Family Planning

Introduction
Family planning means planning the size of the family in a manner,
compatible with the physical and socioeconomic resources of the parents and
conducive to the health and welfare of all members of the family.
Definition
WHO defined family planning as, ‘A way of living and thinking, that is
adopted voluntarily upon the basis of scientific knowledge, attitude and
responsible decisions by individuals and couples, in order to promote the
health and welfare of the family groups and thus contribute effectively to the
social and economic development of a country’.
Another definition refers to the ‘practices’ that help the individuals or
couples to attain the following objectives:
• To avoid unwanted births
• To bring about wanted births
• To regulate the interval between the pregnancies
• To control the time at which births occur in relation to the age of the parents
• To determine the number of children in the family.
CONTRACEPTIVE METHODS (Fertility Regulating Methods)
Contraceptive methods are, by definition, preventive methods to help
women avoid unwanted pregnancies. They include all temporary and
permanent measures to prevent pregnancy resulting from coitus.
An ideal contraceptive method is the one, which is safe, effective,
acceptable, inexpensive, reliable, reversible, simple, long lasting, independent
of coitus and requires less medical supervision.
A method suitable for one group may not be suitable for another group
because of different cultural background, religious beliefs and socioeconomic
status. Thus, there can never be an ideal contraceptive method. Therefore, the
present approach is to allow the couple to select any method of their choice
to promote FP. This is called ‘Cafeteria choice’.
The contraceptive methods may be broadly grouped into two classes
spacing methods and terminal methods, as shown below

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I. Spacing methods
1. Barrier methods
(a) Physical methods
(b) Chemical methods
(c) Combined methods
2. Intra-uterine devices
3. Hormonal methods
4. Post-conceptional methods
5. Miscellaneous.

II. Terminal methods

1 Male sterilization ( Vasectomy )
2 Female sterilization ( Tubectomy )

I Spacing Methods

1. Barrier Method
These are the methods, which act as barrier between the sperms and the
ovum. They are of three types:
a. Physical methods
b. Chemical methods
c. Combined methods.

a. Physical methods
The devices employed for physical barrier methods are condom,
diaphragm, cervical cap, vault cap and vimule cap.
A.Condom: There are two types, male condom and female condom.
Male Condom 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. In addition to preventing
pregnancy, condom protects both men and women from sexually transmitted
diseases. The condom is fitted on the erect penis before intercourse. The air
must be expelled from the teat end to make room for the ejaculate. The
condom must be held carefully when withdrawing it from the vagina to avoid
spilling seminal fluid into the vagina after intercourse. A new condom should
be used for each sexual act.

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 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.

There are three varieties of condoms marketed with the following trade
names:
Dry types (Non lubricated): Nirodh, Durapac, Kohinoor (‘Nirodh’ is a
sanskrit word, meaning prevention) Lubricants can be applied over this, such
as glycerine, spermicide and even water. Oil based lubricants should never be
applied such as cooking oil, coconut oil, mineral oil, petroleum jelly,
Vaseline, cream, lotion, butter, etc. because they weaken thelatex rubber very
quickly.
Deluxe types (lubricated): Adams, Fiesta, Kamasutra, Durex, Kohinoor-pink,
etc.
Super deluxe types: They are colored, thinner varieties lubricated with
spermicides, i.e. share, rakshak, etc.
Condoms can be a highly effective method of contraception, if they are
used correctly at every coitus. Failure rates for the condom vary enormously.
Surveys have reported pregnancy rates varying from 2-3 per 100 womenyears
to more than 14 in typical users. Most failures are due to incorrect use.
ADVANTAGES of condom are : (a) they are easily available (b) safe
and inexpensive (c) easy to use; do not require medical supervision (d) no
side effects (e) light, compact and disposable, and (f) provides protection not
only against pregnancy but also against STD.
DISADVANTAGES
• If not properly used, it may slip off or tear during sex-play
• It interferes with sex sensation but many get used to it
• Rarely allergic reaction can occur to latex
• It becomes weak when stored for long time
• It cannot be used more than once
• It causes little embarrassment to buy, to put on, to take off and throw away
• Allergy to condom is the only contraindication.

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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. 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 .
Merits: Controlled by woman, prevents both pregnancy and STDs, including
AIDS, no apparent side effects, no allergy and no contraindications. It can be
used even during menstruation. More comfortable to men. Offers greater
protection as it covers both internal and external genitalia.
Demerits: Expensive, not impressive, woman must touch her genitals. It is
now available in India, but widely available in Europe and USA. It is costly
in India. Improvements are being worked out for universal acceptability.

2. Diaphragm
It is also known as Dutch cap. It is named so after a German physician
Dutch Neo Mathusians, who first published it in 1882. It is a shallow, soft
rubber cup, with a stiff but flexible rim, made up of coiled spring, which
helps in retention
Size varies from 5 to 10 cm in diameter. The required size for a woman can
be determined by inserting two fingers in the posterior fornix and noting how
far on the finger the symphisis pubis comes. The distance indicates the
approximate diameter of the diaphragm, required for that woman.

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Method of insertion
She holds the diaphragm with the dome down, like a cup, with a
tablespoonful of jelly into the cup. She then presses the opposite sides of the
rim together and pushes the diaphragm into the vagina as far as it goes and
makes sure that it covers the cervix with her fingers.
When it is inserted, it lies snugly between the sacrum and the pubic
symphisis. It is held in position partly by the tension of the spring and partly
by the tone of the vaginal muscles.
It is to be inserted just before the intercourse. It must remain there at
least for 6 hours after the act. For each additional act of intercourse during
these 6 hours, she must use spermicide to be more effective. It should not be
retained for more than 24 hours.
She should not douche for at least 6 hours after sex.
Method of removal
She should hook the rim from behind the pubic symphisis and pull out
carefully. After removal, it should be washed with soap and water.
Meanwhile she checks for holes either by filling it with water or by
holding against light. After drying, it should be stored in a cool, dark and
clear place.
Merits
Simple, safe, effective and easy to use.
Demerits
It requires the services of a medical or paramedical person for the
demonstration of using it.
It may tear while removing, if not careful. There are some contraindications
such as prolapse of uterus, cystocoele, too long or too short cervix.
If left in the vagina for a long time, it may result in ‘Toxic shock syndrome’,
caused by Staphylococcus pyogenes, proliferating in the upper vagina,
characterized by fever, myalgia, rashes, dizziness, vomiting and diarrhea. It is
rare but serious.
Failure Rate
Failure rate is 10 to 20 per 100 women years of exposure (HWYE). It can be
reduced to 2 per HWYE by using along with the spermicidal jelly.

