Jeff (Fertility/Infertility and conception/contraception)

Question 1

What is fertility, infertility, and virility?

Answer 1

Fertility- for a couple (man and woman) it is the ability to conceive and have children through normal sexual intercourse.

Infertility- defined as the failure to conceive after a year of regular intercourse (every 2-3 days throughout the month) without contraception.

Virility- (in a man) the quality of having strength, energy, and a strong sex drive, masculinity (possession of normal primary sex characteristics e.g. facial hair, deep voice).
(Virility and fertility are closely linked in a male’s mind. Talking about fertility problems can cause them to be defensive about their masculinity).

Question 2

2 types of infertility

Answer 2

Primary infertility: one who’s never conceived a child in the pat struggling to do so. (More severe infertility)

Secondary infertility: one who’s had 1 or more children/pregnancies in the pas but now having difficulties in doing so again. (Due to things from childbirth e.g. scarring/damage)

Question 3

What sort of questions would you ask a couple trying to conceive?

Answer 3

How long have they been trying
Age of patient
General history (do they have any children)
Family history (e.g. narrow fallopian tubes)
Any diseases/illnesses (e.g. STIs)
How often do they have sex
Contraception
Current medications
Lifestyle (alcohol, smoking, job, stress, drugs)

Question 4

What physical examinations can be performed on couples trying to conceive?

Answer 4

Women:
- Weight (BMI)
- Pelvic examination (PID- pelvic inflammatory disease, fibroids, lumps, tenderness)

Men:
- Weight (BMI)
- Penial/testicular examination for any abnormalities (Peyronie’s disease- scar tissue forms in deeper tissued under skin of penis, Phimosis- the inability to retract the skin covering the head of the penis, Paraphimosis- when the foreskin becomes trapped behind the corona of the glans penis, Balanitis- inflammation of the glans penis)

Question 5

Tests to diagnose infertility

Answer 5

1. Sperm test
2. Blood tests to check ovulation
3. Test for chlamydia
4. X-ray of fallopian tubes
5. Ultrasound scan
6. Laparoscopy

These tests will uncover a cause in around 80% of persistent failure to become pregnant. In the remaining 20% of cases, no clear cause can be found.

Question 6

Sperm test

Answer 6

1 in 3 cases of infertility problems are due to the male partner. Tests can help identify issues like oligozoospermia (low sperm count), azoospermia (no sperm count) and motility issues.
A sperm count anywhere in the range from 15 million to 150 million per ml is considered normal, as long as the total ejaculate sperm count is over 22 million sperm.
As well as sperm count, the motility and health of the spermatozoa is also very important- any structural differences can make the sperm less effective or ineffective.

Question 7

Sperm

Answer 7

Boys start producing sperm at puberty.
It takes about 70 days for a sperm to be produced, but production is a continuous process, there is always plenty of fully matured sperms at any one time.
Sperms are minute. Only 1/25mm long and 1/250mm wide.
They are made up of 3 parts- a head (containing sex chromosomes), a middle (which gives them the energy), and a tail (for swimming).
On average men produce around 150-1000 million sperms daily so they are unlikely to run out.
Sperms are excellent swimmers. They can swim through the cervix into the uterus in about 2 minutes given the right conditions.
Sperms are survivors and can live for up to 7 days in a woman’s body.
Sperm production can be damaged by untreated STIs, excess heat, alcohol, smoking, and recreational drugs.

Question 8

Blood tests to check ovulation

Answer 8

Hormone imbalances can cause ovulation problems, and a blood test can help determine whether this is happening. This can help with the diagnosis of conditions like polycystic ovary syndrome (lots of cysts on one or both ovaries, usually just on one so can cause painful alternative months when ovulating).

Question 9

Eggs

Answer 9

Unlike men, women are born with all the eggs they’ll ever have.
At zygote stage, they have about 4 million eggs.
At birth this is reduced to around 1 million.
At puberty this is further reduced to around 300,000.
Only 300-400 will be ovulated during a women’s reproductive lifetime.
The quality of eggs reduces as a woman ages and so does fertility.
At age 40 most women only have 3% of eggs left.

