NCM 107- PRELIM PERIOD

PHYSIOLOGY of FEMALE REPRODUCTION

1. Puberty
2. Menstruation
3. Menopause
A. Pubertal Development
 Begins with the onset of the first menstruation = MENARCHE
 GnRH (from hypothalamus) Gonadotrophins (LH and FSH from the anterior pituitary)
levels are increased
 Tanner- states that the initial sign of puberty in girls is breast development
B. Secondary Sex Characteristics
Adolescent sexual development is categorized into stages.
In girls, pubertal changes typically are manifest as:
1. Growth spurt
2. Increase in the transverse diameter of the pelvis
3. Breast development
4. Growth of pubic hair
5. Onset of menstruation
6. Growth of axillary hair
7. Vaginal secretions
Of boys usually occur in the order of:
1. Increase in weight
2. Growth of testes
3. Growth of face, axillary, and pubic hair
4. Voice changes
5. Penile growth
6. Increase in height
7. Spermatogenesis (production of sperm)

THE MENSTRUAL CYCLE

A. MENSTRUATION
Is the visible manifestation of cyclic physiologic uterine bleeding due to shedding of the
endometrium following invisible interplay of hormones mainly through hypothalamo-pituitary-
ovarian axis.

Table 2. Characteristics of Normal Menstrual Cycles

Characteristic Description
Beginning Average age at onset, 12.4 years; average range,
(menarche) 9–17 years
Interval between Average, 28 days; cycles of 23–35 days not unusual
cycles
Duration of Average flow, 2–7 days; ranges of 1–9 days not
Menstrual Flow abnormal
Amount of Difficult to estimate; average 30–80 mL per
Menstrual Flow menstrual period; saturating pad or tampon in less
than an hour is heavy bleeding
Color of Menstrual Dark red; a combination of blood, mucus, and
Flow endometrial cells
Odor Similar to that of marigolds
Physiology of Menstruation
Four body structures are involved in the physiology of the menstrual cycle: the
hypothalamus, the pituitary gland, the ovaries, and the uterus. For a menstrual cycle to be
complete, all four structures must contribute their part; inactivity of any part results in an
incomplete or ineffective cycle.

Figure 15 Pituitary-Uterine-Ovarian Interaction

HYPOTHALAMUS
 The release of GnRH (also called luteinizing hormone– releasing hormone, or LHRH) initiates
the menstrual cycle.
 With puberty, becomes less sensitive to estrogen feedback; this results in the initiation every
month in females of the hormone GnRH.
 GnRH is transmitted to the anterior pituitary gland and signals the gland to begin producing
the gonadotropic hormones FSH and LH.
 GnRH is cyclic, menstrual periods also cycle.
 Disease that cause deficiency of the releasing factor result in delayed puberty.
 Early activation of GnRH lead to abnormally early sexual development or Precocious
Puberty.

PITUITARY GLAND
 Under the influence of GnRH, the anterior lobe of the pituitary gland (the adenohypophysis)
produces two hormones that act on the ovaries to further influence the menstrual cycle:
a. FSH - is active early in the cycle and is responsible for maturation of the ovum.
b. LH - becomes most active at the midpoint of the cycle and is responsible for ovulation or
release of the mature egg cell from the ovary and growth of the uterine lining during the
second half of the menstrual cycle.

B. OVARIAN CYCLE (Preovulatory /Follicular)

 FSH and LH are called gonadotropic hormones because they cause growth (trophy) in the
gonads (ovaries).
 Every month during the fertile period of a woman’s life (from menarche to menopause), the
ovary’s primordial follicles is activated by FSH to begin to grow and mature.
 Its cells produce a clear fluid (follicular fluid) that contains a high degree of estrogen
(mainly estradiol) and some progesterone.
 Follicle matures is propelled toward the surface of the ovary and becomes Graafian follicle.
  Day 14 (the midpoint of a typical 28-day cycle), the ovum has divided by mitotic division
into two separate bodies:
a. primary oocyte, which contains the bulk of the cytoplasm
b. secondary oocyte, which contains so little cytoplasm.
 Upsurge of LH, prostaglandins are released and the graafian follicle ruptures.

