4. Contraception / Infertility

About how many pregnancies result in miscarriage?

1 in 5

What are the most effective forms of birth control?

LARKs — Injectable/implanted long-acting progestins, IUDs

How long until sperm is deposited into cervical mucus? Relevance?

About 90 seconds after ejaculation — Reason why postcoital is ineffective

Lactational amenorrhea as birth control

- Exclusive breastfeeding → Increase in GnRH, LH, FSH & decline in dopamine resulting in anovulation & amenorrhea

How long is lactational amenorrhea as birth control effective?

1st 3-6 months after birth

Periodic abstinence as birth control

Avoidance of interourse during time of ovulation & 2-3 days after

Methods for utilization of periodic abstinence as birth control

Calendar method: Predict by tracking menstrual pattern (MC method)

Temperature method: Monitoring basal body temp daily for elevated temp — elevation for 3 days → end of fertile period

Cervical mucus method: Thin & watery mucus through ovulation

Symptothermal method: Combination of temperature and cervical mucus method

Downfall of temperature method for periodic abstinence as birth control

Not protected for slight drop in temperature 24-36 hours after ovulation

What is the most effective periodic abstinence approach?

Symptothermal method

Vaginal diaphragm

- Must be used with contraceptive jelly

- Can insert up to 6 hours before intercourse, must be left in place for 6-24 hours after (must plan ahead)

- Must be fitted

Cervical cap

- Held in place over cervix by suction

- Difficult to insert correctly

- Must be left in place for 8-48 hours after intercourse

OCP as birth control

Utilization of low doses of estrogen & progestin → suppresses ovulation by inhibiting natural mid cycle changes in LH & FSH

Initiation of OCPs

Require backup contraceptive for 1st 7 days

When does ovulation return with cessation of OCPs?

Within a month

Advantages of OCPs

- Decreased risk of ovarian, endometrial, colorectal CA

- Decreased risk of ectopic pregnancy, PID

- Lighter periods, acne

- Protects bone loss

Disadvantages of OCPs

Increased risk of MI w/ ACS risk factors & DVT/PE

**Discuss RF before initiation

What further increases risks associated with OCPs?

Smoking

MC reasons for d/c of OCP

- Breakthrough bleeding **

- Nausea **

- HA

- Weight gain

**Resolve within 1st 6 months

Contraindications for OCPs

- Hx of DVT, PE, MI, stroke

- Uncontrolled DM / HTN

- Cig smoker age >35

- Current / Hx of breast CA

- Liver disease

- Migraine w/ aura

Alternate option for OCPs for women that cannot tolerate estrogen component / has contraindications

Progestin-only pill

Progestin-only pill

Small dose of only progestin (norethindrone or levonorgestrel) → Alteration of cervical mucus & endometrial lining

MC ADR of progestin-only pill

Irregular spotting

Combined OCP vs. Progestin-only pill

Combined OCP: More contraindications, suppresses ovulation

Progestin-only pill: Indicated for intolerance of estrogen component / contraindications, high failure rate if not taken at same time each day

Depot medroxyprogesterone acetate (DMPA)

Progesterone IM injection q3 months

Benefits of DMPA

- Decreased risk of endometrial CA

- Improvement of endometriosis

- Reduction of sickle cell crises

Contraceptive implant (Nexplanon) & duration of use

- Thin, rod-shaped progestin implant under skin of upper arm

- Lasts up to 5 years / Nexplanon is 3 yaers

ADRs of contraceptive implant (Nexplanon)

Weight gain & menstrual abnormalities

Vaginal ring

Ring of ethinyl estradiol/etonogestrel worn in vagina for 3 weeks/month

Transdermal patch

Adhesive patch delivering progestin & estrogen for 7 days, applied weekly for 3 weeks

Types of IUDs

Copper & levonorgestrel

When are copper IUDs ideal?

Contraindication for hormonal contraception w/ low risk for STI (higher risk of PID)

Duration of effectiveness of copper IUDs

10 years

Hormone-releasing IUDs & benefits

- Reservoir releases progestin daily → thickening of cervical mucus

- Useful for menorrhagia & significant decrease in menstrual blood flow

3 options for female sterilization

Tubal ligation, tubal obstruction, bilateral salpingectomy

What is the MC used contraceptive method in US?

Sterilization

Important counseling points for sterilization

- Risks of failure & ectopic pregnancy

- Alternatives such as long-acting reversible contraception & vasectomy

Tubal obstruction / ligation

Procedure to prevent pregnancy by occluding / disrupting potency of fallopian tubes

Benefit of salpingectomy for sterilization

Decreased risk of ovarian CA

Options for emergency contraceptive pills

- Ulipristal acetate (anti-progestin) 30 mg single dose

- Progestin only (lenonorgesterhol) 75 mg 12 hours apart x2 OR 150 mg single dose

- Combined PO (ethinyl estradiol/levonorgesterol) 50mg 12 hours apart x2 doses

- Copper IUD — interferes w/ implantation / sperm function

When must emergency contraceptive pills be taken?

