learn about various methods of contraception , how to use various contraceptive devices and also learn about the hormonal and emergency contraceptives' methods. here is the detail of post coital methods to prevent pregnancy and terminal methods for sterilization.

1. Sameeksha Patial
Nursing Tutor
ACN

2. Contraceptive methods
 Preventive methods to help women avoid unwanted
pregnancies. They include all temporary and permanent
measures to prevent pregnancy resulting from coitus.

3.  The contraceptive methods may be broadly grouped into two classes
- spacing methods and terminal methods, as shown below:
I. Spacing methods
1. Barrier methods
 (a) Physical methods
 (b) Chemical methods
 (c) Combined methods

4. 2. Intra-uterine devices
3. Hormonal methods
4. Post-conceptional methods
5. Miscellaneous
II. Terminal methods
1 Male sterilization
2 Female sterilization.

5. Barrier methods
 Physical methods:
1. Condoms: Male and Female
condom
2. Diaphragm
3. Vaginal Sponge

6. Condom
Male Condom is the most widely known
and used barrier device by the males
around the world.
In India, it is better known by its trade
name NIRODH, a sanskrit word, meaning
prevention. Condom is receiving new
attention today as an effective, simple
"spacing" method of contraception,
without side effects. In addition to
preventing pregnancy, condom protects
both men and women from sexually
transmitted diseases.

7. Condom prevents the semen from
being deposited in vagina.
The effectiveness of a condom
may be increased by using it in
conjunction with a spermicidal
jelly inserted into the vagina
before intercourse. The spermicide
serves as additional protection in
the unlikely event that the condom
should slip off or tear.

8. Advantages
 Easily available
 Safe and inexpensive
 Easy to use
 Don’t require medical supervisions
 No side effect
 Light compact and disposable
 Provide protection against pregnancy as well as STDs.

9. Disadvantages
 (a) it may slip off or tear during coitus due to
incorrect use, and
 (b) interferes with sex sensation locally about
which some complain while others get used
to it.
 The main limitation of condoms is that many
men do not use them regularly or carefully,
even when the risk of unwanted pregnancy or
sexually transmitted disease is high.

10. Female condom
 The female condom is a pouch made
of polyurethane, which lines the
vagina. An internal ring in the close
end of the pouch covers the cervix
and an external ring remains outside
the vagina. It is prelubricated with
silicon, and a spermicide need not be
used. It is an effective barrier to STD
infection.

11.  However, high cost and
acceptability are major
problems.
 The failure rates during the first
year use vary from 5 per 100
women-years pregnancy rate to
about 21 in typical users .

13. Diaphragm
 The diaphragm is a vaginal barrier. It was
invented by a German physician in 1882.
Also known as "Dutch cap", the diaphragm is
a shallow cup made of synthetic rubber or
plastic material.
 It ranges in diameter from 5-10 cm (2-4
inches). It has a flexible rim made of spring
or metal. It is important that a woman be
fitted with a diaphragm of the proper size.

14.  It is held in position partly by the
spring tension and partly by the
vaginal muscle tone. This means,
for successful use, the vaginal tone
must be reasonable. Otherwise, in
the case of a severe degree of
cystocele, the rim may slip down.

15.  The diaphragm is inserted before sexual
intercourse and must remain in place for
not less than 6 hours after sexual
intercourse. A spermicidal jelly is always
used along with the diaphragm. The
diaphragm holds the spermicide over the
cervix. Side-effects are practically nil.
Failure rate for the diaphragm with
spermicide vary between 5 to 12 per 100
women-years

16. Advantages
 The primary advantage of the
diaphragm is the almost total
absence of risks and medical
contraindications.

17. Disadvantages
 Initially a physician or other trained person will be needed to
demonstrate the technique of inserting the diaphragm into the vagina
and to ensure a proper fit.
 After delivery, it can be used only after involution of the uterus is
completed.
 Practice at insertion, privacy for this to be carried out and facilities for
washing and storing the diaphragm precludes its use in most Indian
families, particularly in the rural areas. Therefore, the extent of its use
has never been great.

