2. Outline of Presentation
• Family planning Introduction
• History of Family planning
• Global scenario
• South East Asia
• Nepal Scenario
• Family Planning methods
• Recent Advance
• Conclusion
• References
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4. Introduction
• Family planning is defined as “the ability of individuals and couples to anticipate
and attain their desired number of children and the spacing and timing of their
births. It is achieved through use of contraceptive methods and the treatment of
involuntary infertility”
-WHO
• Family planning refers to supplies and services which enable individuals and
couples to attain and plan for their desired number of children, and the spacing and
timing of births.
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5. Introduction (2)
• Supplies include modern contraceptive methods and services include health care,
counselling and information and education related to sexual and reproductive
health.
• The ability of individuals to determine their family size and the timing and spacing
of their children has resulted in significant improvements in health and in social
and economic well-being.
• International studies have repeatedly confirmed that family planning ranks among
the most cost-effective of all health services, along with other basic and preventive
health measures such as vaccinating children and preventing HIV/AIDS.
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6. Introduction (3)
• Family planning could prevent up to one-third of all maternal deaths by allowing
women to delay motherhood, space births, avoid unintended pregnancies, and
unsafely performed abortions, and stop childbearing when they have reached their
desired family size.
• Contraceptive information and services are fundamental to the health and human
rights of all individuals.
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7. Introduction (4)
• The Family Planning Sustainable Development Goals model demonstrated that
improvements in socioeconomic status along with investments in family planning
maximize long-term progress towards reducing poverty and food insecurity and
increasing income.
• At the individual level, there are benefits in infant, child and maternal health
outcomes (SDG 3), improved educational outcomes (SDG 4), gender equality and
women’s empowerment (SDG 5) and equal access to the labor market, social
protection and the political process (SDGs 5, 8, and 16).
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8. History of Family planning
• Family planning has been of practice since the 16th century by the people of West
Africa.
• In 1968, Human Rights Conference was held in Tehran which considered
voluntarism in family planning
• Reproductive health and right was defined by the United Nations (UN) in 1994 at
the Cairo International Conference on Population and Development.
• The Government of Nepal began to offer family planning services from 1965
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9. Milestone of Family planning program in
Nepal
Year History
1965 Government adopted family planning policy as a means of maintaining a balance
between population growth and economic growth.
1968 a national service delivery system was started with the establishment of the Family
Planning and Maternal-Child Health board
1995 Ministry of population and environment was established following the FP and
reproductive health principles of ICPD
1998 National reproductive health strategy was formed
1998 Safe motherhood policy: need of FP services as a key components of maternal care.
2000 National adolescent health and development strategy was endorsed
2003 National safe abortion policy
2005 MoPE dissolved and its population division was merged in the MOH and the MOH
renamed as MOHP.
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13. Global Scenario (1)
• Expanding access to contraception is an essential component of achieving
universal access to sexual and reproductive health-care services, as called for in
the 2030 Agenda for Sustainable Development.
• In 2020, among 1.9 billion women of reproductive age (15-49 years), 1.1 billion
women are considered to have a need for family planning, meaning that they
desire to limit or delay childbearing.
• Of these women, 851 million are using a modern method of contraception and 85
million are using a traditional method.
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14. Global Scenario (2)
• An additional 172 million women are using no method at all, despite their desire
to avoid pregnancy, and thus are considered to have an unmet need for family
planning.
• Still, nearly 1 in 10 women of reproductive age worldwide have an unmet need
for family planning: they want to avoid or postpone pregnancy but are not using
any form of contraception.
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15. 4/6/2022 15
Source: United Nations, Department of Economic and Social Affairs, Population Division. (2020). Estimates and Projections of Family Planning Indicators 2020.
16. South East Asia
• Central and Southern Asia has seen the largest decline in the number of
women with unmet need since 2000.
• Globally, the number of women aged 15-19 years who had unmet need for
family planning decreased from 17 million in 2000 to 14 million in 2020.
• The large decline in unmet need among adolescent girls and young women
in Central and Southern Asia from over 6 million women in 2000 to 2.6
million in 2020 was the primary reason for the decrease at the global level.
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17. 4/6/2022 17
Source: United Nations, Department of Economic and Social Affairs, Population Division. (2020). Estimates and Projections of Family Planning indicators 2020.