Geriatric mothers are ones who are pregnant at/after 46 years old. Risk for Down syndrome and other illnesses increase after this age due to ageing of the eggs and breakdown of them. More chance of a damaged egg being fertilised.

Question 10

Test for chlamydia

Answer 10

Chlamydia is the most common STI in the UK. It can cause pelvic inflammatory disease and fertility problems.
Both both men and women can be tested.

Question 11

X-ray of fallopian tubes

Answer 11

This is called a hyterosalpingogram (HSG). Opaque dye is injected through the cervix while women have an x-ray. The dye will help doctors to see if there are any blockages in their Fallopian tubes. Blockages can prevent eggs passing down the tubes to the womb, and so stop pregnancy occurring.

Question 12

Ultrasound

Answer 12

Trans-vaginal ultrasound scan is a small probe placed in the vagina. This scan can help doctors check the health of ovaries and womb.
Certain conditions that affect the womb such as endometriosis and fibroids, can prevent pregnancy from happening.
Endometriosis- a common condition where tissue that behaves like the lining of the womb is found outside the womb. The endometrium can attach to different organs such as the abdomen and cause pain. It can take 10 years for a woman to be diagnosed with endometriosis.

Question 13

Laparoscopy

Answer 13

Keyhole surgery where a camera at the end can be inserted into a small cut in the lower abdomen to examine the health of a woman’s womb, Fallopian tubes and ovaries.
dye might be injected into the Fallopian tubes through the cervix to highlight any blockages in them.
Laparoscopy is usually only used if its likelihood of a problem, for example, history of PID, or if a scan suggests a possible blockage of one or both Fallopian tubes.

Question 14

Treatment options

Answer 14

No single fertility treatment is best for everyone. The right treatment will depend on circumstances, including the cause of fertility problems, the age of the female partner and medical history.
There are 3 main categories for treatment:
1. Fertility medicines
2. Surgical procedures
3. Assisted conception

Question 15

Fertility medicines

Answer 15

Usually prescribed to women.
e.g.:
- Clomifene- to help ovulation problems
- Tamoxifen- alternative to clomifene (also used for breast cancer)
- Metformin- can be used but it is unlicensed in the UK. It stimulates ovulation which encourages regular monthly periods and lowers the risk of miscarriage. It also lowers high BG levels and reduces the risk of heart disease and helps in the management of PCOS.
- Gonadotropins- used if unsuccessful with Clomid or metformin but high risk of multiple births. Can also be used in men to improve sperm production.
- Dopamine agonist- e.g. bromocriptine and cabergoline.

Question 16

Surgical procedures

Answer 16

These include Fallopian tube surgery, which can helpful if the Fallopian tubes become blocked or scarred preventing pregnancy.
Men can have surgery too if sperm production is normal but there is a blockage.
A common problem is a varicocele, or varicose vein in the testicles, that interferes with sperm development. Surgery can correct this problem in more than half of cases.

Question 17

Assisted conception

Answer 17

This can include intrauterine insemination (IUI) in which sperm is placed into the uterus using a fine plastic tube. This can be helpful in cases of mild sperm problems (e.g. sperm blocked from getting out, pelvic injuries, low motility)

Assisted conception also includes IVF (in vitro fertilisation) in which sperm and eggs are mixed outside the body and put back into the womb. This can be helpful in cases of unexplained infertility and more severe sperm problems (blocked tubes).

If eggs and sperm are both fine but womb is faulty the zygote won’t survive. Can use surrogate mother. Can also be used if mother wouldn’t survive the pregnancy. NHS doesn’t directly find surrogate but can help if part of a fertility service.