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 3. Cervical Cap
It is thimble shaped. It is like diaphragm but smaller. It covers the vaginal
portion of the cervix, thus acting as a barrier.
The woman inserts the cervical cap with spermicide, in the proper
position in the vagina before having sexual intercourse.
She fills the dome of the cap 1/3 full with spermicidal jelly or cream.
She squeezes the rim of the cap between thumb and index finger and with the
dome side towards the plam of the hand, slides the cap into the vagina and
presses the rim around the cervix.
She leaves the cap for at least 6 hours after the act. She should not
douche for at least 6 hours after the sex. Leaving in situ for more than 48
hours can cause bad odor and may increase the risk of toxic shock syndrome
She presses the cap rim and tilts. Then hooks a finger around the rim
and pulls it. She washes the cap with soap and water after each use, then,
cheeks for holes as in diaphragm. She then dries the cap and stores in a clean,
cool and dark place.

4. Vaginal Sponge
Another barrier device employed for hundreds 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. It is a small polyurethane foam sponge
measuring 5 cm x 2.5 cm, saturated with the spermicidal, nonoxynol-9. The
sponge is far less effective than the diaphragm, but it is better than nothing .
The failure rate in parous women is between 20 to 40 per 100 women-years
and in nulliparous women about 9 to 20 per 100 women years.

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b. Chemical Method
These are the contraceptives that a woman places in her vagina shortly
before sex. These are all spermicides These methods are grouped as follows:
a. Foams
b. Creams, jellies, pastes
c. Suppositories
d. Soluble films
All these devices are impregnated with spermicides. They are surface
active agents. They have to be inserted high up in the vagina. They attach
themselves to sperms, inhibit oxygen uptake and kill them.
Foams: 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 in the vagina. Foam is produced and spreads to all parts of vagina.
The commercial name is ‘Today’. This contains Nonoxynol-9 spermicide,
which paralyses the sperm. The effect lasts for about 1 hour. Foam aerosols
are better than foam tablets because they dissolve better than tablets.
Cream and paste: These have a soapy base.
Jelly: This has an acqueous base. They are supplied alongwith the applicator,
which is like a syringe with screw. They also contain Chloramine T or Phenyl
mercuric acetate. For example Delfen cream, volper cream, orthogynol jelly,
perception jelly, etc.
Merits
• They are simple, safe and easy to use
• They offer contraception just when needed
• Do not require medical assistance
• They are free from systemic toxicity.
Demerits: Some women complain of burning or irritation and messiness.
They often cause local allergic reaction and urinary tract infection. They have
to be used at each act of sex.
Failure rate: It is quite high, i.e. 25 pregnancy per 100 WYE. This can be
reduced by using it in conjunction with physical barriers.
All physical methods, except male condom and all chemical methods
are vaginal methods. All these vaginal methods were widely used before
1960s. With the introduction of IUDs and oral pills, the vaginal methods have
become outdated.
c. Combined Method This consists of combination of both physical and
chemical methods, i.e. condom and cream; diaphragm and jelly.

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2. Intra-uterine devices
Intrauterine devices (IUDs) are the devices, which when placed inside
the uterus, prevent the birth of the child, by acting as a foreign body.
In 1959, Openheimer of Israel and Ishihama of Japan published the excellent
results of IUDs, discovered by Grafenberg and Ota.
In 1960, Margulies spiral was launched, a plastic device, impregnated
with barium sulphate, a radio opaque substance. In 1962, Dr Jack Lippe of
US introduced a device, named after him as Lippe’s loop, which was very
popular for two decades in India
During 1970s, it was modified by adding copper to IUDs, which was
found to have strong antiferlility effect. Copper-T has now been widely used
under National Family Welfare Program. During 1990s, it was further
modified and improved by impregnating the IUDs with slow releasing
hormones, Hormonal IUDs.
An IUD is a small, stiff but flexible, nontoxic, polyethylene plastic
frame, incorporated with Barium sulphate, to make it radio opaque and
prevents conception by acting as a foreign body when inserted into the uterus
of the woman, through vagina. 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 and also to remove it by pulling when
pregnancy is desired.
Introduction of IUD has opened a new avenue in the control of
population growth.

Type Of IUDs
A. First generation IUDs
B. Second generation IUDs
C. Third generation IUDs.

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A. First generation IUDs
These are inert, non medicated devices, i.e. Lippe’s loop. It is a double
S-shaped, serpentine device, made up of poly-ethylene, nontoxic, non tissue
reactive material, incorporated with barium sulphate. It has two nylon trans
cervical threads, attached to lower end of the loop. It is available in four
sizes, A, B, C and D, latter being the largest, recommended for multiparous
women. In India, it is available in two sizes, 27.5 and 30 mm. For purposes of
identification, smaller one has black thread and bigger one yellow threads Fig
Because of side effects and more expulsion rates, (19/100 WYE) with the
introduction of copper IUDs, it became outdated and not used at all.

Fig. Lippe’s loop

B. Second generation IUDs

During 1970s, it was found that metallic copper has a strong
antifertility effect. Addition of copper to IUD has made it possible to develop
smaller and safer devices than Lippe’s loop, thereby minimizing the side
effects and expulsion rates; Thus, copper IUDs became morepopular.
The different copper bearing IUDs are:
• Earlier devices—T Cu 200, T Cu 200 B, Copper 7, Shangai-V-Cu-200.
• Newer devices—T Cu-220 C, T Cu—380 A, T Cu 380 S (Slim line) Cu
Nova—T 200 Cu Nova T 380
• Multiload devices—mL - Cu - 250, mL - Cu - 375
The number indicates the surface area of the copper in square mm, on
the device. Nova T and Copper T 380 Ag are distinguished by a silver core
over which is wrapped the copper wire. All copper T and multi load devices
are effective for at least 5 years, except T Cu 380 A, which is much more
effective for prevention of pregnancy up to 10 years.

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Advantages of copper devices
- Low expulsion rate Lower incidence of side-effects, e.g., pain and bleeding
- easier to fit even in nulliparous women better tolerated by nulli para
increased contraceptive effectiveness
- effective as post-coital contraceptives, if inserted within 3-5 days of
unprotected intercourse

C. Third generation IUDs.(medicated IUDs):

These were first pioneered by Scommegna et al. These are also ‘T’
shaped devices, made up of permeable, polymer membrane, incorporated
with a slow releasing progesterone hormone, which prevents pregnancy, i.e.
Progestasert, LNG-20.
Progestasert: This contains natural progesterone hormone, released in the
uterus slowly over a period of one year, at the rate of 65 mcg daily. As the
hormone is depleted, regular replacement is necessary, every year.
LNG-20: This device contains potent synthetic hormone, i.e. levonorgestrel,
releasing 20 mcg daily. This is effective for 3 to 5 years Compared to copper
devices, hormonal devices are still better in that the expulsion rate and the
incidence of side effects are lesser. But more expensive.

