Infertility 1.

Infertility 1

Infertility The inability to conceive following unprotected sexual intercourse 1 year (age < 35) or 6 months (age >35) Normally a fertile couple has approximately a 20 % chance of conception in each ovulatory cycle 2

Infertility Primary infertility Secondary infertility
a couple that has never conceived Secondary infertility infertility that occurs after previous pregnancy regardless of outcome 3

Requirements for Conception
normally developed reproductive tract in both the male and female partner normal functioning of an intact hypothalamic-pituitary-gonadal axis supports gametogenesis (the formation of sperm and ova). timing of intercourse Unblocked tubes that allow sperm to reach the egg The sperms ability to penetrate and fertilize the egg Implantation of the embryo into the hormone-prepared endometrium Finally a healthy pregnancy 4

Infertility. Statistic
A female factor (ovulatory dysfunction, pelvic factor) is in approximately 50% A male factor (sperm and semen abnormalities) is in approximately 35% Unexplained factors and causes (e.g., coital techniques) related to both partners are in approximately 15%

Causes for infertility
6

Cause of Female Infertility
CONGENITAL OR DEVELOPMENTAL FACTORS Abnormal external genitals Absence of internal reproductive structures HORMONAL FACTORS Anovulation-primary Pituitary or hypothalamic hormone disorder Adrenal gland disorder Congenital adrenal hyperplasia Anovulation-secondary Disruption of hypothalamic-pituitary-ovarian axis Early menopause Amenorrhea after discontinuing OCP Increased prolactin levels TUBAL/PERITONEAL FACTORS Absence of fimbriated end of tube Tubal motility reduced Absence of a tube Inflammation within the tube Tubal adhesions UTERINE FACTORS Developmental anomalies Endometrial and myometrial tumors Asherman syndrome (uterine adhesions or scar tissue)

Cause of Female Infertility CONGENITAL OR DEVELOPMENTAL FACTORS

Cause of Female Infertility TUBAL/PERITONEAL FACTORS
Chlamidial infection Pelvic infections (ruptures appendix, STIs)

Cause of Female Infertility UTERINE FACTORS
Uterine fibroids

Endometrial tumor

Asherman syndrome

Cause of Female Infertility VAGINAL-CERVICAL FACTORS
Vaginal-cervical infection Sperm antibody

Cause of Male Infertility
STRUCTURAL OR HORMONAL DISORDERS Undescended testes Hypospadias Testicular damage Varicocele Low testosterone levels caused by mumps OTHER FACTORS Endocrine disorders Genetic disorders Psychologic disorders Sexually transmitted infections Exposure of scrotum to high temperatures Exposure to workplace hazards such as radiation or toxic substances SUBSTANCE ABUSE Changes in sperm (Smoking, heroin, marijuana, amyl nitrate, butyl nitrate, ethyl chloride, methaqualone, Monoamine oxidase) Decrease in sperm (Hypopituitarism, Debilitating or chronic disease, Trauma, Gonadotropic inadequacy, Decrease in libido Heroin, methadone, selective serotonin reuptake inhibitors, and barbiturates) Impotence (Alcohol, Antihypertensive medications) OBSTRUCTIVE LESIONS OF THE EPIDIDYMIS AND VAS DEFERENS NUTRITIONAL DEFICIENCIES

Cause of Male Infertility STRUCTURAL OR HORMONAL DISORDERS

Evaluation of the Infertile couple
History and Physical exam Semen analysis Thyroid and prolactin evaluation Determination of ovulation Basal body temperature record Serum progesterone Ovarian reserve testing Hysterosalpingogram 19

Assessment of woman 1.Age
2. Duration of infertility (length of contraceptive and noncontraceptive exposure) 3. Obstetric A. number of pregnancies, miscaridges and abortion B. Length of time required to initiate each pregnancy C. Complication of pregnancy D. Duration of lactation 4. Gynecologic: detailed menstrual history 5. Previous tests and therapy of infertility 6. Medical: general (chronic&hereditary disease), medication, family problem, sexual development, galactorrhea 7. Surgical: abdominal or pelvic surgery

