Fertility and Contraception Flashcards
When can investigation and referral for infertility take place?
When a couple has been trying to conceive without success for 12 months, can be reduced to 6 months if woman is older than 35.
What are common causes of infertility?
Sperm problems Ovulation problems Tubal problems Uterine problems Unexplained
What general lifestyle advice is given to couples trying to get pregnant?
Woman taking 400mcg folic acid daily
Aim for healthy BMI
Avoid smoking and drinking excessive alcohol
Reduce stress - negatively affects libido and relationship
Intercourse every 2-3 days
Avoid timed intercourse
What are the investigations for infertility?
BMI - low = anovulation, high = PCOS
Chlamydia screening
Semen analysis
Female hormone testing:
Serum LH and FSH on day 2-5 of the cycle
Serum progesterone on day 21, or 7 days before end if not a 28-day cycle
Anti-Mullerian hormone
TFTs if symptoms suggestive
Prolactin if galactorrhoea or amenorrhoea
Ultrasound pelvis looks for PCOs or structural abnormalities
Hysterosalpingogram
Laparoscopy and dye test
Semen analysis for male factor infertility
Hormonal testing, genetic testing, transrectal ultrasound, vasography, testicular biopsy
What does high FSH suggest about fertility?
Poor ovarian reserve - the number of follicles left
Pituitary gland is producing extra FSH in an attempt to stimulate follicular development.
What does high LH suggest about fertility?
May suggest polycystic ovarian syndrome.
What does Anti Mullerian hormone suggest about fertility?
Can be measured at any time during the cycle, most accurate marker of ovarian reserve, released by granulosa cells, falls as eggs are depleted
High level means good reserve
What is a hysterosalpingogram?
Assesses shape of uterus and patency of fallopian tubes
Can increase rate of conception without other intervention
Contrast medium injection, can help show tubal obstruction
Risk of infection, prophylactic abx given, screening for chlamydia and gonorrhoea done beforehand
What is the management of anovulation?
Weight loss
Clomifene
Letrozole instead of clomifene - aromatase inhibitor with anti-oestrogen effects
Gonadotropins for those resistant to clomifene
Ovarian drilling
Metformin if insulin resistance and obesity
What is clomifene?
Anti-oestrogen - selective oestrogen receptor modulator
Given daily between days 2-6 of menstrual cycle
Stops negative feedback of oestrogen on hypothalamus, more GnRH release, so more FSH and LH.
How can tubal factors causing infertility be managed?
Tubal cannulation during hysterosalpingogram
Laparoscopy to remove adhesions or endometriosis
IVF
How can sperm problems causing infertility be managed?
Surgical sperm retrieval if there is a blockage - collects directly from epididymis
Surgical correction of obstruction in vas deferens
Intra-uterine insemination - collect and separate high quality sperm then inject into uterus
Intracytoplasmic sperm injection ICSI injected into the cytoplasm of an egg, then injected into uterus of woman.
Donor insemination
How should I assess a man who is concerned about infertility?
Take a full medical, sexual, and social history, including:
Children born to man (with same or different partner).
Length of time trying to conceive.
Frequency and difficulties of sexual intercourse.
Symptoms or history that may suggest primary spermatogenic failure or obstructive, including:
History of mumps, sexually transmitted infections (STIs), or testicular trauma or torsion. Previous urogenital abnormality and treatment (for example undescended testis or orchidopexy). Systemic diseases (for example cardiac failure, chronic renal failure, neoplasia, uncontrolled diabetes, liver cirrhosis, or thyrotoxicosis). Previous surgery (for example hernia repair or orchidopexy).
Ejaculatory or erectile dysfunction.
Drug history.
Details of occupation, for possible exposure to hazards that can reduce fertility (such as pesticides and solvents).
Lifestyle factors - smoking, excessive, or social or occupational situations that may cause testicular hyperthermia.
Physical examination
Examine the penis, check position of urethral meatus, for structural abnormalities.
A scrotal examination may reveal lumps (cancer, varicocele, or hernia); small, soft testes (which may indicate hypogonadism); or undescended testes.
Assess secondary sexual characteristics. In hypogonadism, there may be a decrease in beard and body hair growth and a decrease in muscle mass.
Look for gynaecomastia, which may indicate hypogonadism.
What initial investigations should I arrange in a man to investigate infertility?
Semen analysis - collected after at least 2 days but no more than 7 days of sexual abstinence.
Needs to be complete, report any loss of fraction.
Screen for chlamydia
What is the treatment for an anovulatory cause of infertility?
Controlled ovarian stimulation 1st line - Gonadotrophins are first-line options for patients with hypothalamic amenorrhoea - e.g. Menotrophin
What is infertility?
Not conceiving after trying to have regular (2/3 x a week) unprotected sex for 1 year
What are the main 2 categories to think about when working out what could be reducing female fertility?
What are some other causes?
Ovulatory disorders
Tubal damage
Other - cervical mucus dysfunction, fibroids that distort uterine cavity, previous cervical surgery, chronic debilitating disease
What can cause tubal damage and therefore lead to infertility?
Adhesions: PID and endometriosis
Previous sterilisation
What are the types of ovulatory disorder and what blood results differentiate them?
1 - Hypothalmic pituitary failure
- low gonadotrophins and oestrogen
2 - HPO failure e.g. PCOS (85%)
- Raised LH, low progesterone
3 - Ovarian failure (5%)
- high gonadotrophins, low oestrogen
What are the causes of hypothalamic pituitary failure
Hypothyroid (decreases FSH and LH)
prolactinoma (inhibits GnRH so decreased LH and FSH)
What male factors can lead to infertility?
Genetic dysfunction
Varicocoele (raises testicular temperature)
Testicular cancer treatment Trauma Pituitary dysfunction Hypospadias Erection/ejaculatory failure
What general factors can lead to infertility?
Age
Stress
Obesity Smoking Alcohol Anabolic steroids Recreational drugs Tight fitting clothing
What would you ask in a history of infertility?
Previous pregnancies/fathered any children
Length of time trying
Type of contraception previously used and when stopped Coital freq. Previous STI's, fertility treatment General health - including BMI Drug Hx Female - menstrual Hx, OBGYN hx Male - mumps or measles
When would you request investigations for infertility?
After 1 year of regular intercourse
How would you investigate a female with suspected infertility?
Progesterone on day 21 (Mid-luteal phase)
Oestrogen, LH and FSH on day 2
Chlamydia screen
+/-Thyroid function
+/-Prolactin
How would you investigate a male with suspected infertility?
Semen analysis - masterbation after 2-7 days abstinence of sexual activity
1 abnormal test = repeat
2 abnormal tests = refer
Chlamydia screen
When would you refer someone to secondary care with suspected infertility?
1 year regular intercourse
+ all investigations in primary care come back as normal
What can be done in secondary care to investigate infertility?
Pelvic USS
Tubal patency testing - hysterosalpingography or diagnostic laparoscopy
In depth sperm analysis
How can hypothalamic-pituitary infertility be managed medically?
Gain weight
Reduce exercise
Pulsatile gonadotrophins
Treat hypothyroidism
How can HPO disorder infertility be managed?
Clomifene citrate
+/- metformin
How can hyperprolactinaemia induced infertility be managed?
Dopamine agonist - bromocriptine
How can male hypogonadotrophic hypogonadism be managed?
Gonadotrophins
How does clomifene citrate work?
Anti-oestrogen –> inhibit negative feedback effect that oestrogen has on hypothalamic pituitary axis
What are the ADR’s and CI’s of clomifene citrate?
CI - Ovarian cyst, unexplained vaginal bleed
ADR - hot flush, bloating, head and abdo pain, N&V, breast tenderness, menstrual irregularities
How can infertility be managed surgically?
Tubal catheterisation or cannulation
Surgical ablation and resection of endometriosis
Surgical correction of any epididymal blockage
What are the methods of assisted conception?
Intrauterine insemination
- sperm into uterus
Donor insemination
- donor sperm into uterus
In vitro fertilisation
- retrieve egg and sperm, mix and incubate, put embryo into uterus
Intracytoplasmic sperm injection
- as above but sperm injected directly into egg
Oocyte donation
- IVF but with donor egg
When is donor insemination used?
Man has no sperm
Man has an infectious disease - HIV
Man has a genetic conditions
No male partner
What are the main complications of artificial conception?
Ovarian hyperstimulation syndrome
Ectopic
Pelvic infection
Multiple pregnancy
How does ovarian hyperstimulation present?
Due to fluid loss in third space (mainly abdo):
Bloating
Abdominal pain N&V Diarrhoea Oliguria Ascites SOB
How is ovarian hyperstimulation syndrome managed?
Supportive - fluids and analgesia
DVT prophylaxis
What is the difference between primary and secondary infertility?
Primary is in couples who have never conceived, whereas secondary is in couples who have previously conceived
What are the disorders of ovulation?
I - hypothalamic pituitary failure
II - hypothalamic pituitary ovulation dysfunction
III - ovarian failure
Other ovulatory causes including Sheehan’s, hyperprolactinaemia, pituitary tumours
What is the classification of male factor infertility?
Obstructive - problem with sperm delivery
Non-obstructive - problem with sperm production
Coital infertility - secondary to sexual dysfunction
What are examples of obstructive infertility in men?
Previous vasectomy
Cystic fibrosis
Ejaculatory duct obstruction e.g. previous prostatitis leading to fibrosis
Epididymal obstruction may occur secondary to chlamydia or gonorrhoea
What are causes of non obstructive infertility in men?
Hormonal causes e.g. hypogonadotrophic hypogonadism, hyperprolactinaemia
Varicocoele
Genetic causes e.g. Klinefelter’s, androgen insensitivity, Kallmann
Cryptorchidism - undescended testes
Previous testicular trauma or damage
Testicular malignancy
What are the causes of coital infertility in men?
Errectile dysfunction
Premature ejaculation
Anejaculation
Primary due to psychosexual or neurological causes
Secondary due to previous abdominal/pelvic surgery or certain drugs e.g. SSRIs
Retrograde ejaculation
Penile deformities e.g. Peyronie’s, hypospadias
When is referral for fertility testing available?
One year after frequent unprotected sex
Or early referral after 6 months if
Woman aged over 36, or known cause of infertility, or history of predisposing factors
What initial investigations are available for infertility?
Male - semen analysis assessing sperm count, motility, morphology, vitality, concentration, volume. Chlamydia screen.
Women - Mid luteal progesterone to assess whether woman is ovulating
FSH and LH to assess ovarian function - poor function may be indicated by high FSH and LH
Chlamydia screen
What further investigations in secondary care can be offered for infertility?
Men - hormone analysis; testosterone, FSH, LH, PL
Genetic testing, USS, testicular biopsy, viral screen HIV Hep B and C for IVF
Female - hysterosalpingogram for tubal patency, laparoscopy and dye if e.g. endometriosis
Investigations of ovarian reserve, measured on Day 3 to predict ovarian response to gonadotrophins in IVF
Total antral follicle count
Anti Mullerian hormone - low count = premature ovarian failure
FSH
Viral screen
What are the processes in IVF?
Suppressing natural menstrual cycle Ovarian stimulation Oocyte collection Insemination or intracytoplasmic sperm injection Embryo culture Embryo transfer
How is the natural menstrual cycle suppressed for IVF?
Prevent ovulation
Ensure ovaries respond correctly to gonadotropins
Use of either GnRH agonist or antagonists.
How does GnRH agonist work to suppress natural cycle in IVF?
e.g. goserelin given in luteal phase, around 7 days before expected period
Stimulates pituitary to produce large amount of FSH and LH, then after initial surge there is negative feedback and suppression.
How do GnRH antagonists work to suppress the natural cycle in IVF?
Injections subcutaneously
Daily
e.g. cetrorelix given starting from day 5-6 of ovarian stimulation, suppresses release of LH and ovulation
Means that follicles can be collected that have been developing, but have not been released
How does ovarian stimulation work in IVF?
Subcutaneous injections of FSH starting on day 2 of menstrual cycle for 10-14 days, promotes development of mature follicles
Development closely monitored
When enough developed, to around 18mm in size, FSH stopped and hCG given 36 hours before collection, works similarly to LH and stimulates final maturation
When are embryos transferred in IVF?
Following oocyte collection under guidance of TV scan
sperm and egg mixed in culture medium, or high quality sperm selected and injected, then left in incubator and observed for 2-5 days until they reach blastocyst
Then catheter inserted through cervix into uterus, after 2-5 days highest quality inserted
Pregnancy test after 16 days
When is progesterone administered in IVF?
From oocyte collection to 8-10 weeks gestation, usually as vaginal suppositories
Mimics progesterone usually released from corpus luteum, then placenta will take over
Are any additional scans required following IVF?
USS at 7 weeks to check for fetal heartbeat and rule out miscarriage or ectopic pregnancy, then can proceed with standard care
What are the main complications of IVF?
Failure
Multiple pregnancy
Ectopic pregnancy
Ovarian hyperstimulation syndrome
What are the complications of egg collection for IVF?
Pain, bleeding
Pelvic infection
Damage to bladder or bowel
What is ovarian hyperstimulation syndrome?
Complication of ovarian stimulation during IVF, associated with the use of HCG
What is the pathophysiology of ovarian hyperstimulation syndrome?
Increase in vascular endothelial growth factor released by granulosa cells of the follicles.
Increases vascular permeability, leads to oedema, ascites, hypovolaemia.
Trigger injection of hcg stimulates release of VEGF from follicles.
Activation of RAAS.
What are the risk factors of ovarian hyperstimulation syndrome?
Younger age Lower BMI Raised anti Mullerian hormone Higher antral follicle count Polycystic ovarian syndrome Raised oestrogen levels during ovarian stimulation
How can OHSS be prevented?
Monitor oestrogen and ultrasound to monitor follicles during stimulation with gonadotrophins
Lower doses of gonadotrophins, lower dose of HCG or alternatives
What are the features of OHSS?
Presents within 7 days of hCG injection, late if presents from 10 days onwards
Abdominal pain and bloating Nausea and vomiting Diarrhoea Hypotension Hypovolaemia Ascites Pleural effusions Renal failure Peritonitis from rupturing follicles releasing blood Prothrombotic state so risk of DVT and PE
What is the management of OHSS?
Oral fluids Monitoring urine output Low molecular weight heparin Ascitic fluid removal IV colloids e.g. human albumin solution
Haematocrit may be monitored to assess volume in intravascular space - if goes up, indicates less fluid in space as blood becoming more concentrated
What general advice would you give about taking contraceptive pills?
Doesn’t interfere with intercourse
Easily reversible
No protection against STI’s
May forget to take
How does the COCP work?
Negative feedback suppress FSH and LH surge - stop ovulation
Also thicken cervical mucus and reduce endometrial receptivity to blastocyst
What is the failure rate of the COCP?
9% with typical use - lot lower if used properly
What are the main risks and ADR’s of the COCP?
VTE
Stroke
MI Breast and cervical cancer Breakthrough bleeding Breast tenderness Mood swings
What are the main benefits of the COCP?
Easy to reverse
Relief from menstrual problems
Reduce risk of ovarian, endometrial and colorectal cancer
Reduce risk of benign breast disease and ovarian cysts
Reversible upon stopping
What is the effect of vomiting, diarrhoea or CYP inducing drugs on the efficacy of COCP?
Reduced efficacy
What are the main contraindications for the COCP?
> 35yo + smoking >15/day
Migraine with aura
Uncontrolled hypertension
History of VTE, stroke or IHD
Current breast cancer
Breast feeding <6 weeks post partum
When should you be cautious with prescribing COCP?
> 35yo + smoking <15/day
Hypertension
BMI >35 FH of VTE Immobility BRCA 1/2 Diabetes diagnosed >20 years ago
What must you advise a woman if she starts COCP on day 10 of her cycle?
Require alternative contraceptive for 7 days
Needed unless starting in first 5 days of cycle
What advice is given regarding taking the COCP?
Take at same time every day
Regimes personalised
- Continuous use 21 day, 7 day off
- Tricycling - 3 packs then 7 day break
Intercourse when on pill free period is safe if next pack started on time
What advice is given if someone misses a pill while taking the COCP?
1 missed - take missed pill next day (2 pills taken) and continue as normal
Multiple missed - take last pill the next day (2 taken) and then continue as normal. Use condoms for 7 days.
If the COCP pill is missed during week 1, what additional action is needed?
Emergency contraception
If the COCP pill is missed during week 2 what additional action is needed?
Nothing
If the COCP pill is missed during week 3, what additional action is needed?
Start next pack as soon as current finish - omit pill free period
What are the forms of combined contraception?
COCP
Transdermal patch - Evra
Vaginal ring - Nuvaring
How is the transdermal contraceptive patch taken?
Change every week for 3 weeks then remove for 7 day patch free period - withdrawal bleed
How is the vaginal contraceptive ring taken?
Ring inserted for 21 day
Remove for 7 days
Insert new ring
What is the mechanism of action of the progesterone only pill?
Thicken cervical mucus - prevent entry of sperm
Thin endometrium - inhibit implantation
Suppress ovulation (vary depending on exact pill)
How does the progesterone implant/injection work?