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Mechanism of Action
IUDs cause foreign body reaction resulting in cellular and biochemical
changes. The cellular or morphological changes are increased vascular
permeability (hyperemia), edema and infiltration of leukocytes (giant cells,
macrophages and polymorphs) in the endometrium of uterus. Certain
biochemical changes also occur in the uterine fluid, thereby the viability of
the ovum is impaired, thus reducing the chances of fertilization. Even if
fertilization occur, because of the increased tubal motility by the foreign
body, the fertilized ovum moves to the uterus much before the bed is
prepared for implantation and dies, thus preventing pregnancy.
In addition, copper ions are released from the copper IUDs, which has
strong anti fertility effect, by enchancing the cellular changes in the
endometrium, biochemical changes in the uterine fluid and cervical mucus
and also by affecting the motility, viability and capacity of the sperms.
Further, Cu-T also causes the release of prostaglandin which increases the
contractility of uterus and makes it uncongenial for the nidation of zygote.
The hormone releasing devices release the progesterone hormone,
which increases the viscosity of cervical mucus and prevent the sperms from
entering the cervix. They also maintain a high level of progesterone in the
endo metrium, making it unfavorable for implantation of zygote

Advantages
• Simple to insert, safe to use.
• Visit to the clinic is only once.
• Effective to the tune of 97 percent (i.e. High success rate) thus reliable.
• High continuation rate (Stays in place for several years).
• Reversible contraceptive method (IUD can be removed easily).
• Free from systemic, metabolic side effects, unlike oral pills.
• Does not interfere with sexual intercourse (so increased sexual enjoyment).
• Does not interfere with lactation.
• Collateral benefit is thorough pelvic examination of the woman, before IUD
insertion.
• Effective as ‘postcoital emergency contraceptives’, if inserted within 3 to 5
days of unprotected intercourse.
• Less risk of ectopic pregnancy.

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The ideal IUD candidate
The Planned Parenthood Federation of America (PPFA) has described
the ideal IUD candidate as a woman :
- who has borne at least one child has no history of pelvic disease
- has normal menstrual periods
- is willing to check the IUD tail
- has access to follow-up and treatment of potential problems, and is in a
monogamous relationship
IUD Insertion
The placement of IUD is done by using a plastic syringe called ‘IUD—
inserter’, which is presterilized by gamma radiation. The device is thus made
available in a presterilized packet.
Hands to be washed, sterile gloves to be worn, thorough pelvic
examination to be done to exclude any pathology, the genitalia (vagina and
cervix) is cleaned with iodine, working slowly and gently, the provider
inserts the IUD by opening the new, presterilized packet.
After insertion, if the woman feels dizzy, she should lie down quietly
for 5 to 10 minutes. Tim\eThe IUD can be inserted to a woman of
reproductive years, at any time during the menstrual cycle, if it is reasonably
sure that she is not pregnant. However, the ideal time is after the
5th day and before 10th day of menstrual period. This is called
‘Intermenstrual insertion’.
Thus, depending upon the timing of IUD insertion, it is named as
follows:
• 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. This is also called as ‘immediate
postpartum insertion’. But the disadvantage is high expulsion rate and high-
risk of infection and perforation of uterus.
• Postpartum insertion: This means insertion of IUD about 6 to 8 weeks after
delivery. This is also called as ‘post puerperal insertion’. The expulsion rate
is almost half of postplacental insertion.
• Postabortum insertion: This means insertion of IUD about 12 weeks after
an abortion. However, following

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 Instruction during IUD Insertion
• She must feel for the filaments in the vagina, every month.
• She must report if it is not felt or expelled out or if it causes any problem.
• In the absence of any complaints, she must report for the examination 1
year and 2 years after insertion.
• Depending upon the types of IUD, it has to be removed after its lifespan is
over.
• In case she becomes pregnant and if she desires that pregnancy, it is better
to remove the IUD to avoid infection and spontaneous abortion. If she does
not want that pregnancy, medical termination of pregnancy is done.
Indication for Removal of IUD
• Development of side effects such as severe pain and heavy bleeding
• Occurrence of pregnancy
• Development of pelvic inflammatory disease (PID)
• Perforation of uterus
• Partial expulsion of IUD
• When the lifespan of IUD has passed
• When the woman reaches menopause
Using aseptic precautions, the IUD strings are pulled slowly and gently with
forceps
Contraindication for IUD Insertion
• Absolute contraindications are pregnancy, STDs, previous ectopic
pregnancy, any pelvic pathology such as infections, tumors, bleeding
disorder, congenital defects in the uterus and cancer of cervix, uterus or
adnexa.
• Relative contraindications are multiple sexual partners and anemia;
Wilson’s disease is a contraindication for copper IUDs only.

Failure Rate
It is 2 to 3 per 100 WY.

Complication
• Menstrual changes (bleeding): These changes are common during the
first-three months. Bleeding can occur in any of the following forms:
Spotting between the periods, longer and heavier menstrual periods
(menorrhagia). More cramps or pain (dysmenorrhea) during periods.
Removal of IUD restores the normal pattern of the cycle.
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 • Pain: This occurs in nearly 30 to 40 percent of the users. Pain is
experienced as low back ache, abdominal cramps or pain down the thighs.
Usually, pain disappears by third month. If pain is intolerable, IUD has to be
removed. If pain is severe during insertion, it indicates that either the IUD is
large or incorrectly placed inside the uterus.
• Pelvic infection: PID (Pelvic inflammatory disease) is a collective
term including acute, subacute or chronic inflammatory conditions of pelvic
organs such as ovaries, fallopian tubes, uterus, the related connective tissues
and the pelvic peritoneum.
PID is clinically characterized by fever, intermenstrual bleeding,
leucorrhea, dysuria, pelvic pain and tenderness and palpable painful adnexal
swelling (indicating tuboovarian abscess). One or two such episodes can
result in blocking of fallopian tubes and infertility. Thus, PID is a threat to
woman’s fertility. When PID is diagnosed, IUD has to be removed.
PID can be prevented by proper selection of cases, thorough
examination of pelvis before IUD insertion and by following aseptic
precautions while inserting IUD and by avoiding multiple sexual partners.
• Uterine perforation: It is rare but potentially a serious complication
following IUD insertion. It is used to be more with Lippe’s loop than with
copper IUDs. It is more common following postplacental insertion than
postpartum insertion. It is also more when inserted by an untrained person.
Perforation of uterus results in migration of the device into the
peritoneal cavity causing obstruction of bowel, and peritoneal adhesions.
Often it could be asymptomatic also. Uterine perforation is suspected when a
search is made for a missing IUD and diagnosis is made by pelvic X-ray or
ultrasound examination. IUD is removed by laprotomy.
• Expulsions: Nonmedicated devices like Lippe’s loop have higher
expulsion rates (6-13/100 WY) than copper devices which have 1-8/100 WY.
Nulliparous women have higher expulsion rate than the parous women.
Among the parous women, it is more among lactating mothers than
nonlactating mothers. Nearly 20 percent of\ the expulsions go unnoticed.
Most expulsions take place within 3 months of IUD insertion and frequently
occur during menstruation. Unnoticed expulsion may lead to unwanted
pregnancy.