1. Follicular development, ovulation, and luteal develop ment are supportive of pregnancy:
a. Basal body temperature (presumptive evidence of ovulatory cycles) is biphasic, with temperature eleva tion that persists for 12 to 14 days before menstruation b. Cervical mucus characteristics change appropriately during phases of menstrual cycle c. Laparoscopic visualization of pelvic organs verifies follicular and luteal development 2. The luteal phase is supportive of pregnancy: a. Levels of plasma progesterone are adequate b. Findings from endometrial biopsy samples are con sistent with day of cycle 3. Cervical factors are receptive to sperm during expected time of ovulation: a. Cervical os is open b. Cervical mucus is clear, watery, abundant, and slip pery and demonstrates good spinnbarkeit and ar borization (fern pattern) c. Cervical examination does not reveal lesions or in fections d. Postcoital test findings are satisfactory (adequate number of live, motile, normal sperm present in cer vical mucus) e. No immunity to sperm demonstrated 4. The uterus and uterine tubes are supportive of preg nancy: a. Uterine and tubal patency are documented by Spillage of dye into peritoneal cavity Outlines of uterine and tubal cavities of adequate size and shape, with no abnormalities b. Laparoscopic examination verifies normal develop ment of internal genitals and absence of adhe sions, infections, endometriosis, and other lesions 5. The male partner's reproductive structures are normal: a. No evidence of developmental anomalies of penis, testicular atrophy, or varicocele (varicose veins on the spermatic vein in the groin) b. No evidence of infection in prostate, seminal vesi cles, and urethra c. Testes are more than 4 cm in largest diameter 6. Semen is supportive of pregnancy: a. Sperm (number per milliliter) are adequate in ejacu late b. Most sperm show normal morphology c. Most sperm are motile, forward moving d. No autoimmunity exists e. Seminal fluid is normal

Abnormalities of Spermatogenesis
22

Normal Sperm made in seminiferous tubules Travel to epididymis to
mature 23

Normal Sperm exit through vas deferens
Semen produced in prostate gland, seminal glands, cowpers glands Sperm only 5% of ejaculation Sperm can live 5-7 days 24

Semen Analysis (SA) Obtained by masturbation
Provides immediate information Quantity Quality Density of the sperm Morphology Motility Abstain from coitus 2 to 3 days Collect all the ejaculate Analyze within 1 hour A normal semen analysis excludes male factor 90% of the time 25

Normal Values for SA Volume Sperm Concentration Motility Viscosity Morphology pH WBC 2.0 ml or more 20 million/ml or more 50% forward progression 25% rapid progression Liquification in min 30% or more normal forms Fewer than 1 million/ml 26

Causes for Abnormal SA Abnormal Count No sperm Few sperm
Klinefelter’s syndrome Sertoli only syndrome Ductal obstruction Hypogonadotropic-hypogonadism Few sperm Genetic disorder Endocrinopathies Varicocele Exogenous (e.g., Heat) 27

Continues: causes for abnormal SA
Abnormal Morphology Varicocele Stress Infection (mumps) Abnormal Motility Immunologic factors Infection Defect in sperm structure Poor liquefaction Abnormal Volume No ejaculate Ductal obstruction Retrograde ejaculation Ejaculatory failure Hypogonadism Low Volume Obstruction of ducts Absence of vas deferens Absence of seminal vesicle Partial retrograde ejaculation Infection 28

Causes for male infertility
42% varicocele repair if there is a low count or decreased motility 22% idiopathic 14% obstruction 20% other (genetic abnormalities) 29

Abnormal Semen Analysis
Azoospermia Klinefelter’s (1 in 500) Hypogonadotropic-hypogonadism Ductal obstruction (absence of the Vas deferens) Oligospermia Anatomic defects Endocrinopathies Genetic factors Exogenous (e.g. heat) Abnormal volume Retrograde ejaculation Infection Ejaculatory failure 30

Evaluation of Abnormal SA
Repeat semen analysis in 30 days Physical examination Testicular size Varicocele Laboratory tests Testosterone level FSH (spermatogenesis- Sertoli cells) LH (testosterone- Leydig cells) Referral to urology 31

Evaluation of Ovulation
32

Female Reproductive System
Ovaries Two organs that produce eggs Size of almond 30,000-40,000 eggs Eggs can live for hours 33

Menstruation Ovulation occurs 13-14 times per year
Menstrual cycles on average are Q 28 days with ovulation around day 14 Luteal phase dominated by the secretion of progesterone released by the corpus luteum Progesterone causes Thickening of the endocervical mucus Increases the basal body temperature (0.6° F) Involution of the corpus luteum causes a fall in progesterone and the onset of menses 34

Ovulation A history of regular menstruation suggests regular ovulation
The majority of ovulatory women experience fullness of the breasts decreased vaginal secretions abdominal bloating Absence of PMS symptoms may suggest anovulation mild peripheral edema slight weight gain depression 36

Diagnostic studies to confirm Ovulation
Basal body temperature Inexpensive Accurate Endometrial biopsy Expensive Static information Serum progesterone After ovulation rises Can be measured Urinary ovulation-detection kits Measures changes in urinary LH Predicts ovulation but does not confirm it 38

Basal Body Temperature
Excellent screening tool for ovulation Biphasic shift occurs in 90% of ovulating women Temperature drops at the time of menses rises two days after the lutenizing hormone (LH) surge Ovum released one day prior to the first rise Temperature elevation of more than 16 days suggests pregnancy 39

Serum Progesterone Progesterone starts rising with the LH surge
drawn between day 21-24 Mid-luteal phase >10 ng/ml suggests ovulation 41