Suppress ovulation
+ thicken cervical mucus
+ thin endometrium
Implant = nexplanon Injectable = depo-provera
When should the progesterone only pill be taken? What should be done if you miss a pill?
Exact time every day! No pill free period
<3hr late - continue as normal
>3hr late - take missed pill ASAP, continue, cover with condoms for 48hrs
Unless started within first 5 days, alternate contraception req. for first 2 days
What are the side effects and risks of progesterone only contraception?
Irregular/heavy bleeding
Headache
Nausea
Breast tenderness
Skin changes
Increased risk of breast cancer
What is the failure rate of the progesterone only pill?
9%
What are the benefits of the progesterone only pill?
Can be used when COCP contraindicated
Reduce risk of endometrial cancer
What are the negatives of the progesterone only pill?
Increased risk of ovarian cysts
What are the contraindications for the progesterone only pill?
History of breast cancer, stroke, IHD, TIA
Liver cirrhosis
Weight >70kg
What are the benefits of the implant?
0.05% failure rate
Pill benefits +
Don’t think about contraception
Can be used at any BMI
Fertility return as soon as removed
Safe when breastfeeding
What are the negatives of the implant?
Fitting and removing can be painful and bruise
Implant may break in situ
How is the implant used?
Last for 3 years
Unless started within first 5 days, other contraception needed for 7 days
Affected by enzyme inducing drugs
What are the contraindications for the implant?
History of breast cancer, stroke, IHD, TIA
Liver cirrhosis
Unexplained vaginal bleeding
What is the failure rate of depo-provera?
6%
What are the benefits of depo-provera?
Pill benefits +
Dont think about contraception
No known drug interactions
What are the negatives of depo-provera?
Take upto 1 year for fertility to return
Gain 2-3kg weight/year
Lose bone mineral density with >1year usage
How long does depo-provera last?
12 weeks
What are the contraindications for depo-provera?
BMI > 35
Current breast cancer
History of severe arterial disease or diabetes with complications
What is the mechanism of action of the copper IUD?
Copper decrease sperm motility and survival
+ reduced penetration - copper effect on cervical mucus
+ endometrial inflammatory response reduce chance of implantation
When does the copper IUD become effective? How long does it last?
Immediately following insertion
Last 5 years
What is the failure rate of the copper IUD?
0.8%
What are the main benefits of the copper IUD?
Effective on insertion
Some last upto 10 years
No hormones
Reduced risk of endometrial cancer
No delay in return to fertility
What are the main problems with the copper IUD?
Higher risk of PID in first 20 days
Intermenstrual spotting and bleeding
Increased menstrual loss
Pelvic pain and dysmenorrhoea
What are the contraindications for copper IUD?
Wilson’s disease
Copper allergy
What is the mechanism of action of the mirena child (IUS)?
Reduce endometrial growth - prevent implantation
+ thicken cervical mucus - progesterone
When is the mirena coil effective and how long does it last?
Need alternate contraception for 7 days post insertion
Licensed for 5 years
What is the failure rate of the mirena coil?
0.2%
What are the main benefits of the Mirena coil?
Reduce blood loss and dysmenorrhoea
Reduced risk of PID compared to IUD - thickened cervical mucus
Act locally - minimal drug interactions
No delay in return to fertility
What are the main problems with the mirena coil?
6 month irregular menstruation common
When is the mirena coil contraindicated?
Breast cancer
What are the common problems associated with intrauterine contraception?
Insertion unpleasant
Risk of displacement or expulsion
Risk of uterine perforation
If pregnancy occur - higher risk of ectopic
What are the common contraindications for intrauterine contraception?
History of PID
Recent STI
Structural uterine abnormality
Ovarian, cervical or endometrial cancer
Unexplained vaginal bleeding
What are the main forms of barrier contraception?
Diaphragm and caps
Female condoms
Male condoms
What are the common benefits of barrier contraception?
No hormones - work by blocking sperm entry
What are the common risks of barrier contraception?
Can get local reaction
Not as effective
What are the ads and disads of diaphragms and caps as contraception?
Insertion before - spontaneity
Women need to be careful in using them
Little protection from STI’s
What are the ads and disads of female condoms as contraception?
Prevent against STI’s
Can be uncomfortable and noisy
What are the ads and disads of male condoms as contraception?
Prevent against STI’s
Readily available
Latex allergy
Lack spontaneity
Can break or slip off
What counselling is required for sterilisation?
