Lecture 5.1: Contraception and Fertility Problems Flashcards
What is the Definition of Contraception?
The deliberate use of artificial methods or other techniques to prevent pregnancy as a consequence of sexual intercourse
Who should use contraception: Women
- Menarche to 55yrs
- If stopped bleeding and are > 50, no need for
contraception after 1 year of no bleeding - If stopped bleeding and are 50 or under, no need for
contraception after 2 years of no bleeding
Who should use contraception: Men
Throughout reproductive life
What is a Vasectomy?
It it contraception that reduces sperm count by dividing the vas defrens
What is the failure rate of a vasectomy?
1 in 2000
What is the regret percentage of a vasectomy?
2%
What is contraception by timing of coitus?
Not to have coitus in fertile calendar period
What are some Fertility Awareness Methods (7)
- Abstinence in a calendar cycle
- Basal body temperature
- Cervical mucous
- Cervical positioning
- Lactational amenorrhoea
- Coitus interruptus/withdrawal
- Urine home LH tests
Examples of contraception by methods which prevent sperm from entering the cervix (5)
- Male Condom
- Female Condom
- Female Diaphragm
- Female Cervical Cap
- Progesterone Only Pill
How does a male condom prevent sperm from entering the cervix? How effective is it?
- Barrier method
- With correct use, 98% efficacy
How does a female condom prevent sperm from entering the cervix?
- Barrier method
- With correct use, 95% efficacy
How does effective is a female diaphragm? What other contraceptive method does it need to be used with?
- ~95% effective
- Use with spermicide
How does effective is a female cervical cap? What other contraceptive method does it need to be used with?
- Use with spermicide
- ~ 95% effective
How does a progesterone only pill prevent sperm from entering the cervix?
- Thickens cervical mucous
- If taken correctly 99% effective (but 92% in most
women)
Examples of contraception to prevent ovulation (4)
- Combined Hormone Contraception
- Progestogen only pill (some)
- Progestogen subdermal implant
- Progestogen injectable
What is the Combined Hormone Contraception? How effective is it?
- Oestrogen and progestogen
- Effective > 99%
What are the benefits of the Combined Hormone Contraception? (3)
- Predictable bleeding pattern
- Helps heavy menstrual bleeding
- Helps painful periods
What are the risks/side-effects of the Combined Hormone Contraception? (7)
- Risk of M.I
- Risk of Stroke
- Risk of VTE
- Headaches
- Nausea
- Breast Tenderness
- Mood Swings
What other changes occur when taking Combined Hormone Contraception? (3)
- Cervical mucous
- Tubal motility
- Endometrial changes
What are the 3 Methods of Combined Hormone Contraception?
- Oral Tablet
- Vaginal Ring (Nuvaring)
- Transdermal Patch (Evra)
How is the Oral Tablet taken?
- Take 1 tablet daily for 21 days
- Then 7 days hormone-free-interval (HFI)
- Then repeat
- Tailored regimes available
- Monophasic
How is the Nuvaring used?
- 1 ring into the vagina for 21 days
- Removed for 7 days for a hormone free-interval (HFI)
- Then repeat
- Tailored regimes available
How is a Transdermal Patch used?
- Apply 1 new patch every week
- Repeat for 3 weeks and then a 7 day hormone free
interval (HFI) - Tailored regimes available.
How effective is the progestogen sub-dermal
implant (Nexplanon)?
> 99%
How is the progestogen sub-dermal implant inserted? How long does it last?
- Inserted in the upper arm
- Local anaesthetic
- Lasts for 3 years
What is the most common side-effect of the progestogen sub-dermal implant?
Irregular bleeding
How is the progestogen injectable used?
- Intra-muscular injection (into gluteal or deltoid)
- Or subcutaneous injection (anterior thigh or abdomen)
- Every 13 weeks
How effective is the progestogen injectable?
> 99%
What are the side-effects of the progestogen injectable? (4)
- Amenorrhoea
- Only contraception ass.with weight gain
- Bone thinning – resolves with discontinuation
- Delay in fertility up to 12 months
Contraception by blocking the sperm meeting the ovum in the Fallopian tube: Tubal Ligation
- Female sterilisation
- ‘Filshie clips’ on each F.tube
What is the failure rate of Tubal Ligation?
1 in 200
What is an Intra-uterine copper device (IUCD)? How does it work? How effective is it?
- Copper wire
- Contraception due to copper toxicity to sperm
- > 99%
What is an Intra-uterine system (IUS)? How does it work? How effective is it?
- Progestogen
- MoA: Pre-fertilisation due to foreign body affect and
endometrial thinning - > 99%
How long does an IUCD last?
5-10 years
How long does an IUS last?