Salivary Estrogen: TCI Ovulation Tester- 92% accurate
42

Add Saliva Sample 43

Non-Ovulatory Saliva Pattern
46

High Estrogen/ Ovulatory Saliva Pattern
47

Anovulation 48

Anovulation Symptoms Evaluation*
Irregular menstrual cycles Amenorrhea Hirsuitism Acne Galactorrhea Increased vaginal secretions Follicle stimulating hormone Lutenizing hormone Thyroid stimulating hormone Prolactin Androstenedione Total testosterone Order the appropriate tests based on the clinical indications 49

Anatomic Disorders of the Female Genital Tract
50

Sperm transport, Fertilization, & Implantation
The female genital tract is not just a conduit facilitates sperm transport cervical mucus traps the coagulated ejaculate the fallopian tube picks up the egg Fertilization must occur in the proximal portion of the tube the fertilized oocyte cleaves and forms a zygote enters the endometrial cavity at 3 to 5 days Implants into the secretory endometrium for growth and development 51

Fertilization 52

Implantation 53

Acquired Disorders Acute salpingitis Intrauterine scarring
Alters the functional integrity of the fallopian tube N. gonorrhea and C. trachomatis Intrauterine scarring Can be caused by curettage Endometriosis, scarring from surgery, tumors of the uterus and ovary Fibroids, endometriomas Trauma 55

Hysterosalpingogram An X-ray that evaluates the internal female genital tract architecture and integrity of the system Performed between the 7th and 11th day of the cycle Diagnostic accuracy of 70% 56

Hysterosalpingogram The endometrial cavity Fallopian tubes
Smooth Symmetrical Fallopian tubes Proximal 2/3 slender Ampulla is dilated Dye should spill promptly 57

HSG: Tubal Infertility
58

??? Unexplained infertility ???
10% of infertile couples will have a completely normal workup Pregnancy rates in unexplained infertility no treatment % clomid and intrauterine insemination 8.3% gonadotropins and intrauterine insemination 17.1% ??? 59

Treatment of the Infertile Couple
60

Inadequate Spermatogenesis
Eliminate alterations of thermoregulation Clomiphene citrate is occasionally used for induction of spermatogenesis 20% success In vitro fertilization may facilitate fertilization Artificial insemination with donor sperm is often successful 61

Anovulation Restore ovulation Clomiphene citrate
Administer ovulation inducing agents Clomiphene citrate Antiestrogen Combines and blocks estrogen receptors at the hypothalamus and pituitary causing a negative feedback Increases FSH production stimulates the ovary to make follicles 62

Clomid Given for 5 days in the early part of the cycle
Maximum dose is usually 150mg 50mg dose - 50% ovulate 100mg -25% more ovulate 150mg lower numbers of ovulation No changes in birth defects If no pregnancy in 6 months refer for advanced therapies 7% risk of twins 0.3% triplets 63

Superovulatory Medications
If no response with clomid then gonadotropins- FSH (e.g. pergonal) can be administered intramuscularly This is usually given under the guidance of someone who specializes in infertility This therapy is expensive and patients need to be followed closely Adverse effects Hyperstimulation of the ovaries Multiple gestation Fetal wastage 64

Anatomic Abnormalities
Surgical treatments Lysis of adhesions Septoplasty Tuboplasty Myomectomy Surgery may be performed laparoscopically hysteroscopically If the fallopian tubes are beyond repair one must consider in vitro fertilization 65

Assisted Reproductive Technologies (ART)
Explosion of ART has occurred in the last decade. Theses technologies help provide infertile couples with tools to bypass the normal mechanisms of gamete transportation. Probability of pregnancy in healthy couples is 30-40% per cycle, live birth rate 25%. this varies depending on age 66

Intrauterine insemination (artificial insemination)
definition: sperm introduced into female reproductive tract by means other than coitus sperm can come from donor / sperm bank or from husband usually, several ejaculations are pooled often used when male has low sperm count or antibodies present in ejaculate 67

Artificial Insemination
Sperm donation or sperm aspiration 68

In Vitro Fertilization
“test - tube babies” 1st performed in 1978 (Louise Joy Brown) often performed on infertile women with tubal blockage Sperm and egg combined in the lab, fertilization Zygote placed back into the uterus Very expensive and not always successful Oldest woman in the US to give birth using in vitro was 62 years old and an Romanian woman gave birth at 66 69

In Vitro Fertilization
70

IVF Protocol GnRH agonist (e.g. Lupron) for 7 days
FSH agonist (follistim, Gonal-F, Repronex) until follicles measure mm in diameter hCG given to induce egg maturation Egg retrieval (transvaginally) h later 71

IVF protocol sperm and ova added to dish; fertilization occurs 12-14hrs. eggs transferred to new dish and cell division occurs embryos squirted into uterus at 4- to 32-cell stage (optimal: blastocyst stage) 72

IVF Protocol, cont’d. 3 to 5 embryos are injected to increase chances of pregnancy woman given progestagen to prevent miscarriage 73

