OBgyn Week

Contraception, Infertility

Contraception• Prevention of pregnancy• Requires prevention of fertilization and/or

implantation• Many different methods in these general

categories:• prevent ovulation (hormonal methods) • prevent sperm from meeting ovum (barrier methods,

female and male sterilization, spermicide, calendar)• prevent implantation (IUD, hormonal methods)

Preg and Contracep stats• In 2002, about 50% of the 6.4 million

pregnancies in the US were unintended• About 18% of these pregnancies ended in

elected abortion (1.4 million)• About 65% of these pregnancies ended in live

birth (4.14 million)

• Any sexually active fertile woman can become pregnant

CONTRACEPTION• Contraceptive use in US women - 2002

– Oral contraceptives 19% – Sterilization

• Female – 17% • Male – 6%

– Male condom 11%– Progestin injection 3.3%– Withdrawal 2.5%– IUD 1.3%%– Periodic abstinence 0.9%%– Implant, Lunelle, or Patch 0.8%%– Diaphragm 0.2%%

• Not using contraception – 38%

Contraceptive Methods

• How to choose? The best option will be:– Medically appropriate– Used every time– A method patient is happy with

TYPES OF CONTRACEPTION CURRENTLY AVAILABLE

• Periodic abstinence • Spermicides• Barrier techniques

– Diaphragm– Cervical cap– Male condom– Female condom

TYPES OF CONTRACEPTION CURRENTLY AVAILABLE

• Hormonal contraceptives – oral, patch, ring• Long acting hormonal contraceptive

– Injectable– Implants

• Intrauterine devices• Sterilization

– Tubal ligation– Vasectomy

• Emergency contraception

Contraceptive Effectiveness and Cost Issues

• Effectiveness rates are usually reported in the following ways– Typical use effectiveness (TER)– Perfect use effectiveness (PER)– Failure rates

• The most effective techniques provide the greatest total cost savings– Top 5 total savings – Copper-T IUD, vasectomy,

implant, injectable, OCPs– Cheapest – barrier methods – condoms, diaphragm,

cervical cap, sponge, spermicides

Contraceptive Methods - Periodic Abstinence

• Avoidance of sexual intercourse during fertile window• Must avoid intercourse on all calculated fertile days

• Four techniques commonly utilized– Calendar rhythm method– Temperature method– Cervical mucus method – Symptothermal method

CALENDAR RHYTHM METHOD• Woman records length of cycle over several months• Establishes fertile period by subtracting 18 days from

shortest cycle, and 11 days from longest cycle• Couple avoids coitus during this fertile period• Cannot be used by women with irregular menses• Perfect use effectiveness rate 91%• Typical use effectiveness rate 75%

TEMPERATURE AND CERVICAL MUCUS METHODS

• Rely on measurement of either BBT or change in cervical mucus to identify ovulation

• Coitus is avoided from onset of menses until third day of elevated temperature in temp method

• Coitus is avoided during menses, then every other day until ovulatory mucus is detected, then daily until 4 days after ovulatory mucus is gone

• Requires highly motivated couples and training in techniques

• PER 97%• TER 75%

SYMPTOTHERMAL METHOD

• Relies on several indices to identify fertile period– Calendar calculations and cervical mucus to establish onset

of fertile period– Cervical mucus or BBT to estimate end of fertile period– Coitus avoided during fertile period– Requires significant training and motivated couples– PER 98%– TER 75%

PERIODIC ABSTINENCE

• Overall, typical use effectiveness rate is 75%• Major objection of users is need to avoid

intercourse for many days each month• Combined with barrier methods during fertile

periods may increase effectiveness rates and decrease discontinuation rates

PERIODIC ABSTINENCE• Home ovulation predictor kits that test

urine for hormone metabolites are now becoming available– Test must be done 12 days each month– Can reduce the number of days of

abstinence required to a maximum of 7

BARRIER METHODS• Diaphragm

– Circular spring with latex rubber coating– Covers the cervix, preventing sperm from entering os– Must be fit by HCP– Woman must demonstrate ability to insert and remove

correctly during fitting– Spermicide should be used with diaphragm– Diaphragm left in place 8 hours after intercourse– Remove device within 24 hours of insertion– UTI’s higher in users vs non-users– PER 94% - TER 84%