Best within 72 hours BUT effective up to 5 days after unprotected sex

**If during ovulation → potentially ineffective

When must a copper IUD be inserted as emergency contraceptive?

Within 7 days of unprotected sex

MC ADR of emergency contraceptives

Nausea

Infertility (duration)

Inability to conceive within 1 year for women age

Primarily infertility

In a couple that has never conceived

Secondary infertility

In a couple that has conceived in past

Fecundability

Likelihood of conception / month of exposure

Risk factors that increase likelihood of infertility

- Weight extremes in women

- Smoking in men & women

- Age 40+ women

- Use of vaginal lubricants

Relevant medical history for female infertility

- Contraceptive hx

- Hx of abnormal pap smears

- Drugs & medications

Relevant medical history for male infertility

- Exposure to toxins

- Decreased frequency of shaving

- Congenital abnormalities

- Undescended tests

Male infertility diagnostic evaluation & details

Semen analysis — No ejac for 2-5 days, lab within an hour, assess sperm count & motility, if abnormal → repeat analysis in several weeks

A very low sperm count requires...

Endocrine evaluation

What testiculat pathology could be present with abnormal semen analysis results?

Varicocele

Female infertility diagnostic evaluation

Ovulatory factor — Specific hx, follicular pool/ovarian reserve & confirmation of ovulation

Pelvic factor

Cervical factor

Follicular pool/ovarian reserve for female infertility diagnostic evaluation

- FSH & estradiol levels on cycle days 2-4, antimullerian hormone (AMH) levels, antral follicle count in early follicular phase via transvaginal US

- Should be completed in age >35

How to confirm ovulation for female infertility diagnostic evaluation?

Hx may be adequate; serum progesterone assay 1 week before menses / pelvis US to monitor developing follicle for maturation and rupture

What progesterone level is consistent with ovulation?

≥3 ng/mL

What does follicular pool/ovarian reserve indicate?

Measure of ability to respond to ovulation induction

If there are abnormal menstrual cycles, how is ovulatory factor monitored?

Assess HPA — Serum FSH, estradiol, prolactin, TSH

Pelvic factor evaluation for female infertility diagnostic evaluation

Evaluation for abnormalities of uterus, fallopian tubes, ovaries

- Pelvic exam

- Transvaginal US

- Hysterosalpingogram — Dye injected in uterus w/ fluoroscopic observation of endometrial cavity & latency of fallopian tubes

Fixed uterus on pelvic exam is indicative of...

Adhesions

What diagnostic method is completed if endometriosis is suspected cause of infertility?

Laparoscopy

Cervical factor evaluation for female infertility diagnostic evaluation

Evaluation via speculum exam — Evidence of cervicitis or cervical stenosis

Diagnostic workup if evidence of cervicitis with evaluation of cervix with infertility workup

Fluid samples

Management of male infertility

Lifestyle changes — Avoid tobacco , marijuana, excessive alcohol

Assistive reproductive technologies (ART) — Intrauterine insemination (mild/mod), IVF w/ intracytoplasmic spern injection (mod/severe)

Management of female infertility — Ovulatory factor

- Weight modulation

- Ovulation induction medications — Clomiphene (1st line), then aromatase inhibitors & gonadotropins; Admin for 5 days starting on day 3-5 of cycle & monitor w/ US and hormones for follicular development

- Metformin in patents w/ PCOS AND insulin resistance

If ovulation occurs with ovulation induction medications then...

3 cycles of timed intercourse are attempted

What medications is used for ovulation induction in individuals with hyperprolactinemia?

Bromocriptidine

What medication can be used to improve ovulatory factor in patients with PCOS AND insulin resistance?

Metformin

Management of female infertility — Pelvic factor

IVF

Indications for surgical intervention for management of pelvic factors for female infertility

- Endometriosis treatment during initial diagnostic laparoscopy

- Fibroids distorting endometrial cavity

Management of female infertility — Cervical factor

Intrauterine insemination (IUI), then IVF

In vitro fertilization (IVF)

- FSH administered to stimulate follicular growth — Monitor with US & estradiol levels

- Maturation of leading follicular → ovulation triggered with hCG

- Oocytes retrieved from follicles before ovulation w/ US guided transvaginal procedure

- Oocyte + sperm

- Embryo transfer to uterine cavity 3-5 days later

Potential complication of fertility treatments

Ovarian hyperstimulation syndrome (OHSS)

Ovarian hyperstimulation syndrome (OHSS)

Hyper stimulation / enlargement of ovaries d/t increased capillary permeability & fluid shifts from intravascular space to 3rd space (abd cavity)

Risk factors for OHSS

- Previous OHSS

- PCOS

- # of follicles

- Rapidly rising estradiol

S/S of OHSS

Mild — Abd distention, nausea

Moderate — Vomiting, diarrhea, ascites on US, elevated Act & leukocytosis

Severe — Severe abd pain, ascites, hypovolemia, oliguria, AKI, acute liver injury, clotting abnormalities