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Obs & Gynae > Fertility Control > Flashcards

Fertility Control Flashcards

1
Q

Give the 3 most common contributors to subfertility:

A
  • ovulatory problems
  • male problems
  • tubal problems
  • unexplained
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2
Q

Elevated serum levels of ____ in the mid-luteal phase can indicate ovulation has occured

A

-progesterone

hence this is called the mid-luteal phase serum progesterone

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3
Q

what are the 3 criteria of which 2 need to be present to make a diagnosis of polycystic ovarian syndrome?

A
  • PCO on ultrasound
  • irregular periods (>35 days apart)
  • hirsutism clinical or biochemical (raised testosterone)
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4
Q

Women w PCOS have disordered LH production and insulin resistance so to compensate produce more insulin.

  • what effect does raised LH and insulin have on the polycystic ovaries?
  • raised insulin also leads to increased adrenal _____ production and reduced hepatic production of __ ___ __ ___ (—-) leading to increased free androgen levels
A
  • increased ovarian androgen production from PCOs

- increased adrenal androgen production, reduced steroid-hormone binding globulin (SHBG)

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5
Q

What effect does high intra-ovarian androgen levels have on folliculogenesis and ovulation ?

A

-excess small ovarian follicles and the polycystic ovarian picture with irregular or absent ovulation

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6
Q

In PCOS FSH levels will be normal. What about AMH levels? Suggest 2 other investigations you may do when investigating PCOS:

A

AMH is high in PCOS

  • TVUS
  • testosterone, prolactin, TSH levels
  • fasting lipids and glucose to screen for complications
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7
Q

What malignancy is more common in those with PCOS due to many years of amenorrhoea due to unopposed oestrogen action?

A

Endometrial cancer increased risk

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8
Q

Hypothalamic hypogonadism is when low GnRH release -> amenorrhoea (low FSH/LH and low E2 levels follow)

  • give 2 environmental causes and 1 genetic cause
  • suggest how to treat this
A
  • anorexia nervosa, secondary to diets, female athletes, those under stress
  • treat with restoration of body weight
  • genetic = Kallman’s syndrome
  • exogenous GnRH pump to induce ovulation
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9
Q

Pituitary damage/tumour can lead to which hormone excess that affects ovulation?
suggest 2 sx

A
  • hyperprolactinaemia reduces GnRH

- sx: oligo/a-menorhoea, galactorrhoea, headaches and bitemporal hemianopia if tumour

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10
Q 
Hyperprolactinaemia can be medically treated with what class of drugs, give example 
-this usually restores ovulation
A

-Dopamine agonists e.g. cabergoline, bromocriptine

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11
Q

Premature ovarian insufficiency: as ovary fails E2 and ____ levels fall, so reduced negative feedback leads to which hormones rising?
NB: on US scan the antral follicle count will be very low

A
  • inhibin levels fall

- FSH and LH rise

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12
Q

What is the 1st line ovulation induction drug in PCOS? what hormone does it antagonise to increase gonadotrophin release?

A

Clomifene, an anti-oestrogen that blocks E2 receptors int he hypothalamus and pituitary, so more FSH and LH is released

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13
Q

What is an alternative to Clomifene in PCOS which can restore ovulation and treats hirsutism at the same time?
NB: can also be used jointly with clomifene as increases the effectiveness

A

Metformin

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14
Q

Describe briefly the process of exogenous gonadotrophin induction of ovulation:

A
  • recombinant FSH/LH given by daily subcut injection, stimulates follicular growth
  • follicular development monitored with US
  • once follicle is adequate size for ovulation (~17mm) injection of hCG or LH artificially stimulates the process
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15
Q

what risk is associated with gonadotrophin stimulation of the follicles which leads to pain especially in attempting IVF, in younger women and in those with PCO
-how is this risk reduced?

A

-OHSS: ovarian hyperstimulation syndrome (follicles overstimulated -> very large and painful)
-reduce risk by using lowest effect gonadotrophin dose, US monitoring of follicular growth, if growth is excessive withdraw injections for a few days or cancel the cycle of IVF
NB: OHSS can be fatal (!).. hypovolaemia, electrolyte disturbance, VTW, pulmonary oedema….

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16
Q

Give 4 causes of abnormal semen analysis:

A
  • smoking
  • alcohol
  • drugs
  • chemical
  • inadequate local cooling
  • genetic factors
  • antisperm antibodies
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17
Q

suggest 2 drugs that can effect sperm/male fertility

A
  • sulfasalazine
  • anabolic steroids
  • exposure to industrial chemicals esp solvents
  • alcohol
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18
Q

does varicocele affect fertility?

A

yes, usually occurs on the left, varicosities of pampiniform plexus
-surgery does not improve fertility

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19
Q

Antisperm antibodies are common after what surgery?

