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

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

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

Copper IUD

What is the most effective non-hormonal birth control?

Letrozole

What agent is used first-line for ovulation induction in patients with PCOS?

IVF

What ART is indicated in cases of tubal factor, severe male factor, or unexplained infertility?

Mulitple gestation, OHSS

What are the two main risks associated with ART?

Barrier Contraception

Contraception types that physically block sperm, such as male condoms, diaphragm, cervical cap, and sponge

-Only condoms reduce STI transmission risk

Spermicide

In patients that use cervical caps, sponge, or diaphragms, what else is needed to prevent pregnancy?

Polyurethane

In the case of a latex allergy, what type of condoms can a patient use?

Emergency Contraception

Prevents pregnancy after unprotected sex, mainly by delaying ovulation

-Most effective option = copper IUD, within 5 days of placement

Ulipristal Acetate

What is the best oral emergency contraceptive?

-Up to 120 hours after intercourse

-More effective at higher BMI

Hormonal Contraception

Uses estrogen-progestin or progestin-only to prevent ovulation/thicken cervical mucus

-Contraindicated in migraine with aura, age > 35 who smoke > 15 cigarettes per day, and prior VTE

-Implant and hormonal IUD are most effective

Ovarian, Endometrial

Use of hormonal birth control for more than 5 years helps to decrease the risk of what two types of cancer?

Depo

What form of contraception is associated with reversible bone-density loss and weight gain?

12, 6

Infertility is defined as the inability to conceive after ___ months of regular, unprotected intercourse or ___ months if the woman is > 35 years old

Anovulation

What is the most common cause of female factor infertility?

Day 21 serum progesterone

During an infertility workup, what test should be done to check for ovulation?

Semen analysis

What is the test for male factor infertility?

TSH, PRL, LH, FSH

In women > 35 or with irregular menstrual cycles who are struggling with infertility, what labs should be drawn to check for potential causes?

HSG

What evaluates tubal patency and the uterine cavity during an infertility workup?

Chlamydia

What is the most common cause of tubal factor infertility?

Non-Hormonal contraception

Effective contraception without hormones, including copper IUD, fertility awareness, withdrawal, lactational amenorrhea, and spermicide

-Copper IUD is most effective

400 mcg

How much folic acid should be taken daily to help prevent neural tube defects?

Live vaccines

What should be updated before pregnancy, as they are contraindicated during?

Vasectomy

Safest, cheapest, most effective form of surgical contraception

-Requires snipping of the vas deferans

-Needs a follow-up semen analysis to confirm sterility

Ectopic pregnancy

Tubal ligation failure carries a higher risk of what?

Ovarian

Bilateral salpingectomy lowers risk of what type of cancer?

Combined Hormonal

What type of contraception is being described?

-MOA: inhibits ovulation, thickens mucus, making it harder for sperm to penetrate

-Benefits: regulates menses, decreases cramps/acne/endometrial/ovarian cancer

-Risks: increased VTE, HTN, nausea

-Contraindicated in smokers > 35, migraines with aura, VTE history

Progestin-Only Pill (POP)

What type of contraception is being described?

-MOA: thickens cervical mucus, thins endometrium

-Benefits: safe during breastfeeding

-Risks: irregular bleeding

Depo

What type of contraception is being described?

-MOA: inhibits ovulation

-Benefits: amenorrhea

-Risks: weight gain, decreased bone density

-Special Considerations: delay in return to fertility

Implant

What type of contraception is being described?

-MOA: inhibits ovulation

-Benefits: highly effective, safe in breastfeeding

-Risks: irregular bleeding

Hormonal IUD

What type of contraception is being described?

-Types: Mirena, Kyleena, Skyla

-MOA: thickens mucus, thins endometrium

-Benefits: decreases menses and cramps

-Risks: irregular bleeding

Copper IUD

What type of contraception is being described?

-MOA: Copper is toxic to sperm, also causes local inflammation

-Risks: increased bleeding and cramps