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Gynae > Infertility and contraception > Flashcards

Infertility and contraception Flashcards

1
Q

What are the Top 5 causes of infertility ?

A
  1. Unexplained 28%
  2. Male factor 25%
  3. Ovulation disorder 21%
  4. Tubal disease 15- 20%
  5. Endometriosis 6-8%
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2
Q

What is the referral criteria for Female Subfertility?

A

Referral for specialist help after 1 year of trying or if -

  • > 35
  • known fertility problems 

  • anovulatory cycles 

  • severe endometriosis 

  • previous PID 

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3
Q

What are the Main causes of Female Subfertility?

A
  • Hypothalamic-pituitary-ovarian axis dysfunction
  • Ovarian factors – PCOS, premature ovarian failure, hypothalamic amenorrhea
  • Tubal disease – pelvic adhesions, prior ruptured ectopic (demonstrated by hysterosalpingogram)
  • Endometriosis
  • Cervical factors – stenosis, cervicitis
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4
Q

What are the causes of Primary ovarian failure?

A
  • Premature ovarian failure
  • Genetics – Turner’s syndrome
  • Autoimmune
  • Iatrogenic – surgery, chemotherapy
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5
Q

What are the causes of Secondary ovarian disorders?

A
  • PCOS
  • Excessive weight loss or exercise
  • Kallman’s syndrome
  • Problems with the HPO axis (LH surge causes ovulation).
    • Pituitary
     Hyperprololactinaemia – prolactin has an inhibitory effect on all pituitary hormones (tumour, stroke, encephalisitis)
     Hypopituitarism – may be isolated to one hormone or global
    • Hypothalamic - weight loss and over exercising, systemic illness, idiopathic hypogonadotrophic hypogonadism, Kallman’s Syndrome – (GnRH deficiency, associated with anosmia)
     Decreased stimulation of pituitary → decreased LH/FHS → decreased oestrodiol
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6
Q

What can cause Tubal Problems leading to infertility?

A
  • Caused by PID from any cause i.e. chlamydia or endometriosis
  • Can also be cause by fibroids and polyps
  • Prior ruptured ectopic
  • Previous abdominal/pelvic surgery = adhesions
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7
Q

What can cause Endometrial Problems leading to infertility?

A

• Abnormalities within the endometrium such as endometriosis, fibroids, polyps or adhesions can stop an embryo from attaching.

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8
Q

What is Male Subfertility?

A

– 20-25%
• Mainly caused by problems with sperm.
• Azoospermia – no traceable sperm in ejaculate.
• Oligospermia - less sperm in ejaculate <15million/ml
• Asthenozoospermia – reduced sperm motility
• Teratozoospermia – abnormal morphology
• Sperm counts vary week by week – repeat if abnormal on one occasion. Also strongly affected by lifestyle factors

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9
Q

What are the causes of Male Subfertility?

A

• Semen abnormality (85%)
o Idiopathic oligoasthenoteratozoospermia (OATS).
o Testis cancer
o Drugs (including alcohol, nicotine)
o Genetic
o Varicocele
• Azoospermia (5%)
o Pretesticular: anabolic steroid abuse; idiopathic hypogonadotrophic hypogonadism (HH); Kalmann’s, pituitary adenoma. 

o Non-obstructive: cryptorchidism, orchitis, 47XXY, chemoradiotherapy. 

o Obstructive: CBAVD, vasectomy, Chlamydia, gonorrhoea. 

• Immunological (5%) 

o Antisperm antibodies
o Idiopathic
o Infection
o Unilateral testicular obstruction. 

• Coital dysfunction (5%) – mechanical cause with normal sperm function. 

o Ejaculation normal (hypospadias, phimosis, disability). 

o Retrograde ejaculation (diabetes, bladder neck surgery, phenothiazines). 

• Failure in ejaculation (multiple sclerosis (MS), spinal cord/pelvic 
injury). 


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10
Q

What are the Investigations of Female subfertility?

