Contraception And Infertility Flashcards by Maya White

What is the role of progesterone at low doses?

Does NOT inhibit the LH surge
Ovulation still likely
Thickens the cervical mucus

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What is the role of progesterone at moderate/high dose before ovulation?

Enhances the negative feedback of oestrogen

Decrease LH and FSH

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What is the role of moderate/high progesterone at ovulation?

Inhibits the positive feedback of oestrogen
No LH surge
No ovulation

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Describe methods for natural contraception

Cervical secretion - increased mucus at most fertile
Length of menstrual cycle
Basal body temperature - progesterone slightly elevates temp just after ovulation

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What is the effect of breast feeding on ovulation?

Delays the return of ovulation
Up to 6 months post-partum
Suppresses GnRH release

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What are the advantages to natural contraception?

No added hormones

No contraindications

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What are the advantages of barrier methods?

Help prevent STIs

Diaphragm/caps can be inserted anytime before intercourse

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What are the disadvantages of barrier methods?

Allergies/sensitivity to latex
Females condoms not as widely available
Local reactions to spermicide

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Describe the action of and how to take the COCP

Oestrogen and progesterone together - prevent ovulation and decrease endometrial receptivity to implantation and thickens cervical mucus
21 days then 7 day break (or dummy pill)

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What are the advantages of COCP?

Can relieve menstrual disorders

Reduces risk of ovarian cysts and cancer

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What are the disadvantages of COCP?

User dependent
Side effects: breakthrough bleeding, breast tenderness and mood disturbance
Increased risk of DVT, MI
Many contraindications

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How long does the progesterone injection last?

8 - 13 weeks

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What are the advantages of the progesterone injection?

Convenient

Can relieve menstrual disorders

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What are the disadvantages of progesterone injection?

Altered/irregular bleeding common
Delayed return of fertility up to 1 year after stopping
Not quickly reversible
Small loss of bone mineral density

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Describe the progesterone implant

4 cm flexible rod
Inserted subdermally in upper arm
Lasts up to 3 years

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What are the advantages of the progesterone implant?

Long duration of action
Convenient
Can relieve menstrual disorders

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What are the disadvantages of progesterone implant?

Small procedure required
Local adverse effects can occur
Changes in bleeding pattern
Can migrate to another location

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Describe the progesterone only pill

Lower dose progesterone
Taken every day
Thickens cervical mucus making in impenetrable to sperm
Ovulation usually not prevented

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What are the 2 different types of coil?

Intrauterine system (IUS) - progesterone 
Intrauterine device (IUD) - copper

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Describe the IUS

Progesterone release to decrease endometrial proliferation to prevent implantation
Small plastic device
Lasts 3 - 5 years

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What are the disadvantages of the IUS?

Insertion may be unpleasant
Displacement/expulsion may occur
Menstrual irregularity common in first 6 months
Risk of uterine perforation

What is the action of IUD?

Release copper
Copper is toxic to sperm and ovum
Therefore prevents fertilisation
Copper causes inflammatory endometrial reaction to prevent implantation

How long does the IUD last?

5 - 10 years

What are the advantages of IUD?

Convenient
Long duration
Can be used as emergency contraception

Describe a vasectomy

Vas deferens interrupted Under local anaesthetic Most confirm post-op with a semen analysis

What are the advantages of sterilisation?

No hormonal side effects | Permanent

What are the disadvantages of sterilisation?

Permanent - not for people in any doubt about wanting children Failure rates quite high

Define infertility

Failure of conception in a couple having regular, unprotected coitus for one year

When looking at infertility cases, how do we define regular coitus?

2 or more times a week

What percentage of couples get pregnant after 12 cycles?

80%

What is the difference between primary and secondary infertility?

Primary - no previous pregnancy | Secondary - has had a previous pregnancy, whether successful or not

Approximately how many couples have difficulty conceiving?

1 in 7

What might we do on examination of an infertile woman?

BMI Look for secondary sexual characteristics Galactorrhoea Pelvic exam - any abnormalities noted

What percentage of cases of infertility are due to the male?

30%

What are the general causes of infertility in women?

Ovulatory disorders Tubal damage Unexplained Uterine or perineal disease

What is the most common male cause of infertility?

Idiopathic oligospermia

Give some examples of causes of infertility in men

``` Oligospermia Varicocele Abnormal sperm production eg.testicular disease Hypothalamic/pituitary dysfunction Ductal obstruction Failure to deliver sperm to vagina ```

How do we treat hypothalmic-pituitary causes of ovulatory disorders?

GnRH therapy

What can we give to induce ovulation? For example in PCOS

Clomiphene citrate

Describe some of the pathophysiology of PCOS

``` Increased androgens Increased LH to FSH ratio Insulin resistance Multiple small ovarian cysts (12+) Anovulation with oligomenorrhoea or amenorrhoea ```

Give some clinical features of PCOS

``` Hirsutism Acne Obesity Oligomenorrhoea Psych Sx = mood swings, anxiety etc ```

What are the categories in the Rotterdam Criteria to diagnose PCOS?

12+ follicles on USS Oligo- or anovulation Clinical/biochemical signs of hyperandrogenism Exclusion of other causes of androgen excess

What are the most likely causes of tubal damage?

``` Past pelvic infection Previous pregnancy Pelvic surgery Endometriosis Mullerian development anomaly ```

Name some uterine/peritoneal diseases that can cause infertility

``` Endometriosis Asherman's syndrome Uterine fibroids Cervical stenosis Cervical hostility ```

What is endometriosis?

Presence of endometrial tissue in sites other than the uterine cavity 10-15% of women have it

What are the clinical features of endometriosis?

Dysmenorrhea Dyspaureunia Chronic pelvic pain Infertility

How might we manage endometriosis?

Contraceptive pill to regulate periods Anti-inflammatory IVF possibly

What would we investigate for an infertile woman?

``` Follicular phase LH and FSH Luteal phase progesterone Prolactin, androgens, TFTs Cervical smear Pelvic USS Tests of tubal potency - dye and x-ray ```

What investigations might we do for an infertile man?

``` Sperm analysis - volume, count, pH, motility Antiserum antibodies LH, FSH, testosterone USS Karyotype Cystic fibrosis? Testicular biopsy ```

How do clomifene citrate work?

Reduces negative feedback of oestrogen | Increases GnRH and FSH