Tutorial - Infertility &

Contraception

Infertility

• Failure to achieve pregnancy despite one year of regular intercourse in a cohabiting couple.

• Primary-Infertility in woman with no previous pregnancy.

• Secondary- Infertility in a woman who has previously been pregnant.

• Incidence -10-15%

Mrs Bee is a 32 year old house wife. She has been trying to get pregnant for last one year following removal of IUCD. The IUCD was in place for 2 years and was removed at her request because of her wish to try for another child. She has recently been experiencing heavy periods that was attributed to the coil. Her periods are erratic.

Her first child was a normal delivery following which she used OCP. Her second child was delivered by C/S for fetal distress. Postnatally she had an episode of endometritis that required a course of antibiotics. She had coil inserted 3 months post delivery.

Her partner is not the father of her two children. He has no children. There are no reported problems with the intercourse.

• What is the diagnosis? Secondary infertility

• What features in her history are significant & what additional questions would you ask?

Age, BMI Periods- length,duration, regular/irregular , menorrhagia

Dysmenorrhea, dyspreunia, Pelvic pain Previous contraceptive Previous pregnancy, previous H/O infertility Pelvic infection surgical history- ruptured appendix, tubal surgery Frequency of intercourse Occupation

• What features in his history are significant & what additional questions would you ask?

?Age Occupation Previously fathered a child Life style- smoking, alcohol, ? Tight Clothes Medical History- mumps orchitis, undescended testis,

varicocele, testicular surgery. Any problems with intercourse ( ? Cyclist) Frequency of intercourse

• What investigations will you carry out? Indicate it’s significance.

• Hormone profile: LH/FSH (D2-3) SHBG/ Testosterone/E2 Prolactin D21 Progesterone (>30mmol/l)• Tubal patency test: HSG HyCosy Lap+ dye insufflation • Pelvic USS: PCO, Hydrosalphinx,Ovarian cyst(endometriotic)• Semen Analysis: volume - 2-5ml (repeat sample count- >10 million/ml if abnormal result) abnormal forms 85% motility > 50%

• What are causes of infertility? What is the likely cause in this case?

• Anovulation *Hypothalamus- Stress, Low BMI * Pitutary- Hyperprolactinemia *Ovarian- PCOS, Premature menopause, ovarian dysgenesis * Endocrine- Cushing & CAH Hypo/hyperthyroidism Poorly controlled DM• Tubal factor* Salphingitis- Chlamydia,gonorrhea, TB, pelvic peritonitis* Peritubal adhesion/scarring- Endometriosis • Uterine- Fibroid, Asherman’s syndrome• Male factor - Hypo gonadotrophism, infection, surgery

• What are the management options for infertility? What may be an option in this case.

- Life style- weight, Stop smoking/alcohol,loose underwear - Ovulation induction *Clomiphene- D2-6, dose 50-150mg daily PO Side effects-Multiple pregnancy(10%), Ovarian hyper

stimulation syndrome *Gonadotrophins - LH/FSH, FSH IM injection prep Expensive; OHSS; multiple pregnancy(25%) *GnRH pump- S/C or IV pulsed release 10-25mcg every

90min; Expensive; multiple pregnancy less common - Tubal surgery - IVF/ ICSI - Treatment for Male factor?

Contraception

• Pearl index- Failure rate of contraceptive method i.e no of unwanted pregnancies which occur in 100 women using that method for a year

• Methods not requiring medical consultation: * Male - Coitus interrupts (PI=15-20) -Sheath (PI 4-10) …..reduces risk of STI * Female - Rhythm method (PI=12-20) ( safe period, basal body temp, consistency of cx

mucus, LH surge ovulation kit)

• Methods requiring medical supervision:

* Oral- OCP, POP

* Parenteral- Injection, Implant

* Intrauterine device- Cu Coil, Mirena

* Other devices- Occlusive diaphragm & caps

• Permanent methods

*Tubal occlusion

*Vasectomy

Combined hormonal prep.• Synthetic Oestrogen & Progesterone• Monophasic,biphasic & triphasic • E2 -20,30,35,40 mcg• Progesterone- II,III generation VTE risk: Non-pill user: 5/100,000 women/year II generation: 15/100,000 III generation: 25/100,000 (pregnancy:60/100,000)• Mechanism- suppress ovulation (inhibits GnRH) - Cx mucus hostile to sperm - Thin & atrophic endometrium• Usage

Advantages of Combined prep.

• Reliable & reversible, PI<1• Reduced dysmenorrhoea , menorrhagia, PMT• Reduce endometrial & ovarian Ca• Reduce risk of PID• Reduce functional ovarian cyst• Reduces benign breast disease• Contraceptive protection- 24 hr ( pill) - 48 hr ( patches)• Acne /hirsutism ( dianette)

Side effects & disadvantages of hormonal preparation

• Nausea, vomitting, abdominal cramps• Weight gain , water retention• Change in lipid metabolism, HTN, VTE• Increase risk of Breast & Cervical Ca ( risk disappears

10yr after discontinuation)• Breast tenderness/enlargement/secretion• Irritability,depression, change in libido• Chloasma, photosensitivity, skin rash,leg cramps• Cervical erosion & Post pill amennorhea• Hepatic impairement /tumour; gallstones• SLE

Contraindication• VTE - history/multiple risk factors /arterial disease• Transient Cerebral Ischemic attack, DM• Migrane - with aura, >72 hrs despite treatment, Rx Ergot• Liver disease/tumour• Gallstones• Acute porphyria• Breast Ca • History in pregnancy- cholestasis,chorea, pemhigoid

gestationis• Active trophoblastic disease• Breast feeding

Missed pill• 1 missed pill- take next pill as soon as & resume

normal pill taking

• 2 or more missed pill in first or last 7 days of pack: Take pill as soon as + resume pill taking &

additional contraception for 7 days ( If 7 days extend into pill free interval, take next

pack without break)

• 2 or more missed pill in first or last 7 days & also if had unprotected intercourse:

Emergency contraception

POP (mini pill)

• Usage • PI < 2• Indication- Risk of VTE Older women Heavy smoker Diabetes HTN Migrane Valvular heart disease Breast feeding

Side effects of mini pill• Nausea, vomitting• Headache,dizziness• Weight changes & disturbance of appetite• Breast tenderness• Skin changes• Changes of libido• Breast cancer( decrease risk after 10 yr of discontinuation)• MENSTURAL IRREGULARITIES

• Contraceptive protection: 3hr ( conventional POP), 12 hr ( cerazette)

Contraindication to mini pill

• Severe arterial disease

• Liver tumour

• Acute porphyrias

• Breast Ca

Parenteral Progestogen• Medroxyprogesterone acetate(Depo-provera) 150 mg deep IM injection, 3 monthly• Norethisterone enantate ( Noristerat) 200mg deep IM ,8 weekly• Etonorgesterol implant (Implanon) 68mg, lasts 3 years• Long acting• PI <1• Suitable for : younger patient Poor compliance with pill Contraindication to combined preparation

Side effects & Disadvantages of Parenteral preparation

- Menstural irreularities/ amenorrhea - Delayed return to fertility - Decrease bone mineral density (avoid in women

> 45yrs) - Progesterone side effect - Injection site reaction - Increased risk of breast & Cervical Ca

Intrauterine device- Mirena

• Levonorgestrel 20 mcg/24 hr• Advantages- Menorrhagia - Endometrial hyperplasia - Does not increase ectopic pregnancy - Decrease risk of PID - Minimal progestogenic side effects - Effective with enzyme inducing drugs• Mechanism- prevent endometrial proliferation - Thickening of cervical mucus - Suppression of ovulation (some women) - local effects of IU device

Contraindications & Side effects of Mirena

• Contraindication- Breast Ca ( avoid for 5 years)

- Emergency contraception

• Side effects

- Menstural irregularities

- Ammenorrhea

- Functional ovarian cyst

Cu IUCD

• Mechanism: : Mild inflammatory reaction in endometrium : Cu inhibits enzyme involved in implantation : Cu is spermicidal• Usage: Flexi T 300,380-5 yr : Gynae fix -5yr : Nova T 380- 5 yr : Multiload Cu 375- 5 yr : T safe Cu 380 A-10 yr : TT80 slim line -10yr

Side effects/ complication of IUCD

• Uterine/cervical perforation-1/1000• PID-1/1000• Menorrhagia, dysmenorrhea• Displacement of coil• Expulsion- 3%• Vasovagal attack • Ectopic pregnancy

Infection & IUCD

• Increased risk of infection within 20 day of insertion

• Screen for STI if: < 25yr

> 25yr if -had multiple partner

-new partner

-their partner had multiple partner

Emergency Contraception

• Levonorgestral 1.5 mg (levonelle)

*With in 72 hrs ( effective upto 120hr but decreased efficacy)

*Counseling- Next period early/late

- Use barrier method until next period

- Return if sudden abd pain- ectopic

- Return in 3-4 wks if period heavy/light/absent• Cu IUCD with in 5 days

Female Sterilization

• Laparoscopy- rings, clip,diathermy • mini laparotomy/ at C/S- Tubal ligation ± diathermy• Stable relationship• Family complete• Permanent • Failure rate- 1/200• Increased ectopic• Does not alter period/ age at menopause• Complication of surgery/ GA• Success rate with reversal - 50-70%

Male sterilization

• Vasectomy• Simple & safer than female steri.• Done under local anaesthetic• Failure rate lower than female steri.• Disadvantage- contraceptive precaution up to 4

months when two samples -ve on lab exam.• Success of reversal 50%

• What is the most appropriate options for contraception & Why ?

1. A 37 year old woman who smokes and has a BMI 35 wishing contraception

(VTE risk->35, smoker, BMI>35) 2. A 30 year old epileptic with difficult control of fit (OCP interaction with hepatic enzyme inducer)3. A 25 year old air stewardess working mainly on long

haul flights (VTE risk)4. A 17 year old fit and well requesting contraception ( STI risk)5. A 28 year old with HIV ( STI risk anti retroviral drug interaction with OCP)

6. 36 year old with 4 children BMI 38, wishing a permanent method of contraception

( Wt-risk of surgery)7. A 40 year old embarking on a new relationship requiring

contraception ( Not long acting preparation)8. A 30 year old wishing long term contraception and multiple

partners ( Risk of STI) 9. 20 yr old patient unprotected intercourse 4 days previously D16 ( Emergency contraception, levonelle less effective)10. Breakthrough bleeding on the COCP (biphasic/triphasic pill) 11. Drug interaction with OCP Hepatic enzyme inducer- phenytoin,phenobarbital,rifampicin,

griseofulvin Antiretrviral drugs Antibiotic- ampicillin, doxycycline ( impair the bacterial flora

that help reabsorption of estrogen from large bowel)