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BARRIER METHODS• Cervical cap – FemCap, Lea’s Shield

– Cup shaped plastic or rubber cap– Fits around the cervix– Must be fitted by HCP– Woman must demonstrate ability to insert and remove during fitting– Can only be used by those with normal PAP– Repeat PAP 3 months after starting use of cap– Can remain in place for up to 48 hours– Spermicide recommended– No increase in UTI’s– PER parous 74% nullip 91%– TER parous 68% nullip 84%

BARRIER METHODS• Male condom

– Latex or animal intestine sheaths that cover penis– Captures semen to prevent deposition into vagina– Must be applied tightly– Tip should extend half an inch beyond end of penis– Care must be taken to prevent spillage after ejaculation– Most effective method to prevent STD transmission (latex)– PER 98%– TER 85%

BARRIER METHODS• Female condom

– Polyurethane vaginal pouches– Soft, loose-fitting with two rings, one internal, one

external– Prevents deposition of semen in vagina– Less likely to rupture than condom– PER 95%– TER 79%

• Noise and distraction are major obstacles

BARRIER METHODS• Sponge

– Made of urethane foam– Contains spermicide– Moistened with H2O, inserted into vagina– PER 91%– TER 84%– Advantages

• Can put in hours ahead of time• Can leave in for up to 30 hours

– Disadvantages• May be irritating or messy

BARRIER METHODS• Barrier methods are most effective

contraceptive method to reduce transmission of STD’s

• Contraceptive effectiveness increased with concurrent use of spermicide

SPERMICIDE• Made up of spermicidal chemical, either nonoxynol-9

or octoxynol combined with a base of cream, jelly, foam, foaming tablet, film, or suppository

• No evidence of teratogenicity in several studies• Toxic to lactobacillus• Increased colonization with E. coli seen, may result in

bacteriuria after intercourse• PER 82% TER 71%

ORAL CONTRACEPTIVES• 1960 marked initial year of use in US• Quickly became the most widely used method

of reversible contraception• Mechanism

– Synthetic progesterone (progestin) inhibits ovulation and thickens cervical mucus

– Synthetic estrogen maintains endometrium, prevents abnormal bleeding, and inhibits follicular development

OC’s• Three major types

– Monophasic combination (fixed dose)• Estrogen/progestin in same doses X 3 weeks• Estrogen/progestin in same dose for 84 days• Most widely used and most effective

– Biphasic or multiphasic combination• Estrogen/progestin in varying doses X 3 weeks• Lower total Est dose for possible lower SEs

– Progestin only• Progestin same dose every day all month• Must be taken every day, at same time (within 3 hrs)

OC’s• All made from synthetic estrogens and/or

progestins– Ethinyl estradiol (EE) most common estrogen

• First generation OCP’s contain > 50ug estrogen– Due to SE’s, these are no longer marketed in US

• Second generation OCP’s contain 20-35 ug estrogen and older progestins

• Third generation OCP’s contain newer progestins – desogestrel, norgestimate, gestodene,

drospirenone, norethindrone

OC’s• Failure of combination OC’s occurs

primarily when pill free interval is extended

• Most important pill to take is the first one of each cycle

• PER combined 99.9% • PER progestin only 99.5%• Overall TER 97%

OC’s• Progestin only OC – AKA “mini-pill”

– Estrogen effects not seen• Thromboembolism• Nausea• Breast tenderness• HTN• No effect on lactation

– Disadvantages• Abnormal bleeding• Amenorrhea• Slightly less effective than COC’s

SIDE EFFECTS OF OC’s• SE’s from estrogen component

– Nausea– Breast tenderness– Headache– Fluid retention– Decreased B-complex vitamins, vitamin C, and increased vit A– Melasma– Breakthrough bleeding– Possibly mood changes/depression– Thrombosis– Increases in some coagulation factors and angiotensinogen– HTN– Neoplastic effects

• Small increase in current and recent users- -probable small promoting effect with breast cancer

• Cervical cancer – may be cocarcinogen• Protective effect on endometrial and ovarian cancer

SIDE EFFECTS OF OC’s• SE’s from progestin components

– Weight gain– Acne– Mood changes– Amenorrhea– Increased insulin, decreased glucose tolerance– Increased LDL, decreased TC, HDL, TG’s– Headache– Breast tenderness

