5.2: Infertility and Contraception

Question 1

Define coitus interruptus

Answer 1

the pull out method

Question 2

Name three methods of ‘natural contraception’

Answer 2

1. Abstinence
2. Coitus interruptus
3. Rhythm method (getting to know your cycle really well)

Question 3

Define vasectomy, other than it being reversible in some cases, what is one disadvantage to this form of contraception?

Answer 3

Cutting (distal to the superficial inguinal ring) the vas deferens to ensure the ejaculate is free of sperm.

One disadvantage is it’s not immediately effective since there may still be sperm existing in the male tract

Question 4

Name three barrier methods of contraception, what product can they all be used in conjunction with?

Answer 4

1. Condoms
2. Diaphragm: lies diagonally across cervix, doesn’t completely occlude passage of sperm but holds the sperm in an acidic environment of the vagina to reduce its survival time
3. Cap: first across the cervix (physical barrier)

Can be used with spermicide: Product inserted into vagina prior to intercourse that kills sperm

Question 5

What is a combined OCP and how does it work?

Answer 5

Hormonal contraception: Has estrogen and progesterone which:
1. stimulates -ve feedback to the hypothalamus/pituitary to inhibit follicular development/ovulation

2. Loss of the estrogen positive feedback means no LH surge

Question 6

Name three methods of taking hormonal contraception

Answer 6

The pill, patch and injections

Question 7

What forms of contraception inhibit the transport of the oocyte down the fallopian tube? Is it 100% effective?

Answer 7

Sterilization to occlude the fallopian tubes; clips, rings, ligation
*Tubes rarely rejoin

Question 8

What form of contraception inhibits sperm from passing through the cervix chemically? (Not physically)

Answer 8

Can change the cervical mucus to make it thick and ‘hostile’ using the combined OCP, or progesterone only pill, implant or depot progesterone/injections

*excess progesterone tricks the body into thinking its pregnant; inducing changes in the endometrium, cervical mucus, etc

Question 9

Name two potential consequences of having excessive progesterone in the body?

Answer 9

1. Can induce over-proliferation of endometrium - leading to cancer
2. Excessive suppression of estrogen

Question 10

Name three forms of contraception that can inhibit implantation of the embryo in the uterine lining

Answer 10

1. Hormonal contraception: can affect the receptivity of the endometrium
2. Postcoital contraception
3. IUDs

Question 11

What are the two main types of IUDs and how do they work?

Answer 11

Can be hormonal or copper:
1. Copper interferes with the endometrial enzymes to prevent implantation and acts a physical barrier against sperm transport

2. Progesterone; -ve feedback in the axis

Question 12

Is male hormonal contraception currently available, why or why not? Which hormone would be involved?

Answer 12

No, some trials have been successful with testosterone being the most suitable exogenous hormone (used in combination with progesterone to reduce the side effects). However, issues such as low level sperm production, persisting side effects (i.e mood swings), reversibility and problems caused with the male repro tract/sexual function still need to be overcome

Question 13

Define infertility (and primary and secondary)

Answer 13

Being unable to conceive within 1 year
Primary: no previous pregnancy
Secondary: previous pregnancy, successful or not

Question 14

Name four factors that might contribute to male infertility (not psychological)

Answer 14

1. Low sperm count
2. Poor sperm morphology/motility
3. Low ejaculate volume; not adequate release from accessory glands
4. Sperm autoimmunity

Question 15

Name two factors that contribute to male infertility during coitus (intercourse ;)

Answer 15

1. Retrograde ejaculation: semen enters bladder rather than emerging through the penis
2. ED

Question 16

Name three major factors that can cause female infertility. Briefly describe each and include the proportion of women with each type of problem

Answer 16

1. Ovulatory failure: Hormone imbalance or polycystic ovaries, 13%
2. Impaired gamete/zygote transport; tube defects, anti-sperm antibodies, non-optimal cervical mucous, 12%
3. Implantation defects; mostly due to problems with embryo itself that make it unable to reach the blastocyst stage; i.e; chromosomal abnormalities or endometrial abnormalities (endometriosis is 6%)

Question 17

Define anovulation, is it ever normal?

Answer 17

When ovaries do not release an oocyte during a menstrual cycle, occasionally normal at the extreme ends of reproductive life

Question 18

What are 6 potential causes of anovulation?

Answer 18

1. Stress factors; stress, exercise, weight loss
2. Pituitary tumours
3. Necrosis
4. Ovarian failure
5. Menopause
6. Chemicals: radio/chemotherapy

Question 19

Why can polycystic ovarian syndrome result in female infertility? What other diseases can arise as result of PCOS?

Answer 19

The syndrome is related to a lack of pulsatile GnRH secretions and increased androgen secretions; which raises/confuses the LH/FSH ratio - making proper follicular development difficult. The follicles respond to pituitary hormones by producing an abnormal pattern of estrogen secretions - and chronic anovulation is thought to occur due to inappropriate feedback signals from the ovary to the hypothalamus/pituitary.