18. Disadvantages contd…
 If the diaphragm is left in the vagina for an extended
period, there is a remote possibility of a toxic shock
syndrome, which is a state of peripheral shock requiring
resuscitation

19. Vaginal Sponge
 Another barrier device
employed for hundred of
years is the sponge soaked in
vinegar or olive oil, but it is
only recently one has been
commercially marketed in
USA under the trade name
TODAY for the sole purpose
of preventing conception.

20.  It is a small polyurethane foam
sponge measuring 5 cm x 2.5 cm,
saturated with the sperm nonoxynol-9.
The sponge is far less effective than
the diaphragm, but it is better than
nothing. The failure sets in parous
women is between 20 to 40 per 100
women and in nulliparous women
about 9 to 20 per 100 women years

21. Chemical method
 In the 1960s, before the advent of IUDS and oral
spermicide (vaginal contraceptives) were used widely.
They comprise four contraceptives, categories:

22.  a) Foams : foam tablets, foam
aerosols
 b) Creams, jellies and pastes -
squeezed from a tube
 c) Suppositories - inserted
manually, and
 d) Soluble films - C-film
inserted manually.

23.  The spermicides contain a base
into which a spermicide is
incorporated. The commonly
used modern spermicides are
"surface-active agents which
attach themselves to
spermatozoa and inhibit oxygen
uptake and kill sperms.

24. Drawbacks
 (a) they have a high failure rate
 (b) they must be used almost immediately before intercourse
and repeated before each sex act
 (c) the must be introduced into those regions of the vagina
where sperms are likely to be deposited, and
 (d) they may cause mild burning or irritation, besides
messiness.

25.  The spermicidal should be free from potential systemic
toxicity. It should not have an inflammatory or
carcinogenic effect on the vaginal skin or cervix.
 Spermicides are not recommended by professionals
advisers. They are best used in conjunction with barrier
methods.

26. Intrauterine devices:
 Intrauterine device (IUD) is a small, flexible plastic frame to be
inserted into the uterine cavity.
 There are two basic types of IUD :
1. Non-medicated
2. Medicated
 are usually made of polyethylene or other polymers; in addition,
the medicated or bioactive IUDs release either metal ions
(copper) or hormones (progestogens).

27. Non Medicated Intra uterine devices
 Inert or non-medicated or First
generation IUDs
 These devices are made of plastic or
stainless steel only. Lippes loop made of
plastic (polyethylene) impregnated with
barium sulphate is still used in many
parts of the world. Stainless steel rings
are widely used in China only.

28. Medicated IUDs
 Copper IUDs/ Second generation IUDs
 Copper wire or copper sleeves are put on the plastic frame (polyethylene
frame). Examples include Copper T, CuT380 A, Multiload 375 etc.
 The various types of Copper IUDs differ from each other by the amount of
copper. The initial Copper IUDs were wound with 200-250 mm2 wire
(CopperT 200). The modern copper containing devices contain more
copper and a part of copper in the form of solid tubal sleeves rather than
wire. This increases the efficacy and lifespan (Cu T-380 A).

29.  CuT 380A - It is a T shaped
device with a polyethylene
frame holding 380 mm2 of
exposed surface area of copper.
The IUD frame contains barium
sulfate thus making it radio-
opaque.

30.  CuT 380 slimline - It has copper
sleeves flushed at the ends of
horizontal arms to facilitate easier
loading and insertion. The
performance of CuT-380 Ag and
the CuT-380 slimline is equal to
that of CuT-380 A.

31.  • CuT-380Ag - It is identical to
380 A except that the copper
wire on the stem has a silver
core to prevent fragmentation
and extend the life span of the
copper.

