Contraception and Infertility

Question 1

What 4 methods fall under ‘Natural Contraception’

Answer 1

1. Abstinence
2. Withdrawl Method
3. Fertility awareness method
4. Lactational Amenorrhoea

Question 2

Explain the principles of Lactational amenorrhoea

Answer 2

• Suckling during breastfeeding causes high levels of prolactin
• Prolactin negatively feedsback to lower release of GnRH
• Method only effective for 6 months and relies on exclusive breastfeeding

Question 3

What kind of things are measured in the fertility awareness method of contraception?

Answer 3

1. Cervical Secretions
2. Basal body temperatures → temperature goes up at ovulation
3. Legnth of menstrual cycle

Question 4

What is barrier contraception? Give some examples?

Answer 4

Physical barriers to prevent entrance of sperm to the cervix

e.g male/ female condoms, diaphragms and caps

Question 5

What are the main advantages of barrier contraception?

Answer 5

• Protection from STI’s
• Male condom is widely available

Question 6

What are some of the main disadvantages of barrier contraception?

Answer 6

• Not romantic
• Can reduce sexual pleasure
• Can expire
• People can be allergic/ sensitive to latex

Question 7

Which hormonal control contraception methods can be classes as ‘short acting’?

Answer 7

• Combined Oestrogen and Progesterone
  
  • COCP
  • Vaginal Ring
  • Patches
• Low Dose Progesterone only pill (POP)

Question 8

Explain how the POP works?

Answer 8

• Low dose of progesterone → not enough to inhibit ovulation
• Thickens cervical mucus
• Taken everyday without breaks

Question 9

Why is there a higher risk of ectopic pregnancy with the progesterone only pill?

Answer 9

The pill does not inhibit ovulation and thick mucus can effect cilia making it hard for oocytes to move out of fallopian tube

Question 10

Explain how the combined oral contraceptive works (COCP)

Answer 10

• COCP combines oesterogen and progesterone to negatively feedback on the GnRH
  
  • Hypothalmus thinks it’s in the luteal phase so will prevent ovulation
• Secondary aim: reduces endometrial receptivity to inhibit implantation
• Secondary aim: thickens cervical mucus
• Usually taken for 21 days with a 7 day break

Question 11

What are the main advantages of the COCP?

Answer 11

• 98% effective
• Can relieve menstrual disorders
• Reduces risk of ovarian cysts
• Reduces risk of ovarian and endometrial cancer

Question 12

What are the main disadvantages of the COCP?

Answer 12

• No STI protection
• Interact with other meds by CYP450
• Contraindicated in those at high risk of Stroke, MI and High BMI as oestrogen is thomboembolic
• Increased risk of breast cancer
• Side effects: breakthrough bleeds, breast tenderness and mood disturbance

Question 13

What advice would you give to a women who has missed her oral contraceptive pill?

Answer 13

• If 1 pill missed: Take missed pill even if it means two pills taken in one day. Carry on as normal
• If 2 pills missed (>48 hrs): taken the most recent forgotten pill (yesterdays) and leave other forgotten pills. Use barrier contraception. If there’s less than 7 pills left don’t have a break between packs

Question 14

How does the DEPO PROVERA injection work?

Answer 14

• High dose of progesterone given intramuscularly every 12 weeks
• High doses of proegestone inhibit the positive feedback of oestrogen → no LH surge → no ovulation
• Also thickens cervical mucus
• Also thins the lining of the endometrium

Question 15

What are the main disadvantages of the Depo Provera injection?

Answer 15

• Need an appointment every 12 weeks
• Contraindications and side effects
• Delay in fertility returning of 18months - 2 years
• No STI protection

Question 16

How does the progestone implant work?

Answer 16

• Small, flexible tube inserted under the skin secreting high dose progesterone
• Inhibits ovulation by preventing the positive feedback of oestrogen → no LH surge → no ovulation
• Secondary actions: thicken cervical mucus and prevent endometrial proliferation
• Lasts for 3 years

Question 17

What are some of the disadvantages of the progesterone implant?

Answer 17

• Amenorrhoea
• Irregular bleeding/ spotting
• Heavy periods

Question 18

What are the 2 main types of coil and how does each work?