A

Reversal of Vasectomy

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20
Q

Give 4 causes of male subfertility

A
  • infections e.g. epididymitis, mumps orchitis
  • testicular abnormalities e.g. in Klinefelter’s XXY
  • obstruction to delivery e.g. congenital absence of vas with CF
  • hyperprolactinaemia
  • retrograde ejaculation into bladder
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21
Q

Give 3 ways male subfertiity can be managed in a couple trying to conceive:

A
  • lifestyle changes (drug exposure, loose clothing, testicular cooling)
  • intrauterine insemination (IUI)
  • if more severe oligospermia then IVF
  • if v severe then intracytoplasmic sperm injection (ICSI)
  • if azoospermia, can extract sperm from testes, surgical sperm retrieval (SSR)
  • donor insemination
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22
Q

IUI can be used to bypass the cervix if it is the cause of failure to fertilise.
Suggest 1 reason cervical factors could contribute to adhesion formation

A
  • women producing antibodies that agglutinate or kill the sperm
  • infection in vagina/cervix that prevents adequate mucus production
  • cone biopsy
23
Q

If someone is starting contraception in the day 1-5 of the cycle (even if they have UPSI during these days) what contraceptives will be effective immediately?

A

Any/all hormonal contraceptives

24
Q

If someone is starting contraception outside/after day 1-5 of the cycle, double protection with barrier methods are required for ____ days with hormonal contraception except ___ which you only need barrier methods for ___ days

A
  • 7 days
  • except Progesterone Only Pill (POP)
  • 2 days
25
Q

If a woman is breastfeeding FULLY (no water even) + amenorrhoea , for how long is this contraceptive? (i.e. when would you need to start contraception again?)

A

-21 days

NB: negative pregnancy test before re-starting any contraception

26
Q

with combined hormonal contraceptives, a daily pill/weekly patch/3weekly ring is used, after the 21 days, a hormone free interval of ___ days is recommended. If women prefer not to see breakthrough bleeding, they can shorten this free interval to ___ days

A
  • 7 days hormone free interval

- 4 days

27
Q

Missed Pill Rules

-if you miss any pills in the last 7 days of the pack, what is the advice?

A
  • don’t have a pill free interval

- have the next pack back to back without any break

28
Q

Missed Pill Rules

  • If someone forgets to take their pill at their usual time, they have how long a window to take that day’s pill?
  • After this point what do you do?
A
  • 48hrs

- after this time, leave that day’s pill, take the next day’s as usual and continue pack

29
Q

Missed Pill Rules

  • If someone forgets to take their pill at their usual time, for 2 consecutive days+
  • After this point what do you do?
A
  • if she is going to be sexually active, must use condoms for next 7 days
  • if not sexually active continue pack
30
Q

Missed Pill Rules

  • If someone forgets to take their pill at their usual time, for 2 consecutive days+
  • is sexually active and comes to you for emergency contraception, what q’s do you need to ask to tailor your advice?
A
  • have you taken the first 7days of the pack regularly? Yes–> an anovulatory cycle has been created
  • now few days missed, hormones are fluctuating, E2 levels rising, risk of LH surge -> ovulation
  • hence no risk of pregnancy (anovulatory) but could get pregnant later, so use barrier method for next 7 days
  • if not taken regularly may need emergency contraception
31
Q

Name 5 absolute CI to COCP:

A
  • migraine with aura
  • HT >160/100
  • Smoking >35ys, >15cigs/day
  • Personal VTE risk
  • Fam hx of stroke/VTE -> death by 45yrs
  • Current Breast Cancer
  • Known thrombotic mutations
  • AF
  • Cardiomyopathy
  • Postpartum 3 weeks
32
Q

Name 5 relative contraindications to COCP

A
  • migraine w aura >5yrs ago
  • migraine w/o aura, any age
  • HT >140/90
  • smoking age >35yrs, <15cigs/day or stopped smoking <1yr ago
  • obesity BMI >35
  • breast conditions e/g/ undiagnosed mass
  • Fam Hx VTE in 1st degree relative <45yrs
  • CVD
  • Systemic disease
33
Q

With POP after a missed pill, extra barrier contraception is only required for __ days

A

2

34
Q

POP has 1 absolute CI, what is it?

Name 2 relative CIs

A
  • Absolute CI: CURRENT BREAST CANCER

- Relative: stroke, ischaemic heart disease, breast cancer history, severe cirrhosis, hepatocellular carcinoma

35
Q

When (at what intervals) is Depo Provera injected? By what route?