IVF Protocol, cont’d. new variations / improvements:
Intracytoplasmic sperm injection (ICSI) use of frozen embryos 27,000 attempts made per year; 18.6% successful (success rates are increasing) 74

GIFT and ZIFT GIFT = gamete intrafallopian transfer
useful for tubal blockage ova are collected and inserted into oviducts below point of blockage husband’s sperm are placed in oviduct 75

GIFT and ZIFT woman is treated with hormones to prevent miscarriage
4200 attempts made / year; 28% successful ZIFT = zygote intrafallopian transfer ZIFT is like IVF, only zygotes (1 cell stage) are inserted below blockage in oviduct (24% success rate) 76

Surrogate mother Woman unable to have children may have IVF in another woman who has the child 77

Emotional Impact Infertility places a great emotional burden on the infertile couple. The quest for having a child becomes the driving force of the couples relationship. The mental anguish that arises from infertility is nearly as incapacitating as the pain of other diseases. It is important to address the emotional needs of these patients. 79

Conclusion Infertility should be evaluated after one year of unprotected intercourse. History and Physical examination usually will help to identify the etiology. If patients fail the initial therapies then the proper referral should be made to a reproductive specialist. 80

Thank You for attention! 81

CONTRACEPTION We use our knowledge of reproductive physiology to promote or avoid pregnancy

Contraception is the voluntary prevention of pregnancy Today, couples choosing contraception must be informed about prevention of unintended pregnancy, as well as protection against sexually transmitted infections (STIs).

HISTORY 1850 B.C. Egyptians used crocodile dung mixed with honey as vaginal pessary China - quicksilver (mercury) was heated in oil and swallowed by women Persia - sponges soaked in quinine, iodine, carbolic acid (phenol) and alcohol were inserted in vagina before intercourse

HISTORY Arabs used pebbles, glass beads, buttons to put into uterus (as IUD) 6th century Greeks scooped out the seeds from half a pomegranate and used the skin of the fruit as a cervical cap

HISTORY Mid 1600’s - the Era of Condom used sheep intestine
Soranus suggested that Greek women jump backward seven times after intercourse. European women used bees-wax to cap the cervix Charles Goodyear developed the first rubber condom in the 19th century

HISTORY 1870’s- vulcanized rubber was produced; rubber was washed and reused until it had cracks or tears Margaret Sanger, a socialist and feminist from New York City, created the term ‘birth control’. In 1950, Dr Gregory Pincus was asked to develop the ideal contraceptive. He derived the steroid compounds from the roots of the wild Mexican yam.

History of contraceptives
An oral birth control pill was tested on 6,000 women from Puerto Rico and Haiti. In 1960, the first oral contraceptive (Enovid-10) was launched in the US market. The ‘Pill’ heralded a revolution in birth control.

According to the Alan Guttmacher Institute
64% of the more than 60 million women aged 15–44 in the United States practice contraception. 31% of reproductive-age women do not need a method because: they are pregnant, postpartum, or trying to become pregnant; have never had intercourse; or are not sexually active. Thus, only 5–7% of women aged 15–44 in need of contraception are not using a method.

The 3 million women who use no contraceptive method account for almost:
Half of unintended pregnancies (47%), whereas the 39 million contraceptive users account for 53% The majority of unintended pregnancies among contraceptive users result from inconsistent or incorrect use.

Contraception Three general strategies: Prevent ovulation;
Prevent fertilization; Keep sperm & oocyte away from each other. Prevent implantation. 92

A multidisciplinary approach may assist a woman in choosing and correctly using an appropriate contraceptive method Nurses, nurse-midwives, nurse practitioners, other advanced practice nurses, physicians have the knowledge and expertise to assist a woman in making decisions about contraception that will satisfy the woman's personal, social, cultural, and interpersonal needs

Using contraception depends of:
frequency of coitus number of sexual partners level of contraceptive involvement, her or her partner's objections to any methods the woman's level of comfort and willingness to touch her genitals and cervical mucus religious and cultural factors an individual's reproductive life plan (contraception/sterilization) A history (menstrual, contraceptive, obstetric), physical examination (including pelvic examination), laboratory tests

BRAIDED B—Benefits: information about advantages and success rates
R—Risks: information about disadvantages and failure rates A—Alternatives: information on other methods available I—Inquiries: opportunity to ask questions D—Decisions: opportunity to decide or change mind E— Explanations: information about method and how it is used D—Documentation: information given and patient's understanding

Expected Outcomes of Care
Verbalize understanding about contraceptive methods. Verbalize understanding of all information necessary to give informed consent State comfort and satisfaction with the chosen method. Use the contraceptive method correctly and consistently. Experience no adverse sequelae as a result of the chosen method of contraception. Prevent unplanned pregnancy or plan a pregnancy.

The ideal contraceptive should be safe, easily available, economical, acceptable, simple to use, and promptly reversible. Although no method may ever achieve all these objectives, impressive progress has been made.

