contraception and infertility

Feb. 10, 2017

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contraception and infertility

  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
  10.  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.
  11.  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
  12. PHYSICALMETHODS OF CONTRACEPTIVES IN FEMALE  Female condom  Diaphragm  Cervical Cap
  13. A sheath made up of thin, transparent, soft plastic, closed at smaller end and opened at the wider end.
  14.  Advantages of female condom  Protect against sexually transmitted diseases and PID  Disadvantages  It is expensive
  15.  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.
  16.  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.
  17.  Advantages of diaphragm method  Cheap  Can be used repeatedly for a long time  Reduces PID/STI to some extent
  18. 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.
  19.  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.
  20. 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.
  21.  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.
  22. 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.
  23. 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.
  24.  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.
  25.  First generation IUDs.  Second generation IUDs.  Third generation IUDs.
  26.  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
  27.  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
  28.  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.
  29.  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.
  30.  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.
  31.  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.
  32.  Postcesarean section insertion:- Insertion of IUD, about 6 to 8 weeks after cesarean section.
  33.  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.
  34.  Menstrual change ( bleeding)  Pain  Pelvic infection  Uterine perforation  Expulsion  Ectopic pregnancy
  35.  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.
  36. 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.
  37.  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 .
  38.  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.
  39.  Sideeffects  Nausea, vomiting, headache and leg cramps  Mastalgia  Weight gain  Chloasma and acne
  40.  Advantages of combine oral contraceptives  Highly effective  Good cycle control  Well tolerated in majority  Reversibility rate is prompt
  41.  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.
  42. 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.
  43.  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. 
  44.  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.
  45.  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.
  46.  Mechanism of action  It works mainly by making cervical mucus thick and viscous, therby prevents sperm penetration.
  47.  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.
  48.  Disadvantages of minipill  Acne, mastalgia,headache,breakthrough bleeding.  Simple cyst of ovary may be seen.
  49.  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.
  50. 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.
  51.  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.
  52.  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.
  53.  Mechanism of action  It inhibits ovulation.  It has got its supplementary effect on endometrium and cervical mucus as well.
  54.  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
  55.  Advantages  Highly effective for long term use and rapidly reversible.  Suited for women who have completed their family but do not have permanent sterilization.
  56.  Disadvantages  Frequent irregular menstrual bleeding  Spotting  Amenorrhoea  Difficulty in removal is felt occasionally.
  57. Effectiveness  Contraception is provided for 5 years approximately. Failure Rate  The 1-6 pregnancies per 100 women years.
  58. 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.
  59. Action  Mainly works by stopping the ovaries from releasing an egg (ovulation). Effectiveness  99% and 94% effective.
  60. 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 .
  61. Side Effect  Bleeding often becomes irregular and can sometimes last longer than before, but heavy bleeding is not very common.  Weight gain.
  63.  Oldest and probably the most widely accepted contraceptive method used by man  It necessitates withdrawl of penis shortly before ejaculation.  96 percent effective.
  64.  Advantages of coituss interruptus(withdrawl)  No appliance is required  No cost.
  65.  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
  66.  This method is based on identification of the fertile period of a cycle and to abstain from sexual intercourse during that period.
  67.  Advantages of rhythm method  No cost  No side effects
  68.  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.
  69.  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.
  70.  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.
  71. ◦ Exclusive breastfeeding. ◦ Lactational amenorrhea. ◦ 1st 6 months postpartum.
  72. This method is effective when:  The mother practices exclusive breastfeeding.  menstrual cycle does not returned back.  child is less than 6 months of age.
  73. 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.
  74. 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.
  75. 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.
  76. 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.
  77. Demerits  Pain in the scrotum, swelling and bruising  Uncomfortable for 2 to 3 days.
  78. 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.
  79.  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.
  80. 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.
  81. 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.
  82. Demerits  Usually painful for several days after surgery.  Postoperative infection or bleeding.  Does not protect against STDs including HIV/AIDS.
  83.  The nursing staff is a key element in the implementation, execution and continuity of family planning practices.  Give accurate information and respond to questions .
  84.  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.
  85.  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).
  87.  “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”
  88.  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.
  89.  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.
  90.  Defective spermatogenesis  Undescended testes
  91.  Failure to deposit sperm high in the vagina-  Hypospadias  Ejaculatory defect  Erectile dysfunction
  92.  Errors in the seminal fluid.  Unusually high or low volume of ejaculate  Low fructose content  Undue viscosity
  93.  Obstruction of the efferent duct system  Obstruction by infections like tubercular,gynoccal and surgical trauma.  Congenital  Undescended testis  Hypospadias
  94.  Thermal factor  the scrotal temperature is raised in conditions such as varicocele, big hydrocele or filariasis.
  95.  Infection  mumps  Orchitis  systemic illness
  96.  Genetic  klinefelter’s syndrome(47XXY)  Iatrogenic  radiation, cytotoxic drugs  Nitrofurantoin  Cimetidine  antidepressant drugs.
  97.  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.
  98.  Chronic debilitating diseases  malnutrition  heavy smoking reduce spermatogenesis.
  99.  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.
  100.  Uterine factors  uterine hypoplasia  inadequate secretory endometrium  fibroid uterus
  101.  Cervical factors-  anatomical defects  scanty mucus  Vaginal factors  atresia vagina  transverse vaginal septum  septate vagina or narrow introitus.
  102. 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
  103.  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.
  104.  Investigations for female  General medical history  Tuberculosis  Sexually transmitted disease  Pelvic inflammatory disease  Diabetes
  105.  Surgical history  Abdominal or pelvic surgery  Peritubal adhesion  Menstrual history  Hypomenorrhoea  Oligomenorrhoea
  106.  Previous obstetric history  Number of pregnancies  Interval between them  Pregnancy related complications  Contraceptive practice  IUCD  Other contraceptive devices.
  107.  Diagnosis of ovulation  menstrual history  BBT  Cervical mucus study
  108. Hormone estimation  serum progesterone  Serum Leutinizing Hormone  Serum oestradiol  Urine Leutinizing Hormone
  109.  Endometrial biopsy  Sonography  Direct -laparoscopy
  110. 1. Counselling and waiting. 2. Treatment of the cause. 3. Ovulation induction. 4. Artificial insemination (IUI) 5. IVF/ICSI (invitrofertilization/intracyt oplasmic sperm injection)
  111. For male To improve spermatogenesis: In hypogonadotrophic hypogonadism – Tab. Clomiphen citrate  Testosterone GnRH therapy
  112. In genital tract infection – Antibiotic In retrograde ejaculation – Phenylephrine In terato/astheno-spermia – Donor insemination In genetic abnormality – IUI with donor’s sperm
  113. In Impotency : Psychological treatment Drugs –Sildenafil & alprostadil
  114. In female In ovulation disorders Clomiphene citrate:  ↑ses secretion of LH, FSH from pituitary
  115. In Endometriosis : Medical – Combined OCP Progesterone GnRH Surgery or both In Tubal block & Uterine malformation : Surgery Assisted reproduction technology IVF
  116.  It is artificial introduction of semen inside the female’s uterus.  Success rate varies, lie between 15% to 20% per cycle.
  117.  It is a process by which the oocyte is fertilized by a sperm outside the body: in vitro, and then a gamete retransferred intrauterine.
  118.  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.
  119.  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.
  120.  Definition  Different types of contraception  Temporary and permanent  Role of nurses in contraception  Definition of infertility  Causes of infertility  Management of infertility
  121.  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.