Transcript 2_Сontraception and infertility

Infertility
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
Infertility
• Primary infertility
– a couple that has never conceived
• Secondary infertility
– infertility that occurs after previous
pregnancy regardless of outcome
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
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
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
CONGENITAL OR DEVELOPMENTAL
FACTORS
Cause of Female Infertility
CONGENITAL OR DEVELOPMENTAL
FACTORS
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
Cause of Female Infertility
UTERINE FACTORS
Endometrial
tumor
Cause of Female Infertility
UTERINE FACTORS
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
Varicocele
Low testosterone levels
Testicular damage
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
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
Abnormalities of Spermatogenesis
Normal
• Sperm made in
seminiferous
tubules
• Travel to
epididymis to
mature
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
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
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 30-60 min
– 30% or more normal forms
– 7.2-7.8
– Fewer than 1 million/ml
Causes for Abnormal SA
Abnormal Count
• No sperm
– Klinefelter’s syndrome
– Sertoli only syndrome
– Ductal obstruction
– Hypogonadotropichypogonadism
• Few sperm
– Genetic disorder
– Endocrinopathies
– Varicocele
– Exogenous (e.g.,
Heat)
Continues: causes for abnormal SA
• Abnormal Morphology • Abnormal Volume
– Varicocele
– Stress
– Infection (mumps)
• Abnormal Motility
–
–
–
–
–
Immunologic factors
Infection
Defect in sperm structure
Poor liquefaction
Varicocele
– 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
Causes for male infertility
• 42% varicocele
– repair if there is a low count or decreased
motility
• 22% idiopathic
• 14% obstruction
• 20% other (genetic
abnormalities)
Abnormal Semen Analysis
• Azoospermia
• Oligospermia
– Klinefelter’s (1 in 500)
– Anatomic defects
– Hypogonadotropic– Endocrinopathies
hypogonadism
– Genetic factors
– Ductal obstruction
– Exogenous (e.g. heat)
(absence of the Vas
• Abnormal volume
deferens)
– Retrograde ejaculation
– Infection
– Ejaculatory failure
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
Evaluation
of
Ovulation
Female Reproductive System
• Ovaries
– Two organs that
produce eggs
– Size of almond
– 30,000-40,000 eggs
– Eggs can live for 12-24
hours
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
Ovulation
• A history of regular menstruation suggests regular
ovulation
• The majority of ovulatory women experience
– fullness of the breasts
– decreased vaginal secretions
– abdominal bloating
– mild peripheral edema
– slight weight gain
– depression
• Absence of PMS symptoms may suggest
anovulation
Diagnostic studies to confirm
Ovulation
• Serum progesterone
• Basal body temperature
– Inexpensive
– Accurate
– After ovulation rises
– Can be measured
• Endometrial biopsy • Urinary ovulationdetection kits
– Expensive
– Static information
– Measures changes in
urinary LH
– Predicts ovulation but
does not confirm it
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
Serum Progesterone
• Progesterone starts rising with the LH surge
– drawn between day 21-24
• Mid-luteal phase
– >10 ng/ml suggests ovulation
Salivary Estrogen: TCI Ovulation
Tester- 92% accurate
Add Saliva Sample
Non-Ovulatory Saliva Pattern
High Estrogen/ Ovulatory
Saliva Pattern
Anovulation
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
Anatomic Disorders of the
Female Genital Tract
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
Fertilization
Implantation
Acquired Disorders
• Acute salpingitis
– 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
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%
Hysterosalpingogram
• The endometrial
cavity
– Smooth
– Symmetrical
• Fallopian tubes
– Proximal 2/3 slender
– Ampulla is dilated
• Dye should spill
promptly
HSG: Tubal Infertility
??? Unexplained infertility ???
• 10% of infertile couples will have a completely
normal workup
• Pregnancy rates in unexplained infertility
– no treatment 1.3-4.1%
– clomid and intrauterine insemination 8.3%
– gonadotropins and intrauterine insemination 17.1%
???
Treatment of
the Infertile
Couple
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
Anovulation
• Restore ovulation
– 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
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
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
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
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
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
Artificial Insemination
• Sperm donation or
sperm aspiration
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
In Vitro Fertilization
IVF Protocol
• GnRH agonist (e.g. Lupron) for 7 days
• FSH agonist (follistim, Gonal-F, Repronex) until
follicles measure 17-20 mm in diameter
• hCG given to induce egg maturation
• Egg retrieval (transvaginally) 34-35 h later
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 32cell stage (optimal: blastocyst stage)
IVF Protocol, cont’d.
• 3 to 5 embryos are injected to increase
chances of pregnancy
• woman given progestagen to prevent
miscarriage
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)
• http://www.advancedfertility.com/sampleivfcalen
dar.htm
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
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)
Surrogate mother
– Woman unable to have children may have
IVF in another woman who has the child
Primary Diagnosis of Women Undergoing ART- 1998
12%
15%
9%
2%
27%
9%
26%
Tubal factor
Male factor
Ovulation dysfxn
Endometriosis
Unexplained
Uterine factor
Other
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.
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.
Thank You
for attention!
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
 Chemical
 Mechanical
• Barrier Methods
male (condom)
female (condom, cervical diaphragm, cervical cap)
• Hormonal Methods
 Combined (oral, injection, transdermal, vaginal ring)
 Pogestin only (oral, injection, implantable)
•
•
Intrauterine Device
Emergency Contraception
Methods of 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 16-24 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,
• 21 - 18 = 3 , 35 - 11 =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.
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
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
Cervical mucus Ovulation-Detection
Method
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
Methods of Contraception
• Natural family planning methods And Fertility
Awareness Methods
• Barrier Methods
 Chemical
 Mechanical
male (condom)
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%
Barrier Methods
Spermicides
• 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
Spermicides
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
Methods of Contraception
• 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
Methods of Contraception
• 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 folliclestimulating 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)
Hormonal Methods
Combined oral contraceptives (COCs)
• 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"
Hormonal Methods
Combined oral contraceptives (COCs)
• 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
Hormonal Methods
Combined oral contraceptives (COCs)










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 estrogendependant malignancies (or history of them)
Pregnancy
Undiagnosed vaginal bleeding
Tobacco user over age 35
Lactation less than 6 weeks postpartum
Hormonal Methods
Combined oral contraceptives (COCs)
 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
Hormonal Methods
Combined oral contraceptives (COCs)
side effects
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).
Hormonal Methods
Combined oral contraceptives (COCs)
side effects
PROGESTIN EXCESS
increased appetite,
tiredness,
depression,
breast tenderness,
vaginal yeast infection,
oily skin and scalp,
hirsutism,
postpill amenorrhea.
PROGESTIN
DEFICIENCY
late spotting and
breakthrough
bleeding (days 15 to
21),
heavy flow with clots,
decreased breast size
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
Hormonal Methods
Combined oral contraceptives (COCs)
• 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 28 + 5 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
Hormonal Methods
Combined contraceptives
Transdermal contraceptive patch
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
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.
Methods of Contraception
• Natural family planning methods And Fertility
Awareness Methods
• Barrier Methods
• Hormonal Methods
• Intrauterine Device
• Emergency Contraception
Intrauterine
Device
(IUD)
Intrauterine Device (IUD)
• 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%
Intrauterine Device (IUD)
• 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
Intrauterine Device (IUD)
• 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
Methods of Contraception
• 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
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
Voluntary
sterilization
female
Voluntary sterilization
male
Voluntary sterilization
• 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
& 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
THANK YOU !!!