Can fail - unlikely
Considered irreversibly - can be reversed privately
No protection against STI’s
Explain all other options
Which sterilisation technique is more likely to succeed/have fewer complications?
Vasectomy
What happens in a vasectomy?
Simple operation - seal vas deferens
Done under local
Doesn’t work immediately - semen analysis 12 weeks later to confirm azoospermia before unprotected sex
What are the main complications of a vasectomy?
Bruising
Haematoma
Infection
Sperm granuloma
Chronic testicular pain
How successful are vasectomy reversals?
Upto 55% if within 10 years
How is tubal occlusion carried out?
Laparoscopically or hysteroscopically
When do you become infertile following tubal occlusion?
Immediately
What are the main complications associated with tubal occlusion?
Operation complications
Risk of ectopic if fails
Some say worsening menstrual problems - pain/heavy
What are the options for emergency contraception? When can each be used?
Levonorgestrel - Within 3 days
Ulipristal - EllaOne - Within 5 Days
IUD - Within 5 days
What is the MOA of levonorgestrel?
Stop ovulation and inhibit implantation
How effective is levonorgestrel?
84% if within 72 hrs
What are the main side effects and drug interactions for levonorgestrel?
Vomiting - if within 2 hr then repeat dose
Disturb current menstrual cycle
Abdominal pain
Double dose if on enzyme inducing drugs
How does ulipristal work?
Progesterone receptor modulator - inhibit ovulation
What are the main side effects of ulipristal?
Vomiting - if within 3hrs - repeat dose
Disturb current menstrual cycle
Abdominal pain
What is important to know about using ulipristal?
Reduces effectiveness of hormonal contraception
Barrier methods should be used for 5 days after
Stop breastfeeding for 1 week
What are the contraindications of ulipristal?
Enzyme inducing drugs
Caution in severe asthma or if on Ranitidine/omeprazole
What other things should be considered when giving emergency contraception?
Offer STI screen
If <16 - prescribe emergency contraception if meet Fraser guidelines
If <12 - safeguarding
Talk about long term contraception
What contraception is given in 40-50year olds?
COCP Injectable - depo-provers POP Implant IUS
Non-hormonal - condoms, IUD - stop after 2 years amenorrhoea
What is the contraception advice in >50year olds for those on non-hormonal contraception?
Stop after 1 year amenorrhoea
What is the contraception advice in >50year olds for those on COCP?
Switch to non-hormonal or progesterone only
What is the contraception advice in >50year olds for those on depo-provera?
Switch to either non-hormonal and stop after 2 years amenorrhoea
OR
Switch to progesterone only with advice for stopping
What is the advice for progesterone only contraception (POP, IUS, Implant) in >50yo?
Can be continued
Amenorrhoeic - check FSH and stop after 1 year if FSH >=30 u/l or stop at 55yo
Not amenorrhoeic - consider investigating abnormal bleeding pattern?
What is the advantage to COCP in >40 yo?
Maintain bone mineral density
Reduce menopausal symptoms
What is the advantage of depo-provera in >40yo?
Small loss in bone mineral density
Delay in return to fertility
What contraception should be used alongside HRT?
Oestrogen and Progesterone - POP
Oestrogen alone - IUS
When is contraception needed post-partum?
After day 21
When can POP be used post partum?
Any time post partum
Need additional contraception for first 2 days
Small amount enter breast milk but harmless
When can the COCP be used post partum?
Absolutely CI if breast feeding and <6 weeks post partum
Caution 6 week - 6 month if breastfeeding
May reduce breast milk production
Can be started day 21 if not breastfeeding - need addition contraception for first 7 days
When can the IUD and IUS be used post partum?
Within 48hrs after childbirth OR
After 4 weeks
What is the lactational amenorrhoea method?
98% effective “contraception” if woman fully breast feeding, amenorrhoeic and <6months post partum
What is the UK Medical Eligibility Criteria for contraception?
UKMEC1 - no restriction in use, minimal risk
UKMEC2 - benefits generally outweigh the risks
UKMEC3 - risks generally outweigh the benefits
UKMEC4 - unacceptable risk, contraindicated
What contraception can be offered after childbirth?
Fertility not considered to return until 21 days after giving birth
Lactational amenorrhoea
POP and implant safe for breastfeeding, can be started at any time
COCP avoided
Copper coil or mirena can be inserted within 48 hours of birth or more than 4 weeks after birth but not in between
What are diaphragms and cervical caps?
