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Gynae > Fertility and Contraception > Flashcards

Fertility and Contraception Flashcards

1
Q

Types of assisted conception

A

Intrauterine Insemination (IUI)
Involves directly inserting the sperm into the patient’s uterus

In Vitro Fertilisation (IVF)
The egg and sperm are fused in a controlled laboratory setting before implanting the zygote into the uterus

Intra-Cytoplasmic Sperm Injection (ICSI)
Form of IVF in which the sperm is injected directly into the egg before implanting the zygote into the uterus

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2
Q

What is intrauterine insemination? What does it consist of?

A

Type of assisted conception

Involves directly inserting the sperm into the patient’s uterusW

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3
Q

What is IVF? What does it consist of?

A

Type of assisted conception

The egg and sperm are fused in a controlled laboratory setting before implanting the zygote into the uterus

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4
Q

What is intra-cyotplasmic sperm injection (ICSI)? What does it consist of?

A

Type of assisted conception

Form of IVF in which the sperm is injected directly into the egg before implanting the zygote into the uterus

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5
Q

NHS criteria for IVF in women <40 years

A

Eligible for 3 cycles of IVF if:
Been trying to get pregnant through regular unprotected sex for 2 years
Been unable to get pregnant after 12 cycles of artificial insemination, with at least 6 of the cycles using IUI

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6
Q

NHS criteria for IVF in women >40 years

A

Eligible for 1 cycle of IVF if:
Been trying to get pregnant through regular unprotected sex for 2 years
Been unable to get pregnant after 12 cycles of artificial insemination, with at least 6 of the cycles using IUI
Have never received IVF before
There is no evidence of low ovarian reserve
Have been informed about the additional implications of IVF and pregnancy at their age

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7
Q

What is classed as regular unprotected sex?

A

Regular sexual intercourse is defined as intercourse every2-3day

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8
Q

Risks of IVF

A

Multiple births
Prematurity and low birth weight
Ovarian hyperstimulation syndrome
Miscarriage
Ectopic pregnancy
Birth defects

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9
Q

Types of short acting contraception

A

COCP
POP
Patch
Ring

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10
Q

What hormone in COCP?

A

Hormone: Ethinyl Oestradiol + Progestin (e.g. desogestrel, levonorgestrel)

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11
Q

Mechanism of COCP

A

Mechanism: Prevents Ovulation

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12
Q

How to take COCP

A

1 tablet per day for 3 weeks followed by 1 week off (withdrawal bleed). Can tricycle (take back to back without pill-free break) to reduce the frequency of withdrawal bleed.
If started on the first 5 days of a 28-day cycle, it confers immediate protection

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13
Q

What does COCP reduce the risk of?

A

Reduced risk of ovarian, endometrial and bowel cancer

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14
Q

Disadvantages of COCP

A

No protection against STIs
Increased risk of VTE, breast cancer, cervical cancer, stroke and ischaemic heart disease

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15
Q

SEs of COCP

A

Headache
Nausea
Breast tenderness

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16
Q

What to do if vomiting in COCP?

A

Vomiting: if vomiting within 2 hours of taking the pill, take another

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17
Q

COCP and surgery

A

Surgery: stop at least 4 weeks before surgery

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18
Q

How many weeks before surgery to stop COCP?

A

4 weeks

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19
Q

Absolute CIs for COCP

A

Less than 6 weeks postpartum and breastfeeding
Smoker over the age of 35 years (> 15 cigarettes per day)
Hypertension (> 160/100 mm Hg)
Current or past history of VTE
Ischaemic heart disease
History of cerebrovascular accident
Complicated valvular heart disease
Migraine with aura
Current breast cancer
Diabetes with retinopathy, nephropathy or neuropathy
Severe cirrhosis
Liver tumour (adenoma or hepatoma)

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20
Q

Can you take COCP with current breast cancer?

A

NO

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21
Q

Can you take COCP with migraine with aura?

A

NO

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22
Q

What age and how many should you smoke to be ineligible for COCP?

A

Smoker over the age of 35 years (> 15 cigarettes per day)

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23
Q

Can you take COCP post partum?