19. Nepal Scenario (1)
• Family planning (FP) is one of the important components of Nepal’s national
health system.
• The aim of National FP program is to ensure individuals and couples fulfil their
reproductive needs and rights by using quality FP methods voluntarily based on
informed choices.
• FP has been enshrined as a fundamental right in the constitution, and included in
the basic health service package under the Public Health Act 2018, thus paving a
way towards universal health coverage.
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20. Nepal Scenario (2)
• FP is an essential health care services of Nepal Health Sector Program II
(2010‐2015), National Family Planning Costed Implementation Plan 2015‐ 2021,
Nepal Health Sector Strategy 2015‐2020 (NHSS) and the Government of Nepal’s
commitments to FP2020.
• The total fertility rate (TFR) of women aged 15-49 declined from 4.1 children per
women in 2000 to 2.3 in 2016 and has declined to 2.0 in 2019.
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21. SDG Target
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Target and Indicators 2020 status Source 2030
3.7.1 Proportion of women of reproductive age (aged
15-49 years) who have their need for family planning
satisfied with modern methods
61.9 NMICS 80
a. Contraceptive prevalence rate (modern methods)
(%)
44.2 NMICS 60
b. Total Fertility Rate (TFR) (births per women aged
15-49 years)
2.0 NMICS 2.1
c. Adolescent birth rate (aged 10-14 years, aged 15-
19 years) per 1,000 women in that age group
63 NMICS 30
24. Major activities (1)
Provision of regular comprehensive FP service including post-partum and post
abortion FP services
Provision of long acting reversible services, Permanent FP Methods or Voluntary
Surgical Contraception (VSC)
FP strengthening program through the use of decision-making tool (DMT)and
WHO medical eligibility for contraceptive (MEC) wheel
Micro planning for addressing unmet need of FP in hard to reach and underserved
communities
Provision of RANM and VSP service to increase FP service use
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25. Major activities (2)
Integration of FP and immunization service
Satellite clinic services for long acting reversible contraceptives
Contraceptive update for Obstetrician/Gynecologist, nurses & concerned key
players
Interaction program on FP and RH including ASRH with pharmacist and
marginalized communities
Community interaction with satisfied clients for promoting permanent method and
IUCD
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30. Reversible Inhibition of Sperm Under
Guidance (RISUG) (1)
• In 1979, Prof. Sujoy K. Guha, School of Medical Science and Technology, Indian
Institute of Technology, proposed a radically new technique of male contraception
• RISUG is a co-polymer of Styrene Maleic Anhydride (SMA) dissolved in
Dimethyl Sulfoxide (DMSO) to form a gel
• It is a non-surgical method of male sterilization that is inexpensive, highly
effective, and reversible.
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https://bacandrology.biomedcentral.com/articles/10.1186/s12610-020-0099-1
31. Reversible Inhibition of Sperm Under
Guidance (2)
• It involves an injection of the solution into each of the patient's Vas deferens,
which forms a layer around the vas walls partially (but not completely) blocking
the flow of sperm cells.
• It causes the disruption of the membrane of spermatozoa and release of enzymes
that are essential for the fertilization of ova.
• Thus the ejaculation after RISUG contains infertile spermatozoa.
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https://bacandrology.biomedcentral.com/articles/10.1186/s12610-020-0099-1
32. Reversible Inhibition of Sperm Under
Guidance (3)
• RISUG was formulated as an occlusive polymer which was claimed to sterilize
subjects by single injection and reversed at any time following vas occlusion.
• Within 72 h of injection, RISUG forms electrically charged precipitates in the
lumen and further layers the lumen wall and inner walls of vas deferens.
• Precipitates are dominated with positive charge creating an acidic environment.
Passing through the RISUG injected vas deferens, sperms suffer ionic and pH
stress, causing acrosomal damage, rendering them unable to fertilize oocytes.
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https://bacandrology.biomedcentral.com/articles/10.1186/s12610-020-0099-1
33. Reversible Inhibition of Sperm Under
Guidance (4)
• RISUG has also been tested successfully in number of human volunteers during
Phase-I, Phase-II and Phase-III clinical trials. Presently the drug is under extended
Phase-III clinical trials at various centers in India.
• In 2018, a total of 315 subjects enrolled at 5 different centers in the country were
reported to show no adverse side-effects of the drug with overall contraceptive
efficacy of 99.02%.