The abnormal estrogen secretions put women at risk of endometrial malignancy. PCOS can also cause insulin resistance, potentially leading to type 2 diabetes.

Question 20

How might you diagnose anovulation?

Answer 20

Can measure hormone levels in the blood

Question 21

Name three methods you can use to induce ovulation in a patient with anovulation

Answer 21

Can induce ovulation with
1. anti-estrogen: tricks the body into thinking estrogen levels are low so there’s an increase in FSH

2. Gonadotrophins: like FSH
3. GnRH agonists; pulsatile to mimic a normal secretion

Question 22

What is tubal occlusion and what particular feature in a patient history might lead you to suspect one? Name two causes, two methods for diagnosis and two treatment options

Answer 22

Occlusion of the fallopian tubes so eggs cannot be transported, particularly suspected if there was a previous pelvic infection

Causes: scarring (from infection or endometriosis), sterilization

Diagnosed by: laparoscopy and dye, hysterosalpingogram/HSG (X-ray involving a thin tube threaded through and a contrast material injected into the uterus)

Treatment: tubal surgery (reanastomosis) or assisted conception (insert fertilized embryo from the lab into the uterine lining)

Question 23

Name three factors that might be causing abnormal sperm production

Answer 23

1. Testicular disease
2. Obstruction of the ducts due to an infection or vasectomy
3. Hypothalamic/pituitary dysfunction

Question 24

List the values that correspond with each category in a normal semen analysis:

a) Volume
b) sperm count
c) % of sperm in the semen that are motile
d) % of sperm in the semen with a normal morphology

What is the normal range of sperm count (millions/ml)

Answer 24

a) 1.5-4mL
b) >15 million/mL
c) >40%
d) >4%

The normal range is 20-200 million sperm/ml

Question 25

Name four things you may have to check when managing a couple with suspected infertility

Answer 25

1. Ensure they are having regular unprotected sex 2. Regular menstrual cycle (it's 21-35 days) and day 21 progesterone levels are normal (serum levels should peak at 21 days, this provides evidence that ovulation has occurred) 3. Check the patient tubes; history of infection, sterilization and can investigate with dye insufflation or HSG 4. Adequate sperm count

Question 26

Name three major methods you can use to manage/solve infertility. When can't you manage infertility?

Answer 26

1. Drugs to overcome hormone problems 2. Surgery to overcome tubal occlusion 3. Overcome timing/fertilization issues with IVF * No treatment if there is an issue with implantation as an embryo cannot be grown to full fetal development in a lab

Question 27

How does an IVF work?

Answer 27

1. Stimulates the ovary to release more oocytes (so you have more to play with and potentially freeze), 2. Take a sperm sample and fertilize the oocyte in vitro (lab). 3. Allow the embryo to develop up to the blastocyst stage in vitro before transferring it back to the uterus

Question 28

Name four ways you could overcome the issue of inadequate sperm/sperm transport in a couple when providing IVF?

Answer 28

IUI: intrauterine insemination ICSI: intracytoplasmic sperm injection TESA: testicular sperm aspiration GIFT: gamete inrafallopian transfer

Question 29

Name two ways you could overcome the issue of inadequate eggs when providing a couple with IVF Bonus: include a scenario/condition that often requires one of these solutions

Answer 29

1. Egg donation | 2. CT (cytoplasmic transfer); often relating to the mitochondria, like mitochondrial disease

Question 30

What is often the cause of early miscarriages/ spontaneous abortions in women who become pregnant shortly after discontinuing the pill? What can be concluded from this?

Answer 30

Chromosomal abnormalities resulting from nondisjunction; such as polyploidy (cells containing 3 or more times the number of haploid chromosomes) In conclusion, it is wise to use another type of contraception 1-2 menstrual cycles before attempting to get pregnant

Question 31

What proportion of young couples that have regular unprotected sex are expected to conceive within a year?

Answer 31

85%

Question 32

How does hyperprolactinemia cause infertility and what clinical sign may indicate this diagnosis?

Answer 32

May stop a woman from ovulating, may be diagnosed by observing the production of small quantities of milk

Question 33

How does a patient with PCOS tend to present clinically?

Answer 33

Secondary amenorrhea/infertility, hirsutism (abnormal growth of facial and bodily hair especially on a woman) and obesity

Question 34

What does the abnormal estrogen secretions put women with PCOS at risk of?

Answer 34

Endometrial malignancy!

Question 35

Briefly describe the mechanism of action of the 'morning-after pill'

Answer 35

Estrogen taken in large doses within 72 hours of intercourse usually prevent implantation (not fertilization) of the blastocyst; likely by altering tubal motility, interfering with corpus luteum function, causing abnormal changes in the endometrium