POPULATION DYNAMICS AND FAMILY PLANNING

COURSE CODE: CHE 222

Course Description

Population Dynamics is the branch of life sciences that studies short term
and long term changes in the size and age composition of populations, and
the biological and environmental processes influencing these changes.

Family Planning is the planning of when to have children, and the use
healthy child spacing and other techniques to implement such plans.

Goal;

This course is aimed at equipping students with the knowledge and skills to
provide relevant information on population dynamics and family planning.

Objectives;

1.0Describe the Concept of Population

2.0Discuss the Concepts of Reproductive Health Rights
3.0Discuss Family Planning, the various methods and demonstrate effective
family planning skills
4.0Describe standards equipment and materials for setting up family
planning services
5.0Discuss the Concept of Infertility and its management

1.0 Introduction

1
Population dynamic is the branch of life sciences that studies short-term
and long-term changes in the size and age composition of populations,
and biological and environmental processes influencing these changes.

1.1 Definitions:

Population: is defined as the whole number of people or inhabitants in a

country or region.

Population: is also defined as the total number of individuals occupying

an area.

Population dynamic: is the study of human population in terms of its

size, composition, and its distribution.

Population dynamic: is also defined as the scientific study of human

population size, composition, growth, dynamic, distribution, and density.

 Population size: is the number of people who lives in a specified

geographical area during a defined time e.g. state, country, and
townetc.
 Population composition: is the description or breakdown of
apopulation according to it characteristics such as age, occupation,
religion, language spoken, literacy, income, marital status. The most
important composition of population is its age and sex.
 Population growth: is the way or how population increases.
 Population dynamic: is the population fluctuating due to birth,
death, migration and emigration.
 Population distribution: is the way in which population are being
spread over an area. (over crowded or not)
 Population density: is the number of people per specific area.

1.2 Elements of Population Dynamics

1. Birth rate

2
 2. Death rate
3. Immigration
4. Emigration

1.3 Causes of Population Growth

 Poverty
 Child labour
 Reduce mortality rate
 Fertility treatment
 Immigration
 Poor contraceptive etc.

1.4 Reasons for Population Distribution, Changes over a period of

time.
Population distribution and changes over a period of time occurs as a
result of;
 Rate of natural increase (birth), death and migration.
 Climate
 Landforms
 Topography
 Soil
 Energy

1.5 Factors Affecting Population Event

1) Birth
2) Death
3) Immigration
4) Emigration

REPRODUCTIVE HEALTH AND RIGHT, INCLUDING FAMILY

PLANNING
3
2.0 INTRODUCTION

The term reproductive started in 1994, where family planning was found
with minimal impact on population control. The whole world was
convinced that the shift was very necessary to achieve desired control on
population. This shift gave rise to the concept of reproductive health.
Reproductive health concept emphasis the strategic roles of information,
education, community mobilization and education, women empowerment
and provision of quality care for all persons, including poor and
marginalize group. Reproductive health is a life cycle approach that is
concern with not only women of reproductive age; perhaps include the life
time concern of both men and women from birth to old age

2.1 REPRODUCTIVE HEALTH

It is a state of complete physical, mental and social well-being and not

merely the absent of disease or infirmity, in all matters relating to the
reproductive system and to its functions and processes (WHO, 1994).

It is defined as the study of science and human effort and act that deals
with the provision of safe motherhood and birth control.
2.2 RIGHT OF HUMAN TO REPRODUCE

Reproductive rights is defined as the basic rights of all couples and

individuals to decide freely on the number and spacing of their children
and have the information education, and means to do so.

It’s based on the recognition of the basic right of all couples and
individuals to decide freely and responsibly the number, spacing and
timing of their children and to have the information and means to do so,
and the right to attain the highest standard of sexual and reproductive
health. They also include the right of all to make decisions concerning
reproduction free of discrimination, coercion and violence.

Reproduction ensures the continuous existence of species because as the

already existing ones are aging and dying, young ones are being born, so

4
replacement continues. Man is endowed from creating with the right to
reproduce to ensure continuity.

2.3 FACTORS INFLUENCING REPRODUCTIVE HEALTH AND RIGHTS

1. Housing: poor housing does not favour reproductive health

and right, but adequate and proper housing does.
2. Poor water supply and environmental sanitation impacts
negatively on reproductive health and right.
3. Epidemic illness: affect reproductive health and right
negatively.
4. Religion : some religious low prohibit leaders at certain
level from getting married, while some doctrine deny
individuals of their reproductive right until certain
obligations are met.
5. Occupation: some occupations tend to separate couples for
a long time. Some occupation even mandates people
involved undergo certain treatment that affect
reproductive and right.
6. Insecurity and disaster:Both causes scarcity, depression,
diseases etc. which does not favour reproductive health
and right.
7. Policy: some policies enacted by the government of the
land influences reproductive health right e.g. policy on
population control which stipulate family size.

2.4 ROLES OF FAMILY MEMBERS IN REPRODUCTIVE HEALTH AND

RIGHT

Mother
 Provide support to father
 Enhance enabling environment
 Proper organisation
 Sustain and nurture love
 Preserve and maintain provision
 Provide warm reception
5
  Adequate caring

Father
 Provision of enabling environment
 Provision of harmony
 Provision of clothes
 Provision of shelter
 Provision of food
 Initiate and sustain love
 Provision of comfort
 Provision of security

Child
 Adheres to rules
 Abide by regulation
 Enhance happiness
 Obedience
 Provide fulfilment

2.5 ADOLESCENT REPRODUCTIVE HEALTH SERVICES (ARH)

It is a state of physical, mental, and social wellbeing of adolescents and

not merely the absence of disease or infirmity in all matters related to
their reproductive health. It includes healthy sexual development, equitable
and responsible relationship and sexual fulfilment and freedom from
illness, disease, disability, violence or other harmful practices related to
sexuality.

Sexual/Reproductive Health Problems of Adolescents

1. Early initiation of sex.

2. Forced and early marriage.
3. Unwanted pregnancy.
4. Induced abortion.
5. Sexual abuse e.g. rape.
6. STIs/ HIV.
Causes of Reproductive Health Problems in the Adolescent
6
1. Lack of understanding rep. health issues.
2. Peer group pressure.
3. Lack of access to information.
4. Anxiety or curiosity to discover.
5. Lack of parental care.
6. Unwillingness of parents to provide guidance to youth on rep. health
issues.
7. Ignorance of rep. health issues on the part of the parents.
Specific Adolescent Reproductive Health Services;

ARH services are more acceptable by the Adolescent in Adolescent

Friendly Clinics;
1. Sexuality education( based on age group)
2. Contraception or family planning services
3. HIV counselling and testing (HCT)
4. Abortion and post abortion care.
5. Prevention and treatment of STIs.
Issues that Influences Quality of Reproductive Health Services for
Adolescents

1. Peer group pressure

2. Sexual health education n
3. Gender perspectives
4. Media
Consequences of ARH & Sexual Problems

1. Psychological trauma.
2. Drop out from school/apprenticeship.
3. Lack of social and survival skills.
4. Poor self-esteem.
5. Child abandonmentor infanticide as result of unwanted pregnancy.
6. Medical and obstetric health problems as result of early pregnancy e.g.
 Anaemia
 Abortion
 Pre-eclampsia

7
  Prolong labour
 Premature labour
 STI
2.6 SYNDROMIC MANAGEMENT OF SEXUALLY TRASMITTED
INFECTIONS AND HIV

These are human infections transmitted through sexual intercourse, which

may be vaginal, oral or anal. The organisms causing the infections are
normally present in the reproductive tract, or introduced from the outside
during sexual contact or medical procedures or as a result of an
imbalance in vaginal bacterial flora.

