NUR 3590 Final: Infertility and Contraception

Infertility

the inability to conceive a child

if you are under 35 you are infertile after trying for...

1 year

if you are over 35 you are infertile after trying for...

6 months

secondary infertility

unable to conceive after one or more successful pregnancies

sterile

unable to reproduce

causes for male infertility

-abnormal sperm production or function

-impaired delivery of sperm (ex. premature ejaculation)

-general health and lifestyle: inflammation/infection

-environmental exposure

how many sperm are needed to impregnate a woman?

20 million/ml

causes of female infertility

-fallopian tube damage or blockage

-endometriosis

-ovulation disorders

-polycystic ovary syndrome

-elevated prolactin

-early menopause

-benign uterine fibroids

-pelvic adhesions

-other causes: medications, thyroid disorders, cancer, other medical conditions

repeated pregnancy loss

-abnormalities of fetal chromosomes, cervix or uterus, endocrine system

-immunologic factors

-environmental agents

-infections

if a woman has more than ___ pregnancy losses in a row she is considered infertile

3

risk factors for infertility

-age

-tobacco smoking

-alcohol

-body mass

-being underweight or overweight

-too much exercise (more than 7 hours a week)

-environmental factors

male fertility tests

-general physical exam

-history

-semen analysis

-hormone testing

female fertility tests

-ovulation confirmation

-hysterosalpingography

-laparoscopy

-basal body temperature

-urinary luteinizing hormone

-ovulation reserve testing

Spinnbarkeit

-checks cervical mucus

-if you are ovulating it will be thin and stretchy

-if you are not ovulating it will be thick

Mittelschmerz

pain during ovulation

complications of infertility

-depression

-guilt

-anger

-stress

-disappointment

-resentment

-blame

-fear of losing partner due to infertility

-diminished confidence and self-esteem

restoring fertility in males

-treatment of general sexual problems (ex. ED or premature ejaculation)

-addressing lack of sperm

-drug therapy: testosterone or tamoxifen

tamoxifen

stimulates gonadotropin release for testosterone production

fertility drugs

-clomiphene citrate (clomid, serophene)

-human menopausal gonadotropin (Repronex, pergonal)

-Follicle-stimulating hormone

-Human chorionic gonadotropin

-gonadotropin-releasing hormone

-Letrozole (Femara)

-Metformin (glucophage)

-Bromocriptine (parlodel)

Clomiphene citrate (Clomid, Serophene)

-oral medication given for 5 days

-patient is then told to have intercourse days 14-18 to maximize ovulation

-if it doesn't work, dose is doubled the next month

-15-25% chance of having multiples

human menopausal gonadotropin (Repronex, pergonal)

-injectable, given once a month

-produces multiple eggs

-35-45% chance of having multiples

Letrozole (Femara)

decrease estrogen to increase FSH/LH

Metformin (Glucophage)

used to treat PCOS

Bromocriptine (Parlodel)

Hyperprolactinemia Therapy

in vitro fertilization

-created by Edwards and Steptoe

-women with fallopian tube problems are good candidates

-eggs are harvested from the woman's ovary, fertilized in the lab with sperm, and embryos are then transferred to the uterus

intracytoplasmic sperm injection (ICSI)

sperm is injected directly into the egg

Gamete intrafallopian transfer (GIFT)

sperm and egg are inserted into the fallopian tube

zygote intrafallopian transfer (ZIFT)

lab fertilized eggs are inserted into fallopian tube

artificial insemination

-also called IUI (intrauterine insemination)

-sperm is injected into the uterus

assisted hatching

-used to improve the probability of the embryo's implantation

-involves the embryologist opening a small hole in the outer membrane known as the zona pellucida of the embryo

-this opening improves the ability of the embryo to leave its "shell" and implant into the uterine lining

complications of fertility treatments

-multiple pregnancy

-ovarian hyperstimulation syndrome

-bleeding

-infection

-low birth weight

-birth defects

traditional surrogacy

Surrogate's egg is fertilized with sperm, making her genetically related to the child.

gestational surrogacy

-usually ZIFT or GIFT

-embryo is from the parents

-surrogate is a "womb for hire" with no biological connection to the child

the "best" contraceptive method is...

