12. Contraception and infertility Flashcards
What is contraception?
Any method to prevent pregnancy
What are 3 mechanisms that contraception
- Blocking transport of sperm to avoid fertilisation of oocyte
- Disrupting the HPG axis to interfere with ovulation
- Inhibiting implantation of the conceptus into endometrium
What are the 6 broad categories of contraceptions?
- Natural
- Barrier
- Hormonal Control
- Prevention of implantation
- Sterilisation
- Emergency contraception
What is the only category of contraceptions that protects against STIs?
Barrier
What are 4 types of natural contraceptions?
- abstinence
- withdrawal
- fertility awareness methods
- Lactational amenorrhoea method
What are the advantages and disadvantages of abstinence?
Advantages: 100% effective
Disadvantages:
• Not an option for most.
• Unprepared if/when sexually active
what is withdrawal?
Aka. Coitus Interruptus
= Withdrawal before ejaculation
What are the advantages and disadvantages of withdrawal?
Advantages: no devices or hormones Disadvantages: • Unreliable • Some sperm in pre-ejaculate • No STI protection
What is the fertility awareness method?
Use of fertility indicators to identify fertile and infertile points of the menstrual cycle
What fertility indicators can be used in fertility awareness method?
- Cervical secretions + Changes in Cervix
- Basal body temperatures
- Length of menstrual cycle
What are the advantages and disadvantages of the fertility awareness method?
Advantages
• No hormones/contraindications
Disadvantages
• Time-consuming, Unreliable, no STI protection
• Not suitable for all - not everyone has regular periods
What is lactational amenorrhoea method and how does it work?
Lactation delays the onset of ovulation, as the hypothalamus is ‘switched off’ because the suckling response lowers the release of GnRH to high levels of prolactin
How long after giving birth does lactational amenorrhoea methodq work?
Can be used effective for up to 6 months postnatally provided:
• Exclusive breastfeeding
• Complete amenorrhoea
What are the advantages and disadvantages of lactational amenorrhoea method?
Advantages: No hormonal/contraindications
Disadvantages: Unreliable after 6 months, no STI protection, Not suitable for all
What are the different types of barrier contraceptives and how do they work?
Provide physical +/– chemical barrier to sperm entering the cervix e.g.
• Male/Female condoms ‘Femidom®’
• Diaphragms/Cervical Caps
• Spermicides
What are the advantages of barrier contraceptives?
- Reliable - 98% effective (if used correctly)
- Protection from STIs
- Male condom is widely available
What are the disadvantages of barrier contraceptives?
- Disrupts intercourse, Risk of Dislodging
* Allergy/sensitivity to latex
How does hormonal control act as a contraceptive?
o interrupt HPG axis, and prevent ovulation. May have effects on endometrial lining.
Short-Acting or Long-Acting Reversible Contraception (LARC)
What are the different types of hormonal contraceptives?
- Combined Oestrogen and Progestogen – COCP, Patch, Ring
- Progestogen-only Pill (POP)
- LARC – Progestogen Depot and Implant
Describe the action of progesterone in high and low doese
- HIGH Levels of Progesterone enhances the negative feedback of oestrogen, hence:
- Pre-ovulation – Reduces FSH and LH secretion
- Inhibits positive feedback of high oestrogen → × LH surge → × ovulation
- LOWER Levels of Progesterone
- Does NOT inhibit LH surge → can still ovulate
- Will thicken cervical mucus
What is the COCP?
Pill containing combination of synthetic oestrogen and progestogen
How often should the COCP be taken?
Usually taken for 21 days with a 7 day break OR 21 days + 7 placebo pills
What are the actions of the COCP?
Principal action:
•Prevents ovulation - by negative feedback of oestrogen and progesterone on HPG axis reducing H surge
Secondary action:
•Reduces endometrial receptivity to inhibit implantation
•Thickens cervical mucus to inhibit penetration of sperm
What are the advantages of COCP?
• Reliable (if used correctly) up to 99% • Can relieve menstrual disorders • reduced risk of ovarian and endometrial cancer • reduced Acne severity in some
What are the disadvantages of COCP?
- User dependant
- No STI protection
- Medication interaction
- Contraindications – raised BMI, migraine + aura, breast cancer
- Side effects – menstrual irregularities, breast tenderness, mood disturbance
- reduced risk of CV disease, Stroke, VTE, Breast cancer, cervical cancer
What dose does the progesterone only pill contain?
low dies progestogen
What are the actions of POP
Main action: Thicken cervical mucus.
Other action: reduced cilia activity in fallopian tubes
Ovulation NOT prevented.