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 • Ectopic pregnancy: Pregnancy itself is rare among IUD users. But
when pregnancy occurs, 1 in every 30 is ectopic (3%). It is life threatening
and requires immediate treatment.
Ectopic pregnancy is characterized by History of amenorrhea, lower
abdominal pain and tenderness, scanty or dark vaginal bleeding, anemia and
fainting. It is confirmed by pelvic ultrasonography. It may result in rupture of
fallopian tubes. Treatment is lapratomy and removal of trophoblast, fetal
parts and tubes.
History of previous ectopic pregnancy is associated with an increased
risk of ectopic pregnancy. So, such women should not use IUD.

3.Hormonal methods
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 areestimated to be in India.
These are the contraceptives containing gonadal steroids, the term
"steroid" refersto adrenocortical hormones, while to those in gynaecology, it
implies gonadal steroids, i.e., oestrogens and progestogens.
a. Synthetic oestrogens : Two synthetic oestrogens are used in oral
contraceptives. These are ethinyl-oestradiol and
mestranol. Both are effective. In fact, mestranol is inactive until converted
into ethinyl oestradiol in the liver b. Synthetic progestogens: These are
classified into three groups - pregnanes, oestranes and gonanes.
(i) Pregnanes : These include megestrol, chlormadinone and medroxy
progesterone acetate. The pregnane progestogens are now not recommended
in oral contraceptives because of doubts raised by the occurrence of breast
tumours in beagle dogs.
(ii) Oestrones : These are also known as 19-nortestosterones, e.g.,
norethisterone, norethisterone acetate, lynestrenol, ethynodiol diacetate and
norethynodrel. These are all metabolized to norethisterone before becoming
active. For some women, oestranes are more acceptable than gonanes. (iii)
Gonanes : The most favoured gonane is
Levonorgestrel

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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
B. Depot (slow release} formulations
1. Injectables
2. Subcutaneous implants
3. Vaginal rings

A. Oral pills
1. Combined pill
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. 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.
The pill is given orally for 21 consecutive days beginning on the 5th
day of the menstrual cycle (for a few preparations 20 or 22 days are advised),
followed by a break of 7 days during which period menstruation occurs.
When the bleeding occurs, this is considered the first day of the next cycle.
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.

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Types of pills
The Department of Family Welfare, in the Ministry of Health and
Family Welfare, Government of India has made available 2 types of low-dose
oral pills under the brand names of MALA-N and MALA-D. It contains
Levonorgestrel 0.15 mg and Ethinyl estradiol 0.03 mg.Mala-Din 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.

2. Progestogen-only pill (POP)

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. 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 modernday 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 (61). The evidence that the
progestogens may lower the high-density lipoproteins may be of some
concern.

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3. Post-coital contraception
Post-coital (or "morning after") recommended within 72 hours of
intercourse. Two methods are available: contraception is an unprotected
(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.
or
Two oral contraceptive pills containing 50 mcg of ethinyl estradiol within 72
hours after intercourse, and the same dose after 12 hours.
or
Four oral contraceptive pills containing 30 or 35 mcg of ethinyl estradiol
within 72 hours and 4 tablets after 12 hours.
or
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
4. 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.
5. 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.

18
 Most of the research is concentrated on interference with
spermatogenesis. An ideal male contraceptive would decrease sperm count
while leaving testosterone at normal to lower testosterone and affect potency
and libido.
A male pill made of gossypol - a derivative of cotton-seed oil, has been
very much in the news. It is effective in producing azoospermia or severe
oligospermia, but as many as 10 per cent of men may be permanently
azoospermic after taking it for 6 months. Further gossypol could be toxic.
Animal studies show a narrow margin between effective and toxic
doses. At present it does not seem that gossypol will ever be widely used as a
male contraceptive

MODE OF ACTION OF ORAL PILLS

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
Side Effect
• Nausea (common during first 2 to 3 months)
• Spotting or bleeding between menstrual periods specially if she forgets to
take pills regularly.
• Mild headache
• Breast tenderness
• Slight weight gain (often considered as a merit)
• Suppresses the quality and quantity of the breastmilk if she is lactating
mother (because of estrogen content)
• May cause mood changes including depression, less interest in sex.
• Very rarely can cause cardiovascular effects such as hypertension,
myocardial infarction, cerebral thrombosis and thrombosis in the deep veins
of the legs. These risks are high among women with hypertension, aged
above 35years, and heavy smokers.
• It does not protect against STDs including AIDS.
• Worsens diabetic condition calling for more insulin.

19
 All these side effects, except thromboembolic and cardiovascular
effects, are not dangerous and generally stops in a few months.
Contraindications
Absolute contraindications are women beyond 35 years of age, or with
hypertension or history of thrombo embolism or cardiovascular diseases,
cancer of breast and genitals, liver diseases and bleeding disorders.
Relative contraindications are pregnancy, lactation, epilepsy and migraine.
These conditions have to be looked for before prescribing
the pills and women should not take for more than 2 to 3 years.