There are different and many types of STI, but the commonest are:

Fungal infections

 Candidiasis (Candida Albican)

Protozoan Infection

 Trichomoniasis (Trichomonas Vaginalis)

Bacterial Infection

 Bacterial Vaginosis (GardnerallaVaginalis)

 Chlamydia (Chlamydia trachomatic)
 Gonorrhoea (Neisseria gonorrhoea)
 Syphilis (Treponemapallidum)
 Chancroid (Haemophilusducreyi)
 Granuloma inguinale (Klebsiellagranulomatis)
 Lymphogranulomavenerum (Chlamydia trachomatis)
Viral Infections

 Herpes simplex or genital herpes

 HIV
 Hepatitis B
 Genital warts (Human Papillomavirus)
 Molluscumcontagiosum (Poxvirus)

8
 STIs have different presentations but similar signs, symptoms and
complication expect for HIV/AID.

The Syndromes Approach

In the syndrome approach, health providers diagnose and treat patients

on the basis of a group of symptoms, or syndromes rather than for
specific STDs, e.g. treatment is given for vaginal discharge rather than
gonorrhoea, Chlamydia, candidiasis or bacterial vaginitis which all
presents with vaginal discharge hence the 4 conditions are treated at
once. The approach makes diagnosis more accurate without extensive
laboratory tests and allows treatment with a single visit.

Information about the patient’s sexual history can help to distinguish

between syndromes that are sexually transmitted and other reproductive
tract infections (e.g. candidaiasis and bacterial vaginosis) which are not
usually, transmitted sexually.

Benefits of the Syndromes Diagnosis

1. It improves clinical diagnosis by avoiding wrong diagnosis and

ineffective treatment.
2. It can be learned by all health providers e.g. CHWs, Nurses etc
3. It allows treatment of symptomatic patients in one visit.
4. It reduce expensive and sometimes unnecessary lab. test
Disadvantages

1. Failure to provide adequate cure for people with asymptomatic STIs

(women with STIs are often asymptomatic).
2. Drug wastage, due to treatment of general symptoms which the
patient may not actually have.
Diagnosis

The WHO has developed STD diagnosis and treatment flow chart
(step-by-step pathways) using the syndrome approach to help PHC
providers manage STD patients. The flow chart classified the four
most common syndromes caused by STDs; which are:

9
 (a) Genital ulcer in a man or woman

(a) Urethral discharge in a man

(b) Vaginal discharge
(c) Lower abdominal pain in a woman.
Genital Ulcers

1. Syphilis: Produces a single painless ulcer with firm borders that

feel like the tip of the nose.
2. Chancroid: Produces a soft, painful ulcer with an irregular shaped
border. In women the ulcer may not be painful.
3. Herpes Simplex: Produces blister like lesions in and around
vagina, anus or on thigh. Pain may be more severe in women than
men.
4. Both syphilis and chancroid may cause enlarge lymph nodes.
In syphilis, lymph nodes are enlarged and firm but painless. In
contract, choncroid, like LGV can cause enlarged and tender lymph
nodes that may burst and leak pus.
5. LGV: Produces ulcers which are small or shallow that looks like
herpes blisters and heal without treatment.
6. Donovanosis: Produces ulcers which begin as nodules under the
skin that erupt and form usually painless, sharply defined lesions.
7. Human PapillomavirusandMolluscumcontagiosum can
cause:non-ulcerative lesions (genital warts) which often looks like a
cauli- flower. The lesions of molluscum are white, smooth pimples
that contains a while cheese like substance.
Urethral Discharge

1. Identify the origin of the discharge, i.e. either the meatus, or the
foreskin of uncircumcised penis.
2. When discharge is not visible, consider milking the penis from the
base to the tip to observe discharge. You may advise the patients to
milk the penis by themselves.
3. If the patient urinated shortly before the examination, discharge will
have been rinsed and may not reappear for several hours

10
 4. Gonorrhoea, Trichomoniasis and choncroid usually lead to urethral
discharge.
Vaginal Discharge

1. Diagnosing an STD on the basis of vaginal discharge is difficult, one

have to determine the consistency, the volume of secretion,
changes in the colour, foul odour, itching and soreness, painful
urination or pain during intercourse.
2. Candidaiasis and bacterial vaginosis cause vaginal discharge
although they’re not usually sexually transmitted. They also alter
the pH level of the vagina.
3. Check the appearance of vagina and vulva. If they are inflammed,
candidaiasis or trichomoniasis may be the cause. Bacterial vaginosis
does not cause inflammation.
4. Vulval itching is also a symptom of candidaiasis and trichomoniasis.
5. The origin of the discharge can help to identify the disease.
(d) Discharge from the cervix possibly indicates - Gonorrhoea or
Chlamydia.
(e) Discharge from the vaginal wall indicates – Trichomoniasis,
candidaiasis, or Bacterial vaginosis. Identifying the origin of
discharge in the vagina may be difficult; however, wiping off
the cervix with a swab can help, where discharge from the
cervix may then be observed. Other signs of cervical infection
are redness and bleeding when the cervix is touched with a
swab.
6. If there is pain when the cervix is touched, use the flow chart for
lower abdominal pain.
7. Patients who return often with candidaiasis may have HIV infection
or diabetes. Refer them to a hospital for testing.
Lower Abdominal Pain

2. Identify emergencies and refer immediately to a hospital, such as

septic abortion, intestinal obstruction, ruptured bowel, appendicitis
or ectopic pregnancy.

11
 3. Pelvic inflammatory disease (PID) can cause pain during intercourse
in addition to lower abdominal pain; heavy or prolonged menstrual
bleeding, dysmenorrhoea, nausea, and vomiting.
4. On speculum exam, an open cervix indicates pregnancy or abortion.
5. Look for other signs of STI like ulcers or vaginal discharge.
6. Ask the patient if she is using an IUCD, as women using IUCDs have
a higher risk of pelvic inflammatory disease.
Complications of STIs

1. Infertility in both men and women

2. Pelvic Inflammatory Disease. (Mostly caused by Chlamydia and
Gonorrhoea)
3. Chronic Pelvic pain
4. Cervical cancer caused by Human papilloma virus (5-30yrs after the
initial infection)
5. Higher risk of Ectopic pregnancy due to PID
6. Epididymitis in men caused by Chlamydia or gonorrhoea which may
lead to infertility.
7. Spontaneous abortion, stillbirth and perinatal death due to syphilis
infection spreading to the amniotic sac and infecting the foetus.
8. OphthalmicNeonatorum due to gonorrhoeal and chlamydial infection
present in the vagina or cervix.
9. Pneumonia in the infant due to Chlamydia infection.
Human Immunodeficiency Virus (HIV) Infection
HIV infects cells in the immune and central nervous system. One of the
main types of cells that HIV infects is the T- Helper lymphocytes. These
cells play an important role in the immune system. A large reduction in
the number of T- Helper cells seriously weakens the immune system. HIV
infects the T- Helper cell because it has the protein CD4 on its surface.
Once it infects a cell it produces new copies of itself which can then
proceeds to infect other cells. Eventually, HIV infection leads to the
reduction in the number of T – Helper lymphocytes available to help fight
diseases. This can be determined by a test called CD4 count/test. It can

12
be take several years before the CD4 count declines to the point that an
individual is said to have progressed to AIDS.