Plan of Care and Interventions
fundamental to initiating and maintaining any form of contraception. The nurse counters myths with facts, clarifies misinformation, and fills in gaps of knowledge Contraceptive failure depends on both the properties of the method and the characteristics of the user Safety of a method depends on the patient's medical history, tobacco use, and age. (Barrier methods offer some protection from STIs, and oral contraceptives may lower the incidence of ovarian and endometrial cancer, but increase the risk of thromboembolic problems)

Methods of Contraception
Natural family planning methods And Fertility Awareness Methods Coitus interruptus Calendar metods Basal body temperature Ovulation-detection method Symptothermal method (cervical mucus+BBT) Predictor test for ovulation Barrier Methods Chemical male (condom) Mechanical female (condom, cervical diaphragm, cervical cap) Hormonal Methods Combined (oral, injection, transdermal, vaginal ring) Pogestin only (oral, injection, implantable) Intrauterine Device Emergency Contraception

Natural family planning methods And Fertility Awareness Methods Calendar metods Basal body temperature Ovulation-detection method Symptothermal method (cervical mucus+BBT) Predictor test for ovulation Coitus interruptus Barrier Methods Hormonal Methods Intrauterine Device Emergency Contraception

Natural family planning methods (NFPM) provides contraception by using methods that rely on avoidance of intercourse during fertile periods And Fertility Awareness Methods combine the charting signs and symptoms of the menstrual cycle with the use of abstinence or other contraceptive methods during fertile periods

Natural family planning methods Fertility determine techniques include
Calendar metod Basal body temperature (BBT) Cervical mucus Ovulation-detection method Postovulation method Symptothermal method (cervical mucus+BBT) Predictor test for ovulation

Natural family planning methods NFPM main principles
The ovum can be fertilized no later than hours after ovulation Motile sperm have been recovered from the uterus and the oviducts as long as 7 days after coitus. However, their ability to fertilize the ovum probably lasts no longer than 24 to 48 hours. Pregnancy is unlikely to occur if a couple abstains from intercourse for 4 days before and for 3 or 4 days after ovulation (fertile period). Work only in woman with regular menstrual periods Depends of length pf menstrual period The typical failure rate is 25% during the first year of use

Natural family planning methods The fertile period can be anticipated by the following:
Calculating the time at which ovulation is likely to occur based on lengths of previous menstrual cycle Recording the increase in basal body temperature, a result of thermogenic effect of progesterone Recognizing the changes in cervical mucus at different phases of menstrual cycle Using combination of several method Using predictor test for ovulation

Natural family planning methods Calendar (rhythm) method
is based on the number of days in each cycle counting from the first day of menses The beginning of the fertile period is estimated by subtracting 18 days from the length of the shortest cycle. The end of the fertile period is determined by subtracting 11 days from the length of the longest cycle. shortest cycle is 21 days and longest is 35 days, = 3 , =24 Fertile period from 3 to 24 days

Natural family planning methods Calendar (rhythm) method
Effectiveness. Pregnancy rate of 9–25 per 100 women in first year of use. Advantages. No physical side effects, economical, immediate return to fertility on cessation of use, no method-related health risks. Disadvantages. High failure rate, no protection against STDs, inhibits spontaneity, requires regular menstrual cycles. 106

Natural family planning methods Basal Body Temperature Method (BBT)
is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. usually varies from 36.2° to 36.3° C during menses and for about 5 to 7 days afterward About the time of ovulation a slight drop in temperature (approximately 0.05° C) may be seen; after ovulation, in concert with the increasing progesterone levels of the early luteal phase of the cycle, the BBT rises slightly (approximately 0.2° to 0.4° C) The temperature remains on an elevated plateau until 2 to 4 days before menstruation.

Natural family planning methods Basal Body Temperature Method (BBT)

Natural family planning methods Cervical mucus Ovulation-Detection Method
requires that the woman recognize and interpret the cyclic changes in the amount and consistency of cervical mucus that characterize her own unique pattern of changes cervical mucus should be free from semen, contraceptive gels or foams, and blood or discharge from vaginal infections, douches and vaginal deodorants, medications such as antihistamines for at least one full cycle

Natural family planning methods Cervical mucus Ovulation-Detection Method

Natural family planning methods Symptothermal method (BBT+cervical mucos)
The woman is taught to palpate the cervix to assess for changes indicating ovulation; that is, the os dilates slightly, the cervix softens and rises in the vagina, and cervical mucus is copious and slippery The woman notes days on which coitus, changes in routine, illness, and so on have occurred Calendar calculations and cervical mucus changes are used to estimate the onset of the fertile period; changes in cervical mucus or the BBT are used to estimate its end

Natural family planning methods Predictor test for ovulation
detects the sudden surge of luteinizing hormone (LH) that occurs approximately 12 to 24 hours before ovulation. Unlike BBT, the test is not affected by illness, emotional upset, or physical activity

