Family planning and resent advanceses

2013 resent advances

1. FAMILY PLANNING by DR.VENU

2. DEFINITION “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 contribute effectively to the social development of a country”.

3. OBJECTIVES To avoid unwanted births To bring about wanted births To regulate the intervals between pregnancies To control the time at which births occur in relation to the ages of the parent ; and To determine the number of children in the family.

4. The United Nations Conference on Human Rights at Teheran in 1968 recognized family planning as a basic human right . The Bucharest Conference on the World Population held in August 1974 endorsed the same view. 'Plan of Action' that "all couples and individuals have the basic human right to decide freely and responsibly the number and spacing of their children and to have the information, education, and means to do so".

5. 3.The World Conference of the International Women's Year in 1975 also declared - “The right of women to decide freely and responsibly on the number and spacing of their children and to have access to the information and means to enable them to exercise that right”.

6. SCOPE OF FAMILY PLANNING SERVICES The proper spacing and limitation of births. (2) Advice on sterility, (3)Education for parenthood. (4) Sex education, (5) Screening for pathological conditions related reproductive system, (6)Genetic counseling,

7. (7) Premarital consultation and examination, (8) Carrying out pregnancy tests, (9) Marriage counseling, (10) The preparation of couples for the arrival of their child, (11) Providing services for unmarried mothers, (12) Teaching home economics and nutrition, (13) Providing adoption services

8. HEALTH ASPECTS OF FAMILY PLANNING 1.WOMEN'S HEALTH Maternal mortality, morbidity of women of child bearing age, nutritional status (weight changes, haemoglobin level, etc.) preventable complications of pregnancy and abortion. 2. FOETAL HEALTH Foetal mortality (early and late foetal death);abnormal development.

9. 3.INFANT AND CHILD HEALTH - Neonatal, infant and pre- school mortality , - Health of the infant at birth (birth weight), - Vulnerability to diseases.

10. THE WELFARE CONCEPT Family planning is associated with numerous misconceptions - one of them is its strong association in minds of people with sterilization. The recognition of its welfare concept came only a decade and half after its inception, when it was named Family Welfare Programme . The concept of welfare is very comprehensive and basically related to quality of life .

11. SMALL - FAMILY NORM 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 1,533million by the year 2050 AD. SYMBOLISED In the 1970s, - do ya teen bas . In the 1980s - 2 - child norm.

12. The current emphasis is on three themes: "Sons or Daughters – two will do"; "Second child after 3 years", and Universal Immunization”. Small differences in the family size will make big differences in the birth rate. A significant achievement of the Family welfare Programme in India has been the decline in the fertility from 6.4 in 1950s to 2.6 in 2010. The national target to achieve a Net Reproduction Rate of 1 by the gear 2006 which is equivalent to attaining approximately the 2-child norm.

13. ELIGIBLE COUPLES A currently married couple wherein the wife is in the reproductive age, which is generally assumed to lie between the ages of 15 - 45. There will be at least 150 to 180 such couples per 1000 population in India. 20 % of eligible couples - age group 15- 24 yrs On an average 2.5 million couples are joining the reproductive age group every year. The "Eligible Couple Register" is a basic document for organizing family planning work.

14. TARGET COUPLES Couples who have had 2-3 living children, and family planning was largely directed to such couples. The definition of a target couple has been gradually enlarged to include families with one child or even newly married couples with a view to develop acceptance of the idea of family planning from the earliest possible stage. In effect, the term target couple has lost its original meaning.

15. Target group for spacing method Target group For Sterilization Couple sterilized = 45.4 million TOTAL ECs = 197.4 million As on march 2010

16. COUPLE PROTECTION RATE (CPR) An indicator of the prevalence of contraceptive practice in the community. It is defined as “the per cent of eligible couples effectively protected against childbirth by one or the other approved methods of family planning”. Demographers are of the view that the demographic goal of NRR : 1 can be achieved only if the CPR exceeds 60 per cent.

