Contraception + infertility Flashcards
What are the methods of contraception (9)?
- Natural family planning
- Condoms/ other barrier
- COCP
- Progestogen only pills (POP)
- Coils
- Progestogen injection
- Progestogen implant
- Surgical sterilisation
- Emergency contraception pill
What guidelines outline the risks of using different contraceptions?
UK medical eligibility criteria (UKMEC)
What are the 4 levels of UKMEC?
- 1 = no risk
- 2 = benefits outweigh the risks
- 3 = risks outweigh benefits
- 4 = unacceptable risk, contraindicated
What should you be aware of when prescribing contraception for older women (5)?
- Women < 50 + last period = contraception for 2 years
- Women > 50 +last period = contraception for 1 year
- HRT is not contraception (need another method)
- COCP can’t be used after 50
- Progesterone injection can’t be used after 50 (due to osteoporosis risk)
When are pregnant women considered fertile after birth?
21 days after
Can women get pregnant when breastfeeding?
Lactational amenorrhoea (breastfeeding and no periods) is 98% effective as contraception for first 6 months
What are some important things to note when giving contraception to women who have given birth (4)?
- Progesterone only pill/ implant can be started at any time
- COCP when breastfeeding is UKMEC 4 (contraindicated) if <6 weeks and UKMEC 2 if >6 weeks
- COCP must be started at least 3 weeks after pregnancy if not breatfeeding
- IUD/ IUS must be inserted within 48 hours or after 4 weeks
What contraception should be avoided in breast cancer?
Any hormonal contraception
What contraception should be avoided in Wilsons disease?
IUD
What is in the COCP?
Oestrogen and progesterone
How effective is the COCP?
99% with perfect use (91% with standard use)
What age can COCP be used until?
50 years
How does the COCP prevent pregnancy (3)?
- Prevents ovulation (prevents LH surge)
- Thickens cervical mucous
- Inhibits proliferation of endometrium preventing implantation
How does COCP prevent ovulation?
Oestrogen and progesterone surpress LH and FSH preventing ovulation
How should the COCP be taken?
Traditionally taken for 21 days, the stopped for 7 to allow for breakthrough bleed, however there is no medical benefit to having a breakthrough bleed, so COCP can be taken continuously
What are the benefits of COCP (3)?
- Decreased risk of endometrial + ovarian cancer
- Rapid return to fertility after stopping
- No menstruation
What are the disadvantages of COCP (6)?
- May forget to take pill
- Unscheduled bleeding
- VTE risk
- No STI protection
- Increased risk of breast + cervical cancer
- Mood changes, breast tenderness, headaches
What are some absolute (UKMEC 4) contraindications to the COCP (8)?
- Uncontrolled hypertension (160/100)
- Migraine with aura
- History VTE
- Over 35 + smoking (15 fags)
- Major surgery with immobility
- Vascular disease/ stroke/ IHD/ AF
- Liver cirrhosis/ tumours
- SLE/ APL
What is an important UKMEC 3 to be aware of for COCP (2)?
- BMI > 35
- Wheelchair user
What is the advice given when starting the COCP (2)?
- If < day 5 of period = immediate protection
- If > day 5 of period = barrier contraception for 7 days
What is the advice if 1 missed pill of COCP (i.e. their last pill was taken 48-72 hours ago) (2)?
- Take missed pill as soon as possible even if 2 pills taken in 1 day
- No additional contraception needed
What is the general advice if 2 or more pills of COCP are missed (i.e. their last pill was taken more than 72 hours ago) (2)?
- Take missed pill ASAP even if this means 2 pills on one day
- Barrier contraception needed for 7 days
What is the additional advice if 2 or more missed pills in day 1-7 of the packet?
They need emergency contraception if they have had sex
What is the additional advice if 2 or more missed pills in day 15-21 of the packet?
- No emergency contraception
- However need to skip pill free interval (7 days) - back to back with next box of pills
What is the additional advice if 2 or more missed pills in day 8-14 of the packet?
No emergency contraception, can still have pill free interval
What are two important things to make patients prescribed COCP aware of?
- Vomiting < 2 hours after pill = equivalent to missed pill
- Some antibiotics e.g. rifampicin inhibit COCP
What are the two types of progesterone only pill?
- Traditional POP (levonorgestrel)
- Desogestrel-only-pill
How do the progesterone only pills work (2)?
- Thicken cervical mucous
- Desogestrel = inhibit ovulation
What extra way does desogestrel work as a contraception?
Prevents OVULATION
What is the advice given when starting the POP (2)?
- If < 5 days of cycle = immediate protection
- If > 5 days of cycle = barrier for 48 hours
Do women who take POP bleed (3)?
- 1/3% amenorrhoea
- 1/3% regular bleeds
- 1/3% irregular bleeds
if beyond 3 months –> needs investigation
What are the side effects/risks of POP (8)?
- Irregular bleeds
- STI risk
- Breast tenderness
- Headaches
- Acne
- Breast cancer increased risk
- Ovarian cysts
- Ectopic pregnancy (due to fallopian tube cilia inhibition)
What is classified as a missed pill for traditional POP and what should be done?
- 3 hours late (more than 26 hours since last pill) = missed pill
- Emergency contraception + 48 hours of barrier
What is classified as a missed pill for desogestrel POP and what should be done?
- 12 hours late (more than 36 hours since last pill) = missed pill
- Emergency contraception + 48 hours of barrier
What is the only absolute contraindication to POP?
