Contraception And Infertility Flashcards
What is the role of progesterone at low doses?
Does NOT inhibit the LH surge
Ovulation still likely
Thickens the cervical mucus
What is the role of progesterone at moderate/high dose before ovulation?
Enhances the negative feedback of oestrogen
Decrease LH and FSH
What is the role of moderate/high progesterone at ovulation?
Inhibits the positive feedback of oestrogen
No LH surge
No ovulation
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
What is the effect of breast feeding on ovulation?
Delays the return of ovulation
Up to 6 months post-partum
Suppresses GnRH release
What are the advantages to natural contraception?
No added hormones
No contraindications
What are the advantages of barrier methods?
Help prevent STIs
Diaphragm/caps can be inserted anytime before intercourse
What are the disadvantages of barrier methods?
Allergies/sensitivity to latex
Females condoms not as widely available
Local reactions to spermicide
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)
What are the advantages of COCP?
Can relieve menstrual disorders
Reduces risk of ovarian cysts and cancer
What are the disadvantages of COCP?
User dependent
Side effects: breakthrough bleeding, breast tenderness and mood disturbance
Increased risk of DVT, MI
Many contraindications
How long does the progesterone injection last?
8 - 13 weeks
What are the advantages of the progesterone injection?
Convenient
Can relieve menstrual disorders
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
Describe the progesterone implant
4 cm flexible rod
Inserted subdermally in upper arm
Lasts up to 3 years
What are the advantages of the progesterone implant?
Long duration of action
Convenient
Can relieve menstrual disorders
What are the disadvantages of progesterone implant?
Small procedure required
Local adverse effects can occur
Changes in bleeding pattern
Can migrate to another location
Describe the progesterone only pill
Lower dose progesterone
Taken every day
Thickens cervical mucus making in impenetrable to sperm
Ovulation usually not prevented
What are the 2 different types of coil?
Intrauterine system (IUS) - progesterone Intrauterine device (IUD) - copper
Describe the IUS
Progesterone release to decrease endometrial proliferation to prevent implantation
Small plastic device
Lasts 3 - 5 years
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
