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2

Family planning and infertility

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Contents

Objectives

When you have completed this chapter you should be able to:

Introduction to family planning

2-1 What is family planning?

Family planning is the ability of a couple to control their fertility so they can have a baby when they plan to and avoid pregnancy when they do not wish to have a child. Family planning is far more than simply birth control. It includes both contraception and infertility management. Ideally it should involve both partners. Family planning is essential to the reproductive health and quality of life for each family and community. Therefore, family planning is an important part of primary healthcare.

Family planning services should:

  1. Promote a caring and responsible attitude to sexual behavior through education and counselling.
  2. Encourage the planning and spacing of the number of children according to a family’s home conditions and financial income.
  3. Offer women and men information, choices about and access to safe and effective contraception.
  4. Educate the community with regard to the disastrous effects of unchecked population growth on the environment.
  5. Provide assistance to couples who wish to have a child when the woman is unable to fall pregnant.
Note
In 2004 the World Health Assembly endorsed the provision of high-quality family planning services, including infertility services, as a key strategy to improve global reproductive health.

2-2 Who requires family planning education?

Because family planning aims at improving the quality of life for the whole community, every person, female or male, requires family planning education. Such education should ideally start during childhood and be given in the home by the parents. It is then continued at school and throughout the rest of the individual’s life. Health services play a central role in family planning education but other community organisations, churches and the media also play important roles.

It is essential to promote community participation in any family planning programme if both contraceptive and infertility services are to succeed in that community.

Normal conception

2-3 What is the process of normal conception?

Each month, when a woman is menstruating, an egg (called an ‘oocyte’) starts growing in one of her ovaries. After approximately 14 days this egg is released from that ovary and is picked up by the Fallopian tube on that side in a process called ovulation.

During intercourse sperm is deposited into the vagina. From here the sperm swim up into the uterus and then into the Fallopian tubes. If the woman has intercourse around the time of ovulation there is a good chance that the egg will meet a sperm in a Fallopian tube and be fertilised (conception).

Conception is the process during which a sperm fertilises an egg.

2-4 What happens after conception?

After the egg is fertilised it is slowly transported through the Fallopian tube into the uterus. The fertilised egg (now called an embryo) is ready to implant into the lining of the uterus (the ‘endometrium’). Following implantation the growing embryo produces a substance which prevents the breakdown of the endometrium and the onset of the next menstrual bleeding.

The embryo continues to grow in the uterus and by about 7 weeks from the start of the last menstrual period (5 weeks after conception) an ultrasound scan will be able to detect the embryo (and heartbeat) inside the uterus to confirm the pregnancy.

Note
The substance which prevents the breakdown of the endometrium and the onset of menstrual bleeding is called hCG (human chorionic gonadotropin). All pregnancy tests are based on measuring hCG in the urine.

2-5 When should a woman have intercourse in order to fall pregnant?

A woman is most fertile if she has intercourse on the day of ovulation or the two days before ovulation.

Some women experience mild pain in their lower abdomen and may have a lot of clear and stringy vaginal mucus when they are ovulating. After ovulation this mucus becomes more opaque and thick. Most women, however, don’t experience these signs and may not be sure when they are ovulating.

The best advice for all women wishing to fall pregnant is to have regular intercourse every 2 to 3 days as the sperm can survive for 2 to 3 days in the female genital tract.

Note
Correct timing helps increase the chance of conception but should not be used as a method of contraception as it is far too unreliable. The mild abdominal pain at the time of ovulation is called ‘mittelschmerz’.

2-6 How long does it take for a woman to fall pregnant?

Most women who want a baby and have regular unprotected intercourse will fall pregnant within 12 months. About half of women who are not pregnant by 12 months will usually fall pregnant within another 12 months (i.e. 24 months after planning a pregnancy).

Thereafter the chance of a spontaneous conception becomes smaller with each year. The longer a woman has tried unsuccessfully to conceive, the less likely she will fall pregnant.

Note
About 85% of couples who are trying to have a baby will conceive within 12 months of having unprotected regular sexual intercourse. Of those who do not conceive in the first year about 50% will conceive in the second year.