B. Depot (slow release} formulations

The need for depot formulations which are highly effective, reversible,
long-acting and only synthetic progesterone (oestrogen-free )for
spacing regnancies in which a single administration suffices
for several months or years cannot be stressed. The injectable contraceptives,
subdermal implants and vaginal rings come in this category.
1. Injectable contraceptives
There are two types of injectable contraceptives. Progestogen-only
injectables and the newer once-a-month combined injectables

A. PROGESTOGEN-ONLY INJECTABLES
Thus far, only two injectable hormonal contraceptives both based on
progestogen - have been found suitable. They offer more reliable · protection
against unwanted pregnancies than the older barrier techniques. These are :
a. DMPA (Depot-medroxyprogesterone acetate)
b. NET-EN (Nor ethisterone enantate)
a. DMPA
DMPA: Depot medroxy progesterone acetate, a microcrystalline suspension,
to be given deep intramuscularly, once in 3 months, each dose containing 150
mgm of progestin (synthetic progesterone) and is less painful, marketed as
Depo-provera, Megestron. One dose protects for 3 months.
b. NET-EN
NET-EN: Norethisterone Enanthate, an oily solution, to be given deep
intramuscularly, once in 2 months, each dose containing 200 mgm of
synthetic progesterone. It is more painful. This disappears more rapidly from
the circulation compared to DMPA. So, it is given more frequently. It is
marketed as noristerat. One dose protects for two months.
20
 Mechanism of action
• These synthetic progestogens inhibit ovulation by inhibiting the secretion of
gonadotrophins (FSH and LH).
• They also thicken the cervical mucus thereby forming a barrier to sperms.
• They also induce a thin endometrium, less suitable for implantation.
Administration
The initial injection of both DMPA and NET -EN should be given
during the first 5 days of the menstrual period. This timing is very important
to rule out the possibility of pregnancy. Both are given by deep intramuscular
injection into the gluteus maximus. The injection site should never be
massaged following injections. Although compliance with regular injection
intervals should be encouraged, both DMPA and Net-EN may be given two
weeks early or two weeks late
For a lactating mother these injections are given as early as 6 weeks
after childbirth. No need to wait for periods to return. It can also be given
after abortion, within 7 days.
Instructions to the user
• Not to massage the site of injection, so that it is absorbed slowly.
• To take the injection once in 3 months if DMPA is given or once in 2
months if NET-EN is given.
• To come back on the due date for the next injection.
• That she will have her cycles once in 2 to 3 months, depending upon the
type of injection.
• She should come back even if she is late.
• She should also come back if she develops side effects, such as heavy
bleeding.
Return of fertility: It is delayed by 4 to 6 months, after
stopping the drugs.
Failure rate: About 0.3 pregnancies per 100 women years.
Merits
• Very safe, effective, convenient and reversible.
• Long-term pregnancy prevention (One injection serves the purpose for 2 to
3 months, depending upon the type).
• Does not interfere with sex (So prolonged sexual pleasure).
• Does not interfere with lactation (So can be given to a lactating mother)
• Quality and quantity of milk is not affected.
• Does not contain estrogen (So free from all the side effects of estrogen).
21
• Can be used by women of any age in the reproductive period, including
nulliparous women.
• Helps prevent ectopic pregnancies, endometrial cancer and uterine fibroids.
• May help prevent ovarian cancer, iron deficiency anemia, and decrease the
frequency of seizures among epileptic women.
Demerits
• Menstrual cycles become irregular, once in 2 to 3 months,depending upon
the type (Once in 2 months with NET-ENand once in 3 months with DMPA).
• Changes in the menstrual bleeding are also likely such as varying from light
spotting to heavy bleeding.
• May cause weight gain of 1 to 2 kg per year.
• Delayed return of fertility by 4 to 6 months or even longer.
• Injection to be taken regularly, every 2 to 3 months, depending upon the
type.
• May cause headache, breast tenderness, mood changes and loss of libido.
Contraindications
• Pregnancy (If given during pregnancy, it is not dangerous. But it is waste).
• Early postpartum period (within 6 weeks of delivery).
• Suspected malignancy.
• Pelvic inflammatory disease.
• Bleeding disorders.
Note: Monthly injectable contraceptives, containing estrogen and
progestin are available in other developed countries but not in India. The
potential advantages are high contraceptive effectiveness, regularity in the
cycles and rapid return of fertility. But monthly visit to the clinic is
necessary.

B. COMBINED INJECTABLE CONTRACEPTIVES

These injectables contain a progestogen and an oestrogen. They are
given at monthly intervals, plus or minus three days. Combined injectable
contraceptives act mainly by suppression of ovulation. The cervical mucus is
affected, mainly by progestogen, and becomes an obstacle to sperm
penetration. Changes are also produced in endometrium which makes it
unfavourable for implantation if fertilization occurs, which is extremely
unlikely.

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Combined injectables are not suitable for women who are fully breast feeding
until 6 months postpartum. It is less suitable for women with risk factors for
oestrogen.

2. 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 .
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. 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.

Norplant

Insertion:
The capsules are inserted subcutaneously, by a small incision under
local anesthesia in the upper arm of the woman using a template as shown in
the figure. After all the capsules are inserted, the incision is closed with an
adhesive bandage. Stitches are not necessary

Mode of action: It is the same as that of IM injectables.

Effectiveness: Contraception is provided for 5 years approximately.

23
Failure rate: The 1-6 pregnancies per 100 women years.

Merits and demerits are same as those of DMPA and NETEN.

Additional merit is that the effect lasts for 5 years and additional demerit is
that removal and insertion is by minor surgery.
Note: There is another version called ‘Norplant II’ which consists of
only two rods instead of 6 capsules. It is under clinical trial. 1-capsule
implant containing disogestrel, is also being studied.

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

3. Post-coital pill
There are three methods:
A. Menstrual regulation
B. Menstrual induction
C. Induction of abortion.

A. Menstrual regulation
Menstrual regulation (MR) means regularizing the menstrual cycle in a
woman, who had her cycles regularly previously, but now missed and
delayed by 1 to 2 weeks, before any pregnancy test can confirm whether she
is pregnant or not. The missed (or delayed) period could be due to the reasons
other than pregnancy, such as psychological factors. The MR consists of
evacuation of the contents of the uterus.
Procedure:
This is done by using a small, flexible, plastic cannula of 5 to 6 mm
diameter (Karman cannula) in association with a gynecological syringe, (MR
syringe) as a source of negative pressure. Cervical dilatation is not necessary,
except in nulliparous women and in those who are too apprehensive.
Interposed between the cannula and the syringe is a bottle to collect the
aspirate. Tip of cannula is shifted to various positions and aspirated.

24
Merits:
This is carried out without anesthesia as an outpatient. It is safe and
simple measure by an experienced person. This procedure does not require
the confirmation of the pregnancy nor does it attract the legal provisions for
abortion.
Demerits:
The immediate complications are trauma, sepsis and perforation of
uterus. Late complications include tendency to abortion, premature labor,
infertility, menstrual irregularities, and ectopic pregnancy. If the delay in the
missed period were to be due to pregnancy, then this procedure is considered
as an early abortion. Thus, menstrual regulation differs from early abortion in
that:
• There is no certainity that she is pregnant
• There is no legal restrictions
• There is increased safety of the early procedure.

