Repro 7.2 Contraception and Infertility

Question 1

What are the natural forms of contraception?

Answer 1

Abstinence
Coitus interuputus
Rhythm method

Question 2

Why is coitus interruptus not 100% effective?

Answer 2

There is some sperm in pre-ejaculate

Question 3

Why is the rhythm method not 100% effective?

Answer 3

Requires a regular cycle and no woman can be 100% certain when ovulation will occur.

Question 4

In the rhythm method, what assumptions are made?

Answer 4

Sperm 7 days, ova 1 therefore with a regular 28 day cycle ovulation day will be day 14/15 and the fertile period is days 17-16 so sexual intercourse is avoided at these times

Question 5

What are the barrier methods of contraception?

Answer 5

Condoms
Diaphragm
Cap

Question 6

What are the benefits of condoms as a form of contraception?

Answer 6

Readily available
Protect against STI
Effective if used correctly

Question 7

How does a diaphragm work and what are the disadvantages?

Answer 7

Lies diagonally across the cervix
Needs correct fitting
Does not completely occlude sperm passage but holds sperm in acidic vagina and reduces survival time

Question 8

How does the cap work as a method of contraception?

Answer 8

Fits across cervix

Question 9

What is commonly used in conjunction with barrier methods of contraception?

Answer 9

Spermicide

Question 10

What forms of contraception prevent ovulation?

Answer 10

Combined oral contraceptive pill
Depot progesterone (3 monthly injections)
Progesterone only pill (maybe)
Progesterone implant (maybe)

Question 11

How can ovulation be prevented?

Answer 11

Inhibit follicular development and by negative feedback to the hypothalamus and pituitary

Question 12

What forms of contraception inhibit sperm transport?

Answer 12

Female sterilisation
Vasectomy
Progesterone mediated contraception:
Progesterone implant
POP
Depot progesterone
COCP

Question 13

How do progesterone contraceptives inhibit sperm transport?

Answer 13

Affect cervical mucous -> thick, hostile mucus

Question 14

Can female sterilisation be reversed?

Answer 14

Yes - 50% success

Question 15

How is female sterilisation achieved?

Answer 15

Occlude fallopian tubes by clips, rings or ligation

Question 16

How common is recanalisation following a vasectomy?

Answer 16

rare - 1:300/500

Question 17

What is a vasectomy?

Answer 17

Vas deferens are divided bilaterally. Ensure ejaculate is free of sperm before relying on it (usually takes approx 20 ejaculations)

Question 18

What forms of contraception inhibit implantation?

Answer 18

Hormonal (COCP, POP, implant, depot)
Post-coital contraception
IUCD

Question 19

How do hormonal contraceptives inhibit implantation?

Answer 19

Affect receptivity of the endometrium directly

Absence of corpus luteum further prevents preparation of the endometrium for implantation

Question 20

What is in post-coital contraception and how does it work?

Answer 20

High dose of combined oestrogen/progesterone or progesterone only
May disrupt ovulation
Blocks implantation

Question 21

In what time frame is post-coital contraception effective?

Answer 21

Up to 72 hrs after intercourse

IUCD may also be used post-coital

Question 22

What is IUCD?

Answer 22

Inert or copper containing or progesterone impregnated (mirena coil)
Copper interferes with endometrial enzymes and may also interfere with sperm transport into fallopian tubes
Interferes with implantation

Question 23

What are the risks of IUCD?

Answer 23

Perforation
Mood swings
Infection (higher risk with copper)

Question 24

Define infertility.

Answer 24

Failure to conceive within 1 year

Question 25

How many couples suffer from infertility?

Answer 25

15%

Question 26

What is the difference between primary and secondary infertility?

Answer 26

Primary - no previous pregnancies | Secondary - previous pregnancies, successful or not

Question 27

What % of infertility is due to problems in the male, female and unexplained?

Answer 27

Male: 20-25% Female: 45-60% Unexplained: 20-30%

Question 28

What are the potential causes of infertility?

Answer 28

Coital problems Anovulation Tubal occlusion Abnormal/absent sperm production

Question 29

How common is anovulation and when is it most common?

Answer 29

Cause of 15-20% of fertility problems | Most common at extremes of reproductive life

Question 30

Where can problems cause anovulation?

Answer 30

Problems in the hypothalamus, pituitary or ovary

Question 31

What problems in the hypothalamus can cause anovulation?

Answer 31

Hyperprolactinaemia Weightloss Exercise Stress

Question 32

What problems in the pituitary can cause anovulation?

Answer 32

Pituitary tumours or necrosis

Question 33

What problems in the ovaries can cause anovulation?

Answer 33

Ovarian failure Menopause Radiotherapy Chemotherapy

Question 34

How is a diagnosis of anovulation made?

Answer 34

Serum progesterone level in mid-luteal phase (day21 / 7 days before menstruation)

Question 35

How is the cause of anovulation determined?

Answer 35

Hormone levels: Menopause or ovarian failure, increased LH and FSH, decreased oestrogen H/P failure, decreased LH, FSH and oestrogen PCOS, increased LH/FSH ratio, normal oestrogen

Question 36

How can ovulation be induced?

Answer 36

Anti-oestrogen drugs - decrease negative feedback to HPA increasing GnRH and FSH Gonadotrophins - FSH administration GnRH agonist - pulsatile to mimic normal secretion

Question 37

What might cause tubal occlusion?

Answer 37

Sterilisation | Scarring from infection or endometriosis

Question 38

How is tubal occlusion diagnosed?

Answer 38

Laproscopy and dye insufflation - hysterosalpingogram

Question 39

How can infertility caused by tubal occlusion be treated?

Answer 39

``` Tubal surgery (reanastomosis) Assisted conception ```

Question 40

What might cause abnormal/absent sperm production?

Answer 40

Testicular disease Obstruction of the ducts (infection, vasectomy) HPA dysfunction

Question 41

What is a normal semsn analysis?

Answer 41

Volume >2ml Sperm count > 20mill/ml Motility >50% Morphology >50%

Question 42

How can infertility due to inadequate sperm be overcome?

Answer 42

Artificial insemination by donor | Intracytoplasmic sperm injection

Question 43

What i PCOS?

Answer 43

Polycyctic Ovarian Syndrome - A disorder displaying great clinical and biochemical variability. A syndrome of hyperandrogenism and chronic anovulation in which other causes have been ruled out

Question 44

How does a patient with PCOS present?

Answer 44

Secondary amenorrhoea/infertility Hirsuitism Obesity

Question 45

How does PCOS cause amenorrhoea/infertility?

Answer 45

Related to a lack of pulsatile GnRH release - Many follicle begin to develop but a dominant follicle is not selected to mature. These follicles respond to pituitary hormones by producing an abnormal pattern of oestrogen secretion. Chronic an ovulation is thought to occur because of inappropriate feedback signals from the ovaries to the hypothalamus

Question 46

Why is hirsuitism a symptom of PCOS?

Answer 46

The syndrome may be characterised biochemically by :H dependent excess androgen production from ovaries and adrenals (perhaps due to an enzyme abnormality)

Question 47

Why are women with PCOS at increased risk of endometrial malignancy?

Answer 47

Abnormal oestrogen secretion. The endometrium is an oestrogen sensitive tissue; increased oestrogen secretion causes an increase in proliferation of the endometrium, increasing the risk of malignancy

Question 48

Why does PCOS carry risks of diabetes and cardiovascular disease?

Answer 48

Insulin resistance can form putting them at risk of diabetes and CV disease

Question 49

What is the treatment of PCOS?

Answer 49

Prevention of long term risks and management of presenting problems. Metformin

Question 50

Why does the LH/FSH ration increase in PCOS?

Answer 50

Inhibin also inhibits FSH and LH

Question 51

Why are there no LH surges in PCOS?

Answer 51

Androgens selectively inhibit LH

Question 52

What proportion of young couples who have regular unprotected sex might be expected to conceive within a year?

Answer 52

75%

Question 53

Where are the possible points in the female reproductive tract where problems may lead to infertility?

Answer 53

Failure to ovulate 33% Fallopian tube problems 22% Uterine problems 11% Cervical problems 3%

Question 54

What factors are assessed in semen analysis?

Answer 54

Sperm count, motility and morphology

Question 55

What hormone provides evidence menstruation has occurred and when should it be tested for?

Answer 55

Progesterone | Day 21 in serum

Question 56

Why is it useful to keep a daily record of body temperature on rising in the morning?

Answer 56

Circadian rhythm so must be done at the same time of day | Progesterone increases body temp by 0.4-0.8 degrees a day or 2 after ovulation

Question 57

What are the 2 most common causes of secondary amenorrhoea and what hormone tests are used to distinguish between them?

Answer 57

Pregnancy - hCG | Menopause - gonadotrophins

Question 58

What clinicalal sign may indicate a diagnosis of hyperprolactinaemia?

Answer 58

Breast lactation

Question 59

What properties of cervical mucus facilitate sperm survival and transport?

Answer 59

Lower viscosity and more alkalinity

Question 60

How might you assess whether cervical sperm transport is disturbed?

Answer 60

Post-coital test - collect cervical mucus soon after copulation