CONTRAINDICATIONS TO OC’s

• Absolute contraindications– Hx vascular disease– Hx SLE, DM with nephropathy or retinopathy– Cigarette smoking > 35 yrs of age– Uncontrolled HTN– Breast or endometrial CA– Pregnancy– Functional heart disease– Active liver disease

CONTRAINDICATIONS TO OC’s

• Relative contraindications– Heavy cigarette smoking under 35 years of age– Migraine headaches– Undiagnosed amenorrhea– Prolactin secreting macroadenoma

• Prior to prescribing, screen for diabetes, lipids, liver disease if patient has personal or family history

OCs– Protect against:

• Ovarian cancer• Uterine cancer• Follicular ovarian cysts• PID from STI (thickened cervical mucus)

– May increase risk for:• Breast cancer• Heart disease

– Deplete levels of (need supplementation:– Folic acid– B 12– B6 (pyridoxine)– B2 (riboflavin)– Vitamin C– Zinc

FOLLOW-UP• Monitor for side effects• Follow-up in 3 months

– Hx, BP

• If patient on medications, check for interactions

• If no SE’s and BP OK, see patient annually

The Patch• Ortho Evra• Synthetic Estrogen and progestin• Patch changed weekly X 3 weeks• PER >99%• TER 92%• Simple, convenient• Same contraindications, disadvantages and

possible SE’s as OC’s

The Ring• NuvaRing• Synthetic estrogen and progestin on plastic ring

– Ethylene vinyl acetate

• Inserted into vagina, left X 3 weeks• PER >99%• TER 92%• Simple, convenient• Same contraindications, disadvantages and possible

SEs as OCs

POTENTIAL BENEFITS OF HORMONAL CONTRACEPTIVES

• Reduced endometrial and ovarian cancer• Reduced menorrhagia, intermenstrual, and

irregular menses• Reduced benign breast disease• Reduced PMS and dysmenorrhea• Reduced PID• Reduced bone loss

LONG ACTING CONTRACEPTIVE STEROIDS

• Injectable– Two types

• Monthly (Lunelle), q 3 months (Depo-Provera)

– PER 97.7% TER 97.7%– Adverse effects

• Amenorrhea or irregular menses• Weight gain• Headache• Mood changes• Increased LDL, decreased HDL

– Potential benefits• Decreased endometrial cancer

LONG ACTING CONTRACEPTIVE STEROIDS

• Subdermal implants– Levonorgestrel in a silastic capsule, implanted under the

dermis– PER 97.7% TER 97.7%

• NORPLANT NO LONGER AVAILABLE, BUT SOME WOMEN STILL HAVE THEM IN THEIR SKIN

• Implanon approved by FDA July 2006• Adverse effects

– Irregular bleeding– Infection or local irritation– Headache– Weight gain– Acne– Mastalgia– Mood changes

INTRAUTERINE DEVICES• Devices implanted into uterus• Creates inflammatory reaction and acts as

spermicide, may also prevent implantation• Two primary types

– ParaGard (Copper T-380A) • PER 99.4% TER 99.2%• Good for 12 years

– Mirena (Levonorgestrel) • PER 99.9% TER 99.9%• Good for 5 years

IUD’s• Advantages

– Highly effective and cost-effective– Convenient, no compliance or perfect use issues– Long lasting, easily reversible– Minimally invasive– Safe during lactation

• Disadvantages– Must be inserted and removed by health care

provider– Does not protect against STDs

IUD’s• Adverse effects

– Menorrhagia or intermenstrual bleeding• Usually diminishes with time

– Expulsion of device - occasional– Perforation of uterus - rare– Complications related to pregnancy - rare– Infection - rare– Does not protest against STD’s

IUD’s• Contraindications

– Pregnancy– Acute or hx PID– Postpartum endometritis– Known or suspected uterine or cervical malignancy– Genital bleeding of unknown origin– IUD previously inserted and still in place– Vaginitis, cervicitis, STD, TB (current)– Allergy to copper or Wilson’s dz (ParaGard)– Liver disease (Mirena)

STERILIZATION• Most common method of non-hormonal contraception used

by couples in US• Female

– No-Incision Method (Essure) – metallic coils placed into fallopian tubes via vagina, cx, uterus