A

Not if Less than 6 weeks postpartum and breastfeeding

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24
Q

Missed pill rules for COCP

A

1 Pill Missed: take last pill and the current pill (even if that means 2 in 1 day), no other contraception needed

2 Pills Missed: take last pill and current pill (even if that means 2 in 1 day) and continue taking pills
Use condoms until pill has been taken correctly for 7 days in a row
If 2 Missed in Week 1: consider emergency contraception
If 2 Missed in Week 2: no need for emergency contraception
If 2 Missed in Week 3: finish pills in current pack and start the new pack immediately with no pill-free break

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25
What to if 1 pill missed in COCP
1 Pill Missed: take last pill and the current pill (even if that means 2 in 1 day), no other contraception needed
26
What to do if 2 pills missed in COCP
2 Pills Missed: take last pill and current pill (even if that means 2 in 1 day) and continue taking pills Use condoms until pill has been taken correctly for 7 days in a row If 2 Missed in Week 1: consider emergency contraception If 2 Missed in Week 2: no need for emergency contraception If 2 Missed in Week 3: finish pills in current pack and start the new pack immediately with no pill-free break
27
What to do if 2 pills missed in week 1 of COCP?
If 2 Missed in Week 1: consider emergency contraception
28
When to use condoms if missed pills in COCP?
If 2 pills missed, Use condoms until pill has been taken correctly for 7 days in a row
29
What to do if 2 pills missed in week 2 of COCP?
If 2 Missed in Week 2: no need for emergency contraception
30
What to do if 2 pills missed in week 3 of COCP?
If 2 Missed in Week 3: finish pills in current pack and start the new pack immediately with no pill-free break
31
Hormone in POP
Hormone: Desogestrel, Levonorgestrel or Norethistrone
32
MOA of POP
Mechanism: Thickens Cervical Mucus NOTE: Desogestrel stops ovulation
33
How to take POP?
How to Take: 1 pill at the same time every day with NO pill-free week If starting within the first 5 days of your cycle, provides immediate protection If starting at any other time, use additional measures for the first 2 days If switching from the COCP, provides immediate protection
34
Does POP have a pill free week?
No, COCP does
35
Does POP have same risks as COCP?
No, there is no Increased risk of VTE, breast cancer, cervical cancer, stroke and ischaemic heart disease
36
Does POP provide immediate protection?
If starting within the first 5 days of your cycle, provides immediate protection If starting at any other time, use additional measures for the first 2 days If switching from the COCP, provides immediate protection
37
Disadvantages of POP
Must be taken at the same time every day Irregular bleeding Osteoporosis Ovarian cysts
38
SEs of POP
Acne Breast tenderness Mood changes Headaches
39
What to if <3 hours late of POP
If < 3 hours late: continue as normal
40
What to do if >3 hours late of POP
If > 3 hours late: take missed pill ASAP, continue with rest of pack, extra precautions (condoms) until pill taking has been correctly re-established for 48 hours If missed 2 or more pills, take the last missed pill and the next pill, and use barrier methods until pill-taking has been correctly re-established for 48 hours Emergency contraception may be needed if the patient had unprotected sexual intercourse during this interval
41
Missed pill rules for POP
If < 3 hours late: continue as normal If > 3 hours late: take missed pill ASAP, continue with rest of pack, extra precautions (condoms) until pill taking has been correctly re-established for 48 hours If missed 2 or more pills, take the last missed pill and the next pill, and use barrier methods until pill-taking has been correctly re-established for 48 hours Emergency contraception may be needed if the patient had unprotected sexual intercourse during this interval
42
What to do if missed 2 or more pills in POP?
If missed 2 or more pills, take the last missed pill and the next pill, and use barrier methods until pill-taking has been correctly re-established for 48 hours Emergency contraception may be needed if the patient had unprotected sexual intercourse during this interval
43
How to take combined hormonal transdermal patch?
How to Take: Apply for 1 patch per week for 3 weeks and take 1 week off (withdrawal bleed)
44
Missed patch rules
Delayed change < 48 hours: change immediately with no further precautions Delayed change > 48 hours in week 1 or 2: change immediately and use barrier contraception for 7 days (if unprotected sexual intercourse took place within the previous 5 days or during extended patch-free period, consider emergency contraception) Delayed removal > 48 hours in week 3: remove immediately and apply next patch on the usual start date of the next cycle (no additional contraception needed) Delayed application at the end of the patch-free week: use barrier contraception for 7 days
45
What to do if delayed patch change <48 hours?
Delayed change < 48 hours: change immediately with no further precautions
