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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
Q

What to if 1 pill missed in COCP

A

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

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26
Q

What to do if 2 pills missed in COCP

A

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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27
Q

What to do if 2 pills missed in week 1 of COCP?

A

If 2 Missed in Week 1: consider emergency contraception

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28
Q

When to use condoms if missed pills in COCP?

A

If 2 pills missed, Use condoms until pill has been taken correctly for 7 days in a row

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29
Q

What to do if 2 pills missed in week 2 of COCP?

A

If 2 Missed in Week 2: no need for emergency contraception

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30
Q

What to do if 2 pills missed in week 3 of COCP?

A

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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31
Q

Hormone in POP

A

Hormone: Desogestrel, Levonorgestrel or Norethistrone

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32
Q

MOA of POP

A

Mechanism: Thickens Cervical Mucus
NOTE: Desogestrel stops ovulation

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33
Q

How to take POP?

A

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

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34
Q

Does POP have a pill free week?

A

No, COCP does

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35
Q

Does POP have same risks as COCP?

A

No, there is no Increased risk of VTE, breast cancer, cervical cancer, stroke and ischaemic heart disease

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36
Q

Does POP provide immediate protection?

A

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

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37
Q

Disadvantages of POP

A

Must be taken at the same time every day
Irregular bleeding
Osteoporosis
Ovarian cysts

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38
Q

SEs of POP

A

Acne
Breast tenderness
Mood changes
Headaches

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39
Q

What to if <3 hours late of POP

A

If < 3 hours late: continue as normal

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40
Q

What to do if >3 hours late of POP

A

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

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41
Q

Missed pill rules for POP

A

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

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42
Q

What to do if missed 2 or more pills in POP?

A

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

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43
Q

How to take combined hormonal transdermal patch?

A

How to Take: Apply for 1 patch per week for 3 weeks and take 1 week off (withdrawal bleed)

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44
Q

Missed patch rules

A

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

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45
Q

What to do if delayed patch change <48 hours?

A

Delayed change < 48 hours: change immediately with no further precautions

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46
Q

What to do if delayed patch change >48 hours in week 1 or 2?

A

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)

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47
Q

What to do if delayed patch removal >48 hours in week 3?

A

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)

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48
Q

What to do if delayed application at the end of patch free week>

A

use barrier contraception for 7 days

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49
Q

Types of long acting reversible contraceptives

A

Levonorgesteral intrauterine system
Copper IUD
Implant
Depot injection

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50
Q

How long does IUS remain?

A

3-5 years

51
Q

Mechanism of IUS

A

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
Q

SEs of IUS

A

Can cause irregular and heavier periods for the first 3-6 months after insertion
Acne
Breast tenderness
Mood disturbance
Headaches

53
Q

Is additional contraception needed for IUS?

A

Additional contraception is needed for 7 days after insertion unless it is inserted in the first 7 days of a cycle

54
Q

How long does Copper IUD last?

A

5-10 years

55
Q

Mechanism of Copper IUD

A

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
Q

What else can copper IUD be used as?

A

Can be used as emergency contraception if inserted within 5 days of unprotected sexual intercourse

57
Q

How long does Copper IUD take to work?

A

Works immediately and can be inserted at any point in the menstrual cycle

58
Q

pill that inhibits ovulation

A

COCP

59
Q

pill that thickens cervical mucus

A

POP

60
Q

thins cervical lining and stops implantaiton

A

IUS

61
Q

acts as a spermicide and stops implantation

A

Copper IUDSE

62
Q

SEs of copper UD

A

Often makes periods heavier and more painful
Risk of expulsion, infection and perforation

63
Q

Mechanism of implant

A

prevents ovulation

64
Q

How to take implant?

A

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
Q

duration of implant

A

3 years

66
Q

Is additional contraception needed with implant?

A

Additional contraception is needed for 7 days if it is not inserted on day 1-5 of the menstrual cycle

67
Q

SEs of implant

A

Irregular bleeding
Mood changes
Breast tenderness

68
Q

What hormone in implant?

A

Hormone: Etonogestrel

69
Q

What hormone in depot injection?

A

Hormone: Medroxyprogesterone Acetate

70
Q

How to take depot injection?

A

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
Q

Is additional contraception needed with depot injection?

A

Use other forms of contraception for the first 7 days unless the injection is given during the first 5 days of a cycle

72
Q

SEs of depot injection

A

Weight gain
Reduced bone density
Irregular periods
May take up to 6-12 months after the last injection for fertility to return

73
Q

Options for emergency contraception

A

Levonorgestrel
Ulipristal
Copper Intrauterine Device

74
Q

When must levonorgesterl be taken?

A

Must be taken within 72 hours of unprotected sexual intercourse

75
Q

Brand name of levonorgestrel

A

Brand Name: Levonelle

76
Q

MOA of levenogesterel

A

Stops ovulation and inhibits implantation

77
Q

Can levnonorgestrel be used more than once in a single menstrual cycle?

A

Can be used more than once during a single menstrual cycle if needed

78
Q

Brand name of Ulipristal

A

Brand Name: EllaOne

79
Q

When must Ulipristal be taken?