– Tubal ligation – Tubes ligated via mini-laparotomy or laparotomy

– PER 99.6% TER 99.6%– Slight surgical risk with ligation– Coils can be expelled or perforate rarely

semi non-surgical – go in through vagina/cervix/uterus– Reversal procedure 75% successful

• Risk of ectopic pregnancy• expensive

STERILIZATION• Male – vasectomy

– Require local anesthesia and office setting– Excision of portion of vas deferens– PER 99.9% TER 99.9%– Sperm still present for up to 3 weeks– Slight surgical risk, no reduction in sexual

performance– Reversal procedure 50% successful, expensive

EMERGENCY CONTRACEPTION

• Emergency contraception pills– Combined E/P

• Preven• Regular OCP’s (certain brands only) • Reduces risk of pregnancy 75%

– Progestin only• Plan B• Reduces risk of pregnancy 89%

• Take first dose within 72 hours, second dose 12 hours later

• Stops ovulation, fertilization, or implantation– May cause nausea and vomiting– Don’t use if pregnant

EMERGENCY CONTRACEPTION

• Emergency IUD insertion– ParaGard (Copper T 380A)– Inserted within 5 days– Can be left in for up to 12 years, or

removed after next menses– Not recommended for women at HR of

STD, including rape victims– Reduces risk of pregnancy 99.9%

EMERGENCY CONTRACEPTION

• Where to get EC– Available OTC to those >18 yo– EC hotline - 1-888-NOT-2-LATE– Planned Parenthood

• 1-800-230-PLAN

INDUCED ABORTION• One of the most common gynecologic

procedures performed in the US and many other countries

• 90% performed in the first trimester• Two primary methods• Vacuum aspiration methods

– Manual vacuum aspiration– Dilation and suction curetttage (D&C)

• Medication methods– Mifepristone (RU 486) or methotrexate followed

by misoprostol

INDUCED ABORTION• Vacuum aspiration abortion

– Procedures take about 10 minutes– May have cramps and clots for 10 days– May bleed for up to 2 weeks– >99% effective

• Medication abortion– Entire process may take from 1-2 weeks– May bleed for up to 4 weeks– May have cramps, N&V, diarrhea – 90-97% effective

INDUCED ABORTION• Safety issues

– Risk of death from abortion: 0.7 per 100,000 abortions

– Risk of death from pregnancy: 7-8 per 100,000 live births

– Performed in outpatient clinics, general anesthesia not required

INDUCED ABORTION• Risks

• Allergic reactions• Infection• Incomplete abortion• Bleeding• Injured organ – vacuum aspiration only

Key Concepts• Major categories of contraception are:

• Periodic abstinence• Barrier methods• Oral contraceptives• Long acting contraceptive steroids• IUD’s• Emergency contraception• Sterilization

• Which are most effective?• What are some pros/cons of each?• Which help prevent STD transmission?

Infertility• Defined as the reduced capacity to conceive

as compared with the mean capacity of the general population

• Inability of couples of reproductive age to establish a pregnancy by having unprotected sexual intercourse within a certain period of time (usu. 1 year)– Primary: woman has never been pregnant– Secondary: infertility after one or more

pregnancies

Infertility• Fecundability (monthly conception rate) in normal,

fertile females is about 20% – Half of the couples who try to conceive do so within the first

3 months– Three fourths will conceive within 6 months– 90% will conceive within 1 year

• Two categories of infertility:– Hypofertile – couples have low fecundability

• Woman with mild endometriosis• Male with low sperm count (oligospermia)

– Sterile – couples who are never able to conceive without therapy

• Woman with complete occlusion of Fallopian tubes

Infertility and Age• Fertility decreases with age

– Failure to conceive within 1 year steadily increases from ages 25-44

– About 1 in 7 couples are infertile if the woman is 30-34 years

– 1 in 5 if woman is between 35-40 years old– 1 in 4 if woman is between 40-44– Monthly ovulation decreases greatly after

age 45

Causes of Infertility– 10-15% annovulation– 10-15% abnormal sperm-mucus penetration– 30-40% abnormalities in the male repro tract

• Oligozoospermia, high semen viscosity, low motility of sperm, low semen volume

– 30-40% pelvic factors • Tubal occlusion• Endometriosis adhesions

– Idiopathic or unexplained infertility • Tend to be hypofertile and eventually able to conceive

without treatment

Anovulation

• Anovulation may be due to:– Physiologic (pregnancy, postpartum, menopause)– Extreme exercise