Table 3. Maturation of Oocytes:

First formed in utero 5 to7 million
First 5 months in utero 2 million immature oocytes per
ovary
At birth 2 million in BOTH ovaries
7 yrs. of age only 500,000/ovary
22y/o only 300,000/ovary
Reproductive age only 300–400 oocytes/ ovary
Menopause None

 MITTELSCHMERZ SIGN - acute pain felt on either side of the abdomen during rupture of the
follicle
 The ovum is set free from the surface of the ovary, a process termed ovulation. Swept into
the open end of a fallopian tube.
 Ovum and the follicular fluid have been discharged from the ovary; the cells of the follicle
remain in the form of a hollow, empty pit.
 FSH has done its work at and now decreases in amount
 LH, continues to rise in amount and acts on the follicle cells of the ovary
 Follicle cells produce lutein, a bright-yellow fluid, the empty follicle, which is then termed a
corpus luteum.

C. THE UTERINE CYCLE

Table 3.1 Four Phases of Menstrual Cycle
1. Menstrual  the end of an arbitrarily defined menstrual
Cycle (Menses) cycle. Because it is the only external marker of
the cycle, however, the first day of menstrual
flow is used to mark the beginning day of a
new menstrual cycle.
 First day of bleeding is the first day
of the cycle (LMP – Last Menstrual
Period)
Composed of:
 Blood from the ruptured capillaries
 Mucin from the glands
 Fragments of endometrial tissue (stratum
functionale)
 Atrophied, and unfertilized ovum
Around 60ml of blood is lost (entire period)
2. Proliferative,  Immediately after a menstrual flow ( first
estrogenic, 4-5days of cycle), the endometrium,or
 follicular, or lining of the uterus, is very thin,
postmenstrual approximately one cell layer in depth.
phase  Endometrium begins to proliferate as
ovary begins to produce estrogen
Growth is rapid and increases the thickness of
the endometrium, continues to increase on day 5
to day 14 of the menstrual cycle.
3. Secretory,  After ovulation, formation of
progestational, progesterone in the corpus luteum (under
luteal, the direction of LH) causes the glands of
premenstrual the uterine endometrium to become
corkscrew or twisted and dilated with
quantities of glycogen (an elementary
sugar) and mucin (a protein).
The capillaries of the endometrium increase in
amount until the lining takes on the appearance
of rich, spongy velvet.

4. Ischemic If fertilization does not occur, the corpus

luteum in the ovary (forms into corpus
albicans) begins to regress after 8 to 10
days,
 Production of progesterone and estrogen
decreases.
 The endometrium of the uterus begins to
degenerate at day 24 or day 25 of the
cycle
The capillaries rupture, with minute
hemorrhages, and the endometrium sloughs off.

Cervix
 During half of the cycle, hormone secretion from the ovary is low, cervical mucus is thick and
scant. Sperm survival is poor.
 Estrogen level is high, cervical mucus becomes thin Sperm penetration and survival
are excellent.
 Second half of the cycle, cervical mucus again becomes thick Sperm survival is again
poor.
 Fern Test - high estrogen surge before ovulation cervical mucus forms fernlike patterns
when placed on a glass slide and allowed to dry. Women who do not ovulate continue
to show the fern pattern throughout the menstrual cycle.
 Spinnbarkeit Test - cervical mucus becomes thin and watery and can be stretched into
long strands at the midpoint of
a menstrual cycle
demonstrates high levels of
estrogen are being produced
and ovulation is about to occur.

Figure 17. Cervical mucus stretch

D. MENOPAUSE
 Cessation of menstruation for at least one year occurring at the age of 45-52 (average: 50
years.)
 Decreased estrogen and progesterone
 Increased FSH (rebound effect)
 Perimenopausal the period during which menopausal changes occur.
 Postmenopausal describes the time of life following the final menses.

Physiologic Changes
Ovaries begin to atrophy, reducing estrogen production
 Hot flashes
 Vaginal dryness
 Osteoporosis
 Urinary incontinence
SEXUAL HEALTH

A. SEXUALITY AND SEXUAL IDENTITY

A multidimensional phenomenon that includes feelings, attitudes, and actions. It has both
biologic and cultural components. It encompasses and gives direction to a person’s physical,
emotional, social, and intellectual responses throughout life.
 Biologic gender denote a person’s chromosomal sex: male (XY) or female (XX).
 Gender identity or sexual identity is the inner sense a person has of being male or female,
which may be the same as or different from biologic gender.
 Gender role is the male or female behavior a person exhibits, which, again, may or may not be
the same as biologic gender or gender identity

