Contraception + Infertility Flashcards
What is contraception?
Any method that is used to prevent a pregnancy
Ways contraception can work
- blocking sperm transport
- disruption of HPG axis
- inhibit implantation of conceptus into endometrium
What are the categories of contraception?
Natural
Barrrier
Hormonal
IUD/IUS
Sterilisation
Emergency contraception
Types of natural contraception
Abstinence
Withdrawal method
Fertility awareness methods
Lactational amenorrhoea method
Advantages and disadvantages of abstinence
Advantages:
- 100% effective
Disadvantages:
- not an option for most
- unprepared if/when sexually active
Advantages and disadvantages of withdrawal method
Advantages:
- no devices or hormones
Disadvantages:
- unreliable
- some sperm in pre-ejaculate
- no STI protection
What is fertility awareness methods of contraception?
Monitoring:
- cervical secretions
- changes in cervix
- basal body temp
- ‘calendar method’
Advantages and disadvantages of fertility awareness methods of contraception
Advantages:
- no hormones/contraindications
Disadvantages:
- time consuming
- unreliable
- no STI protection
- not suitable for all
What is the lactational amenorrhoea method of contraception?
- Effective for up to 6 months postnatally if woman is exclusively breastfeeding + complete amenorrhoea
- Lactation delays the onset of ovulation, due to high levels of prolactin which lowers the release of GnRH
Advantages and disadvantages of lactational amenorrhoea method
Advantages:
- no hormonal/contraindications
Disadvantages:
- unreliable after 6 months
- no STI protection
- not suitable for all
Describe the combined oral contraceptive pill
Including its actions
- pill containing combination of synthetic oestrogen + progesterone
- usually taken for 21 days with a 7 day break
- main action: prevents ovulation
- secondary action: reduces endometrial receptivity to implantation + thickens cervical mucous
Advantages and disadvantages of combine oral contraceptive pill
Advantages:
- reliable if used correctly
- can relieve menstrual disorders
- reduces risk of ovarian + endometrial cancers
- decreases acne severity in some
Disadvantages:
- user dependant
- no STI protection
- medication interaction
- contraindications: raised BMI, migraines with aura, breast cancer
- side effects: menstrual irregularities, breast tenderness, mood disturbance
- increased risk of CV disease, stroke, breast + cervical cancer
Contraindications of combined oral contraceptive pill
High BMI
Migraine with aura (vision impact)
Breast cancer
Impact of high levels of progesterone
Inhibits ovulation
- reduces FSH + LH secretion pre-ovulation
- inhibits positive feedback of high oestrogen > no LH surge > no ovulation
Impact of lower levels of progesterone
- does not inhibit LH surge > can still ovulate
- thickening cervical mucous
Describe the progesterone only pill
Including its actions
- low dose progesterone
- taken daily with no breaks
- main action: thickens cervical mucous
- secondary action: reduced cilia activity in fallopian tubes
- ovulation is NOT prevented
Advantages and disadvantages of progesterone only pill
Advantages:
- reliable if used correctly
- can be used id COCP contraindicated
Disadvantages:
- no STI protection
- strict timing > user dependent
- menstrual irregularities
- increased risk of ectopic pregnancy if pregnancy occurs
Describe the progestone injection
Including its actions
- high dose progesterone
- long acting contraception
- given IM every 12 weeks
- e.g. Depo-Provera
- main action: inhibits ovulation, thickens cervical mucous, thin endometrial lining
Advantages and disadvantages of progesterone injection
Advantages:
- reliable
- no known medication interaction
- can be used if oestrogen contraindications and raised BMI
Disadvantages:
- no STI protection
- not rapidly reversible (can take 18 months for fertility to return)
- menstrual irregularities
Describe the progesterone implant
Including its actions
- high dose progesterone
- long acting contraception
- nexplanon
- main action: inhibits ovulation, thickens cervical mucus, thins endometrial lining
Advantages and disadvantages of progesterone implant
Advantages:
- reliable
- lasts for up to 3 years
- can be used if oestrogen contradindicated or raised BMI
- fertility retunes faster than injection
Disadvantages:
- no STI protection
- menstrual irregularities
- complications with insertion + removal
- procedure needed
What are the types of intrauterine contraceptions?
Intrauterine system IUS
Intrauterine device IUD (copper coil)
Describe the intrauterine system
Including its actions
- low dose progesterone releasing coil
- e.g. Mirena
- main action: prevents implantation, reduced endometrial proliferation , thickens cervical mucous
- ovulation normally continues
Describe the IUD (copper coil)
Including its actions
- copper containing coil
- main action: cooper toxin to ovum + sperm which prevents fertilisation
- secondary action: cervical mucous changes, endometrial inflammatory reactions inhibit implantation
- often causes heavy bleeding
Advantages and disadvantages of intrauterine contraceptives
Advantages:
- convenient
- reliable
- long acting contraceptive
- IUS treatment for Menorrhagia
Disadvantages:
- no STI prevention
- IUD can cause heavy periods
- menstrual irregularities
- complications with insertion (perforation)
- displacement may occur
Describe sterilisation method of contraception
Vasectomy or tubal ligation
Permanent
Describe tubal ligation/clipping
- fallopian tube occluded to prevent ovum transport
- under local/general anaesthetic
Describe a vasectomy
- vas deferens snipped or tied to prevent sperm entering ejaculate
- under local anaesthetic
- must do post vasectomy semen analysis
Types of emergency contraception
Levonorgestrel (morning after pill)
Ulipristal acetate (EllaOne)
Copper IUD
Describe the morning after pill (levonorgestrel)
- high dose progesterone
- inhibits ovulation
- up to 72 hours post unprotected sexual inter course
How long can the morning after pill be used after UPSI?
