Practical training in reproductive health techniques
The contents of the course builds on guidelines in family planning prepared by our Institution in collaboration with the Program for Appropriate Technology in Health (PATH).
Contraception:
- Hormonal contraception (Combined Oral Contraceptives, Progestagen-only pill (POP), combined injectable contraceptives, progestagen-only injectable contraceptives, RU 486, subdermal implants (Norplant), vaginal contraceptive devices);
- Intrauterine devices (IUD);
- Barrier methods (condom, diaphragm, cervical cap, spermicide).
- Definition, indications, contra-indications, complications, counselling, information and instruction, providers, medical assessment, client screening, choice of brands, follow-up, side-effects, equipment, special techniques (administration of injectable methods; insertion and removal of Norplant; insertion of vaginal devices; IUD insertion and removal techniques; fitting of diaphragm, and cervical cap), service management, including quality control of contraceptives and logistics (storage, shelf-life and supplies).
- Voluntary surgical contraception (male and female surgical contraception)
- Definition, indications, contra-indications, complications, counselling, information and instructions, informed consent, providers, medical assessment, client screening, preoperative preparation, timing of surgery, anaesthesia and operative procedure, postoperative care, follow-up, facilities and equipment, safety principles, reversal, service management.
- New contraceptive technologies
Abortion:
- D & C
- Aspiration
Counselling and other quality of care issues:
Definition of counselling; objectives of contraceptive counselling; providers; counsellor's approach and attitude; focus of the counselling session; special needs; clients rights.
Training of trainers:
Assessment of training needs; definition of training objectives; training content; selection of trainees; selection of training methods and materials; assessment of learning achievements; evaluation of effectiveness of training; trainers; management of training.
With our Institution's emphasis on the clinical aspects of contraception, family planning and abortion, it is envisaged that candidate centres and countries with low exposure to modern family planning will qualify the best for this element of the practical training.
General
The candidate centre needs to identify a local family planning network in which the family planning services can be provided. This includes medical and paramedical staff. If surgical contraception is going to be provided, staff for these methods will be required.
Equipment
The continuity of contraceptive supplies needs to be ensured. Method-specific requirements need to be identified (for instance, Norplant guidelines) as well as equipment and supplies needed for surgery.
Laparoscopy and laparoscopic surgery are new approaches to diagnosis and treatment of gynecologic diseases. The world is exploring this method and is developing new indications and new instruments are being rapidly introduced in different parts of the world. When new procedures and instruments are used by doctors not trained in these methods, complications and technical problems occur.
The purpose of the course is to give in-depth knowledge of the physics of the equipment and specific knowledge of, and skills in, the applications of the technology so as to enable the participating centres to diagnose and treat more precisely gynaecological disorders, like ectopic pregnancy, tubal occlusion, etc.
The basic objective of the training is to create a network of centres of excellence of endoscopy. They will constitute reference centres for the regions concerned and should be able to organise local endoscopic training.
The contents of the course builds
on guidelines in endoscopy prepared by our institution (in preparation:
Laser physics; Electrosurgery physics; Physics of the optics used in endoscopy;
Demonstration of instruments by the manufacturers (optics and sterilizable
instruments); Demonstration of disposable instruments; Pelvitrainers (knot
tying, clips, etc.).
Complications and safety principles in laparoscopy; Complications and safety principles in hysteroscopy.
Anesthesic management of laparoscopic and hysteroscopic operations.
Urological applications of laparoscopy; Laparoscopic operations in general surgery (cholecystectomy, appendectomy, colectomy, etc.).
Tubal sterilization.
Ovarian cysts; Fibroids (laparoscopy, hysteroscopy); Ectopic pregnancy.
Uterine septum and intrauterine adhesions: hysteroscopic treatment.
Resection of polyps and endometrial ablation.
Laparoscopic hysterectomy.
Laparoscopic operations in the treatment of infertility.
General
The hospital should preferably be equipped for long term admissions, with supervision by qualified nursing personnel and, if possible, a resident physician.
An experienced surgeon or a gynaecologist who already has practiced surgical endoscopy should be available.
Equipment
If the equipment mentioned below is not available, reassurance by institutions or donors should be made to install such equipment prior to the training.
- high luminosity laparoscope with a 100 mm trocar
- 400 W source of cold light
- pressure and flow auto regulator of CO2 insufflation, permitting a high flow rate
- video camera with screen (monitor)
- high rate irrigation aspiration system
- equipment for mono,- and bipolar electrosurgery
- endoscopic instruments like scissors, two pincers (one atraumatic),
- bipolar coagulation pincers, pincers with clips
- three 5 mm secondary trocars, one 10 mm secondary trocar
- In addition for hysteroscopy (which should be considered as a option):
- Hopkins 30 optics
- sheath for hysteroscopic diagnosis
- resectoscope Ch, 26 with choice of electrodes
- auto regulated irrigation-aspiration system for pressure and flow Hamou type hysteromat, seroconditioner or equivalent equipment
- if possible, an instrument for rapid detection of blood sodium level (natremia)
The basic objective of the training is the creation of several centers of excellence in the field of transvaginal ultrasonography with the assistance of our institution. These centers should then serve as reference centers for larger areas, and should be able to organize their own training in the field.