• If approved for widespread application, it could provide an alternative to the
current two major methods of male contraception: Condoms and vasectomies
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https://bacandrology.biomedcentral.com/articles/10.1186/s12610-020-0099-1
34. 4/6/2022 34
RISUG: mode of action. (A) Vas is exposed from inguinal region and RISUG is injected in both vas
deferens towards distal region by a micro-syringe. (B) RISUG coats the wall of the vas deferens
blocking sperm movement. (C) Complete reversal obtained after DMSO/NAHCO3 is injected
bilaterally, flushing component of RISUG
35. Advantages of RISUG over other methods of
male contraception
RISUG creates a physical and chemical barrier preventing sperm from reaching the
oocyte. The polymer is injected into the vas deferens through the non scalpel
technique, thus avoiding surgery in the initial sterilization procedure.
1. Early azoospermia:
• Clinical trials with RISUG demonstrate promising results showing azoospermia in
subjects as early as 4 weeks after the injection that is sustained over years. A few
sperms that are observed in ejaculates after RISUG were found to be functionally
inactive.
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36. Advantages of RISUG over other methods
of male contraception
2) Reversibility:
• In any contraceptive method a great concern is the reestablishment of fertility
when required.
• Removal of SMA co-polymer can be induced by injecting DMSO or
NaHCO3 that acts as partial solvent.
• After preclinical trials in various animal models based on blockage of vas
deferens without any toxicity, the studies have been moved toward its reversibility
aspect without affecting cellular integrity.
• Despite the promising results of reversibility in animal models, the reversibility
studies have not yet been carried out in humans.
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37. Kyleena
• Smallest and the lowest dose of 5 years IUD
• The Kyleena IUD consists of a soft, flexible polyethylene (plastic) frame in the
shape of a T.
• The Kyleena IUD contains 19.5 milligrams (mg) of levonorgestrel. It releases
17.5 micrograms (mcg) of this hormone per day. After one year, this rate slowly
declines to 9.8 micrograms daily, and then to 7.4 micrograms per day.
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Kyleena
Source: https://www.kyleenahcp.com/
39. Sayana Press (1)
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• It is a lower-dose formulation and presentation of the contraceptive Depo-
Provera, manufactured by Pfizer Inc.
• a subcutaneous self administered contraceptive injection for women.
• pre-filled with the drug, so the injection is ready-to-use.
• single-dose container with 104 mg medroxyprogesterone acetate (MPA) in 0.65
ml suspension for injection.
• prevent pregnancies for 3 months.
•
41. • It is suitable for community-based distribution and for women to administer
themselves through self-injection with minimal training.
• The first Sayana Press introduction launched in Burkina Faso in July 2014.
• It is being launched in Nepal in two districts: Nawalpur and Sindhuli, by the
reproductive health agency Ipas Nepal in coordination with the UK’s Department
for International Development (DFID) and the MoH.
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Sayana Press (2)
42. • The drug has already been tried and approved, and is available for use in 40
European countries including UK.
• Introductions of Sayana Press also aim to support the Family Planning 2020
coordinated effort to ensure that voluntary family planning services reach an
additional 120 million women and girls in the world’s poorest countries by 2020.
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Sayana Press (3)
43. • In 2015, the UK Medicines & Healthcare products Regulatory Agency (MHRA)
authorized Sayana Press for self-injection in the United Kingdom.
• The World Health Organization (WHO) also recommends self-administration of
Sayana Press “in contexts where mechanisms to provide the woman with
appropriate information and training exist, referral linkages to a healthcare
provider are strong, and where monitoring and follow-up can be ensured.”
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Does Sayana Press have regulatory approval for self
injection?
45. 4/6/2022 45
This study recruited women seeking injectable contraception at 14 public health
facilities in Nepal selected for geographic diversity. They enrolled women who self-
selected either Sayana Press or DMPA-IM and used structured interviews to obtain
baseline demographics and assess satisfaction and continuation rates at 1, 3, and 6
months.
What they concluded is Sayana Press is acceptable to women in Nepal with the
preference for Sayana Press over DMPA-IM (higher proportion chose the method
when counseled and given the option, better continuation).
Implications: The potential for self-injection with Sayana Press may have
implications for continuation and opportunity for future research and strategies to
roll out this innovative technology must be explored.
