Reproductive Health, Infertility, Contraception & Menopause – Lecture Review

Diagnostic Testing for Infertility

• General Strategy

  • Multiple etiologies are common; run an entire diagnostic battery.
  • Testing starts with the male (independent of menstrual cycle).

• Male Evaluation

  • Semen Analysis – assess count, morphology, motility, viability.
  • Non-structural/Structural Studies
  • Physical exam for varicocele (scrotal varicose vein → warmth → ↓ spermatogenesis).
  • Testicular biopsy or scrotal US when indicated.
  • Hormone Panel – verifies endocrine adequacy.

• Female Evaluation

  • Hormone Studies – interpreted relative to cycle day.
  • Basal Body Temperature (BBT)
  • Measure before any activity each morning.
  • Biphasic curve: follicular baseline then 0.5\text{--}1^{\circ}\text{C} post-ovulatory rise.
  • Ovulation Predictor Kit – detects LH surge.
  • Postcoital Test
  • Cervical mucus sampled after intercourse; checks sperm presence & viability; screens for antisperm antibodies.
  • Uterine/Tubal Imaging & Procedures
  • Endometrial biopsy, transvaginal US, hysteroscopy.
  • Laparoscopy (+ lysis of adhesions for endometriosis).
  • Hysterosalpingogram (HSG): radiopaque dye tracks tubal patency; also therapeutically flushes tubes, raising fertility for \approx2\text{--}3 cycles.

Infertility Treatment Modalities

• Gamete Stimulation

  • Women: Clomiphene (first-line) ± gonadotropins ± HCG trigger → multiple follicles.
  • Men: avoid heat/toxins; varicocele repair; do not give testosterone (negative feedback); Clomiphene can boost spermatogenesis.

• Intrauterine Insemination (IUI) – lab-processed sperm injected into uterus; requires patent tubes.

• Assisted Reproductive Technology (ART)

  • IVF: ovarian hyperstimulation → egg retrieval → lab fertilization → embryo transfer; bypasses blocked tubes; success falls with maternal age.
  • ICSI: single sperm micro-injected into oocyte (severe male factor).
  • Donor gametes/embryos, gestational carrier, surrogacy, adoption.

• Psychosocial Care – counsel on emotional roller-coaster; keep relationship central.

Contraceptive Methods & Effectiveness

• Guiding Principle: best method = one compatible with lifestyle & values.
• Failure Rates (annual)
  • Fertility awareness/spermicide 24\%.
  • Barrier methods 18\text{--}24\%.
  • Short-acting hormonal 6\text{--}12\%.
  • Sterilization 0.15\text{--}0.5\%.
  • LARC (implant/IUD) <0.1\% (most effective reversible).

Natural/Fertility Awareness

• Lactational amenorrhea effective only if baby <6 mo, exclusive BF, amenorrheic.
• Calendar, BBT, cervical mucus: high failure.

Barrier Methods

• Spermicide (nonoxynol-9) – no STI protection; avoid in HIV or sensitivity.
• Condoms – male & female; STI protection.
• Diaphragm – provider-fit; + spermicide; insert pre-coitus, keep \ge6 h <24 h; inspect for holes.
• Cervical Cap – similar; best for nulliparas; leave 6\text{--}8 h.
• Sponge – OTC, spermicide-impregnated; higher failure.

Hormonal Methods

• Combined Oral Contraceptives (COC)
  • 28-day packs: 21 active + 7 inert (withdrawal bleed) – packs may be run together.
  • Non-contraceptive benefits: regulates cycles, ↓ dysmenorrhea/menorrhagia, treats PCOS, PMS/PMDD, ↓ ovarian/uterine/colon CA.
  • ACHES danger signs; contraindications: thromboembolism, migraines + aura, age >35 smoker, etc.
• Mini-pill (progestin-only) – safe in breastfeeding & clot disorders; frequent breakthrough bleeding.
• **Injectable (Depo) q3 mo; Patch (weekly*3 + 1 off); Vaginal Ring (in 3 wk, out 1): ring ineffective with BMI >29 or oil lube.