-medically appropriate

-effective in preventing pregnancy

-used consistently and correctly

-satisfactory to the woman at her stage of life

family planning

the attempt to control the number and spacing of children

most effective contraceptives

-implants

-IUD

-female sterilization

-vasectomy

least effective contraceptives

-withdrawal

-spermicides

oral contraceptives

-progestin alone or progestin and estrogen

-stop ovaries from releasing eggs and keep mucus thick

combination contraceptives (estrogen and progestin) advantages

-highly effective when taken correctly and consistently

-not related to coitus, generally improve sexual satisfaction because they do not interfere with intercourse

-their effectiveness allows women to relax and not worry about becoming pregnant

-rapid return to fertility after discontinuation (about 2 weeks)

-very safe when prescribed for appropriate users

-can be used throughout reproductive years

combination contraceptives health benefits

-fewer pregnancies= fewer maternal deaths

-reduction in risk of ectopic pregnancy

-decrease in dysmenorrhea

-decrease in menorrhagia (helps prevent anemia)

-reduction in PMS symptoms

-elimination of Mittelschmerz

-decreased anovulatory bleeding

-fewer ovarian cyst problems (stimulation of the ovaries by FSH and LH is reduced)

-endometrial and ovarian cancer risk reduction

-decreased risk of benign breast conditions

-suppression of endometriosis

-improvement of androgen-sensitivity or androgen-excess conditions (PCOS)

-can reduce acne

-improvement in hot flashes and hormonal fluctuation symptoms in perimenopausal women

combined contraceptives disadvantages

-must be taken consistently and correctly to be effective

-storage, access, lack of privacy

-can interfere with lactation

-no protection against STIs

combination contraceptives side effects

-nausea, vomiting

-weight gain

-decreased libido

-headaches

-breast tenderness

-skin hyperpigmentation

combination contraceptives complications

-venous thromboembolism

-myocardial infarction and stroke

-hypertension

who should not be prescribed combination contraceptives?

WOMEN OVER 35 WHO SMOKE!

combined contraceptives contraindications

-personal history of thrombosis; known clotting disorders (factor V Leiden mutation, etc.)

-personal history of stroke or MI

-labile hypertension (uncontrolled HTN)

-estrogen-sensitive malignancy (such as breast cancer)

-active liver disease

-migraines with focal neurologic symptoms

how to take birth control pills

-"first day" start, "sunday start" or "quick start"

-continuing one pill per day every day

-withdrawal bleeding will occur during placebo week (THIS IS NOT TRULY MENSTRUATION)

"first day" start

-start on the first day of menstrual cycle

-advantage: absolutely certain the patient is not pregnant

"Quick start"

-patient takes first pill right away in the office

-most effective in getting women started on pills

cost of birth control pills

about $35 per cycle

patches

-norelgestromin and ethinyl estradiol transdermal system (Ortho Evra)

-applied once a week for 3 weeks, followed by patch-free week

-can be applied on buttocks, stomach, upper outer arm, or upper torso

patch advantages

95-99% effective

patch disadvantages

-have to remember when breakthrough week ends

-rest are same as pill

Depo-provera

-injection every 3 months

-okay for nursing mothers

-lead to irregular period and weight gain

-all progestin, no estrogen

-can get rubella vaccine while on this

Lunelle

-injection given monthly, every 28-30 days

-decreased side effects

NuvaRing

-placed in vagina for 3 weeks, which gives protection for month

-remove for one week

-exact position is not critical for ring to work

extended use regimens

-temporarily manipulating the cycle for convenience (to avoid having a period while traveling, competing in athletic event, etc.)

-“bicycling” or “tricycling” --- taking 2 or 3 months’ worth of active pills and then stopping for a withdrawal bleed

-monthly withdrawal bleeding is NOT necessary!

-Any monophasic pill, the patch, or the ring can be used on an extended basis.

-ex. Seasonale

Seasonale

-a monophasic, low-dose combination pill that provides 84 active pills followed by 7 placebo pills for 4 "periods" a year

-about $100 per pack

progestin-only contraceptives mechanism of action

-inhibiting ovulation by inhibiting positive feedback of estradiol on LH and FSH

-prevention of sperm penetration by thickening and decreasing the quantity of cervical mucus

-endometrial atrophy (lining is not receptive to blastocyst)

progestin-only contraceptives advantages

-no estrogen

-reversible

-amenorrhea or scanty bleeding

-improvement in dysmenorrhea, menorrhagia, PMS, endometriosis symptoms

-decreased risk of endometrial or ovarian cancer

-decreased risk of PID

-compatible with breastfeeding

progestin-only contraceptives disadvantages

-menstrual cycle disturbances

-weight gain

-depression

-lack of protection against STIs

progestin-only pills

-Micronor, Nor-QD, Ovrette

-cycle consists of 28 active pills; no "placebo week"

-vulnerable efficacy!