46
What to do if delayed patch change >48 hours in week 1 or 2?
Delayed change > 48 hours in week 1 or 2: change immediately and use barrier contraception for 7 days (if unprotected sexual intercourse took place within the previous 5 days or during extended patch-free period, consider emergency contraception)
47
What to do if delayed patch removal >48 hours in week 3?
Delayed removal > 48 hours in week 3: remove immediately and apply next patch on the usual start date of the next cycle (no additional contraception needed)
48
What to do if delayed application at the end of patch free week>
use barrier contraception for 7 days
49
Types of long acting reversible contraceptives
Levonorgesteral intrauterine system Copper IUD Implant Depot injection
50
How long does IUS remain?
3-5 years
51
Mechanism of IUS
Mechanism: Thins the lining of the uterus and prevents implantation Patients tend to experience lighter, less painful periods Additional contraception is needed for 7 days after insertion unless it is inserted in the first 7 days of a cycle
52
SEs of IUS
Can cause irregular and heavier periods for the first 3-6 months after insertion Acne Breast tenderness Mood disturbance Headaches
53
Is additional contraception needed for IUS?
Additional contraception is needed for 7 days after insertion unless it is inserted in the first 7 days of a cycle
54
How long does Copper IUD last?
5-10 years
55
Mechanism of Copper IUD
Mechanism: Acts as a spermicide and causes sterile inflammation of the uterus, thereby preventing implantation Works immediately and can be inserted at any point in the menstrual cycle Can be used as emergency contraception if inserted within 5 days of unprotected sexual intercourse
56
What else can copper IUD be used as?
Can be used as emergency contraception if inserted within 5 days of unprotected sexual intercourse
57
How long does Copper IUD take to work?
Works immediately and can be inserted at any point in the menstrual cycle
58
pill that inhibits ovulation
COCP
59
pill that thickens cervical mucus
POP
60
thins cervical lining and stops implantaiton
IUS
61
acts as a spermicide and stops implantation
Copper IUDSE
62
SEs of copper UD
Often makes periods heavier and more painful Risk of expulsion, infection and perforation
63
Mechanism of implant
prevents ovulation
64
How to take implant?
How to Take: A small rode containing progesterone is inserted into the non-dominant arm and lasts for 3 years Fertility is restored immediately after removal Additional contraception is needed for 7 days if it is not inserted on day 1-5 of the menstrual cycle
65
duration of implant
3 years
66
Is additional contraception needed with implant?
Additional contraception is needed for 7 days if it is not inserted on day 1-5 of the menstrual cycle
67
SEs of implant
Irregular bleeding Mood changes Breast tenderness
68
What hormone in implant?
Hormone: Etonogestrel
69
What hormone in depot injection?
Hormone: Medroxyprogesterone Acetate
70
How to take depot injection?
How to Take: Intramuscular injection that provides effective contraception for 12-14 weeks Use other forms of contraception for the first 7 days unless the injection is given during the first 5 days of a cycle
71
Is additional contraception needed with depot injection?
Use other forms of contraception for the first 7 days unless the injection is given during the first 5 days of a cycle
72
SEs of depot injection
Weight gain Reduced bone density Irregular periods May take up to 6-12 months after the last injection for fertility to return
73
Options for emergency contraception
Levonorgestrel Ulipristal Copper Intrauterine Device
74
When must levonorgesterl be taken?
Must be taken within 72 hours of unprotected sexual intercourse
75
Brand name of levonorgestrel
Brand Name: Levonelle
76
MOA of levenogesterel
Stops ovulation and inhibits implantation
77
Can levnonorgestrel be used more than once in a single menstrual cycle?
Can be used more than once during a single menstrual cycle if needed
78
Brand name of Ulipristal
Brand Name: EllaOne
79
When must Ulipristal be taken?
Must be taken within 120 hours of unprotected sexual intercourse
80
MOA of ulipristal
Inhibits ovulation
81
Should ulipristal be used with levonorgestrel
NO
82
Who can't use ulipristal?
Caution is advised in patients with severe asthma
83
What to do if patient's bodyweight >70 or BMI >26 and require emergency contraception?
Ulipristal is the preferred option If levonorgestrel is taken, a double dose should be given (3 mg)
84
When to give double dose of levonorgestrel?
If Patient's Bodyweight > 70 kg or BMI > 26
85
When must copper IUD be inserted?
Must be inserted within 120 hours of unprotected sexual intercourse
86
MOA of copper IUD
Acts as a spermicide and prevents implantation
87
What is PID?
Inflammation of the reproductive tract due to infection (usually ascending from the vagina and endocervix).
88
Types of PID
Cervicitis Endometritis Salpingitis Oophoritis Peritonitis
89
Causes of PID
Neisseria gonorrhoea Chlamydia trachomatis Mycoplasma genitalum
