Lecture 12 - Contraception And Fertility Flashcards
What are the 3 main methods of contraception?
Blocking sperm transport (cervical mucus)
Disrupting HPG axis preventing OVULATION
Inhibiting implantation of conceptus into endometrium (thinning endometrium)
What are the categories of contraception?
Natural
Barrier
Hormonal
Intrauterine (IUD/IUS)
Sterilisation
Emergency contraception
What are some natural methods of contraception?
Abstinence
Withdrawal
Fertility awareness methods
Lactational amenorrhoea
What are the advantages of abstinence as a contraception method?
100% effective
What are the disadvantages for abstinence as a method of contraception?
Not an option for most
Unprepared when sexually active
What are the advantages and disadvantages of using the withdrawal method for contraception?
Adv:
-no devices or hormones
Disadvantage:
-unreliable (some sperm in pre-ejaculate)
-No STI protection
What is the natural fertility awareness method of contraception??
By using cervical secretions and basal body temperature changes can work out what stage in the cycle they’re at and therefore when they’re most fertile or not
What happens to the basal body temperature at ovulation?
Lots of progesterone produced by the corpus luteum, this leads to an increase in Basal Metabolic Rate which increases the body temperature
What are the advantages and disadvantages of using the fertility awareness methods as contraception?
Adv:
-no hormonal/contraindications
Disav:
-time consuming
-unreliable
-no sti protection
-not suitable for everyone
How do cervical secretions change during the cycle?
What hormones are high in these phases?
Follicular phase;
-high oestrogen
-thin alkaline cervical mucus
Luteal phase:
-high progesterone
-thick sticky acidic cervical mucus
How does lactational amenorrhoea work as contraception?
When lactating up to 6 months postnatal Prolactin levels are very high
Prolactin inhibits GnRH release
This inhibits production of sex hormones
What are the advantages and disadvantages of the lactational amenorrhoea method of contraception?
Adv:
-no hormonal/contraindications
Disadvantage:
-unreliable after 6 months
-No STI protection
-not suitable for all
What are some barrier methods of contraception?
Condoms
Diaphragms/cervical caps
Spermicides
What are the advantages and disadvantages of the barrier method of contraception?
Adv:
Reliable (if used correctly)
-STI protection
Disadvantage:
-disrupts intercourse
-risk of dislodging
-allergy to latex
What does the combined oral contraceptive pill contain? (COCP)
Oestrogen and progesterone
What is the main action of how the combined oral contraceptive pill works?
What is its secondary actions?
STOPS OVULATION
Secondary:
-thins endometrium
-thickens cervical mucus
What are the advantages of the Combined oral contraceptive pill?
Reliable
Can relieve menstrual disorders (can take back to back to prevent periods helping with endometriosis)
Decreased risk of ovarian cancer (less ovulation) and endometrial cancer (reduced proliferation of endometrium)
Reduced acne severity
What are the disadvantages of using the combined oral contraceptive pill (COCP)?
User dependant
No STI protection
Medication interaction
Contraindications (raised BMI, migraines, breast cancer)
Side effects = menstrual irregularities, breast tenderness and mood disturbance
Inc risk of CV disease, stroke, VTE, breast and cervical cancer
What is the action of high dose progesterone?
Enhances negative feedback of oestrogen
So low oestrogen means low FSH and LH
This prevents the LH surge leading to ovulation
Prevents ovulation by preventing LH surge
What is the action of lower levels of progesterone?
Thickens cervical mucus
Ovulation still occurs since the progesterone is not high enough to inhibit oestrogen enough to prevent LH surge
What are the levels of progesterone in the progesterone only pill (POP)?
Low dose progesterone taken daily
What is the main method of action of the progesterone only pill if its low dose progesterone?
Thickens cervical mucus
Secondary:
Reduced cilia activity in fallopian tubes
OVULATION is NOT prevented
What are the advantages of the progesterone only pill?
Reliable
Can be used if the COCP contraindicated
What are the disadvantages of the progesterone only pill?
No STI protection
Strict timing
Menstrual irregularities
Inc risk of Ectopic pregnancy
The progesterone causes menstrual side effects (mood swings, acne)
What is the progesterone injection?
High dose progesterone
(LARC)
Long acting reversible contraception
Given IM every 3months
What are the main actions of the progesterone injection?
INHIBITS OVULATION (inhibits LH surge by inhibiting oestrogen)
Thickens cervical mucus
Thins endometrial lining
What re the advantages of the progesterone injection?
Reliable
No medical interactions
Cn be used if oestrogen contraindicated and raised BMI
What are the disadvantages of the progesterone injection?
No STI protection
Can take 18months for fertility to return
Menstrual irregularities (spotting, acne, mood swings)
How does the progesterone implant work?
High dose progesterone (Long acting reversible contraception)
Inhibits OVULATION
Thickens cervical mucus
Thins endometrial lining
What are the advantages of the progesterone implant?
Reliable
Last up to 3 years
Can be used if oestrogen contraindicated and raised BMI
Fertility returns faster than injection
What are the disadvantages of the progesterone implant?