17. National Population Policy was to attain a CPR of 42 per cent by 1990 , and 60 per cent by the year 2000. During 2010-2011, the total number of family planning acceptors by different methods . Sterilization- 5 million Vasectomy- 0.219 million Tubectomy- 4.78 million IUD insertion- 5.6 million Condom users- 16 million Oral pill users- 8.3 million

18. However about 60 per cent eligible couples are still unprotected against conception. STATE-WISE BREAK-UP Punjab, Gujarat, Maharashtra, Karnataka, Haryana and Tamil Nadu etc – ahead Bihar, Uttar Pradesh, Assam, Rajasthan, West Bengal, Jammu and Kashmir etc - low

19. NATIONAL POPULATION POLICY 2OOO National population policies intended to decrease the birth rate or growth rate.   In April 1976 India formed its first National Population Policy.   Legal minimum age of marriage was increased from 15 to 18 for girls and from 18 to 21 for boys

20. IMMEDIATE OBJECTIVE : To address the unmet needs for contraception, Health care infrastructure and health personnel and To provide integrated service delivery for basic reproductive and child health care. MEDIUM TERM OBJECTIVE : To bring the TFR to replacement level by 2010 through vigorous implementation of inter sectoral operational strategies. LONG TERM OBJECTIVE : Achieve a stable population by 2045 at a level consistent with requirement of sustainable economic growth, social development and environmental protection.

21. NATIONAL SOCIO - DEMOGRAPHIC GOALS FOR 2010 Address the unmet needs for basic RCH services, supplies and infrastructure. Make school education up to age 14 years free and compulsory, and reduce drop outs rate from primary and secondary school levels to below 20 percent for both boys and girls. Reduce IMR to 30/1000 live births. Reduce maternal mortality ratio (MMR) to less than 100 per 1000 live births. Achieve universal immunization of children against all Vaccine Preventable Disease (VPD). Promote delayed marriage for girls, at age not less than 18,and preferable after 20 years. Achieve 80% institutional delivery and 100% by trained personnels

22. 8. Achieve universal access to information/ counseling services for fertility regulation and contraceptive with wide basket of choices. 9. Achieve 100% registration of births, deaths, marriage, and pregnancy. 10. Containment of AIDS, and greater integration between the management of AIDS and STD. 11. Prevention and control of communicable diseases. 12. Integration of Indian system of medicine in provision of RCH services, and in reaching out to households. 13. Promote small family norm to achieve replacement level of Total Fertility Rate 2.1. 14. Bring about convergence in implementation of related social sector programmes so that family welfare become people centered programme.

23. CONTRACEPTIVE METHODS   Preventive methods to help women avoid unwanted pregnancies. IDEAL CONTRACEPTIVE Safe Effective Acceptable Inexpensive Reversible Simple to administer Independent of coitus Long lasting to avoid frequent administration Requiring little or no medical supervision

24. The present approach in family planning programmes is to provide a "cafeteria choice" that is to offer all methods from which an individual can choose according to his needs and wishes and to promote family planning as a way of life. The term conventional contraceptives is used to denote those methods that require action at the time of sexual intercourse, e.g., condoms, spermicides, etc.

25. Classification of contraceptive methods II . TERMINAL METHODS Male sterilization Female sterilization

26. MALE CONDOMS Mostly made of fine latex rubber. Silicon used nowdays to produce semi-dry, pre-lubricated forms. Spermicidal – coated with nonoxynol 9 on inner and outer surfaces. In India, dry condoms are manufactured and supplied free of cost by the government under brand name ‘ Nirodh ’ ADVANTAGE: Simple spacing method No side effects Easily available, safe & inexpensive Protects against STDs DISADVANTAGE: Chances of slip off and tear off Failure rate: 2-3/HWY

27. FEMALE CONDOM Advantages Woman controlled method Prevents STDs including HIV/AIDS Not damaged by oils and other chemicals Disadvantages High motivation Only women who can use diaphragms can use female condom Slippage occurs Expensive Failure rate 21% with typical use and 5% with correct and consistent use

28. VAGINAL DIAPHRAGM Most common and easiest to fit and use Thin, nearly hemispherical dome made of rubber or latex material, with circular, covered metal spring at periphery (flat type and coil type) External diameter of rim is size of diaphragm – 45 mm diameter rising in steps of 5 mm to 105mm (most common 60, 65, 70, 75, 80) Coil spring type ( ortho diaphragm mostly used in India

29. CERVICAL CAP OR CHECK PESSARY Small dome shaped rubber appliances designed to cover the cervix Remain in place by suction Cap must be tailored to fit cervix Loosely fit caps may be displaced during intercourse Not suitable if cervix lacerated or irregular in shape 3 or 4 sizes between 22 and 31 mm