A

• Primary care 

o Chlamydia screening
o Baseline (day 2–5) hormone profile including FSH (high in POF; low in 
hypopituitarism), LH, TSH, prolactin, testosterone
o Rubella status
o Mid-luteal progesterone level (to confirm ovulation >30nmol/L
o Semen analysis

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11
Q

What are the Investigations of Male subfertility?

A
  • FSH: elevated in testicular failure. 

  • Karyotype: exclude 47XXY. 

  • Cystic fibrosis screen
  • Examine for congenital bilateral absence of the vas deferens 
(CBAVD)

  • 1st line
  • FHS (+/- LH) and oestrogen at days 1-5 – should be low – confirms ovarian reserve
  • Progesterone at day 21 – should be high – confirms ovulation
  • Semen analysis
  • Check for HPO axis dysfunction – so levels of FSH LH and oestrogen
  • For tubal dysfunction do a hysterosalpingogram – contrast through tubes to look for blockages and take x rays (there’s an ultrasound version of this) or can do an laparoscopy and dye test -
  • Check for chlamydia etc prior to test
  • Risk of PID, endometriosis, fibroids
  • Pelvic USS look for fibroids and other masses and polycystic ovaries and endrometrioma
  • Anti-Mullerian hormone (AMH) is a marker of ovarian reserve. It can be measured in the blood and is proportional to the amount of any many antral follicles are left in the ovaries
  • Check ovulation has occurred – raised serum progesterone in luteal phase, LH in urine
  • Semen analysis – should be performed after 3-4days abstinence. Need two abnormal results for diagnosis
  • Volume > 2ml
  • pH 7.2 - 8.0
  • Count >15million/ml
  • Motility >40%
  • Morphology >4% normal
  • Antisperm Antibodies - negative
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12
Q

What is the treatment for Male subfertility?

A

• Treat underling medical conditions
• Review medications:
o antispermatogenic (alcohol, anabolic steroids, sulfasalazine) 

o antiandrogenic (cimetidine, spironolactone) 

o erectile/ejaculatory dysfunction (α or β blockers, antidepressants, 
diuretics, metoclopramide)
• Medical treatments:
o gonadotrophins in hypogonadotrophic hypogonadism 

o sympathomimetics (e.g. imipramine) in retrograde ejaculation

• Surgical: 

o relieve obstruction 

o vasectomy reversal

• Sperm retrieval:
o from postorgasmic urine in retrograde ejaculation
o surgical sperm retrieval from testis with 50% chance of obtaining 
sperm (greater if FSH is normal)
o For obstructive azoospermia, microsurgical reconstruction or surgical sperm retrieval (SSR) - MESA/PESA/TESE
• Assisted reproduction – IVF + ICSI
• Donor sperm
• Adoption


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13
Q

What is the treatment for Female subfertility?

A

• Lifestyle changes + timed sexual intercourse
• Ovulation induction
- Hyperprolactinemia cause: give a dopamine agonist to lower prolactin
- Clomiphene citrate
 it increases endogenous FSH and LH
 Binds to oestrogen receptors
 blocks the negative feedback effect of oestrogens on the CNS
 This leads to increased secretion of GnRH and gonadotrophins from the hypothalamus and the pituitary
 Need USS monitoring (abandon cycle if overresponsive)
• Insulin sensitizers - Metformin may be given as an adjunct (benefit of treating hirsuitism and no risk of multiple pregnancy) – used in women with PCOS
• Gonadotrophins or pulsatile GnRH:
o used for low oestrogen/normal FSH or clomifene-resistant PCOS 

o multiple pregnancy risk
o Hypogonadotrophic hypogonadism stimulate follicular growth by injecting FSH, LH +/- hCG twice weekly for 6-12 months (hCG given when 1 follicle >16mm = ovulation)
• Laparoscopic ovarian diathermy:
o aims to restore ovulation in patients with PCOS 

o effect lasts 12–18mths if successful. 

• Surgery:
o preferably laparoscopic 

o treat endometriosis (laser/diathermy/excision) 

o tubal surgery (microsurgery/adhesiolysis). 