3-6 years
What are the options for Emergency Contraception (3)
- Levonorgestrel/‘Levonelle’ (tablet)
- Ulipristal/‘EllaOne’ (tablet)
- Intra-Uterine Copper Device (IUCD)
What is UPSI?
Unprotected sexual intercourse
How does Levonorgestrel work? How long after UPSI can it be used? How effective is it?
- It is a progestogen
- Delays ovulation by 5 days
- Licensed for up to 72 hours after UPSI
- 97% effective
How does Ulipristal work? How long after UPSI can it be used? How effective is it?
- Selective Progesterone Receptor Modulator
- Delays ovulation by 5 days
- Licensed for up to 120 hours after UPSI
- 98% effective
How does IUCD work? How long after UPSI can it be used? How effective is it?
- Prevents fertilisation due to copper toxicity on sperm
embryo - Also impairs implantation in the endometrium
- < 120 hours after 1st episode of UPSI since LMP OR
within 5 days of earliest likely date of ovulation - > 99% effective
What is the Definition of Fertility Problems/Infertility?
Infertility is the inability to conceive, a couple is regarded as infertile if, after regular sexual intercourse, they have not conceived in 1 year
What are the main causes (and percentages) of infertility in the UK? (5)
- Factors in the male causing infertility (30%)
- Unexplained infertility (25%)
- Ovulatory disorders (25%)
- Tubal damage (20%)
- Uterine or peritoneal disorders (10%).
Causes of Male Infertility (7)
- Infection (mumps)
- Vasectomy
- Environmental Chemicals
- Retrograde Ejaculation
- Medication (steroids)
- Smoking
- Alcohol
Causes of Female Infertility
- Ovulatory and ovary problems
- Fallopian tube problems
- Uterine cavity problems
How do we test for ovulation?
- Basal body temperature (BBT) chart
- Urine test kits to measure LH levels
- Blood tests to measure levels of certain hormones
- Transvaginal ultrasound
If there is evidence of no ovulation, what are the 5 potential causes of anovulation?
- Hypothalamus Pituitary Ovarian dysfunction
- Hypergonadotrophic Hypogonadism
- Hypogonadotrophic Hypogonadism
- Hyperprolactinaemia
- Thyroid disorder (hypothyroidism and
hyperthyroidism)
What is HPO dysfunction?
Hypothalamic-Pituitary-Ovarian Axis Dysfunction
How does HPO dysfunction present? (4)
- Infrequent or absent menses (oligo or a-menorrhoea)
- Fertility problems
- Acne and male pattern hair distribution
- Multiple small ovarian cysts on pelvic ultrasound
Management Options for HPO dysfunction present (3)
- BMI Optimisation
- Clomiphene
- Ovarian Drilling
Hypergonadotrophic Hypogonadism
A disorder of abnormal function of gonads with decreased testosterone in males and estradiol in females, which results in delayed sexual development
When is Ovarian Failure seen? (5)
- Premature Menopause
- Turners Syndrome
- Chemotherapy
- Radiotherapy
- Surgical Oophorectomy
When is general depression of the HPO axis seen? (5)
- Extreme Exercise/Athletes
- Stress
- Anorexia Nervosa
- Low BMI
Hyperprolactinaemia
Prolactin released from the anterior pituitary
How does Hyperprolactinaemia present? (4)
- Headache
- Peripheral visual field loss
- Irregular or absent menses (oligo or amenorrhoea)
- Galactorrhoea
Management of Hyperprolactinaemia (2)
- Treat underlying condition
- Dopamine agonist (inhibits Prolactin), e.g.
Bromocriptine
What is Endometriosis?
Endometrium tissue found at other sites other than the
lining of the uterus
Symptoms of Endometriosis (8)
- Pain in your lower tummy or back (pelvic pain)
- Period pain that stops you doing your normal
activities - Pain during or after sex.
- Pain when peeing or pooing during your period
- Nausea
- Constipation
- Diarrhoea
- Blood in your pee or poo during your period
What is a Hysterosalpingogram?
An x-ray procedure used to see whether the fallopian tubes are patent (open) and if the inside of the uterus (uterine cavity) is normal
What is a Laparoscopy and Dye Spill Test?
An operation using keyhole surgery to look at your abdominal and pelvic organs, particularly your fallopian tubes
What conditions may cause blocked fallopian tubes?
- Endometriosis
- Pelvic Inflammatory Disease (PID)
- Not always known
Pelvic Inflammatory Disease (PID) (3)
- Pain in the tummy
- Pain when peeing
- Heavy or painful periods
What is a Hydrosalpinx?