Table 4. Development of Gender Identity

Infancy  Female and male babies are treated
differently by their parents.
 Girls are treated more gently and held and
rocked more than male babies.
 A girl might be told, “Don’t cry. You don’t
look pretty when you cry.” A boy might be
told, “You’ve got to learn to be tougher
than that if you’re going to make it in this
world.”
 Boys demonstrate more innate aggression,
even at this early stage, than do girls
Preschool Period  can distinguish between males and females
as early as 2 years of age
 At 3-4 years, they can say what sex they
are, and they have absorbed cultural
expectations of that sex role
 boys will play rough-and-tumble games
  girls will play more quietly
 Sex role modeling is reinforced through
behavior toward and expectations of the
child.
School-Age Child  Imitating adult roles as a way of learning
gender roles
 Form strong impressions of what a female
or male role should be.
Adolescent  Maintain strong ties to their gender group.
 Certain that they understand and feel
comfortable with their own sex before
they reach out and interact with members
of the opposite sex
Young Adult  Choose the way they will express their
sexuality along with other life patterns.
 Begins commitment to one sexual partner
 Couples begin childbearing
Middle-Age Adult  Masculinity or femininity and comfortable
patterns of behavior have been established
Older Adult  Continues to enjoy active sexual
relationships

B. HUMAN SEXUALITY
DEFINITION OF TERMS

1. Puberty – encompasses the physiologic changes leading to the development of adult

reproductive capacity.
2. Adolescence – encompasses the physiologic, social, and cognitive changes leading to the
development of adult identity. The process includes individual, achievement of personal
independence and maturation of cognitive reasoning skills.
3. Thelarche – budding of the breasts
4. Adrenarche – development of axillary and pubic hair

C. SEXUAL DEVELOPMENT

Table 1
Criteria Males Females
Start of growth Around 13 years old After onset of
spurt menses, around
10-12 years old
Growth rate Rapid early growth Sharp decrease
after menses
occur
Growth cessation Early cessation 1-2 years after
onset of menses
Order of sexual 6 months later than females
maturation Completed in 5 years
1. Darkening and thinning
 of scrotum and
enlargement of testes
and scrotum – first
visible sign
2. Appearance of body hair
a. Pubic area
b. Axilla
c. Upper lip
d. Face

3. Penis grows, enlarges

4. Nocturnal emissions
(wet dreams) - male
counterpart of
menstruation
5. Spermatogenesis
D. TANNER STAGING
a. A rating system for pubertal development
b. It is the biologic marker of maturity
c. It is based on the orderly progressive development of:
1. Breasts and pubic hair – in females
2. Genitalia and pubic hair – in males

Table 2. Tanner Stages of Pubertal Development: Thelarche & Genitalia

Stages Males Females
I Childhood size of penis, testes, scrotum Prepubertal, no breast tissue
II Enlargement of testes and scrotum Appearance of breast bud
III Lengthening of the penis Further Enlargement of the breasts
enlargement of testes and scrotum and areola
Deepening pigmentation of scrotal skin
IV Widening and further lengthening of Areola and nipple form a
penis Further enlargement of testes and mound atop underlying
scrotum Deepening pigmentation of breast tissues
scrotal skin
V Adult configuration and size of genitalia Adult configuration and size
of genitalia Areola and
breasts have smooth contour

Table 3. Tanner Stages of Pubertal Development: Adrenarche

Stages Males Females
I Prepubertal, no pubic hair - same -
II Sparse, downy hair at the base of the At the medial aspect of the
phallus labia majora
III Darkening, coarsening, curling of hair - same -
which extend upward and laterally
IV Hair of adult consistency limited to the - same -
mons pubis
 V Hair spreads to the medial aspect of the - same -
thighs
E. Sexual Response Cycle
Four Phases of the Sexual Response Cycle

