Lecture 13: Contraception and infertility Flashcards
What are the methods of contraception?
Any method to prevent pregnancy
- block sperm transport to avoid fertilisation of the oocyte
- disruption of the HPG axis: interfere with ovulation
- inhibiting inplantation of conceptus into endometrium
What are the categories of methods of contraception?
- Natural
- Barrier
- Hormonal control
- Prevention of implantation
- Sterilisation
- Emergency contraception
What are the natural methods of contraception?
Abstinence
Pros: 100% effective
Cons: not an option for most, unprepared when they become sexually active
Withdrawal (coitus interruptus)
Pros: no devices or hormones
Cons: unreliable, some sperm in pre-ejaculate, no STI protection
Fertility awareness methods (monitoring and recording fertility indicators in cycle e.g. cervical secretions, changes in cervix, basal body temp, length of menstrual cycle)
Pros: no hormones/no contraindications
Cons: time-consuming, unreliable, no STI protection, not suitable for all
Lactational amenorrhoea method (breastfeeding after childbirth to avoid pregnancy, delays the return of ovulation by disrupting gonadotrophin release, can be used for 6 months postnatally provided exclusive breastfeeding and complete amenorrhoea)
Pros: no hormones/no contraindications
Cons: unreliable after 6 months, no STI protections, not suitable for all
What are some examples of barrier contraceptives?
Provide physical +/- chemical barrier to sperm entering the cervix
-male/female condoms
-diaphragms/cervical cups (used in conjunction with spermicides)
-spermicides
Pros: reliable if used correctly, STI protection
Cons: disrupts intercourse, risk of dislodging, allergy/sensitivity to latex
What are the options for hormonal control?
Interrupt HPG axis and prevent ovulation, may have effects on endometrial lining
-short-acting or long-acting reversible contraception (LARC)
- Combined oestrogen and progesterogen (COCP, patch, ring)
- POP (progestogen only pill)
- LARC (progestogen depot and implant)
What is progestogen?
Synthetic progesterone
What is the action of the COCP?
Taken 21 days with 7 day break
Main action: prevent ovulation (-ve feedback to HPG axis to prevent LH surge: continued levels of oestrogen and progesterone prevents LH surge, so the whole cycle is like the luteal phase, hence no ovulation)
Secondary action: reduce endometrial receptivity to implantation, thicken cervical mucous (due to high progesterone)
What are the pros and cons of the COCP?
Pros
-reliable if used correctly
-can relieve menstrual disorders
-reduced risk of ovarian and endometrial cancer (reduced frequency of disruption to ovaries as no ovulation, and by reducing proliferation of endometrium)
-reduces acne severity in some
Cons
-user dependant
-no STI protection
-medication interaction
-contraindications (can’t give it to people with) (raised BMI, migraines +aura, breast cancer)
-side effects: menstrual irregularities, breast tenderness, mood disturbance
-increased risk of CV disease, stroke, breast cancer, cervical cancer, venous thromboembolism
What is the action of the POP?
Low dose progesterone
-thickens cervical mucus (main action)
-reduced cilia activity in fallopian tubes (other action)
Ovulation is not prevented, as no oestrogen
Taken daily with no breaks
What are the pros and cons of the POP?
Pros -reliable if used correctly -can be used if COCP is contraindicated Cons -no STI protection -strict timing: user dependant -menstrual irregularities -increased risk of ectopic pregnancy (due to reduced action of the cilia in the fallopian tubes)
What is the action of the progesterone injection?
High dose progesterone (LARC) (Depo-provera)
-inhibits ovulation (while body is producing high levels of progesterone the body will not ovulate, due ot negative feedback from high levels of progesterone), thickens cervical mucus. thins endometrial lining
Given intramuscularly every 12 weeks
What are the pros and cons of the progesterone injection?
Pros -reliable -no known medication interactions -used if oestrogen is contraindicated and raised BMI Cons -no STI protection -not rapidly reversible -menstrual irregularities
What is the action of the progesterone implant?
Small subcutaneous tube inserted in the arm
- high dose progesterone (LARC)
- inhibits ovulation, thickens cervical mucus, thin endometrial lining
What are the pros and cons of the progesterone implant?
Pros
-reliable
-lasts for up to 3 years
-can be used if oestrogen is contraindicated and raised BMI
-fertility returns faster than with an injection
Cons
-no STI protection
-menstrual irregularity
-complications with insertion and removal
What are the different options of contraception which act to inhibit implantation?
Intrauterine system (IUS)
-progestogen releasing coil-local release
-prevents implantation, reduces endometrial proliferation, thickens cervical mucus
-ovulation usually continues as local release of progesterone so no effect on HPG axis
Intrauterine device (IUD)
-copper-containing coil
-copper is toxic to the ovum and sperm, preventing fertilisation
-cervical mucus changes, endometrial inflammatory reactions which inhibit implantation
What are the pros and cons of the coil?
Pros -convenient -effective -LARC (3-10 years) -IUS treatment of menorrhagia Cons -no STI protection -complications with insertion -menstrual irregularities -displacement/expulsion may occur
What are some types of sterilisation?