• Assisted reproduction (IUI, IVF, oocyte donation)
o IUI:
• Requires patent tubes and regular menstrual cycle
• Ovarian induction often used. If not measure urinary LH to detect ovulation
• Follicle development tracked ultrasonographically
• Sperm prepared
• Placed in uterine cavity with USS and catheter
• Dysparaenia/paraplegia/same sex couples/mild sperm dysfunction
o IVF requires some ovarian reserve (follicles – not possible in ovarian failure) – test using antimullerian hormone or antral follicle count (AFC) by USS
• Embryo transfer – max 2 in women <40. More than this increases miscarriage rates. If transferring a blastocyst may only transfer one as they have a higher implantation rate
• 25% twin rate
• Give progesterone for luteal support – until 4-8 weeks gestation
• Pregnancy test 2 weeks after implantation

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14
Q

What is Contraception?

A
  • Method of preventing pregnancy before implantation has occurred (as UK law states that pregnancy begins at implantation)
  • Anything that happens after implantation is abortion
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15
Q

What are the different Types of contraception?

A

Shorter Acting Contraceptive Methods
• Pills: Progestogen only & Combined pill (Oestrogen & Progestogen)
• Combined contraceptive patch
• Combined contraceptive ring
• Barrier Methods (Diaphragm, caps, condoms)
Longer Acting Reversible Contraception (LARC)
• Injectable Methods (Depo Provera & Sayana Press)
• Sub-dermal Contraceptive Implants (Nexplanon)
• Intrauterine Devices (Copper IUD & Levonorgestrel IUS)
Irreversible Contraception
• Female Sterilisation (Laparoscopic & Hysteroscopic)
• Male sterilisation

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16
Q

What ais the Effectiveness of different Types of contraception?

A
  • Non LARC – are more human factor dependent (less effective)
  • LARC – rules out human factors so little difference between perfect use and typical use (more effective)
  • Implant is the most effective method – after ruling out any contraindications.
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17
Q

What is the UKMEC UK Medical Eligibility Criteria of contraception?

A

offers guidance to providers of contraception regarding who can use contraceptive methods safely.
1 = no restriction/ no concern in giving the contraception at any time
2 = advantages outweigh risk
3 = risk out weight advantage – need specialist clinical opinion to prescribe
4 = do not prescribe – unacceptable health risk
Prescribe for 1 and 2 MEC’s
For example, if previous breast cancer. Woman who wants the IUD is UKMEC 1. Woman who wants the COCP is UKMEC 4.

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18
Q

What should you consider when giving a contraceptive?

A

• Side effects – bleeding, weight gain, pain
• Risks to future fertility
• Efficacy
o Patients with IBD – malabsorption = non-oral contraceptives
• Risks for patients
• Patient’s choice
• Compliance – user failure

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19
Q

What do you need to know about confidentiality and consent in terms of contraception?

A

• Any competent young person in the United Kingdom can consent to medical, surgical or nursing treatment, including contraception and sexual and reproductive health. They are said to be competent if they are capable of fully understanding the nature and possible consequences of the treatment.
• Young people are owed the same duties of care and confidentiality as adults. Confidentiality may only be broken when the health, safety or welfare of the young person, or others, would otherwise be at grave risk
• Sex under the age of 13yrs is illegal
o Deemed incapable of consenting
o Must be reported to authorities
• Under 16s
o Under the age of consent but no legal obligation to report
o Safety of young person must be checked with risk assessment
o Fraser competence must be checked prior to prescribing contraception

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20
Q

What is Fraser competence ?

A

• Fraser guidelines – It is considered good practice for health professionals to follow the criteria commonly known as the Fraser guidelines:
• UPSSI – un-planned sex is silly
o that the young person understands the advice and has sufficient maturity to understand what is involved
o that the doctor could not persuade the young person to inform their parents, nor to allow the doctor to inform them
o that the young person would be very likely to begin, or continue, having sexual intercourse with or without contraceptive treatment
o that, without contraceptive advice or treatment, the young person’s physical or mental health would suffer
o that it would be in the young person’s best interest to give such advice or treatment without parental consent.

