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.
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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.
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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
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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
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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
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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
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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
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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
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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
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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)