HIV infection is generally classified into 4 stages: -

- Primary infection
- Clinically asymptomatic stage
- Symptomatic infection
- Progressive AIDS stage

HIV Counselling and Testing

HIV counselling and testing (HCT) is a client centred, community based
and confidential counselling aimed at asymptomatic individuals wishing to
know their status.

HIV-VCT was initiated in the health facilities by the WHO in order to

support and improve access to HIV prevention, treatment and care. It is a
key element of treatment and essential for prevention of vertical
transmission.

HCT usually involves 2 counselling sessions: 1prior to taking the test,

called pre- counselling and 1 after the result is obtained called post- test
counselling.

Counselling focuses on the HIV infection the disease (AIDs), and positive
behaviour changes, it is proven to be one of the most powerful weapons in
halting the spread of HIV/AIDS.

It also offers the chance to discuss with a professional, thereby alleviating

the anxiety in both infected and uninfected persons.
Benefits

1. To seek treatment early and prolong life.

2. To put your mind at rest
3. To prevent and control the spread of HIV.

13
Implication of HIV testing

1. How to cope with the news.

2. Who to tell
3. Who not to tell
4. How to protect others from being infected
5. How to look after one health

Voluntary Disclosure – it is when a person shares information about his

or her status with others.

Advantages

1. It helps one to accept his status and reduce the stress of coping on his
own. (A problem shared can be a problem halved).
2. Access to medical services, care and support that the individual needs
3. Reduces the risk of transmitting the HIV to others
4. Get support from family members and friends so that one will not be
alone to cope with his problems
Disadvantages

1. Stigma
2. Problems with relationships e.g. family, friends, partner etc.
3. Rejection by family and friends
4. Refused visa
5. Denied job opportunities.
6. Violence from partner.
Consequence of non-disclosure

1. Emotionalstress.
2. Lack of support.
3. Exposing others to the risk of infection.
4. Lack of access to appropriate medical care.
UNIT 3.0
TOPIC - FAMILY PLANNING

14
3.0 INTRODUCTION

Ensuring access for all people to their preferred contraceptives methods

advances several human rights including the right to life and liberty,
freedom of opinion and expression and the right to work and education, as
well as bringing significant health and other benefits.

Family Planning is a primary health strategy with important benefits for

both maternal and child health. It is also an important component of the
strategies adopted to combat rising maternal mortality at the Safe
Motherhood Conference. As direct obstetric causes are responsible for
most maternal deaths in Nigeria, Family Planning can save lives.

3.1 DEFINITION OF FAMILY PLANNING

The World Health Organization (WHO, 1970), defined it as a way of

thinking and living that is adopted voluntarily upon the basis of
knowledge, attitudes and responsible decisions by individuals and couples
in order to promote the health and welfare of the family group and thus
contributes effectively to the socio-economic development of the country.

Family planning is also defined as the spacing of number of children and

having a baby when youwant, by choice not by chance.

Family planning also referred to the conscious effort of couple to regulate

the number of children and spacing of births.

3.2Families that Needs Family Planning

 Women under 18years.

 Mothers above 35years.
 Mothers or fathers having genetic disease e.g. sickle cell disease
etc.
 Mother with previous history of severe problems of pregnancies,
labour and puerperium.

15
  Women having chronic or severe medical illness e.g. Diabetes,
Hypertension, Heart disease e.t.c.
 Couples with birth interval less than 2years.
 Multiparous couples.

3.3 Family Planning Methods

1. Traditional methods.
2. Modern methods.

3.3.1 TRADITIONAL METHOD OF FAMILY PLANNING

Traditional method of family planning: Is the traditional way of child

spacing (family planning) before the advent of scientific methods, our fore
fathers were aware of the need for child spacing. Traditional medicine
havebeen prescribed.The mode of action may vary from one local
herbalist to another, who may refuse to discuss the mode of action of
family planning. Examples of these traditional methods of family planning
are;

 Abstinence (avoidance of intercourse)

 Prolonged lactation
 Withdrawal methods
 Charm / armlet
 Herbs
 Beads
 Use of potassium powder or blue powder

Advantages of traditional methods of family planning

1. It was the method used even when modern methods were not
available.
2. The methods are accessible to the grassroot individuals.
3. Support the belief system already held by men
4. Does not require change in behaviour.

16
 5. Some methods such as breastfeeding and abstinence are effective
and beneficial to mother and baby.

Disadvantages of traditional methods of family planning

1. The mechanisms of action are not clearly defined.

2. Effectiveness cannot be measured.
3. Some of the articles are injurious to the body e.g. potassium
powder blue powder.
4. Some of the methods are irreversible, especially when there is
mistake from the operator.
5. Some of the articles are difficult to get e.g. leopard’s skin.
6. Some methods can only be operated by traditional medicine
men.
7. Women using the methods may be at the mercy of the traditional
medicine man
8. Some methods are executed in unhygienic ways.

3.3.2 MODERN METHODS OF FAMILY PLANNING

1. Natural or Fertility awareness

2. Hormonal Method
- Oral pills
- Injectable contraceptive e.g. depoprovera, noresterate,
sayana press.
- Implant

3. Sterilization Method
- Vasectomy in men and
- Bilateral tubal ligation in women
4. Barrier Method
- Diaphragm
- Condom (Male & Female)

17
 - Spermicide {e.g. form tablet, cream or jelly}
5. Intra-uterine contraceptive device (I.U.C.D.)
6. Hormonal Methods
7. Intra-uterine Contraceptive Devices
8. Barrier Methods
9. Natural Family Planning
10. Voluntary Surgical Contraception
11. Immunological Methods
12. Male Methods

HORMONAL CONTRACEPTIVE METHOD

ORAL CONTRACEPTIVE PILLS

Oral pills: oral drugs containing female sex hormones. The dose is one
(1)pill every day consecutively for 21 days. It preventsovulation; thicken
cervical mucus to keep away. Prevent the lining of the uterus from
thickening so that fertilized ova cannot implant.
18
Types

- Combined oral contraceptives (COCs) contain both oestrogen and

progestin:
- Low dose COC (those containing 0.03 m of oestrogen) are commonly
Used for ongoing contraception
- High dose COCs (those containing 0.05) are used mostly for emergency
contraception
􀁕 Progestin-only pills (minipills) (POPs)
􀁕 Emergency contraceptive pills (ECPs)

Advantages of oral contraceptive pills

1. Very effective when used correctly.

2. No need to do anything at time of sexual intercourse.
3. Increased sexual enjoyment because no need to worry about
pregnancy.
4. Monthly periods are regular, lighter monthly bleeding and fewer
days of bleeding, milder and fewer menstrual cramps.
5. Can be used at any age from adolescent to menopause
6. Can be used by women who have children and by women who do
not.
7. User can stop taking pills at any time.
8. Fertility returns soon after stopping.
9. Can be used as an emergency contraceptive after unprotected sex.
10. Can prevent or decrease iron deficiency anaemia.
11. Can be used as long as a woman wants to prevent
pregnancy. No rest period needed.