32.  Multiload 375 - It has 375 mm2
of copper wire wound around its
stem. The flexible arms are
designed to minimize
expulsions. The multiload 375
and cu T-380 A are similar in
their efficacy and performance.

33.  Nova T - It is similar to the CuT-
200, containing 200 mm2 of
copper. However, the Nova T
has a silver core to the copper
wire, flexible arms, and a large
flexible loop at the bottom to
prevent cervical perforation.

34. Hormone-Releasing IUDs/ Third
Generation IUDs
Hormone-Releasing IUDs/
• Progestasert - It is a T shaped IUD
made of ethylene and vinyl acetate
copolymer containing titanium dioxide.
The vertical stem contains a reservoir of
38 mg progesterone together with
barium sulfate dispersed in silicone
fluid. The progesterone is released at the
rate of 65 µg per day.

35.  LNG - 20 (Mirena) - This T shape
& device has a collar attached to
vertical arm containing 52 mg of
levonorgestrel dispersed in poly
dimethyl siloxane. It releases 15µg
of levonorgestrel per day in vivo
and is effective for 7-10 year.

36. Mechanism of action
 IUD mainly work by changing the intra-uterine
environment and making it spermicidal. Non-medicated
IUD cause a sterile inflammatory response by producing a
tissue injury of minor degree but sufficient enough to be
spermicidal.

37.  Copper containing IUD, in addition, release free copper
and copper salts that have both a biochemical and
morphological impact on the endometrium and also
produce alteration in cervical mucus and endometrial
secretions. No measurable increase in serum copper is
observed.

38.  Hormone releasing IUD add progesterone effect on endometrium to the foreign
body reaction. The endometrium becomes decidualized with atrophy of glands.
The progesterone IUD does not increase the serum progesterone level
and mainly acts by inhibition of implantation, sperm-capacitation and survival.
Levonorgestrel IUD produces serum concentrations of the progestin half those of
Norplant and therefore, ovarian follicular development and ovulation is
not inhibited. The LNG-20 IUD decreases the blood loss (by about 40-50%) and
dysmenorrhoea.

39. Contraindications
 pregnancy
 puerperal sepsis or immediate post septic abortion
 distorted uterine cavity (congenital or acquired)
 unexplained vaginal bleeding
 suspected genital malignancy
 high-risk candidate for STI
 genital tuberculosis
 active Pelvic Inflammatory Disease (PID)

40. Ideal candidates
 The Planned Parenthood Federation of America (PPFA has described the
ideal IUD candidate as a woman :
1. who has borne at least one child
2. has no history of pelvic disease
3. has normal menstrual periods
4. is willing to check the IUD tail
5. has access to follow-up and treatment of potential problems,
6. and is in a monogamous relationship.

41. Timing of Insertion
After childbirth
• immediately after delivery of placenta
(post-placental insertion)
• four to six weeks after childbirth

42. After spontaneous or induced abortion
• immediately after 1st trimester abortion (aseptic).
• after 2nd trimester abortion it is advisable to wait till involution of
uterus is complete.

43. Menstrual cycle
• can be inserted any time, during menstrual cycle, if reasonably sure that woman
is not pregnant and has not been having sex without contraception.
• insertion during menstruation offers following advantages :
– pregnancy is ruled out
– insertion is easier due to open cervical canal
– any minor bleeding caused by insertion is less likely to upset the client

44. Information to the client after Copper T insertion
 She can expect some cramping for a day or two after insertion,
vaginal discharge for a few weeks after insertion and slightly heavier
menstrual period with possible bleeding between the menstrual
periods during first few months after insertion
 follow-up visit after 3-6 weeks or after next menstrual period to
ensure that IUD is in place and no infection has developed.
 information about kind of IUD and when to have her IUD removed
or replaced.