• Low body fat• Too much stimulation of breasts may elevate prolactin

– Psychogenic • Acute physical or emotional stress• Traveling, lifestyle changes• Chronic stress• Anorexia nervosa (amenorrhea a likely early symptom)

Anovulation

• May be due to hormone imbalance– Decreased progesterone production (or problem

with progesterone receptors)– Estrogen deficiency– Hyperprolactinemia (endocrine tumors, breast

feeding, hypothyroidism)– Insufficient function of hypothalamus/ pituitary– Ovarian insufficiency (cysts, tumors, insulin

resistance, autoimmune)

Annovulation/ Hormone Imbalance

• Systemic diseases:– Hypothyroidism (elevated TSH associated

with elevated prolactin)– Adrenal abnormalities (Cushings,

Addisons: heavy irregular menses; adrenal insufficiency/ burnout)

– Diabetes, Anemia– Malnutrition

InfertilityGeneral Counseling

• Timing– Best chance for conception the day prior to

ovulation– Sperm has ability to fertilize 5-7 days– Ova viable for only about 24 hrs. – Daily intercourse for 3 consecutive days

midcycle

InfertilityGeneral Counseling

• Stop smoking– Lowers sperm count, higher proportion of

malformed sperm– Worse response to fertility treatment– Lengthens time to conceive– Women who smoke are twice as likely to

be infertile

InfertilityGeneral Counseling

• Avoid coffee– Coffee drinking during pregnancy is

associated w >2x inc risk of miscarriage– Risk of not conceiving for 12 months is:

55% higher for women drinking 1 cup/ day

100% higher for 1.5-3 cups/day

176% higher for 3 or more cups/ day

InfertilityGeneral Counseling

• Avoid alcohol• Alcohol consumption by the woman 1 week

prior to IVF treatment reduces success nearly 3 times

• Alcohol consumption by the man the month before IVF reduces success rate 2.5 times; 8 times if the week prior

• Alcohol consumption by either partner the week prior to conception associated with increased risk of miscarriage

InfertilityGeneral Counseling

• Avoid marijuana– Males: decreases sperm count– Lowers testosterone

• Males: avoid increase in pelvic temperature:– Hot tubs, laptop on lap for extended periods

• Sperm motility may be decreased by keeping cell phone in front pocket

• Avoid pesticide and chemical exposure• Manage stress well

InfertilityGeneral Counseling

– Avoid douches – Avoid use of saliva or petroleum-based

lubricants– Even some water-based lubricants may

interfere with sperm motility and integrity• FemGlide, Replens, and Astroglide (laboratory

study)• KY had lowest negative effect on sperm

Infertilityand Body Weight

• Small amounts of weight loss (5-10%) may dramatically improve ovulation and pregnancy rates in overweight women (BMI> 25)

• Sperm counts lower in both over- (21%) and underweight (28%) men

Diagnostic Evaluation:

• Documentation of ovulation– Regular menstrual cycles– Serum progesterone level in midluteal phase (should

be above 10ng/ml to indicate adequate luteal function)– BBT

• Semen analysis: volume, viscosity, sperm density, sperm morphology, sperm motility– Male partner should abstain from ejaculation 2-3 days

prior to specimen collection– Analysis should be performed as soon as possible

after the liquefaction of semen

(Semen Analysis)• Volume: >2.0ml• Concentration: >20 million/ml• Total Cells: >40 million• Motility: ~50%• Normal Forms: >14%• White & red blood cell counts

If abnormally high, antibiotics may be recommended

• Semen Viscosity • Coagulated sperm should liquefy within an hour

• Sperm Agglutination • Sperm that "clump together” - indicates autoimmune response or

presence of infection

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Infertility Workup• CBC, UA, cervical cytology (PAP)• If over 35 years old, serum FSH, estradiol on day

2, 3, or 4 of cycle– If FSH >24 mlU/ml, ova unable to be artificially fertilized

• CA-125 serum levels• Serum prolactin• Pelvic ultrasound• Thyroid panel - esp if cycles irregular• Antibodies to Chlamydia