Disadvantages of oral contraceptive pills

1. Not highly effective unless taken every day.(difficult for some

women to remember every day)
2. New packet of pills must be at hand every 28days.
3. Not recommended for breastfeeding women because they affect the
quantity and quality of breast milk.
19
 4. In a few women, may cause mood change including depression, less
interest sex.
5. Very rarely can cause stroke, blood clot in deep vein of the legs or
heart attack. Those at highest risk are women with high blood
pressure and women who are age 35 or older and at the same time
smoke more than 20 cigarettes per day.
6. Do not protect against sexually transmitted diseases {STDs}

Common side effect {not sign of sickness}

1. Nausea {Most common in the first 3months}

2. Spotting or bleeding in between menstrual periods, especially if
woman forgets to take her pills or take them late{most common in
first month}
3. Mild headache
4. Breast tenderness
5. Slight weight gain {some women see weight gain as advantage}
6. Amenorrhoea {some women see weight gain as advantage}
INJECTABLE CONTRACEPTIVE

This is hormonal injection given by health worker. It prevents ovulation,

thicken cervical mucus and prevent the lining of the uterus from building.

Types

12.1.1 Progestin-only Injectable Contraceptives

12.1.2 Norethisteroneenanthate (Noristerat, NET-EN)
12.1.3 Depot-medroxy-progesterone acetate (DMPA,
Depo-Provera)
Combined Injectable Contraceptives
12.1.4 Cyclofem
12.1.5 Mesigyna

Effectiveness

20
As commonly used, about three pregnancies occur per 100 women using
progestin only injectable over the first year. When women have injections
on time (perfect use) less than one pregnancy occurs per 100 women in
the first year of use.

Mechanism

Suppresses ovulation by inhibiting LH and FSH surge, thickens cervical

mucus impeding sperm entry into female upper reproductive tract, and
slows sperm transport in the Fallopian tube and causes thinning of the
endometrium.

Advantages of injectable contraceptive

1. No action required prior to sexual intercourse.

2. Effective for up to 3months depending on the type used.
3. No worry about pregnancy.

Disadvantages of injectable contraceptive

1. Not effective against STI.

2. Required regular visit to health worker for injection.
3. May cause irregular bleeding.
4. Weight gain.
5. Sore breast
6. Nausea

Contra-indications

 Those who wish for a short duration family

planning method.
 Pregnant women.
 Women who have not given birth.
 Breast feeding mothers of less than 6weeks old.

21
CONTRACEPTIVE RING

It is a flexible ring inserted in a woman’s vaginal for 21 days. Release a

low dose of female sex hormone prevent ovulation, thicken cervical
mucus against sperm penetration and prevent the thickening of the
endometrial lining so that fertilized egg cannot implant.

Advantages contraceptive ring

1. No action require prior to intercourse.

2. Regular use may result in shorter more regular menstrual periods.
3. Reduce premenstrual related iron deficiency.

Disadvantages of Contraceptive ring

1. Not effective against STI transmission.

2. May cause vagina irritation and discharge.
3. May cause irregular bleeding.
4. Weight gain or loss
5. Breast tenderness.
6. Nausea.
7. Vomiting.
8. Headache.
9. Mood change.

Contra indications

 Those who are reacting to the material.

IMPLANON

Implanon is a contraceptive rod containing the hormone etologestrel,

which is similar to the naturally occurring hormone progesterone. It is
about the size of match stick, four centimetre long and two millimetre
wide, inserted under the skin of the inner upper arm, it stops the body
from releasing ovum {egg} each month, it thickens the cervical mucus
which makes it very difficult for sperm cells to get into the uterus.
22
Advantages of Implanon

1. Implanon is highly effective, inexpensive and usually easily

reversible
2. No need to do anything at time of intercourse
3. Bleeding may be lighter and less painful or even stops menstruation
{Advantage to some women}
4. When implanon is removed, the contraceptive effect and side effect
are quickly reversed
5. Can be used by those that are allergy to contraceptive containing
oestrogen
6. Implanon is safe to lactating mothers

Disadvantages of Implanon

1. Implanon can only be inserted and removed by a trained

health personnel
2. May be difficult to get in some areas
3. Bruising and pains may be experience in the area of insertion
4. Changes bleeding pattern
5. No protection against sexual transmitted infection {STIs}
6. Really, client need to be refer to specialist for removal of
implanon rod

Contra-Indications

1. Women who have breast cancer within the last five

years
2. Women taking certain medication

Side – Effect of Implanon

1. Change in bleeding pattern

2. Amenorrhoea {in some women}
3. Irregular bleeding {in some women}
4. Breast tenderness{ in some women}

23
 5. Mood change {in some women}
6. Headache
7. Increased appetite {in some women}
8. Acne

Procedure for Implanon Insertion

1. Establish rapport
2. Explain procedure to the client
3. Wash hand
4. Wear a sterile gloves
5. Assemble equipment/materials needed
6. Instruct client to lie on her back {dorsal position}
7. Identify the insertion site, which is at the inner side of the upper arm
about 8-10cm {3-4 inches} above the medial epicondyle of the
humerus.
8. Mark the insertion site
9. Clean the insertion site with an antiseptic solution
10. Anesthetize the insertion area with 2cc of 1% lignocaine just
under the skin along the planned insertion tunnel.
11. Carefully remove the Implanon rod applicator from its blister,
keep the shield on the needle. Check the Implanon rod{a white
cylinder inside the needle tip}
12. If the Implanon rod is not seen, tap the top of the needle
shield against a firm surface to bring the rod into the needle tip.
13. Following visual confirmation, lower the Implanon rod back
into the needle by tapping it back into the needle tip. Then remove
the needle shield, while holding the applicator upright.
14. After removing the needle shield, keep the applicator in the
upright position until the moment of insertion.
15. Keep the Implanon needle and rod sterile if contamination
occur use new package of Implanon with a new sterile applicator.
16. Apply contraction to the skin around the proposed insertion.