Contraception

2-7 What is contraception?

Contraception is a range of methods used to prevent a woman falling pregnant. Contraception is the same as birth control.

2-8 Who needs contraceptive counselling?

Every person who is sexually active, or who will soon become sexually active, needs contraceptive counselling (i.e. information and advice about birth control). While the best time to advise a person on contraception is before they have their first intercourse, every visit to a primary-care clinic provides an excellent opportunity to talk about contraception. Some patients will ask you for contraceptive advice. However, many others who do not ask need to be told as they will only use contraception by knowing and believing the many benefits.

2-9 How can you motivate a woman to consider using contraception?

A good way to motivate a woman to use contraception is to discuss with her the health, social and economic effects that having a child could have on her and the rest of the family. Explain the immediate benefits of a smaller, well-spaced family.

2-10 Should men be involved in contraceptive counselling?

Yes. Traditionally, contraceptive services have focused on women as they carry the main burden of pregnancy and child rearing. However it is important to involve men wherever possible. Women who are supported by their partner are more likely to use contraception while contraceptive counselling will help men make responsible decisions and practise safe sex.

If possible, both partners should receive contraceptive counselling together.

2-11 How should you give contraceptive counselling to a woman?

Ask if she wants to bring her partner. It is best if the couple can be counselled together. Then follow 5 important steps:

  1. Help the woman plan her pregnancies.

    Ideally a woman should consider and plan her family before her first pregnancy. Unfortunately this hardly ever happens in practice. When planning her family the woman should decide on:

    • The number of children wanted
    • The time intervals between pregnancies
  2. Discuss contraceptive options.

    It is important to give women clear, unbiased information about all the available contraceptive options and the advantages and disadvantages of each method. One method is not the most suitable for all women. Women need to know they have many options to choose from.

  3. Find out the woman’s choice of contraceptive method.

    This is the method she is most likely to accept and continue using

  4. Consider the suitability and contraindications to her method of choice:

    You must decide whether the chosen contraceptive method is a good choice for her, considering:

    • Effectiveness
    • Contraindication
    • Side effects

    If the contraceptive efficiency of the preferred method is appropriate, if there are no contraindications to it, and if the woman is prepared to accept the possible side effects, then the method she has chosen should be used. Otherwise discuss alternative methods.

  5. If needed, help the woman to select the most appropriate alternative method of contraception.

    The selection of the most suitable alternative method of contraception will depend on a number of factors including the woman’s wishes, her age, medical history, the risk of side effects and whether or not a very effective method of contraception is required.

Every woman should be knowledgeable about contraceptive options and be allowed to choose a contraceptive method that suits her.

2-12 What contraceptive methods are available?

  1. Combined hormonal contraceptives:

    • Combined oral contraceptive pills
    • Transdermal patches (skin patches)
    • Hormone-releasing vaginal rings
  2. Progestogen-only contraceptives:

    • Progestogen-only pills
    • Injectable contraception
    • Subdermal implants (implants under the skin)
  3. Intra-uterine contraception

    • Copper intra-uterine devices
    • Hormone-releasing intra-uterine devices
  4. Condoms for both males and females
  5. Sterilisation by tubal ligation in women or vasectomy in men.

Not all methods are available in the public service, while some methods may only be available on referral to hospital or special clinics. Subdermal implants may soon be introduced in South Africa, but are not currently available here.

Breastfeeding alone, coitus interruptus (withdrawing or pulling out) and the ‘safe period’ are all very unreliable.

Women should also know about emergency contraception.

Note
Progestogens are a major group of natural steroid hormones, including progesterone. Progestins are synthetic progestogens used in progestogen-only oral contraceptives, injectables, implants and hormone releasing intra-uterine systems.

2-13 How effective are contraceptive methods?

Contraceptive methods may be divided into very effective and less effective ones. Oral contraceptives, injectable contraceptives, intra-uterine contraceptive devices, implants, patches, vaginal rings and sterilisation are all very effective when used correctly. Condoms are less effective contraceptives.