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21
Q

What are hormonal methods of contraception?

A

Short acting reversible contraception -
1. Progesterone as a tablet – progesterone only pill/mini-pill
2. Combined hormonal contraception – oestrogen and progesterone – COCP, vaginal rings, transdermal patches
Long acting reversible contraception -
1. Progesterone as a depot – IUS, nexplanon, depro-provera
2. Emergency contraception

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22
Q

What is the effect of of rifampicin on combined hormonal contraception?

A

• Enzyme inducing drugs - rifampicin
• Reduce the efficacy of CHC
• If CHC used with enzyme inducing medication
o Additional protection is needed
o At least a 30ug EE pill should be used
o Consider extended regime with shortened PFI
o Continue additional contraception while taking and till 4 weeks afterwards
*ALL PILLS, PATCHES AND RINGS ARE EFFECTED BY ENZYME INDUCERS

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23
Q

What is the Progesterone only pill – Mini pill?

A
  • Used by 5% of women – aged 16- 50 years
  • Small dose of progesterone (350mg of norethisterone)
  • Must be taken every day without a break, at the same time
  • Particularly good for those who COCP is contraindicated
  • Short Acting
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24
Q

What is the Mechanism of Progesterone only pill – Mini pill?

A

• Makes the cervical mucus hostile for sperm and in 50% of women it inhibits ovulation.

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25
Q

What are the side effects of Progesterone only pill – Mini pill?

A
  • Weight gain
  • Depression
  • Vaginal spotting – breakthrough bleeding
  • Premenstrual like symptoms are common
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26
Q

What happens if you Miss doses of Progesterone only pill – Mini pill?

A

• If missed for more than 3 hours of usual time – then take another pill as soon as, and use a condom for 2 days.
Not affected by broad spectrum antibiotics.

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27
Q

What are the contraindications of Progesterone only pill?

A

CVA, severe cirrhosis/hepatoma, and breast Ca in last 5yrs (absolute), pregnancy, unexplained PV bleeding

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28
Q

What is the Combined oral contraceptive pill?

A

• Contains Oestrogen (Ethinyl estradiol EE, Oestradiol valerate)
• Progestogen (Levonorgestrel, Gestodene, Desogestrel, others)
• Regimes
o Standard (21/7)
o Tailored (Extended use, shortened pill free interval)

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29
Q

What is the Mechanism of the Combined oral contraceptive pill?

A
  • suppression of ovulation
    • Inhibit FSH and LH; therefore ovulation- main
    • Makes the endometrium atrophic and less likely for implantation to occur –progesterone effect
    • Altering cervical mucus to make it harder for sperm to ascend
    • Progesterone does all of the above, oestrogen is given to make the women feel more physiological so decrease the acne and mood changes and keep libido which effectively balances out the negative effect of the progesterone
    • P - inhibits ovulation (inhibits FSH/LH)
    • P - atrophies endometrium (↓implantation)
    • P - alters cervical mucus
    O - ↓acne, mood changes, keeps libido
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30
Q

What are the Indications of the Combined oral contraceptive pill?

A
  • Contraception
  • Menorrhagia
  • Dysmenorrhea
  • Acne and hirsutism
  • Prevent recurrent simple ovarian cysts
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31
Q

What is the Regimen of the Combined oral contraceptive pill?

A

• In a course have 21 pills and take 7 days off to allow for menstruation (can be taken back-to-back but increase in IMB)
• Start taking on day 1-5 of LMP
o Can start at any time if low risk of pregnancy but must use condoms for 7 days
• Monophasic pills have a standard dose of estrogen(30-40ug) and progesterone every day (can get low dose 20ug)
• Biphasic, triphasic and quadriphasic preparations have doses of estrogen and progesteone- this is so that different amount of hormones are given at different stages of the cycle to counteract certain side effects experienced at certain times.
• Progesterone controls bleeding pattern
• Can have everyday preparations which contain 7 placebo pills – improve compliance

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32
Q

What are the Benefits of the Combined oral contraceptive pill?

A
  • 99% effective if taken properly
  • Less PID. Up to 50% Even if infected with chlamydia less chance of PID complication
  • Decrease in ovarian cysts, ovarian cancer, uterine cancer, colon cancer (with higher oestrogen doses)
  • Control of menstruation – periods tend to be light and pain free and always on time
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33
Q

What are the Side effects of the Combined oral contraceptive pill?

A

• Nausea, mastalgia, headache, irregular bleeding initially, low mood, mood swings, appetite stimulant, settles in 12 weeks

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34
Q

What are the Risks of the Combined oral contraceptive pill?

A

• All from giving oestrogen
• Main risks are –
o Increase risk of VTE 3-5x (worse with 3rd generation progesterones)
o MI in smokers – no risk in non smokers
• Stroke – ischaemic only
• Breast cancer – tiny risk if no other risk factors Cervical cancer
• HTN
• Focal migraine

35
Q

What are the Absolute contraindications of the Combined oral contraceptive pill?

A

• Smoking - >15 a day or >35yrs.
• BMI >40 (relative CI if 35-39)
• Hypertension 160/95
• Migraine with aura
• Vascular disease – CVA, MI and diabetes with complications
• History of VTE
• Congential heart disease
• Breast or endometrial cancer
• Liver disease - abnormal LFT’s or tumour
• Thrombophilia
• (relatively CI in breastfeeding up to 6 months as affects milk volume)
*Women about to have surgery are taken off the pill due to its prothrombotic effect.
Reduced absorption of COCP
• If you vomit within 3hours of taking it for if you have diarrhoea
• Gastroenteritis – use condoms during illness and 7 days afterwards

36
Q

What happens if you Miss doses of the Combined oral contraceptive pill?

A

• Defined as when you don’t take it for >24hrs. so if its 23 hours late take it and take the other pill one hour later
• If one pill is missed take it as soon as you remember and carry on cycle as normal
• If two or more pills are missed
o Take the most recent missed pill as soon as remembers carry on with the cycle
o Abstain from sex or use condoms for 7 days.
o If first week of pack may require Emergency contraception
 if the patient had unprotected sex in the previous 7 days
o Missed in last week run packs back to back.

37
Q

What are the complications of the Combined oral contraceptive pill?

A 
Cerebrovascular incident
Focal migraine
HTN
Breast carconome
DVT, PE
38
Q

What is the Combined Patch (Evra)?

A

Transdermal 7 day patch
• Has 20 mcg of ethinyl estradiol and 150mcg of norelgestromin released daily
• Patches are applied weekly every 3 weeks and have a patch free week
• Better compliance than COCP
• Same mechanism, side effects, contraindications and benefits as COCP

39
Q

What happens if you Miss doses of Combined Patch (Evra)?

A

o A patch gives you enough contraception for 9 days
o If a patch is on for more than 9 days assume that cover is lost
o Assume that cover is lost if patch has fallen off and not replaced within 24hours
o If patch falls off replace with new patch

40
Q

What are the Side effects of Combined Patch (Evra)?

A
  • Local reaction
  • Patch detachment
  • ?Efficacy when body weight > 90kg
  • Compliance better (88% compared to 68% COC)
  • Affected by enzyme inducers
41
Q

What is the Combined Hormonal Vaginal Rings (Nuvaring)

A
  • 15ug of ethinyl estradiol and 120ug of etonogestrel released daily for 3 weeks
  • Ring inserted vaginally for 3 weeks and 1 week ring free
  • Avoidance of first pass metabolism
  • Low incidence of break through bleeds
  • Easy to use
  • Better cycle control
  • Same side effects, contraindications and benefits as COCP
  • Perhaps lower oestrogenic side effects as lower dose
42
Q

What are the consequence of missing your Combined Hormonal Vaginal Rings (Nuvaring)?

A
  • Advised not to remove during intercourse
  • If a ring is out for more than 3 hours cover is lost
  • If removed may wash with tepid water and replace if <3 hours
43
Q

What are the Non contraceptive benefits of CHC?