45. when she should see a nurse or
doctor after IUD insertion?
– missed menstrual period
– lower abdomen pain / vaginal discharge / fever
– missing IUD string
– very heavy and prolonged bleeding that bothers her

46. Hormonal contraceptives
 Hormonal contraceptives when properly used are the most effective
spacing methods of contraception. Oral contraceptives of the combined
type are almost 100 per cent effective in preventing pregnancy. They
provide the best means of ensuring spacing between one childbirth and
another. More than 65 million in the world are estimated to be taking the
"pill" of which about 9.52 million are estimated to be in India.

47. Classification
 Hormonal contraceptives currently in use and/or under study may be classified as
follows:
A. Oral pills
 1. Combined pill
 2. Progestogen only pill (POP)
 3. Post-coital pill
 4. Once-a-month (long-acting) pill
 5. Male pill

48. Classification contd…
B. Depot (slow release) formulations
 1. Injectables
 2. Subcutaneous implants
 3. Vaginal rings

49. Combined pill
 The combined oral contraceptive pill is often just called "the pill". It
contains artificial versions of female hormones oestrogen and
progesterone, which are produced naturally in the ovaries.
 If sperm reaches an egg (ovum), pregnancy can happen. Contraception
tries to stop this happening usually by keeping the egg and sperm apart
or by stopping the release of an egg (ovulation).

50.  The combined pill is one of the major spacing methods of contraception.
The "original pill" which entered into the market in the early 1960s
contained 100-200 mcg of a synthetic oestrogen and 10 mg of a
progestogen. Since then, a number of improvements have been made to
reduce the undesirable side-effects of the pill by reducing the dose of both
the oestrogen and progestogen.

51.  At the present time, most formulations of the combined pill contain
no more than 30-35 mcg of a synthetic oestrogen, and 0.5 to 1.0 mg
of a progestogen. The debate continues about the minimum effective
dose of the progestogen in the pill which will produce the least
metabolic disturbances.

52. When to take Combined pill
 The standard way to take the pill is to take 1 every day for
21 days, then have a break for 7 days, and during which
menstruation occur. When the bleeding occurs, this is
considered the first day of the next cycle.

53.  The pill should be taken everyday at a fixed time, preferably
before going to bed at night. The first course should be started
strictly on the 5th day of the menstrual period, as any deviation in
this respect may not prevent pregnancy. If the user forgets to take
a pill, she should take it as soon as she remembers, and that she
should take the next day's pill at the usual time.

54. Types of pills
 Mala-N
 Mala-D

55.  It contains Levonorgestrel 0.15 mg and Ethinyl estradiol 0.03 mg.
 Mala-D in a package of 28 pills (21 of oral contraceptive pills and 7
brown film coated 60 mg ferrous fumarate tablets) is made available to
the consumer under social marketing at a price of Rs. 3 per packet.
 Mala-N is supplied free of cost through all PHCS, urban family welfare
centres, etc.

56. Progestogen-only pills
 This pill is commonly referred to
as "minipill or "micropill". It
contains only progestogen, which
is given in small doses throughout
the cycle. The commonly used
progestogens are norethisterone
and levonorgestrel.

57. Progestogen-only pills
 The progestogen-only pills never gained widespread use because of poor
cycle control and an increased pregnancy rate. However, they have a
definite place in modern day contraception. They could be prescribed to
older women for whom the combined pill is contraindicated because of
cardiovascular risks. They may also be considered in young women with
risk factors for neoplasia. The evidence that the progestogens may lower the
high-density lipoproteins may be of some concern.

58. Post-coital contraception
 Post-coital (or "morning after") contraception is
recommended within 72 hours of an unprotected
intercourse.

59. Two methods are available :
(a) IUD : The simplest technique is to insert an IUD, if acceptable,
especially a copper device within 5 days.
(b) Hormonal : More often a hormonal method may be preferable. In
India Levonorgestrel 0.75 mg tablet is approved for emergency
contraception. It is used as one tablet of 0.75 mg within 72 hours of
unprotected sex and the 2nd tablet after 12 hours of 1st dose.