24
 17. At a slight angle not greater than 20 degree only the tip of the
needle with the bevelled side up into the insertion side.
18. Lower the applicator to horizontal position lift the skin up with
tip of the needle.
19. While lifting the skin, gently insert the needle to its full length,
keep the needle parallel to the surface of the skin during insertion.
20. If implanon is place deeply, the removal process can be
difficult or impossible. If the needle is not inserted to its full length,
the implant may protrude from the insertion site and fall out.
21. Break the seal of the applicator by pressing the obtructor
support
22. Turn the obturator 90 degree in either direction with respect
to the needle
23. While holding the obturator fixed in place on the arm.
24. Confirm that implanon has been inserted by checking the tip
of the needle for the absence of the rod. After Implanon insertion
the grooved tip of the obiturator will be visible inside the needle.
25. Always verify the presence of implanon in the client’s arm
immediately after insertion by palpating.
26. Ask client’s to palpate the inserted implanon
27. Place a small adhesive bandage over the insertion site
{plaster}.
28. Apply a pressure bandage with sterile gauze to minimize
bruising. The client may remove the pressure bandage in 24 hours
and the small bandage over the insertion site in three days.
29. Complete the user card and give it to client to keep.

Discard the applicator in accordance, the applicator is for single use only.

STERILIZATION METHODS

25
VASECTOMY:

It is a surgical procedure to permanently block of men’s vasdeferenceto

prevent ejaculation of sperm cells.

Advantages of vasectomy

1. Permanently prevent pregnancy

2. No need to do anything at time of intercourse
3. It is very effective
4. Permanent, a single, quick procedure leads to life long, safe and
very effective family planning method.
5. No interference with sex{Does not affect a man’s ability to have
sex}
6. Increase sexual enjoyment because no need to worry about
pregnancy
7. No supplies to get, and no repeated clinic visit required.

Disadvantages of vasectomy

1. Usually uncomfortable for the first 2 to 3 days.

2. Uncommon surgical complications such as :-
 Bleeding or infection at the incision site or inside the incision.
 Blood clot in the scrotum.
3. General irreversible
4. Not immediately effective, the first 20 ejaculations after vasectomy
may contain sperm. The couples must use another contraceptive
method for the first 20 ejaculations or the first 3 months.
5. Reversal surgery is difficult, expensive, and not available in most
areas of the world. If done success cannot be guaranteed. Men who
may want to have more children in future should choose another
method
6. No protection against sexually transmitted diseases {STDs}
including HIV/AIDS

BILATERAL TUBAL LIGATION:

26
It is a surgical procedure to permanent block of a woman’s fallopian tubes.

Advantages of Bilateral tubal ligation

1. Permanently prevents pregnancy.

2. Very effective.
3. Permanently, a single procedure leads to life-long, safe and very
effective family planning.
4. Nothing to remember, no supplies needed and no repeated clinic
visit required.
5. No interference with sex. Does not affect ability to have sex.
6. Increase sexual enjoyment because no need to worry about
pregnancy
7. No effect on breast milk {if done after C/S}
8. Minilaparotomy can be performed just after a woman give birth {the
woman has to decide before she goes into labour

Disadvantages of Bilateral tubal ligation

1. Usually pains at first, but pain start to go away after a day or two.
2. Not effective against STI transmission.
3. Reaction to surgery may include :-
 Infection or bleeding at incision site
 Internal infection or bleeding
 Injury to internal organ(s)
 Anaesthesia risk
4. With local anaesthesia alone or with sedation, rare risk of a long
reaction of over dose.
5. With general anaesthesia, occasional delay recovery and side
effect. Complications are more severe than that of local
anaesthesia. Risk of over dose.
6. Very rare, death due to anaesthesia over dose or other
complication.
7. Compare with vasectomy, female sterilization is:
 Slightly more risk
 Often more expensive
27
 8. Reversal surgery is difficult, expensive and not available in most
areas, successful reversal is not guaranteed{women who may
want to become pregnant in the future should choose a different
method}
9. No protection against sexually transmitted diseases {STDs}

BARRIER METHODS

DIAPHRAGM

It is a shallow rubber cap with flexible rim inserted into a woman’s vagina
over the cervix to prevent sperm from entering the uterus, used with
spermicide.

Advantages of diaphragm

1. It is reusable.
2. Can last for one to two years.
3. Safe woman birth controlled methods that almost every
woman can use.
4. Offer contraceptive just when needed.
5. Prevent pregnancy effectively if used correctly.
6. No side effect of hormone.
7. No effect on breast milk.
8. Can stop at any time.
9. Easy to use with little practice.
10. Can be inserted up to 6 hours before sex to avoid
interrupting sex. It can be inserted even earlier since it
protects for up to 48hours after insertion.

Disadvantages of diaphragm

1. Effectiveness requires having method at hand and taking correct

action before each act of sex.

28
 2. May be hard to conceal from partner{hard to hide to}
3. May be difficult to remove diaphragm can tear as the woman
remove it {rare}
4. Woman may need a different size of diaphragm after child birth.
5. It needs careful storage to avoid developing holes.
6. Not effective against sexually transmitted disease{STDs}
7. Must be inserted before each act of sex

Contra-indication of diaphragm

1. Woman who are allergic to the material.

2. Women who have abnormal cervix

MALE CONDOM

It is a latex shield which helps prevent both pregnancy and sexually

transmitted diseases {STDs}. When used correctly it keep sperm and
disease organisms out of the vagina. Condoms also stop any disease
organisms in the vaginal from entering the penis.

Advantages of condom

1. Prevent sexually transmitted diseases, as well as pregnancy, when

used correctly with every act of sexual intercourse.
2. Can be used soon after child birth.
3. Safe, no hormonal side effects.
4. Help prevent ectopic pregnancy.
5. Can be stopped at any time.
6. Easy to keep on hand in case sex occurs unexpectedly.
7. Can be used without seeing a health care provider first.
8. Usually easy to obtain and sold in many places.
9. Enable a man to take responsibility for preventing and diseases.
10. Increase sexual enjoyment because no need to
worry about pregnancy or STDs.
11. Inexpensive {available, affordable, accessible}

29
Disadvantages of condom

1. Latex condoms may cause itching for a few people who are
allergy to latex. Also, some people may be allergy to the
lubricant on some brand of condoms.
2. May decrease sensation, making sex less enjoyable for either
partner.
3. Couple must take the time to put the condom on the penis
before sex.
4. Supply must be ready even if the woman or man is not
expecting to have sex.
5. There is possibility that condom will slip off or break during
sex.
6. Condom can weaken if stored too long or in too much heat,
sunlight, or humidity, or if used with oil based lubricants and
then may break during use.
7. Poor reputation, many people connect condoms with immoral
sex, sex outside marriage, or sex with prostitute.
8. May embarrass some people to buy, ask partners to use on,
take off and throw away condoms.

FEMALE CONDOM

It is a Polyurethane sac inserted into a woman’s vagina over cervix to

prevent sperm from entering the uterus. May be used with a spermicide:

Advantages of Female condom

1. Reduce risks of many STIs.

2. Available all over the country.
3. Inexpensive.

Disadvantage of Female condom

1. Lessens sensation.
2. May break during intercourse.
30
Contra indications

 Women who are reacting to the rubber.