A
  • Treatment of benign gynaecological conditions
  • Menstrual disturbances: HMB, irregular MC
  • Dysmenorrhoea
  • Endometriosis
  • PCOS
  • PMS
  • Protection from ovarian cancer
  • Protection from endometrial cancer
  • Benign breast disease
  • Benign ovarian cyst
44
Q

What are Injectables (Depo-provera and Noristerat)?

A

Long acting
99% effective, less than 4 women in 1000 will get pregnant over 2 years
• Medroxyprogesterone acetate 150mg AKA Depo-provera
• Same three effects thicken mucus endometrial atropy and prevent ovulation
• Get an injection every 12 weeks (3 months) IM

45
Q

What are the Benefits of Injectables (Depo-provera and Noristerat)?

A
  • Good for women who have v poor compliance
  • Good for women who are on p450 inducers
  • Not effected by other medications, diarrhoea or vomiting
  • Benefits in menorrhagia
  • Good for women breastfeeding
  • 99%effective
46
Q

What are the contraindications of Injectables (Depo-provera and Noristerat)?

A
  • Multiple risk factors for cardiovascular disease
  • CVA
  • Diabetes with vascular complications
  • Severe cirrhosis, hepatoma
  • Breast cancer - ABSOLUTE
47
Q

What are the side effects of Injectables (Depo-provera and Noristerat)?

A

• Causes irregular bleeding in the first few weeks- but usually followed by amenorrhea
o Prolonged amenorrhea may lead to cessation of menarche, so females need to be aware of this if they are considering pregnancy in the near future.
• Weight gain 3kg by 2 years
• Delay in the return of periods and fertility – 6months
• Persistently irregular periods
• 70% of women become amenorrheic (good if heavy bleeding)
• Decreases oestrogen levels this can decrease bone marrow density in first 2-3 yrs
• Avoid in teenagers and women at high risk of osteoporosis
• Progestogenic effects
*Noristat is a 8 weekly IM depot. Used as interim contraceptive

48
Q

What is the Subdermal Implant –Implanon?

A

Long acting
99% effective – less than 1 in 1000 women will get preggers over 3 years)
• Thin rod. Nexplanon and Implanon (40 mm)
• Releases second generation etonogestrel into system which is metabolised to desogestrel
• Lasts for three years
• Rapid return of fertility once removed
• No decrease in bone density

49
Q

What is the Mechanism of Subdermal Implant –Implanon?

A
  • Releases second generation etonogestrel into system which is metabolised to desogestrel
  • Inhibit ovulation
  • Thin endometrium
  • Hostile cervical mucus
50
Q

What are the contraindications of Subdermal Implant –Implanon?

A
  • Breast cancer in past 5 years – absolute
  • Continuing use following a cva
  • Liver cirrhosis or hepatoma
51
Q

What are the benefits of Subdermal Implant –Implanon?

A
  • Rapid return of fertility once removed

* No decrease in bone density

52
Q

What are the Side effects of Subdermal Implant –Implanon?

A

• Progestogenic – mainly irregular bleeding

53
Q

What is Intrauterine contraception - Copper containing devices?

A

Long acting

54
Q

What is the Mechanism of Intrauterine contraception - Copper containing devices?

A

• Copper is toxic to sperm
• Slow release of copper prevents fertilization
• Copper is either –
o Wound around an inert frame which sits within the uterine cavity or
o In threads which are attached to the fundus

55
Q

What are the Indications of Intrauterine contraception - Copper containing devices?

A

Used when hormonal contraception is contraindicated, especially in older women.