No STI protection
Menstrual irregularities
Complication with insertion and removal (infection risk)
How does the Mirena (IUS) work?
A progesterone releasing coil (low level progesterone)
Prevents implantation:
Thickens cervical mucus
Thins endometrium
How does the IUD work?
Copper coil is toxic to the ovum and sperm preventing fertilisation
The coil causes a constant endometrial inflammatory response which prevents implantation
What are the advantages and disadvantages of Intrauterine contraceptives?
Adv:
-convenient
-effective
-LARC (3 to 10ths)
-IUS can treat menorrhagia
Disadvantage:
-No STI protection
-complications with insertion (perforation)
-menstrual irrregularities
-displacement
What are the 2 types of sterilisation methods of contraception?
Vasectomy
Tubal ligation/clipping
What is a vasectomy?
Vas deferens snipped to prevent sperm entering ejaculate
What are the advantages and disadvantages of sterilisation?
Adv:
-permanent
Disadvantage:
-permanent
-infection risk
What are the 3 types of emergency contraception?
Levonorgestrel ((morning after pill = high dose progesterone)
EllaOne (acts like progesterone stopping LH surge)
Copper IUD (stops implantation)
What is the definition of infertility?
The failure to achieve a pregnancy after 12 months or more of regular (2-3 times a week) unprotected sexual intercourse
What is primary infertility?
What is secondary infertility?
Primary = never been pregnant
Secondary = previous pregnancy but struggling to conceive
What is subfertility?
Gerenally describes any form of reduced fertility that results in a prolonged duration of unwanted lack of conception
What are some causes of infertility?
Unidentifiable
Male causes
Ovulation causes
Tubul factors
Uterine and peritoneal disorders
What are the 3 types of male causes for infertility?
Pre-testicular
Testicular
Post-testicular
What is a pre-testicular cause of male infertility?
Hypogonadotrpopic hypogonadism
Thyroid disorders
What is a testicular cause of male infertility?
Klinefelter syndrome (XXY)
Cryptorchidism (testes not descending)
Infective (mumps)
Antispermatogenic agents like chemo
Vascular (Torsion or varicocele)
What are some post testicular causes of male infertility?
Absent vas
Infective
Vasectomy
Coital problems:
-sexual dysfunction
-hypospadias
What is hypospadias?
Congenital urethral opening is lower down
What are the 3 types of ovulation disorders?
Group I: hypothalamic pituitary failure
Group II: hypothalamic pituitary ovarian dysfunction
Group III: ovarian failure
What are some examples of Group I Hypothalamic pituitary failure?
Stress
Weight loss
Hypothalamic amenorrhoea
Hypogonadotropic hypogonadism
What are some examples of Group II Hypothalamic pituitary ovarian dysfunction?
PCOS
High prolactin (breast feeding, certain meds, tumours)
What are some examples of Group III Ovarian failure?
Premature ovarian failure
Turner’s syndrome (45X0)
What can cause tubal damage leading to infertility?
Endometriosis
Ectopic pregnancy
Pelvic surgery
Pelvic inflammatory disease (PID)
They all cause scarring
Mulllerian developmental anomaly (agenesis)
What are some uterine and peritoneal disorders?
Uterine fibroids
Condtions causing scarring/adhesions:
-endometriosis
-PID
-Previous surgery
-ashermans syndrome
What is asherman syndrome?
Scarring of endometrial lignin
What examinations are done in women with suspected infertility?
BMI
Secondary sexual characteristics
Hirsutism, Acne (PCOS)?
Pelvic/abdominal exam and swabs
What advice can be given to patients with infertility issues?
Smoking cessation
Reduce alcohol intake
Lifestyle changes
Regular intercourse
Weight loss
What investigations can be done in men to check for infertility?
Semen analysis
Bloods (LH/FSH and testosterone)
STI screen
Ultrasound scan testes
Karyotyping
What investigations can be done to check for infertility in women?
FSH/LH (day 2)
Midluteal phase progesterone (DAY 21)
Thyroid function tests, prolactin levels and androgens
STI
Pelvic ultrasounds
Hysterosalpingogram
Laparoscopy
What is a hysterosalpingogram?
Where dye is inserted into the female tract and is used to view the uterus and the fallopian tubes
When may you consider referring somebody to secondary care with infertility?
Normal history and exam and not conceived in a year
Early referral if:
Woman > 35 after 6months of trying
Or
Known cause
How can infertility be managed?
Medical treatment - ovulation induced by Clomifene
Surgical treatment - removal of tubul occlusions (laparascopy)
Assisted Reproductive Techonology
What factors are assessed in semen analysis?
Semen vol
Total sperm count
Total motility
Progressive motility
What is the physiological basis of viagra?
Vasodilation/stimulation of parasympathetics
Due to the viagra decreasing the rate of degradation of cGMP meaning the affects of NO last longer
When would the most previous ovulation have occured if the person started bleeding today?
14 days ago
What day is progesterone the highest?
21