How often should the POP be taken?
Taken daily with no breaks.
What are the advantages of POP?
- Reliable (if used correctly) up to 99%
* Can be used if COCP contraindicated
What are the disadvantages of POP?
- No STI protection
- Strict timing – user dependant
- Menstrual irregularities
- increased Risk of Ectopic pregnancy - due to effect on cilia
WHat does the progesterone injection contain?
High dose progestogen – LARC e.g.
Depo-Provera®
What is the action of progesterone injection?
inhibit ovulation, thicken cervical mucus,
thin endometrial lining
What are the advantages and disadvantages of Progestogen injection?
Advantages:
• Reliable
• No known medication interactions
• Can be used if oestrogen contraindicated and raised BMI
Disadvantages:
• No STI protection
• Not rapidly reversible
• Menstrual irregularities
How is progesterone injection administered?
Given intramuscularly (IM) every 12 weeks
What is a progesterone implant?
Small subcutaneous tube inserted in the arm
High dose progestogen – LARC
What is the action of progesterone implants?
inhibit ovulation, thicken cervical mucus,
thin endometrial lining
What are the advantages progesterone implant?
• Reliable
• Lasts for up to 3 years
• Can be used if oestrogen contraindicated
and raised BMI
• Fertility returns faster than injection
What are the disadvantages progesterone implant?
- No STI protection
- Menstrual irregularities
- Complications with insertion and removal
What can be used to prevent implantation?
Coils
What are 2 different types of coils?
Intrauterine device, intrauterine system
What is a intrauterine system (IUS) and how does it work?q
- Progestogen-releasing coil – local e.g. Mirena®
- Main action: prevents implantation and reduces endometrial proliferation, thickens cervical mucus
- Ovulation usually continues
What is a intrauterine device (IUD) and how does it work?
- Copper-containing coil
- Main action: copper toxic to ovum and sperm, preventing fertilisation.
- Secondary actions: cervical mucus changes, endometrial inflammatory reactions inhibit implantation
What are the advantages of Coils?
Convenient
• Effective up to 99%
• LARC – from 3 to 10 years
• IUS for treatment of menorrhagia
What are the advantages of Coils?
- No STI protection
- Complications with insertion - perforation
- Menstrual irregularities
- Displacement/expulsion may occur
What are 2 different methods of sterilisation?
Vasectomy and tubal ligation/clipping
What is vasectomy and how is successful vasectomy confirmed?
- Vas deferens snipped or tied to prevent sperm entering ejaculate
- Under local anaesthetic
- Must do post-vasectomy semen analysis (PVSA) – 12 weeks post
What is tubal ligation/clipping?
- Fallopian tube occluded to prevent ovum transport
* Under local/GA
What are the advantages and disadvantages of sterilisation?
Advantages: Permanent
Disadvantages: No STI protection, Regret, Not easily
reversed
What are the 3 types of emergency contraception?
• Levonorgestrel “morning after pill” – high
dose progestogen, inhibits ovulation - upto 72 hrs after SI
• Ulipristal acetate – selective progesterone receptor modulator, inhibits/delays ovulation - upto 120 hrs after SI
• Copper IUD - upto 120 hrs after SI
Define subfertility.
a couple who are having regular (every 2-3 days), unprotected coitus, who have failed to conceive within 1 year
Define primary and secondary infertility.
Primary infertility: When someone who’s never conceived a child in the past has difficulty conceiving
Secondary infertility: When someone has had one or more pregnancies in the past, but is having difficulty conceiving again (Includes abortion and ectopic pregnancy)
What are the main causes of sub fertility?
- Unidentifiable in 25%
- Male and Female – 40%
- Male causes – 30%
- Ovulatory causes – 25%
- Tubal factors – 20%
- Uterine and Peritoneal disorders – 10%
- Others: gamete/embryo defects, coital problems, concurrent health problems
What are the 3 divisions of male causes of sub fertility?
- PRE-TESTICULAR
- TESTICULAR
- POST-TESTICULAR
What are some pre-testicular causes of male subfertility?
• Endocrine:
- Hypothalamus/ pituitary dysfunction
- Hypogonadotropic hypogonadism
- Hyperprolactinoemia
- Hypothyroidism
- Diabetes
- Coital problems – ejaculatory disorders, erectile dysfunction
- GENERAL HEALTH/SYSTEMIC ILLNESS
What are some testicular causes of male subfertility?
• Genetic - Klinefelter syndrome (XXY) - Y chromosome deletion - Immotile cilia syndrome • Congenital – Cryptorchidism • Infective – STI’s • Antispermatogenic agents - Heat, Irradiation, Drugs, Chemotherapy • Vascular – Torsion, Varicocele
What are some post-testicular causes of male subfertility?
