Fertility and Infertility Flashcards
1
Q
Give an overview of the use of Combined hormonal contraceptives (CHC)
A
- Available as tablets (COC), transdermal patches (CTP), and vaginal rings (CVR).
- Highly user-dependent methods where the failure rate if used perfectly (i.e. correctly and consistently) is less than 1%.
- Certain factors such as the person’s weight, malabsorption including diarrhoea and vomiting (COC only), and drug interactions (enzyme-inducing drugs) may contribute to contraceptive failure.
- Prescriptions of up to 12 months’ supply for CHC initiation or continuation may be appropriate to avoid unwanted discontinuation and increased risk of pregnancy.
- Should not be continued beyond 50 years of age as safer alternatives exist.
2
Q
What are the benefits of CHC?
A
- Reduced risk of ovarian, endometrial and colorectal cancer;
- Predictable bleeding patterns
- Reduced dysmenorrhoea and menorrhagia;
- Management of symptoms of polycystic ovary syndrome (PCOS), endometriosis and premenstrual syndrome;
- Improvement of acne;
- Reduced menopausal symptoms;
- Maintaining bone mineral density in peri-menopausal females under the age of 50 years.
3
Q
What are the risks of CHC?
A
- Breast cancer and cervical cancer associated with current or recent use of CHC is small, but is greater than that with progestogen-only or non-hormonal contraception.
- Venous and arterial thromboembolism
- CHC is associated with a 3- to 3.5-fold increase in VTE risk compared with non-use of CHC.
- Absolute risk of VTE during use of CHC is estimated by the European Medicines Agency to be between 5 and 12 per 10 000 women per year of use compared to 2 per 10 000 non-CHC users per year.
- NB VTE risk is lower during CHC use than during pregnancy and the postpartum period.214–221 By reducing rates of unplanned pregnancy, CHC use lowers the overall rate of VTE in the population in comparison to populations without access to effective contraception.
- VTE events that do occur during use of CHC, approximately 1% are fatal
- CHC is associated with a 3- to 3.5-fold increase in VTE risk compared with non-use of CHC.
- Levonorgestrel (LNG), norethisterone (NET) and norgestimate COC are associated with a lower risk of venous thromboembolic events than COC containing newer progestogens, the combined transdermal patch and the combined vaginal ring.
- COC containing higher EE (ethinylestradiol) doses may be associated with greater risk of arterial thrombotic events than lower EE doses.
4
Q
What are eh potential regimens for CHC use?
A
5
Q
How do Oral Progesterone-only contraceptives work?
A
- Alter cervical mucus to prevent sperm penetration and may inhibit ovulation in some women;
- Oral desogestrel-only preparations consistently inhibit ovulation and this is their primary mechanism of action.
- Progestogen-only contraceptives offer a suitable alternative to combined hormonal contraceptives when oestrogens are contra-indicated
- in women with increased risk of atrial thrombosis
6
Q
What are the parenteral progestogen-only contraceptives?
A
-
Medroxyprogesterone acetate: long-acting progestogen given by injection
- delayed return of fertility and irregular cycles may occur after discontinuation of treatment (up to 1-2 years) but there is no evidence of permanent fertility
-
Norethisterone enantate: long-acting progestogen given as an oily injection, gives contraception for 8 weeks
- used as short-term interim contraception (before vasectomy becomes effective)
-
Etonogestrel-releasing implant: inserted subdermally into the lower surface of the arm, provides contraception for up to 3 years
- weight dependent (larger woman may not be as effective in the 3rd year)
- rapid reversal of removal
7
Q
What are the Inra-uterine Progestogen-only devices used for contraceptive?
A
- Mirena®, Jaydess® and Levosert® release levonorgestrel directly into the uterine cavity.
- Licensed for contraception and some licensed for the treatment of menorrhagia
- Effects
- prevent endometrial proliferation
- thickening of cervical mucus
- suppression of ovulation in some women in some cycles
- the intra-uterine system itself may contribute slightly to the contraceptive effect
- return of fertility after removal is rapid and complete
- has advantages over copper intrauterine devices: improvement in any dysmenorrhoea and a reduction in blood loss, possibly reduced pelvic inflammatory disease
8
Q
What are the comparative contraceptive success rates
- CHC
- various progestogen-only
A
9
Q
What types of emergency contraception are there?
A
- hormonal emergency contraceptives these should be taken as soon as possible after unprotected intercourse, if an inter-uterine coil is not effective, use of hormonal emergency contraceptives after ovulation is ineffective
-
Levonorgestrel
- effective within 72 hours of unprotected intercourse (up to 92hours), efficacy decreases with time
-
Ulipristal acetate
- effective within 120 hours (5 days), potentially more effective than levonorgestrel
- first-line treatment
- a higher body-weight or BMI could reduce the effectiveness of oral emergency contraception
- ulipristal first-line or double dose of levonorgestrel
10
Q
What are the options for male hormonal contraceptives?
(non are licensed in the UK)
A
- Testosterone enanthate on larges of 200mg/week
- Testosterone undecanoate
- Depot medroxyprogesterone acetate as a depot
- targeting testosterone to produce a negative feedback loop whereby GnRH is reduced —> reduced follicle stimulation so spermatogenesis is reduced
11
Q
What are the side effects of male contraceptives?
A
- testosterone-only regimens: acne, altered libido, night sweats, increased weight, and mood changes.
- The combination of testosterone with a progestin allowed a reduction of testosterone dose minimizing androgenic side effects.
- Progestins derived from nortestosterone, which retain their androgenic activity, more often caused androgen-related adverse side effects such as weight gain, acne, or decreased HDL-cholesterol.
- Interestingly, adverse side events reported by 93% of men on active treatment were also reported by 81% of men on placebo treatment.
12
Q
What doe NICE guidelines say about infertility?
A
- refer the individuals early for specialist consultation
- Women aged >36 years
- There is a known cause of infertility or history of predisposing factors
- Investigations show there is no chance of pregnancy with expectant management
13
Q
What is infertility?
A
- Failure to achieve pregnancy after two years of frequent unprotected intercourse
- Six months for 2ry infertility and women above 36 year old
- Affects 1:6 couples (15%)
“The period of time people have been trying to conceive without success after which formal investigation is justified and possible treatment implemented”
14
Q
What are the rates of inferitlity in terms of the individual?
A
- Female Factor - 30%
- Male Factor -30%
- Combined - 10%
- Unexplained - 25%
- Other causes - 5%
15
Q
What are the female factors that cause infertility?
A
- Ovulation disorder:
- PCO (80%),
- POF: premature ovarian ageing/failure
- Hypopituitarism,
- RadioChemo Tx
- Tubal blockage:
- PID, pelvic inflammatory disease (chlamydia)
- Endometriosis, ectopic pregnancy
- Age-related: Limited Ovarian Reserve (number and quality of eggs)
- Uterine problems:
- Synechiae (adhesions inside the uterine cavity),
- polyp,
- fibroid (distorts the cavity of the womb)
