Management of Fertility & Infertility Flashcards
Management of Fertility and Pregnancy Prevention
* Almost 3 million unintended pregnancies occur in the US each year
* 43% of which occurs in women who use their contraceptives incorrectly or inconsistently
* Provide counseling and education to women
Check Your Bias
* Culture, religion, and personal beliefs can play roles in contraception, the prevention of contraception, and how we do that
* Educate based on facts and allow patients to choose based on their will and individual circumstances
?
Used by approximately 1 in 3 married couples
* Must consider divorce, death of a spouse, and future marriages
* Reversal is difficult, expensive, and not always successful
> Tubal ligation in females and vasectomy in males
> Designed to be a permanent contraceptive method
Sterilization
Sterilization: Tubal Ligation
* Is the cutting or occluding of the fallopian tubes to prevent fertilization
Surgical Methods for Tubal Sterilization
* Easiest to perform during abdominal surgery (e.g. cesarean birth [or done 48 hours > a vaginal birth]
* Blocks tubes w/clips, bands, rings
* Removes a piece of the tube (we clip OR cut out a portion of the tube)
* Ties or uses electrocauterization
Nonsurgical Methods for Tubal Sterilization
___, ___
Done by insertions that occur through the vagina, up into the uterus that get placed in each fallopian tube
* 1 is a small coil and the other a radiofrequency and silicone implant
* Can be done in the MD’s office; takes up to 3 months for scar tissue to form around implant sites
* Could have someone still being fertile when they think they aren’t and this increases the risk of contraceptive failure
Essure, Adiana
Sterilization: ___?
Cut, tie, cauterize, or remove a section of the vas deferens (which transport sperm from testes to penis)
- Safer, easier, less expensive, and a lower failure rate than tubal ligation
- Can be performed in a physician’s office under local anesthesia or some will request general anesthesia
- May take 3 months or more for there to be no sperm within the semen
* Is why men are told they need to have “x” amount of ejaculations prior to being sterile
* Need to submit semen specimens for analysis
Vasectomy
Intrauterine Devices (IUDs)
* Inserted into the uterus to provide continuous pregnancy prevention
* Can be good for 3 to 10 years depending on device used
> Copper T 380A (ParaGard) [nonhormonal, can also be used as an emergency contraceptive)
> Levonorgestrel Intrauterine System (Mirena, Skyla) [Mirena - 5 yrs, Skyla - 3 yrs] (hormonal, good for 3-5 yrs)
* Fertility returns after device is removed
* Side effects: menorrhagia [have seen menstruation heavier in ParaGard than Mirena], dysmenorrhea
* Complications: expulsion of the IUD, perforation of the uterus, ectopic pregnancy, spontaneous abortion, infection
* Education: women should feel for the strings once per week x 4 weeks, then monthly after menses, as well if any signs of expulsion [uterine cramping] are present
Hormonal Contraceptives: Oral
Progestin only (POPs)
Combination (COCs)
Combination (COCs)
Have ___ and ___
* Take at same time each day
estrogen; progestin
Progestin only (POPs)
Only ___ (some may have a sensitivity to estrogen)
! Take at same time each day; has a 3 hour window
progestin
Many cautions exist surrounding contraceptive use - p. 670, Box 31.1
Side effects: nausea, breast tenderness, breakthrough bleeding (bleeding at time outside the menses), weight gain, fluid retention, amenorrhea, melasma, high risk of ___ development
> Long flights increase the risk of this
> Risks include if had a previous clot, stroke, or PE
thromboembolism
Rx interactions
> Interact with St. John’s wort, anticonvulsants, some antibiotics can affect efficacy but many do not
Effects of illness
> Vomiting or diarrheal illnesses affects the absorption of an oral contraceptive
> Use a back-up contraceptive for 7 days
Follow-up
> Yearly BP measurements taken
> A high BP increases the risk for thromboembolism development
> Pelvic exams, PAP smears, breast exams on a normal schedule
- Pelvic exams for adolescents not needed until 21 years and older
> Return of fertility about 3 months after discontinuation of use
* Remember: these don’t work for males, only females
Education:
- Failure to take properly is a common cause of unintended pregnancy;
- when to begin taking OCs (wait 3-4 weeks before starting combination pills > birth)
- side effects;
- effects of illness;
- missed doses;
- postpartum and lactation considerations;
- medication interactions;
- follow-up needs
3 Starts
- Consider a quick start, right away
- Encourage a Sunday start
- If possibility of pregnancy, first day after menstrual period begins
* Progestin-only pills can start immediately after delivery
- These can help with milk supply
Hormonal Contraceptives: ___?
