost
 No side effects

74.  Disadvantages of rhythm method
 Difficult to calculate the safe period
reliably.
 Compulsory abstinence from sexual
act during certain periods.
 Not applicable during lactational
amenorrhoea or when the periods are
irregular.

77.  After ovulation quality of mucus
changes,mucus produced under the
influence of progesterone is thicker,
stickier and its quantity is reduced
 Sperm cannot swim through the
mucus, and it forms the barrier to
sperm entry into the uterine cavity.

79.  Monitor resting body temperature each day
before ovulation women’s temperature is
slightly low.
 After ovulation temperature slightly raises.
 If temperature slightly rises, abstain from
intercourse for 3 days.

80. ◦ Exclusive breastfeeding.
◦ Lactational amenorrhea.
◦ 1st 6 months postpartum.

81. This method is effective when:
 The mother practices exclusive breastfeeding.
 menstrual cycle does not returned back.
 child is less than 6 months of age.

82. Vasectomy
 It is a simple safe, very effective, cheap,
convenient, permanent and quick, surgical
method of family planning for men, who
decide that they do not want any more
children.
 It does not affect the testes and it does not
affect sexual ability.

83. Procedure
 A small incision is made in the scrotum on
either side above the testes under local
anaesthesia, under aseptic precautions, vas-
deferens tubes are lifted, cut and tied with
thread or clamped and the incisions are
closed with stitches. Then bandages is put.

86. Instruction after surgery
 Rest for two days.
 should not do any heavy work.
 The wound should be kept clean and dry.
 If possible put ice on the scrotum for four
hours to lessen swelling.
 Wear snug underwear or pants for two to
three days to help.
 Can have intercourse within 2 to 3 days after
the procedure.

87. Effectiveness
 Vasectomy is highly effective and permanent
method.
 Failure rate is about 0.15 pregnancies per 100
men.
Merits:
 It is simple highly effective.
 Prolonged sexual pleasure because no need to
worry about pregnancies.
 Compare to tubectomy vasectomy easy to
perform.
 Does not need hospitalization.

88. Demerits
 Pain in the scrotum, swelling and bruising
 Uncomfortable for 2 to 3 days.

89. Tubectomy:
 This is also known as ‘Voluntary surgical
contraception, and ‘ Tubal ligation’ and
‘Minilap’.
 It is a simple , safe, very effective, cheap,
convenient and permanent method of
contraception for women, who do not want
any more children.
 It consists of blocking both the fallopian
tubes. The procedure is permanent and
probably cannot be reserved.

90.  A small incision of 2 to 5 cm is made in the
anesthetized area, just above the pubic hair
line, under aseptic precautions.
 The uterus is raised and turned with the
elevator to bring each of the fallopian tubes
under the incision.
 Each tube is tied and cut or else closed with a
clip or ring. Incision is closed with stitches
and bandage is put.

92. Instructions after surgery:
 Rest for 2 to 3 days and avoid strenuous work
for one week.
 Keep the wound clean and dry.
 Not to have sex for at least one week or until
all pain gone.

93. Effectiveness:- Failure rate is about 0.5
pregnancies per 100 women years.
Merits:
 It is simple, safe, very effective, permanent,
lifelong method of family planning.
 No interference during intercourse.
 No effect on breast milk.
 No long- term side effect.
 Helps to protect against ovarian cancer.

94. Demerits
 Usually painful for several days after surgery.
 Postoperative infection or bleeding.
 Does not protect against STDs including
HIV/AIDS.

95.  The nursing staff is a key element in the
implementation, execution and continuity of
family planning practices.
 Give accurate information and respond to
questions .

96.  To be aware of the needs of people that they
attend entirely, promoting health and
creating quality of life.
 The nurse must guide, inform and educate
the user about it and warning signs.
 Importance of check-ups: users should be
informed about the importance of attending
consultation for regular check-ups.

97.  RESEARCH EVIDENCE:
 Title :Use of contraception among women who request
first trimester pregnancy termination in Norway.
 Journal name :Contraception
 Author : Strøm-Roum EM, Lid J, Eskild A
Objective : proportion of women who reported having
used contraceptionwhen they became pregnant, and the
contraceptive method that they had used.
 Results : 36.5% of the women who requested pregnancy
termination , reported having used contraception when
they became pregnant. Of all women, 16.6% reported
having used the combined contraceptive pill/progestin
pill, 11.5% the condom, and 1.1% long-acting reversible
contraceptives (1.0% intrauterine contraception).

99. INFERTILITY

100.  “A woman of
reproductive age who
has not conceived after
1 year of unprotected
vaginal sexual
intercourse, in the
absence of any known
cause of infertility”

101.  Primary infertility; couple have failed to conceive
before.
 Secondary infertility; woman has previously been
pregnant regardless of the outcome of the pregnancy
and now unable to conceive.

102.  Conception depends on the fertility potential
of both the male and female partner. The
male is directly responsible in about 30-40
percent, the female in about 40-55 percent
and both are responsible in about 10 percent
cases.