56
Q

What is Intra-uterine contraception – Progesterone coil - Mirena

A 
99% effective and less than one woman in 100 will get preggers over 5 years
•	Levonorgestrel releasing device
o	52mg
o	20mcg in 24hrs 
•	Lasts 5 years
57
Q

What is the Mechanism of Progesterone coil - Mirena

A
  • Effects on cervix and endometrium classic 2/3.
  • Can also prevent ovulation in some women
  • Local effect of foreign body in uterus
58
Q

What are the Indications of the Progesterone coil - Mirena

A

• Periods become much lighter so also used as a treatment for heavy menstrual bleeding/dymenorrhoea

59
Q

What are the Benefits of Progesterone coil - Mirena

A
  • Also use in a hormone replacement therapy regime
  • When removed fertility returns to normal
  • Not user dependent
  • Can be inserted straight after TOP or in puerperium
  • Can be used as emergency contraception if inserted 5 days of ovulation
  • Very safe to use
60
Q

What are the Side effects of Progesterone coil - Mirena

A
  • Progestogenic – should settle in 12 weeks
  • Fewer SE than mini-pill as lower dose
  • Irregular light bleeding
  • May get ovarian cysts
  • Uncomfortable insertion
61
Q

What are the Complications of both the copper and progesterone coil?

A
  • Device can be expelled – risk only within the first moth
  • Perforation of uterine wall – can occur during insertion
  • Only with copper – heavier and more painful menstruation can occur
  • Screen for STI first before insertion – especially with younger patients. To help prevent PID or spread. PID
62
Q

What are the Contraindications of both the copper and progesterone coil?

A
  • Pregnancy
  • Undiagnosed bleeding
  • Cancer pre-treatment
  • PID in last 3mths
  • Current STI
63
Q

What are barrier methods of contraception?

A

Male and female condom – good for protection against STIs. Males – protection against HIV
Diaphragms and caps – Good protection against pelvic inflammatory disease, but less against HIV
Spermicides – Not recommended for use on their own, but in conjunction with other barrier methods.

64
Q

What is Sterilization?

A
  • Seen as a permanent method, but can be reversed. Reversal leaves pregnancy rates of about 25% and not NHS funded. So must be sure no more children
  • Should try and push for a LARC as opposed to sterilisation in counselling sessions
65
Q

What is Female sterilization?

A
  • Block both fallopian tubes to prevent sperm reaching egg. Can either do this via clips or rings or cautery
  • Eggs will still be released from the ovaries as normal, but they’ll be absorbed naturally into the woman’s body.
  • Fails 1 in 200 lifetime risk
  • Higher if inserted post-partum or TOP
  • 10% ectopic pregnancy rate
66
Q

What is Male sterilization?

A

• Chop the vas deferens on each testae to prevent the release of sperm during ejaculation
• Test ejaculate 12 weeks and 16 weeks after to check for presence of sperm
• Will still ejaculate secretions from prostate
• 1 in 2000 lifetime risk
• most effective contraception
• Vasectomy – Surgical procedure to cut or seal the tubes that carry a man’s sperm
• 2 types of vasectomy –
o A conventional vasectomy using a scalpel (surgical knife) - doctor first numbs your scrotum with a local anaesthetic. They then make 2 small cuts in the skin on each side of your scrotum to reach the tubes that carry sperm out of your testicles (vas deferens).
Each tube is cut and a small section removed. The ends of the tubes are then closed, either by tying them or sealing them using heat.
The cuts are stitched, usually using dissolvable stitches that go away on their own within about a week.
o A non scalpel vasectomy - The doctor first numbs your scrotum with local anaesthetic. They then make a tiny puncture hole in the skin of your scrotum to reach the tubes. This means they don’t need to cut the skin with a scalpel.
The tubes are then closed in the same way as a conventional vasectomy, either by being tied or sealed

67
Q

What is Medical termination of pregnancy ?

A

• Used usually <7wks, 7-9wks and 13-24wks (legal until 24 weeks unless… - see book!)
• Following steps:
o Mifepristone (oral antiprogesterone) = 24-48hrs later: second appointment where misoprostol (prostaglandin) is taken – PO/SL/PV = stimulates uterine contractions
- If mifepristone unavailable, prostaglandin alone can be used
o Within 4-6 hours, endometrium breaks down, causing bleeding and loss of the pregnancy
• If >22wks:
o Feticide by injecting KCl into umbilical vein/foetal heart – usually only when foetal abnormality present

68
Q

What is Surgical termination of pregnancy?