1. Excitement Phase - Physical and psychological stimulation causes parasympathetic nerve

stimulation.
 Leads to arterial dilatation and venous constriction in the genital area; blood supply
increases and muscular tension also increases.
 In women, vasocongestion causes the clitoris to increase in size and lubrication to occur.
The vagina widens and lengthens. The nipples become erect.
 In men, erection occurs with scrotal thickening and elevation of the testes.
 For both male and female, the heart rate and respiratory rate increase and blood
pressure.
2. Plateau Phase
 In women, the clitoris is drawn forward and retracts; lower vagina congests and there is
increased nipple elevation.
 In men, full distention of the penis occurs with an increase in heart rate up to 175/ min
and the respiratory rate up to 40 / min.
3. Orgasm Phase
 The body suddenly discharges accumulated sexual tension. Average number of
contractions for women is 8 – 15 contractions at intervals of 1 per 0.8 seconds. In men,
three to seven propulsive ejaculatory contractions which force the semen out the penis.
 This is the shortest stage yet intense pleasure occurs which affects the entire body.
4. Resolution phase
 Return to normal phase; this phase takes about 30 minutes for both man and woman.
 For the male, a refractory period occurs during which further orgasm is impossible.
 Women do not go through a refractory period; possible to have additional orgasms
immediately after the first.

Types of Sexual Orientation

1. Heterosexual – sexual fulfillment derived with opposite sex (man-woman)
2. Homosexual – fulfillment with same sex (gays, lesbians)
3. Bisexual – fulfillment with both homo and hetero (double-blade)
4. Transsexual – feels he/ she should be of the opposite gender (cross-dresser)

Types of Sexual Expression

1. Celibacy – abstinence from sexual activity
2. Masturbation – self-stimulation for erotic pleasure
3. Erotic stimulation – use of visual materials for sexual arousal
4. Fetishism – use of objects or situation for sexual pleasure
5. Transvestism – dressing up to take on role of the opposite sex
6. Voyeurism – arousal by looking at another’s body
7. Sadomasochism – inflicting pain (sadism) or receiving pain (masochism) for sexual
satisfaction.
8. Exhibitionism - revealing one’s genitals in public.
9. Bestiality - sexual relations with animals
10. Pedophiles – individuals interested in sexual encounters with children.
 Sexual Dysfunctions – Primary
1. Erectile dysfunction – formerly called impotence; inability to maintain or produce erection
long enough for vaginal penetration or partner satisfaction.
2. Premature ejaculation – ejaculation before penetration
3. Failure to achieve orgasm or diminished sexual desire – due to poor sexual technique,
concentrating too hard on achievement, or negative attitude towards sex.
4. Vaginismus – involuntary contraction of the muscles at the outlet of the vagina when coitus
is attempted. Common with rape victims.
5. Dyspareunia – Painful intercourse
6. Inhibited sexual desire – Lack of desire due to circumstances like divorce, stressful job, etc.

Sexual Dysfunctions – Secondary (Acquired)

1. Chronic Illness – ex. Peptic Ulcer Disease, Chronic Obstructive Pulmonary Disease
2. Sexually - Transmitted Diseases (STD) – ex. Gonorrhea, Chlamydia, etc.
3. Obesity
REPRODUCTIVE LIFE PLANNING
Includes all the decisions an individual or couple make about whether and when to have children,
how many children to have, and how they are spaced. Methods of Contraception

National FP Policy- AO No. 50-A, s. 2001

 FP program is a health intervention to promote the overall health of all Filipinos by:
 Preventing high-risk and unplanned pregnancies
 Reducing maternal deaths
 Responding to unmet needs of women.
 FP information and services will be provided based on voluntary and informed choice to all
women and men of reproductive age regardless of age, sex, number of children, marital
status, religious beliefs, and cultural values.

Healthy Timing & Spacing of Pregnancy

 Timing of first pregnancy (not less than 18 years old)
 Proper birth spacing (3-5 years)
 Use of an FP method of choice

Table 5. Ten Basic Rights of all Family Planning Clients

Information To learn about benefits and availability of the family planning
Access To obtain services regardless of sex, creed, color, marital status,
or location
Choice To decide freely whether or not to practice family planning and
which method to use
Safety To be able to practice safe and effective family planning
Privacy To have a private environment during counseling and services
Confidentiality To be assured that personal information will remain confidential
Dignity To be treated with courtesy, consideration and attentiveness.
Comfort To feel comfortable when receiving services
Continuity To receive family planning services and supplies as long as
needed
Opinion To express viewed of the services offered