Natural family planning methods Coitus interruptus
male partner withdrawing the penis from the woman's vagina before he ejaculates. It is a good choice for couples who do not have another contraceptive available Effectiveness depends on the man's ability to withdraw his penis before ejaculation The failure rate is 19% Does not protect against STIs or human immunodeficiency virus (HIV) infection

Natural family planning methods And Fertility Awareness Methods Barrier Methods Chemical male (condom) Mechanical female (condom, cervical diaphragm, cervical cap) Hormonal Methods Intrauterine Device Emergency Contraception

Barrier Methods Provide barrier for sperm AND
Mechanical condoms provide a mechanical barrier to STIs Chemical barriers slightly reduce the risk of gonorrhea and chlamydia but may increase the transmission of HIV

Barrier Methods Exposure to multiple partners is defined as having had more than one partner in the past year or having had a partner who had other partners around the same time.

Barrier Methods Spermicides
Nonoxynol-9 is a surfactant that destroy the sperm sell membrane, Mode of action Provide a physical and chemical barrier that prevent viable sperm from entering the cervix frequent using increase the transmission of HIV, can cause genital lesion aerosol foams, foaming tablets, suppositories, creams, films, gels, and sponges Should be inserted no longer than 1 hour before intercose Effectiveness depends on consistent and accurate use Typical failure rate in the first year of use is 29%

Advantages Easy to apply Safe Low cost Available without a prescription or previous medical examination Aids in lumbricate of the vagina Alternative to lacting woman and premenopausal, foget oral contraceptive Disadvantages Maximall effectiveness lasts no longer 1 hour Repeated intercourse need additional spermicides Alergic reaction and irritation of vaginal and penile tissue Decrease sensation Increase STI

Barrier Methods male condom
prevent sperm from entering the cervix FAILURE RATE Typical users, 14% Correct and consistent users, 3% ADVANTAGES Safe No side effects Readily available Premalignant changes in cervix can be prevented or ameliorated in women whose partners use condoms Method of male nonsurgical contraception DISADVANTAGES Must interrupt lovemaking to apply sheath. Sensation may be altered. If used improperly, spillage of sperm can result in pregnancy. Occasionally, condoms may tear during intercourse. STI PROTECTION If a condom is used throughout the act of intercourse and there is no unprotected contact with female genitals, a latex rubber condom, which is impermeable to viruses, can act as a protective measure against STIs. The addition of nonoxynol-9 increases protection against transmission of STIs.

Barrier Methods female condom
is made of polyure-thane and has flexible rings at both ends The closed end of the pouch is inserted into the vagina and is anchored around the cervix, and the open ring covers the labia. The female condom can be inserted up to 8 hours before intercourse and is intended for one-time use. Typical failure rate is 21% in the first year of use

Barrier Methods diaphragm
is a shallow, dome-shaped rubber device with a flexible wire rim that covers the cervix The diaphragm is a mechanical barrier preventing the meeting of the sperm with the ovum. The diaphragm holds the spermicide in place against the cervix for the 6 hours it takes to destroy the sperm. Typical failure rate of the diaphragm alone is 20% in the first year of use. Effectiveness of the diaphragm can be increased when combined with a spermicide

Barrier Methods diaphragm
Disadvantages reluctance to insert and remove the diaphragm. A cold diaphragm a cold gel temporarily reduce vaginal response to sexual stimulation if insertion of the diaphragm occurs immediately before intercourse. Side effects irritation of tissues related to contact with spermicides and urethritis and recurrent cystitis caused by upward pressure of the diaphragm rim against the urethra Contraindication woman with relaxation of her pelvic support (uterine prolapse) or a large cystocele. Women who have a latex allergy should not use diaphragms made of latex.

Barrier Methods cervical cap
soft, natural rubber dome with a firm but pliable rim. It fits snugly around the base of the cervix close to the junction of the cervix and vaginal fornices. It is recommended that the cap remain in place no less than 8 hours and not more than 48 hours at a time. It is left in place at least 6 hours after the last act of intercourse. The seal provides a physical barrier to sperm: spermicide inside the cap adds a chemical barrier. The extended period of wear may be an added convenience for women. Contindication abnormal Papanicolaou (Pap) test results, those who cannot be fitted properly with the existing cap sizes, those who find the insertion and removal of the device too difficult, those with a history of Toxic Shock syndrome, those with vaginal or cervical infections, those who experience allergic responses to the latex cap or spermicide.