Additional contraceptive precautions must be taken when the effectiveness of any oral contraceptive may be impaired, e.g. vomiting and severe diarrhoea or when taking antibiotics. There is no medical reason for stopping oral contraceptives to give the body a rest.

Note
The effectiveness of a contraceptive method is given as an index which indicates the number of women who would be expected to fall pregnant if 100 women used that method correctly and consistently for 1 year. The higher the index, the less effective is the method of contraception. The perfect efficacy index is 0. The efficacy of the various contraceptive methods is as follows:
  • Oral contraceptives: Combined pill (0.3) and Progestogen-only pill (1.2)
  • Injectables: Depo medroxy progesterone acetate [DMPA] marketed as Depo-Provera and Petogen (0.2) and Norethisterone enantate[ NET-En] marketed as Nur-Isterate (0.6)
  • Copper IUCD (0.5)
  • Hormone-releasing IUCD marketed as Mirena (0.2)
  • Transdermal patch marketed as Evra (0.3)
  • Vaginal ring (0.3)
  • Single-rod subdermal implant marketed as Implanon (0.05)
  • Sterilisation: Vasectomy (0.05) and tubal ligation (0.5)
  • Condom: Male (2–15) and female (5–15). The efficacy of condoms and other methods requiring patient compliance depends on the reliability with which they are used and failure rates during typical use are usually considerably higher than those quoted above.

2-14 Do contraceptive methods have side effects?

Most contraceptive methods have no or very mild side effects which usually settle within a few months. However, some side effects may be unacceptable to a woman and will cause her to discontinue that particular method. It is therefore important to counsel all women about possible side effects and to deal with them if they arise.

Combined oral contraceptives

2-15 What are combined oral contraceptives?

Tablets (‘pills’) which contain both oestrogen and a progestogen are called combined oral contraceptives (‘COCs’). One tablet should be taken every day. Combined oral contraceptives are usually available in packs of 28 tablets containing 21 active tablets and 7 non-active tablets of a different colour. The non-active tablets allow menstruation to take place normally.

Transdermal (skin) patches and vaginal rings both work in the same way as the combined oral contraceptives without need for remembering to take a tablet every day. Transdermal patches should be changed every seven days while vaginal rings can stay in place for 21 days.

Note
Combined oral contraceptives were first used in the USA in 1960.

2-16 Who should use combined oral contraceptives?

Combined oral contraceptives are suitable for women who require effective contraception, are happy to have regular periods and can remember to take a pill every day.

2-17 Who should not use combined oral contraceptives?

Women should not use combined oral contraceptives if they:

Note
Risk factors for cardiovascular disease include smoking, hypertension, diabetes, hypercholesterolaemia (high serum cholesterol) and a family history of cardiovascular disease.

2-18 What are the side effects of combined hormonal contraceptives?

Common side effects are:

If a woman complains of irregular bleeding, check if she is taking her tablets regularly, is not vomiting or using enzyme-inducing drugs. If she has just started on the tablets encourage her to keep taking them daily and wait to see if the bleeding settles over 3 to 4 months. If the bleeding continues change her to a different combined oral contraceptive or suggest another contraceptive method after excluding other gynaecological causes of abnormal uterine bleeding.

If she complains of nausea advise her to take her tablet with food or at night. Breast tenderness often disappears after the first few months. If not, change her to a different combined oral contraceptive or suggest another contraceptive method.

Headaches can be managed with a mild analgesic such as paracetamol. If they are severe or get worse, change to a different pill or another method. Refer the patient if the headaches continue after she has changed her contraceptive.

Try to establish if mood changes are related to the tablet, as there can be many unrelated causes. Change to a different combined oral contraceptive or another method. Refer if the mood changes continue.

Progestogen-only contraceptives

2-19 What are progestogen-only contraceptives and who should use them?

Progestogen-only contraceptives (also called progesterone-only pills or ‘POPs’) contain a very low dose of hormone. They provide a steady dose of progestogen and do not contain oestrogen. Progestogen is taken continuously as a daily tablet with no inactive tablets or breaks between packs. The method is suitable for breastfeeding women as it does not suppress lactation. It is also suitable for older women, especially those with risk factors for cardiovascular disease for whom combined oral contraceptives are unsuitable.