Vasectomy
- vas deferens are snipped/tied to prevent sperm entering the ejaculate
- under local anaesthetic
- must do post-vasectomy semen analysis
Tubal ligation/clipping
- fallopian tube occluded to prevent ovum transport
- under local/general anaesthetic
- higher failure rate
What are the pros and cons of sterilisation?
Pros -permanent Cons -no STI protection -regret -not easily reversed
Give some examples of emergency contraception:
Used following unprotected sexual intercourse ot contraceptive failure Levonorgestrel (morning after pill): high dose progesterone, inhibits ovulation (up to 72 hrs after) Ulipristal acetate: selective progesterone receptor modulator which delays/inibits ovulation (120 hrs after) (effectiveness may be reduced if patient is taking progesterone) Copper IUD (120 hrs after)
If already ovulated= pregnant lol
What is the definition of subfertility?
A couple who are having regular (every 2-3 days) unprotected sex, who have failed to conceive within 1 year
What are the categories of infertility?
Primary infertility: never been pregnant
Secondary infertility: previous pregnancy (including ectopic and terminations), but struggling to conceive again
What are the broad causes of infertility?
-unidentifiable (25%)
-male and female (40%)
-male causes (30%)
-ovulatory causes (25%)
-tubal factors (20%)
-uterine and peritoneal disorders (10%)
(others are gamete/embryo defects, coital problems e.g. ED, concurrent health problems)
WHat are the male causes of infertility?
Pre-testicular Endocrine: -hypogonadotropic hypogonadism -hyperprolactinaemia -hypothyroidism -diabetes Coital problems: -ED, ejaculatory disorders
Testicular Genetic: -Klinefelter syndrome (XXY) -Y chromosome deletion -immotile cilia syndrome Congenital: -cryptorchidism Infections: -STI (untreated) Antispermatogenic agents: -heat, irradiation, drugs, chemotherapy Vascular: -torsion -varicocele
Post-testicular Obstructive: -congenital (absence of vas deferens) -acquired (vasectomy/ infective) Coital: -sexual dysfunction -hypospadias
What are some ovulatory disorders which lead to infertility?
Hypothalamic-pituitary failure (10%)
- hypothalamic amenorrhoea
- hypogonadotropic hypogonadism
Hypothalamic-pituitary-ovarian dysfunction (85%)
- PCOS (polycystic ovary syndrome)
- hyperprolactinaemic amenorrhoea
Ovarian failure (5%)
- premature ovarian failure
- congenital (Turner’s syndrome)
What are some uterine and peritoneal disorders that lead to infertility?
- uterine fibroids
- conditions causing scarring/adhesions (endometriosis/PID/previous surgery/asherman syndrome)
- mullerian developmental abnormalities
How can tubal damage lead to infertility?
Conditions affecting the fallopian tubes
- endometriosis (due to scarring)
- ectopic pregnancy (can lead to salpingectomy-removal of a fallopian tube)
- pelvic surgery
- PID
- mullerian development abnormality (agenesis)
What questions would you askif a patient came to GP about infertility?
- FMHx
- surgical Hx
- social Hx
- previous children/pregnancies
- sexual health Hx
- sexual dysfunction
Male
- any testicular trauma/disorders
- ejaculatory/erectile dysfunction
Female
- age (no and quality of follicles in ovaries decline)
- menstrual disorders
- obstetric/gynae Hx (cycle, cervical smear, procedures)
How do you exam a patient who comes in for infertility concerns?
Male (not usually required)
-examine penis for structural abnormalities
-scrotal exam
-secondary sexual characteristics
Female
-BMI (increased is associated with reduced fertility)
-secondary sexual characteristics
-acne/hirsutism
-abdominal/pelvic/vaginal exam: masses, tenderness, infection, uterus size/position, vaginismus (fear of vaginal penetration)
What advice would you give patients whilst waiting for investigations to be done?
- smoking cessation
- reduce alcohol intake
- lifestyle changes (limit stress)
- regular intercourse
- weight loss
- reassurance
What investigations would we do on someone with suspected infertility?
Male
- semen analysis (sperm count, motility, liquifaction studies)
- bloods (LH/FSH/testosterone)
- STI screen
- USS of testes
- karyotyping
Female
- bloods (FSH/LH at day 2 as should be low, mid-luteal phase progesterone as this is when its highest, androgens, prolatic levels, thyroid function)
- STI screen
- pelvic USS
- diagnostic laparoscopy
- hysterosalpingogram (HSG)
When would you refer to secondary care?
If history, exam, and investigations are normal in both partners, and they have not conceived after a year
-consider early referral in women >36,or if there are known causes/predisposing factors
What are some specialist management options for infertility?
Medical treatment:
-ovulation induction (clomifene)
Surgical treatment:
-to remove tubal occlusions (laparoscopy)
Assisted reproductive technology (ART): IVF/intrauterine insemination
What is the most common cause of male infertility?
Abnormal semen analysis
What is the most common cause of female infertility?
Anovulation
What is the most common cause of unpredictable, irregular upper genital tract bleeding?
Anovultion
What is a cause of primary/secondary anovulation?
Secondary: PCOS
Primary: dysgenetic gonads
What is responaible for production of acellular mucus with low viscosity and high stretchibility?
Oestrogen action of cervical glands