B. Menstrual induction
Means inducing menstruation in a woman, who is in early pregnancy,
by intrauterine application of 2.5 to 5 mgm solution of prostaglandin F2
under sedation. Within about 10 minutes, there will be sustained, spasmodic
contractions of the uterus lasting for 3 to 4 hours, resulting in expulsion
of product of conception, thus terminating the pregnancy. Bleeding starts and
lasts for about 5 days.

Oral abortifacient
Mifepristone (RU 486) in combination with misoprostol is 95 per cent
successful in terminating pregnancies of upto 9 week's duration with
minimum complications. The commonly used regimen is mifepristone 200
mg orally on day 1, followed by misoprostol 800 mcg vaginally either
immediately or within 6-8 hours. Commercially it comes as MTP kit having
combipack tablets of mifepristone 200 mg one tablet and misoprostol 200
mcg 4 tablets {800 mcg). The other regimen is a dose of mifepristone 600 mg
on day one, followed by 400 mcg orally of misoprostol on day three.

25
C. Induction of abortion.
Means terminating the pregnancy as a contraceptive method,
deliberately in a pregnant woman before the fetus becomes viable (i.e. before
28th week of pregnancy), which may be legal or illegal. Abortion is sought
by women for many reasonsincluding birth-control (Spontaneous abortion is
Nature’s method of birth control).
Legal abortion is the one which is done by a qualified doctor, in a
recognized hospital, under specific reasons (indications).
Illegal abortion is the one which is performed by an unqualified person
clandestinely, under unhygienic conditions, when the pregnant women
approach such persons as the last resort to end their pregnancies at the risk
of their own lives.
Medical Termination Of Pregnancy Act 1971
Introduction:
` Before 1970, illegal abortion was one of the causes of increased
maternal morbidity and mortality and it was also considered as a crime
because of feticide. Since induction of abortion is a method of contraception,
in order to reduce the hazards of population explosion and to reduce MMR,
termination of pregnancy was legalized and not considered as crime by
passing an Act by the Indian parliament, called Medical termination of
pregnancy Act in 1971, which came into force from April 1, 1972, modified
in 1975. It is applicable to the state of Jammu and Kashmir from
Nov 1976. Now MTP is considered as a health care measure to reduce
MMR resulting from abortion.
The MTP-Act lays down the following considerations:
a .The conditions under which a pregnancy can be terminated.
b.The person or persons who can perform such terminations.
c.he place where the pregnancy can be terminated.

a. The conditions (indications) under which the pregnancy

can be terminated are:
• Medical (therapeutic)—where continuation of pregnancy endangers the life
of a woman physically or psychologically. So, it is done as a part of the
treatment as in mitralstenosis, severe anemia, viral hepatitis, etc.
• Eugenic—where there is a risk of the child being born with serious physical
or mental handicap as in German measles, mother with steroids, antimitotic
drugs or radiotherapy, etc.
26
• Humanitarian—where the pregnancy is the result of rape.
• Socioeconomic—where the extreme poverty can injure mother’s health.
• Failure of contraceptive method—where the unwanted pregnancy occurring
from failure of contraceptive method can affect mental health of the woman.
A written consent of the guardian is necessary before performing abortion in
women under 18 years of age and in lunatics, even if they are older than 18
years.
b. The person or persons who can perform abortion:
Under the Act, only Registered medical practitioner (RMP) having the
following criteria, is authorized to perform the abortion.
• A postgraduate degree or diploma in ObG
• Has undergone 6 months of residency in ObG
• Has assisted at least 25 MTPs in approved institutions
• Registered before the Act, 3 years of practice in ObG (before 1971)
• Registered after the Act, 1 year of experience in ObG. AND
He/she should have obtained licence from Dist. health officer, based on
the above criteria. Such an authorized RMP can perform MTP where the
length of the pregnancy does not exceed 12 weeks.
However, if pregnancy exceeds 12 weeks but less than 20 weeks,
requires the opinion of another RMP.
c. The place where MTP can be performed:
• A Government hospital
• Any other health care institution approved for this purpose by Government.
Thus, MTP should be performed in a right time, by a right Person, in a right
place by a right technique.
Methods of MTP: There are three methods:
Suction evacuation: Where the pregnancy is less than 12 weeks,
evacuation of the contents of uterus is done by using acannula and a suction
apparatus. The apparatus is started to run and the cannula is passed slowly
over the entire lining of the uterus. The contents are evacuated under a
pressure of 70
mmHg and aspirated.
Extraovular injection: This is done when the pregnancy is between 12
and 14 weeks and the product of conception is so big that it cannot be sucked
out. This consists of giving injection transcervically using a Folley’s catheter,
either prostaglandin F2a 500 g or Ethacridine acetate 150 mL. Abortion
occurs within 24 hours.

27
 Intra-amniotic injection: This is done when the pregnancy is between
14 and 20 weeks duration. This consists of injection of 150 mL of saline or
80 mgm of urea or 50 mgm of prostaglandinF2a into the amniotic cavity,
under local anesthesia, through a lumbar puncture needle, passed just below
and left to the umbilicus. Penetration of the needle into the amniotic cavity is
confirmed by the free flow of the amniotic fluid through the needle. Abortion
takes place within 72 hours.

5. Miscellaneous.
1.Abstinence
2.Coitus interruptus
3. Safe period (rhythm method)
4. Natural family planning methods
5. Breast-feeding
6. Birth control vaccines.
1. Abstinence
Complete sexual abstinence is easy to say but impossible to practice. It
amounts to repression of a natural biological necessity, which may result in
temperamental changes and even nervous breakdown. So, this cannot be
advocated.
2. Coitus interruptus
In this method, during the act of intercourse, the male partner
withdraws his organ at the time of climax, so that deposition of semen into
the vagina is prevented.
Merits: It is better than not using any method at all.
Demerits: Difficult to practice. Precoital secretion may contain sperms and
result in pregnancy. Delay in withdrawl results in pregnancy. Failure rate is
high.
Failure rate: Failure rate is 25 percent.

3. Safe period (rhythm method)

This is also known as the "calendar method" first described by Ogino
in 1930. The method is based on the fact that ovulation occurs from 12 to 16
days before the onset of menstruation period.

