Intro To Contraception And Infertility

Question 1

What are some fertility indicators?

Answer 1

Cervical secretions

Basal body temp (goes up ovulation)

Length of menstrual cycle

Question 2

What is lactational amenorrhoea method?

Answer 2

Breastfeeding delays the return of ovulation after childbirth

Suckling stimulus disrupts release of GnRH affects feedback cycle of HPG axis

Relies on exclusive breast feeding only effective up to 6 months after giving birth, must be amenorrheic

Question 3

What are 4 methods of hormonal control?

Answer 3

Combined oestrogen and progesterone

• COCP
• vaginal ring
• patches

Progesterone depot

• high dose progesterone
• LARC

Progesterone implant

• high dose
• LARC

Low dose progesterone
-POP

Question 4

Why do you get ovulation at low doses progesterone but not moderate/ high?

Answer 4

Moderate/ high enhances negative feedback of natural oestrogen -> reduces LH and FSH

Also inhibits positive feedback of oestrogen -> no Lh surge

At lower douses Lh surge not inhibited -> thicken cervical mucus

Question 5

Positives of COPD?

Answer 5

98% effective

Can relive menstrual disorders

Reduces risk ovarian cyst

Reduced risk ovarian cancer and endometrial cancer

Question 6

Negatives of COCP?

Answer 6

Contradiction: high BMI, migraine, breast cancer

Side effects

Increased risk of breast and cervical cancer, VTE, MI/ stroke

Question 7

Negatives of progesterone injection?

Answer 7

App every 12 weeks

Delay in fertility return

Contradictions

Side effects

Question 8

How does progesterone implant work?

Answer 8

Inhibits ovulation, thickens cervical mucus, prevents endometrial proliferation

Lasts for three years

1/3 no periods
1/3 normal periods
1/3 bleeding all the time

Question 9

Progesterone only pill how does it work? And negatives

Answer 9

Chen’s cervical mucus
Ovulation is usually not presented

Risks of ectopic pregnancy

Interacts with other meds

Menstrual problems common

Question 10

What is the intrauterine system?

Answer 10

Progesterone releasing plastic device 3-5yrs

Prevents implantation and reduces endometrial proliferation
Thickens cervical mucus

Helps with irregular/ heavy periods

Question 11

What is the intrauterine device?

Answer 11

Plastic device with added copper 5-10yrs

Copper toxic to sperm and ovum

Endometrial inflammatory reaction preventing implantation and changes consistency of cervical mucus

Question 12

Negatives of coils (IUS and IUD)

Answer 12

Insertion unpleasant

Risk of uterine perforation 1/500

Menstruated irregularity

Displacement/ expulsion may occur

Increased risk STI

Question 13

How is a vasectomy done?

Answer 13

Vas deferens cut or tied to prevent sperm entering ejaculate

12-16 weeks post semen analysis
Failure rate 1/2000

Local anaesthetic

Question 14

How is tubal ligation/ clipping done?

Answer 14

Fallopian tubes cut/ blocked to stop ovum travelling from ovary to uterus

Local/ general anaesthetic

Failure rate 1/200-500

Question 15

Three types of emergency contraception

Answer 15

Emergency IUD - 5 days

Emergency pill with ulipristal acetate - 5 days

Emergency pill with levonorgestrel - 3 days

Question 16

What’s the UKMEC?

Answer 16

UK medical eligibility criteria for contraceptive use

Question 17

What is subfertility?

Answer 17

Failure of conception in a couple having regular, unprotected coitus for one year

Question 18

What is primary and secondary infertility?

Answer 18

Primary - never conceived before

Question 19

How common is subfertility?