Ethinyl estradiol and norelgestromin Transdermal Contraceptive Patch (___)
* A new patch is applied to a different site on the same day of the week each week for 3 weeks, and is worn continuously for 7 days
* Apply to clean, dry, non-irritated skin on the abdomen, buttock, upper torso (excluding on the breasts), or upper outer arm
* Risk of thromboembolism is higher with patch use than with OC use because estrogen exposure is significantly higher over time
! Don’t cut or alter the patch
* Can help to regulate the menstrual cycle
Transdermal
Ortho-Evra
Hormonal Contraception: ___
Ethinyl estradiol Contraceptive Ring (___)
* Soft, flexible ring inserts into the vagina and remains in place for 3 weeks; can replace ring if trying to extend cycle
* Prescription required; fitting is not
* Side effects are less common than with OCs; see breakthrough bleeding
* Some women experience expulsion, vaginal discharge, or discomfort from feeling the ring within the vagina
* May be removed for short periods
Transvaginal
NuvaRing
Hormonal Contraceptives: Implants
Progestin-containing (___) (NO estrogen)
* Single rod implant subcutaneously into upper inner arm
* Provides 3 years of contraception
* Side effects: irregular menstrual bleeding, amenorrhea with longer use
* Safe during lactation (progestin helps with milk production)
* Fertility returns within a few weeks after the implant is removed
> If gets inserted within 7 days of start of menses, no backup method needed. If inserted at any other time in the cycle, should be a backup contraceptive used for 3 days
Nexplanon
Hormonal Contraceptives: Injections
Medroxyprogesterone acetate/DMPA (___)
Intramuscular or subcutaneous injection
Prevents ovulation for 14 weeks
Side effects: menstrual irregularity, spotting, breakthrough bleeding, amenorrhea, weight gain, breast tenderness, headaches, depression, decreased ___ (which increases the risk of osteoporosis development)
* Should not be used for more than 2 years unless no other contraceptive is suitable
Depo-Provera
(decreased) bone density
Hormonal Contraceptives: Emergency
“Morning-After Pill”
* Prevents pregnancy after unprotected intercourse or rape
* Available at pharmacies without a prescription for all women 17 years and older
* Effective if ovulation has not already occurred; reduces risk of pregnancy by approximately 85%
* Most effective if used as soon as possible within 72 hours of intercourse
* Does not harm a developing fetus
Barrier Devices: Chemical
* Spermicides
- Creams, gels, foaming tablets, suppositories, vaginal films
* Inserted deep into the vagina approximately 30 minutes before intercourse
* Length of effectiveness varies; times of reinsertion may be needed but messy
* Readily available without prescription, inexpensive, easy to use
! Do not protect against STDs
* May cause irritation; interrupt sensation with intercourse
* Most effective when used WITH a mechanical barrier (e.g. condom)
Barrier Devices: Male Condoms
* Covers the penis to prevent sperm from entering the vagina
* Most popular contraceptive method in the United States
* Latex condoms provide the best protection available (other than abstinence) against STDs, including HIV
* Readily available, inexpensive, and can be carried inconspicuously by a man or woman
* Effectiveness is increased when combined with another contraceptive method
Barrier Devices: Female Condom
Also called ?
