Tutorial - Infertility

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Tutorial - Infertility Contraception
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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

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• 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.

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• 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

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• 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

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• 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

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• 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

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• 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?

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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)

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• 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

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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

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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)

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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

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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

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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

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POP (mini pill)

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

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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)

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Contraindication to mini pill

• Severe arterial disease
• Liver tumour
• Acute porphyrias
• Breast Ca

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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

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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

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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

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Contraindications Side effects of Mirena

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

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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

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Side effects/ complication of IUCD

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

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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

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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

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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

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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

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• 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)

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• 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)