46. 4/6/2022 46
In this prospective cohort study, 380 18–45-year-old participants completed self-
injection training by licensed study nurses, guided by a client instruction booklet,
and practiced injection on prosthetics until achieving competence. Nurses
supervised participants' self injection and evaluated injection technique using an
observation checklist. Those judged competent were given a Sayana Press unit,
instruction booklet and reinjection calendar for self-injection at home 3 months
later. Participants completed an interview before and after self-injection.
The study concluded that Self-injection is feasible and highly acceptable among
most study participants in Uganda.
Results can inform self injection programs which aim to increase women's
autonomy and access to injectable contraception.
Source:Ref:eader.elsevier.com/reader/sd/pii/S0010782416304590? &originRegion=eu-west-1&originCreation=20211210063631
48. References
Program, I., Butler, A. and Clayton, E., 2021. Overview of Family Planning in the United
States. [online] Ncbi.nlm.nih.gov. Available at:
<https://www.ncbi.nlm.nih.gov/books/NBK215219/>
Who.int. 2021. Contraception. [online] Available at: <https://www.who.int/health-
topics/contraception
Countdown2030europe.org. 2021. [online] Available at:
<https://www.countdown2030europe.org/storage/app/media/IPPF_FactSheet-
5_poverty.pdf
Who.int. 2021. Family planning/contraception methods. [online] Available at:
<https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception
Un.org. 2021. [online] Available at:
<https://www.un.org/en/development/desa/population/publications/pdf/family/fam
4/6/2022 48
49. References
PRB. 2021. ENGAGE Snapshot: Family Planning Leads to Poverty Reduction. [online] Available
at: <https://www.prb.org/resources/engage-snapshot-family-planning-leads-to-poverty-reduction/>
2021. [online] Available at:
<https://www.un.org/development/desa/dpad/wpcontent/uploads/sites/45/WESP2021_CH3_SA.pd
f>
Dhsprogram.com. 2021. [online] Available at:
<https://dhsprogram.com/pubs/pdf/FA119/FA119.pdf>
2021. [online] Available at:
<https://asiapacific.unfpa.org/sites/default/files/pubpdf/210112_unfpa_impact_of_covid19_on_hu
man_fertility_sp.pdf>
4/6/2022 49
50. References
Un.org. 2021. [online] Available at:
<https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/docu
ments/2020/Sep/unpd_2020_worldfamilyplanning_highlights.pdf>
2021. [online] Available at:
<https://nepal.unfpa.org/sites/default/files/pubpdf/FP%20Costed%20Implementation%20Plan.pdf>
Usaid.gov. 2021. Family Planning and Reproductive Health. [online] Available at:
<https://www.usaid.gov/global-health/health-areas/family-planning#dataSources>
PRB. 2021. Family Planning Saves Lives. [online] Available at:
<https://www.prb.org/resources/family-planning-saves-lives/>
https://www.injectsayanapress.org/
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Involuntary infertility is a disease of the reproductive system: where a woman is unable to become pregnant when desired
Egypt capital is Cairo
Ministry of population and environment MoPE
ICPD- international conference in popn and development
Global popn has increased rapidly over the past 100 years. At the beginning at the entry on popn growth, the global popn grew only very slowly upto 1700 that is 0.04% per year. Particularly over the 20th century global popn has quadripled. Peak popn growth was reached in 1968 with an annual growth of 2.1 % since then increased in world popn has slowed and today grow by just 1% per year. A/c to UN projection, by the end of the century, popn growth rate will fall to 0.1%
In the first graph we can see Nepal population is currently growing at the rate of 1.85% in 2020 which has increased from 2015. In 2nd figure we can see increasing trend of popn since 1960 A/c to current projection Nepal’s popn is expected to cross 34.9 million in 2040 After 2050 the popn is expected to shrink falling back down to 24.04 million people by the end of the century.
According to current projections, Nepal’s population is expected to surpass 30 million people in 2022 and will reach its peak population of 35.32 million by 2049. After 2050, the population is expected to shrink, falling back down to 24.04 million people by the end of the century.
After experiencing a small decline in its population from 2011 to 2014, Nepal’s population is currently growing at a fairly quick rate of 1.85%. Since 2015, this rate has increased every year from 0.00% in 2015, to 0.92% in 2016, 1.35% in 2017, 1.68% in 2018, and 1.83% in 2019. The population growth rate is expected to slow down significantly in the next three decades.