 Women with abnormal cervix.

SPERMICIDE

It is a sperm killing materials made of foams, cream jelly film

suppositories that are inserted into a woman’s vagina to block the cervix,
preventing sperm from fertilization by killing them.

Advantages of spermicide

1. Available all over the country.

2. Can be used with other methods to improve effectiveness.
3. Does not require professional.

INTRA UTERINE DEVISES

Intrauterine device (IUD), also called intrauterine contraceptive device
(IUCD) is a small plastic object inserted in the uterine cavity to prevent
pregnancy.

There are two types of IUDs.

12.1.6 Non-medicated

31
 12.1.7 Medicated
Non-medicated IUDs are made of inert plastic materials (e.g. Lippes loop,
SAFcoil, and are not available in Nigerian clinics now).

Medicated IUDs are made of plastic with copper sleeve or wire around it or
impregnated with hormones, which are released in small amounts over
time. Those available in Nigeria:
12.1.8 Copper T (Cu-T 380A) effective for 10-12 years
12.1.9 Norgestrel- T (LNG-IUD or LNG-IUS) - contains
levonorgestrel effective for 5 years
Mechanism of Action
It causes inflammatory reaction in the endometrium leading to
phagocytosis of sperms thus preventing fertilization. Copper ions are also
spermicidal, inhibiting sperm motility and acrosomal enzyme activation so
that sperms rarely reach the tube and are unable to fertilize the ovum.

Progestogen-impregnated IUDs cause thickening of the cervical mucus,

changes the uterotubal fluid that hinders sperm migration and some
anovulatory effects (5-15%) of treatment cycles.
Advantages
 IUDs are highly effective and safe for majority of women
 They are reversible
 They are independent of intercourse
 They are private
 No day-to-day action is required
 IUDs are easily available
 They have no effect on lactation
 There is no drug interaction
 May help protect from endometrial cancer
 They are long-acting (Cu-T-380A is effective for as long as 12 years)

Disadvantages
 Have common side effects (usually diminish after the first three
months of use)
32
- Prolonged and heavy monthly bleeding
- Irregular bleeding
- More cramps and pain during monthly bleeding complications are rare,
but may occur:
- Expulsion of IUD, which may lead to pregnancy
- Uterine perforation
- PID (if inserted in woman with current gonorrhoea or chlamydia)
- IUDs do not protect against STIs/HIV/AIDS
- They require trained provider to insert and remove

Women who can use IUDs without restriction (WHO Category 1)

Women who
 􀁕 are 20 years or older
 􀁕 have had children
 􀁕 are within the first 48 hours postpartum
 􀁕 are more than 4 weeks postpartum, regardless of breastfeeding
status
 􀁕 have past ectopic pregnancy
 􀁕 have hypertension
 􀁕 have deep vein thrombosis (DVT)
 􀁕 have current or history of cardiovascular disease:
- Stroke
- Ischemic heart disease
- Multiple risk factors
 􀁕 have lupus
 􀁕 have headaches (migrainous and nonmigrainous)
 􀁕 have diabetes
 have any type of liver disease: tumor or hepatitis
 take certain drugs – Rifampicin, Rifambutin, anti-convulsants (e.g.
Phenytoin) or ARVs (e.g. ritonavir)
 􀁕 are obese
 􀁕 have uterine fibroids (without distortion of uterine cavity)
 􀁕 have cervical ectopy
 􀁕 have current breast cancer
33
  􀁕 have cervical intra epithelial neoplasm (CIN)
 􀁕 have past pelvic inflammatory disease with subsequent pregnancy
 􀁕 smoke irrespective of age
 􀁕 had first trimester abortion (no sepsis)

Women who can generally use IUDs; some follow up may be

needed (WHO category 2)

Women who:

 􀁕 have menarche up to <18 years

 􀁕 are nulliparous
 􀁕 had second trimester abortion
 􀁕 have heavy or prolonged vaginal bleedingpattern
 􀁕 have endometriosis
 􀁕 have severe dysmenorrhea
 􀁕 have pelvic inflammatory disease withoutsubsequent pregnancy
 􀁕 have iron-deficiency anaemia
 􀁕 have current STI other than gonorrhoea orchlamydia
 􀁕 was diagnosed with chlamydia or gonorrhoea while already using
IUD (continuation only)
 􀁕 have vaginitis including trichomonasvaginalis and bacterial
vaginosis(initiation and continuation)
 􀁕 have increased risk for STIs (e.g. have multiple sexual partners,
but reportconsistent condom use, or live in the area with high
prevalence of gonorrhoea and chlamydia )
 􀁕 developed AIDS while using IUD and are not on antiretroviral
therapy(continuation only)
 􀁕 have HIV infection or have AIDS and are on antiretroviral therapy
(clinicallywell)

Use of IUDs usually not recommended in these women (WHO

Category 3)

Women who:

34
  􀁕 are at increased individual risk of STIs, e.g. have multiple sex
partners and don’t use condoms consistently, or have partner with
multiple sex partners (initiation only)
 􀁕 are between 48 hours and 4 weeks postpartum
 􀁕 have AIDS and not on ARV therapy or are not clinically well on ARV
therapy (initiation only)
 􀁕 have ovarian cancer (initiation only; women who are diagnosed
with ovarian
 cancer while using IUD can continue while awaiting treatment)
 􀁕 have benign gestational trophoblastic disease (GTD)

Women who should not use IUDs (WHO Category 4)

Women who:

 􀁕 are pregnant
 􀁕 have current PID (initiation only)
 􀁕 have current STIs such as gonorrhoea and chlamydia, or purulent
cervicitis(initiation only)
 􀁕 have sepsis – puerperal and post-abortion
 􀁕 have cervical cancer (pre-treatment)
 􀁕 have endometrial cancer (initiation only; women who are
diagnosed withendometrial cancer while using IUD can continue
while awaiting treatment
 􀁕 have unexplained vaginal bleeding (initiation only)
 􀁕 have uterine fibroids with cavity distortion
 􀁕 have pelvic tuberculosis

NATURAL FAMILY PLANNING (NFP)& FERTILITY AWARENESS

BASED METHODS (FAM)

Use of physical signs, symptoms and cycle data to determine when

ovulation occurs, same techniques may be used to help couples become
pregnant by detecting ovulation. When couples are using NFP, they should
abstain from intercourse during the at-risk fertile days. With FAM, couples

35
use another method such as barriers or withdrawal during those days. The
same techniques used to teach fertility – awareness can be used either to
prevent pregnancy or to help a woman become pregnant.