-each pill MUST be taken on time at a 24-hour interval

-compatible with breast-feeding and recommended in combination with lactational amenorrhea

-about $45 per cycle

Depo-Provera advantages

-highly effective

-discreet and private

-use not linked to coitus

-requires user to "remember" only 4 times a year

Depo-Provera disadvantages

-weight gain

-impossible to discontinue immediately

-delayed return to fertility

-adverse effects on lipids

-decreased bone mineral density with long-term use

-CALCIUM INTAKE AND EXERCISE MUST BE EMPHASIZED!

depo-provera side effects

-headaches

-nervousness

-depression

-acne

-hair loss

progestin implants advantages

-highly effective

-eliminate "user error"

-long term (3 years)

-reversible

progestin implants disadvantages

-high initial cost

-insertion and removal require specialized training

-cannot be easily discontinued

progestin implants side effects

-mood swings

-headache

-depression

-acne

male condoms

-thin covering which fits over an erect penis

-made out of latex rubber, polyurethane, or animal membrane

-85% efficacy

minimizing user error for male condoms

• Use with every act of intercourse

• Use "from start to finish"

• Unroll condom onto penis (do not unroll first; do not test by filling with air or water first)

• Hold rim during withdrawal to prevent slippage or leakage

• Have several condoms available

• Use appropriate lubricants

• Store condoms correctly

female condoms

-made of a thin plastic called polyurethane, NOT latex or rubber

-protects against STDs

-can possible increase orgasms

-cannot use with male condoms

-efficacy is less than male condoms

diaphragms

-a thin rubber dome-shaped cup with a flexible rim

-it fits over a woman's cervix and covers part of the inside of the vagina

-comes in different sizes and must be fitted by a clinician

-should always be used with spermicide like a contraceptive gel or cream

-not protective against STDs

-must be kept in 6-8 hours after intercourse

cervical cap

-a small rubber cap with a firm, rounded rim

-fits on a woman's cervix and is held in place by suction

-comes in four sizes and must be fitted by a clinician

-must be used with spermicide like a contraceptive gel or cream

natural family planning

-eggs released 14 days before start of menses

-fertilization can result from intercourse that took up to 4 days before egg release

-methods: calendar rhythm, temperature, mucus, symptothermal

fertility awareness/periodic abstinence advantages

-no hormones

-no side effects

-enables a woman to understand her body's cycles

-promotes cooperation between partners

-can be used to achieve pregnancy or identify infertility problems

-the only method approved by the Catholic church

fertility awareness/periodic abstinence disadvantages

-methods require varying amounts of training and cost

-detracts from spontaneity, causes friction between partners if they are not in agreement

fertility awareness/periodic abstinence can be difficult to use if...

-recent childbirth

-breastfeeding

-recent menarche

-approaching menopause

-recent discontinuation or a hormonal method

-irregular cycles

-unable to interpret fertility signs

two types of intrauterine devices

-progesterone release

-copper release

intrauterine devices patient education

teach patient to check for strings every month to make sure they are still there

Mirena advantages

-can remain in place up to 5 years

-protective against endometrial cancer

-reduces menstrual bleeding by 90%; 20% of users become amennorheic

-low incidence of progestin side effects such as weight gain (only 10% systemically absorbed)

Mirena disadvantages

irregular bleeding, especially during the first 6 months

emergency contraception

-copper T 380 A IUD for up to 5 to 8 days after unprotected intercourse to prevent implantation (this is the most effective method)

-morning after pills (MAPs): two large doses of ordinary birth control pills take within 72 hours

emergency contraception indications for use

-contraceptive failure (condom broke, pills forgotten)

-error in withdrawal or periodic abstinence

-rape

-any unintended "sperm exposure"

emergency contraception contraindication

pregnancy

Plan B

-0.75 mg of levonorgestrel per pill

-take first tablet as soon as possible within 72 hours after unprotected intercourse

-take second tablet 12 hours later

-the sooner is it taken the better but can be taken up to 120 hours after intercourse

-costs about $35 per pack

tubal ligation

-an operation which blocks the tubes carrying a woman's egg to her uterus

-100% effective in preventing pregnancy

vasectomy

-a small cut is made in the scrotum and the vas deferens are blocked

-sperm will not be cleared until after 20 ejaculations

-100% effectiveness