Barrier Methods Sponges
is a small, round, polyurethane sponge that contains nonoxynol-9 spermicide. It is designed to fit over the cervix (one size fits all). The side that is placed next to the cervix is concave for better fit. The opposite side has a woven polyester loop to be used for removal of the sponge. The sponge must be moistened with water before it is inserted. It provides protection for up to 24 hours and for repeated instances of sexual intercourse. The sponges hould be left in place for at least 6 hours after the last act of intercourse. Wearing longer than 24 to 30 hours may put the woman at risk for TSS

Barrier Methods Sponges

Natural family planning methods And Fertility Awareness Methods Barrier Methods Hormonal Methods Combined (oral, injection, transdermal, vaginal ring) Pogestin only (oral, injection, implantable) Intrauterine Device Emergency Contraception

Hormonal Methods Combined oral contraceptives (COCs)
Consist of synthetic estrogen and progestin preparations suppresses the action of the hypothalamus and anterior pituitary, leading to inappropriate secretion of follicle-stimulating hormone (FSH) and LH; ovulation is inhibited because ovarian follicles do not mature. maturation of the endometrium is altered, making it a less favorable site for implantation should ovulation and fertilization occur; the cervical mucus remains thick as a result of the effect of the progestin and reduces the chance for sperm penetration Decrease tubal motility

Hormonal Methods Combined oral contraceptives (COCs) Noncontraceptive Benefits of COCs
. Less endometrial cancer (50% reduction) Less ovarian cancer (40% reduction) Less benign breast disease Fewer uterine fibroids (31% reduction) Fewer menstrual problems --more regular --less flow --less dysmenorrhea --less anemia Fewer ectopic pregnancies Increased bone density Probably less endometriosis Possibly protection against atherosclerosis Besides providing protection from the above medical disorders, СOCs are used to manage many gynecologic disorders Fewer ovarian cysts (50% to 80% reduction)

Examination include: medical and family history, weight, blood pressure, general physical and pelvic examination, and screening cervical cytologic analysis (Pap smear) Use of oral hormonal contraceptives is usually initiated on one of the first 7 days of the menstrual cycle (day 1 of the cycle is the first day of menses). With a "Sunday start"

Effectiveness. Pregnancy rate of 0.1–5.0 per 100 women in first year of use. Advantages. Taking pill does not relate directly to the sexual act Women know when to expect the next menstrual flow Decreased menstrual blood loss, iron-deficiency anemia, decrease menstrual irregularities, reduce incidence of dysmenorrhea and PMS, risk ectopic pregnancy protect against ovarian and endometrial cancer, benign breast disease, functional ovarian cysts, salpingitis, associated with improvement in mild acne

Thromboembolic disorder (or history of them) Cerebrovascular accident (or history of them) Coronary artery disease (or history of them) Impaired liver function, liver tumor Hepatic adenoma (or history of them) Breast cancer, endometrial cancer, other estrogen-dependant malignancies (or history of them) Pregnancy Undiagnosed vaginal bleeding Tobacco user over age 35 Lactation less than 6 weeks postpartum

headaches with focal neurologic symptoms, Hypertension (blood pressure greater than 160/100 mm Hg) Uterine leiomyomata Diabetes mellitus (of more than 20 years' duration) with vascular disease or previous gestational diabetes Elective surgery (needs 1 to 3 month discontinuation) Seizure disorder, anticonvulsant use Obstructive jaundice in pregnancy Sickle cell disease (SS or sickle C disease (SC) Gall bladder disease.

Hormonal Methods Combined oral contraceptives (COCs) side effects
are attributable to estrogen, progestin or both ESTROGEN & PROGESTIN Stroke, myocardial infarction, thromboembolism, hypertension, gallblader disease, liver tumor 138

ESTROGEN EXCESS nausea and vomiting, dizziness, edema, leg cramps, increase in breast size, chloasma (mask of pregnancy), visual changes, hypertension, vascular headache. ESTROGEN DEFICIENCY early spotting (days 1 to 14), hypomenorrhea, nervousness, atrophic vaginitis leading to painful intercourse (dyspareunia). 139

PROGESTIN DEFICIENCY late spotting and breakthrough bleeding (days 15 to 21), heavy flow with clots, decreased breast size PROGESTIN EXCESS increased appetite, tiredness, depression, breast tenderness, vaginal yeast infection, oily skin and scalp, hirsutism, postpill amenorrhea. 140

Hormonal Methods Combined oral contraceptives (COCs) sign of potential complications ACHES
A— Abdominal pain: may indicate a problem with the liver or gallbladder C—Chest pain or shortness of breath: may indicate possible clot problem within lungs or heart H—Headaches (sudden or persistent): may be caused by cardiovascular accident or hypertension E—Eye problems: may indicate vascular accident or hypertension S—Severe leg pain: may indicate a thromboembolic process

Right products of COCs Contains the lowest dose of hormones that prevent ovulation and that has the fewest and least harmful side effects After discontinuing oral contraception return fertility usually happens quickly, but fertility rates are slightly lower the first 3-12 months after discontinuating Oral contraceptives do not protect a woman against STIs and HIV

Hormonal Methods Combined contraceptives Injection
Lunelle 25 mg medroxyprogesterone acetate +5 mg estradiol cypionate Intramuscularly in the deltoid or gluteus maximus every days Failure rate 3%

Hormonal Methods Combined contraceptives Transdermal contraceptive patch
Releases 150 mg Norelgestromin and 20 mg Ethinyl Estradiol daily 4.5 cm square that can be worn lower abdomen, buttocks, upper outer arm upper torso (except breasts) 1 patch every week for 3 weeks, followed by a patch-free week 144