• Obstructive - Congenital – CBAVD/CUAVD - Acquired – Infective, Vasectomy • Coital Problems - Sexual Dysfunction - Hypospadias
What advice should be given to a woman who has pissed a COCP pill?
- If one pill is missed… take the pill you missed even if it means two in one day, and carry on as normal.
- If >48 hours has been missed… take the most recent forgotten pill (i.e. yesterdays) as above, and leave the other forgotten pills.
- Use extra protection i.e. condoms or barrier contraception.
- If there are less than 7 pills left, don’t have a break and start the next pack straight away.
What are the 3 groups of ovulatory disorders?
Group 1-hypothalamic-pituitary failure (Failure of GnRH to act on the pituitary)- 10%
Group 2-hypothalamic-pituitary-ovarian dysfunction (. Failure of the axis to respond appropriately to stimulation)- 85%
Group 3-ovarian failure - 5%
What can cause group 1 ovulatory disorder?
◦ Hypothalamic amenorrhea
◦ Hypogonadotrophic hypogonadism
What can cause group 2 ovulatory disorder?
◦ Polycystic ovary syndrome
◦ Hyperprolactinaemic amenorrhoea
What can cause group 3 ovulatory disorder?
o Congenital (Eg Turners X0) o Premature ovarian failure / Primary ovarian insufficiency
What are some uterine/peritoneal disorders that can cause subfertility?
Physical reasons why implantation fails e.g.
a) Uterine Fibroids
b) Conditions causing scarring/adhesions:
i. Endometriosis
ii. PID
iii. Previous Surgery
iv. Asherman syndrome
c) Mullerian developmental Anomalies
What are 4 types of mullerian developmental anomalies?
- Agenesis - failure for the uterus or tubes to form
- Didelphys- Complete duplication of the uterus, cervix, and vagina
- Bicornuate - two uteri sharing a single cervix and vagina
- Septate - a single uterus with a fibrous band going down the centre of the uterus
What can cause tubal damage that can lead to subfertility?
Conditions affecting fallopian tube → disrupted transport of ovum e.g.
• Endometriosis
• Ectopic pregnancy
• Pelvic surgery
• PID
Mullerian developmental anomaly – Agenesis
What questions should be asked to both males and females?
- Full Medical hx
- Surgical hx
- Social hx – Alcohol/smoking, occupation
- Previous children/pregnancies
- Sexual health hx
- Sexual Dysfunction
What extra questions should be asked to a male?
- Testicular trauma/disorders
* Ejaculatory/erectile dysfunction
What extra questions should be asked to a female?
- Age
- Obstetric/Gynae Hx – cycle, cervical smear, procedures
- Menstrual disorders
What examinations should be done on a male in regards to subfertlity?
- Not usually required.
- Examine Penis for structural abnormalities
- Scrotal exam
- Secondary sexual characteristics
What examinations should be done on a female in regards to subfertlity?
- BMI
- Secondary sexual characteristics
- Hirsutism, Acne
- Abdominal/Pelvic/Vaginal exam – masses, tenderness, infection, uterus size/position, vaginismus etc.
What investigations might a GP do for a male?
- Semen analysis
a. Sperm count, motility, liquification studies - Hormone levels
a. LH, FSH, testosterone - Ultrasound scan of testes
- Exclude STI
- Karyotyping
What investigations might a GP do for a female?
- Hormone levels to assess whether ovulation is occurring; these have to be timed appropriately
a. LH, FSH (day 2)
b. Progesterone (day 21)
c. Androgens - Systemic blood tests
a. Prolactin
b. Thyroid function - Swabs to exclude STI
- Pelvic USS
- Test to check tubal patency
Hysterosalpingogram (HSG)
Diagnostic laparoscopy
when will patients be referred to secondary care?
Consider referral if hx, exam and Ix normal in both partners, and not conceived after 1 year. Consider Early Referral in: Women > 36y/o (after 6 months) Known cause/predisposing factors Offer counselling throughout process
What advice should be given to patienst?
- Smoking cessation
- Reduce Alcohol intake
- Lifestyle changes – stress mx
- Regular intercourse
- Weight loss
- REASSURANCE!
What are the management options for subfertility?
• Medical Treatment – ovulation induction e.g. Clomifene
• Surgical Treatment – to rx tubal occlusions e.g. laparoscopy
• Assisted Reproductive Technology (ART) = means of
conception other than normal coitus e.g. intrauterine
insemination, IVF etc.