A

Must be taken within 120 hours of unprotected sexual intercourse

80
Q

MOA of ulipristal

A

Inhibits ovulation

81
Q

Should ulipristal be used with levonorgestrel

A

NO

82
Q

Who can’t use ulipristal?

A

Caution is advised in patients with severe asthma

83
Q

What to do if patient’s bodyweight >70 or BMI >26 and require emergency contraception?

A

Ulipristal is the preferred option
If levonorgestrel is taken, a double dose should be given (3 mg)

84
Q

When to give double dose of levonorgestrel?

A

If Patient’s Bodyweight > 70 kg or BMI > 26

85
Q

When must copper IUD be inserted?

A

Must be inserted within 120 hours of unprotected sexual intercourse

86
Q

MOA of copper IUD

A

Acts as a spermicide and prevents implantation

87
Q

What is PID?

A

Inflammation of the reproductive tract due to infection (usually ascending from the vagina and endocervix).

88
Q

Types of PID

A

Cervicitis
Endometritis
Salpingitis
Oophoritis
Peritonitis

89
Q

Causes of PID

A

Neisseria gonorrhoea
Chlamydia trachomatis
Mycoplasma genitalum

90
Q

RFs of PID

A

Multiple sexual partners
Younger age
Intrauterine device
Previous pelvic inflammatory diseas

91
Q

Presentation of PID

A

Abnormal vaginal discharge or bleeding
Lower abdominal pain
Deep dyspareunia
Fever
Dysuria
Cervical excitation (upon bimanual examination)

92
Q

What may be seen on bimanual examiantion in PID/

A

Cervical excitation

93
Q

Investigations for PID

A

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
Q

What swabs should be done in investigations for PID?

A

Endocervical and High Vaginal Swabs

95
Q

Important blood tests to do for PID

A

HIV Test
Syphilis Serology

96
Q

What are you trying to rule out on TVUSS of PID?

A

Useful to rule out tubo-ovarian abscess formation

97
Q

How to manage PID if IUD is in situ?

A

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
Q

Outpatient AB regimen for PID

A

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
Q

Management of PID if pyrexial or failure of oral treatment

A

1st Line: IV Cefoxitin and Doxycycline
Doxycycline is contraindicated in pregnancy
2nd Line: IV Clindamycin and Gentamicin

100
Q

BIGGEST COMPLICATION OF PID

A

SUBFERTILITY

101
Q

Complications of PID

A

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
Q

What is fitz-hugh-curtis syndrome?

A

Perihepatitis in the context of pelvic inflammatory disease

103
Q

Defintion of premature ovarian insufficiency

A

Reaching menopause before the age of 40 years.

104
Q

RFs for premature ovarian insufficiency

A

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
Q

Most common cause of secondary amenorrhoea

A

pregnancy

105
Q

Clinical features of premature ovarian insufficiency

A

Hot flushes
Mood swings
Night sweats
Sleep disturbance
Weight gain

105
Q

What can be used as a measure of ovarian reserve?

A

Anti-Mullerian hormone (measure of ovarian reserve)

105
Q

Investigations for premature ovarian insufficiency

A

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
Q

Management of menopausal symptoms in premature ovarian insufficiency

A

Hormone Replacement Therapy
Non-Hormonal Agents (e.g. lubricants, SSRIs, clonidine)

106
Q

What blood tests are diagnostic of premature ovarian insufficiency?

A

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
Q

Management of infertility in premature ovarian insufficiency

A

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
Q

What is subfertility defined as?

A

Inability to get pregnant after 12 months of regular unprotected sexual intercourse.

109
Q

Requirements for conception

A

Release of normal oocyte
Production of adequate sperm
Adequate motility of sperm
Favourable uterine conditions for implantation

110
Q

What can female causes of subfertility be split into?

A

Ovulatory
Fallopian tube

111
Q

Ovulatory causes of subfertility

A

Hyperprolactinaemia
Hyperthyroidism
Premature Ovarian Failure
Polycystic Ovarian Syndrome

112
Q

Fallopian tube causes of subfertility

A

Previous pelvic inflammatory disease
Endometriosis
Scarring from surgical procedures (e.g. management of ectopic pregnancy)
Previous ectopic pregnancy

113
Q

Investigations for subfertility

A

Bloods
Midluteal Progesterone (to check whether ovulation is happening)
Hormone Profile

Imaging & Other
Transvaginal Ultrasound Scan
Hysteroscopy or Hysterosalpingogram
Laparoscopy
STI Screen

114
Q

What blood test can be done to check whether ovulation is happening?

A

Midluteal Progesterone (to check whether ovulation is happening)

115
Q

Male causes of subfertility

A

Oligospermia (not enough sperm)
Asthenozoospermia (poor motility of sperm)
Teratozoospermia (abnormal sperm morphology)
Azoospermia (no sperm in ejaculate)

116
Q

Oligospermia

A

not enough spermA

117
Q

Asthenozoospermia

A

poor sperm motility

118
Q

Teratozoospermia

A

abnormal sperm morphology

119
Q

Azoospermia

A

no sperm in ejaculate

120
Q
A

Gynae (8 decks)

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