Hormonal Methods Combined contraceptives
Transdermal contraceptive patch 145

Hormonal Methods Combined contraceptives Vaginal Ring
Etonogestrel + ethynyl estradiol Worn for 3 weeks + 1 week without ring Withdrawal bleeding occurs during “no ring” week

Hormonal Methods Progestin-only contraceptives
synthetic progestin preparations suppressing ovulation, Thickening and decreasing the amount of cervical mucus, Thinning the endometrium altering cilia in the uterine tubes They have advantages over COCs because they may be used by breast-feeding women, they are not thrombogenic, and they are not associated with liver disease. However, because protective changes to cervical mucus begin to decrease 22 hours after the pill is taken, effectiveness is decreased if the pill is not taken at the same time every day.

Hormonal Methods Progestin-only oral contraceptives
Effectiveness. Failure rate is about 8% in first year of use Taken correctly Take at the same time every day Irregular vaginal bleeding

Progestin-only injectable contraceptives
Hormonal Methods Progestin-only injectable contraceptives Depot medroxyprogesterone acetate (DMPA, Depo-Provera), 150 mg injected intramuscularly in the deltoid or gluteus maximus, don’t massage every 3 months Advantages. Rapidly and highly effective, long-acting, only 4 times a year, lacting period Disadvantages - Prolonged amenorhea, or uterine bleeding, increased risk of of venous thrombosis and thrombembolism, no protection against STI

Hormonal Methods Progestin-only implants, The Norplant system

Hormonal Methods Progestin-only implants The Norplant system
6 flexible, nonbiodegradable polymeric silicone capsules filled with levonorgestrel that are inserted under the skin Providing up to 5 years of contraception Prevent some, but not all ovulatory cycles, thickens cervical mucus Advantages Reversibility, long-term continuos contraception, not related to coitus Side effect: irregular menstrual bleeding, headaches, nervousness, nausea, skin changes, and vertigo No STI protection Fertility returns within the first month after removal of the capsules.

Natural family planning methods And Fertility Awareness Methods Barrier Methods Hormonal Methods Intrauterine Device Emergency Contraception

Intrauterine Device (IUD)
153

small, T-shaped device inserted into the uterine cavity. loaded with either copper or a progestational agent with barium sulfate for radiopacity. copper-bearing IUD damages sperm in transit to the uterine tubes and few sperm reach the ovum, thus preventing fertilization progesterone-bearing IUD causes progestin-related effects on cervical mucus and endometrial maturation Failure rate of the IUD ranges from 0.8% to 2.0%

Advantages. Without need to remember to take pills each days, or engage in other manipulation before or between coital acts. If pregnancy can be excluded, an IUD may be placed at any time during the menstrual cycle. An IUD may be inserted immediately after childbirth or abortion immediately effective after insertion with prompt return of fertility after removal, long-term protection less blood loss during menstruation and decreased primary dysmenorrhea Disadvantages. The risk of pelvic inflammatory disease, bacterial vaginosis high occurrence of dysmenorrhea and menorrhagia (usually) within the first few months after device insertion, risk of uterine perforation with insertion, higher risk of ectopic pregnancy if pregnancy does occur. No protection against STI or HIV

Recommended for long term contraception Had at least 1 child State monogamous relationships contraindicated history of pelvic inflammatory disease, known or suspected pregnancy, undiagnosed genital bleeding, suspected genital malignancy, or a distorted intrauterine cavity. not recommended for teenagers, Without children

Intrauterine Device (IUD) signs of potential complications PAINS
P—Period late, abnormal spotting or bleeding A—Abdominal pain, pain with coitus I —Infection exposure, abnormal vaginal discharge N— Not feeling well, fever or chills S—String missing, shorter, or longer

Natural family planning methods And Fertility Awareness Methods Barrier Methods Hormonal Methods Intrauterine Device Emergency Contraception

Emergency contraception
used within 72 hours of unprotected intercourse to prevent pregnancy. High doses of oral progestins or combined OCPs or insertion of IUD Before ovulation: inhibiting follicular development After ovulation: prevent implantation First dose within 72 hour, second dose 12 hour later 159

Voluntary sterilization
surgical procedures involve the occlusion of the passageways for the ova (uterine tube) and sperm (vas deferens) Absolute sterility Removal of the ovaries, uterus (or both), or testis

female 161

Voluntary sterilization male

Female: tubal ligation, tubal oclusion (electrocoagulating, application of bands or clips) Laparotomy, laparoscopy Male: vasectomy Up to 20 ejaculations are required before the procedure becomes effective 163

& if contraception fails …
RU-486 Blocks progesterone receptors Uterus & anterior pituitary behave as if no progesterone present Endometrium sloughs. 21 Dec. 2008 Contraception.ppt 164

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Infertility 1.

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