Answer 19

1/7 couples

84% of couples will conceive naturally within one year regular unprotected sex

CouplEs who’ve been trying for more than 3 years likelihood of getting preferential next year is

Question 20

Subfertility main causes

Answer 20

Male 30%

Unexplained 25%

Ovulatory 25%

Tubal damage 20%

Uterine/ peritoneal 10%

Other

40% cases both man and woman problem

Question 21

Pre testicular causes of Male subfertility

Answer 21

Endocrine

Hypothalamus/ pituitary dysfunction

Hypogonadotropic hypogonadism

Hyperprolactinoemia

Hypothyroidism

Diabetes

Question 22

Testicular causes of Male subfertility

Answer 22

Genetic:
Klimefelter syndrome (XXY)

Y chromosome deletion

Immobile cilia syndrome

Congenital:
Cryptorchidism

Infective:
Stis

Antispermatigenic agents:
Heat
Irradiation 
Drugs
Chemotherapy

Vascular:
Torsion
Varicocele

Question 23

Post testicular causes of Male subfertility

Answer 23

Obstructive:
Congenital - structure
Acquired- infective
Vasectomy

Coital:
Ejactulatory failure
Erectile dysfunction

Question 24

What are the three groups of ovulatory disorders that can lead to subfertility? Give examples of each

Answer 24

Group 1 - hypothalamic- pituitary failure 10%: hypothalamic amenorrhea, hypogonadotrophic hypogonadism

Group 2 - hypothalamic-pituitary- ovarian dysfunction 85%:
Polycystic ovary syndrome, hyperprolactinaemic amenorrhoea

Group 3 - ovarian failure 5%:
Congenital (Turners X0), premature ovarian failure/ primary ovarian insufficiency

Question 25

What are some uterine/ peritoneal disorders that can lead to subfertility?

Answer 25

Uterine fibroids (Asherman syndrome), endometriosis, PID, previous surgery, cervical stenosis, Müllerian developmental abnormality e.g. agenesis, didelphys (duplication), bicornuate (two uteri sharing single cervix & vagina), septate (single uterus with fibrous band down centre)

Question 26

What tubular damage can lead to subfertility?

Answer 26

Endometriosis, ectopic pregnancy, pelvic surgery, past pelvic infection e.g. chlamydia, Mullerian development anomaly e.g. agenesis of tubes

Question 27

What examinations could you do on men and women if they present as sub-fertile?

Answer 27

Men: don’t usually examine without element history but if needed: testicular examination check descent/ swellings

Women: BMI, secondary sexual characteristics (breast exam), galactorrhoea, pelvic exam e.g. visual external inspection, insertion of speculum, bimanual exam determine size and character of uterus/ ovaries

Question 28

What investigations could you do on men and women if they present as subfertile?

Answer 28

Men: semen analysis (sperm count, motility), blood test: anti-spermantibodies, FSH/ LH/ testosterone, penile/ urethral swabs, UUS testes, karyotype, cystic fibrosis

Women: blood test: follicular phase LH/ FSh (day 2), luteal phase progesterone (21), prolactin/ androgens/ TFTs. Cervical smear, vaginal/ cervical swabs, pelvic USS, test of tubal latency (hysterosalpingogram)

Question 29

What is a hysterosalpingogram?

Answer 29

Insert dye into uterus and see how it moves through Fallopian tubes x-ray

Dye should move freely from ends of Fallopian tubes

(No spill of dye= swollen tubes)

Slide 38

Question 30

When can you refer to a fertility clinic?

Answer 30

Women: reproductive age who has not conceived after 1yr unprotected vaginal sex in absence of known cause infertility
Early referral: >35yrs, known clinical cause infertility or history predisposing factors for infertility

Men: early referral: previous risks for infertility, significant systemic illness

Question 31

3 fertility treatment categories once a diagnosis has been made

Answer 31

• medical treatment e.g drugs stimulate follicular development/ ovulation (clomiphene, GnRH agonist/ antagonist, gonadotrophins)
• surgical treatment e.g. Laparoscopy for ablation of endometriosis, removal of fibroids
• assisted reproduction techniques e.g. artificial insemination and IVF