Question 18

Egg and sperm donation

Answer 18

Donors can donate eggs or sperm to help people conceive. Treatment with donor eggs is usually carried out using IVF. Treatment with donor sperm can be IVF or IUI.
Donors must provide information about their identity.
This is because a child born as a result of donated eggs or sperm is legally entitled to find out the identity of the donor when they become an adult.
People may need donor eggs/sperm if they are a same sex couple, have damage to ovaries/uterus, abnormality with either egg or sperm that will never be viable

Question 19

Conception

Answer 19

Conception is when a woman’s egg is fertilised by a man’s sperm, and then implants itself into the woman’s womb.
To conceive a child, a woman must ovulate- release a mature egg from one of her ovaries.
Her male partner must ejaculate tens of millions of mature motile sperm.
A sperm must reach and penetrate the egg as it travels from the ovary to the uterus.
There fertilised egg must then be able to divide many times, implant in the uterus, and form the placenta that is its lifeline until birth.

Complete conception process:
1. Ovulation
2. Into the Fallopian tube
3. There sperm’s journey
4. Sperm penetrates egg
5. Cells start to divide
6. Implantation
7. Pregnancy hormones
8. Foetal development

Question 20

Menstrual cycle

Answer 20

Women of childbearing age have a period approximately every 24-32 days
It can be irregular in many women and thus an unreliable means of natural contraception.

Question 21

Zygote, embryo and foetus

Answer 21

Zygote: the very first stage of life and starts after the union of egg and sperm. About 24 hours after the fusion, the first division of the new cell happens, and it is no longer called zygote. The embryonic period begins (fertilised but a single cell)
Embryo: mid way between zygote and foetus. It is the active cell division period of conception. (24hrs -8weeks after fertilization) (once it has divised)
Foetus: from week eight of pregnancy onwards, the embryonic period ends and makes space for the so-called foetal period of pregnancy.

Cytotoxic medicines can cause cell death of embryo. If the embryo is made up of 4 cells and 1 cell dies from the medicine, you lost 25% of the embryo. Need to be careful when handling or using these medicines.

Question 22

Ovulation

Answer 22

Ovulation test kits detects Luteinising hormone (LH)

Signs of ovulation include;
- Change in cervical fluid: cervical fluid that resembles “egg whites” is a sign that you are near ovulation or are ovulating. (Thin mucus helps sperm swim and becomes thick to aid protection)
-Increase in basal body temperature: prior to ovulation, the basal body temperature is rather consistent. Closer to ovulation, there might be a slight decline, but it will be followed by a sharp increase after ovulation. The increase in temperature is the sign that ovulation has just occurred
- Change in cervical position or firmness: during ovulation, the cervix will be soft, high, open and wet

Question 23

Pregnancy and Folic acid

Answer 23

Pregnancy test kits detect hCG (Human Chorionic Gonadotropin). Test should be done with the first urination of the day, mid stream.
Folic acid (key vitamin for development of spine) (also known as vitamin B9) is very important for the development of a healthy foetus, as it can significantly reduce the risk of neural tube defects (NTDs), such as Spina bifida (unprotected, exposed spinal cord) and Anencephaly (neural tube high up doesn’t close and baby does not survive for very long).
The Department of Health recommends that women should take a daily supplement of 400 micrograms of folic acid while they are trying to conceive, and should continue taking this dose for the first 12 weeks of pregnancy when the baby’s spine is developing. However, it is safe to continue taking folic acid supplements after 12 weeks (minimal benefits though).
Some women (e.g. obese BMI) have an increased risk of having a pregnancy affected by a neural tube defect and are advised to take a higher dose of 5 milligrams (5mg) of folic acid each day until they are 12 weeks pregnant.

Question 24

Risk factors for neural tube defects

Answer 24

Woman or her partner have a neural tube defect.
Woman previously had a pregnancy affected by a neural tube defect.
Woman or her partner have a family history of neural tube defects.
Women with diabetes or epilepsy.

Question 25

Dietary sources of folic acid

Answer 25

• Green, leafy vegetables
• Brown rice
• Granary bread
• Breakfast cereals fortified with folic acid.
  Always check the food labels. However, it would be almost impossible to get enough folic acid just from food – the only way to be sure you are getting the right amount is by taking a supplement.
  Liver is also very rich in folic acid, although it is not safe to eat while you are pregnant or trying to become pregnant. This is because liver is also very rich in vitamin A, too much of which can cause birth defects in your baby.

Question 26

Contraception

Answer 26

Contraceptive methods allow you to choose when and whether you want to have a baby. However, most of them don’t protect you from sexually transmitted infections (STIs). Barrier methods such as condoms are a form of contraception that help protect against both STIs and pregnancy.
Contraceptives are used BEFORE sex and emergency contraception are needed AFTER sex.

Question 27

Contraceptive effectiveness

Answer 27

Most effective –> least effective:
Implant
IUD
Female sterilisation
Vasectomy
Injectables
LAM
Pills
Male condoms
Female condoms
Standard days method
Withdrawal
Spermicides

Question 28

15 contraceptive methods

Answer 28

Caps
Combined pill
Condoms (female)
Condoms (male)
Contraceptive implant
Contraceptive injection
Contraceptive patch
Diaphragms
Intrauterine device (IUD)
Intrauterine system (IUS)
Natural family planning
Progestogen-only pill
Vaginal ring
Female sterilisation
Male sterilisation (vasectomy)

Female and male sterilisation are considered permanent because reversal is difficult and not always successful.

Implant, injection, IUD, and IUS are the only ones with no risk of human error.

Question 29

Hormonal contraception

Answer 29

2 types:
1. Combined Hormonal Contraception (CHC): contain both estrogen and progesterone
- MOA: acts on the hypothalamopituitary-ovarian axis to suppress LH & FSH and thus inhibit ovulation.
- Examples:
- CoC (pill)
- CTP (patch)
- CVR (ring)

2. Progesterone Only Contraception (POC)
   
   • MOA: Inhibit ovulation and thicken cervical mucus
   • Examples
     
     • PoP (pill)
     • PTP (patch)
     • PVR (ring)

Question 30

Hormonal contraception- choice of CHC

Answer 30

Most contain oestrogen range of 20 – 40 mcg.
Use preparation with lowest oestrogen content that gives good cycle control with minimal side effects.
CoC not generally recommend after age 50, as safer alternatives exists.
Low dose oestrogen preps (20mcg) are particularly appropriate for women with increased risk of circulatory disease (blood clot), provided CoC is otherwise appropriate.

There are various types of hormonal contraceptives with different combinations/varieties of progestogens +/- oestrogens that can also be used to cater for women experiencing other side effects such as acne, headache, depression, breakthrough bleeding and breast symptoms.
It is not unusual for a lady to try a few until they find the perfect one.

Question 31

CHC risks

Answer 31

• Use of CHC is associated with an increased risk of VTE (venous thromboembolism), but the absolute risk of VTE for an individual CHC user remains very small
• Very small increased risk of myocardial infarction (MI) and ischaemic stroke that appears to be greater with higher doses of oestrogen in COC
• Small increased risk of breast cancer which reduces with time after stopping CHC
  use of CHC for more than 5 years is associated with a small increased risk of cervical cancer; risk reduces over time after stopping CHC and is no longer increased by about 10 years after stopping

Question 32

CHC: Non-contraceptive health benefits

Answer 32

• Can reduce heavy menstrual bleeding and menstrual pain and improve acne.
• May be beneficial for women with premenstrual syndrome (PMS) symptoms.
• CHC (particularly continuous CHC regimens) can reduce risk of recurrence of endometriosis after surgical management.
• Management of acne, hirsutism and menstrual irregularities associated with polycystic ovary syndrome (PCOS).
• Significant reduction in risk of endometrial and ovarian cancer that increases with duration of CHC use and persists for many years after stopping CHC.
• Use of CHC is associated with a reduced risk of colorectal cancer

Question 33

Assessment of suitability of CHC

Answer 33

Assessment of medical eligibility for CHC should include medical conditions.
A drug history (rule out potential critical drug interactions).
A recent, accurate blood pressure recording should be documented for all women prior to first CHC prescription (due to increased risk of heart attack).
BMI should be documented for all women prior to CHC prescription. (≥35 kg/m2 generally should not use CHC).
Pelvic examination is not required prior to initiation of CHC.
Breast examination, cervical screening, testing for thrombophilia, hyperlipidaemia or diabetes mellitus and liver function tests are not routinely required prior to initiation of CHC.