The population growth rate is slowing down due to a decreasing fertility rate, which is currently at 1.93 births per woman. The fertility rate is below the population replacement rate of 2.1 births per woman and has significantly decreased since 2000 when it was 4.41 births per woman.
In the first bar diagram we can see decreasing trend in total fertility rate. It was 4.6 average birth in 1996 which has decreased to 2.3 average birth in 2016.
The 2nd figure is a trend in contraceptive use blue line indicates any modern method and red line indicates traditional method. After an impressive increase in use of modern methods from 1996 to 2006, there has been no increase over the past 10 years (Figure 7.2). The stagnant modern CPR could be due to various factors, such as migration leading to spousal separation, an increase in use of traditional methods from 4% in 2006 to 10% in 2016, and legalization of abortion services.
shows differentials in wanted fertility rates and total fertility rates among women age 15-49. The wanted fertility rate indicates what fertility would be if women had only the children they desired. The total wanted fertility rate and the actual total fertility rate in Nepal are 1.7 and 2.3, respectively. This means that women in Nepal want an average of 0.6 children less than the current fertility rates. Trend: The difference between the wanted and the actual fertility rate declined steadily between 1996 and 2016, from 1.7 children to 0.6 children (
Here is the bar diagram showing distribution by type of contraceptive use or unmet need for women with a need for fp by region 2020. In Eastern and south Eastern Asia 86% of women use modern method 5% use traditional and 9% have unmet need. While in the world, it shows that 77% of women used modern contraceptive 8% used traditional and 16% have unmet need.
This figure shows the estimates and projections of the % of women aged 15-49 years who used contraception or who have an unmet need for family planning by region 2000-2030 Here we can see the proportion of women of reproductive age who use some methods of contraception has increased in all regions since 2000 and unmeet need has declined in most region. In eastern and south eastern asia we can see women of reproductive age using contraception was 59.2% in 2000 which has increased to 60.1% in 2020 and is projected to 59.5% Similarly 6% had unmet need in 2000 which was stagnant till 2020 and is projected to decrease to 5.7%
India the world most second populated country National family health survey
Not only India but most of the part of the world fertility is in decreasing trend. Singapore 1.1, Hongkong 1.1, Spain 1.3, Italy 1.3 Canada 1.5 US 1.7 China 1.7
Women today are choosing to be child free. Becoming more than just a reproductive machine. In south Korea there is no marriage movement. They are choosing career over children and marriage
By 2030, ensure universal access to sexual and reproductive health-care services, including for fam
ily planning, information and education, and the integration of reproductive health into national strategies and programmes
NMICS; Nepal Multiple Indicator cluster survey
The modern contraceptive prevalence rate (mCPR) at national level as well as at provinces (except Karnali and Sudurpaschim) is in decreasing trend. The national mCPR stands at 37% in 2076/77 which was 39% in 2075/76 and 40% in 2074/75 (Figure 4.5.3). Province 2 has the highest mCPR of 44% while Bagmati has the lowest (32%). Three Provinces (Bagmati, Gandaki and Karnali) have mCPR less than national average (39%)
This is a piechart showing Fp method mix among all new acceptors, 2076/77 where Depo (39%) occupies the greatest part of the contraceptive method mix for all method among new acceptors, followed by condom (23%), pills (21%), implant (12%), IUCD (2%), female sterilization (-
2%) and lastly male sterilization (NSV-1%) in 2076/77 (Figure 4.5.10). Second is a chart showing trend of FP new acceptors (all method)
as % of MWRA has decreased at national level and all other provinces except Karnali and Sudurpaschim (Figure 4.5.11)
With stagnant CPR over last many years GON introduced microplanning on a pilot basis in low CPR districts of Nepal . Microplanning is an effective strategy to analyse the current FP situation. It helps to identify issues, gaps, weakness and strength of FP and make context specific plan. It was conducted in Doti and Udaypur.
The introduction of RANMs is consistent with Government of Nepal policies around expanding equitable access to and quality of community level health services under the Nepal Health Sector Strategy 2015-2020 (NHSS 2015-20). Such a strategy also contributes to the “Reaching the Unreached Strategy” (RTU 2016-2030). In addition to “reach”, the integrated household and community approach to health service provision offers a significant opportunity to address the multiple barriers contributing to poor health access, particularly among HTR groups.