28
 Before relying on this method, the woman records the number of days
in each menstrual cycle for at least 6 months. The first day of bleeding is
counted as day 1. Thus, she should record the period of shortest and longest
cycle.
Ovulation occurs from 12 to 16 days before the onset of menstruation
(Average = 14 days). Suppose, intercourse takes place on 10th day, and
ovulation takes place on 12th day, fertilization can occur, because sperms live
for 2 days. Similarly, if ovulation occurs on 16th day, even if sexual
intercourse is performed on 17th day, fertilization can take place, because
ovum lives for 1 day.
Thus, period from 10th to 17th day is fertile period, provided her cycle
is of 28 days regularly. In case of variations in the cycle to know the fertile
period, subtract 18 from the length of the shortest cycle. This gives the
estimated first day of the fertile period.
Then subtract 11 days from the length of the longest cycle. This gives
the last day of the fertile period. The couple should avoid sex or use condom
during the fertile period.
Example: If the recorded cycles vary from 26 to 32 days,
26-18=8. Avoid sex from 8th day.
32-11=21 can have sex from 21st day of her cycle.
Fertile period = 8th day to 21st day.
In normal cycle, 28-18=10 and 28-11=17, the fertile time is from 10th to 17th
day. Thus, the first week and the last week of the cycles is the ‘Safe period’
(Infertile period).
Demerits: If the cycles are irregular (as in most of the women) it is difficult
to predict fertile period and safe period. If the couples are illiterate, it is
difficult to practice. Compulsory abstinence during the fertile period or
condom to be used.
This method is not applicable during postnatal period.
Failure rate is high, i.e. 21 per 100 women years (It is due to wrong
calculations).

4. Natural family planning methods

The term "natural family planning" is applied to three methods: (a)
basal body temperature (BBT) method (b) cervical mucus method, and (c)
symptothermic method.

29
 The principle is the same as in the calendar method, but here the
woman employs self-recognition of certain physiological signs and
symptoms associated with ovulation as an aid to ascertain when the fertile
period begins. For avoiding pregnancy, couples abstain from sexual
intercourse during the fertile phase of the menstrual cycle; they totally
desist from using drugs and contraceptive devices. This is the essence of
natural family planning.
(a) Basal body temperature (BBT) method
This depends upon an event that Basal body temperature method (BBT)
rises by about 0.5º C on the day of ovulation, because of an increase in the
progesterone level. The woman should record her temperature daily in the
morning, at the same time, before she gets out of the bed.
This method is reliable if the couple avoid sex or use condom from the
first day of the cycle till the day the woman’s temperature is raised and also if
the couple restrict the intercourse to the postovulatory safe period,
commencing three days after the rise of BBT.
Practically difficult to record the temperature daily and adopt. Failure
rate is about 20 per 100 women users.
(b) Cervical mucus method
This is based on the observation that at the time of ovulation, the
cervical mucus becomes watery, can be stretched, clear (like raw egg
white), smooth, slippery and profuse. After ovulation, because of
progesterone, the mucus thickens and lessens in quantity
This requires a high degree of motivation to the women.
Feel of the cervix: As the fertile time begins, the cervix opens slightly and
cervix is felt soft and moist. During the remaining period the cervix is firm
and closed.
(c) Symptothermic method
This method combines the temperature, cervical mucus and calendar
techniques for identifying the fertile period. If the woman cannot clearly
interpret one sign, she can "double check" her interpretation with another.
Therefore, this method is more effective than the "Billings method" ..

30
5.Breast-feeding
Field and laboratory investigations have confirmed the traditional belief
that lactation prolongs postpartum amenorrhoea and provides some degree of
protection against pregnancy Thus, this method is effective when:
• The mother practices exclusive breastfeeding (i.e. frequent feeding during
day and night as during the first six months after delivery).
• Her menstrual periods have not returned.
• Her child is less than six months of age.
When weaning is started, protection from pregnancy decreases because
of decrease in prolactin level. Thus, this method is very effective up to first
six months However, once menstruation returns, continued lactation no
longer offers any protection against pregnancy.By and large, by 6 months
after childbirth, about 20-50 per cent of women are menstruating and are in
need of contraception
Failure rate: 0.5 to 2 pregnancies per 100 women users.
Merits
• Simple, safe and effective, specially during the first six months after child
birth.
• Encourages scientific practice of breastfeeding.
• No direct cost for family planning.
• No hormonal side effects.
• Child gets all the benefits of exclusive breastfeeding.
• Encourages the mother to start a follow on method after six months.
Demerits
• Effectiveness after six months is not certain
• Frequent feeding is difficult for working mothers
• Does not protect against STDs including HIV
• If the mother is HIV positive, there is a risk of transmission to the baby.

6. Birth control vaccine

There are three types of vaccines under research, namely:
1. Anti-hCG vaccines
2. Anti-zona vaccine
3. Anti-sperm vaccine.

31
Anti-hCG vaccine: It is anti human chorionic gonadotrophin vaccine.
Normally, hCG is produced by the trophoblast cells of the human blastocyst
during implantation in early pregnancy. Immunization with hCG would block
continuation of the pregnancy. Antibodies appeared in about 4-6 weeks and
reached maximum after about 5 months and slowly declined reaching zero
levels after a period ranging from 6-11 months.
Anti-zona vaccine: It is a vaccine against the zona pellucid of the ovum. The
antibodies produced against the zona pellucida exert their contraceptive effect
by occluding the sperm receptor sites on the surface of the ovum, thereby
preventing fertilization.
Anti-sperm vaccine: The antibodies produced with this cause either
immobilization of the sperms or their agglutination resulting in diminution of
fertility. Researches are going on.
II. Terminal methods ( Sterilization)
Voluntary sterilization is a well-established contraceptive procedure
for couples desiring no more children. Currently female sterilizations account
for about 85 per cent and male sterilizations for 10-15 per cent of all
sterilizations in India, inspite of the fact that male sterilization is simpler,
safer and cheaper than female sterilization.
Sterilization offers many advantages over other contraceptive methods
it is a one-time method; it does not require sustained motivation of the user
for its effectiveness; provides the most effective protection against
pregnancy; the risk of complications is small if the procedure is performed
according to accepted medical standards; and it is most cost-effective. It has
been estimated that each procedure averts 1.5 to 2.5 births per woman
These are the permanent methods. They are also called as ‘Sterilization
methods’.
There are two methods—
1 Male sterilization ( Vasectomy )
2 Female sterilization ( Tubectomy )

Guidelines for sterilization

Sterilization services are provided free of charge in Government
institutions. Guidelines have been issued from time to time by the
Government covering various aspects of sterilization. These are
a. The age of the husband should not ordinarily be less than 25 years nor
should it be over 50 years.
32
b. The age of the wife should not be less than 20 years or more than 45 years.
c. The motivated couple must have 2 living children at the time of operation.
d. If the couple has 3 or more living children, the lower limit of age of the
husband or wife may be relaxed at the discretion of the operating surgeon,
and
e. It is sufficient if the acceptor declares having obtained the consent of
his/her spouse to undergo sterilization operation without outside pressure,
inducement or coercion, and that he/she knows that for all practical purposes,
the operation is irreversible, and also that the spouse has not been sterilized
earlier.