Question 34

CHC: Key indications for medical review

Answer 34

Key symptoms that should prompt women to seek urgent medical review :
- Calf pain, swelling and/or redness (sign of VTE)
- Chest pain and/or breathlessness and/or coughing up blood (sign of heart attack)
- Loss of motor or sensory function (sign of stroke)

Key symptoms that should prompt women to seek medical review:
- Breast changes: lump, unilateral nipple discharge, new nipple inversion.
- Unilateral nipple discharge
- New onset sensory or motor symptoms in the hour preceding onset of migraine
- Persistent unscheduled vaginal bleeding

New medical diagnoses that should prompt women to seek advice and review of the suitability of CHC:
- High blood pressure
- High body mass index (>35 kg/m2 )
- Migraine or migraine with aura
- Deep vein thrombosis or pulmonary embolism
- Blood clotting abnormality
- Antiphospholipid antibodies (cancer symptom)
- Angina, heart attack, stroke or peripheral vascular disease
- Atrial fibrillation
- Cardiomyopathy
- Breast cancer or breast cancer gene mutation
- Liver tumour
- Symptomatic gallstone

Question 35

Standard or Tailored CHC use

Answer 35

Women should be given information about both standard and tailored CHC regimens to broaden contraceptive choice
Tailored CHC regimens can reduce the frequency of withdrawal bleeds and can reduce withdrawal symptoms associated with the hormone-free interval (HFI); however, unscheduled bleeding is common
Women should be advised that use of tailored CHC regimens is outside the manufacturer’s licence but is supported by FSRH.

Standard 21/7 CHC cycles were designed to induce a bleed each month, mimicking naturally occurring menstrual cycles.
There is, however, no health benefit from a monthly withdrawal bleed, and the 7-day HFI has the following drawbacks:
- Withdrawal bleeding may be heavy, painful or simply unwanted.
- The HFI may be associated with symptoms such as headache and mood change.
- Ovarian suppression is reduced, Errors in pill-taking (or patch or ring use), risk of ovulation, and thus potential risk of pregnancy.

Tailored (non-standard) CHC regimens reduce the frequency of HFI (extended regimens), abolish the HFI (continuous regimens) and/or shorten the HFI. Using tailored regimens, women can reduce or avoid HFI-associated symptoms and could potentially reduce the risk of escape ovulation and resulting contraceptive failure.

Question 36

Hormonal contraceptive and surgery

Answer 36

Preferred to discontinue CoC 4 weeks prior to major elective surgery and ALL surgeries to legs or surgeries that involve prolong period of immobilisation of lower limb.
Ensure suitable alternative contraceptive is in place (Progestogen only or barrier).
CoC can be re-started at first menses at least 2 weeks after full mobilisation.
If CoC cannot be stopped prior to surgery then a Thromboprophylaxis is a must.
- Unfractionated or Low molecular weight heparin and compression stocking.
These recommendations do not apply to minor surgery with short duration of anaesthesia (e.g. tooth extraction) or to women on oestrogen- free hormonal contraceptives.

Question 37

Progestogen only contraceptives

Answer 37

MOA: alter cervical mucus to prevent sperm entry and may inhibit ovulation (desogestrel).
Suitable alternative when CoC is contraindicated:
- History / current / very high risk of venous thrombosis
- Heavy smokers
- BP of =/> 160/95mmHg
- Valvular heart disease
- DM with complications
- Migraine with aura

Question 38

Contraception in patients taking meds with teratogenic potentials

Answer 38

MHRA guidancerecommends that, when using any medicine with teratogenic potential, e.g Isotretinoin, a woman should be advised of the risks and encouraged to use the most effective contraceptive method, taking into account her personal circumstances.
One way to avoid inadvertent exposures is for a pregnancy test to be performed before prescription of a medicine with teratogenic potential. (Pregnancy Prevention Programme).