60.  Two oral contraceptive pills containing 50 mcg of ethinyl
estradiol within 72 hours after intercourse, and the same dose
after 12 hours.

61.  Four oral contraceptive pills containing 30 or 35 mcg of
ethinyl estradiol within 72 hours and 4 tablets after 12
hours.

62.  Mifepristone 10 mg once within 72 hours.
 Post-coital contraception is advocated as an emergency method; for
example, after unprotected intercourse, rape or contraceptive failure.
Opinion is divided about the effect on foetus, should the method fail.
Although the failure rate for post-coital contraception is less than 1 per
cent, some experts think a woman should not use the hormonal method
unless she intends to have an abortion, if the method fails. There is no
evidence that foetal abnormalities will occur. But some doubts remain

63. Once-a-month(long-acting) pill
 Experiments with once-a-month oral pill in which
quinestrol, a long-acting oestrogen is given in combination
with a short-acting progestogen, have been disappointing.
The pregnancy rate is too high to be acceptable. In
addition, bleeding tends to be irregular

64. Male pill
 The search for a male contraceptive began in 1950. Research is
following 4 main lines of approach:
 (a) preventing spermatogenesis
 (b) interfering with sperm storage and maturation
 (c) preventing sperm transport in the vas and
 (d) affecting constituents of the seminal fluid.

65.  A male pill made of gossypol- a
derivative of cotton seed
producing azoospermia or
severe oligospermia.

66. Mode of action
 The mechanism of action of the combined oral pill is to prevent the
release of the ovum from the ovary. This is achieved by blocking the
pituitary secretion of gonadotropin that is necessary for ovulation to
occur. Progestogen-only preparations render the cervical mucus thick and
scanty and thereby inhibit sperm penetration. Progestogens also inhibit
tubal motility and delay the transport of the sperm and of the ovum to the
uterine cavity

67. EFFECTIVENESS
 Taken according to the prescribed regimen, oral contraceptives of
the combined type are almost 100 per cent effective in preventing
pregnancy. Some women do not take the pill regularly, so the
actual rate is lower. In developed countries, the annual pregnancy
rate is less than per cent but in many other countries, the
pregnancy rate is 1 considerably higher.

68.  Under clinical trial conditions, the effectiveness of progestogen-only
pills is almost as good as that of the combination products. However, in
large family planning programmes, the effectiveness and continuation
rates are usually lower than in clinical trials. The effectiveness may also
be affected by certain drugs such as rifampicin, phenobarbital and
ampicillin

69. Adverse effects
 Cardiovascular effects
 Carcinogenic effects
 Metabolic effects
 Hepatocellular edema
 Cholestatic jaundice
 Breast tenderness
 Weight gain
 Headache and migraine
 Bleeding

70. Benefits
 100 percent effectiveness in preventing pregnancy and thereby removing
anxiety about the risk of unwanted pregnancy.
 Prevention of :
 Benign breast disorders
 Ovarian cysts
 Iron deficiency anemia, pelvic inflammatory diseases
 Ectopic pregnancy
 Ovarian cancer.

71. Contraindication
 Cancer of breast and genitals
 Liver disease
 History of thromboembolism
 Cardiac abnormalities
 Congenital hyperlipidemia
 Undiagnosed uterine bleeding
 Age over 40 years
 Smoking and age over 35 years mild hypertension
 Chronic renal disorder

72. Duration of use
 The pill should be used primarily for spacing pregnancies in
younger women. Those over 35 years should go in for other
form of contraception. Beyond 40 years of age, the pill is not
to be prescribed or continued because of the sharp increase
in the risk of cardiovascular complications.