METHODS OF CONTRACEPTION
1. NATURAL METHOD
 Involves no introduction of chemical or foreign material into the body or sustaining from
sexual intercourse during a fertile period
a. Abstinence - refraining from sexual relations
b. Calendar (Rhythm) Method
 couple abstains coitus during fertile days
 Useful for those experiencing regular menstruation.
 Woman observes her menses for 6 straight months and documents the pattern.
 To calculate safe days,
 the longest cycle is subtracted by 11, this represents last fertile days
 The shortest cycle (interval) is subtracted by 18 this result predicts her first fertile
day.
Example:
January – February = 28
February – March = 31
March – April = 26
April – May = 28
May – June = 30
June – July = 27
Longest is 31 (minus 11) = 20
Shortest is 26 (minus 18) = 8

c. Basal Body Temperature Method

 One day before ovulation, the temperature falls about half degree Fahrenheit and it
increases by one degree Fahrenheit during ovulation.
 The temperature is taken by the woman upon awakening and before getting out of
bed.
 The woman has to be accurate in recording the temperature.
 Implication: no sex or protected coitus must be observed in the next three days
(fertile).

Figure 18 BBT method courtesy of demo.oppia-mobile.org

d. Cervical Mucus Method (Billing’s Method)
 The woman checks the consistency, color and amount of cervical mucous/ discharges.
 slippery and stretches at least 1 inch before the strand breaks
 Spinnbarkeit Test
 Fern’s / Ferning Test
e. Symptothermal Method
 Combines the cervical mucus and BBT methods. The woman takes her temperature daily,
watching for the rise in temperature that marks ovulation. She also analyzes her cervical
mucus every day and observes for othermsigns of ovulation such as mittelschmertz
f. Lactation Amenorrhea / LAM
 Ovulation is suspended during breastfeeding; only good within 4 – 6 months with
exclusive breastfeeding
g. Coitus Interruptus
 Withdrawal of the penis from the vagina before ejaculation that needs precise control
from the male.
h. Ovulation Detection
 An over-the-counter ovulation detection kit. Detect the midcycle surge of luteinizing
hormone (LH) that can be detected in urine 12 to 24 hours before ovulation.

Table 5.1
Factors to Access Menstrual Cycle Phase
Lutheal phase Follicular Phase
Dominant Hormone Progesterone Estrogen

Vaginal Characteristics Dry Wet

Cervical Mucous
Characteristics Scanty Profuse
– Amount Cloudy, white to yellow Clear
– Color Thick and sticky Thin, watery,
– Consistency slippery, stretchable,
Spinnbarkeit present
at ovulation

Microscopic No Ferning Ferning

Appearance

2. ARTIFICIAL METHOD
1. Hormonal Contraception
Hormones that cause such fluctuations in a normal menstrual cycle that ovulation does
not occur
a. Oral Contraceptives “The Pill”
 2 Types:
 Combined Oral Contraceptive (COC)
 synthetic estrogen combined
with a small amount of synthetic
progesterone
 99.7% effective in preventing
conception when used correctly
 not for breastfeeding women

Figure 19. Combined Oral Contraceptive 28 –pill dispensers (21 active

pills and 7 placebo pills)

 Progestin Only Contraceptive (POP/ mini-pills)

 Progesterone content thickens cervical mucus and helps prevent sperm entry into the
uterine cervix.
 Ovulation may occur but, because the endometrium does not develop fully,
implantation will not take place
 can be used by breastfeeding women (99.5% effective)
 Side effects: nausea, vomiting, weight gain, breast tenderness, bleeding/ spotting, mild
hypertension, depression.
 b. Injectables
 2 Types:
 Combined Injectable Contraceptive (CIC)
 not for breastfeeding (99.9% effective)
 Progestin Only Injectable (POI)
 Depo-Provera [DMPA] given every 12 weeks inhibits ovulation, alters the
endometrium, and changes the cervical mucus
 100% effective
 can be used by breastfeeding women
 Side effects: irregular menstrual cycle, headache, weight gain, and depression.
May impair glucose tolerance, an increase risk for osteoporosis from loss of bone
mineral density
c. Transdermal Route
 Patches that slowly but continuously
release a combination of estrogen and
progesterone.
 Applied each week for 3 weeks. No patch is
applied the fourth week for menstrual flow.
After flow apply patch again
 Applied on four areas: upper outer arm, upper
torso (front or back, excluding the breasts),
abdomen, or buttocks.
 Mild breast discomfort and irritation at the
application site may occur.

Figure 20 estrogen/progesterone-based patches

d. Vaginal Insertion
 Vaginal ring (NuvaRing) a silicone ring that surrounds
the cervix and continually releases a combination of
estrogen and progesterone.
 Inserted vaginally and left in place for 3 weeks, then
removed for 1 week for menstrual flow.

