11.8.1 Combined Oral Contraceptives (COS) and Injectables
Before initiating oral contraceptive pills:
- Check blood pressure
- Perform vaginal examination (to check normal size of uterus)
- Check for contraindications like deep vein thrombosis
Follow up:
- Instruct women always to inform the doctor or nurse that they are on contraceptives while attending clinic or hospital.
- Women on oral contraceptives need regular physical check-ups including blood pressure measurement every six months
- Need to withdraw COCs or Progesteron Only Contraceptives (POPs) in:
o Pregnancy
o Severe headaches especially associated with visual disturbances
o Numbness or paresis of extremities
o Unexplained chest pain or shortness of breath o Severe leg pains etc.
The recommended oral contraceptives are:
A: Ethinyloestradiol + Norgestrel Tablets 0.03mg + 0.3mg
OR
A: Ethinyloestradiol + Levonogestrel Tablets 0.03mg + 0.15mg
OR
A: Ethinyloestradiol + Desogestrell Tablets 0.03mg + 0.15mg
OR
A: Medroxyprogesterone acetate IM 150 mg every three months
| Note
|
Take the first pill on the 5th day of menstruation and then continue every day without any interruptions |
| | Check blood sugar and hypertension after every 6 months |
Caution! Avoid use in women with severe hypertension and women without proven fertility
Post-coital contraception (“morning-after pill”)
The method is applicable mostly after rape and unprotected sexual intercourse where pregnancy is not desired. Within 3 days (72 hours) of unprotected sexual intercourse, give:
A: Combined oral Contraceptive ethinyloestradiol 100 µg and levonorgestrel
500 µg (2 high dose COC tablets)
OR
A: Ethinyloetradiol 30–35 µg and levonorgestrel 150–250 µg –3 tablets (3 low dose COC tablets).
- Repeat this dose after twelve hours
- Advice to return to physician if menstruation does not occur within 3 weeks; give advice on contraceptive use
11.8.2 Implant Contraceptives
Implants are contraindicated to: Severe hypertension
- Thromboembolism
- Active liver disease
- Sickle cell anaemia
- Genital bleeding
- Severe headaches
The following are the recommended implants:
B: “Implanon 68mg “containing etonogestrol in single silastic capsules is implanted in the left upper arm with local anesthesia. Is effective for 3 years
OR
B: Implanon NXT, 68mg is an implant containing etonogestrel in single silastic capsule with applicator is implanted in the left upper arm with local anesthesia. Is effective for 3 years
OR
B: Jadelle, “containing levonogestrel 75mg in two silastic capsules is implanted subdermal in the left upper arm with local anesthesia. Is effective for 5 years and is recommended for women who have completed their family or not ready for sterilization or those not able to take estrogen containing contraceptives.
NOTE:Use the WHO Medical eligibility criteria (MEC) wheel on providing FP methods
11.8.3 Infertility
Infertility is a condition of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.12
Investigation: Not every fertility test will be done for every case.
WOMEN: For women, fertility testing may include basic gynaecologic examination VDRL tests
- Urine routine and microscopic
- Cervical mucus examination
- Abdominal pelvic USS-to look for polycystic ovaries, larger ovarian cysts, fibroids, and, sometimes, to confirm ovulation is taking place.
- HSG (hysterosalpingogram) to check that the fallopian tubes are open and not blocked, as well as to evaluate the shape of the uterus.
- Hysteroscopy- This is done if an HSG examination showed potential abnormalities or was inconclusive.
- Diagnostic laparascopy- This test is only done when symptoms point to possible endometriosis, as part of treatment for blocked fallopian tubes, or in some cases of unexplained infertility.
- Hormonal profile- FSH, LH,T3 & T4,Testosterone, prolactin, estradioland progesterone
MEN: Perform the following
- Semen analysis
- VDRL tests
- Hormonal profile-FSH,Testosterone, but sometimes also LH, estradiol, or prolactin
Treatment will depend on the underlying cause
Non-pharmacological treatment
- Weight reduction in obese clients.
- Educate the couple on the importance of having sexual intercourse during the fertile window
- Try to avoid smoking/excessive drinking
Pharmacological treatment
Ovulation stimulation;
C: Clomiphene citrate 50mg (PO) once per day for seven days from the 2nd–5th day of menstruation.(maximum 6 cycles)
Polycystic Ovarian Syndrome (PCOS)
A: Metformin 500mg 8 hourly (sometimes used during PCOS treatment, alone or along with fertility drugs)
Hyperprolactinemia
B: Bromocriptine 2.5–5mg once per day until the prolactin level is within the normal range Surgeries:
- Tubal surgery for Tubal blockage
- Myomectomy for uterine fibroids
- Ovarian drilling is a possible surgical infertility treatment for PCOS–related infertility
Referral
Refer all patients with infertility to a gynecologist.