30. VAULT CAP Hemispherical, dome shaped rubber or plastic cap that fits into vaginal vault covering the cervix Rim is thick but does not contain metal spring External diameter of rim is size of vault cap, ranging from 50 to 75 mm in 5mm steps Correct size – smallest that fits evenly in vaginal vault VINULE CAP Type of cervical cap made of rubber, fairly rigid String attached for easy removal Useful in cystocele or mild prolapse where diaphragm not retained External diameter of rim is size – 45 to 51 mm in 3mm steps

31. Failure rate : DIAPHRAGM: 18-28% with typical use and 6% with correct and consistent use CAPS: parous women – 30-40% with typical use 20-26% with correct and consistent use nulliparous – 16-20% with typical use 9% with correct and consistent use

32. Advantages No gross medical side effects Control of pregnancy in hands of woman Reasonably safe when properly used Prevent spread of STDs though less effective than condom Disadvantages Use of spermicidal unacceptable and messy for some Suitable for intelligent, highly motivated women of middle or high socioeconomic groups Allergy to rubber Infection may occur if used for long time Erosion Urinary tract infection Occlusive caps do not prevent spread of AIDS Rarely, toxic shock syndrome

33. VAGINAL SPONGE Introduced in 1980s ‘Today’ most popular Soft, disposable foam sponge made of polyurethane. Round shaped with depression at centre of upper surface to fit over cervix Saturated with spermicide nonoxynol 9 Attached nylon loop for removal Moistened with water, squeezed gently to remove excess water and inserted high up in vagina to cover cervix Acts for 24 hrs Failure rate – 9 – 27 per 100 women years Must be removed and thrown away after 8-24 hrs but not before 6 hrs of last act

34. Drawbacks: May get broken – difficult removal High pregnancy rate Toxic shock syndrome Allergic reactions Vaginal dryness, soreness May damage vaginal epithelium – increase risk of HIV transmission

35. SPERMICIDES Non ionic surfactants which alter sperm surface membrane permeability, resulting in killing of sperms Developed in late 19 th century Use decreasing due to high failure rate Types and distribution: spermicidal agents contain nonoxynol 9. few products contain octoxynol 9 and menfegol Chemical suppositories: Cheapest but least effective Melt at body temperature Manual insertion high in vagina 10-15 min before sexual act

36. 2. Contraceptive creams and jellies liquefy at lower temperature than most creams so more suitable for women with dry vagina 3. Foam tablets effervesce on contact with vaginal moisture placed deep in vagina close to cervix more effective than pessaries Tablets have to be used about 10 min before act and action lasts for 1 hour Failure rate – 0.3-5 per 100 women years ‘Today’ tablets 4. Aerosols or foams foaming chemical contraceptive creams with butane propellant stored under pressure that may be released by pressing valve slightly more effective but more messy 5. C-film 5cm squares of water soluble , semitransparent plastic impregnated with nonoxynol9 either placed over glans penis before coitus or high in vagina 3-5 min before coitus active for 2 hrs

37. Advantages No instructions by doctors or nurses Easily available and easy to use No gross medical side effects Disadvantages Messy to use Failure rate high when used alone Can increase spread of HIV infection by irritating vaginal and cervical mucosa Failure rate – 21% with typical use and 6% with correct and consistent use.

38. classification 3/8/2013 38

39. First generation iud They are inert or Nonmedicated devices made up of polyethylene Different shapes and sizes LIPPE’S LOOP: Double ‘S’ shaped device Made up polyethylene material Non toxic, non tissue reactive & extremely durable Small amount of Barium Sulphate is also added for radiological examination Available in 4 sizes A,B,C &D Failure rate: 3-5 / HWY 39

40. Second generation Iud Made up of metal – copper. EARLIER DEVICES Copper - 7 Copper - T 200 NEWER DEVICES Variants of T device T copper 220C T copper 380A Nova T Multi load devices Failure rate: 0.8/HWY ML-Cu250 ML-Cu375 40

41. Third generation iud Hormone releasing IUD Progestastert Most commonly used T shaped device filled with 38mg of progesterone Releasing rate 65µg/day . Effective for 1 yr Failure rate: 0.2 / HWY LNG-20 (Minera ) Releases 20µg of levonorgesterol. Effective for 5 yrs Effective rate 99% 3/8/2013 41