103.  Defective spermatogenesis
 Undescended testes

104.  Failure to deposit sperm high in the vagina-
 Hypospadias
 Ejaculatory defect
 Erectile dysfunction

105.  Errors in the seminal fluid.
 Unusually high or low volume of ejaculate
 Low fructose content
 Undue viscosity

106.  Obstruction of the efferent duct system
 Obstruction by infections like
tubercular,gynoccal and surgical trauma.
 Congenital
 Undescended testis
 Hypospadias

107.  Thermal factor
 the scrotal temperature is raised in conditions
such as varicocele, big hydrocele or filariasis.

108.  Infection
 mumps
 Orchitis
 systemic illness

109.  Genetic
 klinefelter’s syndrome(47XXY)
 Iatrogenic
 radiation, cytotoxic drugs
 Nitrofurantoin
 Cimetidine
 antidepressant drugs.

110.  A study done in 2014 in India on Environmental
& lifestyle factors in deterioration of male
reproductive health found that The presence of
abnormal semen parameters was significantly
higher among the lifestyle and/or environmental
exposed subjects as compared to the non-
exposed population.
 These findings indicated that various lifestyle
factors such as tobacco smoking, chewing and
alcohol use as well as exposure to toxic agents
might be attributed to the risk of declining
semen quality and increase in oxidative stress
and sperm DNA damage.

111.  Chronic debilitating diseases
 malnutrition
 heavy smoking reduce spermatogenesis.

112.  Causes of female infertility
 Ovarian factors
 anovulation or oligo ovulation
 Decreased ovarian reserve luteal phase
defect, luteinized unruptured follicle
 Tubal and peritoneal factors
 pelvic infections
 Salphingitis
 tubal endometrosis,polyps or mucous debris.

113.  Uterine factors
 uterine hypoplasia
 inadequate secretory endometrium
 fibroid uterus

114.  Cervical factors-
 anatomical defects
 scanty mucus
 Vaginal factors
 atresia vagina
 transverse vaginal septum
 septate vagina or narrow introitus.

115. Objectives of investigation
 To detect the etilogical factors
 To rectify the abnormality in an attempt to
improve the fertility.
 To give assurance with explanation to the
couple if no abnormality is detected

116.  Investigations for male
 Routine investigations
 Seminal fluid analysis-normal semen value as
suggested by WHO
Volume 2 ml or more
Ph 7.2-7.8
Sperm concentration 20 million/ml or more
Total sperm count >40 million per ejaculate
Motility 50 percent or more
Viability 75% or more living.

117.  Investigations for female
 General medical history
 Tuberculosis
 Sexually transmitted disease
 Pelvic inflammatory disease
 Diabetes

118.  Surgical history
 Abdominal or pelvic surgery
 Peritubal adhesion
 Menstrual history
 Hypomenorrhoea
 Oligomenorrhoea

119.  Previous obstetric history
 Number of pregnancies
 Interval between them
 Pregnancy related complications
 Contraceptive practice
 IUCD
 Other contraceptive devices.

120.  Diagnosis of ovulation
 menstrual history
 BBT
 Cervical mucus study

121. Hormone estimation
 serum progesterone
 Serum Leutinizing Hormone
 Serum oestradiol
 Urine Leutinizing Hormone

122.  Endometrial biopsy
 Sonography
 Direct -laparoscopy

123. 1. Counselling and waiting.
2. Treatment of the cause.
3. Ovulation induction.
4. Artificial insemination (IUI)
5. IVF/ICSI
(invitrofertilization/intracyt
oplasmic sperm injection)

124. For male
To improve spermatogenesis:
In hypogonadotrophic hypogonadism –
Tab. Clomiphen citrate
 Testosterone
GnRH therapy

125. In genital tract infection – Antibiotic
In retrograde ejaculation – Phenylephrine
In terato/astheno-spermia – Donor
insemination
In genetic abnormality – IUI with donor’s
sperm

126. In Impotency :
Psychological treatment
Drugs –Sildenafil & alprostadil

127. In female
In ovulation disorders
Clomiphene citrate:
 ↑ses secretion of LH, FSH from pituitary

128. In Endometriosis :
Medical –
Combined OCP
Progesterone
GnRH
Surgery or both
In Tubal block & Uterine malformation
: Surgery
Assisted reproduction technology
IVF

129.  It is artificial introduction of semen inside the female’s
uterus.
 Success rate varies, lie between 15% to 20% per cycle.

130.  It is a process by which the oocyte is fertilized by a
sperm outside the body: in vitro, and then a gamete
retransferred intrauterine.

131.  Once fertilization occurs (in the lab), the tiny
embryo produced is transferred (at the four
to eight cell stage) into the woman’s uterus
and is expected to develop through a normal
pregnancy.

133.  In 2012, a total of 157,635 ART procedures
performed in 456 U.S. fertility clinics were
reported to CDC. These procedures resulted
in 51,261 live-birth deliveries.

134.  Definition
 Different types of contraception
 Temporary and permanent
 Role of nurses in contraception
 Definition of infertility
 Causes of infertility
 Management of infertility

135.  Couple needs to balance their sexual lives,
their reproductive goals, health and safety.
 Infertility refers to an inability to conceive
after having regular unprotected sex.