Integration in HIV intervention program site, post partum care, program for migrant couples, urban health etc
A/c to Nepal health fertility survey 2015, only 4 out of 10 health facility 44% offered 5 modern contraceptives.
A/c to 2016 NDHS in the Eastern region revealed that one fifth of women experienced difficulties in accessing their choice of FP for free or low cost. (reason is due to limited availability of LARC service, commodity only limited to pills and condom
In the 1970s while investigating some cost effective techniques to purify rural water systems, he discovered that when pipes were coated with a common polymer called styrene maleic anhydride (SMA), it could kill bacteria present in the water supply. In concert with Government of India, Prof. Guha worried regarding rapidly growing population of the country and suggested use of SMA to be developed as a male contraceptive The proposed design was modified to work safely inside male genitalia and then considering, vas deferens similar to a water pipe and sperm travelling through the narrow tubes analogous to microbes, reproductive tract of male rats were injected with SMA. Positive results, indicated by sterility in rats, were observed and published in 1979 [34]. Later on, the procedure was further refined and also tested in rhesus and langur monkeys.
The vas deferens is a male reproductive system that transports mature sperm to the urethra, the tube that carries urine or sperm to outside of the body, in preparation for ejaculation.
Normal sperm cells have an oval-shaped head with a cap-like covering called the acrosome. The acrosome contains enzymes that break down the outer membrane of an egg cell, allowing the sperm to fertilize the egg.
For flushing: 200-500 microlitre DMSO (90 days for reversible) or 5% of sodium bicarbonate is used
Vasectomy is a surgical method of male sterilization considered to be highly effective and permanent form of contraception.
However, absence of sperms in ejaculates is mostly observed at-least 12 weeks after the procedure.
Azoospermia is the medical term used when there are no sperm in the ejaculate
RISUG presents an advantage over other male contraceptive methods like vasectomy with its effective and easy reversibility, as observed in different animal models. RISUG® has several advantages such as effectiveness, no interruption before the sexual act, cost factor, outpatient procedures means patients can leave the hospital immediately after an injection and resume their normal sex lives within a week, duration of effect that for at least 10 years no side effects with greater reversibility.
Side effects of Mirena and Kyleena that are similar include ovarian cysts, abdominal/pelvic pain, headache or migraine, acne, breast tenderness or pain, heavier bleeding during the first few weeks after device insertion, depression, and changes in hair growth (including hair loss).
This table shows different IUD. As we know there are two types of IUD. One is hormonal and another is non hormonal. In Nepal we have copper IUD that is cu 380 A that works for 10 years. And other hormonal iud are………M S K are manufactured by same company that is Bayer health care pharmaceuticals inc. while compairing Mirena and Kyleena progestins may work in several different ways, such as:
thickening your cervical mucus to stop sperm from entering your uterus during sex
thinning the lining inside of your uterus to prevent a fertilized egg from implanting there
reducing the movement and survival of sperm inside your uterus to lower the likelihood of fertilization
In Nepal as we see the trend of IUD there was 4.3% of new acceptor in 74/75, reduced to 3% in 75/76 and 2% in 76/77 and this decreasing trend is due to limited choice of IUD accessibility and availability and lack of trained health personnel and various stigma related to IUD
Results: Seven hundred ninety-four women (71%) selected and received Sayana Press, while 318 women (28.6%) selected and received DMPA-IM. One hundred and seventy-eight (48%) women continuing Sayana Press injection reported that they experienced “no possible side effects”compared to 29 (22%) among DMPA-IM selectors during the previous 6 months. The continuation rate of Sayana Press at 6 months was higher than DMPA-IM (Sayana Press 46.5% vs DMPA-IM 34.4%; p < 0.001). Selection of Sayana Press method (OR adj . 1.74; 95% confidence interval 1.32–2.3) and approval from husband (OR adj . 1.59; 95% con- fidence interval 1.21–2.09) were associated with injection continuation.
. Results: Of 368 participants followed up 3 months post training, 88% [95% confidence interval (CI) = 84–91] demonstrated injection competence, and 95% (95% CI=92–97) reinjected on time, while 87% (95% CI=84–90) were both on time and competent. Nearly all (98%) expressed a desire to continue