42. ADVANTAGES OF IUDs: Safe, Effective, Reversible Inexpensive High continuation rate DISADVANTAGES OF IUDs: Heavy bleeding and pain Pelvic Inflammatory diseases Ectopic pregnancy May come out accidently if not properly inserted 3/8/2013 42

43. TIMING OF INSERTION: Inserted with a plunger Any time during women’s reproductive period Except in pregnancy Most ideal time is during or within 10 days of the beginning of menstruation t he diameter of cervical cavity is greatest at this time. 3/8/2013 43

44. IDEAL IUD CANDIDATE: Who has borne at least 1 child Has no history of PID Has normal menstrual periods Is willing to check IUD tail Has an access to follow up and treatment of potential problems Is in monogamous relationship 3/8/2013 44

45. Classification of hormonal contraceptives 3/8/2013 45

46. Combined pills Composition : In early 1960s – Oestrogen - 100-200µg and Progesterone - 10mg Greater side effects Nowadays Oestrogen - 30-35µg and Progesterone - 0.05-0.15mg. Taken from 5 th to 25 th day of menstrual cycle, followed by a break of 7 days ( withdrawal bleeding ). FAILURE RATE: 0.1/HWY

47. Main type MALA-D: ( Levonorgestrol 0.15mg + EE 0.03mg) Packet of 28 tabs. 21 are white and 7 are brown coloured containing Ferrous Fumarate .(Rs – 3/-) MALA-N : ( Levonorgestrol 0.15mg + EE0.03mg) Packet of 28 tabs. Govt Supply. Mechanism of action : Prevents ovulation Prevents implantation Makes cervical secretions thick Effectiveness 100% effective if taken correctly.

48. Eg . MALA-D MALA-N Combined pills

49. Contraindications to OCP Use Absolute Contraindications Cancer of breast and Genitals H/O venous thrombo - embolism Vascular disease- CAD or CVD Liver disease ( i.e. Viral hepatitis, cirrhosis) Pregnancy Congenital hyper lipidaemia Age above 40 yrs. Smoking and age above 35 yrs HTN with SBP>160, DBP>99 Chronic renal diseases Epilepsy , Migraine Hyper lipidaemia LDL>160 DM with secondary complications Infrequent bleeding, Amenorrhea. 49

50. Progesterone only pills Minipill or Micropill. Composition: Low dosage of progesterone, mainly Norethisterone (or) Levonorgestrel. Dosage: One tab daily throughout the menstrual cycle It is mainly given in older women in whom combined pills are C/I as in CVDs Efficacy 96-98% Failure rate:0.5/HWY

51. Mechanism of action: Makes cervical mucosa thick – action starts in 2-4 hrs last for 24hrs. Decreases the motility of Fallopian tubes. Prevent pregnancy without preventing ovulation, as ovulation occurs in 20-30% women. Suitable for Lactating women Smokers above 35 yrs old Estrogen sensitive women Disadvantages: Higher risk of neoplasia in women taking POP than in women on Combined Pills Poor control of cycle.

52. POST-COITAL COTRACEPTIVE (a) IUD : WITH IN 5 DAYS (b) HORMONAL : More often a hormonal method may be preferable. In India Levonorgestrel 0.75 mg tablet is approved .( 1Tab-with in 72 hrs) (or) 2 tab-50mcg of EE with in 72 hrs after intercourse & same dose after 12 hrs. (or) 4 tab-30-35 mcg of EE with in 72 hrs& 4 tab-after 12 hrs (or) mifepristone 10 mg in 72 hrs

53. Mechanism of action: Hypermotility of fallopian tube Hypermotility of uterus hence no implantation and fertilization Disadvantages: Nausea and vomiting. Next period may start earlier or later Do not protect against STI & HIV 1 % failure rate

54. Male pills The hormones which reduce sperm count tend to reduce testosterone levels hence they affect potency and libido Gossypol: Cotton seed derivative Causes azoospermia and severe oligospermia Toxic Use for 6 months leads to complete sterility 3/8/2013 54

55. Once a month (long acting) pill In this method a long acting oestrogen ( Quinestro l) + short acting progesterone is given. But the results are highly disappointing. 3/8/2013 55

