Contraception/Subfertility

Question 1

Mechanism of Action of COCP

Answer 1

Inhibition of ovulation (via negative feedback on the hypothalamus and pituitary)

Thickening of the cervical mucus prevents sperm penetration

Endometrial atrophy (decreased endometrial receptivity) prevents implantation

Question 2

Side Effects of COCP?

Answer 2

breakthrough bleeding (consider STIs, missed pills, or pregnancy)

weight gain

mood change

breast tenderness

headaches

bloating

nausea, vomiting

acne

libido changes

Question 3

Contraindications to COCP?

Answer 3

Question 4

Advantages of the COCP?

Answer 4

Menstruation tends to become regular, lighter and less painful

The menstrual cycle can be regulated and controlled

Improvement in the symptoms of acne and endometriosis

Decreases the incidence of PID

Decreases the risks of benign ovarian tumours and cysts

Decreases the risk of colorectal, ovarian (decreases risk by >50%) and endometrial cancer

Question 5

Disadvantages of the COCP?

Answer 5

User compliance is essential for efficacy

Increased risk of venous thromboembolism

Small increased risk of stroke and cardiovascular disease

Increased risk of breast cancer (risk returns to background risk 10 years after stopping)

Association with cervical cancer (increased risk of contracting HPV in the absence of barrier contraception)

Question 6

Administration of the COCP?

Start time/precautions?

Answer 6

Question 7

Missed pilled COCP?

Answer 7

Question 8

Efficacy of COCP?

Answer 8

Failure rate of 2-3 per 1000 woman-years with perfect use, and 90 per 1000 woman-years with typical use

Question 9

Other combined oral contraceptives

• Efficacy?
• Use?
• Advantages?
• Disadvantages

Answer 9

Question 10

Mechanism of Action of Progesterone only contraception?

Answer 10

Thickening of the cervical mucus prevents sperm penetration

Endometrial atrophy (decreased endometrial receptivity) prevents implantation

Inhibition of ovulation (in 60% of cases with older POPs and up to 97% with newer POPs)

Question 11

Indications for Progesterone only pill?

Answer 11

POP is useful if the COCP is contraindicated

Particularly useful after childbirth and during breastfeeding (the POP has no effect on breastmilk)

Question 12

Administration of Progesterone only pill?

Answer 12

Question 13

Intrauterine Systems (IUS)

• Efficacy
• Doses
• Adverse Effects
• Advantages

Answer 13

Extremely effective; failure rate of 1.8 per 1000 woman-years

Mirena, Liletta and Eloira IUSs contain 52mg of levonorgestrel, the Kyleena IUS contains 19.5mg, and the Jaydess IUS contains 13.5mg

Adverse effects

• irregular bleeding or spotting for 3-6 months
• Expulsion (5%)
• Infection (1%)

Advantages

• Fertility returns as soon as the IUS is removed
• useful in the management of menorrhagia, endometriosis and fibroids
• Menstrual blood loss decreases substantially (30% of women become amenorrhoeic after 1 year)

Question 14

Types of Emergency Contraception?

Answer 14

Levonorgestrel
- should be taken as soon as possible after unprotected sex; can be taken up to 72h after UPSI

• preventing or delaying ovulation

Ulipristal acetate

• should be taken as soon as possible; can be used up to 120h after UPSI

Copper IUCD

• inhibits fertilisation by direct toxicity, prevents implantation by inducing an inflammatory reaction in the endometrium, and inhibits sperm motility
• Efficacy – failure rate of <0.1%

Question 15

Clinical Features of PCOS?

Answer 15

Question 16

Diagnosis of PCOS?

Answer 16

Rotterdam Criteria (2/3):
* Irregular or absent ovulation
* Signs of hyperandrogenism (Acne, hirstuism)
* Polycystic overies on pelvic US

Question 17

Pathogenesis and Pathophysiology of PCOS?

Answer 17

Question 18

Investigations for PCOS?

Answer 18

Increased LH, increased LH to FSH ratio

Androgens

Metabolic- glucose/lipids

Exclude differential diagnoses – HCG (pregnancy), TFTs (thyroid disease), prolactin (hyperprolactinaemia), cortisol (Cushing’s syndrome)

Pelvic US – ovarian cysts (the ‘string of pearls’ sign)

Question 19

Management of PCOS?

Answer 19

Lifestyle modification – weight loss through diet and exercise

Restoring fertility – weight loss, metformin, ovulation induction, assisted reproductive techniques, surgery

Managing hyperandrogenism – general measures, weight loss, the COCP, antiandrogens (spironolactone)

Restoring regular menstruation – weight loss, metformin, the COCP

Managing insulin resistance – weight loss, metformin

Question 20

Pathophysiology of Endometriosis?

Answer 20

Endometriosis refers to the presence of ectopic endometrial tissue outside the uterus

Question 21

Assessment/Investigations of Endometriosis?

Answer 21

HISTORY

BIMANUAL pelvic examination
* adnexal masses (endometriomas) or tenderness
* nodules or tenderness in the posterior fornix or uterosacral ligaments
* fixed retroverted uterus (due to fibrosis of the uterosacral ligaments)
* rectovaginal nodules

Laparoscopy ± biopsy – gold standard for diagnosis

Question 22

Management of Endometriosis?

Answer 22

First line – NSAIDs plus COCP (This treatment can be started empirically, without laparoscopic confirmation of endometriosis)

Question 23

Epidemiology of Subfertility

Answer 23

Failure to conceive with regular unprotected sexual intercourse affects 16% of couples after 1 year, and 8% of couples after 2 years

Question 24

Causes of Subfertility?

Answer 24

Question 25

Epidemiology of Male Subfertility?

Answer 25

Male subfertility accounts for 20-25% of cases of subfertility

Subfertility affects 5% of men

Question 25

Management of Female Subfertility?

Answer 25

Question 25

Examination/Investigations for Female Subfertility?

Answer 25

Question 26

Casues of Male Subfertility?

Answer 26