Contraception and Infertility Flashcards
What 4 methods fall under ‘Natural Contraception’
- Abstinence
- Withdrawl Method
- Fertility awareness method
- Lactational Amenorrhoea
Explain the principles of Lactational amenorrhoea
- 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
What kind of things are measured in the fertility awareness method of contraception?
- Cervical Secretions
- Basal body temperatures → temperature goes up at ovulation
- Legnth of menstrual cycle
What is barrier contraception? Give some examples?
Physical barriers to prevent entrance of sperm to the cervix
e.g male/ female condoms, diaphragms and caps
What are the main advantages of barrier contraception?
- Protection from STI’s
- Male condom is widely available
What are some of the main disadvantages of barrier contraception?
- Not romantic
- Can reduce sexual pleasure
- Can expire
- People can be allergic/ sensitive to latex
Which hormonal control contraception methods can be classes as ‘short acting’?
- Combined Oestrogen and Progesterone
- COCP
- Vaginal Ring
- Patches
- Low Dose Progesterone only pill (POP)
Explain how the POP works?
- Low dose of progesterone → not enough to inhibit ovulation
- Thickens cervical mucus
- Taken everyday without breaks
Why is there a higher risk of ectopic pregnancy with the progesterone only pill?
The pill does not inhibit ovulation and thick mucus can effect cilia making it hard for oocytes to move out of fallopian tube
Explain how the combined oral contraceptive works (COCP)
- 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
What are the main advantages of the COCP?
- 98% effective
- Can relieve menstrual disorders
- Reduces risk of ovarian cysts
- Reduces risk of ovarian and endometrial cancer
What are the main disadvantages of the COCP?
- 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
What advice would you give to a women who has missed her oral contraceptive pill?
- 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
How does the DEPO PROVERA injection work?
- 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
What are the main disadvantages of the Depo Provera injection?
- Need an appointment every 12 weeks
- Contraindications and side effects
- Delay in fertility returning of 18months - 2 years
- No STI protection
How does the progestone implant work?
- 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
What are some of the disadvantages of the progesterone implant?
- Amenorrhoea
- Irregular bleeding/ spotting
- Heavy periods
What are the 2 main types of coil and how does each work?
-
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
Explain the 2 different types of sterilisation
-
Vasectomy (males)
- Vas deferens cut/ tied to prevent sperm entering ejaculate
-
Tubal Ligation (females)
- Fallopian tubes cut/blocked to stop ovum travelling from ovary to uterus
What important things should be considered before sterilsation takes place?
- Sterilisation is permanent
- Should not be chosen if there is any doubt about having children in the future
What are the the different types of emergency contraception?
- Emergency pill with levonorgestrel
- must be used within 72 hours → the sooner the better
- 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
Define subfertility
A couple having regular, unprotected sex (every 2-3 days) who have been able to concieve within 1 year
What is the difference between primary and secondary infertility?
- Primary = never been pregnant
- Secondary = pregnant in the past (including ectopics and terminations) but struggling to convieve again
What are the different types of male infertility?
- Pre- testicular - issues effecting the HPG axis
-
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
- Post- testicular - obstructive causes, erectile dysfunction, ejaculatory failure
What are the 3 broad classes of ovulatory disorders?
- Hypothalmic PItuitary Failure (10%) - failure of GnRH to act on pituitary
- Hypothalmic - pituitary - ovarian dysfunction (85%) - failure of axis to respond to stimulation e.g. PCOS, Hyperprolactinaemic amenorrhoea
- Ovarian failure (5%) - failure of ovary to respond appropriately e.g Turner’s syndrome or early menopause
What uterine and peritoneal disorders can lead to subfertility?
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
What tubal damage disorders can lead to subfertility?
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
What investigations would you like to do if a man presents with infertility?
Full clinical examination and history then…
- Semen analysis: sperm count, motility, liquifaction studies
- Hormone levels: LH, FHS, testosterone
- Ultrasound testes
- Exclude STI
- Karyotyping
What investigations would you like to do if a woman presents with infertility?
- 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
What advice can a GP give to increase chances of concieving for men and women?
When would someone be referred to a fertility clinic?
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
When would someone get an early referall to the infertility clinic?
- Woman >36 years
- Known clinical cause of infertility or a history of predisposing factors for infertility
What fertility treatment can be offered by the fertility clinic?
- Medical treatment to restore fertility
- Surgical treatment
- Assisted reproductive technique
Explain how the drug clomiphene works?
- 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