A
  • every 12 weeks

- intramuscularly

36
Q

Sayana Press is an injectable contraception, how is it given? NB: Medroxyprogesterone

A

-Self-administered subcut injection

37
Q

When would we not give the Depo provera/Sayana Press? NB: think it is a large bolus dose of progesterone

A
  • someone who plans to get pregnant in next year
  • if the woman has osteoporosis
  • after 45yrs (as approaches menopause, good to switch to a different one)
  • cannot give after 50yrs due to osteoporosis risk
38
Q

Ulipristal for emergency contraception is not effective if used alongside what?

A

if they are on a contraceptive injection

39
Q

Progesterone contraception used long term (5yrs+) can lead to an ______. If they also have ___ they are at an increased risk of developing ______ cancer

A
  • ectropion
  • HPV +
  • cervical
40
Q

Oral COCP or POP interact with Lamotrigine, what is the effect?

A

-Contraceptive is unaffected, works as usual
-but can decrease the efficacy of the Lamotrigine (pt may seize more)
NB: all other contraceptives have no interaction with lamotrigine

41
Q

What type of medications interact strongly with COCP, POP and implant meaning effectiveness is altered during use and for 4 weeks afterwards?

A

-Enzyme inducers (CYP-450)

42
Q

What is the basis of how IUS works e.g. mirena?

A
  • prevents sperm entry

- thins endometrium so prevents implantation

43
Q

What are the 3 criteria for when you would need to do an STI screen before inserting an intrauterine contraception?
NB: if they have a steady sexual partner, no need to screen

A
  • if they have changed sexual partner within 6 months
  • If they are symptomatic
  • if they had unprotected sex w someone else
44
Q

Sometimes you may need to do an STI screen before inserting an intrauterine contraception, what action do you take if you identify they are at high risk?

  • e.g. postpone or no?
  • e.g. if symptomatic what do you give? vs. action if asymptomatic?
A
  • don’t postpone fitting
  • take swab but go ahead with insertion
  • if symptomatic, give prophylactic stat dose of azithromycin
  • if asymptomatic await results, if + treat, if - no action required
45
Q

Complications of Intrauterine Contraception:

  • 1 in 20 risk of _____, highest in 1st 3 months
  • 2 in 1000 risk of ______, but increases six fold during ____ _____
A
  • expulsion

- perforation, during breast feeding

46
Q

Post-partum when can you fit an intra-uterine contraceptive?

A

After 4 weeks (if uterus is involuted on palpation)

47
Q

Requirement of contraception around the menopause

  • if they go into menopause >50yrs, you continue for ____ yr
  • if they go into menopause <50yrs, you continue for ___ yrs
A

-1 year (12 consecutive months with no bleeding)
-continue for 2 years. (12 consecutive bleeding free moths, then 1 additional year)
-

48
Q

What contraceptive methods should be stopped at age 50?

A

-COCP (switch to non-hormonal method)
-progesterone injectable, switch due to osteoporosis
-implant, stop at 55yrs
-

49
Q

Emergency Contraception for obese patients

  • if BMI 26+ or weight 70kg+ instead of 1.5mg Levonorgestrel morning after pill you should….
  • Ulipristal is not as effective in obese, so recommendation is instead use…
A
  • double the dose hence 3mg Levonorgestrel

- Copper IUD instead of Ulipristal if BMI 30+/85kg+

50
Q

Emergency Contraception

  • Copper IUD, works immediately, prevents implantation
  • can be used up to ____hrs after UPSI or up to ____ days after earliest possible ovulation (day ___ of 28 day cycle)
A
  • 120 hours

- 5 days (day 19 of cycle as ovulation would be day 14, then add 5)

51
Q

Emergency Contraception Oral

  • delays ovulation
  • 1.5mg Levonorgestrel, use up to ___ hrs after UPSI
  • 30mg Ulipristal, ‘ella one’, use up to ___ hrs after UPSI
A
  • Levonorgestrel up to 72hrs after

- Ulipristal Acetate up to 120hrs after

52
Q

If someone has a copper coil inserted for emergency contraception and doesn’t want it for long-term contraception, what is the earliest it can be removed?

A

-after the next period

53
Q

Emergency Contraception Oral (has delayed ovulation)

  • for Levonorgestrel, what contraception is required?
  • for Ulipristal, what contraception is required?

NB: as ellaone is a progesterone receptor modulator, progesterone in any contraceptives will stop the pill working

A
  • Levonorgestrel: COCP with condoms for 7days or POP with condoms for 2 days
  • Ulipristal: use condoms for next 5 days, if then wants to start:
  • COCP, continue condom use for 7 days
  • POP, continue condom use for 2 days
54
Q

Suggest 4 parameters that are assessed in semen analysis:

A
  • Count (>15million/ml)
  • Motility >50%
  • Progressive Motility >30%
  • No agglutination
  • Antibodies (<10%)
  • No signs of infection

Obs & Gynae (9 decks)

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