Breast cancer
How often is the injection (depot provera) given?
12 weekly
What is in the depot provera?
A type of progestin
How is depot provera injected?
IM injection
What are some side effects of the depot provera (5)?
- Osteoporosis
- Irregular bleeds
- Mood changes
- Weight gain
- Delayed fertility return
How often is the implant changed?
Every 3 years
What are some side effects/ risks of the implant (3)?
- Irregular bleeding
- Acne
- Mood changes
What are the two types of coils used for contraception?
- Copper IUD
- IUS
What are some contraindications to the coil (5)?
- PID
- Pregnancy
- Unexplained bleeding
- Endometrial cancer
- Distorted uterus (large fibroids)
What are some risks/ side effects of the coils (4)?
- Bleeding + pain on insertion
- PID
- Vasovagal reaction
- Uterine perforations
- Ectopic pregnancy
What is important to exclude if the threads of a coil cannot be seen (3)?
- Pregnancy
- Uterine perforation
- Expulsion
How frequently do the coils need to be changed?
- IUS = every 5 years
- IUD = every 5-10 years
What are the two surgical sterilisations available (2)?
- Vasectomy (snipping vas deferens)
- Tubal occlusion (clipping, tying or snipping the fallopian tubes)
What are 3 forms of emergency contraception available?
- Levonorgestrol (within 3 days)
- Ulipristal (within 5 days)
- IUD (within 5 days)
What percent of couples will get pregnant after 1 year of UPSI?
85%
1/7 couples struggle to get pregnant
What are some causes for female reduced fertility (4)?
- Reduced reserve (e.g. menopause)
- Anovulation (PCOS, sheehans, hyperthyroid, high PRL)
- Structural (endometriosis, fibroids, turners, ashermanns)
- Tubular (PID)
What are some causes of male reduced fertility (6)?
- Reduced sperm quality
- Reduced testosterone
- High prolactin
- CF
- Haemochromatosis
- Kallmans, noonans, kleinfelters
What is some general advice given to couples trying to get pregnant to improve fertility and for a healthy pregnancy (5)?
- 400 mcg folic acid
- Healthy BMI
- Avoid smoking + drinking
- Intercourse 2-3/ week
- Avoid timing intercourse as increases stress
How is fertility investigated in primary care (4)?
- BMI
- STI screening (esp chlamydia)
- Semen analysis
- Hormone testing
What is analysed about the semen in semen analysis (4)?
- Volume
- Concentration
- Motility
- Normal morphology
What hormones are tested to investigate infertility (6)?
- FSH + LH
- Prolactin
- Testosterone (in males)
- Oestrogen + progesterone (female)
- Anti-mullerian hormone - AMH (female)
- Sex hormone binding globulin (female)
What investigations are done in secondary care to investigate infertility (3)?
- TV USS
- Hysterosalpingogram
- Laparoscopy + contrast
What is looked for on a TV USS to investigate fertility (2)?
- PCOS
- Uterine structural abnormalities
What is looked for on a hysterosalpingogram to investigate fertility?
Patency of fallopian tubes
What is looked for on a laparoscopy + contrast to investigate fertility (2)?
- Patency of fallopian tubes
- Endometriosis + adhesions
contrast injected into uterus and should spill out ends of fallopian tubes
Who should be referred more urgently for fertility treatment?
Over 35 year olds
try for another 6 months if < 35
How should anovulation be managed (5)?
- Weight loss + healthy lifestyle
- Clomifene
- Ovarian drilling (burning part of ovaries that produce testosterone)
- Metformin
- IVF
How does clomifene work?
Selective oestrogen modulator - stops negative feedback of oestrogen on hypothalamus –> increases LH + FSH
What are some side effects of clomifene (3)?
- Flushing
- Period pain
- Blurred vision
How can tubal fertility problems be managed?
Tubal cannulation during hysterosalpingogram
How can structural uterine problems interfering with fertility be managed?
Surgical correction
What general advice can men be given to increase sperm quality?
- Avoid hot baths
- Loose underwear
- Stop smoking + alcohol + caffeine
- Weight loss
How can sperm problems causing infertility be managed (2)?
- Surgical sperm retrieval + intrauterine insemination (IUI)
- Surgical correction
How many rounds of IVF are most couples entitled to?
3
What is IVF vs IUI (intrauterine insemination)?
- IVF = eggs removed + fertilised in petri dish
- IUI = sperm injected into uterus
What are the steps in INF?
Suppressing natural menstrual cycle –> ovarian stimulation –> oocyte collection –> insemination –> embryo culture –> embryo transfer
What are the complications associated with IVF (4)?
- Multiple pregnancy
- Ectopic pregnancy
- Failure
- Ovarian hyperstimulation syndrome
What is the pathophysiology of ovarian hyperstimulation syndrome?
High BhCG (given as part of IVF) –> high VEGF (vascular endothelial growth factor) –> increased vascular permeability –> fluid movement from intravascular to extravascular space –> ascites + oedema + hypovolaemia
What are some signs/ symptoms of ovarian hyperstimulation syndrome (6)?
- Abdo pain + bloating
- N+V
- Diarrhoea
- Hypotension + hypovolaemia (tachycardia)
- Ascites
- Pleural effusion
How is ovarian hyperstimulation syndrome managed (4)?
- IV colloids (albumin)
- LMWH (reduce VTE risk)
- Monitor urine output
- Encourage oral fluids