Answer 18

• Interuterine device (Copper coil)
  
  • Copper toxic to sperm and ovum
  • Causes endometrial inlammation preventing implantation
  • Changes consistency of cervical mucus
  • No effect on endometrial lining
  • Lasts 5-10 years
• Intrauterine System (IUS)
  
  • Progesterone releasing coil → acts locally (not in systemic circulation)
  • lasts 3-5 years
  • Prevents implantation and reduces endometrial proliferation
  • Thickens cervical mucus

Question 19

Explain the 2 different types of sterilisation

Answer 19

1. Vasectomy (males)
   
   • Vas deferens cut/ tied to prevent sperm entering ejaculate
2. Tubal Ligation (females)
   
   • Fallopian tubes cut/blocked to stop ovum travelling from ovary to uterus

Question 20

What important things should be considered before sterilsation takes place?

Answer 20

• Sterilisation is permanent
• Should not be chosen if there is any doubt about having children in the future

Question 21

What are the the different types of emergency contraception?

Answer 21

1. Emergency pill with levonorgestrel
   
   • must be used within 72 hours → the sooner the better
2. Emergency pill with ulpristal acetate

• can be used within 5 days but the sooner the better
  3. Emergency IUD up to 5 days after unprotected sex

Question 22

Define subfertility

Answer 22

A couple having regular, unprotected sex (every 2-3 days) who have been able to concieve within 1 year

Question 23

What is the difference between primary and secondary infertility?

Answer 23

• Primary = never been pregnant
• Secondary = pregnant in the past (including ectopics and terminations) but struggling to convieve again

Question 24

What are the different types of male infertility?

Answer 24

1. Pre- testicular - issues effecting the HPG axis
2. Testicular - issues with sperm production or storage
   
   • Chromosomal/ Congental absnormalities causing decreased sperm production
   • STIs
   • Vascular changes e.g. testicular torsion
   • Drugs e.g. chemotherapy
3. Post- testicular - obstructive causes, erectile dysfunction, ejaculatory failure

Question 25

What are the 3 broad classes of ovulatory disorders?

Answer 25

1. **Hypothalmic PItuitary Failure (10%)** - failure of GnRH to act on pituitary 2. **Hypothalmic - pituitary - ovarian dysfunction (85%)** - failure of axis to respond to stimulation e.g. PCOS, Hyperprolactinaemic amenorrhoea 3. **Ovarian failure (5%)** - failure of ovary to respond appropriately e.g Turner's syndrome or early menopause

Question 26

What uterine and peritoneal disorders can lead to subfertility?

Answer 26

Any physical reason why implantation is not possible once fertilsation has occurred * **Uterine fibroids** * Conditions causing **scarring/ adhesion** * PID * Asherman's syndrome * Endometriosis * Abdominal surgery * **Abnormal uterine structures** e.g septate or bicornate uterus from defect in **mullerian duct**

Question 27

What tubal damage disorders can lead to subfertility?

Answer 27

Conditions affecting fallopian tubes causing **disruption of transport** of the ovum from the ovary to the uterus * Endometriosis * Iatrogenic from pelvic surgery * Infection * Ectopic pregnancy

Question 28

What investigations would you like to do if a **man** presents with infertility?

Answer 28

Full clinical examination and history then... * **Semen analysis**: sperm count, motility, liquifaction studies * **Hormone levels:** LH, FHS, testosterone * **Ultrasound testes** * **Exclude STI** * **Karyotyping**

Question 29

What investigations would you like to do if a **woman** presents with infertility?

Answer 29

* Hormone levels to assess whether **ovulation** is occuring- need to be **appropriately timed** * ​LH, FSH (day 2 of cycle) * Progesterone (day 21 of cycle) * Androgens * Systemic blood tests for **prolactin** and **thyroid** function * Swabs to exclude STI * Pelvic **ultrasound** * Test to check tubal patency

Question 30

What advice can a GP give to increase chances of concieving for men and women?

Answer 30

Question 31

When would someone be referred to a fertility clinic?

Answer 31

A woman of reproductive age who has not concieved after 1 year of unprotected vaginal sexual intercourse, in the **absence of any known cause of infertility**

Question 32

When would someone get an early referall to the infertility clinic?

Answer 32

* Woman \>36 years * Known **clinical cause** of infertility or a history of **predisposing** factors for infertility

Question 33

What fertility treatment can be offered by the fertility clinic?

Answer 33

1. Medical treatment to restore fertility 2. Surgical treatment 3. Assisted reproductive technique

Question 34

Explain how the drug **clomiphene** works?

Answer 34

* Clomiphene is a **partial agonist** of **oestrogen receptors** * It reduces the concentration of oestrogen receptors so the HPA is blinded to normal levels of oestrogen → **negative feedback doesn't occur** * Causes surge in LH and FSH meaning **follicles develop** causing **ovulation**