Figure 21 a Vaginal Ring

e. Intrauterine Devices
 small plastic object that is inserted into the uterus through the vagina
 inserted before a woman has had coitus after a menstrual flow
 Copper T380 (ParaGard), a T-shaped plastic device wound with copper with 2 nylon
threads at its end. It is effective for 10 years.
 Figure 22 (A) Intrauterine device. (B) An IUD in place in the uterus.

f. Subdermal Hormone Implants

 Five subdermal implants, rods the size of pencil lead are embedded just under the skin
on the inside of the upper arm
 The rods contain etonogestrel, the metabolite of desogestrel, once embedded, the
implants appear as irregular lines on the skin, simulating small veins.
 Use for 3 to 5 years, inserted with the use of a local anesthetic, during the menses or no
later than day 7 of the menstrual cycle, to be certain that the woman is not pregnant
 Disadvantages: its cost and side effects such as:
Weight gain, Irregular menstrual cycle such as spotting, breakthrough bleeding,
amenorrhea, or prolonged periods, depression, scarring at the insertion site and
need for removal

2. Barrier Methods of Contraception

Forms of birth control that work by the placement of a chemical or other barrier between
the cervix and advancing sperm so that sperm cannot enter the uterus or fallopian tubes and
fertilize the ovum.
 Chemical Barriers
a. Spermicide is an agent that causes the death of spermatozoa before they can enter
the cervix
 Available in gels, creams, sponges, films, foams, and suppositories.
 Should be done 1 hour before coitus and remain 6 hours after intercourse to
ensure sperm destruction.

Figure 23 Vaginal insertion of Spermicidal agent

 Mechanical Barriers
a. Diaphragm a circular rubber disk that is placed over the cervix before intercourse
 Should remain in place for at least 6 hours after coitus, it may be left in place for
as long as 24 hours.
 Reusable, will last for 2-3 years.
 Figure 24. Proper insertion of a
diaphragm. (A) After spermicidal
jelly or cream is applied to the
rim, the diaphragm is pinched
between the fingers and thumb.
(B) The folded diaphragm is then
inserted into the vagina and
pushed backward as far as it will
go. (C) To check for proper
positioning, the woman should
feel the cervix to be certain it is
completely covered by the soft
rubber dome of the diaphragm.
(D) To remove the diaphragm, a
finger is hooked under the
forward rim and the diaphragm is pulled down and out.

 Side Effects and Contraindications:

 Diaphragms may not be effective if the uterus is prolapsed, retroflexed, or anteflexed.
 Users may experience a higher number of urinary tract infections.
 Allergy to rubber or spermicides

b. Cervical Caps made of soft rubber, are shaped like a thimble

with a thin rim, and fit snugly over the uterine cervix.
 advantage is can remain in place longer, they do not
put pressure on the vaginal walls or urethra
 time period should not exceed 48 hours, to prevent
cervical irritation

Figure 25. Cervical cap

placed over the cervix

c. Male Condoms latex rubber or synthetic sheath that is placed over

the erect penis before coitus to trap sperm.
 Must be applied before any penile-vulvar contact, because even
preejaculation fluid may contain some sperm.

Figure 26. Condom

d. Female Condoms latex sheaths made of

polyurethane and prelubricated with a spermicide.
 May be inserted any time before sexual activity
begins and then removed after ejaculation.
 Intended for one-time use and offer protection
against both conception and STIs

Figure 27. A female condom. (A) The REALITY (WP-333) female condom
(B) Insertion technique.
3. Surgical Methods often called sterilization.

a. Vasectomy small incision made on

each side of the scrotum. The vas
deferens are cut and tied, cauterized,
or plugged, blocking the passage of
spermatozoa.

Figure 27. Vasectomy. (A) Site of vasectomy incisions. (B)

The vas deferens being cut with surgical scissors. (C) Cut
ends of the vas deferens are cauterized to completely
ensure blockage of the passage of sperm. (D) Final skin suture

b. Tubal Ligation the fallopian tubes are occluded

by cautery, crushing, clamping, or blocking,
thereby preventing passage of both sperm and
ova.
 99.5% effectiveness rate

Figure 28. Laparoscopy for tubal sterilization. (From Richard Wolf

Medical Instruments Corporation)