73. Depot Formulations
Injectable contraceptives
Progestogen only injectable Combined injectable contraceptives
NET-EN
DMPA
DMPA-SC
104mg
Progesterone and estrogen

77. Side effects
 Disruption of the normal menstrual cycle
 Unpredicted bleeding
 Amenorrhea
 Anxiety

78. Contraindication
 Breast cancer
 Genital cancers
 Undiagnosed uterine bleeding
 High blood pressure
 Cardiac abnormality
 Breast feeding women with a baby less than 6 weeks of age

79. Advantages
 Highly effective
 Long lasting effect
 Reversible contraceptive

80. Combine injectable contraceptives
 These injection contain
progesterone and an oestrogen.
They are given at monthly
interval, plus or minus three
days.

82. Subdermal Implants
 The Population Council, New York has
developed a subdermal implant known as
Norplant for long-term contraception. It
consists of 6 silastic (silicone rubber)
capsules containing 35 mg (each) of
levonorgestrel (85). More recent devices
comprise fabrication of levonorgestrel into 2
small rods, Norplant (R)-2, which are
comparatively easier to insert and remove.
The silastic capsules or rods are implanted
beneath the skin of the forearm or upper arm.

83.  Effective contraception is provided for over 5
years. The contraceptive effect of Norplant is
reversible on removal of capsules. A large
multicentre trial conducted by International
Committee for Contraception Research (ICCR)
reported a 3-year pregnancy rate of 0.7. The
main disadvantages, however, appear to be
irregularities of menstrual bleeding and
surgical procedures necessary to insert and
remove implants.

84. Vaginal rings
 Vaginal rings containing
levonorgestrel have been found to
be effective. The hormone is
slowly absorbed through the
vaginal mucosa, permitting most of
it to bypass the digestive system
and liver, and allowing a
potentially lower dose.

85.  The ring is worn in the vagina for 3 weeks of the cycle and
removed for the fourth.

86. Post conceptional methods
 Menstrual Regulation
 Menstrual Induction
 Oral abortifacient

90. Miscellaneous
1. Abstinence
2. Coitus interrupts
3. Safe period
4. Natural Family planning methods
5. Breast feeding
6. Birth control vaccine

91. Abstinence
 The only method of birth control which
is completely effective is complete
sexual abstinence. It amount to
repression of a natural force and is liable
to manifest itself in other direction such
as temperamental changes and nervous
breakdown.

92. Coitus interrupts
 This is the oldest method of voluntary fertility control. It involve no cost or
appliances. It continues to be a widely practiced method. The male withdraw
before ejaculation, and thereby tries to prevent tries to prevent deposition of
semen into the vagina. The failure rate of this method is as high as 25%.

93. Safe period
 This is also known as the calendar method.
This method is based on the fact that ovulation
occur from 12 to 16 days before the onset of
menstruation.

94.  Fertile period : Shortest menstrual cycle- 18 and Longest
menstrual cycle- 10. (this will give the first to last day of the
fertile period)
 E.g. Shortest menstrual cycle of a woman is 26 and longest
menstrual cycle is 32 days;
 Then fertile period for that woman is : 26-18 , 31-10 i.e. 8 to 21

95. Drawbacks
 Women menstrual cycle are not always regular.
 Only educated and responsible couple with a high degree of
motivation and cooperation can use it effectively
 Compulsory abstinence
 This method is not applicable during the postnatal period.
 High failure rate due to wrong calculation

96. Natural family planning methods
1. Basal body temperature
2. Cervical mucus method
3. Symptothermic methods

97. Basal body temperature

98. Cervical mucus method

99. Symptothermic methods
 This methods combines the temperature, cervical mucus
and calendar method/technique for identifying the fertile
period.

100. Breastfeeding

101. Birth control vaccine

102. Terminal Methods
 Male sterilization: Vasectomy
 Female sterilization: Tubectomy

103. Male sterilization
 Male sterilization is a permanent method of
contraception for men. It works by blocking
the Vas (tubes connecting testicles to urethra).
After vasectomy procedure, there is no sperm
in semen. While testicles still produce sperm,
it is not transported outside the testicles and is
instead absorbed by the body.

