Fertility Control Flashcards
Give the 3 most common contributors to subfertility:
- ovulatory problems
- male problems
- tubal problems
- unexplained
Elevated serum levels of ____ in the mid-luteal phase can indicate ovulation has occured
-progesterone
hence this is called the mid-luteal phase serum progesterone
what are the 3 criteria of which 2 need to be present to make a diagnosis of polycystic ovarian syndrome?
- PCO on ultrasound
- irregular periods (>35 days apart)
- hirsutism clinical or biochemical (raised testosterone)
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
- increased ovarian androgen production from PCOs
- increased adrenal androgen production, reduced steroid-hormone binding globulin (SHBG)
What effect does high intra-ovarian androgen levels have on folliculogenesis and ovulation ?
-excess small ovarian follicles and the polycystic ovarian picture with irregular or absent ovulation
In PCOS FSH levels will be normal. What about AMH levels? Suggest 2 other investigations you may do when investigating PCOS:
AMH is high in PCOS
- TVUS
- testosterone, prolactin, TSH levels
- fasting lipids and glucose to screen for complications
What malignancy is more common in those with PCOS due to many years of amenorrhoea due to unopposed oestrogen action?
Endometrial cancer increased risk
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
- 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
Pituitary damage/tumour can lead to which hormone excess that affects ovulation?
suggest 2 sx
- hyperprolactinaemia reduces GnRH
- sx: oligo/a-menorhoea, galactorrhoea, headaches and bitemporal hemianopia if tumour
Hyperprolactinaemia can be medically treated with what class of drugs, give example -this usually restores ovulation
-Dopamine agonists e.g. cabergoline, bromocriptine
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
- inhibin levels fall
- FSH and LH rise
What is the 1st line ovulation induction drug in PCOS? what hormone does it antagonise to increase gonadotrophin release?
Clomifene, an anti-oestrogen that blocks E2 receptors int he hypothalamus and pituitary, so more FSH and LH is released
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
Metformin
Describe briefly the process of exogenous gonadotrophin induction of ovulation:
- 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
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?
-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….
Give 4 causes of abnormal semen analysis:
- smoking
- alcohol
- drugs
- chemical
- inadequate local cooling
- genetic factors
- antisperm antibodies
suggest 2 drugs that can effect sperm/male fertility
- sulfasalazine
- anabolic steroids
- exposure to industrial chemicals esp solvents
- alcohol
does varicocele affect fertility?
yes, usually occurs on the left, varicosities of pampiniform plexus
-surgery does not improve fertility
Antisperm antibodies are common after what surgery?
Reversal of Vasectomy
Give 4 causes of male subfertility
- 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
Give 3 ways male subfertiity can be managed in a couple trying to conceive:
- 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
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
- women producing antibodies that agglutinate or kill the sperm
- infection in vagina/cervix that prevents adequate mucus production
- cone biopsy
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?
Any/all hormonal contraceptives
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
- 7 days
- except Progesterone Only Pill (POP)
- 2 days
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?)
-21 days
NB: negative pregnancy test before re-starting any contraception
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
- 7 days hormone free interval
- 4 days
Missed Pill Rules
-if you miss any pills in the last 7 days of the pack, what is the advice?
- don’t have a pill free interval
- have the next pack back to back without any break
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?
- 48hrs
- after this time, leave that day’s pill, take the next day’s as usual and continue pack
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?
- if she is going to be sexually active, must use condoms for next 7 days
- if not sexually active continue pack
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?
- 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
Name 5 absolute CI to COCP:
- 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
Name 5 relative contraindications to COCP
- 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
With POP after a missed pill, extra barrier contraception is only required for __ days
2
POP has 1 absolute CI, what is it?
Name 2 relative CIs
- Absolute CI: CURRENT BREAST CANCER
- Relative: stroke, ischaemic heart disease, breast cancer history, severe cirrhosis, hepatocellular carcinoma
When (at what intervals) is Depo Provera injected? By what route?
- every 12 weeks
- intramuscularly
Sayana Press is an injectable contraception, how is it given? NB: Medroxyprogesterone
-Self-administered subcut injection
When would we not give the Depo provera/Sayana Press? NB: think it is a large bolus dose of progesterone
- 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
Ulipristal for emergency contraception is not effective if used alongside what?
if they are on a contraceptive injection
Progesterone contraception used long term (5yrs+) can lead to an ______. If they also have ___ they are at an increased risk of developing ______ cancer
- ectropion
- HPV +
- cervical
Oral COCP or POP interact with Lamotrigine, what is the effect?
-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
What type of medications interact strongly with COCP, POP and implant meaning effectiveness is altered during use and for 4 weeks afterwards?
-Enzyme inducers (CYP-450)
What is the basis of how IUS works e.g. mirena?
- prevents sperm entry
- thins endometrium so prevents implantation
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
- if they have changed sexual partner within 6 months
- If they are symptomatic
- if they had unprotected sex w someone else
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?
- 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
Complications of Intrauterine Contraception:
- 1 in 20 risk of _____, highest in 1st 3 months
- 2 in 1000 risk of ______, but increases six fold during ____ _____
- expulsion
- perforation, during breast feeding
Post-partum when can you fit an intra-uterine contraceptive?
After 4 weeks (if uterus is involuted on palpation)
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
-1 year (12 consecutive months with no bleeding)
-continue for 2 years. (12 consecutive bleeding free moths, then 1 additional year)
-
What contraceptive methods should be stopped at age 50?
-COCP (switch to non-hormonal method)
-progesterone injectable, switch due to osteoporosis
-implant, stop at 55yrs
-
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…
- double the dose hence 3mg Levonorgestrel
- Copper IUD instead of Ulipristal if BMI 30+/85kg+
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)
- 120 hours
- 5 days (day 19 of cycle as ovulation would be day 14, then add 5)
Emergency Contraception Oral
- delays ovulation
- 1.5mg Levonorgestrel, use up to ___ hrs after UPSI
- 30mg Ulipristal, ‘ella one’, use up to ___ hrs after UPSI
- Levonorgestrel up to 72hrs after
- Ulipristal Acetate up to 120hrs after
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?
-after the next period
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
- 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
Suggest 4 parameters that are assessed in semen analysis:
- Count (>15million/ml)
- Motility >50%
- Progressive Motility >30%
- No agglutination
- Antibodies (<10%)
- No signs of infection