90
RFs of PID
Multiple sexual partners Younger age Intrauterine device Previous pelvic inflammatory diseas
91
Presentation of PID
Abnormal vaginal discharge or bleeding Lower abdominal pain Deep dyspareunia Fever Dysuria Cervical excitation (upon bimanual examination)
92
What may be seen on bimanual examiantion in PID/
Cervical excitation
93
Investigations for PID
Bedside Urine Pregnancy Test Urine Dipstick and MSU Speculum Examination Endocervical and High Vaginal Swabs Bloods HIV Test Syphilis Serology FBC and CRP Blood Cultures Imaging & Other Transvaginal Ultrasound Scan Useful to rule out tubo-ovarian abscess formation
94
What swabs should be done in investigations for PID?
Endocervical and High Vaginal Swabs
95
Important blood tests to do for PID
HIV Test Syphilis Serology
96
What are you trying to rule out on TVUSS of PID?
Useful to rule out tubo-ovarian abscess formation
97
How to manage PID if IUD is in situ?
Consider removal if the patient has failed to respond after 72 hours of treatment If removing intrauterine device, must ask when last unprotected sexual intercourse was and offer emergency contraception if required If removed, the device should be sent for culture
98
Outpatient AB regimen for PID
Ceftriaxone 500 mg IM STAT Doxycycline 100 mg BD PO for 14 days Metronidazole 400 mg BD PO for 14 days Alternative: Ofloxacin and Metronidazole for 14 days
99
Management of PID if pyrexial or failure of oral treatment
1st Line: IV Cefoxitin and Doxycycline Doxycycline is contraindicated in pregnancy 2nd Line: IV Clindamycin and Gentamicin
100
BIGGEST COMPLICATION OF PID
SUBFERTILITY
101
Complications of PID
Subfertility Increased future risk of ectopic pregnancy Chronic pelvic pain Tubo-ovarian abscess formation Asherman Syndrome Fitz-Hugh-Curtis Syndrome Perihepatitis in the context of pelvic inflammatory disease
102
What is fitz-hugh-curtis syndrome?
Perihepatitis in the context of pelvic inflammatory disease
103
Defintion of premature ovarian insufficiency
Reaching menopause before the age of 40 years.
104
RFs for premature ovarian insufficiency
Often idiopathic Genetic conditions (e.g. Turner syndrome) Autoimmune diseases (e.g. thyroid disorders) Previous chemotherapy or radiotherapy Infections (e.g. tuberculosis, malaria and mumps) Iatrogenic (surgicla removal of ovaries)
105
Most common cause of secondary amenorrhoea
pregnancy
105
Clinical features of premature ovarian insufficiency
Hot flushes Mood swings Night sweats Sleep disturbance Weight gain
105
What can be used as a measure of ovarian reserve?
Anti-Mullerian hormone (measure of ovarian reserve)
105
Investigations for premature ovarian insufficiency
Bedside Urine Pregnancy Test Pregnancy is the most common cause of secondary amenorrhoea Bloods Serum LH and FSH 2 x FSH results > 40 IU/L recorded at least twice at an interval of 4-6 weeks is diagnostic of premature ovarian insufficiency Serum oestrogen and testosterone TFT Antral follicle count Anti-Mullerian hormone (measure of ovarian reserve)
106
Management of menopausal symptoms in premature ovarian insufficiency
Hormone Replacement Therapy Non-Hormonal Agents (e.g. lubricants, SSRIs, clonidine)
106
What blood tests are diagnostic of premature ovarian insufficiency?
Serum LH and FSH 2 x FSH results > 40 IU/L recorded at least twice at an interval of 4-6 weeks is diagnostic of premature ovarian insufficiency
107
Management of infertility in premature ovarian insufficiency
May still be able to have children via IVF using eggs from a donor or if the patient's own eggs had been frozen Surrogacy and adoption are other options
108
What is subfertility defined as?
Inability to get pregnant after 12 months of regular unprotected sexual intercourse.
109
Requirements for conception
Release of normal oocyte Production of adequate sperm Adequate motility of sperm Favourable uterine conditions for implantation
110
What can female causes of subfertility be split into?
Ovulatory Fallopian tube
111
Ovulatory causes of subfertility
Hyperprolactinaemia Hyperthyroidism Premature Ovarian Failure Polycystic Ovarian Syndrome
112
Fallopian tube causes of subfertility
Previous pelvic inflammatory disease Endometriosis Scarring from surgical procedures (e.g. management of ectopic pregnancy) Previous ectopic pregnancy
113
Investigations for subfertility
Bloods Midluteal Progesterone (to check whether ovulation is happening) Hormone Profile Imaging & Other Transvaginal Ultrasound Scan Hysteroscopy or Hysterosalpingogram Laparoscopy STI Screen
114
What blood test can be done to check whether ovulation is happening?
Midluteal Progesterone (to check whether ovulation is happening)
115
Male causes of subfertility
Oligospermia (not enough sperm) Asthenozoospermia (poor motility of sperm) Teratozoospermia (abnormal sperm morphology) Azoospermia (no sperm in ejaculate)
116
Oligospermia
not enough spermA
117
Asthenozoospermia
poor sperm motility
118
Teratozoospermia
abnormal sperm morphology
119
Azoospermia
no sperm in ejaculate
120

Gynae (8 decks)

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