1 Male sterilization ( 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 is not castration, it does not affect the testes
and it does not affect sexual ability.
Procedure
A small incision is made in the scrotum on either side above the testes
under local anesthesia, under aseptic precautions, vas-deferens tubes are
lifted, cut and tied with thread or clamped and the incisions are closed with
stitches. Then bandage is put
Post-operative advice
To ensure normal healing of the wound and to ensure the success of the
operation, the patient should be given thefollowing advice :
1. The patient should be told that he is not sterile immediately after the
operation; at least30 ejaculations may be necessary before the seminal
examination is negative.
2. To use contraceptives until aspermia has been established.
3. To avoid taking bath for at least 24 hours after the operation.
4. To wear a T-bandage or scrotal support (langot) for 15 days : and to keep
the site clean and dry.
5. To avoid cycling or lifting heavy weights for 15 days; there is, however, no
need for complete bed rest.
6. To have the stitches removed on the 5th day after the operation.

33
Effectiveness
Vasectomy is highly effective and permanent method. Failure rate is
about 0.15 pregnancies per 100 men in the first year after the procedure. It
can still be reduced if he uses condom or any other effective method
consistently for the first 20 ejaculations or for three months after the
procedure, whichever comes first.
Merits
• It is simple, safe, highly effective, life-long permanent method of family
planning.
• Nothing to remember except to use condoms till he becomes aspermic.
• Prolonged sexual pleasure, because no need to worry about pregnancy.
• Compared to tubectomy, vasectomy is easy to perform, more effective, less
expensive and able to be tested for effectiveness at any time.
• The surgery can be done even in the clinic.
• Does not require hospitalization.
Demerits
Common short-term surgical complications are:
• Pain in the scrotum, swelling and bruising
• Uncomfortable for 2 to 3 days
• Feeling of faintness after the procedure.
Uncommon complications are:
• Bleeding or infection of the wound
• Blood clots in the scrotum
• Not immediately effective
• It will be effective only when he becomes aspermic.

34
Causes of failure
The failure rate of vasectomy is generally low, 0.15 per 100 person-
years. The most common cause of failure is due to the mistaken identification
of the vas. That is, instead of the vas, some other structure in the spermatic
cord such as thrombosed vein or thickened lymphatic has been taken.

No scalpel vasectomy
This is a newer procedure, that is safe, convenient and acceptable to
males only one small puncture is made instead of incisions. At the end, it is
not sutured, just a bandage is sufficient. It is of shorter duration, less painful
and bruising and shorter recovery time.
This new method is now being canvassed for men as a special project,
on a voluntary basis under the family welfare programme. Under trained.
Availability of this new technique at the peripheral level will increase the
acceptance of male sterilization in the country. The project is being funded by
the UNFPA (United Nations Fund for Population Activities)

2. Female sterilization ( Tubectomy )

This is also known as ‘Voluntary surgical contraception’, ‘Tubal
ligation’, and ‘Minilap’
Two procedures have become most common, namely laparoscopy and
minilaparotomy.

(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 visualize 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.

35
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.
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.
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.Laparoscopic sterilizations have become very
popular in India. Nearly 41.4 per cent of all female sterilizations during
2010-11 were through laparoscopic method
(b) Minilap operation
Minilaparotomy is a modification of abdominal tubectomy. It is a much
simpler procedure requmng 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.This is more suitable than
laproscopy for immediate postpartum period, i.e. six weeks after childbirth.
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Instruction 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 is gone.
• To report at once if she develops, fever, bleeding or pus in the wound.
Effectiveness
Failure rate is about 0.5 pregnancies per 100 women years. Postpartum
tubal ligation is one of the most effective female sterilization techniques. In
the first year after the procedure 0.05 pregnancies per 100 women years.

Merits
• It is simple, safe, very effective, permanent, lifelong method of family
planning.
• Nothing to remember (like using condoms unlike in vasectomy).
• No interference with sex; so prolonged sexual pleasure.
• No effect on breast milk.
• No long-term side effects.
• Helps to protect against ovarian cancer.
Demerits
• Usually painful for several days after surgery.
• Postoperative infection or bleeding.
• In rare cases when pregnancy occurs, it is more likely to be ectopic.

Small-family norm
Small differences in the family size will make big differences in the
birth rate. The difference of only one child per family over a decade will have
a tremendous impact on the population growth.
The objective of the Family Welfare Programme in India is that people
should adopt the "small family norm" to stabilize the country's population at
the level of some 1,533 million by the year 2050 AD. Symbolized by the
inverted red triangle, the programme initially adopted the model of the 3-
child family.

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 In the 1970s, the slogan was the famous Do Ya Teen Bas. Inview of the
seriousness of the situation, the 1980s campaign has advocated the 2-child
norm. The current emphasis is on three themes : "Sons or Daughters two will
do"; "Second child after 3 years", and "Universal Immunization".
A significant achievement of the Family . Welfare Programme in India
has been the decline in the fertility rate from 6.4 in the 1950s to 2.4 in 2012.
The national target was to achieve a Net Reproduction Rate of 'l' by the year
2006, which is equivalent to attaining approximately the 2-child norm. All
efforts are being made through mass communication that the concept of small
family norm is accepted, adopted and woven into lifestyle of the people.

Advantage for Mother

1. Maintain her health
2. Loss of fear about unwanted pregnancy
3. More time for care of child
4. Give proper attention for child
5. Better job opportunities
6. Have more time for education

Advantage for Father

1. Can provide better education, comfort, food, clothing, recreation
2. He will more relaxed and enjoy good health
3. He will improve living standard, better health
Advantage for Child
1. Chid gets proper nutrition, education , love
2. Child have conductive atmosphere for his proper physical and
psychological growth and development
Advantage for Community
1. Leads to conservation of natural resources and savings
2. Helps nation to have enough schools, hospitals and other basic services
3. Happiness, peace , harmony

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