Effectiveness
The success of the fertility awareness based methods depends on:
 The accuracy of the method in identifying the woman’s actual fertile
days
 Couples’ ability to correctly identify the fertile time
 Couple’s ability to follow the rules of the method they are using

Methods
1. The basal body temperature (BBT) method
2. The calendar/rhythm method
3. The cervical mucus method (CMM) or Billings ovulation
method.
4. The sympto-thermal method (STM)

Advantages
 Involves men in family planning
 No physical side effect
 No effect on breastfeeding or breast milk
 Safe
 Helpful for planning or preventing pregnancy
 Inexpensive
 Acceptable too many religious groups that oppose conventional
methods.
 Encourage couples to communicate about family planning and
sexuality
 Educate people about women’s fertility cycles
 No effect on fertility

Disadvantages
􀁕Requires high motivation for success
36
􀁕 Restricts sexual spontaneity
􀁕Not suitable for women with irregular menstrual cycles,
􀁕 Require a long time of practice
􀁕It has no protection against HIV/AIDS andother STIs; to achieve dual
protection (use condom or abstinence)
􀁕 Difficult to use after childbirth until menstrual cycle becomes regular
again
􀁕 Fever, Vaginal infection and bleeding may affect effective use of NFP
􀁕 Challenge in polygamous settings

When can fertility awareness-based methods be used?

This method can be used when:
􀁕 Client’s choice is influenced by religious or other personal reasons
􀁕Other methods are contraindicated
􀁕 Medical care is inaccessible
􀁕An inexpensive method is required

When can fertility awareness-based methods not be used?

This method cannot be used if:
 There is no knowledgeable instructor to teach the client
 Client is not motivated
 Client is not comfortable touching her genitals
 Client cannot understand how to use the methods
 Menstrual cycle is irregular (for calendar method)
 There is alteration of cervical mucus e.g. infections, erosions
 Immediate post-partum or post abortion
 Poorly educated clients (except cycle beads)

Equipment and Materials

 Special basal body temperature thermometer
 Temperature chart
 Calendar
 Fertility regulation calculator
 Cycle beads
37
Procedure
12.1.10 Obtain history including regularity of menstruation
12.1.11 Do a physical examination
Instruction to Client

1. Basal Body Temperature Method

Instruct clients to:
 Take temperature in the morning before getting out of bed and
before eatingor drinking anything or putting anything in the mouth
(after at least three hoursof sleep)
 Take temperature at the same time every morning, in the same
way, eitherorally, rectally or vaginally, orally for 5 minutes, vaginally
for 3 minutes andrectally for 2 minutes
 Record the reading at the level the mercury stops
 If mercury stops in between two readings take the lower reading
asyour temperature
 Record reading on a temperature chart
 Abstain from intercourse from the first day of your period until after
the thirdconsecutive day of rise in the body temperature( use a
backup or abstain)
 Do not use this method if you are breast feeding (temperature may
not riseduring this period)
 Request client to repeat instructions and demonstrate charting of
temperatureon the chart.

Effectiveness
Basal body temperature method is 99% effective with perfect use

2. Calendar/Rhythm Method
Instruct clients as follows
 Record the first day of each menstrual cycle for 6 – 12 months
 Determine the beginning of the fertile period by subtracting 18 days
from theshortest cycle
38
  Determine the end of the fertile period by subtracting 11 days from
the longestcycle

If your longest period is 31 days and the shortest is 23 days your fertile
periodis from the 5th to the 20th day of your cycle, i.e. 16 days
 Abstain from intercourse during this period every month
 If your period is irregular do not use this method of contraception,
usespermicidal or other barrier methods as well
 Request client to repeat instruction

Effectiveness
Calendar/rhythm method is 91% effective with perfect use

3. The Cervical mucus (Billings) Method

Explain the following to the client
Billing’s method is based on changes that take place in the quantity and
quality of the cervical mucus during the menstrual cycle.
12.1.12 Prior to ovulation the mucus is thick.
12.1.13 At ovulation the mucus becomes thin, clear, plenty in amount
and watery.
12.1.14 Itis easily stretched out between the fingers, like egg white.
After ovulation itbecomes thick again and does not flow.

Instructions to client
o Abstain from intercourse during menstruation
o Feel the vagina daily for mucus
o Record findings daily on appropriate chart
o Have sexual intercourse during the ‘dry’ days when no mucus
appears
o Abstain from intercourse once mucus appears and continue
abstinence until four days after mucus has ceased to be felt
o Do not douche, as this alters the nature of the cervical mucus

39
 o 􀁕 Abstain from intercourse whenever there is inter-menstrual
bleeding
o 􀁕 Abstain on alternate days, during the learning phase, prior to
onset of the feeling or observation of mucus. This is to reduce the
confusion that may arise as a result of the presence of seminal fluid

Effectiveness
Cervical mucus (Billings) method is 97% effective with perfect use
National Training Manual on Family Planning for Physicians and
Nurses/Midwives

BREASTFEEDING, LACTATION AMENORRHEA METHOD (LAM)

In general, breastfeeding delays the return of fertility at postpartum.
However,LAM is a contraceptive method based on exclusive
breastfeeding. Baby suckling on the mother’s nipple causes a surge in
maternal prolactin, which inhibits estrogen production and ovulation. LAM
is aneffective method only under specific conditions;
12.1.15 Woman breastfeeding exclusively
12.1.16 The woman is amenorrhoeic
12.1.17 The infant is less than 6 months old
The medical duration of exclusive breast-feeding is approximately 6
months. It is wise to provide a woman with another method to use when
she no longer fulfils all the conditions.
Effectiveness
Perfect use failure rate in first 6 months: 0.5%
Typical use failure rate in first 6 months: 2%

Advantages
Note: Most advantages and disadvantages are attributable to
breastfeeding itself. The additional benefits accruing to LAM as a
contraceptive method are minimal. These are:
 Involution of the uterus occurs more rapidly; suppresses
menstruation
 Breast-feeding pleasurable to some women
40
  Facilitates bonding between mother and child (if not stressful)
 Reduces risk of ovarian cancer and endometrial cancer; possible
slightprotective effect against breast cancer
 Can be used immediately after childbirth
 Protects baby against asthma, allergies, URIs, diarrhea and other
infectionsby passage of mother’s antibodies into breast milk
 Facilitates postpartum weight loss in the mother.
 No expense and less time used for preparing and feeding

Disadvantages
- Return of ovarian function and menstruation unpredictable
- Breastfeeding mother may be self-conscious
- Woman may be self-conscious about breast milk leaking
- Tender breasts may decrease sexual pleasure
- Effectiveness after 6 months is markedly reduced; return to fertility
canprecede menstruation
- Frequent breastfeeding may be inconvenient or perceived as
inconvenient
- No protection against STIs and HIV/ AIDS
- If the mother is HIV+, there is a 14%- 29% chance that HIV will be
passed toinfant via breast milk. Antiretroviral therapy decreases
risk of transmission
- Sore nipples, breast engorgement and risk of mastitis are
associated withbreast-feeding
STANDARDS EQUIPMENTS AND MATERIALS FOR SETTING UP A
FAMILY PLANNING CLINIC

12.2 Equipment/ Materials

 Examination couch/insertion couches
 Light source (torch or angle-poised lamps)
 A trolley containing the following:
- Speculum (various sizes) Disposable preferable
- Tenaculum (vulsellum)
- Sponge holding forceps

41
 - Uterine sound (plastic preferably)
- A pair of scissors
- Sterile gloves
- Plastic dilators
- Straight artery forceps
- Gallipots (2)
- IUDs
- Implants (Implanon&Jadelle)
- Inserters and introducers (where applicable)
- Antiseptic lotion, e.g. Savlon, Hibitane, Purit
- Sterile receiver with cover containing 1 in 2500 iodine solution or
75% alcohol

 Bowl with lid, swabs, pads, sterile towel

 Sodium hydrochloride bleach (e.g. Jik, Parozone) 0.5%
 Drugs interaction checker
 Alligator forceps
 Retriever Hook
 Medical Eligibility Criteria (MEC) Wheels
 Checklists for Initial Users of Hormonal Contraceptives
 Logistic management tools (registers, requisition forms etc.)
 Weighing scales
 Blood pressure apparatus

12.3 Managing FP Clinic

Definition - Quality of Care is defined in terms of the way individuals and

couples are treated by the system providing family planning services.