LARC

• Implant (Nexplanon) – \le3 yr; progestin; breakthrough bleeding common.
• IUDs
  • Copper (10 yr)—spermicidal; may ↑ bleeding.
  • LNG (2\text{--}5 yr)—lighter/amenorrheic cycles.
  • Teach monthly string check; rule out infection pre-insert.

Emergency Contraception

• Plan B (levonorgestrel) – best
• Ulipristal prescription – \le120 h.
• Copper IUD within 7 days: most effective, BMI-independent.
• Nursing triage: elapsed time, BMI, possible pregnancy.

Sterilization

• Tubal Ligation – outpatient; ↓ ovarian CA risk; failure \approx0.5\%.
• Vasectomy – hormones/libido unchanged; backup contraception until semen analysis shows 0 sperm (≈ 20\text{--}30 ejaculations or 1\text{--}3 mo).
• Male reversible gel (Vasalgel) expected 2026.

Menstrual & Gynecologic Disorders

• Dysmenorrhea – primary (common) treated with NSAIDs; secondary often endometriosis.
• Endometriosis – ectopic implants cause pain, adhesions, infertility; laparoscopy ± lysis; COC therapy.
• PMS vs PMDD
  • PMS: ≥ 1 physical + 1 emotional symptom in luteal phase.
  • PMDD: severe, function-impairing; treat with SSRIs, COC, lifestyle.
• Lifestyle: exercise; limit salt, sugar, caffeine, ETOH; eat complex carbs, cruciferous veggies.

Menopause & Perimenopause

• Definitions
  • Perimenopause ≈ 10 yr pre-LMP; irregular menses.
  • Menopause: 12 mo amenorrhea.
• Shared Symptoms – hot flashes, urogenital atrophy, mood change, insomnia, ↓ libido; irregular menses only in perimenopause.
• Risks Post-Estrogen – CVD, osteoporosis.
• Management
  • Diet (↑ Ca, ↓ ETOH/caffeine/sugar), weight-bearing exercise, lubricants.
  • Hormone Therapy (HT)
  • Estrogen + progestin; start early to avoid ↑ CVD/DVT/CA.
  • Benefits: ↓ vasomotor sx, ↓ atrophy pain, ↓ hip Fx.
  • Continue contraception until \ge12 mo after LMP.

Male Reproductive Disorders

• Hydrocele – fluid in tunica vaginalis; newborns self-resolve; adults may need aspiration.
• Varicocele – scrotal varices; dull pain, infertility; surgery if symptomatic.
• Testicular Torsion – acute pain; emergent surgery within hours to save fertility.

Prostate Issues

• BPH – >75\% men >70; LUTS (weak stream, dribble, nocturia); meds, then TURP; post-TURP continuous bladder irrigation; ED possible.
• Prostate Cancer – most common male CA; screen 55\text{--}69 yr via shared PSA/DRE decision; risks: age, Black race, BRCA; very slow growth.
  • Screening stats/1000 men: 1 death prevented, 3 metastasis avoided, 50 ED, 15 incontinence.

Low Testosterone (Hypogonadism)

• Symptoms – ↓ libido/ED, fatigue, ↓ muscle/bone, mood issues.
• Diagnosis – morning serum T; re-check 6\text{--}12 mo.
• Treatment – gel/patch (apply to non-contact area); avoid oral except genetic cases.
• Risks – ↑ BPH/CA growth, ↓ spermatogenesis, ↑ DVT, possible CVD/stroke.

Key Nursing Pearls

• Postcoital test screens sperm survival & cervical hostility (antisperm Ab).
• Male fertility: avoid heat (sauna, tight jeans), toxins (nicotine, THC, alcohol, pesticides).
• HSG is both diagnostic & therapeutic for tubal patency.
• Diaphragm education: inspect for holes, use spermicide, leave \ge6 h <24 h.
• ACHES mnemonic for COC danger signs.
• After vasectomy continue backup until semen report shows 0 sperm.
• Perimenopausal women are still fertile—continue contraception.
• Cruciferous veggies aid estrogen metabolism in PMS/PMDD.