Up to 72 hours
Describe the ulipristal acetate (EllaOne)
- selective progesterone receptor modulator
- inhibits/delays ovulation
- up to 120 hours post UPSI
How long can ulipristal acetate (EllaOne) be used after UPSI?
Up to 120 hours
How long can the copper IUD be used as emergency contraception?
Up to 5 days post ovulation
What is used to help clinicians decide what contraptives they can safely recommend?
UKMEC
Types of barrier contraceptives
Condoms
Diaphragms/cervical caps
Spermicides
Advantages and disadvantages of barrier contraceptives
Advantages:
- reliable if used correctly
- STI protection
Disadvantages:
- disrupts intercourse
- risk of dislodging
- allergy to latex
Define infertility
Failure to achieve a pregnancy after 12 months or ore of regular (2-3 times a week) unprotected sexual intercourse
Define primary infertility
Never been pregnant
Define secondary infertility
Previous pregnancy (including ectopic + terminations) but struggling to conceive
Define subfertility
Describes any form of reduced fertility that results in prolonged duration of unwanted lack of conception
Causes of infertility
- unknown
- male causes
- female cases: ovulatory causes or tubal factors or uterine + peritoneal disorders
Types of male causes of infertility
Pre testicular
Testicular
Post testicular
Pre testicular causes of male infertility
Hypogonadotropic hypogonadism
Thyroid disorders
Testicular causes of male infertility
- genetic: Klinefelter syndrome XXY (testis don’t descend)
- congenital: cryptorchidism
- infective: mumps
- antispermatogenic agents e.g. chemo
- vascular: torsion, varicocele
Post testicular causes of male infertility
Obstructive:
- congenital: absent vas
- acquired: infective, vasectomy
Coital problems
- sexual dysfunction
Hypospadias
What is hypospadias?
Congenital condition where the urethral opening is lower than normal
Types of ovulatory disorders
- hypothalamic pituitary failure: hypothalamic amenorrhoea, hypogonadotropic hypogonadism
- hypothalamic pituitary ovarian dysfunction: PCOS (most common cause) , high prolactin
- ovarian failure: premature ovarian failure, congenital e.g. Turner’s syndrome 45XO
Causes of tubal damage causing female infertility
PEPE
- PID
- Ectopic pregnancy
- Pelvic surgery
- Endometriosis
- agenesis of fallopian tubes
Uterine + peritoneal disorders that can cause female infertility
- uterine fibroids
- conditions causing scarring/adhesions: e.g. endometriosis, PID, previous surgery, Asherman syndrome
- mullerian development anomalies
Female examination for investigating infertility
- BMI
- secondary sexual characteristics
- acne
- Hirsutism (excess hair)
- pelvic/abdominal exam + swab
Advice to patients experiencing infertility
- smoking cessation
- reduce alcohol intake
- lifestyle changes e.g. stress
- regular intercourse
- weight loss
- reassurance
Investigation of male infertility
- semen analysis
- bloods: LH/FSH, testosterone
- STI screen
- ultrasound scan testes
- karyotyping
Investigations of female infertility
- FSH/LH day 2
- mid luteal phase progesterone (day 21)
- TFTs, prolactin levels, androgens
- STI screen
- pelvic ultrasound scan
- hysterosalphinogram
- laparoscopy
When should you consider early referral to secondary care in infertility?
Woman is >35 after 6/12months
If cause if known
Management options of infertility
- medical treatment: ovulation induction e.g. clomifene
- surgical treatment: tubal occlusions e.g. laparoscopy
- assisted reproductive technology: IVF, intrauterine insemination
When should you consider referral to secondary care in infertility?
If history, exam and investigation are normal in both partners and not conceive after 1 year
What is placenta accreta?
Invasion of conceptus that is too deep
What percentage of couples will conceive naturally within 1 year with regular unprotected intercourse?
84%
Relationship between dopamine and prolactin
Dopamine inhibits prolactin
What is measured in a semen analysis?
- semen volume
- total sperm count
- sperm conc.
- total + progressive motility
- vitality
- sperm morphology
What is a hysterosalphinogram?
Dye inserted into uterus (hystero) and imaging is used to see if the dye spread through the uterine tubes (salphino) to see if there is a blockage
Most common cause of male infertility
Abnormal semen analysis
What is the most common cause of female infertility?
Anovulation
Primary vs secondary anovulation
- Primary: ovary has never been able to ovulate
- Secondary: ovary had normal function in past but is now unable to ovulate normally
Causes of secondary anovulation
PCOS
Emotional stress
Pregnancy
Hyperprolactinaemia
Causes of primary anovulation
Dygenetic gonads
Hypothalamic dysfunction
Hypothyroidism