A

requires Abx cover
• Under local or general anaesthetics, or conscious sedation
• Two methods:
o Vacuum or suction aspiration (suction curettage)
 Can be used 7-13wks of pregnancy
 Involved inserting a tube through the cervix and then removing the foetus via suction
 Vacuum aspiration takes about 5-10 mins as outpatient
o Dilatation and evacuation (D&E)
 Used >13wks of pregnancy
 The cervix is gently dilated for several hours or up to a day before the surgery to allow the forceps to be inserted
 Forceps are inserted through the cervix and into uterus to remove the pregnancy
 D&E is carried out with conscious sedation or general anaesthetic. It normally takes about 10-20 mins as outpatient

69
Q

What are Complications of Termination of pregnancy?

A
  • Haemorrhage
  • Infection
  • Uterine perforation
  • Cervical trauma (surgical)
  • Failure
  • Subsequent preterm delivery (multiple surgical)
  • Psychological sequelae (esp. if pre-existing problems)
70
Q

What is Emergency Contraception?

A

Levonorgestrel (Levonelle) – OTC
Ulipristal Acetate (EllaOne) – SPRM (selective progesterone receptor modulator)
Copper IUD = GOLD standard
EC – needed if >2 pills missed in week 1 of packet + UPSI in PFI or week 1

71
Q

What is the time frame of use of Levonorgestrel?

A

72hrs from UPSI (before ovulation)

72
Q

What is the Mechanism of Levonorgestrel?

A

Suppress ovulation

73
Q

What are the Interactions of Levonorgestrel?

A
  • Double dose if used with enzyme inducers
  • Repeat dose if vomit <2hrs
  • UPA or double dose if BMI >26 or >70kg
74
Q

What are the advantages of Levonorgestrel?

A
  • Do not disrupt existing pregnancy

* Not assoc. with foetal abnormality

75
Q

What happens when you transition off Levonorgestrel?

A

Start suitable hormonal contraception immediately, abstain/condoms until effective

76
Q

What is the time frame of use of Ulipristal Acetate (EllaOne)?

A

120hrs from UPSI (before ovulation)

UPSI needs to have occurred within the 120hrs prior to estimated ovulation

77
Q

What is the Mechanism of Ulipristal Acetate (EllaOne)?

A

SPRM (selective progesterone receptor modulator)
• Suppress ovulation
• Reduces implantation
• More effective than levo

78
Q

What are the Interactions of the Ulipristal Acetate (EllaOne)?

A

Enzyme inducers + PPIs + progesterones
• Reduced efficacy if progesterone taken 7 days prior or 5 days after use additional contraception if taking POP/OCP
• NOT to be used with enzyme inducers – can NOT double the dose
• Repeat dose if vomit <3hrs
• BMI >26 or >70kg
Avoid breast feeding for a week after taking

79
Q

What are the advantages of Ulipristal Acetate (EllaOne)?

A
  • Do not disrupt existing pregnancy

- Not assoc. with foetal abnormality

80
Q

What happens when you transition off Ulipristal Acetate (EllaOne)?

A

Wait 5 days before starting hormonal contraception, abstain/condoms until effective

81
Q

What is the time frame of use of copper IUD?

A

Gold standard

120hrs from UPSI OR within 5 days of earliest calculated day of ovulation (if failed above/ multiple episodes of UPSI)

82
Q

What is the Mechanism of copper IUD?

A

Pre and post fertilization:
• Reduces implantation
• Toxic/hostile to sperm/ova/ blastocyst
• Slows down egg transport

83
Q

What are the advantages of copper IUD?

A
  • Most effective- gold standard

* Ongoing contraception: 5-10yrs

84
Q

What are the disadvantages of copper IUD?

A
  • Prolonged, heavy, painful periods
  • Infection at insertion
  • Expulsion
  • Perforation
  • Ectopic
  • Needs fitting by trained professional
  • No STI protection
  • If implantation already = abortion

Gynae (6 decks)

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