Fluid blockage in your fallopian tubes that may make it difficult for you to become pregnant
Management Option for Hydrosalpinx
‘Laparoscopic Salpingectomy’
Uterine Cavity Abnormalities and how to manage them (3)
- Fibroids: Manage by Removal/Resection
- Septations: Manage by Adhesiolysis
- Polyps: Manage by Polypectomy
Routine Fertility Investigations (7)
- Semen analysis
- Pelvic ultrasound
- Mid-luteal progestogen
- Hysterosalpingogram or Laparoscopy and dye test
- Chlamydia
- Rubella
- Cervical smear
How can people suffring with inferrtiloty have children?
- Sperm and egg donation in the UK (and abroad)
- Intra-uterine insemination
- IVF
Awareness of Ovarian Hyperstimulation Syndrome (OHSS). - ICSI for e.g. obstructive azoospermia.
- Surrogacy
- Fostering
- Adoption
How can people suffering with infertility have children? (7)
- Sperm and egg donation in the UK (and abroad)
- Intra-uterine insemination
- IVF
- ICSI for e.g. obstructive azoospermia.
- Surrogacy
- Fostering
- Adoption
What is Ovarian Hyperstimulation Syndrome?
It is an exaggerated response to excess hormones, causes ovaries to swell and become painful
How long can sperm survive in female reproductive system?
c. 5 days
What is Lactational Amenorrhoea?
- Aka Postpartum Infertility
- You’re unlikely to have any periods if you breastfeed
exclusively and your baby is under 6 months old
When does Lactational Amenorrhoea become unreliable? (4)
- Gaps between feeds are longer than 4 hours during
the day or longer than 6 hours at night - Other foods or liquids are substituted for breast milk
- Your baby reaches 6 months old
- You have a period
UKMEC Criteria
A set of guidance criteria that enable and support clinicians to deliver safe, evidence-based contraceptive care to women
What is 1-4 on UKMEC Criteria
1= safe
2= benefits outweigh risks
3= risks outweigh benefits
4= unsafe
What is the Pearl Index
The number of pregnancies that happen for one method per 100 women over a year, it is for showing effectiveness of a particular contraceptive method
What is the medical name for period pain?
Dysmenorrhea
What is the medical name for heavy periods?
Menorrhagia
Types of Tubal Ligation (9)
- Bipolar Coagulation
- Fimbriectomy
- Irving Procedure
- Monopolar Coagulation
- Tubal Clip
- Tubal Ring
- Pomeroy Tubal Ligation
- Essure
- Adiana
Types of Tubal Ligation: Bipolar Coagulation
This method uses electrical current to cauterise sections of the fallopian tube
Types of Tubal Ligation: Fimbriectomy
Removing a portion of the fallopian tube closest to the ovary
Types of Tubal Ligation: Irving Procedure
- This procedure calls for placing two ligatures (sutures)
around the fallopian tube - Then removing the segment of tubing between the
ligatures - To complete the procedure, the ends of the fallopian
tubes are connected to the back of the uterus and the
connective tissue respectively
Types of Tubal Ligation: Monopolar Coagulation
Uses electrical current to cauterise the tube together, but also allows radiating current to further damage the tubes as it spreads from the coagulation site
Types of Tubal Ligation: Tubal Clip
The tubal clip or Hulka Clip technique involves the application of a permanent clip onto the fallopian tube
Types of Tubal Ligation: Tubal Ring
The silastic band or tubal ring method involves a doubling over of the fallopian tubes and application of a silastic band to the tube
Types of Tubal Ligation: Pomeroy Tubal Ligation
- A loop of tube is “strangled” with a suture.
- Usually, the loop is cut and the ends cauterised or
“burned“ - This type of tubal ligation is often referred to as cut,
tied, and burned
Types of Tubal Ligation: Essure
- Two small metal and fiber coils are placed in the
fallopian tubes - After insertion, scar tissue forms around the coils
- Blocking off the fallopian tubes and preventing
sperm from reaching the egg
Types of Tubal Ligation: Adiana
- In this method of tubal ligation, two small silicone
pieces that are placed in the fallopian tubes - During the procedure, your health care provider heats
a small portion of each fallopian tube and then inserts
a tiny piece of silicone into each tube - After the procedure, scar tissue forms around the
silicone inserts - Thus blocking off the fallopian tubes and preventing
sperm from reaching the egg
Why is it important to test for Rubella in individuals trying to conceive?
The Rubella virus is classified as a teratogen
What is PCOS?
Polycystic Ovary Syndrome
Symptoms of PCOS
- Irregular Periods
- Infertility
- Weight Gain
- Painful Periods
- Acne
- High Testosterone Levels
Rotterdam Criteria
String of Pearls
Hyperandrogenism
Oligomenhhorea
Prolactin
Tranexamic Acid
Tranexamic acid is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation
