WH Fertility Flashcards
Track menstrual cycle pattern and calculate ovulation date (14 days before menses), anticipate some variability and consider the fertile window to be 11-18 days before the next expected menses
Calendar rhythm
another rhythm method using a ring of beads to track the days, must have regular cycles no more than 32 days in length, fertile days are marked with white beads
Standard days “cycle beads”
using a special thermometer, women monitor their resting (waking) temperature everyday on a chart, there should be a small drop and then rise in temperature with ovulation, this method can be greatly affected by external factors and takes many months to interpret charts.
Basal body temperature (BBT)
hormone changes during the menstrual cycle greatly affect cervical mucous in the vagina, making it remarkably slippery and stretchy following ovulation (this may help in the transport of sperm), this change is called “spinnbarkeit”, women evaluate the mucous at the introitus (opening) of the vagina daily and record the changes
Cervical mucous
vaginal secretions almost disappear following the fertile window, so the absence of secretions for 2 days should indicate that the fertile phase has passed
2- day method
Mumps (as an adult) Endocrine disorders Genetic disorders Reproductive disorders Substance abuse Environmental exposure to hazardous substances or excessive heat to scrotum
Male Risk Factors for Infertility
Age: reduced fertility after age 35
Endocrine disorder: symptom may include irregular or absent menses, atypical body hair distribution and body fat distribution.
Prior pelvic, uterine or tubal surgery with resultant scarring or occlusion
Prior miscarriages (3 or more)
Prior uterine or tubal infections
Uterine malformations
Prior STI (sexually transmitted infections) particularly chlamydia and gonorrhea
Environmental exposure to hazardous materials
Morbid obesity or underweight status
Substance abuse
Female Risk Factors for Infertility
Men: semen analysis, ultrasound, genetics
Women: pelvic exam, ultrasound, hormone analysis, post-coital mucous test, hysterosalpingogram (HSG), hysteroscopy, laparoscopy, genetics
Couples are usually referred to fertility centers for complex workups and treatment
Genetic testing is often done after referral to a genetic counselor.
Fertility testing and treatment
Refraining from sexual intercourse (intercourse or coitus involves insertion of the penis into the vagina)
Abstinence
removing the penis prior to ejaculation
Withdrawal “coitus interruptus”
scheduled intercourse using guidance from calendar, cycle beads, basal body temp, cervical mucous
Natural Family Planning/ Fertility Awareness
male & female condom, contraceptive diaphragm, cervical cap, contraceptive sponge
Barrier methods
kills sperm, placed into vagina prior to coitus, also used with barriers
Spermicide
estrogen & progesterone combination as a pill, ring, or patch; progesterone only as a pill, injection, subdermal implant, or embedded in an IUD
Hormonal Birth Control Methods
tubal ligation, vasectomy, trans cervical (hysteroscopic) sterilization (tubal occlusion)
Sterilization
apply on the erect penis, leave space at the tip for ejaculate, remove penis from vagina with it still on to prevent spillage, helps reduce STI exposure
Male condoms
insert closed end into vagina prior to intercourse, let the open end cover the labia, helps reduce STI exposure
Female condoms
silicone cup that fits over the cervix, used with spermicide, place up to 6 hours before coitus, important to LEAVE IN PLACE for 6 hours after coitus (up to 24 h), now available OTC (no fitting required – tell ATI), wash with soap & water between uses, does not protect against STIs, does not fit everyone, may increase frequency of UTIs & toxic shock syndrome
Diaphragm
same use as diaphragm, smaller and fits more snugly against the cervix, not for use with cervical / pap smear abnormalities
Cervical Cap
fits against cervix, wet with water and squeeze to fully moisten, insert before coitus and leave in place for 6 hours after, leave in place with repeat coitus, does not protect against STIs
Contraceptive sponge
apply 15 min before coitus, only effective for 1 hour, reapply with each act, available OTC. comes as film, foam, cream, gel, suppository
does not protect against STIs
Spermicide Considerations
also called transcervical sterilization. Small flexible coils are placed via the vagina, cervix and uterus into the fallopian tubes. The body responds by creating permanent scar tissue over these coils which then blocks (occludes) the tube. The scarring process takes several months.
The woman must return for testing 3 months after the procedure to be sure that the tube is completely blocked. Very effective with proven blockage. Failures in preventing pregnancy have high risk of ectopic pregnancy. Tubal perforation and chronic pain are known risks.
Tubal Occlusion
“tying the tubes” is a permanent surgical procedure to tie, cut and cauterize (burn) the ends of the fallopian tubes so that ova cannot become fertilized. Surgery can be done postpartum through the umbilicus, at the time of cesarean section, or laparoscopically through the abdomen. Reduces risk of ovarian cancer by 50% and some recommend removal of the entire tube. The ovaries and uterus remain unaffected so menstrual cycles are unchanged. Risks are related to surgery and possible regret. Failure leading to pregnancies following BTL have increased risk of being ectopic.
Bilateral tubal ligation
a surgical outpatient procedure to tie and cut the vas deferens to block the passage of sperm into ejaculate. Men should be tested after 20 ejaculates to prove no more sperm can be detected. Reversal can be attempted but is complicated and expensive. Sperm can be banked for potential future use. Sexual function is not impaired. Risks are surgical.
Vasectomy
Oral “Morning after pill” prevents fertilization by inhibiting ovulation and the transport of sperm
Must be taken within 72 hours of coitus (and don’t have unprotected sex again)
Can be nauseating / may need anti emetic medication
Contraindicated if already pregnant!
Copper IUD can also be used as this if placed within 5 days of coitus
Emergency contraception
Both provide continuous release of estrogen and progesterone, inhibit ovulation and thicken cervical mucous and have the same risks and benefits as COCs
Ring and Patch
insert vaginally and leave in place for 3 weeks, then remove for 1 week (menstrual week)
Contraceptive Ring
apply to arm, back, abdomen or torso (not on breast), replace weekly x 3, then take one week off (menstrual week)
Contraceptive Patch
The ability to achieve pregnancy. It requires the effective female systems of HPO axis (hypothalamic-pituitary-ovarian axis) for hormonal regulation, ovaries, fallopian tubes, uterus and vagina and the male systems coordinating ejaculation and adequate sperm morphology & motility.
Fertility
The onset of menstrual cycles. Average age is 13.8 years but ranges widely.
Menarche
Cessation of menstrual cycle
Menopause
Failure to achieve pregnancy after 12 months of trying may be normal but is termed this because it is an appropriate time to begin analysis of potential fertility problems.
Can arise from hormonal, structural or unexp;ained causes. 40% is male factor related to abnormal semen analysis
Infertility
Increase risk of multiples. Considered high risk even if singleton. Includes ovarian stimulation meds, intrauterine insemination, IVR, surrogate mother, donor insemination
Fertility treatments
Meds that trigger follicle production
Ovarian stimulation
Sperm are collected and transferred into the uterus at ovulation. Gamete intrafallopian transfer. Retrieval of ova and sperm which are then replaced together into fallopian tube.
Intrauterine insemination
a strategy or device used to reduce the risk of fertilization or implantation in an attempt to prevent pregnancy. No method will disrupt an established pregnancy. Choices should involve the desires of the sexual partners, their priorities and ethical concerns, their health, and tolerance for the use, effectiveness and risks of each method
Contraception
contain estrogen and progestin which act to suppress ovulation, thicken the cervical mucous, and alter the uterine decidua to prevent implantation; traditional use results in controlled vaginal bleeding monthly (usually very light) during the placebo week, frequently now women will take a placebo week every 3 or 6 months;
benefits are improved menses and dysmenorrhea, protection against endometrial and ovarian cancer, cyclic acne and mood disorders
Risks include increased risk of thromboembolism, stroke, HTN, gallbladder disease, liver tumor
use with extreme caution with breast cancer (or history of), bariatric surgery, lupus, liver tumors, severe cirrhosis
Effectiveness may be reduced with anticonvulsant or antibiotic medications
Combined Oral Contraceptives (COCs)
“minipill” are similar to COCs but without estrogen they are less effective at suppressing ovulation, and they do not regulate vaginal bleeding (often there is irregular light bleeding instead of cyclic bleeding), safer to use while breastfeeding and with estrogen related risks (thrombosis)
use with extreme caution with breast cancer (or history of), bariatric surgery, lupus, liver tumors, severe cirrhosis
Effectiveness may be reduced with anticonvulsant or antibiotic medications
Progestin only pills (POPs)
Take pills everyday, minipills must be taken at the same time of day everyday
If a pill is missed, take it as soon as you realize (OK to double up) and use backup method for 1 week Irregular bleeding is common – do not change the pill pattern because of the bleeding
Nausea is common, especially when first starting Breast tenderness is also common when first starting
Danger signs include sx of PE or DVT (leg edema, calf pain, SOB, chest pain, headache, visual changes)
Estrogen containing pills can contribute to HTN. Typically women return to have their BP assessed after 2-3 months on OCPs
Teaching for Birth Control Pills
“The shot” IM injection given every 12 weeks, no breaks or menstrual weeks, very effective, multiple adverse side effects: irregular bleeding or spotting is common, can inhibit calcium absorption into bone, can cause weight gain and worsen depression
Medroxyprogesterone injection
a small rod containing progestin which is implanted under the skin on the inner upper arm, lasts for 3 years and can be replaced at that time, adverse effects include irregular bleeding and spotting, mood changes, weight gain, usually results in small scarring at insertion site, infection can occur following insertion (rare)
Nexplanon
flexible T shaped device which is inserted through the cervix during an examination and placed into the uterus, procedure is quick but crampy, often clients are given premedication to soften the cervix and relieve discomfort, testing for STIs and a pap smear are performed prior to or with insertion, pregnancy must be ruled out before placement
Depending on the choice, lasts from 3 – 10 years and can be removed at any time Immediately effective, immediate return to fertility once removed
Intrauterine device
no hormones, lasts 10 years, menses continue on spontaneous cycle but may get heavier and crampier, women should check the strings monthly, increases risk of PID and ectopic pregnancy
Copper T IUD
last 3-7 years, usually causes lightning of menses or amenorrhea (yay!), protects against PID (tell ATI)
Progesterone containing IUDs