Elements of Quality of Care

- Choice of methods
- Information given to users
- Technical competence

42
 - Interpersonal relations
- Mechanisms to encourage continuity
- Appropriate constellation of services
- Safety

Benefits of Good Quality of Care in Family Planning Services

- 􀁕 Safety and effectiveness
- 􀁕 Increased client satisfaction
- 􀁕 Increased patronage and use of family planning services
- 􀁕 Securing confidence of clients/community
- 􀁕 Expanded access to Reproductive Health services
- 􀁕 Increased job satisfaction for providers

INFERTILIY
It is defined as the inability of a couple to achieve a clinically recognizable
pregnancy after 12 months of regular unprotected intercourse. On the
other hand fertility is defined as the capacity to reproduce or the state of
being fertile. As a woman’s’ age increases the incidence of infertility also
increases

Subfertility is sometimes used synonymously

Infecundability is the inability of a couple to achieve a live birth after a

year of unprotected intercourse

Sterility is total inability to achieve a pregnancy

5.2 Classification of Infertility

43
  Primary infertility – it is the inability of a couple to conceive at all
despite regular unprotected sex.

 Secondary infertility – it is the inability of a couple to conceive

after 12 months of unprotected sex following a previous pregnancy
and there is no other reason such as breastfeeding or postpartum
amenorrhoea.

 Voluntary infertility – those couple that have never tried for a

pregnancy or are deliberately avoiding pregnancy by contraceptive
use

5.3.1 Causes of Infertility

Infertility is primarily a disorder of couples. The man is responsible in

about 30% of cases, the woman in about 40% of cases and both in the
remaining 30%.

Reproduction requires the interaction and integrity of the female and male
reproductive tracts, which involves;
1. The release of normal ovum
2. The production of adequate spermatozoa
3. The normal transport of the gametes to the ampullary portion of the
fallopian tube
4. The subsequent transport of the fertilized zygote to the endometrial
cavity for implantation and development.

Infertility occurs when something in this pattern does not happen. The
problem could be with the woman, the man or both. About 10% of cases
the cause is unknown. For infertility with an unknown cause, all findings
from standard test may be normal. The actual cause may not be detected
because the problem may be with the egg or sperm itself or the embryo
and its ability to implant.

44
For Men;
The most common cause of infertility is the sperm. Either no sperm cells
are produce or few are produced. The sperm can also be deformed or die
before reaching the ovum. Mumps orchitis, Prostatitis and STIs are some
of the causes.’

For women;
The most common cause is an ovulation disorder. Other causes include
blocked fallopian tube as a result of PID or endometriosis, congenital
anomalies involving the structure of the uterus, uterine fibroid may also
cause repeated miscarriage.

The following conditions can predispose couple to the risk of infertility:

1. Pelvic inflammatory disease
2. Endometriosis
3. Environmental and occupational factors
4. Toxic effect related to tobacco, marijuana, and other drugs
5. Vigorous exercise
6. Poor diet associated with extreme weight loss or gain (obesity or
anorexia nervosa)
7. Age
8. Physical and psychological stress
9. Medications
10. Genetic conditions e.g.klinifelters syndrome in men and x-syndrome in
females
11. Exposing the testes to high temperature.

FUNCTIONAL CLASSIFICATION OF CAUSES

 TIME
Timing of coitus
Frequency of coitus
 SEMEN
Sperm disorders
45
Disorders of other components
Antisperm antibodies
 OVA
Growth and development of viable ova
Ovulation
Implantation
Adequacy of the corpus luteum
 TRANSPORT
MALE
Sperm transport
COITAL
Ejaculatory disorders
FEMALE
Cervical transport failure
Uterine transport failure
Tubal transport failure
 INCUBATOR (UTERINE CAVITY)
Endometrial dysfunction – affecting implantation
 OTHER PROBLEMS
Generalized endocrine disorders
Systemic diseases
Diabetes mellitus
Chronic renal disease
Cardiac disorders
Tuberculosis
Investigations
A thorough evaluation should identify one or more causes in about 90% of
couples and appropriate therapy will result in pregnancy in about 40% of
couples

There are 3 main reasons for infertility investigations

 To determine the cause of infertility
 To arrive at a prognosis
 To serve as a basis for treatment
46
5.3.2 Prevention
1. Life style adjustment – quit smoking, regular exercise, minimize
caffeine and alcohol.
2. Practice safe sex to avoid contracting STIs
3. Maintain reasonable ideal body weight
4. Avoid exposure to environmental hazards e.g. pesticides, heavy metals
like mercury and lead, proper protection from radiation
5. In the event of STI, seek early medical treatment
6. Maintain good diet
7. Have regular physical examination
5.3.3Managements
Manage condition based on the Standing Orders

References

Bradley, S.E.K., T.N. Croft, J.D. Fishel, and C.F. Westoff. (2012 Revising
unmet need for family planning (DHS Analytical Studies No. 25).
Calverton, Maryland, USA: ICF International.
Conde-Agudelo et al (2006). Birth and risk of adverse perinatal outcomes
: a meta-analysis. JAMA 2006 295: 1809-1823
DaVanzo et al. (2005) The effects of birth spacing on infant and child
mortalitMatlab, Bangledesh as reported in WHO Technical
Consultation on Birth Spacing Geneva, Switzerland 13-15 June 2005
Federal Ministry of Health (2013). National Reproductive Health Working
Group meeting report. Abuja, Nigeria:

Federal Ministry of Health.National Population Commission [Nigeria] and

ORC Macro (2000). Nigeria Demographic and Health Survey 1999.
Calverton, Maryland, USA: National Population Commission and ORC
Macro

47
Federal Ministry of Health (2002).National Reproductive Health Strategic
Framework and Plan. 2002-2006. FMOH June 2002

Federal Ministry of Health (2006).National Clinical service protocol for

obstetric and neonatal care. Abuja: FMOH

Federal Ministry of Health (2010) National Training Manual for Physicians

and Nurse/Midwives. (Revised ed). FMOH; Abuja, Nigeria

National Population Commission [Nigeria] (2009) Final results of 2006

census. Abuja, Nigeria: National Population Commission.
CHPRBN; CHEW Pre-service Curriculum 2015 Revised Edition.

48