104. Procedure
 In vasectomy, it is customary to remove a
piece of vas at least 1 cm after clamping. The
ends are ligated and then folded back on
themselves and sutured into position so that
the cut ends face away from each other. This
will reduce the risk of recanalization at a
later date.

105.  It is important to stress that the acceptor is not immediately
sterile after the operation, usually until approximately 30
ejaculations have taken place. During this intermediate
period, another method of contraception must be used. If
properly performed. vasectomies are almost 100 per cent
effective.

106.  Following vasectomy, sperm production and hormone output are not
affected. The sperm produced are destroyed intra-luminally by
phagocytosis. This is a normal process in the male genital tract, but
the rate of destruction is greatly increased after vasectomy.
Vasectomy is a simpler, faster and less expensive operation than
tubectomy in terms of instruments, hospitalization and doctor's
training Cost-wise, the ratio is about 5 vasectomies to one tubal
ligation.

107.  There are two methods of male sterilization:
1. Conventional Vasectomy which requires an incision.
2. Non-Scalpel Vasectomy (NSV) which does not require an incision
and is a simple, safe, sound, short, stitch less and scalpel less
procedure. It takes only 5-15 mins to perform and the beneficiary
can walk out within 10 minutes after the operation. It does not
interfere with manual labour of any kind nor does it affect a
person’s sex drive.

108. Conventional Vasectomy
 The doctor first numbs the scrotum of the client with a local
anaesthetic. They then make 2 small cuts in the skin on each side of
scrotum to reach the tubes that carry sperm out of testicles (vas
deferens).
 Each tube is cut and a small section removed. The ends of the tubes
are then closed, either by tying them or sealing them using heat.
 The cuts are stitched, usually using dissolvable stitches that go away
on their own within about a week.

109. Non-Scalpel Vasectomy (NSV)
 The doctor first numbs the scrotum with local anaesthetic. They then
make a tiny puncture hole in the skin of scrotum to reach the tubes.
This means they don't need to cut the skin with a scalpel.
 The tubes are then closed in the same way as a conventional
vasectomy, either by being tied or sealed.
 There's little bleeding and no stitches with this procedure. It's
thought to be less painful and less likely to cause complications than
a conventional vasectomy.

110. Misconceptions
 NSV leads to inability in ejaculation NSV does not affect
erection or ejaculation. Ejaculatory fluid, semen, is made in the
prostate and the seminal vesicles, which are not cut during
vasectomy. The amount of fluid that comes out of the testicle
with sperm is less than 1% of the overall ejaculated volume.
The muscle contractions that force fluid out during ejaculation
come from the pelvis and are not affected by NSV.

111.  NSV leads to decrease in levels of testosterone The
testicles make both sperm and testosterone. The testicle
makes testosterone and transports it through the blood
stream, not the vas deferens. Testosterone levels do not go
down as a result of permanent sterilization.

112.  NSV leads to prostate cancer There is no established
relationship between NSV and prostate cancer. Prostate
cancer is primarily identified through screening. A man
who undergoes vasectomy is more likely to get screened
for prostate cancer than a man who doesn’t.

113.  NSV affects semen production Vasectomy does not
decrease semen production. Men continue to make semen
in the same way as before the procedure.

114. Complications
 (a) Operative': The early complications include pain,
scrotal haematoma and local infection. Wound infection is
reported to occur in about 3 per cent of patients. Good
haemostasis and administration of antibiotics will reduce
the risk of these complications.