Silicone caps fit over the cervix
Placed before having sex, kept in 6 hours after
Use with spermicide
What are dental dams?
Used during oral sex
Prevention against chlamydia, gonorrhoea, herpes 1 and 2, HPV, E coli, pubic lice, syphilis, HIV
What is a first line cocp?
Pill with levonoregestrel or norethisterone e.g. Microgynon or Leostrin, lower risk of VTE
What COCP is first line for premenstrual syndrome?
Yasmin or others containing drospirenone as has anti mineralocorticoid and anti androgen activity
What are the cancer risks of the COCP?
Small increased risk of breast and cervical cancer
Returns to normal ten years after stopping
What is the issue with BMI and COCP?
BMI above 35 is a UKMEC 3 - risks generally outweight benegits
What is it important to discuss in consultation for the COCP?
Different options inc LARC Contraindications Adverse effects e.g. HTN, headaches, VTE, cancer, MI Instructions Missed pills Efficacy STIs not protected Safeguarding concerns
When must COCP be stopped before surgery?
Four weeks before major operation lasting >30 mins or any procedure requiring the lower limb to be immobilised
What are missed more than one pill rules?
Day 1-7 - emergency contraception
Day 8-14 - if days 1-7 fully compliant, no emergency contraception
Day 15-21 no emergency contraception if fully compliant, skip break
Take most recent missed pill, use additional contraception e.g. condoms for 7 days
When can the POP be started?
On day 1 to 5 of menstrual cycle and be protected immediately
Can be started at other times, but then need 48 hours use of other contraception
When can switching to POP occur?
Can be switched between types of POPs mmediately without any other contraception
From COCP, depends where in packet, best to swap during hormone free period after finishing pack
Otherwise at any other point need to use condoms for 28 hours
When is emergency contraception required for the POP?
More than 3 hours late on traditional, or more than 12 hours late on desogestrel
Take pill ASAP use extra contraception for next 48 hours
If had sex since missed pill, or within 48 hours of restarting regular pills then need emergency contraception
Same for diarrhoea and vomiting
What are the contraindications to progesterone only injection?
UKMEC 4 - active breast cancer
UKMEC3 - ischaemic heart disease, stroke, unexplained vaginal bleeding, severe liver cirrhosis, liver cancer
When can the depo injection be given?
Day 1-5 immediate protection
After Day 5, need 7 days of extra contraception
What are the benefits to the injection contraception?
Improves dysmenorrhoea
Improves endometriosis symptoms
Reduces risk of ovarian and endometrial cancer
Reduces severity of sickle cell crisis
When can the implant be inserted?
Day 1 to 5 immediate protection
After Day 5 7 days of extra contraception needed
Where is the implant inserted?
One third up the upper arm on the medial side
Lidocaine used for insertion
What are some of the benefits of the implant?
Effective, reliable Improve dysmenorrhoea Make periods lighter No need to remember Does not cause weight gain No effect on bone mineral density unlike depo No increase in thrombosis risk unlike COCP No restrictions if obese
What are the risks of insertion of the coil?
Bleeding
Pain on insertion
Vasovagal reactions e.g. dizziness, bradycardia, arrhythmias
Uterine perforation
PID
Expulsion rate highest in first three months
What needs to be excluded if the threads of the coil cannot be felt?
Expulsion
Pregnancy
Uterine perforation
Extra contraception required until can be located
What are side effects of levonorgestrel?
Spotting and changes to next menstrual period Diarrhoea Breast tenderness Dizziness Depressed mood
What are side effects of ella one?
Spotting and changes to next period Abdominal or pelvic pain Back pain Mood changes Headache Dizziness Breast tenderness
When can EllaOne be given?
Up to 120 hours after intercourse, one 30mg dose
Breastfeeding should be avoided for 1 week after taking ulipristal
Ulipristal should be avoided in patients with severe asthma
What are the fraser guidelines?
Mature and intelligent enough to understand the treatment
Cannot be persuaded to discuss with parents or let the health professional discuss it
Likely to have intercourse regardless of treatment
Physical and/or mental health likely to suffer without treatment
Treatment in their best interest
What is a normal sperm count in ejaculate?
39-928 million
What is the normal ejaculate volume?
1.5-7.6 mL
What is a normal sperm concentration?
15-259 million per mL
What is normal total motility on sperm analysis?
40-81%
If semen analysis is abnormal, when should it be repeated?
3 months time