Question 39

Hormonal contraceptive and epilepsy

Answer 39

Most anti-epileptic drugs (carbamazepine, phenytoin, and phenobarbital) can reduce the efficacy of hormonal contraceptives.
These are metabolic enzyme inducing drugs.
Women of child-bearing age with epilepsy who are taking enzyme inducing anti-epileptic drugs should be considered for long-acting reversible contraceptives (LARCs) such as Depo injections (Depo provera), copper IUD, and hormonal IUS
Sodium valproate is not recommended in women of childbearing age because of high teratogenicity.
Should have a conversation about recommending contraception to make sure any pregnancies are avoided.C

Question 40

Contraceptives- user failure vs no user failure

Answer 40

Methods with NO user failure:
- Contraceptive injection (e.g. Depo-provera, Noristerat, Sayana Press)
- Implant (e.g. Nexplanon)
- Intra-Uterine System (IUS) contains progestogen (e.g. Mirena)
- Intra-uterine Device (IUD)- Is a copper device. Contains no hormones (e.g. Copper T 380A, Flexi-T 300, Gynefix)
- Vasectomy
- Female sterilization

Methods with user Failure:
- Patch (e.g Evra patch)
- Combined oral contraceptives(COC) (e.g. Microgynon, Yasmin, Marvelon, Cilest, Ovranette)
- Progestogen Only Pills (POP) (e.g. Cerazette, Micronor, Noriday)
- Male condom
- Female Condom
- Caps
- Diaphragms
- Natural methods (e.g Withdrawal method, calendar method and LAM)
- Vaginal rings (e.g, NuvaRing)

Question 41

Missed pill

Answer 41

If you miss a pill or pills, or you start a pack late, this can make the pill less effective at preventing pregnancy. The chance of getting pregnant after missing a pill or pills depends on:
- Which type of Pill you take (CoC or PoP)
- When the pills are missed
- How many pills are missed
A missed pill is defined as one that is more than 24hours late for a Combined Oral Contraceptive (COC) or More than 3hours late for Progestogen Oral Pill (POP). Except for DESOGESTREL (Cerezette) which is 12hours.

Question 42

Drug interactions with HC

Answer 42

Effectiveness of CoC and Progestogens (tabs, patches and vaginal rings) can be considerably reduced by hepatic enzyme inducing drugs e.g.
Carbamazepine, phenytoin (antiepileptics)
Nevirapine, Ritanovir (NNRTIs / PIs)
St john’s Wort
Rifabutin and rifampicin (Especially)

Question 43

EHC interaction (emergency contraception)

Answer 43

When Ulipristal (ella-One) is given as EC, the effectiveness of CoC and PoP may be reduced.
Barrier method required for 14 days for CoC and parenteral Progesterone only hormonal contraceptives.
16 days Qlaira.
9 days for PoP.

Question 44

Vomiting and Diarrhoea

Answer 44

If vomiting occurs within 2 hours of taking a contraceptive pill, it would not have been fully absorbed by the body.
Another pill should be taken straight away. As long as patient is not sick again, she will protected against pregnancy. She can then take her next pill at the usual time.
If patient continue to be sick for more than 24 hours or have severe diarrhoea for more than 24 hours, she should count each day with sickness or diarrhoea as a day that she’s missed her pill.
If she can, she should carry on taking her pills at the normal time, but she may need to use extra contraception, such as condoms.

Question 45

Lactational Amenorrhea Method (LAM)

Answer 45

This is a method of avoiding pregnancy, based upon the natural postpartum infertility associated with fully breast-feeding.
Suckling by an infant reduces the release of gonadotrophins, which suppress ovulation but, as suckling reduces, ovulation returns
It is about 98% effective in preventing pregnancy if a woman is:
- Less than six months postpartum.
- Amenorrhoeic (no vaginal bleeding after the first 56 days postpartum).
- Fully breast-feeding day (at least four-hourly feeds) and night (at least six-hourly feeds). (Breast pumps or expression of milk in other ways do not count).

The risk of pregnancy is increased if:
- Breast-feeding decreases, particularly stopping night feeds, or with the introduction of formula or solids and where pumping rather than nursing occurs.
- Menstruation resumes.
- The woman is more than six months postpartum