* Polyurethane or nitrile sheath inserted into the vagina
* Male and female condoms should not be used together → increases breakage risk and risk of exposure to infection or to sperm in ability to conceive
“Vaginal Pouch”
Barrier Devices: Sponge
* Soft polyurethane sponge that traps and absorbs semen
* Contains spermicide
* “Dimple” covers cervix
* Can use for repeated intercourse without additional spermicide
* Remains in place for at least 6 hours, no longer than 30 hours
* Use during menstruation increases risk of ?
Toxic Shock Syndrome (TSS)
Barrier Devices: ___
Latex dome surrounded by a spring or coil
Filled with spermicidal cream or gel and inserted into the vagina, covering the cervix
Prevents passage of sperm into the cervix
! Must be fitted by a healthcare provider
> Changes in weight or in cervix from vaginal delivery require re-fitting
* Increased risk of ___ and bladder infection due to pressure on the urethra
Diaphragm
urinary tract infections
Barrier Devices: ___
* Similar to the diaphragm, but smaller
* Remains in place by suction for up to 48 hours
* Spermicide is placed on both sides of the cap before insertion
* Must be fitted by a healthcare provider
* Women should be educated to confirm placement before and after intercourse as this can be dislodged
* Should not be used during menses or in women with a history of toxic shock syndrome (TSS)
Cervical cap
Natural Family Planning
* Predict ovulation and avoid coitus when conditions are favorable for fertilization
* Also helpful for women who want to become pregnant
* Helps women learn about their bodies throughout the menstrual cycle
* Acceptable to most religious groups and avoids the use of medication, chemicals, and devices
! High failure rate; 1 out of 4 fail
Natural Family Planning: Rhythm Method
* Also referred to as the “Calendar Method”
* Based on ___
* Abstain or use alternative method of contraception during the days calculated to be fertile
* Unreliable; ovulation can be delayed due to illness, stress
timing of ovulation
Natural Family Planning: Standard Days Method
* String of color-coded beads
* Used with cycles ranging from 26-32 days
* Days 8 through 19 are considered “fertile days”
Natural Family Planning: Cervical Mucus Method
Based on changes in cervical mucus
> First 3-4 days post-menses = no cervical mucus
> Thick, sticky mucus appears - not conducive to pregnancy
> Mucus changes to clear, slippery, stretchy (beyond 2 inches), and egg-white (?)
spinnbarkeit
* Avoid intercourse from time mucus is first present post-menses until 4 days after the end of the slippery mucus
Two-Day Method
> Any vaginal secretions are present today and yesterday = fertile
> No secretions today or yesterday = infertile
Natural Family Planning: Symptothermal Method
* Assessment of basal body temperature (BBT) and cervical mucus daily
* Assess for symptoms of ovulation
> Weight gain, abdominal bloating, ___ (a pain associated with ovulation), increased libido
* Electronic fertility monitors may be used
* A rise is a sign of ovulation
mittelschmerz
Abstinence
* Only completely effective method in preventing pregnancy and STDs
* Abstinence-only education programs are ineffective in reducing teenage pregnancies
! Remember, informed consent
* For any method of contraception that we’re prescribing or for performing a procedure
Considerations When Choosing A Contraceptive Method
* Safety
* Protection from STDs (male latex condoms are best at prevention of)
* Effectiveness / acceptability
* Convenience / education needed
* Benefits
- e.g. oral contraceptives help acne and decrease amount of bleeding with each period and prolong amenorrhea
* Side effects
* Effect on spontaneity
* Availability
* Expense - less expensive tends to be less effective
* Preference
* Religious or personal beliefs
* Culture
Special Considerations: Adolescents
* Because of the serious effects of pregnancy on the teenager, finding methods to increase contraception amongst sexually active adolescents is extremely important
Therapies to Facilitate Pregnancy: Therapeutic Insemination
* Intrauterine Insemination (IUI); bypass the cervix
* Donors are screened to reduce disease transmission or genetic defects; physical exams and laboratory tests performed
* Donor semen is held and frozen for 6 months before use to reduce disease transmission (retested during the 6 months)
* Inadvertent consanguinity (a blood relation to the recipient)
* Is a good method for same-sex couples or women without a partner