The progestogen-only pill must be taken regularly at the same time every day for the method to be effective.

2-20 Who should not take a progestogen-only contraceptive?

Women who cannot remember to take a tablet at the same time every day. All progestogen-only methods may give rise to menstrual irregularities ranging from spotting, irregular bleeding to amenorrhoea. Other side effects are similar to combined oral contraceptives although they are usually milder and occur less frequently. Side effects should be managed in the same way.

Injectable contraception

2-21 What are injectable contraceptives?

Progestogen-containing injections (injectables) which are given intramuscularly and which cause a steady, slow release of hormone into the body. They include:

2-22 What are the side effects of injectable contraceptives and how should they be managed?

Common side effects are:

Reassure women that irregular bleeding on injectable contraceptives is common in the first few months and usually stops. Having no period is also common and not unhealthy. Heavy or prolonged, troublesome bleeding can be controlled with short term use of a combined oral contraceptive if this is not contraindicated. It is important to remember and to exclude other medical causes of abnormal bleeding.

Weight gain of 1 to 2 kg is common, so discuss diet and healthy eating. Headaches can be managed with a mild analgesic such as paracetamol. Try to establish if mood changes are related to the tablet, as there can be many unrelated causes. Switching to the alternative injection may be helpful. Otherwise offer another form of contraception. Refer if the headaches or mood changes continue.

Other contraceptive methods

2-23 What are other contraceptive methods?

2-24 What are the advantages and disadvantages of an intra-uterine contraceptive device?

Copper IUCDs are an excellent contraceptive method for women who want long-acting, reversible contraception. They are safe, convenient and very effective. The Cu T 380 functions for at least 10 years and is as efficient as female sterilisation. IUCDs are usually not the first choice for contraception in women under the age of 18 years. There is no increased risk of infertility in women who have previously used IUCDs.

The hormone releasing intra-uterine contraceptive device, marketed as Mirena, is also highly effective and lasts for 5 years. It is also registered for treatment of heavy menstrual bleeding. While not widely available in the public sector, service providers need to know about this method as clients who have had Mirena fitted privately may attend their services, especially if they are no longer on medical aid.

Possible disadvantages are:

The intra-uterine contraceptive device is an excellent method for women who want long-term, reversible contraception.

Note
An IUCD does not cause pelvic inflammatory disease unless it is inserted at a time when the woman already has a genital infection. It also does not increase the risk of HIV infection and is safe to use in women with HIV infection, provided she is clinically well (stage I or 2 disease with a CD4 count above 350 cell/mm³) or with more advanced disease but already stable on antiretroviral treatment. IUCDs may be used by nulliparous as well as multiparous women.

2-25 What are the advantages and disadvantages of condoms?

The important advantage of condoms is the prevention of sexually transmitted infections, including HIV. They also have no hormonal side effects and are generally easy to obtain.

Disadvantages are:

For contraception, condoms must always be used together with a more effective method. While very useful as protection against sexually transmitted infections, condoms cannot be relied upon as a primary method of contraception.

Note
The female condom is available, but has not been very popular in South Africa.

2-26 What are the advantages and disadvantages of sterilisation?

Tubal ligation (female sterilisation) and vasectomy (male sterilisation) provide permanent contraception and, with few exceptions, are not reversible. They require a small surgical procedure but once the sterilisation has been done there are no side effects with no need for follow up. They should be highly recommended to all men and women who have completed their family and are certain that they do not want a baby in the future. Some people may however regret sterilisation, especially if it was done when they were relatively young. People under the age of 32 years are therefore advised to delay sterilisation and use a reversible method.

Note
Vasectomy is a simpler, quicker and more effective procedure than tubal ligation. Remember that sperms may be present in the ejaculate for up to 3 months following vasectomy. Therefore, an additional contraceptive method must be used during this time.

Sterilisation is an excellent method for older couples who have completed their family.

Health benefits of contraception

2-27 What are the important health benefits of contraceptives?

The main objective of all contraceptive methods is to prevent unwanted pregnancy. In developing countries pregnancy is a major cause of mortality and morbidity in women. Therefore, the prevention of unplanned pregnancy is a very important health benefit.

Many contraceptive methods have additional important health benefits which are often not known by women and healthcare workers:

  1. Women who use oral contraceptives have less:

    • Dysmenorrhoea
    • Heavy vaginal bleeding
    • Iron-deficiency anaemia
    • Premenstrual syndrome
    • Ovarian cysts
    • Benign breast disease
    • Endometrial and ovarian carcinoma
    • Acne
  2. Women who use the injectable contraceptives have less:
    • Dysmenorrhoea
    • Premenstrual syndrome
    • Iron-deficiency anaemia
    • Benign breast disease
    • Endometrial and ovarian cancer
  3. Women and their partners who use female or male condoms have less:
    • Risk of HIV infection and other sexually transmitted diseases
    • Risk of infertility
    • Risk of cervical cancer

The condom is the only contraceptive method that provides protection against HIV infection.

When discussing contraception always talk about the risk of HIV infection. Unless the person is in a mutually monogamous relationship (both partners are faithful to each other) and both know their HIV status to be negative, advise the use of condoms together with a reliable contraceptive method (the dual method).

Contraceptive choice in specific circumstances

2-28 What is a suitable method of contraception for a teenager?

Teenagers need a simple method which has minimal side effects and is easy to use. Provided the young woman considers herself reliable, she could use a combined oral contraceptive pill. Alternatively, injectable progestogens, implants and IUCDs are convenient to use, with additional use of condoms to protect against sexually transmitted infections.

While you may encourage teenagers to speak to their parents about sex and contraception, by South African law they do not need their parents’ permission for using contraception.

2-29 What is suitable contraception for a woman who is at risk of sexually transmitted infections?

A woman may be at high risk of sexually transmitted infections if she has multiple partners or if she has a sexual partner who has other partners. She can use any contraceptive method she prefers and to which she can adhere, but should ideally not use an IUCD. She must also make sure that she or her partner(s) always use a condom with every sexual interaction, as condoms are the only contraceptive that also provide protection against STIs.

2-30 What is a suitable method for women who are 35 years or older and smoke or have risk factors for cardiovascular disease?

Any method except combined oral contraception. Consider sterilisation if her family is complete.

2-31 What is a suitable method for a woman who is HIV positive?

There are important drug interactions between some of the antiretroviral drugs and both oral and injectable contraceptives, which lowers the effectiveness of these hormonal methods of contraception.

An IUCD may be an excellent choice. It is proven to be safe in HIV-positive women who are well on antiretroviral treatment, provided there are no other contraindications to using this method.

Sterilisation should only be offered in older patients who have completed their family. HIV infection in itself is not a reason to sterilise a person as many HIV-positive people can have a child without excessive risks.

In addition to choosing a safe contraceptive method the woman should also use or ask her partner to use a condom. This is called ‘dual protection’. The use of condoms will protect her against other sexually transmitted diseases and against super-infection with another HIV strain, and it will reduce the risk of her infecting an HIV-negative partner.

Emergency contraception

2-32 What is emergency contraception?

A form of contraception given soon after unprotected intercourse, either because no contraceptive has been used, or because the contraceptive has not been used correctly (such as forgotten pills or late injections) or when a contraceptive fails (e.g. a condom breaks or an IUCD is expelled).

Forms of emergency contraception are:

  1. Oral hormone pills such as Norlevo or Escapelle (progestogen only contraceptives), or Ovral (combined oral contraceptive) are effective within 5 days of unprotected sexual intercourse, but are more reliable the earlier they are used.
    • If Norlevo is used, give 2 tablets as soon as possible after intercourse (within 72 hours).
    • If Escapelle is used, give 1 tablet as soon possible after intercourse (within 72 hours).
    • If Ovral is used, give 2 tablets as soon as possible after intercourse (within 72 hours), followed by another 2 tablets exactly 12 hours later.
    • If Nordette is used, give 4 tablets as soon as possible (within 72 hours), plus another 4 tablets 12 hours later.

    Ovral and Nordette often cause nausea and vomiting as they contain high doses of oestrogen. This may reduce their effectiveness. Therefore, Norlevo or Escapelle are better options and should be used if available. They can be obtained without prescription from a pharmacy. If vomiting occurs within two hours of taking the medication a further dose should be administered or a copper IUCD fitted.

  2. A copper intra-uterine contraceptive device can be inserted within five days of unprotected intercourse. It has the advantage of providing ongoing contraception. Alternatively, it can be removed at the time of the next menstrual period when a more suitable method can be started.

Post-coital methods should only be used in emergency situations and should not be relied on as a regular method of contraception. However knowledge about, and access to, emergency contraception can prevent many unwanted pregnancies and should not be denied or rationed if requested. A regular method of contraception should be recommended and begun as soon as possible.

Note
Norlevo and Escapelle are trade names.

The definition and diagnosis of infertility

2-33 What is infertility?

Infertility is a dysfunction of the reproductive system. It is defined as the failure to get pregnant after 12 months of regular unprotected sexual intercourse.

Infertility is the failure to fall pregnant after 12 months of unprotected sexual intercourse.

2-34 How is infertility diagnosed?

Simply by listening to the patient. If a woman tells you that she is trying to have a baby and that she is having regular intercourse without using any contraception for the last 12 months or longer, then the couple is infertile.

2-35 Are all women without children infertile?

No. Some women may have decided not to have children at all, while others may only want to have children in the future. This is called voluntary infertility.

In some cases, women are able to fall pregnant, but then lose the pregnancy through miscarriage. These women are not infertile, because they are able to get pregnant, but they must be investigated and treated for the problem of recurrent pregnancy failure, if they lose more than one pregnancy.

2-36 Why is infertility important?

Having a child is an important life goal for most people. Not being able to have a child can cause a lot of personal grief and suffering. Infertility also causes marital instability and can even lead to abuse. Families and communities often treat infertile women with less respect, and many infertile women feel isolated and excluded.

Infertility is a condition which causes suffering and stigmatisation.

2-37 Is infertility common?

Yes, infertility is common. It is estimated that 10 to 15% of couples suffer from infertility.

2-38 Why should we use precious resources on infertile women when there are so many children in South Africa already?

High population growth is a concern. But withholding treatment from infertile couples is not the answer. Instead the solution lies in responsible sexual behaviour and good family planning services, so that every child conceived is a planned and wanted child.

Causes of infertility

2-39 What are the causes of infertility?

The many causes of infertility can be grouped into:

The most important female causes are:

A male factor is present when the man has no sperm or very poor quality sperm. Infrequent or no intercourse is a combined cause of infertility. When no cause of infertility can be found it is called unexplained (or ‘idiopathic’) infertility.

Note
Anovulation is usually due to a hormonal disturbance. Tubal obstruction is caused by genital tract infections and by pregnancy-related sepsis. Women over the age of 40 have only a very small chance of falling pregnant. Poor sperm or no sperm can be due to male genital tract infection, genetic causes, environmental causes and unknown causes.

2-40 Does contraception cause infertility?

Only irreversible contraceptive methods (female tubal ligation or male vasectomy) cause permanent infertility. All other methods are reversible and only prevent conception while in use. However, after stopping a reversible contraceptive method it may take 3 to 9 months before normal fertility returns.

2-41 How can the cause of infertility be determined?

Only through special investigations.

Note
Routine infertility investigations include a mid-luteal phase serum progesterone (to assess ovulation), a semen analysis, and a test for tubal patency (hysterosalpingogram or laparoscopy).

The cause of infertility can only be determined through special investigations.

Management of women with infertility

2-42 What is the approach to infertility management at primary level care?

The primary-care workers should identify women suffering from infertility. However, some women may not speak about their fertility problem unless asked directly. Therefore it is important to ask all women if they are sexually active, if they are using contraception and if they are trying to fall pregnant (and for how long they have been trying).

Once infertility has been diagnosed it is important to involve the male partner. Some men may be reluctant to come to the clinic because of fear, embarrassment or because they believe it is ‘not their problem’. Men must however be encouraged to attend because infertility is a couple problem and cannot be managed with only one partner.

2-43 What can be done about infertility at primary level care?

Couples suffering from infertility should be given basic fertility advice. This includes:

Couples who have infrequent intercourse should be advised to have intercourse more regularly (every 2 to 3 days). Couples who have problems with libido or other intercourse-related difficulties should be referred for counselling.

Men and women who are overweight or obese have a lower chance of falling pregnant, therefore healthy eating and weight loss (5 to 10% of the body weight) are important parts of infertility management in overweight patients. It is not uncommon for pregnancy to happen naturally once overweight patients have started to lose weight.

Both partners must be advised not to smoke as smoking reduces the chance of falling pregnant. This is true even if only the man smokes.

All women who are trying to conceive should take folic acid 5 mg daily as this reduces the risk of abnormalities in the baby if conception does occur.

Alcohol does not cause fertility problems but can cause abnormalities in the unborn baby.

2-44 What investigations should be offered?

Both partners should be tested for HIV and for syphilis. In addition, women should be tested for rubella (German measles). Women who are not immune to rubella should be immunised.

If a patient or couple test positive for HIV infection it is important to determine their CD4 counts and assess the need for antiretroviral therapy. Further infertility management depends on the treatment criteria of the local referral clinic regarding the management of HIV-positive infertile patients.

All other infertility investigations will be done after the couple has been referred.

2-45 What counselling should be offered?

Infertility is a distressing experience which may be associated with marital problems and even abuse. Couples should be asked about how they live and cope with their fertility problem. Those who have distressing experiences or are not coping should be referred to a social worker or professional counsellor.

2-46 When should patients be referred for infertility investigations?

Women who have unsuccessfully tried to fall pregnant for 12 months or longer should be referred to a specialist clinic together with their male partner.

Women who have been on contraceptive pills can wait an extra 3 months, while women receiving injectable contraceptives can wait an extra 9 months.

Young women (age 34 or younger) may be encouraged to wait for 2 years before they seek specialist help, provided there is nothing to suggest that either the woman or her partner have a clinical problem resulting in infertility.

Problems to look for include:

Couples should only be referred if the request for fertility treatment has been carefully considered, the couple is in a stable relationship with suitable means to care for a child, and if both partners are willing to undergo fertility investigations and, at times, lengthy treatment.

2-47 Is there an upper age limit for referral?

This depends on the referral clinic. Some specialist clinics have an age limit (usually between 41 and 45 years) for accepting patients for infertility treatment. Women over the age of 40 have a very small chance of having a successful infertility treatment, regardless of the underlying cause of infertility.

2-48 Can single women or lesbian couples be referred for infertility investigations?

Single women and lesbian couples may receive fertility treatment according to South African law. Treatment involves insemination with sperm from an anonymous sperm donor. As with heterosexual couples, they should only be referred if the request for fertility treatment has been carefully considered, the couple is in a stable relationship, and the woman or couple has suitable means to care for a child.

2-49 Can a couple with children be referred for infertility treatment?

Yes, provided all existing children are adequately cared for. However, most fertility clinics in the public health sector will set some limit to the number of children a couple can have. They may only help a couple to have one or two children together. They may also refuse treatment if both partners have many children even if they do not have a baby together, or if a further pregnancy may be dangerous for the woman.

Case study 1

A young married woman attends a primary-care clinic where she is counselled about family planning. She has not started a family yet as she and her husband have decided to complete their studies first.

1. Should all women at a primary-care clinic be provided with education about contraception?

Yes. It is very important to assist all women to plan their families. Everyone who is sexually active should be well informed about contraception.

2. Should she bring her partner for counselling?

Yes. If possible couples should receive family planning counselling together.

3. What contraceptive method should she use?

Once she has been told the health benefits, effectiveness, possible side effects and contraindications of each contraceptive method, she should choose a method that she feels is most suitable for her.

4. What three methods would probably be most suitable for her?

Combined oral contraceptive, injectable or intra-uterine contraceptive device (IUCD).