115.  (b) Sperm granules Caused by accumulation of sperm, these are a common
and troublesome local complication of vasectomy. They appear in 10-14 days
after the operation. The most frequent symptoms are pain and swelling.
Clinically the mass is hard and the average size approximately 7 mm. Sperm
granules may provide a medium through which re anastomosis of the severed
vas can occur, The sperm granules eventually subside. It has been reported
that using metal clips to close the vas may reduce or eliminate this problem

116. Spontaneous recanalization
Autoimmune response
Psychological

117. Post operative advise
 The patient should be told that he is not sterile
immediately after the operation; at least 30 ejaculations
may be necessary before the seminal examination is
negative
 To use contraceptives until aspermia has been established.

118.  To avoid taking bath for at least 24 hours after the operation.
 To wear a T bandage or scrotal support for 15 days and to keep the site clean
and dry.
 To avoid cycling or lifting heavy weights for 15 days; there is , however, no
need for complete bed rest.
 To have the stitches removed on the 5th day after operation.

119. Female sterilization
 Female sterilization is a permanent procedure
to prevent pregnancy. It works by blocking the
fallopian tubes (tubes connecting ovaries to
uterus). Sterilization is a viable option for
women who decide not to have any more
children. Sterilization does not give protection
from Sexually Transmissible Infections (STIs).

120. There are two methods of female sterilization:
 Interval Sterilization(suprapubic approach) which can be
done any time after ruling out pregnancy and at any time
after 6 weeks of giving birth.
 Post partum sterilization(subumblical approach) which
can be done within 7 days after giving birth.

121. (a) Laparoscopy
 This is a technique of female sterilization through abdominal approach
with a specialized instrument called "laparoscope". The abdomen is
inflated with gas (carbon dioxide, nitrous oxide or air) and the instrument
is introduced into the abdominal cavity to visualise the tubes. Once the
tubes are accessible, the Falope rings (or clips) are applied to occlude the
tubes. This operation should be undertaken only in those centres where
specialist obstetrician-gynaecologists are available. The short operating
time, shorter stay in hospital and a small scar are some of the attractive
features of this operation

122. Patient selection :
 Laparoscopy is not advisable for postpartum patients for 6
weeks following delivery; however, it can be done as a
concurrent procedure to MTP. Haemoglobin per cent should
not be less than 8. There should be no associated medical
disorders such as heart disease. respiratory disease, diabetes
and hypertension. It is recommended that the patient be kept
in hospital for a minimum of 48 hours after the operation.

123.  The cases are required to be followed-up by health
workers (F) LHVs in their respective areas once between
7-10 days after the operation, and once again between 12
and 18 months after the operation.

124. Complications :
 Although complications are uncommon, when they do
occur they may be of a serious nature requiring
experienced surgical intervention. Puncture of large blood
vessels and other potential complications have been
reported as major hazards of laparoscopy

125. Minilap operation
 Minilaparotomy is a modification of abdominal tubectomy. It is a much
simpler procedure requiring a smaller abdominal incision of only 2.5 to 3
cm conducted under local anaesthesia. The minilap/Pomeroy technique is
considered a revolutionary procedure for female sterilization. It is also
found to be a suitable procedure at the primary health centre level and in
mass campaigns. It has the advantage over other methods with regard to
safety, efficiency and ease in dealing with complications. Minilap
operation is suitable for postpartum tubal sterilization.

126. Procedure
 For a mini-laparotomy, either a general or regional
anesthesia (most commonly an epidural)will be given to
the patient. The surgery would then be performed in the
following steps:

127.  The surgeon will make a small but visible incision right
beneath the umbilicus.
 The fallopian tubes will then be pulled up and out of the
incision.
 The tubes will then be put back into place and the incision
closed with stitches.

128. Advantages of postpartum minilap tubectomy:
 Woman is already admitted in a facility and her current health status
usually can be established from delivery and prenatal records.
 • The uterus is high in the abdomen and a small incision (1.5-3.0 cm)
just below the umbilicus is usually sufficient to access the tubes.
 • Local anaesthesia with light sedation/analgesia is usually sufficient.
 • Hospital stay beyond what is required for a normal delivery (often
72 hours ) is not required after the procedure.