– High correlation between Ab titer and tubal adhesions/ obstruction

Infertility - other possible factors

• Women may have an occult (asymptomatic) infection of upper genital tract

• Women may produce antibodies to sperm that may immobilize them or cause them to agglutinate– These antibodies have been found in both fertile

and infertile women– Not a established cause of infertility

Infertility WorkupHysterosalpingogram if tubal adhesions/ blockage

suspected• Performed during the week following menses• Involves a steady beam of X-rays to visualize

uterus and Fallopian tubes while a contrast media is applied through cervical os

Diagnostic laparoscopy if suspect endometriosis• Usually performed after several rounds of ovarian

hyperstimulation and intrauterine insemination

Infertility Prognosis

• Better in cases due to:– Anovulation– Uterine adhesions

• Lower in cases due to:– Sperm abnormalities– Tubal disease

Infertility Management

• Annovulation– Agents to induce ovulation

• Clomiphene citrate/ Clomid (synthetic estrogen), hMG, FSH, GnRH

• Bromocriptine if due to hyperprolactinemia• Corticosteroids if due to excess adrenal androgens

• Intrauterine adhesions– Hysteroscopic lysis– Good prognosis if no other contributing factors

Infertility Mgmt

• Leiomyoma• May physically distort the endocervix and interfere with

normal sperm transport or if submucous could interfere with implantation

• Myomectomy justified in cases where they are of moderate size and position and no other factor that contributes to infertility

• Infection causing cervicitis– High levels of WBC kill off sperm as they enter os– Cervical mucus may be to acidic for sperm– Appropriate antibiotic or antimicrobial agent

Infertility Mgmt

• Tubal problems– Scarring from PID is leading cause of female infertility– Scarring may also be from prior surgery (e.g. ectopic

pregnancy) or congenital tube defects

• Management of tubal problems:– Selective salpingography and tubal cannulation

• Done in cases of proximal tubal obstruction• Purpose is to “open” tubes– achieve tubal patency

– Surgical tubal reconstruction• Prognosis depends on amount of damage to tubes• If damage extensive, greater chances of conceiving with IVF

than with tubal reconstructive surgery

Infertility Mgmt

• Endometriosis: up to 40% of infertile women have endometriosis– Blood from endometrial tissue irritates tubes,

producing scarring, adhesions, or cysts– May cause hypertrophy of uterine lining, interfering

with implantation

• Mild cases: 65% of women can conceive without treatment (if no other contrib factor)

• Moderate to severe cases: only 0-25% can conceive

Infertility Mgmt

• Endometriosis– Surgical treatment in absence of tubal adhesions or

endometrioma (mild endometriosis) does not result in improved fertility rates

– Medical treatment of mild endometriosis has not been shown to improve fertility rates (vs. no treatment)

– Surgical treatment of moderate (over 1cm size endometrioma) endometriosis slightly improves fertility rates

– Surgical treatment of severe endometriosis improves fertility rates

Infertility Mgmt

• Unexplained infertility– Controlled ovarian hyperstimulation (usu.

via Clomid)– Intrauterine insemination (IUI)– Initial treatment consists of 4-6 cycles– Pregnancy rates with this method decrease

dramatically after age 40

IVF

• In Vitro Fertilization– Ovarian hyperstimulation to harvest as many ova

as possible• Success rate proportional to number of implanted

embryos

– Ova are retrieved via follicle aspiration– Oocytes cultured and incubated in a rigidly

controlled, sterile environment– A few hours post retrieval, sperm separated from

semen are added to culture medium

IVF continued

– 18 hours later oocytes are observed to determine if fertilization has occurred

– Those that have been fertilized are cultured for 48-96 hours

– Embryos are placed via catheter through cervical canal

– Rate of pregnancy following IVF is directly related to number of implanted embryos

– After six failed cycles of IVF, chances of pregnancy very low

Infertility

• Unexplained infertility • May be due to environmental pollutants or

exposure to other toxic chemicals– Heavy metal burden (lead, mercury, cadmium, etc.)– Chelation therapy– The couple must REFRAIN from actively trying to

conceive during ANY form of chelation / cleanse

• Endocrine disruptors: – exogenous estrogens, pesticides, chemical solvents

• Electromagnetic radiation

InfertilityOther Helpful Modalities

• Energy work

• Counseling

• Spinal manipulations

• Mayan uterine/abdominal massage

• …