Women's Health: Fertility Management

Infertility

Failure to conceive after 12 months of unprotected intercourse

-Etiologies: anovulation, mid-luteal phase defect, anatomical defects, and spermatogenesis issues

-Dx: labs, semen analysis

Fecundability

The ability to achieve a pregnancy in one menstrual cycle

Fecundity

Probability of achieving a life birth in one menstrual cycle

Clomiphene

What is indicated for fertility treatment in the following patient?

-Progesterone level < 3 ng/mL → TSH, prolactin, FSH, estradiol levels → treat underlying cause → consider ovulation induction

ART

What is indicated for fertility treatment in the following patient?

-Progesterone level > 3 ng/mL → assess for tubal patency or uterine abnormalities with hysterosalpingography or laparoscopy → surgical correction

Anovulation

Considering these conditions, what is the underlying etiology for these patients’ infertility?

-PCOS, HPA axis dysfunction, hyperprolactinemia, thyroid dysfunction

-Sx: hirsutism, irregular menses/amenorrhea, acne, galactorrhea

Clomid

SERM that competitively inhibits estrogen binding to the receptors at the hypothalamus and pituitary gland

-Induces gonadotropin release from the pituitary, stimulating follicle development in the ovaries

-MC used medication for infertility due to anovulation

COH

Exogenous gonadotropins are given to achieve multifollicular ovulation in anovulatory women (those who do not respond to clomid) and ovulation in severe mature follicles in other infertile women

-Requires TVUS and serum estradiol monitoring

-Risk of OHSS

IUI

Intrauterine insemination

-Sperm is washed to remove prostaglandins, bacteria, and protein before being inserted into the uterus with a small catheter

IVF

Embryos are inserted into the uterus

-Need a gonadotropin to stimulate follicle development, gonadotropin releasing hormone analogue to prevent premature ovulation during follicle development, hCG to initiate final maturation of oocytes

-Monitoring with TVUS and serum estradiol

Oral Contraceptives

Hormonal contraceptives that improve dysmenorrhea and controls menstrual cycle, helping to decrease the risk for endometrial and ovarian cancer

-Types: combined estrogen + progesterone, progestin only minipill, and transdermal patch

Combined OCP

Hormonal contraceptive that cannot be used in women 35+ who are smokers, history of blood clot, breast cancer, or migraines with aura

Progestin Only Pill

Hormonal contraceptive that is safe in lactation and is without estrogenic side effects

-Decreased risk of ovarian and endometrial cancer

Emergency Contraceptive

“Morning after pill”, taken within 72 hours of unprotected intercourse

-Types: copper IUD, PlanB, ulipristal acetate

Copper IUD

Most effective form of emergency contraceptive

-May be effective at any time in the menstrual cycle, must establish negative pregnancy status before placement

-MOA: copper particles may disrupt sperm and ovum function

PlanB (Levonorgestrel)

Emergency contraceptive that is effective when taken up to 3 days after UPI

-MOA: prevents ovulation by blocking LH surge, thus inhibiting follicular development and egg release

-Loses efficacy for patients > 165 lb

Ulipristal acetate

Emergency contraceptive that is effective when taken up to 5 days after UPI

-MOA: delays ovulation in both the pre-ovulatory period and after the LH surge has started

-Less effective for patients > 195 lb

Tubal Ligation

Permanent sterilization where the fallopian tubes are ligated

-0.5% failure rate

Vasectomy

Permanent sterilization where the vas deferens from each testicle is clamped, cut, or otherwise sealed

Non-hormonal

What type of birth control should be used in patients who are > 35 or smoke > 15 cigarettes per day?

Increased stroke risk

Why can’t patients with a history of migraine with aura be prescribed estrogen containing contraceptives?

Non-hormonal

What type of contraceptives should be used in patients with breast cancer or are in remission?

Loloestrin

What birth control is recommended for peri-menopausal patients?

Rhythm Method

What type of contraception is being described?

-Withdrawal method, post-coital douching, and periodic abstinence

Condoms

Made for both male and female genitalia

-Decreases STI rate by about 50%

-Reservoir tip to prevent breakage, which is a common reason for failure

Diaphragm

Small, latex covered dome shaped cap used for contraception

-Can be inserted 6 hours prior to intercourse and left 6-24 hours after

-2x more likely to have a UTI

Cervical Cap

Smaller version of the diaphragm applied to the cervix only

-High degree of displacement, associated with TSS and cervicitis

Spermicide

Contains an active chemical to kill sperm

-Inserted high into the vagina near the cervix 10-30 minutes prior to intercourse

Phexxi

Combination of lactic acid, citric acid, and potassium bitartrate

-Used right before intercourse or up to one hour after

-Lowers vaginal pH rendering sperm immobile

-93% effective when used properly

Hormonal Birth Control

-MOA: progesterone provides contraceptive effect by inhibiting mid-cycle LH surge and estrogen potentiates the progesterone effect

-ADRs: weight gain/bloating, breast tenderness, depression, breakthrough bleeding, amenorrhea, VTE, PE, MI, stroke, cholestasis, CV side effects

Nexplanon

Implantable birth control that is effective for up to 5 years

-Progesterone only

-Thickens cervical mucus and inhibits implantation

IUD

Intrauterine birth control that makes the uterine environment unfavorable for implantation

-Types: Mirena (5 years), Skyla (3 years and progesterone), Paraguard (10 years)

Annovera

Annual birth control ring

-Lasts 13 cycles

-Leave in for 3 weeks and have one ring free week

NuvaRing

Insertable vaginal ring, which should be left in for 3 weeks and removed for 1

-Can be removed during intercourse for a period of up to 3 hours without altering efficacy

Depo

Injectable progesterone only q 3 months

-Should not be used for longer than 2 years at a time

-Takes 12 months to return to fertility

BMD loss

What is the BBW associated with depo-provera?

Folic Acid

What should be supplemented prior to conception and continued throughout the first TM to help prevent neural tube defects?

Letrozole

What is the first line for ovulation induction in PCOS?

Copper IUD

What is the most effective non-hormonal birth control?