56. Injectable contraceptives CLASSIFICATION 3/8/2013 56

57. Progesterone only injectables DMPA: Dose: 150mg IM every 3 months. MOA: suppresses ovulation Advantage: doesn’t affect lactation, useful in postpartum period. Can be used in the multiparae of age >35yr NET-EN: Dose: 200mg IM every 2 months Both DMPA & NET-EN are given in 1 st 5 days of menstrual cycle. They are given deep IM in gluteus muscle. 57

58. New formulation of DMPA ( Uniject ) Prefilled, single use syringe could be particularly They contain a special formulation of DMPA, called DMPA-SC (104 mg). Short needle meant for subcutaneous injection Useful to provide DMPA in the community. Injections by appropriately trained community health workers is safe, effective, and acceptable. 58

59. Side effects : Disruption of normal menses Amenorrhoea Contraindications: Breast cancer Genital cancer Undiagnosed uterine bleeding Suspected malignancy Lactating women FAILURE RATE: 0.3/HWY 3/8/2013 59

60. Combined injectables Containing long-acting progesterone with short action estrogen 25 mg DMPA + 15 mg estradiol cypionate ( Cyclofem ) and 50 mg NET-EN + 5 mg estrdiol valerate ( Mesigyna ) Given once a month and produce a menstruation like pattern. The trials are currently taking place in India. MOA : Suppression of ovulation A lteration of cervical and endometrial secretions. C/I : Pregnancy Thrombo embolytic disorders C erebrovascular disease Coronary artery disease M igraine Breast cancer DM 60

61. NORPLANT Sub dermal implants A flexible plastic single flexible rod 4cm long x 2mm diameter Contains 35mg LEVONOGESTREL 3 years pregnancy rate 0.7 3/8/2013 61

62. Benefits Reliable long term contraception Improvement in menorrhagia and dysmenorrhoea Beneficial effect on acne in 59% No adverse effects on bone mass No significant effect on lipids, haemostasis or liver function Adverse side effects Bleeding pattern altered: Amenorrhoea 20% Weight gain of >10% in 21% Hormonal ‘nuisance’ effect eg breast pain, headache, libido decrease, dizziness, nausea Other (<2.5%) alopecia , depression, change in libido 3/8/2013 62

63. The Patch (OrthoEvra) Is a thin & plastic patch That sticks to the skin. The sticky part of the patch contains the hormones: norelgestromin (progestin) and ethinyl estradiol (estrogen). Weekly for 3wks then patch free 1 week. These hormones are absorbed continuously through the skin and into the bloodstream. 3/8/2013 63

64. 64 Vaginal ring ( Nuvaring) Etonorgestrel 120mcg + Ethinylestradiol 15mcg daily Use for three weeks with a withdrawal week Inhibits ovulation Cycle control good Non-latex Implanted intra vaginally The progesterone is absorbed slowly through the vaginal mucosa. Store 2-8 degrees; if room temperature, up to 4-12 Effectiveness: Overall perfect use failure rate 0.3%, typical use failure rate 8% 64 3/8/2013

65. Post conceptional methods Classification 3/8/2013 65

66. Menstrual regulation No legal restriction Aspiration of uterine content Within 6-14 days of missed period Cervical dilatation needed in nullipara Early complications : Bleeding, Uterine perforation and trauma. Late complications : Tendency to abortion or premature births, infertility, menstrual disorders, ectopic pregnancy & Rh isoimmunization 66

67. Menstrual induction Based on disturbing the normal progesteron - prostaglandin balance by IU application of 1.5mg solution or 2.5-5mg pellet of prostaglandin F 2. Causes sustained uterine contraction for 7 min. followed by cyclical contraction for 3- 4 hrs. Bleeding starts and continues for 7-8 days. 3/8/2013 67

68. Oral Abortifacient Mifepristone + Misoprostol – 95% successful in terminating pregnancies upto 9 weeks. Commonly used regimen Mifepristone 200mg oral on day 1 followed by Misoprostol 800mcg vaginally immediately or 6 -8 hrs later. Other regimen is Mifepristone 600mg oral on day 1 followed by Misoprostol 400mcg orally on day 3 Follow up visit is must within 14 days for clinical and/or USG examination 3/8/2013 68

69. abortion Definition: Termination of pregnancy before the foetus becomes viable . LEGALISATION Medical termination of pregnancy act 1971 1) Conditions under which abortion is done Medical Eugenic Humanitarian Socio-economic In failure of contraceptive device 3/8/2013 69

70. 2) Who can perform abortion? If < 12 weeks 1 RMP having experience in OB-GYN If > 12 weeks -20 weeks then 2 RMP opinion 3) Where can abortion be done? Place approved by Chief medical officer of district i.e DM& HO. 3/8/2013 70

71. Miscellaneous methods Abstinence Coitus Interruptus : failure rate 25/HWY Safe period/rhythm period/ calendar method Basis: ovulation from 12 th - 16 th day before onset of menses Calculation: 1 st day of fertile period = shortest cycle-18days Last day of fertile period = longest cycle-10days 3/8/2013 71

72. Drawbacks : Irregular cycle so difficult to predict Only for educated and responsible couples Programmed Sex High Failure rate 9/ HWY Complication : Embryonic Abnormalities, Ectopic Pregnancy 3/8/2013 72

73. 4) Natural family planning method : Basis: same as calendar method but here the women employs self recognition of certain signs and symptoms associated with ovulation. Basal Body temperature method Cervical mucous method Symptothermic : It is based on the observation of changes in different body signs: cervical secretions, basal body temperature and the position of the opening of the cervix. 5) Lactation 3/8/2013 73

74. Terminal methods 3/8/2013

75. vasectomy 3/8/2013 75

76. Failure Rate: 0.15/HWY (due to mistaken identification of vas) COMPLICATIONS: Operative Sperm granules Spontaneous recanalisation Autoimmune response Psychological response 3/8/2013 76

77. No scalpel vas occlusion METHODS Elastomer plugs : Gets hardened and plugs the vas SHUG : preformed silicon rubber plug is inserted. RISUG : Reversible Inhibition of Sperm Under Guidance 3/8/2013 77

78. Tubectomy Failure rate: 0.5/HWY 78

79. Approaches to the fallopian tubes, surgical procedures, timing of procedure,and related occlusion techniques 3/8/2013 79

80. Evaluation of contraceptive methods Contraceptive efficiency: It is the measurement of unplanned pregnancies even after the use of contraceptive measures. 1) Pearl Index : no. Of failures/100 woman-yr of exposure Failure rate/HWY= Total accidental pregnancies × 1200 total months of exposure 2)Life-table analysis - calculates a failure rate of each month of use. 3/8/2013 80

81. RECENT ADVANCES

82. 1.New Male Pill The pill contains desogestrel as well as testosterone. B locks the production of sperm while maintaining male characteristics and sex drive. It must be taken daily. 100% effective and completely reversible in preliminary clinical trials . In clinical trials, all of the participants’ sperm counts dropped to zero, which means that the male pill would be more effective than the condom and even the female pill. 82

83. 2. CatSper Blocker Sperm rely on calcium ions in sperm- tail for mobility and fertilization. Humans -ion-channel gene - CatSper . Blocking CatSper action - effective form of birth control. Men or women could take this potential CatSper “blocker” because it could be made to act ”wherever sperm are present.”

84. 3. Spray On -Contraceptive Australian biotech company Acrux has come up with a world’s first — a contraceptive spray for women. Metered Dose Transdermal System (MDTS) to administer a pre-set dose of the Nestorone to the skin (forearm) every 14 days. The fast-drying spray gradually absorbed into the bloodstream. Suitable for Breastfeeding mothers Who cannot tolerate contraceptive pills with oestrogens . Leaves no visible residue & less irritation than patches. Because it does not have to be taken at the same time every day, it will suit women who often forget to take the Pill.

85. 4. Adjudin “ The male Patch” Adjudin ( 2,4-dichlorobenzyl- 1H-indazole-3-carbohydrazide) is non-hormonal male contraceptive drug, which acts by blocking the maturation of sperm in the testes, but without affecting testosterone production. Normal spermatogenesis returned in 95% within 210 days after the drug had been discontinued. The oral dose effective for contraception is so high that there have been side effects in the muscles and liver, therefore the drug is being manufactured as implant or patch for males.

86. 5. Contraction Inhibitor Pill “Dry Orgasm” 2 different types of smooth muscle in vasa deferentia L ongitudinal muscle fibers and circular muscle fibers. W hen segments of vasa deferentia were exposed to phenoxybenzamine or thioridazine , the longitudinal smooth muscle fibers did not contract. The circular smooth muscles did, causes , clamping the vas shut. Thioridizine’s side effects were so extreme( hives, difficult breathing;,swelling of face) that the manufacturer discontinued it in 2005, the common side effects of phenoxybenzamine are dizziness , fast heartbeat & stuffy nose. 3/8/2013 86

87. 6. Anti-Fertility Vaccines Contraceptive vaccine either target Gamete production ( FSH and LH) Gamete function Gamete outcome ( hCG ). CVs targeting gamete function are better choices but induce oophoritis affecting sex steroids. Antisperm antibody-mediated immunoinfertility provides a naturally occurring model to indicate how an antisperm vaccine will work in humans. The hCG vaccine is the first vaccine to undergo clinical trials in humans. Both the efficacy and the lack of immunotoxicity have been reasonably well demonstrated for this vaccine.

88. 7. R.I.S.U.G Reversible Inhibition of Sperm Under Guidance ( RISUG ), developed at IIT Kharagpur in India by Dr. Sujoy K Guha . It is currently undergoing clinical trials in India. RISUG is a non-hormonal injectable contraceptive composed of SMA (styrene maleic anhydride) mixed with DMSO (solvent dimethylsulfoxide ). Partially blocks the vasa deferentia and destructs the sperm The differential charge from the gel ruptures the sperm’s cell membrane, stopping the sperm before they can even start their journey to the egg. R eversals by multiple injection of dimethyl sulfoxide or sodium bicarbonate – and several months to reverse.

89. 8 . Hydrothermal Male Control Methods used include Hot water applied to the scrotum Heat generated by ultrasound Artificial cryptorchidism (holding the testicles inside the abdomen) using specialized briefs. Raising the body temperature above 42 degrees Celsius initiates certain processes, resulting in cells disability. It is called Heat Shock Factor (HSF).It disable sperm cells. Hot water bath (about 46.7 degrees Celsius)for 45 minutes daily for 3 weeks - simple wet heating - ensure up to 6 months of male infertility. ultrasound method - the testicles are heated with the help of ultrasound - only two procedures 48 hours - temporary infertility for up to 10 months.

90. 10. SILCS Diaphragm The SILCS diaphragm is a silicone barrier contraceptive device . Its dome is filled with BufferGel that acts both as a spermicide and microbicide that not only immobilizes the sperms but also kills them and fights infections. It avoids the need for many sizes and a pelvic exam for a correct fit; it is designed as a “one size fits most” device. T he new device is being evaluated for comfort and ease-of-use in studies, underway in the Dominican Republic, South Africa, Thailand, and the United States.

91. 11. Injectable silicone plugs O ften used by men in China as a potential alternative to vasectomy. There are two tested types of injected plugs: Medical-grade polyurethane (MPU) M edical-grade silicone rubber (MSR). The polymer (special ingredient) is injected directly into the vasa differentia, Once injected, the polymer solidifies in place, forming a flexible plug. The procedure takes less than 30 minutes under local anesthesia. It is easier to reverse. It takes 2 to 4 years after the reversal procedure.

92. 12.Essure The Essure procedure involves placing a small & flexible device called a Micro- insert into each fallopian tubes. The Micro- inserts are made from materials that have been well studied and used successfully in the heart and other parts of the human body for many years. Once the Micro-inserts are in place, body tissue grows into the Micro- inserts, blocking the fallopian tubes.

93. SOCIOLOGY OF FAMILY PLANNING Basic social cell. Sociologists and economists believed that living standards of the people can not be improved while population growth unchecked. Attitude surveys have shown that awareness of family planning is very widespread and over 60 per cent people have favorable to restricting or spacing births.

94. Studies have shown that the population problem complicated by deep-rooted religious and other believes. Attitudes and practices favoring larger families. Preference for male children. Most of these beliefs stem from ignorance and lack of communication. The experience of all countries which a successful population control show that the best motivation is economic, a desire to improve standard of living. The solution to the problem is one of mass education and communication.

95. UNMET NEED Women have an unmet need if they are sexually active do not want to have a child soon or at all are not using any contraceptive method are able to conceive In 1960s – “KAP – gap” In 1977 - Unmet Need

96. Who has unmet need? Fifteen percent of married women in developing countries: 24% in Sub-Saharan Africa 11% in South and Southeast Asia 10% in North Africa and West Asia 12% in Latin America and the Caribbean

97. More than 100 million married women have an unmet need for contraception Number (in millions) and % distribution of married women with unmet need 60 (56%) 29 (27%) 7 (7%) 9 (8%) 3 (3%)

98. Reasons for nonuse can be grouped into a few broad categories Opposition to family planning Lack of knowledge Access and cost Health concerns and side effects of methods Misconceptions about pregnancy risk

99. CONTRACEPTION AND ADOLESCENCE 10 and 20 per cent of all pregnancies- developing countries - USA. "At Risk“- Many are undesired, and occur in unmarried adolescents who then resort to legal or illegal abortion, performed under unsatisfactory medical conditions. PREVENTION -Through educational programmes dealing with responsible sexual behavior. Adolescents are ambivalent about family planning to request contraception is to reveal one's sexuality.

100. For this reason, adolescent girls sometimes choose the risk of an undesired pregnancy and of an abortion. BARRIER METHODS HORMONAL CONTRACEPTION; Hormonal methods are perfectly suitable for adolescents, who generally do not suffer from such problems as cardiovascular contraindications. The demographic future of the world will depend on them, on how well informed they are, and on their sense of responsibilities.

101. SERVICE DELIVERY SYSTEM OF FAMILY PLANNING

102. The National Institute of Health and Family Welfare acts as an apex technical institute for promoting health and family welfare in the country through education, training services, research and evaluation. “Central Family welfare Council” consisting of all the State Health Ministers to review the implementation of the programme. “ A Population advisory Council” headed by the Union Health Minister, members of Parliament, and persons from the fields related to population control was set up in 1982. This body acts like a “think tank” .

103. AT STETE LEVEL

104. Community Needs Assessment Approach Involvement of private sector Incentives and Dis-incentives Family Welfare linked health insurance scheme Postpartum Programme Population education

105. VOLUNTARY ORGANIZATIONS The Family Planning Association of India, The Family Planning Foundation and the Population Council of India. The Indian Red Cross, The Indian Medical Association, Rotary Clubs, Lions Clubs, Citizens Forum, Christian Missionaries and Private Hospitals.

106. INTERNATIONAL LEVEL “International Planned Parenthood Federation” is the world's largest private voluntary organization supporting family planning services in developing countries. The United Nations Fund for Population Activities (UNFPA). the US Agency for International Development (USAID) Population Council, Ford Foundation, The Pathfinder fund and World Bank besides WHO and UNICEF.

107. NATIONAL FAMILY WELFARE PROGRAMME India launched a nation-wide family planning programme in 1952,first country in the world. Beginnings the programme were modest with the establishment of a few clinics and distribution of educational material, training and research. Third Five Year Plan (1961-66)- " the very centre of planned development ”.- the purely “clinic approach " to the more vigorous "extension education approach " for motivating the people for acceptance of the 'small family norm".

108. The introduction of the Lipples Loop in 1965 necessitated the creation of a separate Department Family Planning in 1966 in the Ministry of Health. Fourth Five Year Plan (1969-74)- "top priority" to the programme. The Programme was made an integral part of MCH activities of PHCs and their sub- centres . In 1970- All India Hospital Postpartum Programme 1972 - Medical Termination of Pregnancy (MTP) act were introduced. Fifth Five Year Plan (1975-80)- 1976- National Population Policy

109. 1977- Ministry of Family Planning was renamed “ Family Welfare” The 42 nd Amendment of the Constitution has made "Population control and Family Planning" . The acceptance of the programme is now purely on voluntary basis. The Rural Health Scheme in 1977 and the involvement of the local people. 1978- the Alma Ata Declaration - The acceptance of the primary health care approach to the achievement of HFA/2000 AD led the formulation of a National Health Policy in 1982.

110. The Sixth and Seventh Five Year Plans were accordingly set to achieve these goals. 1985 – 86- Universal Immunization Programme The oral rehydration therapy 1992 these programmes were integrated under Child Survival and Safe Motherhood (CSSM) Programme. 1994- the International Conference on Population and Development in Cairo- implementation of Unified Reproductive and Child Health Programme (RCH).

111. Ninth Five Year Plan the RCH Programme integrates all the related programmes of the Eighth Five Year Plan. The concept of RCH is to provide need based, client oriented, demand driven, high quality integrated services. The investment on family welfare programme 0.65 crores during the first plan, the Eleventh Plan period-136,147 crores

112. Evaluation of Family Planning Evaluation of need Evaluation of plans Evaluation of performance Services Response Cost analysis Other activities Evaluation of effects Evaluation of impact

113. Thank u