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Tutorial - Infertility

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Tutorial - Infertility & Contraception * Infertility Failure to achieve pregnancy despite one year of regular intercourse in a cohabiting couple. – PowerPoint PPT presentation

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Title: Tutorial - Infertility


1
Tutorial - Infertility Contraception
2
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

3
  • 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.

4
  • 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

5
  • 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

6
  • What investigations will you carry out? Indicate
    its significance.
  • Hormone profile LH/FSH (D2-3)
  • SHBG/
    Testosterone/E2
  • Prolactin
  • D21 Progesterone
    (gt30mmol/l)
  • Tubal patency test HSG
  • HyCosy
  • Lap dye
    insufflation
  • Pelvic USS PCO, Hydrosalphinx,Ovarian
    cyst(endometriotic)
  • Semen Analysis volume -
    2-5ml
  • (repeat sample count- gt10 million/ml
  • if abnormal result) abnormal forms 85
  • motility gt 50

7
  • 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, Ashermans syndrome
  • Male factor - Hypo gonadotrophism, infection,
    surgery

8
  • 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?

9
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 (PI15-20)
  • -Sheath (PI 4-10) ..reduces risk
    of STI
  • Female - Rhythm method (PI12-20)
  • ( safe period, basal body temp, consistency
    of cx mucus, LH surge ovulation kit)

10
  • 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

11
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
    (pregnancy60/100,000)
  • Mechanism- suppress ovulation (inhibits GnRH)
  • - Cx mucus hostile to sperm
  • - Thin atrophic
    endometrium
  • Usage

12
Advantages of Combined prep.
  • Reliable reversible, PIlt1
  • 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)

13
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

14
Contraindication
  • VTE - history/multiple risk factors /arterial
    disease
  • Transient Cerebral Ischemic attack, DM
  • Migrane - with aura, gt72 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

15
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

16
POP (mini pill)
  • Usage
  • PI lt 2
  • Indication- Risk of VTE
  • Older women
  • Heavy smoker
  • Diabetes
  • HTN
  • Migrane
  • Valvular heart disease
  • Breast feeding

17
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)

18
Contraindication to mini pill
  • Severe arterial disease
  • Liver tumour
  • Acute porphyrias
  • Breast Ca

19
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 lt1
  • Suitable for younger patient
  • Poor compliance with
    pill
  • Contraindication to
    combined preparation

20
Side effects Disadvantages of Parenteral
preparation
  • - Menstural irreularities/ amenorrhea
  • - Delayed return to fertility
  • - Decrease bone mineral density (avoid in
    women gt 45yrs)
  • - Progesterone side effect
  • - Injection site reaction
  • - Increased risk of breast Cervical Ca

21
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

22
Contraindications Side effects of Mirena
  • Contraindication- Breast Ca ( avoid for 5 years)
  • - Emergency
    contraception
  • Side effects
  • - Menstural irregularities
  • - Ammenorrhea
  • - Functional ovarian cyst

23
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

24
Side effects/ complication of IUCD
  • Uterine/cervical perforation-1/1000
  • PID-1/1000
  • Menorrhagia, dysmenorrhea
  • Displacement of coil
  • Expulsion- 3
  • Vasovagal attack
  • Ectopic pregnancy

25
Infection IUCD
  • Increased risk of infection within 20 day of
    insertion
  • Screen for STI if lt 25yr
  • gt 25yr if -had
    multiple partner
  • -new
    partner
  • -their
    partner had multiple partner

26
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

27
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

28
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

29
  • 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-gt35, smoker, BMIgt35)
  • 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)

30
  • 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,phenobarbit
    al,rifampicin, griseofulvin
  • Antiretrviral drugs
  • Antibiotic- ampicillin, doxycycline ( impair
    the bacterial flora that help reabsorption of
    estrogen from large bowel)
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