1. Facts about Pakistan One birth every 7 seconds 3 mothers die during childbirth every hour 12 million children under 5 years are malnourished 50% of population are lacking safe drinking water. 60% lack safe sanitary facilities One doctor per 2008 persons One nurse per 6500 persons One hospital bed per 1506 persons

2. Population Profile (2002) 3.2 million 1947 140 million 2002 160 million 2005 235 million By year 2015 Population below poverty line 33.1% Growth rate 2.1% fertility rate 4 %

3. Contraceptive prevalence rate (CPR) Iran23% Bangladesh40% Indonesia48% Malaysia51% Turkey72% Pakistan 21%

4. resulting in Unemployment, law and order problems,and social unrest.

6. CONTRACEPTION

7. Contraception Saves Lives

8. Contraception means prevention of conception by any method with out abstinence from sexual intercourse.

9. MOTIVATION

10. Counselling Is the process of helping clients to make informed and voluntary decisions about choice of contraception.

11. Counseling FM counseling has 06 elements GATHER Greet Help Ask Explain Tell Return

12. Methods of Contraception Physiological methods –Rhythm method –Incomplete methods Chemical methods Barrier methods Intrauterine contraceptive devices Hormones Sterilization

13. Natural Family Planning Abstaining from sexual intercourse during fertile phase of menstrual cycle.

15. Fertility Cycle Phase I:Relatively infertile phase (approx first 7 days) Phase II:Fertile phase (approx 8 to 16 th day) Phase IIIinfertile phase (approx 17 th to 28 th day)

16. Rhythm Method Advantage:- No expense involved. No side effects. Disadvantage:- Planning of coitus. Dependence on regularity of the cycle. Suitable for educated,intelligent & cooperative women. Failure rate:- 3- 24 / HWY

17. Barrier methods of C.C Male condom Advantages –Simple –Responsibility on male –Protects against the transfer of venereal diseases Failure rate 6-18/100 women years

18. Male condom Disadvantages Expensive Less satisfying sex Allergic reactions Failure rate - 6-18 per HWY Advantages Safe,cheap,easy Does not influence with the orgasm of either partner. Disadvantage Less effective in case of prolapse and retroversion Failure Rate:- 6-12/HWY

19. Female condom

20. Diaphram Functions 1.Retainer of the spermicide 2.To keep sperms away from alkaline receptive cervical mucus 3.Prevent the cervical mucus reaching the vagina 4.Prevents the aspiration of the sperms into the cx & the uterus

21. Diaphram

22. Advantages –Safe,cheap,easy –Orgasm Does not influence the orgasm of either partner. Disadvantage Less effective in case of prolapse and retroversion Failure Rate 2-15/100 women years

23. Intrauterine C.C Device

24. GROUPING OF DEVICES BY FAILURE (PREGNANCY) RATE Device pregnancy rate per 100 women year of use Group 1Lippes loop, copper 7, Copper T 200 Significantly greater than 2.0 Group 2Nova T, Multiload ML Cu 250, Copper T 220 C Less than 2.0 but not less than 1.0 Group 3Copper T 380, Multiload ML Cu375, Levonova Significantly less than 1, most less than 0.5

25. Intrauterine C.C device Multiload Hormone releasing IUCDs Progestasert Levonorgesrel (intrauterine system) levonova Preloaded doesn't require to be loaded in the inserter.

29. Mode of action Immobilize the sperms and prevent it from fertilizing the ovum. By producing inflammatory reaction in the endometrium prevents embedding of the fertilized ovum. Hormonal Effects.

30. Contraindications Bicornuate uterus Nullipara Women with irregular,heavy periods s& fibroids. Present & past PID Suspected pregnancy

31. Multiload Pass uterine sound to measure the length of uterine cavity Introduce the multiload with the inserter until it touches the fundus Then withdraw the inserter.

34. Conformation of proper insertion Easy insertion Excellent retention by the uterus Minimal uterine irritability Easy removal USG

37. Complications Insertion is painful Uterine bleeding Infection Uterine perforation Expulsion Complications relating to pregnancy: congenital malformation, abortion, ectopic pregnancy & prematurity

38. EXPULSION Rate is high in Nulliparous women Pts with endometrial cavity < 40 mm Uterus with acute uterine flexion Smaller devices PREVENTION Proper IUCD size Checking of thread Screening USG

44. HORMONAL CONTRACEPTION

46. Hormonal Contraception COC pills Progesterone only pill Injectables Long acting pill Vaginal rings Implants Dermal patches

49. Contraindications Oral Contraception Absolute –Cholestatic jaundice of pregnancy –Porphyria –Pruritis of pregnancy –Herpes gestationalis –Cancer of breast.

50. Contraindications oral contraception Relative –Thromboembolism –Blood dyscrasias –Diabetes –Obesity –Chorea –Migraine –Varicose veins –Asthma –Depressive psychosis –Elective surgery

51. SEQUENTIAL PILL Two types of pill First 14 containing only oestrogen And last seven a combination of oestrogen and progesterone

52. PROGESTRONE ONLY PILL Mini pill 28 or 35 tablet packet - femules-500ug28 - Noriday-250ug28 - Microval-30ug35

54. ADVANTAGES - POP Do not reduce breast milk Suitable for women with contraindication of estrogens Minimal side effects No risk of circulatory or malignant disease

55. LONG ACTING PILLS Once a month Quinestrel + Levonorgestrel

56. INJECTABLES DEPOPROVERA (DMPA) 150mg every 12 wks NORIGEST (NET-EN) 200 mg every 08 wks CYCLOPROVERA Once a month

58. ADVANTAGES of INJECTABLES Highly effective Easy to deliver Use independent of sexual intercourse Do not reduce breast milk May reduce anaemia Less dysmenorrhoea & PMT

59. DISADVANTAGES of INJECTABLES Requires regular visits to the clinical for injections Irregular uterine bleeding Progesterone side effects eg acne,malaise,fatigue,depression etc

60. VAGINAL RINGS Shell type Core type Contain Oestrogen + Progesterone or only Progesterone Rings changed every 03 months

61. CONTRACEPTIVE IMPLANTS NON – Biodegradable –Norplant – 1 -5 yrs –Norplant – 2-3 yrs –Implanon-3yrs Biodegradable Capronor-one year

63. POST COITAL CONTRACEPTION Immediate insertion of copper- T The YUZPE method –2 tabs of COC at once and 02 tabs after 12 hours Ethinyl Oestradiol -2.5 mg BD * 05 days Conjugated equine estrogens -10 mg TDS * 05 days

64. MECHANISM OF ACTION POST COITAL CONTRACEPTION Block implantation Uterine fluid / genital tract mucus rendered hostile to sperm or blastocyst

65. RISK OF PREGNANCY POST COITAL CONTRACEPTION 20 % 30 % on the day of maximum risk

66. Surgical Contraception Female Sterilization Laparoscopic Minilap Vaginal tubectomy Male sterilization Vasectomy

67. Non surgical Tubal Occlusion Quinacrine pellets Tetracycline methyl cyanoacrylate Oviduct plugs

69. Thank You