5. If she chooses a combined oral contraceptive, what side effects may occur?

Menstrual abnormalities, nausea, headaches, breast tenderness and mood changes. Usually these are mild and settle after a few months.

Case study 2

A single woman aged 28 years with three children visits a family planning clinic. She is not on contraception and asks to be sterilised. While being counselled she mentions that she has multiple sexual partners and had unprotected sex the previous day. She also smokes heavily.

###1. Would you advise tubal ligation as a suitable method of contraception?

As she is single and only 28 years of age it would be better if she used a reversible method such as oral or injectable contraceptives.

###2. Would an intra-uterine contraceptive device be suitable?

No, because she has multiple sexual partners and is at high risk of sexually transmitted diseases.

3. What would you advise if she chose condoms as a method of contraception?

Support and encourage her choice of condoms as they help her to protect herself from sexually transmitted infections. Advise her to use a condom each and every time she has sex, but tell her that the method is unreliable in preventing pregnancy. She must consider an additional, more efficient, method of contraception.

4. What are the health benefits of oral combined contraceptives?

Less dysmenorrhea, heavy vaginal bleeding, iron-deficiency anaemia, premenstrual syndrome, ovarian cysts, benign breast disease and carcinoma of the endometrium and ovary.

5. At what age should smokers not use oral combined contraceptive?

When they reach the age of 35 years.

6. What additional contraceptive care does this women need?

She should be offered emergency contraception as she had unprotected intercourse less than 72 hours ago. An oral hormonal pill such as Norlevo can be used. This method should only be used in an emergency and not as a regular method of contraception.

Case study 3

A woman aged 28 years with two children of her own has recently remarried. She and her husband have discussed family planning and decided to wait for a year before trying for a baby. She is concerned that injectable contraceptives cause weight gain and infertility and therefore has decided to use combined oral contraceptives. She gives a history of dysmenorrhea and heavy periods.

1. Would combined oral contraception be a good choice for this couple?

Yes. Combined oral contraception is very effective and would probably improve both her dysmenorrhea and heavy periods.

2. Would a progestogen-only method also be suitable?

Yes, provided she is confident that she will be able to take the tablet at the same time every day.

3. Do women on injectable contraceptives pick up weight?

Some women do gain weight on injectable contraceptives, but usually only 2 to 3 kg. All women starting this contraceptive method should be advised to eat a healthy diet and watch their weight.

4. Is it true that injectable contraceptives cause infertility?

No. However some women using injectable contraceptives may stop having periods. Fertility returns to normal within 9 months of stopping this method.

5. How often should injectable contraceptives be given?

Nur-Isterate is given every 8 weeks while Depo-Provera and Petogen are given every 12 weeks.

6. Once she has had a child, would it be safe to use oral contraception while breastfeeding?

Yes, but she should use progestogen-only contraceptives as oral combined contraception will suppress her breast milk production.

Case study 4

A young heterosexual couple has been having regular unprotected sexual intercourse for two and a half years without the woman falling pregnant. The man wants to know what is wrong with his partner as she is not conceiving. Both are overweight and smoke.

1. Is this couple infertile?

Yes, as the woman has not fallen pregnant after 12 months of regular unprotected intercourse.

2. Is infertility common?

Yes. 10 to 15% of couples suffer from infertility.

3. Is it reasonable for the man to assume that his partner has some problem which is causing infertility?

No, as there are many causes for infertility. The cause may be due to male or female factors or there may be factors in both partners. Sometimes a cause for the infertility cannot be found.

4. What are the common female causes of infertility?

Failure to ovulate (anovulation), blockage of the Fallopian tubes or being too old to have a child.

5. What lifestyle changes may improve fertility in this couple?

They should both lose weight and stop smoking.

6. How should this couple be managed?

Ask them how they feel about their inability to have a child. If they are distressed or feel that their relationship is suffering, offer to refer them to a social worker or professional counsellor. Test for HIV infection, syphilis and rubella. Ask the couple if they both are willing to go for infertility investigations. If they both agree, refer them.