The introduction of high-frequency transvaginal ultrasonography has had a profound effect on diagnosis and management of patients with adnexal masses, suspected ectopic pregnancy, uterine enlargement and endometrial dysfunction. Because clinical acceptance of transvaginal ultrasonography has become widespread, education in the field has jumped ahead in the last two years, and teaching of the technique has been incorporated in a number of residency programmes in the western world.
The transvaginal ultrasound technology decreases the morbidity in gynecological patients and, therefore, reduces the expenses for the maternal and child health care services as well. Consequently, access to transvaginal ultrasonography and to medical staff trained in this technique is crucial in countries with limited health care budget and is of major interest for the patient, the practitioner, and the health care system.
Another aspect of enhancing the knowledge and technical skills in the field of ultrasonography should be considered: Teaching transvaginal sonography is also combined with teaching of clinical research methods. This will help the qualified sonographists to assess the progress and possible needs in the field, and will give them the opportunity to develop research programs, adapted to their own center and region.
1) Content of the course on transvaginal ultrasound
Basics
The physics of sound (including
Doppler)
Equipment
The limitations of transvaginal sonography examination
How to do a pelvic examination
Gynecology
The ovary and the endometrium
in the normal menstrual cycle
Screening for ovarian and endometrial cancer in the post-menopause
Imaging of pelvic infection
Imaging in infertility patients
Invasive procedures
Post-operative pelvic imaging
Ultrasound, laparoscopy, and hysteroscopy: respective value of modern
tools Obstetrics
Normal organogenesis and biometry in the first trimester
Role of ultrasound in early antenatal screening
Uterine bleeding, early failure and ectopic pregnancy
Invasive procedures
2) Indications of clinical uses for transvaginal ultrasonography
Gynecology
Pelvic evaluation in the obese
patient
Localization of intrauterine device (IUD)
Amenorrhea
Dysmenorrhea
Menometrorrhagia
Postmenopausal bleeding
Follow-up of hormone replacement therapy
Pelvic inflammatory disease (PID)
Pelvic pain
Evaluation for pelvic adhesions
Hydrosalpinx
Tubo-ovarian abscess
Uses in conjonction with the pelvic examination
Evaluation of the internal character of ovarian cysts
Diagnosis, location, and size measurement of uterine fibroids
Evaluation of PID
Screening of postmenopausal patients for ovarian and endometrial cancer
Differential diagnosis of adnexal masses
Obstetrics
Early pregnancy evaluation
Gestational dating
Search for congenital anomalies
Location of gestation (ectopic pregnancy)
Threatened abortion
Management of spontaneous abortion
Vaginal bleeding
Diagnosis of hydatiform mole
Evaluation and localization of placenta praevia
Evaluation for incompetent cervix
Evaluation of post-abortus bleeding
Ovarian function
Confirmation of ovulation-anovulation,
Diagnosis of polycystic ovaries; Diagnosis of LUF syndrome.
Follicular growth tracking during clomiphene citrate or human menopausal
gonadotropin treatment
Endometrial function
Accurate endometrial growth under follicular stimulation treatment
In-vitro fertilization (IVF)
Oocyte pick-up
Miscellaneous
Diagnosis and follow-up of endometriomas
Diagnosis of congenital anomalies of the uterus
General
Medical staff with experience in transabdominal sonography.
Equipment
The centre should be fully equipped with ultrasound material, vaginal probe 5 to 7 MHz being mandatory.
Diagnosis and treatment of infertility
- Definition and epidemiological aspects of infertility
- Infertility work-up
- Evaluation of the female partner
History taking and physical examination
Assessment of tuboperitoneal factor
Assessment of ovulatory factor
Assessment of uterine factor
Assessment of cervical factor
- Evaluation of the male partner
History taking and physical examination
Interpretation of semen analysis and related specialized tests
Assessment of secretory causes of male infertility
Assessment of excretory causes of male infertility
Assessment of sexual disorders
- Laboratory
Hormone laboratory
Laboratory for medical assisted conception
Laboratory for semen analysis
- Treatment of female infertility
Medical treatment
Surgical treatment
- Treatment of male infertility
Medical treatment
Surgical treatment
General
The centre should be able to demonstrate an adequate number of patients with the problem of infertility.
Equipment
The centre should be equipped for diagnosis, management and treatment of the infertile couple as follows:
Equipment for hormone analysis
Equipment for semen analysis
Endoscopic equipment (laparoscopy, hystoroscopy)
Supplies for hormone therapy
Equipment and supplies for medically assisted conception
If the above-mentioned equipment is not available, reassurance by institutions or donors should be made to install such equipment prior to the training.
Edited by Aldo Campana,